How to deal with performance anxiety

Here's a really interesting insight from a musician about one way to deal with performance anxiety.  Or Ben-Natan is a vocalist who sings bass in classical and other music concerts in Israel. At a recent rehearsal with a chamber group in Zichron Ya'akov, his wife made sure that their little granddaughter was sitting near her in the front row to watch the performance.

When we asked Or if this was a distraction, he said that it actually helped him.  "When I am performing, I feel the tension between the anxiety of the performance and the desire to relax and enjoy the music. I know that my granddaughter would immediately sense it if I became too anxious, and so she helps me consciously move along the spectrum towards relaxation and enjoyment of the music."

A remarkable and lovely insight.

Shaking the hubris of the profession

My friend Danny Sands writes a remarkable story about a recent medical problem he faced. It's called "On The Ultimate Loss of Control, Living with Uncertainty, Reflecting on the Future, and Being a Patient."  It is beautifully written and worth a look.

I have been struck by a number of similar types of stories recently in which doctors have become patients or have been with close families members in that situation.  I think it is a wonderful thing that physicians now feel comfortable relating such experiences.  The common theme is one of shock and a new understanding of what it is like to be a "customer" in the health care system, especially when the episode involves an error or near-miss that is made in your treatment.  Here is a "minor" example in Danny's case: 

Because of the uncertainty of the diagnosis, I was prescribed atorvastatin to lower my LDL cholesterol and risk of future strokes. When I asked if they measured it in the hospital, I was told it was 107 (which is rather low already) so I politely declined. Besides, the imaging showed no evidence of plaque in my carotid arteries, my blood pressure was low, and I had no family history of cerebrovascular disease or coronary artery disease.

But--and I mean this with great affection for my colleagues who have written, in that I view them as among the best of their profession--isn't it a sign of the hubris of our profession that these doctors do feel the shock they write about?  After all, they have spent years in training and practice and treated thousands of patients.  In other fields of endeavor, the most important part of being and staying in business is to understand the needs of the customers.  The most successful firms, indeed, are driven by the needs of their customers.

In contrast, look at what Ashish Jha noted after a recent injury brought him to the emergency room:

The biggest lesson for me was that this was not an extraordinary story at all.  When I told my story to colleagues the next day, no one was surprised. We accept that when we walk into a hospital, we give up being people and become patients.  We stop receiving care, the way I did on the bike path.  Instead, we receive services. And when you are in pain, the difference between care and services is stark.

This is why I implore the medical profession to move to the idea of patient-driven care.   

As I have said at some recent conferences, patient-driven care does not mean foregoing the expertise, judgement and experience of clinicians.  Nor does it suggest the abdication of their clinical responsibilities. But we must go beyond patient-centered care, in which the doctors and nurses decide what is best for the patient.  Patient-driven care, in contrast, is based on a partnership between the provider and the customer.

And one thing more, returning again to Ashish's story:

Now that we are measuring patient experience and ER wait times as quality measures, I wondered how Falmouth hospital did.  Out of curiosity, I looked up its ratings. They are fine.  Average. This is not an outlier hospital. My experience was not an outlier experience. And that is the biggest disappointment of all.

I often say, "There is no virtue in benchmarking yourself to a substandard norm." Hospitals have come to accept that a "normal" level of (even just) patient-centered care is acceptable.  It is not.

I am pleased to see the hubris of my doctor friends being shaken by their personal experiences.

In memoriam: Arik Einstein

The story goes that, on his 70th birthday, Arik Einstein was invited to lunch by the president of Israel. "Mr. President," he replied, "please let me stay home."

This week this legendary performer, an icon in the country, died from a ruptured aneurysm at age 74.  The outpouring of grief and appreciation has been truly remarkable.  For example, thousands of people attended hours-long open-air concerts in Tel Aviv, singing the well-known lyrics of dozens of his songs.  The participants?  People of all ages, from teen-agers through the elderly.

Although Einstein had been writing and recording songs into his later years, he had not appeared in concerts for three decades.  How is it that young folks, then, took him into their hearts in such a manner?  After all, their musical heroes tend to be the people who give concerts, dance in sexy clothes, construct music videos, and the like.

One theory is that Einstein embodied the values of "the old Israel," and that this resonates with mutiple generations. Let's face it: Ever since the 1967 war (the Six Day War), this has been a country in which hubris has grown in disproportion to other characteristics.  It was that hubris that likely led to the debacle of the Yom Kippur War in 1973.  It is that hubris that encourages governments to support settlements in the Occupied Territories.  It is that hubris that impedes multiple chances at the peace process.

