Monday, September 15, 2014

Turning Turtle -- Is this how doctors are socialized?

Here's another short excerpt from a draft of a book--Turning Turtle--being written by my friend and colleague.  As I described below, Samuel Jay Keyser--Professor of Linguistics (Emeritus) at MIT--suffered from a debilitating fall that left him severely injured and experiencing the health care system in a way he could have never imagined.  This moment takes place after his second surgery for spinal cord injuries. 

One day a solo doctor came into the room, introduced himself, and without much preamble told me that while the operation was a success, I probably would never walk again. 

“Fuck you,” I said to myself.

To him, I said, “I’m sorry to hear that.”

“I know it isn’t what you want to hear,” he said in a consoling way. “But it’s best to be realistic in situations like yours.” 

I wonder why he felt the need to be “realistic.” Perhaps it was his way of defending himself from becoming too close to a patient.

I learned later that the nurse on duty had overheard the conversation and had given him hell when he left the room. Much later in my hospital stay, he exchanged his severe demeanor for one with an engaging smile. I wonder if the nurse’s dressing down had changed him. I wonder if that’s how doctors are socialized on the job.

Sunday, September 14, 2014

Turning Turtle -- Tribute to the EMTs

My friend and colleague Samuel Jay Keyser--Professor of Linguistics (Emeritus) at MIT--writes of a recent incident that left him severely injured and experiencing the health care system in a way he could have never imagined. He's in the midst of writing about the events and was kind to share a draft of his first chapter of a forthcoming book--Turning Turtle--with several of us.  He gave me permission to provide you with excerpts.  There are many themes even in this first chapter, but I thought you'd enjoy the one presented here.

I was like a turtle that some malicious child had turned.  My hands felt like flippers. They were slapping me in the face.  I couldn’t recognize them as belonging to me. Thank goodness Nancy was at home.  Or maybe I would’ve died. Maybe that would have been the best thing to have happened. But it didn’t. Instead Nancy came running.

She saw me floundering at the foot of the stairs where I had fallen in a disastrous attempt to exercise. I was trying to stretch my left leg. I lifted it toward the fourth step. Suddenly my right leg collapsed under me. I fell flat on my back.

"Don’t panic! Don’t panic!” Nancy said in a panicked tone of voice as she frantically dialed 911. In a matter of moments I heard a siren come to a high-pitched halt outside our house. Six black-clothed, heavy-booted first responders came stampeding up the stairs. The one in charge leaned over me. His face hovered above mine like a harvest moon.

“Can you hear me?” he bellowed.

“Yes,” I said.

“Good! Don’t move a muscle,” he commanded.

He said something to his partner. She disappeared and returned with what looked like a large valise. I heard it click open. Then some clanging of metal parts against one another. The next thing I knew my head was being screwed in place with something that felt like a vice. Nancy said the contraption made me look like Frankenstein’s monster.

They placed me on a stretcher. Although I could feel my body tipping from side to side as they navigated the landing and down the stairs, my head remained absolutely fixed. It was April 26, 2014. I was surprised at how cold the outside air felt. I heard the back of an ambulance open. The stretcher slid inside. Someone got in with me. Someone else slammed the doors shut. The ambulance started to move. I listened for the siren. I couldn’t hear it. All I could hear were noises from a game someone was playing on a cell phone. I remember staring at the ceiling wondering why the lights were so bright. Such small thoughts for so large an event. I couldn’t focus on the big picture – that is, that I might be dying and that these were my very last moments on earth, that I might never see Nancy or my children again. I concentrated on the ambulance’s suspension. The vehicle dipped and rocked at every pothole. I thought about the suspension on hearses. They were surely better than this. How odd that a vehicle carrying the living was badly sprung while a vehicle carrying the dead was not.

[After a couple of days, it was time for surgery:]

What “going under the knife” meant for me was 13 hours in the operating room. Divided into two operations weeks apart, the first lasted 9.5 hours, the second, 3.5. The condition I had was quite rare. In fact I never knew I had it. In a nutshell, my spinal column has aged faster than my body. This means that it is riddled with bone spurs. When I took the fall, the bone spurs at the top of the column hammered into my cord like tiny little hatchets. To make matters worse, my spinal column is abnormally narrow. A normal spinal column is about 15mm in diameter. Mine is about 7 or 8mm.

One doctor's report put it this way:

Patient has diffuse idiopathic spinal hypertrophy/DISH, leading to cervical stenosis, or narrowing of the cervical spinal column. Due to this, there was no room for the cord to move. This combined with minimal shock absorption from the CSF (cerebrospinal fluid) led to a cervical spinal cord injury.

After 33 days in MGH it was time for me to move on. That meant a six-week stay in a rehab hospital. I was wheeled on a stretcher to the loading dock.

“Aren’t you the driver who brought me here a month ago?” I asked. I won’t ever forget the face that hung over me like a harvest moon yelling, “Don’t move a muscle.”

“How are you doing?” he asked, nodding.

“Pretty well, considering,” I said. “These guys saved my life.”

“No, they didn’t,” he objected. “We did.”

“I don’t understand,” I said.

“When I saw you lying on the floor,” he explained, “I could tell from the angle of your head that you had suffered a spinal cord injury. If we hadn’t put your head in a vise, you wouldn’t be here now.”

He was right, of course. Had my head and spine not been frozen in place, those potholes en route to MGH would have chopped my spine into coleslaw. Even so, it strikes me as odd that the villagers who saved my life – the surgeons and the first responders – have never met one another.

Saturday, September 13, 2014

A terrible burden imposed on doctors

Please take a look at this short video from Danielle Ofri, author of What Doctors Feel.

