Medical errors happen every day. Few make the headlines, but when they do, almost everyone who chimes in to comment offers the same type of solution for avoiding them. Three of the most common are guidelines, decision support and checklists.
From my vantage point as a primary care physician I agree that checklists, in particular, can enhance clinical accuracy, but some of the lists I have to work with in today’s healthcare environment are more likely to bog me down and distract me than focus my attention on the essentials. I call them choke lists.
Re-reading “The Checklist Manifesto” by Atul Gawande, published in 2010, the year before my clinic implemented their first EMR, I am reminded of how much has changed since then.
How I work and where my attention is drawn has changed because of the minutia of Meaningful Use, Patient Centered Medical Home, Accountable Care and all the other new philosophies and forces that define primary health care.
Continue reading “The Great Checklisting of American Medicine”
Filed Under: THCB
Tagged: Atul Gawande, Checklist, Checklist Manifesto
Oct 22, 2014
Last week, a study in the New England Journal of Medicine called into question the effectiveness of surgical checklists for preventing harm.
Atul Gawande—one of the original researchers demonstrating the effectiveness of such checklists and author of a book on the subject—quickly wrote a rebuttal on the The Incidental Economist.
He writes, “I wish the Ontario study were better,” and I join him in that assessment, but want to take it a step further.
Gawande first criticizes the study for being underpowered. I had a hard time swallowing this argument given they looked at over 200,000 cases from 100 hospitals. I had to do the math. A quick calculation shows that given the rates of death in their sample, they only had about 40% power .
Then I became curious about Gawande’s original study. They achieved better than 80% power with just over 7,500 cases. How is this possible?!?
The most important thing I keep in mind when I think about statistical significance—other than the importance of clinical significance —is that not only does it depend on the sample size, but also the baseline prevalence and the magnitude of the difference you are looking for. In Gawande’s original study, the baseline prevalence of death was 1.5%.
This is substantially higher than the 0.7% in the Ontario study. When your baseline prevalence approaches the extremes (i.e.—0% or 50%) you have to pump up the sample size to achieve statistical significance.
So, Gawande’s study achieved adequate power because their baseline rate was higher and the difference they found was bigger. The Ontario study would have needed a little over twice as many cases to achieve 80% power.
This raises an important question: why didn’t the Ontario study look at more cases?
Continue reading “Why Bad Research Makes It into Good Medical Journals”
Filed Under: OP-ED, THCB
Tagged: Atul Gawande, Checklists, Josh Herigon, NEJM, Ontario Checklist Study
Mar 18, 2014
The human connection is threatened by medicine’s increasingly reductive focus on data collection, algorithms, and information transaction.
If you follow digital health, Rachel King’s recent Wall Street Journal piece on Stanford physician Abraham Verghese should be required reading, as it succinctly captures the way compassionate, informed physicians wrestle with emerging technologies — especially the electronic medical record.
For starters, Verghese understands its appeal: “The electronic medical record is a wonderful thing, in general, a huge improvement on finding paper charts and finding the old records and trying to put them all together.”
At the same, he accurately captures the problem: “The downside is that we’re spending too much time on the electronic medical record and not enough at the bedside.”
This tension is not unique to digital health, and reflects a more general struggle between technologists who emphasize the efficient communication of discrete data, and others (humanists? Luddites?) who worry that in the reduction of complexity to data, something vital may be lost.
Technologists, it seems, tend to view activities like reading and medicine as fundamentally data transactions. So it makes sense to receive reading information electronically on your Kindle — what could be more efficient?
Continue reading “Being Human”
Filed Under: Uncategorized
Tagged: Abraham Verghese, Atul Gawande, Bedside Manner, David Shaywitz, digital health, Eric Schmidt, humanism, Physicians, Rachel King, Technologists, Vinod Khosla, WSJ
Nov 6, 2012
In a well-publicized and well-written article in the New Yorker, Atul Gawande (one of my doctor writing heroes) talks about his visit to the popular restaurant, The Cheesecake Factory, and how that visit got him thinking about the sad state of health care.
The chain serves more than eighty million people per year. I pictured semi-frozen bags of beet salad shipped from Mexico, buckets of precooked pasta and production-line hummus, fish from a box. And yet nothing smacked of mass production. My beets were crisp and fresh, the hummus creamy, the salmon like butter in my mouth. No doubt everything we ordered was sweeter, fattier, and bigger than it had to be. But the Cheesecake Factory knows its customers. The whole table was happy (with the possible exception of Ethan, aged sixteen, who picked the onions out of his Hawaiian pizza).