Meanwhile, in the manner that is the contradiction that is this country, Israel sets a remarkable standard in other respects.  We know, for example, of its reputation as "start-up nation" and other well deserved credit in other realms, like the medical education advances I recently discussed.

But, perhaps the young people responded to the unassuming nature and modesty of Arik Einstein, as exemplified in the story above.  Perhaps the message of Einstein's death is that the next generation seeks that kind of guidance, direction, and example from their national leaders.

Happy holidays!

My friend Lisa Popick Coll offers this version of a Thanksgivukkiah on Facebook.

Reportedly the two holidays will not coincide for another 70,000 years.  More or less. The explanation:

The overlap this year is because according to the Jewish calendar, this is a leap year, meaning that an entire extra month is added to the calendar. Because of that, most major Jewish holidays moved up by nearly a month. Couple that with the extremely late date of Thanksgiving in 2013, and you've got a convergence of holidays that comes once in many, many generations.

Ma, can we go to the hospital mall?

Traveling in Chicago recently, I saw these ads on the side of a major hospital.  I was struck by the idea that advertising for a mall was getting equal billing to advertising for orthopaedic services.  Orthopaedics has always been a high profit item for hospitals.  I guess dining and shopping has now reached that same level.

Remembering Monique Doyle Spencer

A reminder of some of the impact of Monique Doyle Spencer, noted on the second yarzheit (anniversary of her death.)  The Sunshine Girls, a breast cancer support group in Southeast US, with copies of The Courage Muscle. 

We'd often laugh about how she was always misplacing her reading glasses!  Here's part of the collection she maintained by her bedside just in case.

The future of simulation is to be found in Tel Hashomer

Simulation centers have been popping up in hospitals across the world.  These are useful, but for the most part their function is to provide technical training in surgical and other interventional techniques, as well as to practice resucitation and the like. Sometimes, too, they are used to study teams in stressful situations to provide lessons in team dynamics.

Amitai Ziv has a broader view of the purpose of simulation. His goal is nothing less than to use this tool to help in the transformation towards a safe, humane, ethical, and patient-centered medical culture.  As the director of MSR, the Israel Center for Medical Simulation at Sheba Medical Center on the outskirts of Tel Aviv, he is pursuing this goal with passion and energy and the support of his home base, philanthropists, and medical professionals throughout the country.

When an adverse event occurs in hospitals, we sometimes say that "the holes in the swiss cheese lined up" to permit a series of small problems to cascade into a big medical error.  Amitai draws on that imagery to describe "the educational Swiss cheese model."

He sees flaws in several key components that comprise the continuum of education and practice for physicians and other health professionals. He suggests that targeted use of simulation can help address the holes in the continuum, and he and his colleagues are out to test that proposition.

MSR is designed as a virtual hospital, offering a wide spectrum of medical simulation technologies. These include computer-driven physiological mannequins, advanced task trainers for manual skills and live simulated patients played by role-playing actors.  MSR combines these different technologies in "high-risk" scenarios to develop and build crucial clinical and communication skills and enable team training in risk-free environments.  Customized audiovisual equipment and one-way glass facilitates real-time observation and allows effective debriefing and constructive feedback to trainees.

Beyond technical training, MSR:

Enhances communication skills through programs dedicated to teaching challenging tasks, such as delivering bad news, obtaining consent and the detection of domestic abuse.

MSR training in a variety of technical and interpersonal competencies is now required of all medical students in Israel before they start their internships.  Interestingly, the center is also working in collaboration with the Tel Aviv University Sackler Faculty of Medicine to provide simulation-based personality screening of medical school candidates.  The aim is to improve the humanistic quality of medical school candidates by assessing their personal and interpersonal characteristics.

MSR conducts hands-on experiential simulation training in a wide variety of clinical domains such as Anesthesia, Cardiology, OB-GYN, Trauma, Chemical & Biological Warfare Management, and more. MSR is an integral part of the accreditation and licensure process of several of Israel's healthcare professional bodies.  These include competence-based board exams for Anesthesiology Residents and for Paramedics. 

The center also conducts a faculty development program for those interested in developing simulation programs in their home institutions.

In short, this is not a view of simulation as an adjunct to the medical education system.  It is a conception of simulation as being deeply integrated into many of the phases of a physician's career--starting before medical school, leading through that school and residency, and then staying with the person throughout his or her career. This larger vision welcomes the use of simulation by regulators and professional societies, as well as risk management organizations. Beyond a focus on safety, there is an attempt to influence the practice of medicine in many dimensions, consistent with the underlying values of clinicians and the roles expected of them by patients and families.

