What will their legacy be?

A danger of being "Thinker in Residence" for several months here in the state of Victoria, Australia, is the danger of diagnostic anchoring--too quickly reaching conclusions about the state of the health care system--followed by confirmation bias--valuing only those observations that support the conclusion you've reached, while ignoring other data.  With cognitive errors of this sort, the best defense in avoiding them is to be aware of their existence.  So, I've tried assiduously to be careful during my visit here.  But the time has come to offer my considered view on several matters.

In a recent blog post, I noted that the extensive program of traffic safety run by the Transport Accident Commission is an example of the strong sense of communitarianism that pervades this society.  I suggested that a future column would explore whether this communitarian view within Victorian society carries over into health care--whether there is a comparable commitment "towards zero" with regard to preventable harm in hospitals.

I conclude, with some sadness, that the answer is "no."

At a meeting with a high government official, I was asked how the the situation with regard to quality and safety in this state compares with other jurisdictions I've visited around the world.  I answered that the situation was comparable.  The offical seemed satisfied with that answer.  I was too polite to point out that satisfaction was not the appropriate response.  As I often note, there is no virtue in benchmarking yourself to a substandard norm.  In most of the developed nations, the situation with regard to quality and safety can best be described as islands of excellence in a sea of mediocrity.  That such is also the case in Victoria should be no cause for contentment--for the simple reason that this state has the potential to do better.

What's behind the failure to act decisively in the communitarian manner exemplified by the TAC in the transportation arena?  A hint was given in a meeting with a senior official in a private hospital system, when I asked if there were any efforts to share advances in quality and safety among the region's hospitals:

"We won't share what we learn about quality and safety improvement because that information gives us a competitive advantage, e.g. with regard to reducing lengths of stay, which has a direct impact on our finances."

I was shocked by this statement, but several of my more knowledgeable colleagues were not when I mentioned the reply to them.

Contrast this attitude with that of several pediatric hospitals in the Midwest United States:  "We compete on everything, but we don't compete on quality and safety."

Like many other countries, increasing health care costs vis-a-vis available public tax-generated money and private health care premiums are big issues here.  There is a tendency for those in government and those in the industry to list financial issues as the primary ones facing the health sector.  That, in turn likely leads to the kind of comment made above about competition.

But such competitive forces and the narrow priorities drawn from them are not compatible with the underlying purposes of the hospitals and people working in them.  Nor are they compatible, if the public understood fully, with what would be the expectations and demands of the populace.

In his marvelous book Legacy, James Kerr writes about the greatest rugby team on earth, and notes:

In answer to the question, "What is the All Blacks' competitive advantage?", key is the ability to manage their culture and central narrative by attaching the players' personal meaning to a higher purpose.  It is the identity of the team that matters--not so much what the All Blacks do, but who they are, what they stand for, and why they exist."

What happens when hospital leadership focuses so intensely on money and competitive standing?  A former trainee from Boston put it this way:

The absence of a sense of purpose of this kind is toxic. For instance, if you have an advertising campaign that emphasizes our kindness or humanity, but we have no policies or practices that distinguish our kindness or goodness from anyone else's, it may be persuasive to our market as a branding tactic, but it's actively alienating to those of us who work within this system. 

Kerr paraphrases Jim Collins' Good to Great by noting that "When enthusiastic and rigorously adhered to, a dramatic, compelling purpose is a fundamental driver of the companies that go from good to great."

So an irony is that, while many health care institutions seek competitive advantage, they will not achieve what is possible even on that front because they fail to focus sufficiently on the public good aspects of their business.  They give their doctors and nurses insufficient reason to have a fulfilling sense of purpose that could in turn make a huge difference on the commercial front.

Here, of course, the penalty for a lack of purpose is worse than the commercial consequences.  People are dying and are being harmed in Victoria's hospitals to a greater extent than is necessary.

As noted earlier, the TAC is not content with even 300 traffic fatalities per year and instead helps the people of the state move that number towards zero. In contrast, in the health care arena, the number is far greater and yet there is a systemic failure to acknowledge the problem.  Government agencies fail to cooperate on solving it to the extent commensurate with the public health hazard.  No one proposes a standard of zero preventable harm for the Victoria hospitals.  Instead, the focus is solely on sentinel events, which are just the tip of the iceberg with regard to preventable harm.

Hospitals themselves fail to work together on the issue.  The various colleges representing the doctors' specialty groups have not addressed it in a meaningful way.  The medical schools, likewise, do not work together on making longitudinal training quality and safety and clinical process improvement part of a shared curriculum.

It may be that that the nascent patient quality and safety movement in Victoria will grow and help nudge government and health sector leaders to make elimination of preventable harm a priority activity comparable to eliminating traffic deaths.  In the meantime, unfortunately, self-satisfaction reigns and harm persists.  The people of Victoria deserve better.

Hear me. Do you know me?

