Product placement, to a new level

Speaking of Intuitive Surgical, do any of my readers find anything wrong with this announcement?

Intuitive Surgical (Nasdaq:ISRG) has awarded technology grants to five top U.S. medical centers to increase training opportunities in minimally invasive surgical techniques. Dartmouth-Hitchcock Medical Center, Duke University, Oregon Health & Science University (OHSU), University of Texas Southwestern and Washington University School of Medicine in St. Louis will each receive a da Vinci System console and Skills Simulator™ equipment for one year. 

I do.  It's this: The line between academic inquiry and education and commercial strategies has become so blurred as to be meaningless.

A bit like killing a fly with nuclear weapons

Not all publicity is good, even if you are Intuitive Surgical, the publicity-seeking makers of the daVinci robot.  They must go nuts when they see allusions like this about their machine:

The surgeons also plan to remove his gallbladder, full of painful stones, although given the routine nature of that procedure they admit that using the robot is “a bit like killing a fly with nuclear weapons.”

“People accept robotics in their life all the time,” Moser told the Herald ahead of Clauss’ surgery. “We have drones — robots blowing up enemies, robots flying planes."

"Government efficiency" is an oxymoron

I always appreciate and pay attention to the thoughtful observations of Sachin Jain, and this article in the Journal of General Internal Medicine is no exception.  It's called "Big Plans, Poor Execution: The Importance of Governmental Managerial Innovation to Health Care Reform."

Here's the introduction:

The Affordable Care Act (ACA)'s implementation failures including the launch of healthcare.gov and delays of several key provisions of the legislation have threatened continued support for the law. At the core of the public's misgivings is trust in whether government agencies can effectively implement programs of importance on massive scale. The ACA rollout has exposed deep flaws in the ways in which federal agencies manage the implementation of legislative efforts. For these reasons, we strongly believe that health policy reform must occur alongside innovation and reform of the managerial processes of the Department of Health and Human Services (HHS) and its constituent agencies. In this paper we draw on experiences implementing significant health care policy legislation to explore the fundamental management challenges that have hampered the implementation of the ACA, and threaten the future viability of government-led health care reform.

The authors go on to itemize the problems:

The first is the overly burdensome and bureaucratic process of soliciting, vetting, and awarding con- tracts. Initially designed as safeguards against kickbacks, regulations have evolved to the point where contracts are awarded to firms with the most experience in navigating the federal procurement process, rather than those with the most experience and skills in the content area.

Second, the operational units within each agency responsible for managing contracts and implementing reforms are too far removed from the procurement process.

Finally, the rigidity encountered early in the contracting process is mirrored in constraints around termination.

These problems are compounded, say the authors, because "federal agencies often struggle to attract and retain appropriate, competitive talent."

After recommending changes, they conclude:

Implementation is the ultimate test of any legislative effort,a difficult reality currently facing the supporters and architects of the ACA. Challenges with the ACA have uncovered fundamental flaws in the federal government's managerial structures for executing complex legislative agendas. If we expect our federal health agencies to take a frontline role in reforming health care, so too must we pay attention to reforming these institutions. 

Well, many of these points are so true, and their impact has been felt over the years in defense and non-defense governmental programs.  (The one with which I would disagree, for the most part, is the one about attracting talented people.)  The recommendations made are thoughtful and appropriate.

But the truth of the matter is that the basic structures underlying federal procurement will not change much.  As noted by the authors, many were designed to prevent corruption: In so doing, Congress made an explicit trade-off between obtaining efficiency and preventing crime. Other federal procurement rules were frankly designed by lobbyists for entrenched government contractors: There is a whole industry of inside-the-Beltway firms that have survived and grown off of federal largess.  Their core competence is influencing the body politic to protect their interests.  Other firms do not have the time or interest to engage in the influence-peddling business and wisely choose to spend their time serving the private sector.

Every well-meaning Administration comes into office thinking that it is going to introduce more "business-like" procedures into the federal government.  Some succeed to a certain extent, but most fail.  It is not an activity that generates public support or political rewards.

So, in my opinion, what is required is a more sophisticated and thoughtful approach to writing the law when you are hoping to invent a new program or policy.  The ACA was an immensely complicated piece of legislation.  Many components relied on having an effective, efficient, and timely procurement plan.  It may have been naive to expect that implementation would be successful.

In addition, whatever problems existed at the procurement regulatory level of the government were aggravated by the fact that the high-level managerial structure, support, and oversight put in place by the President and his Secretary of Health and Human Services were inadequate.  The recommendations contained in this article are thoughtful, but no amount of bureaucratic redesign can survive against incompetent leadership.

Learning from Smart Patients

Roni Zeiger, Gilles Frydman, and colleagues have been successfully plugging away for some time in the development of Smart Patients, "an online community where patients and caregivers learn from each other about treatments, clinical trials, the latest science, and how it all fits into the context of their experience."

A sign of the success is that a growing number of doctors and other clinicians have been asking if they might join Smart Patients to learn what the patients and caregivers are saying.  Roni and Gilles have been designing a way of allowing this but that still is respectful of a strong desire to keep the space devoted to the patients and caregivers.

So now, they are launching Learn from Smart Patients, to create learning materials based on conversations in Smart Patients--but the curated conversations are de-identified and used with patient permission.

Three health care institutions have signed up so far:

The George Washington University School of Nursing is piloting the service with Nurse Practitioner students studying the role of caregivers. 

Physicians at Allegheny Health Network (AHN) will use the new service to better understand the needs of cancer patients. 

At Cincinnati Children’s Hospital Medical Center (CCHMC), clinicians who care for patients and families affected by cystic fibrosis are reviewing and discussing issues that arise in the Smart Patients cystic fibrosis community. 

I'm hoping other centers decide to sign up, as I am really excited to see where this all leads.  I have a feeling it is going to lead to helpful insights and stronger partnerships between clinicians and families--consistent with my hope for more patient-driven care.

“Deny and defend” has become an indefensible approach to medical error.

