42

A fabulous movie got me thinking this afternoon about the desegregation of healthcare.

chadwick boseman at the plate

Witten and directed by Brian Helgeland, “42” captures the sheer courage, will and heroism of Jackie Robinson, the first black baseball player in the major leagues (1947), better than any screenwriter or director before.  Chadwick Boseman (playing Mr. Robinson) and Harrison Ford (playing Branch Rickey, the GM of the Brooklyn Dodgers 1943-1950), should receive Academy Award Nominations for Best Actor and Supporting Actor, respectively.  Mr. Boseman in particular captured the intellectual, emotional and athletic prowess of Mr. Robinson, including his swing and run.  A heroic story, told with authentic dialogue and set design, beautifully acted.

harrison ford as branch rickeyThrough the 1950s, separate (and unequal) hospitaIs were operated for African-Americans. In Memphis, where I attended medical school 1981-1985, I received some of my training in the EH Crump Hospital, built and opened in 1956 for black residents of the city. By the late 1960s, blacks in all regions of the country could use the same hospitals as whites, although in some states (Alabama), access was enforced by withholding Medicare payments to the hospital (see the history of The Mobile Infirmary). It would be another 20 years before Skilled Nursing Facilities (SNF) were truly integrated. But in any case, healthcare facilities of the South were integrated sooner than any other region of the US (J Health Polit Policy Law 1993 Winter; 18(4):851-869).

Many county medical societies of the 1950s and 1960s behaved more like autonomous physician fraternities than inclusive professional societies.  Separate associations were created by African American physicians, such as the Atlanta Medical Association (founded 1890).  Integration of nursing staffs preceded that of physician staffs, largely due to the operational impracticality of segregating them.

jackie robinson, right oblique profile

The personal dignity and athletic accomplishments of Jackie Robinson had an important role in shifting public opinion toward the integration of our society.  While manifestations of racism persist in our society (see the Trayvon Martin case), most have thankfully been vanquished from the medical profession.   We owe a little of that to Mr. Robinson.

Healthy Babies are Worth the Wait

When I was in medical school, residency and fellowship (the entirety of the 1980s and early 1990s), I recall 80% of babies being born following an uneventful pregnancy precisely when it was their time (39-41 weeks gestation), with little or no pharmacological or surgical help from the obstetrician.  Given the uncertainty of when (exactly) that baby would be ready within that two week window, the OB practice had an obstetrician in the hospital 24 / 7 / 365, in order to accommodate any timeline the baby wanted, or emergencies encountered.

healthy babies are worth the wait, pregnant mom

Then I entered fee-for-service practice (FFS) here in Atlanta in 1992 and saw something VERY different.  Often the obstetrician was not in the hospital.  And worse, sometimes the baby’s delivery was “scheduled” prior to full term (39 weeks) – the mom-to-be checked into the hospital at 7am on a given day, delivering the baby that afternoon, following the administration of labor-inducing drugs, which led to Cesarean Section more frequently than during my training.

I was given varying explanations by the labor nurses for the excessive medical/surgical intervention: (1) mom wanted to ensure the presence of grandparents to help the first week or two (~5% of the time according to later studies), or (2) the solo-practice or small-group doctor wanted to “control the delivery” in order to have a civil work-life (minimize night-time deliveries), or be the one to deliver the child rather than a competing obstetrician (self-serving financial interests).   Such “convenience deliveries” put babies (and sometimes moms) at risk.  This observation, among many others, drove me from FFS into Permanente Practice in 1994.