It isn't often that I can report that I was honored to see a play, but such was the case recently when I was invited to view the showing of a short four-person drama at West Gippsland Hospital in Warragul and especially because I was permitted to attend the staff discussion that followed the performance.  Here's the background:

The Australian Institute for Patient and Family Centred Care was established a few years ago by Catherine Crock and colleagues to promote just what its name implies.  As noted:

We aim to to transform people’s experience of healthcare through a three-fold approach:

1. Develop partnerships between patients, their families and health professionals
2. Create a culture that is both supportive and effective
3. Improve healthcare environments through high-quality integrated art, architecture and design.

One medium used by the AIPFCC is to commission short plays on key themes in health care delivery and present them, upon invitation, to hospitals throughout the country.  The hospital plays a small fee for the show, and the balance of the cost is covered by donations to the Institute.  The plays have now been seen in dozens of health care institutions by thousands of people.

Two plays are offered, Hear me and "Do you know me? The first deals with medical error, disclosure, apology, and communication.  The second deals with care of the aging population.

We viewed the latter play in Warragul.  It was organized and supported by CEO Dan Weeks. The audience of doctors, nurses, and trainees were deeply affected by the performance and the themes raised.  Afterwards, Dr. Crock facilitated a discussion, and the honesty and vulnerability displayed in the comments was truly extraordinary.

The actors had permitted people to reach into their experiences--whether with their own family members or with patients--and share observations that will help bring a better sense of clinical teamwork in the hospital and empathy with patients and families.

I was particularly pleased to see that medical students and more advanced trainees were permitted time away from their ward-based clinical activities and were invited to attend.  They, too, were active participants in the discussion and clearly benefitted from the experience.

Meanwhile, the actors stayed and listened, no doubt enhancing their own ability to offer even more engaging performances in the future.

Towards zero on the roads in Oz

In America, drivers don't try to kill other drivers. In Australia, drivers try not to kill other drivers.

After almost three months here, I've decided that this difference in attitudes is the biggest thing that separates these two cultures.

America was built on a culture of individualism, sometimes called "rugged individualism."  In Australia, society is characterized by a much greater degree of communitarianism.

The place of traffic fatalities in the two countries provides a nice example.

There are about 32,000 traffic-related fatalities in the US per year, about 10 per 100,000 population.  I think if you were to ask most American drivers about this figure, they would probably answer, "These things happen."  There is virtually no concern in the general population about these deaths, and there is certainly little or no evidence that road dangers influence the manner in which people drive.

In Australia, there are about 1200 deaths per year, or about 5 per 100,000 population.

A two-fold difference is pretty significant, and Australia would certainly be entitled to rest on its laurels.  But folks here understand that there is no virtue in benchmarking yourself to a substandard norm.  Instead, as illustrated by the a program of the Victorian Transport Accident Commission, they've set an objective of zero.  The agency explains:

At the heart of Towards Zero is the belief that human health is paramount to all else. It acknowledges that, as people, we all make mistakes. However, when mistakes happen on our roads they can cost us our lives or cause serious injury. That's because our bodies aren't made to absorb the forces of high impact speeds. We are fragile, and there's only so much physical force we can withstand and this is why we need to build a safer road system. Improving the safety of our roads, our speeds, our vehicles and our people will improve safety for everyone. The move Towards Zero is a collaborative effort between everyone in the community. Together, we can build a safer road system and help change road safety for the better.

A campaign is just a campaign if it does not take hold in the minds and behavior of the target audience.  I'm here to report that as I drive on the highways and streets of Victoria, I see it in action.  When you are on the highway, and the speed limit is 100 km/hour, people go at 100 km/hour.  In the US, when the speed limit is 60 mph, the expectation is that you will go above that.  In Victoria, you don't see people engaged in a "Grand Prix" form of driving, weaving in and out of lanes to pull ahead of cars in front of you.  As a result, automobile travel is a lot less stressful and more comfortable, not to mention safer.

In talking with friends here, they acknowledge that very strict enforcement of the speed laws--and high penalties--keeps your mind on doing the right thing.  But they also follow up by saying that they are pleased that such is the case.  Why, they say, should people die when they don't have to.

In the US, if we think about the issue at all, we tend view those who might die as "somebody else," and we feel no sense of responsibility towards those potential victims.  In Australia, when they think about the issue, they view those who might die as a member of their community, and they feel a great sense of responsibility in minimizing the potential for harm.

In a future column, I will explore whether this communitarian view of Australian society carries over into health care--whether there is a comparable commitment "towards zero" with regard to preventable harm in hospitals.

Ultimate advice

When I was growing up, ultimate (originally known as ultimate frisbee) had not yet been invented.  While we played with frisbees, it was mainly just a lot of tossing them around.  Since then, the sport has developed and highly skilled players and teams compete worldwide.

I've had a forced sabbatical from playing soccer here in Melbourne (no one plays during the summer apparently), but have been lucky to be invited to join a local co-ed division three ultimate team.  It's been great fun to play a sport which in which the rules are self-enforced, i.e., without referees, and where the "spirit of the game" is the dominant culture.

Nonethless, there remains a role for a team leader, often a player-coach, and in this case we are blessed to have Michelle Phillips, a world class player, as ours.  Off the field, she and I have traded stories about leadership, and I've also had a chance to watch her skills in that regard during games and her post-game advisories to the team.  The latest one struck me as having lessons well beyond the playing field.  Here's an excerpt:

There's a tendency in teams (whether sporting or otherwise) to try to 'fix' everything, to try to have the strategy perfect, to try to get everything absolutely right.