Please check out this excellent article by Bruce L. Lambert and Timothy B. McDonald.  Key excerpts:

In our research on communication and resolution approaches to malpractice, patients and families who have been victims of medical errors tell us that without hearing an explanation or apology, every hour that passes after the initial harm event feels like an additional injury.

Fortunately, there is now a viable alternative.

Several hospitals around the country, notably the University of Michigan and the University of Illinois at Chicago, have adopted the so-called communication and resolution approach to unexpected patient harm.

This approach emphasizes rapid reporting of harm events, rapid communication with patients and families, and rapid investigations to identify possible system failures and to determine whether or not the patient was harmed by inappropriate care.

When an investigation reveals inappropriate care, the health professionals who were involved meet with the patient and family, admit liability, describe in detail what happened, apologize and offer emotional support, and maintain contact for ongoing communications.

Depending on the nature and severity of the harm, the hospital will often waive fees and charges related to the care that caused the harm, waive fees for subsequent care to remedy the harm, and offer financial settlements to compensate patients and families for pain and suffering and for the cost of ongoing care — all without litigation.

Research shows that communication and resolution programs have many benefits. Those include fewer claims and lawsuits, increased reporting of near misses and errors, more rapid settlements for patients, lower malpractice insurance costs, lower legal fees and expenses for hospitals, and less defensive medicine being practiced by physicians.

More importantly, telling the truth to patients after they have been harmed by medical errors is the right thing to do. It is more just, equitable, and humane.

It is better for providers too, who are often traumatized by unintentionally harming the people they were trying to heal, and who are prevented from apologizing, and even speaking, to patients and families.

“Deny and defend” has become an indefensible approach to medical error. The time has come to abandon it.

In Katoomba

A weekend break between health care presentations in Sydney and Melbourne: Some views of the Blue Mountains and local flora west of Sydney, Australia.

If we were on the Serengeti, we would not be the lions.

I have often viewed hospitalists as "the real doctors" in a hospital, people whose inclination, geographic location, and practice patterns allow them to be fully engaged in creating a partnership between the clinical staff and patients and families.  But this view is not always widely adopted by other medical specialties.  Brad Flansbaum offers this essay about the status--perceived and real--of hospitalist doctors vis-a-vis other practitioners in hospitals.  He titles it, "Do I look like a PGY?"

I engaged my team in a short non-scientific exercise. I asked them to plot their impression of how the world at large, defined broadly, views the worth of various specialties versus how they see them.  They assessed the following four disciplines: intensivists, cardiologists, palliative care docs and hospitalists.

He wryly notes:

Do you notice a pattern? If you don’t, let me make it easy: if we were on the Serengeti, we would not be the lions.  

Beyond the humor, there are serious questions raised about the profession:

Now I could speculate about how any specialist might rate themselves and the biases each would bring to the table. I could also speculate proceduralists and physicians engaged in high tech care have deeply embedded cultural advantages in U.S. medicine—and no matter how we spin the story, docs without toys will always drop to the lower rungs of the ladder.

However, I think our station has much to do with our need to mature as a field, and how the public (and HM) views a young, unassimilated specialty.

Many of us still lack confidence. 

An interesting call to arms of sorts for a group of doctors who, in my mind, have shown that they can be at the forefront of clinical process improvement.  Brad's article suggests that more can come, and should come, from this dedicated group.

TOP 5 is tops!

As noted below, I've been having a wonderful time meeting with folks at the New South Wales Clinical Excellence Commission.  This is an agency with a broad-ranging agenda to improve the safety and quality of patient based care in Australia's largest state.

The CEC has a slew of initiatives, and I thought I would share one with you from their Partnering with Patients program.  The overall objective of PwP is to include patients and family as care team members to promote safety and quality.

The particular program I present here is called TOP 5.  It is lovely in its simplicity and low cost . . . and in the power of its results. It could be replicated anywhere there is a will. 

The idea is to come up with strategies to help caregivers who are responsible for dealing with people with dementia--and particularly the anxiety and agitation that can characterize this disease in the presence of certain environmental factors.  As described by the CEC, "TOP 5 is a simple process that encourages health professionals to engage with carers to gain non-clinical information to help personalise care. This information is then made available to every member of the care team, thus improving communication."

5 strategies are developed after consultation between staff and the carer to ensure they are workable in the ward setting. The agreed strategies are recorded on an identifiable TOP 5 form and included in the patient's bed chart notes, enabling all staff to access this information and support the care provided. Up to five strategies may be recorded, however, in some cases there may only be one or two relevant strategies.

Dr. Karen Luxford, Director, Patient Based Care, and Anne Axam, the project coordinator, kindly gave me some examples, which I summarize here:

One gentleman had been a paramedic.  All the "bells and whistles" that are typical in a community hospital setting only escalated his anxiety:  He felt he needed to jump into action at a each "emergency." The strategy that was developed was to speak to him as if he were member of the team--using professional terminology--and advise him that "another car is responding." He would then become settled. 

Another example was Mr. G, a very gentle and proud man, who would become very agitated after his shower. "A discussion with his wife helped us learn that he became very upset if he did not have his watch on his wrist. She always made sure it was replaced as soon as possible." The strategy that was developed was that, during his shower, the staff would reassure Mr G that they would put his watch back on after he was dry, and then they would put his watch back on as soon as possible. With his watch on his wrist he did not become agitated. 

A third example.  A gentleman (Bob) without a primary carer was admitted to the service. He used to get very agitated each morning at 4:30 and was very difficult to settle. One day a visitor came into the room and recognised Bob. The staff asked the visitor if he knew anything about Bob that might explain his daily agitation. He was able to shed some light on the situation: Bob used to manage a delivery yard and part of his job was to get the trucks on the road by 4:30am. The strategy adopted was for the staff to just say, "Bob, the trucks are all gone" and he would settle down. 

Beyond this reduction of anxiety, which is reason enough to run the program, I look forward to learning more about the possible clinical benefits of TOP 5.  The program reminds me of a similar approach adopted in Saskatchewan to help avoid falls among the elderly with dementia. One success story involved a gentleman who regularly fell, usually when experiencing stress.