A perceptive quote from her:

"As doctors, if we fail, it’s not something outside of us; it is us. We are the error. The shame is so powerful that most doctors will never come forward about an error. I think the socialization of doctors makes it extremely hard for us to admit a mistake. We tend to pick perfectionists as medical students, knowing that the medical system is not for the faint of heart. Then they’re trained to be perfectionist doctors. There’s no place for a 'good enough" doctor. You’re either excellent or terrible."

This is a awful burden, one reinforced by the medical education process, especially during many residency programs.  I wonder how to get those involved in medical education to understand that this attitude contributes to patient harm.

Thanks to Gene Lindsey for pointing out the article and video.  He also sends us to view some thoughts from Justin Locke, author of Principles of Applied Stupidity:

We all are imperfect of course, but our society is intolerant of such things, and demands that we conceal it. Doctors are under particular cultural pressure to “be perfect.” But when it comes to medical error, shame energy can actually blind the mind to reality. The ongoing pretense that we “don’t make mistakes” is a leading cause of why the mistakes we make don’t get acknowledged, much less fixed.

Our immersion in what I call “smartism” starts early and is taught systematically. We attach enormous shame (i.e., inner-directed personal loathing of self) to failing tests in school, and enormous pressure to get into Harvard. This is a flawed system. There is no big victory for the “A” students; they start to think that their social acceptance is based solely on superstar performance, and they become fractured spirits, becoming human doings instead of human beings. Instead of a sense of social teamwork, shame energy, i.e., our intolerance of the reality of our imperfections, puts us in an unwinnable bitter battle to always be better than someone else. No matter how well you do in such a battle, you lose, for in the end, you do not have community acceptance, the glorious opposite of the dark energy of shame.

Friday, September 12, 2014

A son's legacy

Here's a short video featuring Patty Skolnik in which she explains how the tragic death of her son led to her engagement in helping clinicians learn how to help patients and families be more properly involved in making informed medical decisions.

Thursday, September 11, 2014

Experts file in Court: The proposed AG-PHS settlement is flawed

Following my earlier post about comments from an FTC official, please see a bit more on the proposed agreement between the Massachusetts Attorney General and Partners Healthcare System--in the form of a filing with the Court from the American Antitrust Institute.  AAI is an independent and non-profit national research, education and advocacy organization devoted to advancing the role of competition in the economy, protecting consumers, and sustaining the vitality of the antitrust laws.  The filing also includes an expert report from Professor John Kwoka of Northeastern University outlining the deficiencies in the settlement and explaining why it should be rejected.

This is powerful stuff and again suggests that both the Democratic and Republican candidates for Attorney General should ask the current AG to withdraw her proposal from the Court and leave future action on this issue to her successor--someone who will assemble an approach that fully addresses the documented anticompetitive practices of this player in the Massachusetts healthcare market.

The introduction:

AAI has an interest in this matter not only because it will affect consumers in a large and important health care market, but because Massachusetts’ national leadership in health care innovation and regulation, as well in as antitrust enforcement, could make the settlement an unfortunate precedent for resolution of anticompetitive hospital mergers by other states. As we shall explain, the proposed remedy is not in the public interest because it will likely fail to restore competition lost as a result of the acquisitions by Partners Health Care Systems, Inc. (“Partners”) of South Shore Health and Educational Corporation (“South Shore”) and Hallmark Health Corporation (“Hallmark”), and it will embroil the Attorney General’s Office and the court in extensive regulatory oversight for which they are ill suited. Therefore, it should be rejected.

(We address the Proposed Final Judgment filed on June 24, 2014. While the Attorney General and Partners are apparently renegotiating the Hallmark aspects of the deal in light of the recent objections by the Massachusetts Health Policy Commission (“HPC”), and this could resolve some of our concerns about the details of the settlement, our fundamental concerns about the effectiveness of using a regulatory decree to resolve anticompetitive horizontal mergers undoubtedly will remain.)

The major points (with my emphasis):

If litigated the Mass AG would have prevailed in court and the merger would have been enjoined.

--Conduct remedies are clearly inferior to blocking an anticompetitive merger or other structural relief, and are typically unsuccessful.  Antitrust enforcers and courts lack the expertise and institutional capability to adequately regulate firms with market power, and to counteract the firms’ natural incentives to exploit it.  Accordingly, the federal enforcement agencies and courts have consistently rejected these types of conduct remedies in hospital and other mergers between direct competitors.  And where remedies like these have been used in the past they have failed.

The proposed settlement is generally flawed for several reasons:
--The settlement is time limited and does nothing to alter Partners’ increase in market power resulting from the mergers.  Accordingly, prices can be expected to rise once the price caps are removed, as has been the case in the few other instances where caps have been tried.
--The settlement is highly complex and technical, with numerous ambiguities that will likely require extensive and continuing court involvement to resolve.  The proposed independent monitor will be helpful, but administering the regulatory decree will still require significant judicial resources.
--Conduct remedies are particularly problematic where, as here, the product is highly complex, the market is undergoing significant changes, and enforcement depends on parties in long-term business relationships with the enjoined firm (here, payers) willing to complain when violations occur.