It's not possible. More importantly, trying to do this is actually detrimental to the overall performance of a team. Let's have a look at why, and at what we can do instead.

When we try to correct every non-perfect action out on field, we crowd our minds with more information than we can process. What that looks like is multiple voices in the circle, talking about strategic points while we're on the line, and tacking extra pieces of information onto the main message. Doing this means that not only do we not remember all the little things we've been told to do, but we forget the most important things that we started with. 

There's a direct parallel between these points and about achieving process improvement in hospitals and other organizations.  Improvement in efficiency, quality, safety, and customer satisfaction occurs one small step at a time, within an overall strategy.  If you try to change too many things at once, the effort usually fails, and because you've changed too many things, you don't know how to analyze the cause of the failure.

Now, let's get back to Michelle's summary as she discusses a leadership (and the followship) issue:

A leader's job is not to fix everything. A leader's job is to filter all the information they receive, decide what is most important for the team, and direct the focus there. If you're leading (and we all do, at different times) you need to be able to give your team one clear set of directions out of the hundreds of possible actions that could be taken. If you've passed information onto a leader and they haven't acted on it, realise that they have made a decision not that it isn't valuable, or true, but that it isn't the message that the team needs in that moment. Trust that they are storing it away, and when the time is right it will be packaged up and delivered.

Finally, we return to the relative importance of strategy versus implementation:

And let me tell you a secret. It's way less about the strategy than we think.

If it was all about strategy, the underdogs would never win. If it was all about strategy, team sport results would be far more predictable than they are. If it was all about strategy, the state of your athletes wouldn't matter - only the state of your coach.

Games are won by the team that controls the mood.

I don't think people think much about this concept of mood in a hospital or an industrial or service organization, but it is key.  We might use another word, like "morale." Having now visited thousands of places, I can usually tell within 15 minutes whether a place is a true learning organization--one described by my late friend and colleague Donald Schön (1973), as one that is “capable of bringing about its own transformation."  You can see it in the faces and demeanor of staff as they walk down the corridors.  You can feel it in how they interact with one another on the front line.  Call it mood, morale, or a shared sense of purpose and mutual support.  I described this in my book Goal Play!

The girls who play soccer in our town’s league in Eastern Massachusetts are among the luckiest kids in the world. They get to go out and play a beautiful game with their friends in a safe environment with terrific coaches and parents who support them. But there is an additional bit of magic that occurs during a game.

As the girls play, they unconsciously adapt to one another’s strengths and weaknesses, creating a seamless web of teamwork. As a coach, when you see this happen, all you can do is smile. You know you had something to do with it, but you also know that something has happened among the girls themselves. It is a marvelous thing. They will remember it all their lives, but they may not entirely understand what they are remembering.

They will think their fond memories of the season had something to do with friendships or other social relationships or new skills acquired or the team’s exceptional record. But there is something even more important that made the season so memorable. It is an elemental statement about the human condition: We are born to work and play together in teams. Many people do not get to experience that sense of ensemble, which requires giving enough of ourselves to let the filaments connect. That the girls discover it for themselves is very, very special. They are, indeed, the luckiest kids in the world, and we are likewise blessed in being able to share this time with them.

Sea spurge, compacts, and other descendants of Wipe off 5

Today's story is about how to implement a cultural change among a large group of people.  Stick with me, as this will take a moment.

Back in 2001 the Victoria Transport Accident Commission wanted people to slow down just a bit while driving.  They understood that "Speeding just 5km/hr over the speed limit can mean the difference between a close call and a serious accident."  The question was how to get people to do it, and do it consistently.  Of course, you could have police and traffic cameras trying to enforce the speed limit, but that is resource intensive and can never be pervasive enough to hold thousands of drivers accountable to this standard. It would be better if people would internalize the message and hold themselves accountable.

What resulted was the Wipe off 5 campaign.  TAC employed a simple statement of principle and combined it with an easily understood and remembered action that every driver could take.

The fact statement was pretty straightforward and incontrovertible:

Each year about 100 hundred people die on our roads every year in crashes where speed was a contributing factor. The TAC spends about $1 billion every year on support services for those affected by road trauma and accepts about 19,000 claims each year from people injured in crashes.

The ask from the public was widely publicized in forums that were frequented by people--standard media and social media.  Highly respected advocates (Footy stars!) lent their names and images.

Low level speeding is the target of this latest TAC campaign - the aim to make people aware that travelling only 5km/hr over the speed limit can have disastrous results.

Throughout the month of August, the Wipe off 5 message will be spread through social media, a Statewide roadshow that will tour Victoria and the commercial featuring famous AFL number 5’s, Carlton's Chris Judd and Collingwood's Nick Maxwell.

The results were both immediate and sustained:

Over time there has been a change in community attitudes towards speeding and also in behaviour. According to Sweeney Research, people who report they speed most, or all, of the time has dropped from 25% to 11%.

