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The F Word …

Fragmentation, Fee-for-service and Futile care are the trifecta of what is supposedly ailing our health care system, or non-system, as it is fashionably described nowadays. Modern health care has reached its crisis point not due to hordes of people keeling over and dying in the streets, as they did during historical health care crises brought on by plagues and famine, but due to exploding costs of delivering decent care to all people. Since the issue now is mostly financial, health care as a discipline is attracting the interests of those who practice the dismal science of Economics. Over the last two centuries, economists have successfully addressed the F words in other industries with spectacular results in developed countries, so why not apply lessons learned to health care?

The obvious reason to treat economists with suspicion in health care is the quintessential argument that people are not widgets, but there is another problem. Most tried-and-true solutions for increasing availability and quality while lowering costs of products are not accounting for the other explosion occurring as we speak – the Internet.  How can this assertion be true when we are in the midst of a government sponsored spending spree to computerize medical records and adopt Health Information Technology (HIT)? Apparently, even those who lead and define the HIT revolution are reluctant (or unable) to grasp its full implication, thus they are consistently underestimating the power of the Internet to serve the individual, and as a result are hedging their bets on technology with classic industrial models from days gone by.

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Huddle of One

There’s nothing new under the sun, or in medicine. I’m not talking about monoclonal antibody targeted chemotherapy; I’m talking about taking care of patients, and specifically about running a medical practice. Not even the incursion advent of all our fancy new electronics has (or should have) a fundamental effect on how we take care of our patients.  The latest thing to come down the pike is the so-called Patient Centered Medical Home, a collection of policies, procedures, and practice re-structuring (webinars, templates, guidelines, etc. all available at low, low prices, of course) that essentially makes large group practices function like a solo doc from the patient’s point of view.

Because the buzzword of this new model is “teamwork”, we’re all supposed to begin the day with a brilliant new concept called the “huddle“:

The team huddle is promoted by many clinicians and practice coaches as an innovative approach to support medical home transformation through visit pre-planning, team building and communication, and workflow redesign.

Radical!

One problem: how do I do that all by myself? I mean, here’s what I generally do every day:

  • Make sure to arrive at least 30-60 minutes before the first scheduled patient
  • Look over the schedule to get a sense of the day, who’s coming, who may need extra time, any new patients
  • Double-checking that rooms are re-stocked with key supplies (ie, three paps on the schedule; wasn’t the speculum drawer low the other day? Couple of well baby visits; enough needles for all their shots? Better top up the bin from the supply closet.)
  • Looking over the charts (now electronically; previously the paper ones — adding pages, seeing whose insurance info needs updating, etc.)
  • Go over all the above with staff whenever they arrive (usually after me)

I’ve always just called it “getting ready for the day,” an organizational strategy for business management that’s called “being prepared” in most other occupations. But now it has a new name: the Huddle. Complete with instructional videos, for chrissakes.

As far as “patient-centered-ness” goes, I’ve used a somewhat different set of concepts from Day One called “Customer Service”. Having people instead of machines answering the phone, same-day appointments, personally communicating test results; all Disney-level customer service, now re-named things like “Open Access”, have been integral to my practice from the git-go.

Why is it happening? One of the oldest reasons in the world, of course: money to be made. I’m sure there are too many doctors and medical practices out there who, sadly, need this kind of help. Sadder still, they have to be force-fed it under the guise of running a “more efficient” practice.

Whatever happened to good old common sense? Next thing you know they’ll be all over us making sure we wash our hands. (Joke intended.) Seriously, though. This whole thing about co-opting perfectly sensible things from other industries for medicine — checklists, for example — and carrying on as if having re-invented the wheel is getting old.

Requiem for the CLASS Act

On Friday, the stepchild of health reform died at the hands of the Obama administration, and the obits for the troubled long-term care program were mostly similar recitations of why the administration was not going forward to implement that portion of the Affordable Care Act, how it was part of Ted Kennedy’s legacy, and how gleeful Republicans were at its demise.