The major elements of the proposed remedy are inadequate to protect consumers from the loss of competition.  Where they have been used in the past they have failed.  Besides the fact that they are time limited, the price caps are flawed because:
--The price caps are limited in scope, with the total medical expenditure (TME) cap covering only 11% of Partners’ commercial business.  Moreover, the caps do not cover quasi-private plans such as Medicaid Managed Care and Medicare Advantage.
 --The proposed price regulation would be difficult to administer—even by a regulatory agency, much less a court—and fails to take into account important considerations, such as how to deal with changes in the scope and types of services.
--The price caps may be ineffective insofar as prices, absent the mergers, would increase by less than the general inflation or medical inflation in the index used in the settlement.
--The price caps do nothing to address the potential diminution in quality competition, and perversely provide incentives to reduce quality.
--If the price caps are exceeded in any year, ultimate health care or insurance consumers may not benefit from the refund mechanism.
--To the extent it is relevant, the price caps do nothing about Partners’ existing supra-competitive pricing and rate advantage over other providers

Besides being time limited, the component contracting provision is flawed because:
--Component contracting will do little or nothing to alter Partners’ ability and incentives to increase prices post-merger.
--The settlement does not provide sufficient protection from actions Partners could take to make component contracting unattractive to payers, such as offering pricing differentials for bundled and non-bundled components and engaging in subtle forms of retaliation against payers that seek to take advantage of the unbundling option.
--There are reasons to be skeptical that payers and consumers will find it attractive to utilize component contracting and when utilized Partners’ physicians can still seek to steer consumers to out of network Partners’ providers.
--Component contracting works at cross purposes with the purported efficiency justification of the mergers, namely the deep integration of South Shore and Hallmark into the Partners’ network.

Once competition is gone, it's gone

Here's something for the two Attorney General candidates in Massachusetts to ponder, some recent statements from Martin Gaynor, the director of the Bureau of Economics at the FTC.  As reported in Politico, he notes:

“The ACA and all other reforms in health care system are built on top of the market-based system” and “will only work as well as those markets.”

“Layered on top of many markets that are dominated by a small number of very large systems, it can be a concern so it’s something we pay very close attention to,” Gaynor said.

Barak Richman, a Duke University law professor, said there was “very little evidence” that consolidation had “provided any efficiencies at all.”

“Barak is right,” Gaynor said. “We’ve had mergers for a very long time. There are a lot of data, and we’ve seen almost no evidence of real efficiency claims. That doesn’t mean it won’t happen, but the most recent evidence doesn’t support those claims.”

Such deals have to be reviewed and if necessary fought before they happen because they are very hard to unwind once they’re completed, he said.

“Once competition is gone — to paraphrase Bruce Springsteen — it’s gone and it ain’t coming back,” Gaynor said.

Does either of these candidates have the guts to ask the current AG to withdraw her pending deal with Partners Healthcare System and let the next AG take a fresh look at the case?

It Ain't Necessarily So

There's an elegant article at Medscape by Christopher Labos called "It Ain't Necessarily So: Why Much of the Medical Literature Is Wrong." Key points:

Given a statistical association between X and Y, most people make the assumption that X caused Y. However, we can easily come up with 5 other scenarios to explain the same situation.

1. Reverse Causality

Given the association between X and Y, it is actually equally likely that Y caused X as it is that X caused Y.

2. The Play of Chance and the DICE Miracle

Whenever a study finds an association between 2 variables, X and Y, there is always the possibility that the association was simply the result of random chance.

The Frequency of False Positives

It is sometimes humbling and fairly disquieting to think that chance can play such a large role in the results of our analyses.

3. Bias: Coffee, Cellphones, and Chocolate

Bias occurs when there is no real association between X and Y, but one is manufactured because of the way we conducted our study.

4. Confounding

Confounding, unlike bias, occurs when there really is an association between X and Y, but the magnitude of that association is influenced by a third variable. 

Real-World Randomization

Confounding can be dealt with through randomization. When study subjects are randomly allocated to one group or another purely by chance, any confounders (even unknown confounders) should be equally present in both the study and control group. However, that assumes that randomization was handled correctly.

5. Exaggerated Risk

Finally, let us make the unlikely assumption that we have a trial where nothing went wrong, and we are free of all of the problems discussed above. The greatest danger lies in our misinterpretation of the findings.

Wednesday, September 10, 2014

Robots around Le Monde

I present this view from France courtesy of patient safety and quality expert Michael Millenson, who saw a copy of Le Monde while in Europe.  Rough translation:  Robotic Surgeons: Stop the Fraud!  The article is by Professor Abdel Rahm√®ne Azzouzi, Chief of Urology of the University Hospital of Angers.

Here are Google-assisted translations of some key excerpts:

For over ten years now, proponents of robotic surgery bombard shameless untruths about the value of surgical robots in their field. As Ezekiel J. Emanuel said, a former adviser on health to the White House and a columnist for the New York Times, this pseudo-innovation increases costs without improving quality of care (New York Times, May 27, 2012 ).  

Given the lack of evidence of the superiority of robotic techniques in the prostate removal surgery, how can we not question the inertia of regional health agencies (ARS), the Council of the College of Physicians and the French Association of Urology, who prefer not to offend, for reasons that escape us, the holders of an innovation with questionable benefit to the patient.  

The overly commercial strategy of Intuitive Surgical - the monopoly on this robotic technology with its model Da Vinci - is shocking in health care and particularly affecting patients with cancer.

In its approach to its surgeon customers, it is only a question of increasing the number of cases for surgery by attracting psychologically fragile patients at the announcement of their disease and touting their results they do not have scientific proof. In other words, if the Da Vinci robot was a drug, it would never have obtained authorization to market.

For their part, supporters of the robot, having invested in the order of 2 to 2.5 million euros to acquire this surgical tool, betting on a return on investment by increasing the number of procedures, which in the case cancer localized prostate would increase the stock of patients operated incorrectly or prematurely. This irresponsible move strengthens the opponents of screening for prostate cancer, and delay the quality of the management of the disease. 

A Republican practice of medicine as expected in France must ensure that patients' interests and those of the community are always higher than the activity of so-called "expert" centers, in terms of fame and financial benefits .

Given the lack of rigorous evaluation today and to better protect patients from a natural attraction to new technologies, our advice to all patients who are diagnosed with prostate cancer . . . is to be vigilant before a proposal to remove the prostate, especially in centers with a robot, and to ensure that all available treatment options has been offered to them.