Market research surveys show that the Wipe off 5 concept is generally understood by Victorian motorists and is having a positive affect on their driving behaviour. Since the campaign began, Vic Roads has reported a drop in average travel speeds in 60km, 70km and 80 km/h speed zones.

Now another story, this time from the beach.  There is an invasive plant species, sea spurge (Euphorbia paralias), that has taken over many of the dune areas in Australia beaches.  As noted here:

Sea spurge can produce up to 5000 salt-tolerant seeds. These seeds can survive for a number of years on ocean currents that spread them from beach to beach. Once established, a sea spurge colony can spread rapidly, displacing the native vegetation and changing the structure of the beach. This can disrupt many native species including the endangered shorebirds (hooded plovers, little terns and oyster catchers) that use open sand spits for nesting.

Although the plant is not unattractive, its displacement of local species is troubling, and a number of people in the Cape Paterson region have banded together to try to remove it from the dunes in their area.  Work parties go out periodically to carefully pull up the plants.  (It has to be done carefully or, as seen above, the remaining root structure will spread into dozens of new plants.)

But two or three dozen stalwart volunteers alone cannot maintain several kilometers of beach front, and so the group has been encouraging other folks who use the beach to pitch in--to be part of the culture of removing the invaders.  But the trick was to make the job memorable and approachable, so that each person would take personal accountability to help out.  Rod Phillips, one of the organizers, suggested that the team adopt a take-off of the Wipe off 5 campaign, and "Take out 10" was born!  As people walk along the beach, they can easily pitch in by pulling up ten of the plants and walk on, knowing they have helped.  There are now several sections of the beach that remain remarkably free of the plant.

Finally, let's turn to a story that is in its early stages.  A group of senior administrators and clinicians at Royal Children's Hospital in Melbourne have spent several months engaging staff in the construction of a compact between and among the medical and managerial staff. Hundreds of people have spent thousands of hours constructing this document, which is meant to reflect the values that should govern behavior in the hospital.

The compact represents a personal commitment of those who sign on to it.  There is no enforcement mechanism.  It is the exemplar of self-accountability.  The as yet unanswered question is whether is will make a difference in changing the culture of RCH.

As one staff member noted:  "Getting the words down is just the first step.  It's all about the deeds."

Another, analyzing behavior patterns in the hospital, said: "We need to look at ourselves as a tribe, not at the tribes within the hospital."

Another noted that there is "a need to call out bad behavior in real time" in a way that is viewed as positive and constructive.

The best summary of one desired outcome was:  "We need to stop saying this is my patient and instead say that this is our patient."

And finally, the clincher: "We should look after each other."

So the question for RCH and other institutions that seek to raise the level of kindness in their delivery of medical care is how to translate excellent words into excellent action.  And it is here that perhaps the lessons of "Wipe off 5" and "Take out 10" might offer assistance.

If staff members at the RCH focus their efforts on the global behavioral change that is envisioned in the compact, the task may seem overwhelming.  There are so many sentences and so many words.  Which should get priority?  How should this affect my daily life?  Viewing such a large task might even be paralyzing.  Instead, what if the hospital were to implement the compact by adopting an analogy to a simple mnemonic, a daily standard that could be incorporated into each person's work flow and interactions?

I'm not clever enough to know what might work, but perhaps something like "Show five types of caring each day."  Or, "Offer ten kinds of kindness."  The point is to make the desired task clear, compelling, and practical--allowing each person to go home at the end of the day claiming success in helping to instill the culture so eloquently set forth in the compact.

Correlation ≠ cause and effect

I was recently directed to a lovely example of how an observation of correlation can be misinterpreted with regard to cause and effect.*  It comes from Mind of the Raven by Bernd Heinrich.  Here's the excerpt:

At dusk on September 7, 1997, a cougar crept up on Ginny Hannum as she was working at the back of her cabin at the head of Boulder Canyon in Colorado.  The cougar crouched low among the rocks, facing her from about twenty feet, and it was ready to pounce.  

Although Mrs. Hannum was unaware of the cougar's presence, she had become "somewhat annoyed" by a raven "putting on a fuss like crazy.  The noisy raven kept coming closer, having started its commotion twenty minutes earlier from about three hundred yards away.  Was this raven trying to say something?  She started to listen more closely.

The cougar was ready to make its kill, but the raven was close, and it made pass over the woman, calling raucously, then flying up above her to some rocks, where she finally saw the crouching cougar.  As the cougar glared down with yellow eyes locked onto hers, Hannum quickly backed off and called her three-hundred-pound husband.  The surprise attack had been averted. She had been saved.  "That raven saved my life." The event was declared a miracle in the news.

A miracle is any event the natural cause of which we do not understand.  Why did the raven call?  To the religious Hannums, it seemed a miracle that a raven would go out of its way to deliberately save a human life.  To me, raven behavior is still a miracle, although I have faith that this raven's behavior was within the realm of what ravens normally do.  They are alert to predators that could potentially provide them with food.  Perhaps the raven had been luring the ion to make a kill, alerting it to a suitable target.  If the lion had feasted, so would the raven.  That is, both would have benefited, as expected in communication.