The media amply quoted Senators Mitch McConnell of Kentucky and John Thune of South Dakota. Thune’s quote in The New York Times, “the Obama administration ignored repeated warnings about the financial solvency of this massive new entitlement,” gives a flavor of what they said.

The CLASS Act, short for the Community Living Assistance Services and Support Act, was a voluntary program where people could join a government plan to pre-fund some of the long-term care they might need in the future. Under the plan they would pay premiums during their working years. If they later became disabled and needed assistance, they would be entitled to a daily cash benefit of say, $50, that they could use to buy services such as a personal care attendant, home improvements that would let them stay in their house, or even to help pay nursing home costs.

Supporters saw the CLASS Act as a first step toward a national long-term care insurance program like those in other countries. Whatever its technical flaws, supporters argued that it would begin to solve the dilemma millions of families face—how to pay for a loved one’s care. Many politicians and the insurance industry weren’t keen on that idea since it could also be a first step to a publicly-financed insurance program (anathema to insurance sellers) and might cut into the market for long-term insurance, a product that has never really become a big seller primarily because of its high cost. The CLASS Act barely made it into the final bill.

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A SOCIAL Approach to Health Reform

Every Sunday, I read the Sunday NYT in search of ideas for a blog. Today is no exception. I found the idea in Thomas Friedman’s column, “The New IT Revolution,” in which he holds forth as follows,

“The latest phase in the IT revolution is being driven by the convergence of social media- Facebook, Twitter, LinkedIn, Groupon, Zynga- with the proliferation of cheap wireless connectivity and Web-enabled smart phones and “the cloud” – those enormous server farms that hold and constantly update thousands of software applications, which are then downloaded (as if from a cloud) to make them into incredibly powerful devices that can perform myriad tasks.”

The SOCIAL Acronym

Friedman then goes on to quote Marc Benioff, founder of Salesforce.com, who describes this phase of the IT revolution with the acronym SOCIAL.

S is for Speed – This means physicians and patients can find anything and everything about health care (and each other),

. O is for Open – This means physicians are out in the open and can no longer hide their results or reputation.

C is for Collaboration – This means physicians must organize among themselves or affiliated hospitals or into loosely coupled teams to take on the new challenges posed by society in general and health reform in particular.

I is for Individuals – This means anyone – physicians, patients, and entreprenuers – as individuals can reach around the globe to start something or collaborate or consolidate to improve care – faster, deeper, and cheaper – as individuals.

A is for Alignment – physicians with each other or with supportive health organizations to make sure all your ships are sailing in the same direction.

• L is for Leadership – This means physician leaders are going to have to mixs top-down and bottom-up forces – from public and private sectors – to provide what is best for themselves, patients, and society.

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How AARP Can Help, Not Harm

In a recent political ad, AARP rejects all attempts to cut Medicare and Social Security as part of a plan to reduce the deficit. But rather than support this losing position, the organization could help work out a plan for benefit cuts that is fair to all.

Two recent news items caught my attention, both of which left me wondering what the originators of them could have in mind. One of them was the announcement that Prime Minister Papendreou was calling a national referendum on whether Greece should accept the harsh conditions laid down by the other E.U. nations to deal with that country’s debt problem. The other was a political ad by the AARP calling for a rejection of any cuts to the Medicare and Social Security programs, as part of the U.S. deficit/debt crisis.

They both raised a similar question in my mind: was this a crafty move on their part, knowing they will lose, to simply strengthen their negotiating position? Mr. Papandreou surely knows from the recent Greek riots that a referendum is likely to come out against the E.U, just as the AARP must know that Medicare must be cut, an unpopular move or not.

I will leave the divining of Mr. Panandreou’s motives to E.U. savants, and focus on the AARP. Its leaders can read the papers and economic forecasts as well as anyone else, so what are they up to? To be sure, no government program threatened with a loss of money is happy about that: the common response is to point out all the harms that will result, most of them probably accurate. They then rally supporters, asking them to protest, to write to their congressman, and to rally their constituents to stand firm.

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Cold Hard Facts or Cold Hard Doctors?