Thankfully, many hospitals in the US are putting an end to such poor practices.  A study recently published in Obstetrics & Gynecology, led by a physician well known for his work in this area (Dr. Bryan Oshiro of Loma Linda University), reported that participating hospitals reduced the rate of these medically unnecessary early deliveries from 28% (!) to 5% of all deliveries.   Other hospital systems have reduced these unnecessary early deliveries to <1%.  As a result, the number of weak babies admitted to the NICU fell.  The Caesarean rate fell too.  Baby brain function appears to be better (lower cerebral palsy rates) the closer the delivery to 40 weeks gestation.

healthy babies are worth the wait, brain development

The story of how Dr. Oshiro and colleagues achieved this result is worth noting.  They used strategies for patient and doctor education/communication, empowerment of L&D nurses to stop an elective delivery that does not meet medical-necessity criteria, and process improvement techniques, all led by physicians and nurses, collaboratively.  And by the way, it all started with Evidence-Based Medicine (see my recent posts on EBM).

SMITH-SHARON-2011Our PMG Obstetricians have always believed “Healthy Babies are Worth the Wait” (the March of Dimes campaign for eliminating convenience deliveries).   Throughout the history of our PMG practice in Atlanta, our obstetricians have been in the hospital 24 / 7 / 365, patiently attending to women in labor, delivering their baby on the baby’s schedule, not ours.  Our primary Caesarean rates are naturally lower too.   Women who want caring, thoughtful, effective obstetrical care should choose a Permanente obstetrician, like Dr. Sharon Smith of our Alpharetta office.

 

The Ongoing Debate for EBM: fighting for the scientific soul of our profession

I live in two worlds.

tspmg logo, with website Sept 2012

On the one hand, I lead the Permanente Medical Group (PMG) in Georgia – a tight fellowship of 460 MDs, 140 APs, and 140 staff dedicated to the continuous improvement of clinical care we provide to 240K Georgians through 35 specialties in 29 offices and 4 hospitals. We follow the science of our profession (evidence-based medicine), we honor the sanctity of the doctor-patient relationship (emphasizing shared-decision making), we do what’s best for each patient, each time (Hippocratic Oath, anyone?), without incentives to do otherwise (unlike FFS healthcare).

maa_new_logo

On the other hand, I proudly serve the Medical Association of Atlanta (MAA) as President this year, and Chair of the Board next, and the Medical Association of Georgia (MAG) as a Director. I feel a strong bond to those fee-for-service (FFS) colleagues, many of whom I served alongside at the bedside for 20 years.

With a foot firmly planted in each world I’m on a campaign to raise the quality and lower the cost of healthcare in our state, impeded in part by a reluctance of my FFS colleagues to fully embrace Evidence Based Medicine (EBM) – a physician-led process of continuous clinical improvement that “…

(1) de-emphasizes intuition, unsystematic clinical experience, and pathophysiologic rationale as sufficient grounds for clinical decision-making and

(2) emphasizes the examination of evidence from clinical research (when available).”

(For the background on the debate, see my post entitled “Intuition v EBM”, which anticipated the MAA debate that took place Wednesday, March 27.)

The debate was unsuccessful in that I was unable to convince most of my FFS colleagues that the definition of EBM does NOT contain the words “clinical protocol” or “clinical guideline”, anathema to many of them.

The debate was successful in that it sampled the opinions and biases of 100 of our 1300+ members, and sought to address the fears of skeptics.

I cannot yet know if the debate moved any skeptics toward embracing EBM, but at least the debate will continue later this year in our MAA Board offsite and the 2013 MAG House of Delegates meeting in October; I am hopeful my FFS colleagues will join Permanente, Emory and other science-minded physicians in embracing the benefits to patients and our profession brought about by the routine incorporation of EBM in our practice.

stephen colbert, sitting square raised eyebrowOr they can follow the example of Dr. Paul Broun, summarily renouncing his or her medical school education, and its scientific foundation.

 

How?

I was walking to the podium yesterday morning to make comments at the monthly Cobb Chamber of Commerce meeting when she greeted me with, “I just have to tell you, we LOVE Kaiser”.  She and her colleagues were skeptical on January 1 when her company’s health insurance changed from the Blues to KP – navigating the new system, learning our model of care, bonding to new physicians and nurses.  “We were blown away by our experience – everyone (in the KP medical office) was happy we were there, they knew who we were, everything was efficient; we saw the doctor, got our vaccines, picked up our meds … all in one visit, one location.  Everyone in our office is SO happy.”

excellent on survey

She was surprised to love it.  I was delighted to hear it.  Both got me thinking “how”.  How do we create WOW?