After presenting some more evidence, the author concludes:

Everything I know about ravens, as well as folklore, is congruent with the idea that ravens communicate not only with each other, but also with hunters, to get in on their spoils.

Whatever else these to incidents illustrate, they show the difficulty of interpreting communication and how much communication can depend on the mind-set of the receiver.  To make sense of communication, the first relevant questions to ask are: What are the costs and the payoff to the givers and potential receivers of the signals given.

All in all, this is an excellent example that shows the dangers of making quick assumptions from a few observations without applying rigorous thinking to possible underlying causal factors.

--

Many thanks to Dr. Rod Phillips.

"A good way for doctors to let patients know they are antiquated and unfriendly"

A friend here in Melbourne visiting a doctor in the community took this picture from the bulletin board in the doctor's waiting room.  I posted it on Facebook with the comment:

"I know some doctors feel frustrated about this issue, but even if they do, is the waiting room a really good place to put up a sign like this?"

Within hours, I received a slew of comments, and I repeat a few of them here.

Condescending, much?

Gotta fight snark with snark! My search engine spends more than 2 minutes with me, doesn't disregard my input, and is available for follow up...so it'd be hard to confuse with a real doc. 

It is offensive to put that in a waiting room. Period. I would turn right around and walk out.

I'd turn around and walk right out too, if I could. Great example of an ego-based practice!

Yikes, not at all appropriate for posting in a waiting room. 

Don't confuse your medical degree with human empathy.

We have had some great doctors lately so have respected my need to research - but I respect their degree and experience. There is a fine line between research for understanding and research used for self diagnosis. It also is hard because anyone can publish anything on the net so weeding thru it to find truth is challenging. I thought the sign was funny but could see how many would be offended.    

The number of doctors I have witnessed Googling (and Wikipedia reading) while I've been in waiting rooms...

Doctors are too sensitive.

I totally understand doctors' frustration at Doctor Google. And equally think doctors need to get a grip and recognize this is the 21st century! Hello? Savvy consumers ARE GOING TO GOOGLE. Medicos need to develop ways of dealing with the information, and likely also the misinformation, that patients and carers may find.  

They are ignorant of empowered, educated patients, sophisticated websites and instant crowdsourcing within correct parameters. It's a mark of an older generation of doctors, perhaps used to dealing w LILE (low income, low education) patients.

Knowledge is Knowlege.

With one in ten misdiagnoses, and that estimate is very low because diagnostic error isn't tracked or reported except by malpractice claims, you bet I'm doing my own research. How am I supposed to engage in shared decision making if I don't educate myself? I go to medical school websites, medical academy and society websites, disease organizations and more for my info. Google gets me there.

Physicians need to take a look at why patients feel the need to google their symptoms and diagnosis. Then they could have a constructive conversations of how to change the patient experience. This poster is just highly offensive and just supports the old notions of dr.s being narcissistic jerks.

Worst kind of paternalism.

Wow. Not an appropriate sign for a waiting area. Why not work with the patient and thank them for being so proactive. Your knowledge can outweigh any Google search. The patient is only scared.

Patients should be involved with their care and ask questions. We do it for many other products that we consume in our life. Health care should be no different.

I would never confuse the two. Google is much better.

I actually went undiagnosed for years with a rare kidney disorder. I mentioned to my doctor on several occasions what I thought was going on and got the "don't self diagnose on the Internet" lecture. I agree, it can be frustrating to doctors who spent years in medical school to have patients act like they know more. However, nobody knows their body better than the one living in it and when a patient says "this is not right" they should keep a open mind. I did get a profuse apology from my doctor and she said that she learned to leave her ego at the door and to listen to her patients.

I like it! It's a good way for doctors to let patients know they are antiquated and unfriendly. I'd rather know that in the waiting room than find out in the exam room.  

If this is how they are choosing to respond to the digital era then its time to find another doctor. Giving such a clear sign is a societal and individual benefit. 

And then this dialogue:

[Kathy] Epitome of arrogance! You'd better believe I will be googling my diagnosis and symptoms. I only go to the doctors office if I need "physician ordered" medicines, diagnostics or treatments.

[reply from Eric] After you spend endless hours debunking the mindless nonsense people read on line you may look at this differently. A little knowledge is very dangerous.

[reply from Kathy] But, that knowledge may be what the doctor does not know! Patients engaging in their own care and learning about their bodies and illness makes them safer, not dangerous (to anyone).  

[reply from Eric] Spend a day in my shoes where people clamor for inappropriate tests and drugs. I believe we should all be proactive but what I see on an almost daily basis is nuts.

[reply from Kathy] Some of those people are right on with what they need. I am a nurse and I have worked in doctors offices. I have also been a patient who knew my diagnosis and what I needed. I didn't get it and as a result I got kidney damage. There are two sides to every story.

[reply from another person] Patient empowerment can come from many places and should. I can understand frustrations with time and teaching and getting more time with patients (nurses and doctors) a solution to many problems. This sign is extremely arrogant and provocative. A power struggle for status and status is something WE can use wisely or unwisely and this is of the latter.