As someone who has been involved in several aspects of simulations, I will tell you that the MSR vision is expansive beyond anything I have seen.  The future of simulation is to be found in Tel Hashomer.  If I were running a center anywhere else in the world, I would be doing my best to learn from Amitai and his colleagues lest my own center fall behind and fail to meet its potential value to society.

Scott Adams: I hope my father dies soon.

Dilbert's Scott Adams writes an entirely serious (and angrily raw) post about an important topic, doctor-assisted suicide.  Excerpts:

I hope my father dies soon.

And while I'm at it, I might want you to die a painful death too.

I'm entirely serious on both counts.

My father, age 86, is on the final approach to the long dirt nap (to use his own phrase). His mind is 98% gone, and all he has left is hours or possibly months of hideous unpleasantness in a hospital bed. I'll spare you the details, but it's as close to a living Hell as you can get.

If my dad were a cat, we would have put him to sleep long ago. And not once would we have looked back and thought too soon. 

. . .

I'm okay with any citizen who opposes doctor-assisted suicide on moral or practical grounds. But if you have acted on that thought, such as basing a vote on it, I would like you to die a slow, horrible death too. You and the government are accomplices in the torturing of my father, and there's a good chance you'll someday be accomplices in torturing me to death too.

. . .

[Update: My father passed a few hours after I wrote this.]

New medical device emerges

At first, I thought it was an isolated incident.  @Bob_Wachter from UCSF reported on Twitter:

Lines betwn personal/professional contnue 2 blur, as I now use my @iPhone flashlght 2 look into my patients mouths. OK 2 clean it w/ alcohl?

I jokingly responded:

This makes me feel a bit uneasy, Bob. What if the phone rings? Or worse, buzzes! :)

He answered:

Good point, tho its not inside mouth (just outsde). Its 1 more sign of Swiss-army-knife nature of iPhone: 1 less thing 2 to carry

But then @drsusanshaw from Saskatchewan jumped in:

Just the other day I used iPhone flashlight to help surgeon identify bleeding vessel in an ICU patient.

They say it usually takes 14 years for a new medical device or procedure to infuse the market. Is this one faster?  Please comment if you have seen similar examples.

Exploring Lean in Tel Aviv

A colleague and I are in the midst of an introductory training session about the Lean process improvement philosophy at Sheba Medical Center on the outskirts of Tel Aviv, Israel.  We were invited by Dr. Eyal Zimlichman, head of quality management for the hospital (seen here with Jessica Livneh, head nurse of the oncology outpatient unit.) As is often the case, we find highly committed, engaged staff and managers facing the usual assortment of hospital management problems. Their interest in the opportunities offered by Lean is palpable, but part of our job is to explain that adoption of this philosophy takes extensive time and effort. Our hope is that this session will give them a taste of the possibilities so they and their leaders can make a more informed decision about the path forward.

We were honored to be joined by Boaz Tamir, Israel's Lean guru.  You see him here with (from right to left--appropriately!) Yoav Shalem (pharmacist); Dr. Einav Nili Gal-Yam (head of the oncology outptient unit); and Miriam Adam (director of pharmacy services).

Competition matters on both sides of the Atlantic

There is often a lot to learn by comparing the US and UK health care systems, but as often as not we revert to Shaw’s “two nations separated by a common language” when looking for lessons. Let me give one example.

Although the UK has had a single payer, nationalized system for over six decades, there also exits a small but vibrant private sector system. In this sector, private insurance companies—supported by premiums paid by individuals or corporations (on behalf of employees)—contract for services from private hospitals and consultants (i.e., doctors.) The system operates in a similar fashion to the US private care system. Insurance companies negotiate with the provider groups as to the rates that will be paid for the various clinical services.

As in the US, there are some private provider groups that have sought to obtain geographic dominance in certain markets. One purpose of that dominance is to have monopoly-like leverage over the insurance companies to obtain super-normal profits.

In the US, when this kind of dominance occurs, it is—for the most part—ignored by public policy makers and regulatory officials. Indeed, it is explained away by assertion that such ACOs (as we now call them) are better able to coordinate care for their patients and thereby achieve efficiencies that will lead to lower costs. As best I can tell, no one with training in economics believes that such an offset is likely to be the result.

Recent rulings by the Competition Commission in the UK have given the lie to those kinds of hopes.  The CC found that dominant private health care networks, particularly by not exclusively those in major metropolitan areas, were able to extract monopoly rents from the insurance companies. The regulatory response: Requiring the divestiture of a sufficient number of hospitals to enable competition to emerge.  The specifics remain to be decided, and portions of the ruling are likely to be contested or appealed, but the logic of the CC will remain intact: Too much market concentration is bad for consumers.