Sure, there’s the beautiful new building, the experienced docs, nurses, pharmacists and fancy equipment.  But that’s not what impressed her.  So what then?

team care

I think it’s our Culture, capital C – our culture of service, team-care, efficiency, continuous improvement and reliance upon and trust of one another.  It took a warm, welcoming greeting from our Customer Service Coordinator (service),  a dedicated LPN to enter prior health information into our electronic medical record (team-care), the care-team expecting the family for their first visit (team + service), electronic transmission of prescriptions from the exam room to the pharmacy (efficiency),  a redesigned nurse advice process called EDGE which substantially reduced the turn-around-time for post-visit questions (continuous improvement), and the trust that all on the team will do today’s work today, effectively, and faithfully.

exponential improvement

She’s proud to be a member.  I’m proud of us.

 

April 1, 2013 – Atlanta, GA

danger april fools

I’m gullible.  For decades on this day my friends have enjoyed crafting tales that begin innocently and plausibly, progressively becoming more outrageous, culminating in the humiliation of being duped once again.  Had the tale begun outrageously, even I would figure it out straight away.  No … It’s in the slow turn of the tale, each successive plot turn plausible, where the magic lies (or is it, the magic of lies).  Perhaps I’ll hear one of these today:

#1 “Rob – immediately following your facilitated discussion regarding the benefits of Evidence Based Medicine (EBM) at the Medical Association of Atlanta (MAA) meeting last week, the many skeptics in the audience were furious.  They thought, ‘How could Rob propose that the benefits to patients of EBM were greater than (real or perceived) harm to doctors?’  But in the days that followed, something odd happened – they read a few of the summary papers you referred to, realizing that EBM is in fact a physician-led process of continuous clinical improvement, rather than narrowly defined ‘rigid, eventually outdated practice guidelines’.   They also read your blog-post entitled ‘Intuition v EBM’ (which annoyed them, by the way).  Anyway, through some strange combination of enlightenment, embarrassment and altruism, the skeptical in the Association have agreed to no longer oppose an MAA position statement supporting the use of EBM as a standard part of every physician’s practice.  They still think you are arrogant when describing Permanente Practice, but nevertheless are eager to learn more.  Congratulations.”

rodent recovery and rescue team

#2 “Rob – as a result of the debate generated by the recently defeated Georgia tort reform bill entitled “Patients for Fair Compensation” (http://www.patientsforfaircompensation.org/), doctors around the state have begun to call for not ONLY the preservation and advancement of tort reform, but also delivery-system culture reform as well.  That is to say, following an unanticipated outcome in a case, the doctor fully and completely discloses the unanticipated outcome, provides authentic empathy and answers hard questions to his/her ability, then fully participates in a process to identify root system causes of the unanticipated outcome, such as they exist.  Doctors are beginning to believe that addressing the soul-wrenching emotional poison caused by baseless allegations of Medical Malpractice requires (1) a fair and effective tort system, true, but also (2) early and complete disclosure of the event or near-event, and (3) an emphasis on process improvement to repair defects in care systems, creating a culture of safety.  Our colleagues around the state are realizing it’s not all about asking the law to protect physicians from baseless allegations of malpractice, rather asking the science of process-improvement and highly-reliable teams to protect the patient and the physician from actual harm.”

#3 “Rob – I hesitate to tell you this, because you are unlikely to believe me … particularly on this day of all days.  But here goes.  In the wake of the Justice Department’s announcement last week it will begin prosecuting many large orthopedic surgery groups in California and Utah for Medicare Fraud (http://online.wsj.com/article/SB10001424127887323466204578384793253488174.html), stemming from their unethical use of so-called Physician Owned Distributorships (POD) to unjustly enrich its physicians via the resale of hardware and implantables, the national academies of many highly compensated specialties have called for those doctors to abandon “fee-for-service” compensation mechanisms, instead opting for case-rates, global payments or some form of pre-payment, eliminating perverse incentives for physicians.  While the latter mechanisms will certainly result in lower annual compensation for those specialties, their compensation will remain in the top 99.3% of the US population on average.”

happy april fools with frog

A man can hope, can’t he?