[and from another] I am a trained scientist with a PhD and I do a lot of research before and after I go see my doctor and also for my friends and family. I actually pick my doctors after asking them their opinion of patients like me who want to make informed decisions, and I WILL most definitely find a different doctor if they give me such attitude. I respect that it can take extra time to deal with the cases where a little knowledge is a dangerous thing but if the doctor wants me to stay ignorant and treat their individual opinion as infallible, I am outta there. Just my 2 cents on this issue.

Ask, instead, why they would want to leave

It isn't often that I am surprised in a negative way by something relating to an Ohio pediatric hospital.  Indeed, the hospitals in that state have been at the forefront of working together to enhance quality and safety for their patients.

But this recent story in the Columbus Dispatch caught my eye. An excerpt:

Non-compete agreements built into contracts help ensure that doctors can’t join a hospital’s crosstown rival or enter private practice across the street — at least for a while.

The choice to relocate elsewhere to practice medicine is especially limited for pediatric specialists employed by Nationwide Children’s Hospital.

The Dispatch reviewed a non-compete agreement that shows that Nationwide Children’s pediatric specialists risk being sued if they take a job within 100 miles of the hospital within two years of leaving it.

It turns out that other Ohio hospitals have similar, if slightly less restrictive clauses.  The rationale:

Recruiting and hiring require a significant upfront investment, Thornhill said. “It’s a classic business practice of protecting the investment.”

Well, maybe it is--although courts have sometimes tossed out such agreements if they are too wide in scope,.  As noted here:

In states where noncompetition clauses for physicians are enforceable, the provision must: 1) protect the employer’s legitimate business interest, 2) be specific in geographical scope, and 3) have a narrowly tailored durational scope. If the language in the clause is vague or does not clearly describe the exact terms of the restrictions on practice, the clause might be unenforceable or open to greater interpretation than either party anticipated.

But I have a different concern, especially for places like Nationwide, Cincinatti Children's and others that put great stock in engaging their staff in ongoing process improvement.  From the point of view of those leading a learning organization--one focused on constant improvement from within--it is far better to figure out why someone would want to leave you than to inhibit them from doing so.

In memoriam: The Boston Courant

In the end, The Boston Courant did not shut down because of the oft-discussed pressures on the print media.  No, it was because of legal fees and a judgment made against the newspaper from a former employee's lawsuit.

David Jacobs and Gen Tracy and their loyal crew worked hard to provide neighborhoods of Boston with relevant, current news--well written and clearly presented.  Advertisers rewarded the paper with their business because it was widely and consistently read.

The owners and staff deserve to feel proud about their contribution to the City, which will be diminished by the absence of their newpaper.

Cruelty and enlightenment

I don’t know if the following observations are profound or trite or somewhere in between. They are prompted by a recent visit to the Cascades Female Factory in Hobart, Tasmania.

Every country, it seems, has something to be ashamed of in its history. Certainly, among other things, the US bears blame for its treatment of native Americans, slaves imported from Africa, and forced detention of Japanese descendants during World War II.

And yet, those same countries have often made contributions to political systems that are truly noteworthy in the advancement of human society.  Think of the principles espoused in the Mayflower Compact, the Declaration of Independence, the Constitution, and in the practice of civil disobedience against injustice, a philosophy that stemmed from the writings of Thoreau and others. 

These contradictions between eras of cruelty and shame and periods of enlightenment may be irreconcilable. Or perhaps there is some underlying theory of the advancement of the human condition that posits that the bad must occur to bring about the good.  Political philosophers of greater wisdom than I have surely offered their hypotheses.

I think, though, that part of the process of societal development depends strongly on exposing the bad times with stories about normal human beings who were caught up in the antisocial maelstroms of their time.  We seem to be emotionally insulated from general histories about thousands or millions of people who were harmed during the cruel eras.  It is hard to pursue political action based on such broad-based summaries.  But when we hear the stories of individuals who were treated badly, we are able to identify with them and then perhaps step back and build a political coalition for change.

It was in that light that a recent visit to the Female Factory was so powerful.  This facility was opened, ostensibly, to punish and help redeem women who had committed crimes in Great Britain. The crimes could be as simple as stealing a handkerchief or food for a starving family.  Poverty was viewed as a sin, caused by the ethical character of the poor person, not by the society in which they lived. 

“Transportation” was the name for forced passage across several oceans in cramped and unhealthy ships to Tasmania, where women were locked up to serve their time. 

The prison bureaucrats were careful to record the arrival of each woman, assigning her such descriptors as they felt were appropriate.  A sample is shown above, an indication of the dehumanization already being experienced by these women.

But the system was actually designed to provide women to help serve and populate the British colony.  While in the factory, the women would do manual labor in support of the community of Hobart.  Laundry was handled here.  Women were also tasked with “making oakum,” disentangling the caustic, tar-laden strands of ship rope into fiber that was used as caulking to fill the cracks between boards for ships.

Babies were forced to be weaned from their mothers at 6 months, then to have a diet of bread and water from the polluted rivulet next to the factory.  Many died from dysentery.  At 3, the children who survived were taken to live in their own orphanage-prison, perhaps to be reunited several years later when their mothers’ terms of servitude were completed.