In other words and as stipulated in Article 35 of the Code of Public Health, the physician must provide clear and honest information, and provide proper care to his patients.

Therapeutic innovation, when it is real, is essential to the evolution of medical practice, but it is only if it is dedicated to the patient, and not to those who support it or to manufacturers who are at the origin.

No more treading water, on WIHI

Madge Kaplan notes:

Hi there,
The next WIHI broadcast — Tread Water No More! Making Sense of Patient Experience Data — will take place on Thursday, September 11, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:
  • Kevin Little, PhD, Improvement Advisor, Institute for Healthcare Improvement (IHI); Principal, Informing Ecological Design, LLC
  • Kristine KS White, RN, BSN, MBA, Faculty, IHI; Principal, Aerate Consulting; Co-founder, Aefina Partners, LLC
  • Kathy Klock, Senior Vice President, Human Resources & Clinical Support Services, Gundersen Health System
  • James Bonner, LMSW, Director of Patient Experience, Spectrum Health
Enroll Now
Have you been poring over some patient survey or patient experience data lately? Chances are good you have. How did you make sense of what you saw? What actions are you taking as a result of what you learned? Not sure? Unclear what to make of the information or what to do with it? You are not alone! In fact, as the ways to learn about how patients experience their care and their caregivers have grown, so has the confusion about how to interpret the data and how to make the best use of it.

That’s why we’ve invited Kris White and Kevin Little to head up our panel on the September 11, 2014, WIHI: Tread Water No More! Making Sense of Patient Experience Data. The two are determined to pull you out of whatever morass of patient-generated information you might be drowning in. Proof positive that it’s possible will be provided by Kathy Klock from Gundersen Health System and James Bonner from Spectrum Health. 

Kris and Kevin have put together a terrific set of guiding principles for appreciating and distinguishing among a wide range of methods health care organizations are using to learn more about and from patients. They’ll discuss everything from patient surveys, to focus groups, to patient and family advisory councils, to patient letters and complaints. When looked at in combination with staff surveys, patient safety metrics, rounding observations, and other organizational performance data, a comprehensive picture can emerge.
We hope you’ll add your ideas to the ones you’re sure to learn about on the September 11 WIHI. You can enroll for the broadcast here.

Tuesday, September 09, 2014

Thanks, Don

The votes are in, and Don Berwick did not succeed in his quest to obtain the Democratic nomination for Governor.  While this is surely a disappointment to Don, his family, and his many supporters, the primary election process has nonetheless been good for the Commonwealth of Massachusetts.

Don's campaign was a principled one--stressing substantive themes in a variety of policy arenas.  He did not duck hard issues: He straightforwardly set forth his positions, supported by logic, reason, and passion.

His demeanor was consistently professional, friendly, and good humored.  While he was direct in disagreeing with his rivals, his approach was civil, never stooping to ad hominem attacks.

In choosing to run from the position of private citizen, Don had the courage to offer himself and his family to the blood sport that is Massachusetts politics, exposing his views, his vulnerabilities, and his private life to the magnifying glass of traditional and social media.  That kind of decision takes courage, undergirded by a commitment to the public good.

By example, then, Don provided us with a refreshing civics lesson.  It is no surprise that he became a Pied Piper of sorts for many young people looking for a political cause.  Hundreds of people in their 20's and 30's joined in helping in the campaign offices and in the field, adding enthusiasm and zest to the political process.  Many of those young people will choose to be active in future political activities, for the good of us all.

So, thanks, Don.  Your campaign--like the rest of your distinguished career--leaves behind a legacy of strength and goodness for the people of the Commonwealth.

Must things be the way they are?

Something to think about as you make your election day choices.  Which candidates are most likely to ask why things must be the way they are?

Refusing to be intimidated by the received traditions and confident of their own integrity and creative capacities, the Founders demanded to know why things must be the way they are; and they had the imagination, energy, and moral stature to conceive of something closer to the grain of everyday reality, and more likely to lead to human happiness.[W]e have the obligation, as inheritors of their success, to view every establishment critically, to remain in some sense on the margins, and forever to ask why things must be the way they are, knowing that it is never enough to say they must be so -- one needs to know why. -- Bernard Bailyn  (age 92 today)

Monday, September 08, 2014

The technology proliferation story that's not often told

Gary Schwitzer puts into perspective the issue surrounding the desire of Ashya King's family for the child to have proton beam therapy.  Excerpts:

In all of this, there is a golden opportunity to improve the public dialogue about new medical technology. Issues such as: how many such devices does one city, one region, one country, the world need?

Why does the US (with more than a dozen operating and more than a dozen in the works) have so many proton beam facilities?  Much of the proliferation – not all of it – is for reasons other than treating kids with difficult-to-treat brain cancer, where the evidence is strongest but where the number of cases is relatively small.  It’s to treat the prostate cancer cash cow, for a condition where the evidence is questionable.

That’s a part of the technology assessment, technology proliferation story that isn’t often told.  

So while the Ashya King story has many ugly angles, let’s not turn it into a story of the big, bad British health care system that doesn’t have any proton beam facilities up and operating for kids like this yet.  That angle – about allocation of limited resources – is a lot more complex.

How not to write a headline

Headline writing is an art and hard to do well.  Some headline writers, though, fall into the trap of just reading the lede and then presenting us with a misleading tag to the story.  Reporters usually have no say over the headline that is assigned to their stories.

You judge in this case.

The headline in this well written and informative Aaron Gregg Washington Post story is:

Companies race to adjust health-care benefits as Affordable Care Act takes hold 

The lede is:

Large businesses expect to pay between 4 and 5 percent more for health-care benefits for their employees in 2015 after making adjustments to their plans, according to employer surveys conducted this summer.