I was first diagnosed with leukemia while travelling on a vacation in 1994. I had a persistent respiratory infection so I went to a local emergency room to get an antibiotic. I had the usual tests, including a blood test. A doctor came into the room where I was waiting and introduced himself as an oncologist. He told me that the blood test showed that I had “a terminal and incurable form of leukemia” and “less than five years to live.” Just like that. He also added that I didn’t need to rush back to New York, as there was nothing to be done.

A few months later, I sat in an office in New York of an oncologist who specialized in my form of leukemia. His manner was soft-spoken and warm. He told me that although there was no cure for my disease, there were a number of relatively mild chemotherapies that were effective in extending patients’ lives for many years, and that given developments in research, during the additional time there may well be a cure for my illness.

It turns out that the second doctor was correct. Five years after being diagnosed, bone marrow transplants became available for people my age with chronic leukemia. I had a transplant and a few years after that there was no longer any sign of the disease.

When I inquired with physician friends about my experience with the first doctor, they spoke of doctors’ fear of instilling in patients “false hope.” In my interactions with many cancer patients, I have yet to hear of any patient who felt they were given false hope. But there were many instances of patients, like myself, who were filled with “false despair.”

Now, I can’t imagine how difficult it must be to be an oncologist, to have to tell patients that they have a terminal illness, to see them go through brutal chemotherapies, to see them die. According to one estimate, during the course of their career, an oncologist will break bad news to their patients almost 20,000 times – from first diagnosis to the news that death is near. Yet, many doctors who approach this task in a cold-hearted manner seem to justify themselves with a “tell it like it is” philosophy. Easy for them, devastating for us.

Medical science readily acknowledges the placebo effect – that many patients who believe they are getting an effective medicine show improvement in their condition even when they are in fact not getting the medicine, but are instead receiving a harmless substitute. If the effect of a patient’s positive expectations can so profoundly affect his health, what then is the impact when a patient is, from the outset, given the difficult news about having cancer in a manner that so discourages his spirit?

Most lay people know the fundamental maxim of Hippocrates to physicians throughout the centuries: “First, do no harm.” This has always been understood to have to do with the medicines and treatments that physicians prescribe. In this day and age it applies equally to how doctors talk to and act toward their patients.

Andrew Robinson was a successful New York trial attorney when he was diagnosed with leukemia and told he had less than five years to live. That was more than 15 years ago. He is the founder and CEO of Patient2Patient, a company that develops disease specific guides to help patients learn how to locate and use medical information and resources on the Internet. This post first appeared at Prepared Patient Forum.

New Physicians, Rethink Your Career Path Before Your First Job

I recently came across an online discussion started by a graduating resident who was looking for advice on how to combat burnout. While the replies that followed offered all sorts of ideas, everyone seemed to agree that a rigorous schedule and stress and strain on work-life balance is par for the course.

Somebody even quipped that when practicing medicine, you can enjoy two of the following in any combination: 1) live where you want; 2) earn what you want; and 3) specialize in what you want, but it’s not possible to enjoy all three.

While many physicians would agree with that belief, I’d like to suggest considering locum tenens – this option proves that enjoying all three is possible.

Locum tenens is a highly respected practice alternative that offers physicians a full spectrum of professional opportunities in every type of practice across the country. Hospitals and healthcare facilities use locum tenens to cover for planned or sudden staff vacancies, and to strategically prepare for the highs and lows of patient demand. It’s become an especially attractive alternative for new physicians; among other things, it offers the opportunity to:

·         Gain real-world experience and build skill set

·         “Road test” different practice settings, options and locations so you can make informed decisions about which is right for you

·         Get an insider’s view of practice management and economics

·         Enjoy a flexible schedule so you can take time off to travel or pursue interests outside of medicine

·         Fill in the gap between residency and fellowship

·         Pay off medical school loans before making more financial commitments

·         Spend more time practicing medicine and forgo the politics

Don’t gamble with your career

Practicing medicine as a locum tenens buys you time to find your dream job while building up your CV. By working at a variety of practice models, you are demonstrating the ability to adapt to all different practice settings which can give you an edge over competing job candidates when the time is right.