Later, “transportation” was transformed to “probation.” Upon landing, women would be sent out to work and live on farms throughout the island in slave-like conditions until they could earn their freedom.  If they failed to do their work well or became pregnant, they would be returned to the factory.

At the museum, there is this simple exhibit on which women’s names are listed.  They remind us that each one had her story of loss and suffering. With luck there could be survival and freedom.  Indeed, there was a lovely photographic exhibition of modern day descendants of some of these women, who live proud lives notwithstanding their “convict” ancestors.

(By the way, there were other types of awful treatment awaiting the male convicts in Van Diemen’s Land—many of whom, too, committed minor crimes and were sent as a work force by the British Empire to squeeze out possible colonization by other European powers.)

I was reminded as I watched the movie Suffragette that Australia was the second country in the modern era (after New Zealand) to grant women the right to vote—well before Great Britain.  Was there something about the earlier history of cruelty and oppression that led to a greater sense of egalitarianism in Oz?  Is it possible that the treatment of men and women convicts created a communitarian culture that led to this and other social advances?  A number of my friends and colleagues here have made this connection.  How ironic it would be if one era of such cruelty helped herald another period of political enlightenment. If so, the women at the factory would have left a legacy for their adopted country that they never could have imagined.

There is no Holy Grail, just small chalices

Given the stakes to society and the persistent growth in health care delivery costs throughout the developed nations, there is an understandable desire to achieve the “breakthrough” technological solutions that will result in a substantial disruption in diagnostic and treatment practices and patterns that have evolved over the decades.  Well intentioned and intelligent people with thoughtful ideas are focused on ways to achieve these solutions.  Investors, seeing the large (and growing) percentage of each nation’s GDP that is devoted to health care, likewise hunger for the opportunity to grab even a small portion of that wealth.

As I noted in a blog post last year, an area that consumes tremendous energy is the search for the Holy Grail of decision support products that would mine health care “big data.” People are looking for the algorithms that could help doctors—in real time—analyze the condition of patients and put in place more efficient and efficacious diagnostic regimes and treatment modalities. I explained in that blog post why these efforts will fail. Let me summarize:

1 -- The data that is collected is not reliable enough to draw connections between patient characteristics, clinical decisions and outcomes.  It is not reliable for two reasons.  First, it is simply not reliable.  Much data that is collected and/or coded in hospitals and physician practices is done so poorly, or in a format that is not clinically accurate.  Second, it is likely to be characterized by such wide standard deviations as to make it unsuitable for predictive purposes.

2 -- It is unlikely that the algorithms that are designed to produce work rules will be trusted by doctors. In part, this is due to the standard deviation problem noted above. That is, the models will not be sufficiently rigorous in their predictive capacity. Maybe more important, there is a general lack of trust on the part of doctors with regard to using formulaic approaches in their practices. While doctors are the victims of many kinds of cognitive errors—diagnostic anchoring, confirmation bias, and the like--they are often not trained to reflect on and catch these biases. They are trained instead to trust their own judgment and take personal responsibility for their patients. It would be but a small minority of doctors who would be able to overcome those biases and that training to use big-data-driven decision support tools—even if such tools were able to overcome the statistical difficulties mentioned above.

3 – The process for selling such systems into the hospital market is complex and almost infinitely slow. The sales cycle will kill off all but the most highly capitalized firms. Even excellent products will often wither and die on the vine.

Does this suggest that there is no potential for disruptive technologies that can improve health care delivery at a reduced cost? No, but it suggests that there is not a Holy Grail, but rather a group of smaller, potentially jewel-encrusted, chalices. Targeted innovation is the way to go. Think small, think focused, and think about how to achieve quick results that benefit the doctor, the patient, and the hospital.

Wait, did I just put the doctor first on that list? The Ptolemeic health care system has the doctor at the center of the solar system, and it will be that way for a long time to come. Unless your product helps the doctor feel that they are doing a better job and can fit into their work flow, it’s not worth pursuing.

I’ll provide an example that originated in Melbourne, produced by a firm called Global Kinetics. The approach is described in this article. A Parkinson’s patient wears a simple device on their wrist for a week or two. The accelerometer contained in the device correlates the extent of the patient’s movement disorder with the drug dosages they have taken. (The “watch” also, by the way, provides the patient with a reminder to take the drug at the specified times, leading to a higher level of adherence and providing a higher level of precision to the experiment.) The report is transmitted to a standard hand-held device, using a patient code that is fully privacy protected.

The technology and the reports produced by this approach do not substitute for the judgment of the neurologist. Rather that judgment—previously based on trial and error--is enhanced by a real-time, patient specific experiment. The process can be repeated as often as the doctor deems necessary--more often for a patient suffering a rapid deterioration from the disease, and less often for a more stable patient.

The device is not bought by the hospital, and so it bypasses the highly competitive capital budgeting process. Rather, the product is provided as part of a service offering, the test result that is provided to the doctor. The fee for each report is well within the normal operating budget of the neurology department, requiring no special allocation of funds. In short, acceptance simply requires a decision by the doctors themselves.