I am struck by how this differs from the situation in the US.  Even Don Berwick, one of the most informed candidates for public office when it comes to health care, avoids the market power issue in his recent platform statement—notwithstanding how many times it has been documented that the dominance of one health care provider network in Massachusetts single-handedly accounts for a substantial portions of the state’s high health care costs.

The CC’s report should be required reading for US health care policy-makers. The UK has a lot to teach us if we can learn to understand our common language.

IWantGreatCare advances the Lean agenda

I don't think Neil Bacon (of IWantGreatCare* fame) meant to reinforce one of the main tenets of Lean process improvement in a recent blog post, but he did do so. I also don't think Neil meant to enhance the Lean philosophy by adding a new key dimension, but he did that, too.  Let's start with his story from University Hospitals Morecambe Bay Trust:

The senior nurse from the surgical unit recounted to her colleagues how last week an elderly patient had used his iPad, from his hospital bed, to provide feedback on his care, highlighting a problem and concern he had using the iWantGreatCare pages for the hospital.

The nurses on the wards are able to receive instant alerts if there are concerns that need addressing for their ward – and thus the nurses were instantly made aware of a problem. Interestingly, in his comment the patient said something along the lines of “this needs sorting at some point, but I don’t want to interrupt anyone now”. Whilst the comments on iWantGreatCare are anonymous there were not many elderly patients sitting in bed with iPads! Thus the nurse was able to go directly to the patient and say “Let’s solve that problem now”.

I am told that the patient (who is still in the hospital) was completely amazed, not really expecting anybody to do anything ever, let alone seconds after he had given his feedback – this was not what he had come to expect from the NHS! Not only was the problem fixed, but the patient has been telling all his visitors and family about the incredible hospital and how the staff really listen, really care and get things fixed. His confidence is high, as is the morale of the staff who see people talking about the great care they deliver.

Lean is about front-line driven process improvement.  We encourage staff to call out problems they see in their work environment, and then managers "swarm" on those call-outs--in real time--and invent experiments that might improve the situation.

Here, though, we've gone a step further.  Here, the patient has been added to the front-line team by being given a simple technological approach that permits him/her to be empowered to make the call-out.

Whether Neil knows it or not, he just advanced the science of process improvement in the health care environment by one great leap forward. Well done!

--
* Think TripAdvisor for health care to get the concept.

"Wounded" comes to America

Emily Mayhew's book Wounded, about which I wrote in early October, is now available in the United States through Amazon.  This is simply the best book I have read about World War I, the 100th anniversary of which occurs this coming year.  It tells the intimate stories of doctors, nurses, and other medical personnel assigned to the front during this terrible war.

Terry Wise shares

Terry Wise is an extraordinary person--wise, empathetic, warm, thoughtful, and vulnerable.  She shares all these attributes with us in her book Waking Up, but she shares the benefit of her work with others through The Missing Peace Foundation:

The Foundation provides financial assistance, public speaking and other resources to entities that lack funding to advance their efforts to help those confronted with mental and physical health issues. Qualifying recipients include organizations, communities, schools, and other associations who aspire to raise awareness and educate others on topics related to long-term caregiving, grief, depression, mental health, suicide prevention, and the process of recovery.

Please check out the website to see if the foundation might be able to help your organization, or whether you might feel moved to contribute money to help the work of the foundation.

How the British Empire lives on

From The Times of London, a new type of Advent calendar!

Leadership Skills on WIHI

Madge Kaplan writes:

The next WIHI broadcast — New Leadership Skills for Better Health and Health Care — will take place on Thursday, November 21, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:

• Gary R. Yates, MD, President, Sentara Quality Care Network; former Senior Vice President and Chief Medical Officer, Sentara Healthcare
• Lee Sacks, MD, Executive Vice President & Chief Medical Officer, Advocate Health Care; Chief Executive Officer, Advocate Physician Partners
• Derek Feeley, Executive Vice President, Institute for Healthcare Improvement
• Andrea Kabcenell, RN, MPH, Vice President, Institute for Healthcare Improvement

IHI has been doing a lot of thinking of late about leaders and leadership… in particular the skills, behaviors, and outlook necessary to steer today's health care organizations toward a very different future. A new IHI white paper (working title: High-Impact Leadership) will be out before the end of the year that captures this complex transition. Among other things, it offers a new framework for leaders who are not just responsible for making change manageable, but enthusiastically supported by all staff. You can get an early look at the new leadership framework on the Nov. 21 WIHI: New Leadership Skills for Better Health and Health Care. One of the goals of this WIHI is to describe the interdependence between the growing focus on population health, the shift from volume to value, and the corresponding leadership skills required to address these challenges. 