The staff noticed that the man enjoyed being engaged in small motor physical tasks and also being near the staff.  In fact, when both occurred, his stress levels were noticably lower. So the staff invented a task for the man, repeatedly putting pennies into a cup, and they arranged for him to be in frequent proximity to the staff.  In the months since they organized this approach, he has had no falls whatsoever.

I'm willing to bet that we'll hear similar results from the CEC, and I look forward to their future reports on this program and other initiatives.

Getting acquainted with clinical governance in Sydney

I've been having a wonderful time meeting with folks at the New South Wales Clinical Excellence Commission.  This is an agency with a broad-ranging agenda to improve the safety and quality of patient based care in Australia's largest state.  Today's audience were principally the Directors of Clinical Governance, the people responsible for enhancing clinical care in the 17 local health districts spread across the state.  Also attending was Kim Oates (left), Director of Undergraduate Quality and Safety Education for the CEC.

My primary topic was on leadership approaches that help bring about the cultural change necessary to reduce harm in hospitals, drawing especially on lessons from my book Goal Play!

Following this, we engaged in a negotiation module using one of my favorite exercises, Michael Wheeler's "Win as Much as You Can."  Here you see some reactions of the participants as they experienced relationship changes with some of their colleagues as the game progressed.  It was an important lesson in considering the structure, context, and people engaged in a negotiation, all with an eye to creating sustainable negotiated agreements that can bring value to the parties.

Now this is leadership!

Now this is leadership, from the Board of Trustees who approved the plan, to the CEO and his folks who conceived it, to everyone who played a role.  What a model for other hospitals!

The email is from Jeffrey Thompson, CEO of Gundersen Health System in Wisconsin, to everyone in the system.

Dear colleagues:

Today we will make a big announcement about our energy program. We are accomplishing something no one else in healthcare has done. This is really a big deal around the country. This is a common theme for us, but others are amazed. The point of this note is to help you understand the why and the how so it is easier for you to understand how it fits into our mission and easier for you to answer questions.

The accomplishment is we have had several days where we produce more energy than we use. October 14^th was the first day that we hit this mark. This means instead of paying millions in natural gas and electric bills we are producing our own. We will extend this to many more days, then weeks, then months. We are using natural gas from landfills and cows, hardwood chips from local sawmills, wind, geothermal wells, and very importantly, conservation.

Why we embarked on this journey has many parts. We believed:

·         it will decrease the pollution we were producing that adds to the health burden of our region and nation,
·         it will save the organization money that can be spent on patient care, staff salaries, or used to keep our prices down,
·         it will boost our local economy, instead of coal from Wyoming (for electricity) and natural gas from Texas ( for heat) – what we do spend  is on local sources
·         it helps define us as an organization, a strong corporate citizen, concerned about the broad health and well-being of our region; both physical and economic health.

Where did the money come from to do all this?  Funding for our conservation projects came out of our regular operating funds. And it was a great bargain. We spent $2 million dollars one time on conservation and reduced our energy costs by $1.2 million every year after; a much better return than any of our personal saving accounts or checkbooks. For other big projects we took money out of savings, not the salary or benefit pool, and used it to invest in these long term projects. Because of our timing and innovation we also received 11 million in state and federal money that would have gone somewhere else in the country if we had not won it.

The effects of this work (in addition to saving money, decreasing pollution and boosting the local economy) has been increased staff pride, enhanced recruiting, community inspiration, as well as national and international recognition for Gundersen and La Crosse.

Has this effort decreased our other important objectives? The best data would say our quality, service, and financial health is as good as it has ever been.

Are we done? Not yet. There is still plenty of waste you can help us decrease. We also have many opportunities to expand our sustainability and waste management programs. Beyond that, it is to help other staff and other communities understand, that a great healthcare organization needs to take care of patients, their families, and our whole community, and that is what we are trying to do every day .

Thanks for your help to make us better, and to help lead our communities.

Pause to remember

As we celebrate Veteran's Day in the US and Remembrance Day in the Commonwealth nations, I recall being in Toronto on this date a few years ago.  A report on the radio noted that at 11am on November 11, the demand for electric power in the province suddenly dropped by 350 megawatts as people stopped using their computers, their washing machines, many industrial machines, and other power-draining activities for a few minutes of silence and contemplation.  The announcer pointed out that this was an amount of power sufficient to serve the entire city of Burlington, Ontario!

Fantastic Voyage is showing in New South Wales

Dr. John McGhee is a researcher and senior lecturer based at UNSW Art & Design. Here you see him taking a virtual voyage through an artery, twisting and turning as he goes through to look for plaque that has been created and watching pieces break off like ice calves from a glacier.

John's passion is to take real data generated from patients and create a three-dimensional dynamic representation that can be viewed by the patients and their families.  He brings to this the kind of techniques that are used in computerized gaming, but his purpose is to allow patients to examine inside of their own body, created from their own radiological images.  This visualization will help them better understand what is happening in their bodies.

The current experiments involve stroke patients.  With the patient's neurologist, John is able to help instruct the patient and family as to the nature of their disease--much more so so than is possible  by viewing the images as CT or MRI slices on the wall. He hoping this visualization "will be a normal thing to request when you go to get feedback on your scan."

I view this technique as an opportunity not only for a patient's understanding, but also for a closer partnership with the doctor.  The virtual reality view is such that he doctor and patient can jointly examine the patient's blood vessels, discussing together what they see and the diagnositic and therapuetic implications.

Here's a video.


There are possible applications beyond strokes, including GI and other imaging.  John is looking for collaborators from other clinical settings around the world, and he is also searching for funding to expand the scope of  his research.

Making time for griefwork

All kinds of cross-connections become evident as you work with people to try to improve the quality and safety of patient care, as we seek to eliminate preventable harm.  But I never expected a psychiatrist's book about combat trauma to offer an insight.  The book (recommended by Budd Shenkin), is Jonathan Shay's Achilles in Vietnam, Combat Trauma and the Undoing of Character.  And a powerful book it is, a must-read to understand the devastating long-term impact on personality that can result from wartime situations.