If locum tenens interests you, it’s well worth your time to research healthcare staffing firms to help you find and prepare for job opportunities. Key considerations should include the company’s breadth of resources and contacts, as well as its reputation for integrity and customer service. Of course, pay is important but it’s only part of the picture; you want to be covered from travel and housing to licensure, credentialing and malpractice. A good resource to help you get started is the National Association of Locum Tenens Organizations (NALTO), an industry organization that ensures the fair practices and collaboration of physician staffing organizations.

Locum tenens is a career choice that puts new physicians in the driver’s seat. The work-life balance that eluded your predecessors is now within your reach—yes, you can have it all!

Melissa Byington is president of the locum tenens division of CompHealth, the nation’s leading provider of temporary and permanent physician staffing. She is also a current board member and past president of NALTO.

Violence in the Media Does Matter

“A thousand studies over the past 40 years have shown that viewing violence in the media changes children’s behavior,” said Michael Rich, MD, Associate Professor of Pediatrics, Harvard Medical School aka the Mediatrician.

Dr. Rich who founded and serves as the Director of the Center on Media and Child Health at Children’s Hospital, Boston reports that viewing violence in the media causes:
1) increased feelings of fear and anxiety in the viewer,
2) desensitizes the viewer, particularly to conflict resolution methods other than violence, and
3) increases the aggressive behavior of the viewer.

A compelling demonstration of the latter was a video taken by hidden camera of toddlers dancing, singing, and shaking maracas after watching a Barney cartoon, and the same toddlers doing karate kicks and tackles on each other after watching a Power Rangers cartoon. (Yes, the girls too.)

Other tidbits that may comfort, or not, us parents and grandparents who wonder about the opportunities and pitfalls of current electronic media include:

1)    NO significant learning occurs from viewing a screen until the child is 30 months old. Baby Einstein videos are entertaining, amusing, and hold the child’s attention, but the child under 2 ½ is NOT getting an academic head start on KG. The American Academy of Pediatrics recommends no TV viewing under the age of 2 years., primarily because it substitutes for “more interactive activities that promote brain development”; ie. free play and social interactions.

2)    53% of 2-4 year olds use computers. 39% of 2-4 year olds have Apps and know how to use them on smartphones and iPads.

3)    The reason that the kids are so much better at operating the iPads, iPhones, and other smartphones is that these devices are designed to be intuitive. Our adult knowledge retards our intuition. The kids, not burdened with pre-conceived frameworks, enjoy a much faster learning curve. On the downside, the fact that my grandchildren can learn to use these devices so quickly is because the software is designed to be very intuitive and NOT because my offspring are “above average.”  Dr. Rich calls kids “Digital Natives” while we adults are “Digital Immigrants.”

4)    After 3 years of age ALL media is educational. Studies show that toddlers learn commercial logos, retain the image, and are able to identify them in another context; ie. the grocery store or restaurant.

5)    Sesame Street viewing between the ages of 3 and 5 is associated with better school performance and social skills compared to children who did not watch Sesame Street. The differences persist to the age of 17. One of the problems now is that the current demographic of Sesame Street viewers is from 18 months to 3 years of age.

6)    47% of 5-8 year olds have a TV in their bedroom. Studies show that the TV reduces the quantity and quality (flashing lights and changing sounds puts the sleeper “on alert”) of sleep and apparently doubles the risk of developing obesity.

What happens as the kids get older?

1)    The average use of electronic media by children ages 8-18 yrs is 7 ½ hours per day, and that study was done before the cell phone “explosion”.

2)    The average number of text messages for high school kids is 300-500 per DAY. Those messages have got to be short like “LOL”, “DIY”, or “PRW” , but they count as messages.

3)    Vewing sexual content in the media advances the first sexual experience by about 2 years.

4)    58% of high school kids who have experienced electronic cyberbullying have NOT revealed it to their parents because “they wouldn’t understand how it all works.”

5)    85% of teenagers take their cell phone to bed at night. They are never “not connected”. “You never know what people might be texting about you.”

What can you do?