Few employers plan to stop providing benefits with the advent of federal health insurance mandates, as some once feared, but a third say they are considering cutting or reducing subsidies for employee family members, and the data suggest that employees are paying more each year in out-of-pocket health care expenses.

Bracing themselves for an excise tax on high-cost plans coming in 2018 under the Affordable Care Act, 81 percent of employers surveyed by Towers Watson said they plan to moderately or significantly alter health-care benefits to reduce their costs.

But wait.  Further into the story we learn:

Others see these changes as less of a result of the Affordable Care Act and more a response to the steadily increasing costs of health care. The expected increase of 4 to 5 percent from 2014 to 2015 is no greater than in previous years, but the continued pressure on businesses has forced a wave of cost-sharing innovation, giving employees what the industry calls more “consumer-directed” choices to make between the quality of care and the cost. 

“I think this in many ways has very little to do with the Affordable Care Act,” said Gail Wilensky, a senior fellow at Project Hope, a health-care advocacy and services group. “It started 10 to 12 years ago, and is being used by employers to try to get their employees to react in what they see as a more responsible way.”

So what should the headline say? Maybe this?

Companies feel pressure to adjust health-care benefits

Sunday, September 07, 2014

A Modern Hippocratic Oath

As we further consider the physician development and training issues in our society, it is illustrative to turn to the oath taken by doctors in training as they begin their careers.  Everyone knows of the Hippocratic Oath and its key theme--"Do no harm"--but there is a modern version of the doctors' oath that might be more reflective of current societal needs.

I learned of it after the Tufts University School of Medicine Class of 2018 White Coat Ceremony.  The medical students recited the oath during the ceremony, and then we asked our friend Katherine Spencer (seen above) to repeat it to us at a post-ceremony celebration.  Here it is:

A Modern Hippocratic Oath by Dr. Louis Lasagna

I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow;

I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science, and that warmth, sympathy and understanding may outweigh the surgeon's knife or the chemist's drug.

I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body, as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection hereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

After all, we are real doctors now.

Pranay Sinha zeroes in on some important physician training and developmental issues in an op-ed in last week's New York Times.  Some excerpts, with my emphases:

Interns are often bewildered at how rapidly things change for us from May to July. As medical students, while we felt compelled to work hard and excel, our shortfalls were met with reassurances: “It will all come in time.” But as soon as that M.D. is appended to our names in May, our self-expectations skyrocket, as if the conferral of the degree were an enchantment of infallibility. The internal pressure to excel is tremendous: After all, we are real doctors now.
In fact, very little about us changes, apart from our legal ability to prescribe medications. But meanwhile, our workload increases along with the expectations and demands we place on ourselves.

This drastic increase in responsibility can and does overwhelm most interns. Despite the support of my supervisors, my first two months were marked by severe fatigue, numerous clinical errors (that were promptly caught by my supervisors), a constant and haunting fear of hurting my patients and an inescapable sense of inadequacy.

We need to be able to voice these doubts and fears. We need to be able to talk about the sadness of that first death certificate we signed, the mortification at the first incorrect prescription we ordered, the embarrassment of not knowing an answer on rounds that a medical student knew. A medical culture that encourages us to share these vulnerabilities could help us realize that we are not alone and find comfort and increased connection with our peers. It could also make it easier for residents who are at risk to ask for help. And I believe it would make us all better doctors.

Compare this to the approach at our Telluride summer sessions, where we spend many hours helping medical students and residents deal with their fallibility--with an emphasis on better communication among clinicians and with patients and families, especially when errors or near-misses occur.  For most residents, this is more time that they have cumulatively spent on such topics than in all their years of medical school and post-graduate training.  Here's recent note from one of our alumni:

Just wanted to share a thank you letter that I received from a patient. I would like to emphasize that I took a lot away from Telluride and came in to internship headstrong to live up to the ideals presented. 

Here's are excerpts from the patient's letter:

From the very first time you came into Mom's room, and introduced yourself, your warmth and open manner immediately made us both feel comfortable and relaxed.  You took the time out of your busy day to sit and talk to me about Mom made me feel like she mattered to you as a person, not just the patient in room 458.

I personally appreciated your telling me to continue to advocate on behalf of my Mom.  You made it ok for me to ask questions.

I valued your detailed breakdown of my Mom's condition. While the news wasn't always uplifting I prefer the truth.

My Mom felt immediately comfortable with you . . . especially the way you explained things to her . . . often times in an analogy or your personal story.

We believe that a humanistic approach to medical education and residency training is better for doctors.  We also agree with Sinha that having such training and support for all would make us all better doctors.

Saturday, September 06, 2014

How paved roads came about

Most people don't realize that many of the first paved roads in New England came about as a result of political pressure from bicycle riders in the late 1800's, well before cars showed up. Here's a pertinent story of the rising interest in that mode. An excerpt:

Cycling was not without its detractors, who viewed the new machine as a menace and wanted it banned from parks and public roads. Realizing that the new sport needed advocates as well as promoters, [Albert] Pope organized the Wheelman Club to fight for cyclists' rights. Declaring American roads "the worst in the civilized world," he financed courses at M.I.T for road engineers and lobbied the state to set up a highway commission. He even paid to have a stretch of Columbus Avenue paved in his campaign for better road surfaces.

Not always

A different and humorous approach to appointment management!  Useful for clinics and hospitals?

Actually, a variation can be, as noted in this story from Lawrence (Kansas) Memorial Hospital.

Friday, September 05, 2014

AG candidates aim to close the barn door, but too late

Brava to Jessica Bartlett at the Boston Business Journal for asking the question more directly than her colleagues in the "major" media outlets, but how much more wimpy could the answers have been from the two Democratic candidates for Attorney General?  Maybe after the primary, reporters will ask the winner and the Republican candidate, John Miller, to respond with some substance.