The first section of the book deals with the impact on troops when their commander betrays the trust of his troops.  The context:

The mortal dependence of the modern soldier on the military organization for everything he needs to survive is as great as that of a small child on his or her parents.  No single English word takes in the whole sweep of a culture's definition of right and wrong; we use terms such as moral order, convention, normative expectations, ethics, and commonly understood social values.  The ancient Greek word that Homer used, themis, encompasses all these meanings.

When a leader destroys the legitimacy of the army's moral order by betraying "what's right," he inflicts manifold injuries on his men.

I don't mean to minimize in any way Shay's application of this concept to the battlefield, but as I read it, I saw an analogy to health care.  Let's see if you appreciate and agree with my extension of the concept.

At our Telluride Patient Safety Camp, it is not uncommon to see evidence of trauma in the faces and stories of our residents and medical students.  A common theme is that they had witnessed a senior physician engaging in a practice that harmed a patient, followed by (at best) a lack of disclosure and (at worst) a lack of acknowledgment that such harm had actually occurred.  The young doctor's shock is exacerbated by the feeling of guilt that he or she had not intervened in the procedure to stop the harm from taking place.  Whether or not the resident had been required to participate directly in the actions being taken or was simply observing was not necessarily germane to the reaction.

What has happened? An idealist young doctor, who only recently had solemnly taken the Hippocratic Oath to "do not harm" at the behest of senior educators, was witnessing a betrayal of "what's right."  This observation is a searing experience. Combined with a feeling of powerlessness to intervene, to use Shay's words, the event "taints the lives of those who survive it."

Each resident or student who has the experience reacts and behaves in a different way afterwards, employing his or her own coping mechanism.  The damage often remains in the form of guilt.  For the vast majority, I suggest, the trauma teaches them a very, very bad lesson:  "Hide your mistakes.  Rationalize them away.  In any event, never acknowledge or disclose to the patients and family members."

The whole effect is compounded by another aspect of such events, the silence that surrounds them. Shay explains:

There is a growing consensus among people that treat PTSD that any trauma, be it loss of family in a natural disaster, rape, exposure to the dead and mutilated in an industrial catastrophe, or combat itself, will have longer-lasting and more serious consequences if there has been no opportunity to talk about the traumatic event and those involved in it, or to experience the presence of socially connected others who will not let one go through it alone.

Griefwork encompasses the whole range of formal and informal social exchanges that soldiers at Troy and Vietnam practiced after a death.

We have seen evidence of the power of such griefwork at Telluride.  Those of us who were present on one session's first day, June 11, 2013, will never forget Michelle Espinoza's story, when she related witnessing a serious medical error in the treatment of an obstetric patient, with the resulting death of the baby. To make it worse for Michelle, she realized the error was occurring as it took place but felt that she, as a trainee, could not intervene.  That trauma, in the form of guilt, had lived with her for months.

As she told the story to the residents and faculty, the group's engagement and empathy were highly evident, from the shared tears to the incredibly supportive comments from all in the room.  Equally evident was gratitude on the part of other young doctors that Michelle had shared her story.  She was not alone in her experience:  Similar stories from other trainees began to flow.

What was the effect of this?  A reaffirmation for Michelle and the others that they could go on and pursue their dreams, consistent with their Hippocratic Oath.  Here are her words:

Today’s experience was life changing. Today it was reaffirmed to me why I had decided to make medicine my vocation. You see for me, Medicine is not just a career, it is a God-anointed life calling. To be here in Telluride is truly a blessing, and to be surrounded by such knowledge, talent, wisdom and passion is AMAZING.

Today I learned that I am not alone in thinking our hospitals are one of the most dangerous places for patients. That my internal conflict regarding my concerns for residency training is not isolated to my hospital, and that there are people who not only believe this is wrong, but have dedicated their lives to making a change. It’s divinely inspiring and I can’t wait to see what the rest of the week brings.

Let's consider the generalizable lesson.  Our society selects the most well-intentioned young people to be physicians, and we invest years of effort and huge financial resources in their training.  We then expose them to betrayal and trauma when their leaders and mentors fail to acknowledge the harm that is being meted out to patients and families. We follow this betrayal with silence, rather than empathy and support.  We leave no time for griefwork.

As Linda Pololi notes, this destructive behavior not only occurs in clinical settings.  It is endemic to the environment of medical schools themselves:

Our data show that the way medical schools are structured and the norms of behavior among faculty can create huge barriers to effective relationship formation . . . a medical school environment that could at times negatively impact patients and our system of health care as a whole.

There is a parallel between disconnection and emotional detachment among medical school faculty and ineffective communication between doctor and patient.

Research shows that physicians remember for decades mistakes they have made, feeling guilty and humiliated and isolated in their shame. Only by creating transparency, so they can discuss mistakes openly, can these destructive feelings be relieved. Equally important, open discussion enables the physician and others to learn from these mistakes and prevent them from recurring.

A similar call for griefwork was offered by a young doctor, Pranay Sinha, in a recent op-ed:

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. . . . . 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.

Often overlooked in discussions of the Hippocratic Oath is its imperative to teach.  In that regard, let's consider that Shay's work reinforces an observation I made a few years ago:

Clinical and administrative leaders in hospitals must strive to undo the culture that is embedded in these centers of learning and help those who have devoted their lives to alleviating human suffering to start, first, to alleviate their own suffering and sense of loneliness and isolation.

Time to pass the baton

As this excellent summary by Robert Weisman and Scott Allen in the Boston Globe reveals, the basis for and the content of the proposed deal between the Attorney General and Partners Healthcare System are deeply flawed. 

A deal that once seemed almost a foregone conclusion [has turned] into one of the most contentious and closely watched hospital expansion pushes in the country.

Suffolk Superior Court Judge Janet L. Sanders, who will hold a hearing on the proposed expansion on Monday, said she’s never seen so much opposition to a negotiated agreement.

Given that the two proponents of the deal, the AG and the CEO of Partners, are both stepping down from their jobs, isn't withdrawing the deal the gracious thing to do?  Let their successors start over again and come up with something in the public interest.

It's a stupid rule. Well, no.