At Advocate Health Care, Dr. Lee Sacks has been hard at work learning by doing, with the help of other physician leaders. He’ll explain in concrete terms what his team’s leadership practices look like day to day, including those needed to lead an Accountable Care Organization (ACO). Sentara’s Dr. Gary Yates will spend his time on WIHI outlining key leadership behaviors that signal to staff how change is going to come about and what’s expected of everyone. If leaders want to alter the perception that they alone have all the answers, hashed out in some corner office, they must become a regular, approachable, and authentic presence throughout the organization. Discussions in the hallways talking with staff, and learning from patients and patient stories, need to become the norm.

Fresh from his leadership perch at NHS Scotland, IHI’s Derek Feeley has been thinking hard about what’s applicable and relevant to the US context and in many other countries seeking better health and health care for their citizens. He, along with Andrea Kabcenell, will discuss how leaders can better manage and prioritize all the tasks necessary to succeed. WIHI host Madge Kaplan invites you to put on your leadership cap wherever you reside in your organization, and take part in this next discussion on Nov 21. Tell us what you’re doing to lead differently, with a different future in mind, and what impact this is already having.

I hope you'll join us!  You can enroll for the broadcast here.

I have no way of knowing whom I may have hurt

A colleague writes with a thought-provoking story:

As is often the case, learning the meaning of something can happen well after the actual events that precipitate our own maturation.  So it was for me when my mother developed a growth on her esophagus just before her stomach, in the fall of 2009.

My mother was scared and my father was trying not to appear scared.  Together, they were preparing themselves to be lead by the healthcare system in the discovery of exactly what my mother was afflicted with and how it would be treated.  Having started my life in healthcare 29 years ago, working then as an X-ray Technologist, it took no time for me to launch into an effort to assist my mother and father in navigating through this event.  The reflexive urge I felt to help is well known by all those who work in healthcare.  As healthcare professionals of all disciplines, we know, that despite the best intentions and the best training in the world, there is no predicting how a health episode will go.  Nor is there an outcome that can be reliably delivered.  

After some phone calls by me, my mother was seen, biopsied and got her results well ahead of the typical time frame for these millstones of care.  She also had the benign growth removed well ahead of what would have been normally scheduled.

When I recount my efforts to help my family, with my friends and acquaintances, who also work in healthcare, every person affirms they would do the same for their spouse, children, family members and friends.  Normally, this affirmation is heartily expressed like those who are part of an exclusive club.  It was not until earlier this year that I was struck with a profound sense of guilt as I reflected on my actions.  I most certainly delayed the care that would have otherwise been given to someone with a malignant growth.  Someone who my mother and father, knowing her growth was benign, would have gladly had go ahead of them.  I have no way of knowing whom I may have hurt or if my actions had no consequence at all.

Aim for muscle fitness

My friend, colleague, and neurologist Seward Rutkove has invented several new fascinating medical devices.  One of these--Aim--is designed for the general marketplace (as opposed to medical clinics.)  He and his partner have started an Indiegogo campaign through which you can support the introduction of this device, plus get one for yourself.  What does it do?

Press Aim against any major muscle to measure the fat percentage and muscle quality (MQ) for that muscle.

• Each measurement takes less than a second and results are immediately displayed
• By measuring four muscles (biceps, triceps, abs, and thigh), you get an accurate estimate of your total body fat percentage and MQ
• Aim sends your results to an online dashboard via Low Energy Bluetooth
• You can review your results on the online dashboard to track progress and get tailored fitness advice

Expanding our horizons as teachers

Bradley Flansbaum tells an amusing story about an international medical graduate he was mentoring and then concludes:

Watching an international graduate take his first step assimilating into a new professional role, American style, opened my eyes once again to the valuable guidance we provide as teachers.  I consider moments with them as prized as the interactions with my patients.  What is the difference really?  In both instances, you provide the knowledge and comfort the other side lacks.

The learning is a two way street however, and I get as much as I receive.  Over the years, I have absorbed distant perspectives on religion, the roles of gender and family in the home, and viewpoints on sickness and death.  As a result, I believe my connection with trainees from other countries has made me a better person.

A lovely, concise, and perceptive observation.

Coaching as a leadership theme

Dr. Brian Wong has written a book called Heroes Need Not Apply.  A number of friends have recommended it to me.  I've not read it yet, but I did watch Dr. Wong's video in which he answers the question: "In your book, why does coaching become such an important leadership theme?"  I found his answers thoughtful and compelling and recommend the short video to you.  I'll look forward to reading the book some day.