Bartlett asked:

Democratic candidates for attorney general Maura Healey and Warren Tolman have both spoken out against the proposed settlement between current Attorney General Martha Coakley and Partners HealthCare, which allows the medical titan to acquire several community hospitals while putting some restrictions on contracting and price hikes.

But if elected, what would either candidate do about the deal?

Neither candidate was available for a phone conversation on the topic. But in email interviews, both were asked how they would deal with the settlement, if approved by a judge in its present form, and how they would lower health care costs in the long term.

Here's the key part of Maura Healey's answer:

This will be a major priority of mine as attorney general. While I’m skeptical of some aspects of the agreement, it will be the task of the next attorney general to hold parties to the agreement and to the outcomes promised to consumers and businesses. The agreement provides for review, and I will exercise that authority as attorney general to meet my commitment to the public.

That means having an attorney general who will continue to put a spotlight on these problems, who understands the nuances of the health care marketplace and who will hold provider and health plan feet to the fire to ensure we do everything in our power to apply the kind of downward pressure we need on health care costs.

Here's the key part of Warren Tolman's answer:

My biggest concern, which has been highlighted by the Health Policy Commission, with the Partners settlement is that it does not ensure a downward pressure on prices. When an increase in prices is locked into the agreement, whether to account for inflation or other reasons, the disparities between competing providers will only grow over time. That increases the power of higher cost providers over the lower cost providers over time, which will hurt competition.

Bolstered by the recently passed Chapter 224, as attorney general, I will use the office’s authority to oversee the health care market to enforce anti-trust laws and reduce anti-competitive behavior. I will also use the office's authority to regulate charitable health services organizations to push to control health costs and improve quality.

So, in short, in spite of reservations, they will not act to stop the agreement from going through.  They will try to close the barn door after the horse is bolted.

Dear Maura and Warren, that will be too late.

Move Over, Big Data!

"Move Over, Big Data!
How Small, Simple Models Can Yield Big Insights" 
MIT SDM Systems Thinking Webinar Series
September 8, 2014
Noon - 1 p.m. Eastern time
Free and open to all
In this talk, managers and policymakers will learn how simple mathematical models of systems can improve intuition and lead to better decisions.

Dr. Richard C. Larson will provide concrete examples from his professional research and consulting engagements, then discuss general applications to industry. He will cover:
  • Flaws of averages—what they are and how to avoid them;
  • Square root laws—how to apply them to locating facilities and more;
  • Singularities—why and how managers of service systems must schedule idle time for servers or face huge waiting lines (aka the "elbow effect");
  • Simple difference equations—how to use them to discover major system instabilities when inputs are year-to-year gross revenues;
  • Going viral—how a major demography parameter can apply to exponential explosiveness in many business sectors; and
  • Lateral thinking—and how it can sometimes make a problem go away.
Learn to cut to the chase, see the big picture, and stay out of the weeds!

A Q&A will follow the presentation. We invite you to join us.

Thursday, September 04, 2014

And soon, a major motion picture?

So this book arrives in the mail, with an accompanying note from my buddy and colleague Jim Womack at the Lean Enterprise Institute.  He's writing to entice me to read Lead with Respect, A novel of lean practice.

A novel?  About Lean? Fat chance I'll read that, even though I'm a Lean devotee.  How could it possibly be engaging?  I put it aside, perhaps to glance over as airplane reading on a long flight after I'm tired of watching in-air movies.

Well, then I was in an airplane and I started reading it.  It's really good!  It is engaging.  It is also one of the clearest presentations of the elements of Lean philosophy that I have seen.  And this is because the book is not about Lean techniques or Japanese words:  It is about the core principle, leading with respect.  In short, this is a leadership book, not a Lean book.  You don't have to do a whit of formal Lean techniques to gain something from this story.  But if you incorporate Lean techniques into your leadership approach, you'll do even better.


Ward (from a Lean company) teaching Jane (CEO of a company that's not):

Problems first is the basic attitude that underlies our success.  I realize this sounds paradoxical, but every other aspect of learning to lead with respect is tied to our ability to face our problems--and when we do, not to ask who, but why?

You want people to be:
--Specific about the problem
--Insightful about the cause
--Clever about the countermeaure
--Open minded about who else is concerned
--Rigorous about status checks

The purpose of go and see is to grasp the real place, real people, and real relationships. We don't want to pressure people to work harder.  That won't get us very far.  We want them to work smarter by working better together, so they don't waste each other's time with nonvalue-added stuff.  We want to understand the waste caused by problems and misunderstandings so that we can solve them together.

Another way of thinking about lead with respect is managing by problem solving.

Basically, you ask "why?" repeatedly until the most obvious answers are swept off the table and people finally consider the real problem together.  Yes, it does take practice. And it's usually awkward as hell.  But it's important to wait it out.

Teamwork is really individual responsibility to solve problems with our colleagues.  What we're aiming for is teaching everyone to work better with each other.

Most managers struggle to teach operators their management problems: profitability, share price, and so on.  Why would the guys in the shop care?  Top brass prattles on about KPI.  The guys on the floor call these numbers "VIP-Is"--they are created for and shared by people high above their pay grade.  These issues have nothing to do with their daily concerns.  If experience has taught operators anything, it's that any new management initiative is likely to end up as added pressure on them.  So why even bother?

One reason managers get to be managers is that they find change more exciting than scary; they're always looking for the next magic bullet.  To operators, change is scary, because they've learned the hard way that things never change for the better--at least not for them.