 

It’s Good To Be Home

It’s an iconic scene in a classic genre.  One of the show’s many protagonists walks through the door, and everyone exclaims “Norm!!”.  It’s good to be home.

Home and House mean different things.  Home is warm, welcoming, and safe.  Home comforts you, and if needed, fixes what ails you, through a community of people who care deeply for you.

The National Committee for Quality Assurance (NCQA) recently recognized five Kaiser Permanente of Georgia (KPGA) Medical Offices as Patient Centered Medical Homes (PCMH). The five medical centers – East Cobb, Lawrenceville, Holly Springs, Sugar-Hill Buford and Cumberland – all earned Level 3 recognition, the highest possible recognition.

PCMHs use systematic, patient-centered and coordinated care processes, which leads to more rapid, effective and personalized healthcare.  Kaiser Permanente is the first organization in Atlanta with multiple locations to receive the recognition.

Our primary care physicians lead a healthcare team that takes collective responsibility for patient care, preventing illness, diagnosing and treating illness, and when needed or desired, arranging for care with other clinicians, often colleagues within our Permanente Medical Group.

Organizations that use the PCMH model of care typically have better patient outcomes, increased patient satisfaction, and deeper staff fulfillment.  Those outcomes reduce waste in healthcare as well.

All adult medicine and pediatric offices should receive PCMH recognition by the end of 2013.  Our members deserve nothing less.

Why is Dr. Welby an endangered species?

From 1969 to 1976, ABC-TV aired the nighttime drama in which Robert Young played a family physician in southern California, devoted to his patients, largely using the nuances of communication and physical exam to explore and heal the sometimes messy human condition. Juxtaposed to the kinder, gentler Welby, the younger Dr. Kiley (James Brolin) represented the aloof physician in “traditional medical practice.” Welby was a student of humanity, Kiley a student of textbooks.

The character didn’t always get it right – or should I say, the show’s writers and producers didn’t always get it right (see the ridiculous treatment of homosexuality) – but the humanity and healing of the insightful, caring doctor, who took his time with patients, and who trusted his powerful subjective skills, came through.

So Dr. Welby represented two things: (1) the doctor who trusted his hard-earned clinical wisdom, rather than overly value technology, when achieving diagnosis and implementing treatment, and (2) the empathetic, laying-on-of-the-hands, ‘I have time for you’ family physician as non-denominational clergy.

What happened to those men and women?

Physicians in training don’t want to become Dr. Welby, for three main reasons: (1) traditional primary care practice doesn’t reliably cover hundreds of thousands of dollars in student loans, (2) the work-life of traditional primary care is too hectic, and (3) the many, varied contributions to healing that take place in a primary care practice are too often devalued by the medical community.

Physicians in practice have too often forsaken the time-consuming task of history-taking, performing a focused physical exam and the hard work of medical reasoning, opting instead to order every test and imaging study under the sun in the hopes doing so will reveal the diagnosis. Some say this phenomenon has to do with our medical-malpractice environment. Bull – a convenient excuse.

We behave differently in the Permanente Medical Group. We pay our primary care physicians more. We give them more time to spend with their patients. We encourage them to trust their hard-earned clinical skills and medical reasoning. We build information architecture (EMR with Decision-Support), create effective workflows (Patient Centered Medical Homes), and nurture a culture of patient-centered group-practice, where colleagues rely upon one another and continuously improve. Oh – and we have one of the lowest rates in the state of medical malpractice allegations.

So the next time someone asks you, “Where did Dr. Welby go?” you’ll know how to answer.