I serve as a mentor to our league's youth referees and get to watch a lot of little kids' games.  At one of yesterday's 3rd grade games, I noticed that one coach was hanging around the goal area, giving constant instructions to his team's goalie.  I went to the other coach of this team, who was on the sidelines in the appropriate place, and asked him to get the other one to move back to the sidelines.  He said, "Would you please tell him?" implying that he had failed in that task.

So I did so, and the coach gave me a very hard time.  "How can you expect the girl to learn if I am not there to explain things to her?"

I said, "You do that during practices.  She'll learn the rest by playing and thinking."

"That's stupid," he said, "This is a developmental program and she needs to be told what to do."

I said, "Well, actually no."

He said, "It makes more sense for me to do it from here rather than yelling from 30 yards away."

I said, "That's not such a good approach either."

"Well, if you tell me it's a league rule, I'll move, but it is a stupid rule."

He moved off, and guess what?  The little girl did just fine on her own.

The Dutch, who are excellent youth development instructors, often put it this way: "Let the game teach the game."

Kwan's messages from Liberia

Ebola is already off the front pages in American newspapers, consistent with the media's fifteen-minutes-of-coverage pattern, but the disease continues in force elsewhere.  Here's an excellent blog with front-line observations by Kwan Kew called Ebola in Liberia. An excerpt:

Seventeen-month-old Jackson, son of Fatu, spiked a fever and was readmitted to Suspected Ward to test for Ebola.  He was initially tested negative but was brought into the Confirmed Ward to be with his mother while waiting for a suitable caretaker.  Then Comfort, a nurse’s aide who recovered from Ebola a few weeks ago, cared for him until last night when he spiked a fever.  We retested him today and unfortunately he is now positive.

Fatu’s three-year-old Theresa, who had one of the highest Ebola titers in the county, died this morning, curled up in bed and her face puffy beyond recognition.  All morning long Fatu lying in the next bed did not realize her child was dead.  Struggling with bloody diarrhea and profound weakness, she barely could take care of herself. 

At the end of our morning round we approached her with the psychosocial nurse to let her know that her daughter had died.  At first there was disbelief in her eyes then despair, she quickly and fleetingly glanced at her daughter in the next bed.  Confirming the truth, she was overtaken with grief, her face dissolved into expressions of pain and deep sorrow, but she shed no tears.  We gently asked whether she wanted to touch her child, she shook her head.  At home news and images of people afflicted by Ebola often moved me to tears so much so that I knew I had to be here.  Seeing Fatu struggling with her loss this morning, for the first time since I came here, tears filled my eyes.  Grateful that no one could see my tears behind my goggles, they just innocuously mingled with my sweats.  As a mother I felt her deepest loss.

Because of the large number of sick patients in the ETU, I stayed again for close to three hours.  When finally my gloves were peeled off, my hands looked macerated as though they had been immersed in water for a long time.  Indeed they were, bathed in my own sweats. 

As if echoing the full moon, the Confirmed Ward was full by the end of the day.

End of season rituals

I've come to hate this point in the soccer season, when we take a break after playing and working hard together with the 12-year-olds.  They've come a long way and have bonded to become a real team. The individual and collective development and growth is real and visible to all.  Being with them is the highlight of my week, and now I have to wait over four months till we start up again.

Good ending, though, winning 4-2 in a rubber match against the top team in our section.  Then, the required pizza party and this nice thank-you card.  Also shown above, our midseason ice cream party on a warmer day--my reward to the girls for a goal scored on a volley!

Words from the Southern Hemisphere

As a result of some recent presentations I made in Johannesburg, I was invited to submit a commentary piece to the widely read Mail and Guardian in South Africa.  Please take a look (and please ignore the typos).  The lede:

With the progress in the delivery of healthcare over the past several decades, one wonders where the next advances will arise. Will it be a new series of drugs developed by scientists and pharmaceutical companies? Will it be new generations of medical devices? Will it be a better understanding of the genetic determinants of disease? 

Certainly all of the above are likely to occur, but each comes with a high cost: years of research and employment of hi-tech approaches will necessarily require that corporations invest in, and protect, their intellectual property rights.  

But there is a hidden gem of intervention in the healthcare system that requires little or no investment, and little or no technological advancement, but has the potential to save more lives than most of the drugs and medical devices that will come to the market over the coming decade. That this intervention remains largely untapped results in the premature death of hundreds of thousands of people around the world.

What can this “miracle drug” be? Well, it is no miracle. Rather, it’s reorganising the way in which hospitals provide quality care . . .

Many people are harmed in hospitals or die from preventable medical errors. I do not refer to the occasional explicit error made by a surgeon during a complicated operation. I refer instead to the insidious presence of infections, missed test results and other similar events that occur in hospitals.  These do not happen out of negligence: rather they result from the manner in which work is organised in hospitals.

In memoriam: John Winthrop Sears

John Sears died this week, appropriately, on Election Day.  Appropriately, because he was a great public servant who held elective office and ran for other positions during his life.  He defined himself as "an old-fashioned, center-fielding Republican," and that's a good summary.

I loved spending time with John.  He was as public-spirited as anybody, a great conversationalist, and one of the last of the old New England "Yankees" to serve in public office.

On February 23, 1996, I interviewed him for a paper I was working on about the Metropolitan District Commission, the first great regional government agency in America, which used to run the Boston metropolitan area water and sewer system as well as an assortment of parks, parkways, and recreational facilities like swimming pools and skating rinks.  He was Commissioner of the agency from 1970-1975.  I wanted to learn how it had fallen from its glory days to a patronage-ridden embarrassment.

We sat in his book and newspaper strewn apartment at 7 Acorn Street on Beacon Hill. His observations included the following:

The [former] MDC commissioners were fairly hefty folk.  Hultman -- I think Hultman and Greenough were the two greats of us -- and Hultman built the aqueducts and sort of finished Quabbin [Reservoir]; and Charles Greenough was the great park MDC commissioner -- more of a road builder, a parkway builder.  But I think the agency was seriously politicized. The Yankee legislatures who came up to about 1956, who tended to be Republican, were unimaginative, reluctant to spend, but they weren't successfully corrupt.  They were succeeded by this flow of colorful folk who were willing to spend, but also wanted to send you a schedule.*  We got an annual list from the Ways and Means Committee of people to hire.