I wondered how they pulled it off. I asked one of the Cheesecake Factory line cooks how much of the food was premade. He told me that everything’s pretty much made from scratch—except the cheesecake, which actually is from a cheesecake factory, in Calabasas, California.
I’d come from the hospital that day. In medicine, too, we are trying to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality. Unlike the Cheesecake Factory, we haven’t figured out how. Our costs are soaring, the service is typically mediocre, and the quality is unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of two or three, even within the same hospital.
Continue reading “The Great Cheesecake Robbery”
Filed Under: THCB
Tagged: Atul Gawande, Cheesecake Factory, da Vinci, Health Care Costs, Hospital Care, Institutes of Medicine, Pharma, Rob Lamberts
Sep 13, 2012
While the nation has been focused on the recent Supreme Court ruling on the Affordable Care Act, innovations in hospitals and physician practices far from Capitol Hill have been triggering an historic transformation of our health care system. Propelled by a mix of urgency and vision, innovators at hospitals, physician groups and companies are remaking American health care by demonstrating that more effective and affordable care is achievable quite apart from statutory changes in Washington.
These organizations are working to achieve the Triple Aim: improve the health of the population; enhance the patient experience of care (including quality, access, and reliability); and reduce, or at least control, the per capita cost of care. This approach, developed by the Institute for Healthcare Improvement, is a sharp break with the traditional focus on single encounters with patients within the strict walls of health care delivery, typically addressing only the most immediate problems.
Continue reading “Health Care Innovations Hiding in Plain Sight”
Filed Under: THCB
Tagged: Atrius Health, Atul Gawande, Bellin Health, CareOregon, Charles Kenney, Costs, HealthPartners, Innovation, Institute for Healthcare Improvement, Intel, Kaiser Permanente, Maureen Bisagnano, Patient-centered care, Quality, The States, Triple Aim, UPMC, Virginia Mason Medical Center
Aug 28, 2012
In the current issue of The New Yorker, surgeon Atul Gawande provocatively suggests that medicine needs to become more like The Cheesecake Factory – more standardized, better quality control, with a touch of room for slight customization and innovation.
The basic premise, of course, isn’t new, and seems closely aligned with what I’ve heard articulated from a range of policy experts (such as Arnold Milstein) and management experts (such as Clayton Christensen, specifically in his book The Innovator’s Prescription).
The core of the argument is this: the traditional idea that your doctor is an expert who knows what’s best for you is likely wrong, and is both dangerous and costly. Instead, for most conditions, there are a clear set of guidelines, perhaps even algorithms, that should guide care, and by not following these pathways, patients are subjected to what amounts to arbitrary, whimsical care that in many cases is unnecessary and sometimes even harmful – and often with the best of intentions.
According to this view, the goal of medicine should be to standardize where possible, to the point where something like 90% of all care can be managed by algorithms – ideally, according to many, not requiring a physician’s involvement at all (most care would be administered by lower-cost providers). A small number of physicians still would be required for the difficult cases – and to develop new algorithms.
Continue reading “Do You Believe Doctors Are Systems, My Friends?”
Filed Under: OP-ED, THCB, The Business of Health Care
Tagged: Algorithms, Atul Gawande, Autonomy, Clayton Christensen, Customer Service, Customization of Care, David Shaywitz, doctor/ patient relationship, low-cost providers, Quality, Standardization, The Cheesecake Factory, Vinod Khosla
Aug 15, 2012
In Healthcare Beyond Reform: Doing it Right For Half The Cost I lay out the five strategies that healthcare must adopt, and is adopting in various ways and places, to make healthcare better and cheaper at the same time.
Strategy Five is “Rebuild Every Process.” It’s about “lean manufacturing,” smart standardization, measurement, “big data,” evidence-based design, teaching the innovation, all the detailed, rigorous, hard attention to intelligent process re-design that healthcare is so obviously lacking — and that is absolutely necessary if healthcare is to improve its abysmal cost/benefit ratio.
Now in The New Yorker writer/surgeon Atul Gawande has done a brilliant turn on this theme, by diving into, of all things, the processes of a restaurant chain, comparing them to the duplicative, chaotic, mistake-prone processes of traditional healthcare, and finally to some examples of smart, rebuilt healthcare processes that drive down costs while killing fewer people.