Dr. Rich has some very “simple” and practical recommendations:

1)    Remove your child’s computer from his/her room and put it on the dining room table because it is now in a “public place” and the child will self-monitor his/her own use.

2)    Move the computers from the dining room table once each day and have a family meal, the single most important influence on children for learning good role models and avoidance of high-risk behavior.

3)    If you don’t want your child to use his/her device during meals or family gatherings PUT YOURS DOWN. “Kids hear about 1% of what we say, but see 100% of what we do.”

4)    Take the TV out of his/her bedroom, and set the rule that all cell phones rest (recharge) in the kitchen overnight.

5)    Increase free play outdoors. Being “Huck Finn with mud between his toes” may better prepare your child for successful problem solving in the modern world than time at video games. (Unless your child aspires to be an Israeli tank driver or a U.S. drone controller.)

Reference:
1) PriMed Continuing Medical Education Conference, Boston, October 29, 2011

Look Outside Hospital Walls to Collaborate, Improve Health

A recent trip to Denmark to speak at an IT conference reminded me how important it is for hospital executives to remember Joy’s Law. Bill Joy famously observed “No matter what business you’re in, most of the smart people work for someone else.” There should be a corollary that states “No matter what industry you’re in, you can learn a lot from people in other fields.”

If you take Joy’s Law seriously you start to think beyond the boundaries of your hospital system and realize there is much to learn and borrow from others. Don Tapscott and Anthony D. Williams in “Wikinomics” (New York: Penguin, 2008) describe how cutting-edge companies outside of healthcare are benefiting from mass collaboration made possible by digital tools.

Procter & Gamble has made “proudly found elsewhere” a mantra for the consumer products company that has a goal of sourcing 50 percent of its new products and service ideas from outside the company. Successful products such as Olay Regenerist, Swiffer Dusters, and Crest Spin-Brush are some of the hundreds of products P&G found by connecting with scientists and engineers who do not work for P&G.

Tapscott and Willams open their book with the Goldcorp Challenge, where a Canadian mining company offered $575,000 in prize money to anyone in the world who could identify targets to mine from analyzing the 400 megabytes of the company’s proprietary data about their 55,000 acres of land. The geologists, graduate students, consultants, mathematicians, and military officers who responded to the challenge identified 110 targets (50 percent of which had not been identified by the mining company) and 80 percent of the new targets yielded substantial quantities of gold.

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Don Berwick, Martyr for Socialized Medicine

I have a piece up at National Review in which I reflect upon Don Berwick’s controversial tenure as Administrator of the Centers for Medicare and Medicaid Services, the 800-billion-dollar federal agency that dominates the American health-care landscape. Despite White House rhetoric to the contrary, I write, Berwick “wasn’t done in by Republican intransigence. He was done in by presidential cowardice. And therein lies a microcosm of everything that’s been wrong with Obamacare.”

The thing to understand about Don Berwick is that there are really two Don Berwicks. There’s the Don Berwick who, through the Institute for Healthcare Improvement, has focused on apolitical aspects of health delivery reform. Here’s what I wrote about Berwick in April 2010:

First, the good. Berwick is a serious and credible health-care analyst. In his capacities both as a Harvard professor and as founder and CEO of a Cambridge-based think-tank called the Institute for Healthcare Improvement, he has written extensively about health-care policy in all of the leading scholarly journals. His focus, in most of these writings, is on the quality and efficiency of health care: things like avoiding medical errors and unnecessary spending. He was granted an honorary knighthood by Queen Elizabeth for his role in shaping Tony Blair’s (mostly futile) attempts to modernize Britain’s National Health Service.

While he was a big supporter of Obamacare, Sir Donald acknowledges its core failing; in an October lecture, he said, “Health-care reform without attention to the nature and nurture of health care as a system is doomed. It will at best simply feed the beast, pouring precious resources into the overdevelopment of parts and never attending to the whole — that is, care as our patients, their families, and their communities experience it.” Indeed, if you put Berwick in a room with a leading market-oriented health-care analyst, the two would find broad areas of agreement as to where our health-care system fails patients.

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