Q. Not just positions, you mean people?

Not just positions, people, names.  Micromanaging in the most awful way.  I resisted that, and caused a lot of trouble.  I even fired some people, and it took me two years to work that out.  When we had put the two zoo societies together -- this is a good sort of parable of what went wrong at the MDC -- I told the brand new Boston Zoological Society that they could go and find a good zoo director, and I would hire him or her and put the new director on the MDC payroll.  Well, all hell broke loose.

First, there was a painter foreman who said that he had seniority.  I carried out my part.  But they really went down kicking and screaming.  There are scars all over me from trying to work down through the politicization at every level in the MDC.

The intrusions of Michael Paul Feeney.   He was the dean of the House.  A charming man. We had a good relationship, but if there was ever a spare dollar, suddenly it would have a use attached to it.  [As a result,] there were something like eight little playgrounds in Hyde Park. It took a certain sense of humor and a certain amount of mischief in order to work one's way through some of this.

The MDC, at that date, was quite like a big, helpless giant.  It was the Corps of Engineers on the Massachusetts scale. Every legislator felt they could send us their nephews and then send us instructions to build a park or a pumping station.  Joe DiCarlo put a pumping station in Beechmont, which is still there, which pumps against the Atlantic Ocean. That's an unequal match, if I may say so.

There was a political engineering firm named Maguire, C. E. Maguire, and anytime Maguire ran a little short of work, all of a sudden the wheels would spin and orders would come over to do some real majestic engineering thing.

Speaker McGee.  We hired a terrific young veterinarian for the zoo.  He  said, "None of your animals are going to breed eating this rancid horsemeat that you're feeding them out there." I said, "Well of course, doctor, tell us what we should buy and we'll buy it." The Speaker of the Massachusetts legislature called me up and said that if we did not go on buying my horsemeat from West Lynn Creamery that he would do a number on our budget.

I said, "Tom, you know I'm going to do what the good doctor tells me, and I don't care at all where we buy it from.  If your friends in West Lynn would franchise this food the doctor says is better, I'll buy it from them gladly." he said, "To hell with you" -- and that isn't all he said -- and he took the salary of a little lady who had been in the sewer division for about 30 years and ravaged it in the budget.  He knew that was how to hurt me.  We managed to save her and put her in the construction division.

[This kind of interference] took a lot of time and patience to cope with.

--
 * A "schedule" was the list of approved jobs included in the yearly appropriation bill.

EHRs and safety on WIHI

Madge Kaplan writes:

The next WIHI broadcast — Optimizing Safety with the Electronic Health Record: The Latest on Glitches and Fixes from the Frontlines — will take place on Thursday, November 6, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:

• David Classen, MD, CMIO, Pascal Metrics; Associate Professor of Medicine and Consultant in Infectious Diseases, University of Utah School of Medicine
• Frank Federico, RPh, Executive Director, Strategic Partners, Institute for Healthcare Improvement
• Ann Bisantz, PhD, Professor and Chair, Industrial and Systems Engineering, University at Buffalo, The State University of New York

As the implementation of electronic health records (EHR) increases across health care, so has awareness of new patient safety risks that the technology has either introduced or exposed. The very same EHR being counted on to improve communication, safety, and continuity of care across multiple settings and providers turns out to have features that can have the opposite effect. Getting a good handle on where the vulnerabilities lie is the first step toward coming up with solutions, which is why we hope you’ll join us for the November 6 WIHI: Optimizing Safety with the EHR: The Latest on Glitches and Fixes from the Frontlines.

The list of problems is growing, but some of the most prominent concerns include EHR systems that generate so many online warnings that clinicians and staff complain of “alert fatigue” and have come up with workarounds to avoid them. To save time, practitioners have also developed the habit of updating a patient’s EHR with a lot of copying and pasting, often forwarding medical information that no one has recently reviewed and that may contain inaccuracies. Computer programs that allow doctors to open up and work on multiple electronic patient records at the same time is another accident waiting to happen, according to some. When combined with being interrupted or distracted, it’s not hard to imagine all the mix-ups that can and do occur.

Guests on the November 6 WIHI have a lot to contribute to our discussion. Dr. David Classen is nationally renowned for his work on safety and is one of the lead authors of a 2011 Institute of Medicine report on health IT and patient safety. Among other things, the report speaks to the need to understand new electronic tools in the context of a “larger sociotechnical system that also includes people — such as clinicians and patients — organizations, processes, and the external environment.” David will be joined by Ann Bisantz, who brings a human factors lens to our topic, crucial to analyzing how health care providers are being challenged by the EHR and health IT today and the need to develop habits consistent with safety goals and best care. IHI’s Frank Federico has been looking hard at the unintended consequences of a number of new health care technologies, including the EHR, and will work with WIHI host, Madge Kaplan, to guide our discussion.

We’re in the middle of a learning curve to ensure the EHR doesn’t bring new harm to patients and facilitates, rather than disrupts, an organization’s reliable processes and patient safety culture. I hope you will join us on November 6.

You can enroll for the broadcast here. We'd also appreciate it if you would spread the word about the show via Twitter.

On election day, a unamimous vote

It didn't make the national news, but the Harvard Faculty of Arts and Sciences voted unanimously to request the school's administration to withdraw its proposed changes to the faculty and non-union staff health plan.  Recall that I wrote about some of the issues a few days ago.

Even though I also saw flaws in the proposal, there was a troubling aspect to this vote in an environment that is supposed to encourage rigorous debate and discourse: Whenever you see a unanimous vote at the FAS, you have to worry that the vote became more about the politically correct thing to do. Indeed, the description felt like a throwback to the demonstrations in the '60s.

“It was a great moment for faculty, total dissent,” History professor Carter J. Eckert said after the meeting. “It was a complete rejection on the part of the faculty.”