Gawande shows how The Cheesecake Factory manages to deliver 308 dinner menu items and 124 beverage choices to exacting standards, on time, from fresh ingredients, with only 2.5% wastage, in a linen-napkin and silverware environment, at lower cost, then compares that with the disconnected, uncoordinated, messy environment that is most of US healthcare. He details several examples of how new drives toward standardization and control of processes in the operating room and the emergency department, for instance, are making a difference, lowering costs and improving not only outcomes but the patient experience, all at the same time.
Continue reading “What Healthcare Must Learn — from a Chain Restaurant”
Filed Under: Uncategorized
Tagged: Atul Gawande, cookbook medicine, Customization, Joe Flower, The Cheesecake Factory, Waste
Aug 14, 2012
At a conference for America’s Health Insurance Plans, Gladwell argued that patients or consumers have been unable to be more empowered because doctors, as the intermediary, held the power of knowledge much the same way chauffeurs did for the early days of the automobile and Xerox technicians did in the early days of photocopying. A person was needed to guide and assist the individual to get the job done. At some point, however, the technology became simpler. People began to drive their own cars and make their own photocopies. The mystique of the chauffeur and technician was lifted. Now everyone could drive. Everyone could make photocopies.
Is it possible that for health care and the health care system, which for many people is a system they interact with rarely and in an area (health / illness) where the uncertainty and stakes many be too “high”, that individuals willingly defer the responsibility to someone else? Gladwell hints that might be a possibility:
“A key step in any kind of technological transition is the acceptance of a temporary deficit in performance at the beginning in exchange for something else,” said Gladwell. That something else can eventually include increased convenience and lower cost. He offered a number of examples, including the shift to digital cameras where early pictures were not as good as film and the advent of the digital compression of music, which he contends has made the quality of music worse….
Continue reading “Doctors, Patients, or Insurers? Who Will Shape Health Care?”
Filed Under: Physicians
Tagged: Atul Gawande, Davis Liu, Future of Healthcare, Insurers, Malcolm Gladwell, patient engagement, Patients, Physicians
Jul 29, 2012
As the new year starts, I’m eager for a fresh start and working on improving myself both physically and emotionally. I’m also eager for the NFL playoffs and seeing how my favorite team, the New England Patriots, fares under the leadership of Coach Bill Belichick and quarterback Tom Brady. Doctors and health care can learn much from their examples.
Over the past decade, the New England Patriots have been dominant appearing in 40 percent of the Super Bowls played and winning 3 out of 4. Nothing prior to 2000, would have suggested this superior performance with playoff appearances only six times from 1985 to 2000 and two Super Bowl appearances, both losses. Their new head coach Bill Belichick hired in 2000 had a losing record in his prior stint at Cleveland. Their current quarterback Tom Brady was drafted in the second to last round.
Continue reading “What Doctors Can Learn from the New England Patriots”
Filed Under: Physicians, THCB
Tagged: Atul Gawande, Checklists, hospital staff, improving medial care, New England Patriots
Jan 9, 2012
Atul Gawande says that we’re used to doctors working like “cowboys” – rugged individualists who are responsible for making sure your care gets done right. We don’t need cowboys, he says. We need “pit crews” – teams of doctors working together toward a common goal, with each playing their own role.
It’s an appealing idea. Pit crew-like teams work, and work well, in trauma units across the country.
But there’s a problem: if you haven’t just been airlifted to a hospital after a horrible accident, you’re not going to be treated by a pit crew. You’re going to be on your own, shuffled from one 15-minute specialist visit to the next, likely with no one person in charge of your care.
Dr. Gawande knows this, and he picks a heck of an example of the problem:
“But you can’t hold all the information in your head any longer, and you can’t master all the skills. No one person can work up a patient’s back pain, run the immunoassay, do the physical therapy, protocol the MRI, and direct the treatment of the unexpected cancer found growing in the spine. I don’t even know what it means to ‘protocol’ the MRI.”
Why is that such a good example? Because it’s exactly what happened to my brother at one of the leading medical centers in the country. He had a person directing the work up of his back pain and all the rest, including deciding on the right treatment for the “unexpected cancer found growing in his spine.” It all worked well….except that he didn’t have cancer at all. In fact, had he been treated for cancer, he might not be with us today.
Continue reading “But There Are No Pit Crews”
Filed Under: OP-ED, THCB
Tagged: Atul Gawande, Hospitals, pit crew
Nov 16, 2011