I offer this as a perfect example of a jeweled chalice. Simple hardware and software technologies; easily incorporated into the doctors' workflow; enhancing their ability to exercise professional judgment; and offered in a sales process that does not create competition among hospital factions and is consistent with normal budget processes. It is by this path that technology can disrupt health care—one carefully designed step at a time.

There is no billing code for compassion

I am borrowing a line from Dr. Amy Ship, the 2009 recipient of the Campassionate Caregiver Award from the Schwartz Center, to remind folks that nominations are now open for this coming year's award. The award recognizes health care professionals who display extraordinary devotion and compassion in caring for patients and families.  It is open to health care professionals who work in any U.S. health care setting. The nomination deadline is March 31, 2016. Here's the link.

There's no better way to express your appreciation to a friend, colleague, or caregiver than to nominate them for this honor.

Plus ça change

I mean no disrespect to my Australian hosts when I say that I've seen this all before.  The details differ, but the same underlying themes emerge. And when stories are placed side by side, it can be confusing to the public.

In Australia, the government strongly encourages private health insurance coverage for a portion of the population, a policy that was designed to reduce overcrowding in the public hospitals.  There are a whole series of regulations that influence both corporate and individual behavior in this arena.  These rules have essentially created the private health insurance market in the country.

As noted just a few days ago, the private hospitals in the country want to assure their investors that the demand for health care services will not diminish over the next several years.  They cite underlying demographic factors:

In a strident statement Ramsay's Mr Rex said the report failed to consider further utilisation growth linked to the ageing population. "Macquarie's report incorrectly concludes that the modest impact of ageing in the past means that the impact will be minimal in the future," he said. "But it is the future impact of ageing – the baby boomers moving into the 60-70 year bracket - that needs to be considered... We have not yet felt the ageing impact – it is yet to come."

Those who provide private health insurance to cover patients for these services have understandably been increasing premiums to cover the costs.  Look at this chart below:

Private health care costs are rising at about 8%, mostly due to higher utilization of the health care system (both number of visits and procedures per visit) and a bit (about equal to the consumer price index) due to hospital and doctor pricing changes.  So the insurers have actually been able to hold premiums increases to something a bit less than the total cost increase. 

But that doesn't keep government officials from taking a strong stand against the current premium rate filings, saying they demand further review.

The insurers then respond by pointing out that part of the problem stems from the government's own policies. For example, the cost of prosthetic devices in Australia's private health care sector is dramatically above that found in other countries.  Why?  Because the government has made a pricing deal with equipment suppliers to keep the cost of such devices low to the public hospitals, subsidizing those facilities with higher prices to the private hospitals.

Health insurers . . . estimate that up to $800 million could be saved on prosthetics, such as hip and knee replacements, if a reference pricing system with Australian and international benchmarks was introduced.

But let's get past this local detail. Even if it is true--and worthy of attention--it can distract from our overview.  There is an old joke about gravity:  "It's not just a good idea.  It's the law."  So, too, for anti-gravity in the health care world in developed countries.  Those countries face common factors that are driving up costs.  I summarized these back in 2009.  Number 8 doesn't apply here in Australia, but the others do to a greater or lesser extent:

1) Demographics. The huge cohort of baby boomers have now entered the age at which they are seeking hospital care. Meanwhile, their parents are living longer than ever and are coming to the hospital for both acute and chronic care.

2) Entitlement. The first cohort named above expects and demands everything for themselves, and of the insurance products they expect their employer to purchase. For their parents, they often expect extraordinary end-of-life care interventions, paid for by Medicare.

3) New stuff. See #2 above. A knee that previously would have remained sore in the past or be treated by physical therapy becomes a target for arthroscopic surgery.

4) The medical arms race. Physicians and hospitals feel compelled to buy the latest technology, even without proof of enhanced clinical efficacy.

5) Defensive medicine. Yes, the threat of malpractice law suits leads to over-testing and other extra costs.

6) Regional medical mythology. Thanks to Brent James for this insight. Local practice patterns often are just that, with no evidentiary basis.

7) Preventable harm in clinical settings leading to extended hospitalization and bodily injuries.

8) Lack of access itself. If people don't have health insurance and can't get proper early diagnostic and preventative care, they are a more expensive burden on society when they get sick.

9) The cottage industry problem. The medical profession, both in physician practices and hospitals, has failed to adopt process improvement approaches that are common in other industries, that result in redesign of work flow and systems to derive efficiency, quality, and standardization.

10) A sedentary and malnourished lifestyle for all age groups, leading to obesity and other associated physiological problems that are the precursors to major health issues.
 
... We can fix some of our inadequacies through legislation, but many components of our problems lie deeper in society.

P.S. While there are pro's and con's of each country's health care systems, similar cost pressures have become evident in much of the rest of the world. Perhaps this suggests that a common organism underlies our problems, homo sapiens and its curious ability to live longer and expect more.

Putting aside the political trading that will inevitably take place, from what I've seen so far, Australia could do a lot by investing in changes to numbers 6, 7, and 9, above--and likely number 10.  Places around the world that have done so have been able to counteract at least part of the anti-gravity tendency of societally driven health care cost increases.