Although English professor Deidre S. Lynch said she would not describe the discussion as “angry,” she said after the meeting that “a lot of us felt as if the committee that decided the benefits condescended to us.”

The meeting drew noticeably greater numbers than is usual, with many attendees sitting on the floor.

“I don’t come every time, but this time I came for this reason,” said Romance Languages and Literature professor Francesco Erspamer.

Lewis said she was “heartened” by the high attendance at the meeting, noting that professors currently on sabbatical were present.

Wow, even those on sabbatical.

Physics lesson

We all learned of Galileo's experiment from the Leaning Tower of Pisa in which he dropped two balls of different masses to test his hypothesis that the difference would not affect the time of transit to the ground.  The idea was that they were both subject to the same force of gravity and would therefore accelerate at the same rate.

Although his theory was correct, the problem with the story is that they did not actually arrive on the ground at the same time because. As noted in this Wikipedia article:

In Dava Sobel's biographical book Galileo's Daughter she recounts that the balls did not land at the same time:

The larger ball, being less susceptible to the effects of what Galileo recognized as air resistance, fell faster, to the great relief of the Pisan philosophy department.

So it is with great interest that we can witness a more controlled experiment.  Here on IFLScience:

You probably know that two objects dropped in a vacuum fall at the same rate, no matter the mass of each item. If you’ve never seen a demonstration of this, then you really should, because it’s incredible to watch.

Here is perhaps the perfect example, brought to us by physicist Brian Cox. He checked out NASA’s Space Simulation Chamber located at the Space Power Facility in Ohio. With a volume of 22,653 cubic meters, it’s the largest vacuum chamber in the world.

In this hypnotizing clip from the BBC, Cox drops a bowling ball and a feather together, first in normal conditions, and then after virtually all the air has been sucked out of the chamber. We know what happens, but that doesn’t stop it from being awesome, especially with the team’s ecstatic faces.

Here's the video. (You can start at 2:41 if you are impatient.)

Normal? Mindfulness without action is stasis.

My friend and colleague Norman Faull, the brains and spirit behind the Lean Institute Africa, asks whether we act (or should act) when we see something out of whack in our environment.

Of course, calling out problems is a key element of Lean process improvement. But whether or not you are a Lean adherent, it's good to consider your own behavior when you see something awry:

Why do we sometimes speak up ‘right now’ and other times not? 

After presenting some examples, Norman asks his readers:

What do you think? Should I have spoken up? How do you handle the everyday ‘abnormal’ that you come across? 

Think about your own examples. In the health care arena and elsewhere, this is all about mindfulness.  David Mayer set forth excellent examples in this story about Cliff Hughes, CEO of the New South Wales Clinical Excellence Commission:

Cliff, and his lovely wife Liz, were visiting from Australia this month, in part to attend our Telluride East Patient Safety Roundtable and Summer Camp in Washington, DC. As a result, my wife Cathy and I were able to spend some social time with Cliff and Liz, and with a consummate teacher like Cliff in the mix, the learning does not stop outside the four walls of a classroom or hospital. I share the following stories because they left such an impression on me, showing me that Cliff’s wisdom comes through living that which he teaches on a daily basis…

As we were walking through a local grocery store, we came across a small puddle of water on the floor in the produce section. I walked around the puddle, pointing out the potential safety hazard to Cliff following behind me. I continued walking, and it took about twenty more steps before I realized Cliff was no longer behind me. Instead of walking around the puddle like I had, Cliff had detoured to find the produce manager and show him the puddle so the safety hazard could be cleaned up. While I was mindful of Cliff’s safety in pointing out the puddle, Cliff was mindful of all others who would be following our same path and could suffer harm by slipping on the wet floor. Cliff acted on his mindfulness, and by reporting the event, helped prevent possible harm to others. I was mindful but didn’t act.

The very next day, Cliff and I were walking through a parking lot after a quick stop at a local Starbucks. I was in deep thought about our upcoming meeting. As we walked, we passed a parked car which I vaguely noticed had a back tire that was quite low…not completely flat, but would most likely soon be so with some extended driving. Momentarily noting the car, I kept walking, thinking about our upcoming meeting, Once again, Cliff disappeared and was no longer behind me. Instead, he was standing by the side of the car with the low tire, writing on a piece of paper. I walked back to where he was standing, and asked what he was doing. He said he was writing a note to the car’s owner, alerting the driver of the possible safety concern. Finishing the note, he placed it under the windshield wiper, clearly visible to the driver. Again, I noticed the potential safety hazard but was distracted by my own thoughts and priorities, and kept walking. I wasn’t fully “in the moment,” a prerequisite of mindfulness. Cliff, however, was fully in the moment. As such, he was able to not only notice potential safety risks, but also to report each incident and act to prevent possible harm to the driver and grocery shoppers. 

Mindfulness without action is stasis.

Healthcare needs more Cliff Hughes’…

The UK says: Scare 'em and they'll change their lives

What's the best way to persuade middle-aged people to adopt a better lifestyle, to reduce drinking and smoking and increase exercise?  Well, according to the British government, apparently the best way is to scare the bejeezus out of them by warning them that they have an increased risk for Alzheimer's.

Really.  I couldn't make up this one.  Here's the story by Laura Donnelly, health editor at The Daily Telegraph. Excerpts:

Middle-aged people will be screened by GPs for their risk of dementia and told how their “brain age” compares to their biological age, under new plans to “scare” people into adopting healthier lifestyles. 

It means a man of 40 could be told that he has the brain of a 60-year-old, and a significantly greater chance of diseases like Alzheimer’s, based on his weight, exercise habits, cholesterol levels and alcohol intake.

The new system of screening, devised by Public Health England (PHE) means patients will be told how their brain is ageing, compared to those with healthier lifestyles, in a bid to shock them into changing their ways.

Officials behind the idea say they hope the warning will encourage people to make major changes in their lifestyle, which will reduce their chance of dementia.

Dr Charles Alessi, PHE lead on dementia, will present details of the screening tool being developed with University College London, to a G7 convention on dementia in Tokyo this week. 

He said officials hoped to harness the public’s fear of dementia to make people take action to reduce their risk. 