So lead with respect is about understanding that change is scary and working as the manager to break down large challenges into small, everyday steps.  The big change we introduce in how we work is helping everyone accept that day-to-day improvement is a normal part of the job.

Cart. Horse. Whatever.

Priyanka Dayal McCluskey at the Boston Globe writes:

Attorney General Martha Coakley is renegotiating a controversial settlement with Partners HealthCare after a state commission said Wednesday that a proposed takeover of two North Shore hospitals would raise costs and increase Partners’ already formidable market power.

I'm trying to figure out how the Attorney General, who has documented for years that the market power of Partners has been a massive force for health care cost and price increases in the region, could have proceeded in the first place with her "antitrust" deal that would have allowed them to take over these additional hospitals.  And, if she had any doubts, why would she have negotiated the deal before the state commission finished its review?

Instead, notes the story:

Coakley had structured the deal, announced in May, so that it could be revised based on findings of the Health Policy Commission, a watchdog agency.

My readers may not know that I spend a great portion of my life teaching and advising on negotiation.  Let's just say that the negotiation technique employed by the AG in this case is one that many people would find highly unusual.

Some cart before some horse just went down the road here in Massachusetts.  It would really be better if the the Attorney General withdrew from this process and let her successor start over again in January.

Don't forget HOPE Award nominations

Please don't forget that nominations for the MITSS Hope Award are due by September 19.

Wednesday, September 03, 2014

Here's one view about Medicare billing transparency

While others have dispassionately made the point that there are unexplained variations in Medicare physician billing data that warrant careful consideration when using such data, one doctor thinks CMS has devious motives.  He says, "I believe that the release of these data by CMS was an attempt by policymakers to sway public opinion against physicians and lessen our political power in Washington." I summarize without comment, but I welcome your reactions.

David F. Penson, Department of Urologic Surgery, Vanderbilt Center for Surgical Quality and Outcomes Research, at Vanderbilt University Medical Center, published an article in the journal Urology, called "The Hidden Agenda in the Release of the Medicare Physician Reimbursement Data."  (Volume 84, Issue 3, Pages 501–502, September 2014.) Excerpts: 

On April 9, the Centers for Medicare and Medicaid Services (CMS) released data on Medicare reimbursements made to individual health-care providers in 2012. The government claims that this was done for the sake of transparency, to reduce fraud, and to encourage Americans to seek high-value healthcare. Call me paranoid, but I cannot help but wonder if there might be something more here.

If the goal of releasing these data is truly to increase transparency, reduce waste, and help market forces to improve the efficiency of health-care delivery in this country, the data have to be complete and accurate. This, however, may not be the case. For example, if Medicare services provided by a number of health-care professionals are billed under a single provider, which may be the case in certain programs and/or clinics, that individual will have these services wrongly attributed to them. In cases where the individual physician did actually provide the services, the data do not account for differences in case mix, as some providers really do see sicker patients than others. To this end, these physicians may get reimbursed to a greater degree, but these larger amounts may be entirely appropriate. Finally, there are going to be cases where the data are just simply wrong. 

It is worth noting that, in reviewing the “frequently asked questions” page on CMS's website, I was unable to find a link for physicians to question the accuracy of their data. However, I do not think CMS is concerned with my opinions on these data.

So, if CMS is not interested in the physician's concerns about the accuracy or validity of the data, what are they concerned with? Certainly, I believe that there is likely some truth to their statements around increasing transparency, eliminating waste and fraud, and trying to empower patients to select high-value healthcare. That being said, I believe there is a hidden agenda here. The Medicare physician reimbursement data were released just weeks after the passage of yet another temporary legislative patch for the sustained growth rate (SGR) cuts to providers. The SGR cuts are always the focus of physician lobbying efforts and, ultimately, politicians are well aware of the negative fallout that would occur if these cuts actually went through. By showing the public just how much Medicare currently pays physicians, it may lessen the political fallout of letting the SGR cuts go through.

In addition, immediately after the release of the data, the media ran a number of stories showing how some of the highest Medicare billers were also some of the largest political donors in the United States. Was either of these events a coincidence? I do not know, but I doubt it. I believe that the release of these data by CMS was an attempt by policymakers to sway public opinion against physicians and lessen our political power in Washington. Ultimately, the clinicians must be the ones at the table informing the discussion on the effectiveness of treatments and defending our patients' right to access to these therapies. If policymakers can turn the public against physicians and neutralize the voice of organized medicine on Capital Hill, it will be easier for them make unilateral changes to the Medicare program in the United States that may lessen costs but may also end up hurting patients.

I suppose the good news is that the modern news cycle seems to get shorter and shorter and the media has already moved on from this story. That being said, the government will release data on physician payments from pharmaceutical and device companies this fall. I am certain physicians again will be the focus of negative publicity when this occurs. Ironically, Congress will be considering another SGR fix at precisely the same time. Coincidence? I think not.

Alice in Wonderland had nothing on this CMS billing issue

Muriel Gillick provides a cogent description of some Medicare billing issues in nursing homes.  If you can provide an explanation for how this can exist side-by-side with federal rules that support extra payments to hospitals for proton beams and to doctors for use of femtosecond lasers for cataract surgery, you are eligible to become the next CMS administrator.

An excerpt:

It's thought to be perfectly reasonable for a physician to be paid $92 in 2015 for a nursing home visit for an acute medical problem such as a new pneumonia (code 99309). To merit this payment, the physician must provide documentation that he or she has taken 2 out of 3 possible steps: obtained a detailed history, performed a detailed physical exam, or engaged in “moderately complex” medical decision making. Only if the physician takes a comprehensive history, performs a comprehensive exam, and engages in highly complex medical decision-making can he or she bill with the code“99310,” earning the somewhat more generous sum of $136. For comparison, note that a gastroenterologist is paid on average $220 for performing a colonoscopy, a 20-minute procedure. 