He said giving people an actual estimate of the age of their own brain [will give] them a "potent health message" to act on. 

Whoa!  This raises a host of issues, as noted:

Critics said the plans were “heavy-handed and intrusive” and would frighten millions of people - without giving them an accurate forecast of their true risk of dementia. 

Indeed.

As noted, the science is apparently unclear:

Dr Richard Vautrey, deputy chair of the British Medical Association’s GP committee said he was not convinced the screening would give an accurate reflection of the chance of developing dementia.

“Giving someone’s brain age in relation to their natural age doesn’t necessarily mean they are likely to develop dementia any earlier,” he said. 

“We’d need to really look at the research evidence and understand if there is any basis for this supposition,” he said. 

And then, look at this related aspect, too.  A bounty for each diagnosis:

Last month health officials introduced a new scheme which means GPs will be paid £55 for every extra patient diagnosed with dementia in the next five months. 

Leading doctors said the initiative was an “ethical travesty” but officials insisted the scheme was necessary to boost low rates of diagnosis in this country, with just half of patients with dementia receiving a diagnosis.

Sorry, but I think the whole scheme is nuts.  Your thoughts?

What's going on at Harvard?

What happens when the WGU ("World's Greatest University," as Harvard is affectionately known around Boston), decides to redesign the health benefits plan that applies to the faculty and other non-union employees? The short answer: A vote (pending this Tuesday) by the Faculty of Arts and Sciences to stop its implementation.

Here's a quick summary of the HMO plan:

[E]mployees would become responsible for annual deductibles of $250 per individual and $750 per family, and coinsurance equal to 10 percent of costs, for hospital expenses, surgeries, diagnostic testing, and outpatient services, effective January 1, 2015. The individual out-of-pocket maximum for such expenses is $1,500 per year; for families, the ceiling is $4,500 (present limits are $2,000 and $6,000). Above these thresholds—toward which continuing copayments for office visits and prescriptions will count, too—Harvard resumes paying 100 percent of the costs. As mandated by the Affordable Care Act, preventive care (annual physical and gynecological exams, well-baby care, immunizations, annual screenings for cholesterol, and so on) remains covered at 100 percent.

Before you jump to conclusions--thinking that people are upset solely because their own benefits have been changed or their direct costs have been increased--read more here at the Harvard Crimson:

[History professor Mary] Lewis and several other faculty members have said that they primarily take issue with the introduction of deductibles for non-routine health appointments and the institution of copays up to $4,500 a year for families. They argue that the new plans are “regressive” and will disproportionately burden junior faculty members and faculty members with families.

The Administration takes issue with that characterization:

[Harvard President Drew} Faust, for her part, indicated that she maintains her support for the new plan in an interview earlier this month. She commended the University Benefits Committee for the care it put into designing the plan, which she said was only finalized after 55 meetings of the committee.

Let's just pause here.  Fifty-five meetings!? I can't resist relating the story of the Committee on Calendar Reform which spent six months trying to achieve uniformity in the academic calendar across the various Harvard schools (so students could easily cross-register) and failed.  ("The Committee recommends that decisions concerning the adoption of common calendar guidelines be deferred. . . .")  At least here, they reached a consensus.

To continue:

Defending these changes, Faust said that in the past other changes to the policy have been made to mitigate effects on employees, but that in order to sustain a “generous” policy, more visible changes had to be made.

Faust also challenged the assertion that the policy is “regressive,” saying, “we have quite explicit provision for lower-income employees, lower-income reaching quite high actually in what is defined as lower-income to mitigate the impact of these, and I think that prevents it from being regressive.”

I'm not going to opine on this back-and-forth (although we could spend a lot of time on the effects of co-pays) because I'd rather focus on a more subtle issue.  A colleague writes:

A key unstated motivation of the plan seems to be to make sure that Harvard faculty and highly paid administrators can go to the high costs Partners hospitals--as opposed to other lower cost hospitals--at no additional cost.  This is implicit in the plan design. After you meet your co-pay, Harvard picks up the rest. So if a patient needs a procedure that costs $100K at the BIDMC or Tufts or Lahey but $150K at MGH, there is no difference in cost to the patient. This is counter to the latest thinking on healthcare benefits, thinking that encompasses population health and also provides effective price signals or other incentives to utilize lower cost (and equally high quality) providers.

These are good points.  Many employers have offered their staff a choice of plans, including those that offer limited low-cost networks.  Ironically, the article cited from Harvard Magazine contains this reference:

Eckstein professor of applied economics David M. Cutler—a former member of the UBC, and now a member of the Massachusetts Health Policy Commission (an independent agency charged with developing policies to reduce the growth of healthcare costs and improve the quality of care)—has written extensively about this mechanism. Last December, in the New England Journal of Medicine, he and two coauthors—writing about the deceleration in the growth of U.S. healthcare spending—observed that patients could be rewarded “for choosing providers and organizational arrangements…that are associated with better outcomes and lower costs of care. Tiered networks constitute an early version of this approach to consumer engagement.” A month earlier, in “Hospitals, Market Share, and Consolidation,” published in the Journal of the American Medical Association, Cutler and Fiona Scott Morton  (of the Yale School of Management) wrote of tertiary-care institutions, “[F]lagship academic medical centers offering perceived higher quality care often wield enormous market power.” They cited a report by the Massachusetts attorney general finding wide differences in pricing but “no correlation between hospital price and quality” in Harvard’s market area. Cutler and Morton suggest insurance programs with differential cost-sharing: “routine surgery could involve higher consumer cost sharing if provided at the dominant health system in a market than in a less expensive one”—a tiered network.

But the UBC decided to foreclose this opportunity. Why?  I clearly did not attend any of the 55 meetings, but I bet one reason was that tiered options would single out some of the Harvard-affiliated hospitals as being among the highest cost in the region.  How embarassing or awkward would that be, for the University to make transparent that some hospitals associated with Harvard Medical School offer less value to patients and families than others?  Instead, in going down this lowest common denominator path, the UBC has built in unnecessarily high health care costs for the University.