No wonder physicians often respond to a call from the nursing home about a sick patient with an order to send the patient to the hospital for evaluation. Send a frail nursing home patient to the emergency room and he has, I would guess, about a 90% chance of being admitted. So instead of paying a physician an appropriate amount for making a visit to the nursing home and instituting on-site medical care, Medicare would fork out a minimum of $5774 (the base DRG payment) for a 5-day hospitalization, exposing the patient to the risk of iatrogenesis.

Tuesday, September 02, 2014

Undisclosed financial ties

In a recent post about the controversy over the use and cost of femtosecond laser cataract surgery, I relied in part on an article in Review of Optometry.  In that article and my post, Dr. Eric Donnenfeld was quoted saying a number of positive things about this device and surgical technique, while other doctors took the opposing view.

What RO neglected to say, and what I failed to realize at the time, is that Dr. Donnenfeld is a consultant to Alcon, a manufacturer of this surgical device.  I found that disclosure here, from a recent continuing medical education conference.

RO also failed to mention that another doctor quoted in the story with positive comments about this technology, William Trattler, also has financial interests with Alcon.

Review of Optometry says it has the following mission:

Review of Optometry is committed to giving optometrists the information they need to provide their patients top-quality care in a personally rewarding practice environment. It is a magazine written for optometrists and by optometrists.

To be clear, there is nothing untoward about doctors having a financial relationship with equipment manufacturers, but it is wrong for a journal to fail to disclose such associations. Readers rely on authors and editors to make such associations evident.

It would also be wrong for a physician to fail to disclose such relationships to his or her patients, particularly when use of the equipment in question is associated with higher out-of-pocket costs to those patients. As noted in the RO article:

Any respectable OD would agree that communication is essential in virtually any patient relationship, but it’s particularly crucial with regards to what they can expect after femto cataract surgery, especially if those expectations—and their personal financial burden—is high.

Bad math in the Midwest

With appreciation to the They Said What? website, we bring this example of some pretty poor math from the Cleveland Clinic:

What's wrong?  As the site notes:

Not only is 144,000 people not “1 out of 19 people in the United States.”  144,000 is barely 1 out of 19 people in greater Cleveland.

Fortunately, the underlying prevention message is valid, but I would have liked to have seen some indication in the infographic that many people can stop having colonoscopies after age 75, something noted by another prominent Midwestern health system.

Monday, September 01, 2014

Don't drive home wet

We all expect our car’s airbag to work in the case of emergency.  So what happens when it has been automatically shut off without warning?

We thought something was wrong with the airbag shutoff switch in our 2012 Subaru Impreza.  We’d be driving along, and all of a sudden the passenger airbag would shut off, leaving the passenger unprotected.

So we called the dealer and had the switch checked (more than once!) No problem, we were told. Maybe the passenger shifted her weight and the switch turned off.

Then, this week, a service attendant mentioned that the on-off switch had nothing to do with weight. It was based on the amount of water in a person’s body.

The light went on in our minds. It turns out that the airbag would shut off after a few minutes when we were driving home from the beach and the passenger was wearing a wet swim suit or sitting on a wet towel! It would stay off until the seat dried out.

We checked this out. Here’s how one Subaru dealer explains this on their website:

Most Occupant Detection Systems measure the weight of the front seat passenger, to determine if the front passenger seat airbag should deploy.

All 2012 and 2013 Impreza and 2013 BRZ models use a new type of Occupant Detection System called Electrostatic Capacitance Sensor ODS. This system does not use weight to determine whether to turn the Occupant Detection System ON and OFF. 

The Electrostatic Capacitance represents a material's capability of storing an electrical charge. 

When water or anything with high moisture content is spilled on the front passenger seat cushion, the airbag is designed to remain OFF until the seat cushion is dry.  This will also be the case if the passenger has moisture on their clothing, such as rain-soaked pants or rain gear.  In each of these situations, the airbag status may remain OFF even if a passenger is seated.

Passengers are advised NOT to sit in the front passenger seat if the seat cushion is wet or if their clothing is wet.  The best way to ensure proper operation is to keep everything off the front seat except a passenger. 

We don’t recall getting notice of this when we bought the car.  And it was clear that the service department staff didn’t always think of mentioning this system when an owner brought up the issue of the airbag cutoff. And if you search for “Subaru occupant detection system” or “Subaru passenger airbag shut-off” on the web, there is no official notice from the company.

There is no warning about this shut-off system on the passenger side visor. And, if you check the owner’s manual, there is nothing about this issue in the opening section’s safety precautions, although there is material about the speed and force of airbag deployment. Later, embedded on page 42, there is this advisory if you happen to turn to that page: “If the front passenger’s seat cushion is wet, this may adversely affect the ability to determine deployment.  If the seat cushion is wet, the front passenger should stop sitting on the front passenger’s seat. Wipe off water from the seat immediately, let the seat dry naturally and then check the SRS airbag system warning light.…”

Let’s say you’ve never noticed this “feature.” You’re driving home from the beach on a crowded highway at 60 mph with your family in a full car, and the passenger airbag shuts off. Perhaps you see the shut-off light suddenly illuminating. How exactly do you stop the front passenger from sitting in the front passenger’s seat? Perhaps you don’t even see the shut-off advisory light, in that you are focused on the holiday traffic. In either case, your passenger faces an unexpected hazard.

Many Subaru owners are outdoor types who will drive home after a jaunt to the beach or a hike in the wet woods. How many of them know they are in danger when they do so?

How and why did Subaru decide that this kind of automatic shut-off mechanism was superior to one based on body weight? Don’t they have an obligation to better inform the owners of these model cars? This is a product design lawsuit waiting to happen.