Does Knowing Something, Do Anything?

L&D ward of the 1850s

The year was 1847; the place, Vienna Austria.  Many women were dying of “the fever” (infection) after childbirth … but mostly only if their baby was delivered by the doctor, rather than the midwife.    Dr. Ignaz Simmelweis figured out the reason, decades before Louis Pasteur and Robert Koch deduced germ theory.  Turns out the midwives washed their hands between deliveries, the docs didn’t. Nice.

simmelweis portrait ca 1857

For the last 150 years the medical profession has known that washing hands, vigorously and often, saves lives.  Yet plenty of observational studies in hospitals today reveal we doctors (and other healthcare personnel) don’t wash our hands as frequently as we should (i.e., prior to and immediately after touching a patient or bedside equipment).   For more information, read the recent series of articles in the Atlanta Journal-Constitution (AJC), “Hospital infections: deadly, preventable“.  Or if you prefer: Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect. 2009 Dec;73(4):305-15.

“I know how to fix that!” you say, “… just educate the docs to do it!”  Well, we’ve been educated about it for 150 years.  We humans (even altruistically minded, warm-hearted healthcare workers) don’t always behave according to “what we know”.  How many times have you run the yellow traffic light, when you “know” you shouldn’t?  How many times have you left your coffee on the kitchen counter, when you ‘knew” you wanted to drink it in the car?  How many times have you skipped your morning exercise, despite “knowing” how important it is to you?

sick of taking the blame for your shennanigans

In the realm of human behavior (and medical leadership, for that matter), this is referred to as “the knowing-doing gap”.  We imperfect humans, even smart, highly-motivated doctors, need help doing everything the patient needs, 100% of the time.   That’s the beauty of “systems-thinking”.

 

knowing doing gap, cover of book

You see, when hospitals increase the number of hand-washing stations, place alcohol foam outside every room, make available hand-lotion to prevent dry skin, and nurture an authentic culture of patient safety (all systems-thinking), patient infection rates fall dramatically.  Forward thinking institutions such as The LeapFrog Group routinely rank Kaiser Permanente hospitals tops in the country for all sorts of reasons, including lower rates of hospital acquired infections.

Systems-thinking works in ambulatory care too.  We have screen pop-ups in our electronic medical record (KP HealthConnect) to notify doctor and patient about needed preventive care, medication monitoring, or attention to a particular condition, even when that’s not necessarily why the patient came to the office today.  We also have a rich culture of patient safety – we train and practice the many techniques of “highly reliable teams”, with great results for patients.

mind the gap

I’m a lifelong advocate for education and a lifelong learner.  That’s why I know education has its limitations in optimizing human behavior inside an integrated delivery system. It pays to design healthcare knowing that human beings need workflows and information technology to cover their back, enabling optimally effective and safe care.

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.

Lies From the Pits of Hell

neil young, early performance

I love Neil Young for the totality of his work, but especially After the Goldrush (1970) and Harvest (1972).  That said, I think Lynyrd Skynyrd had it more right (“Sweet Home Alabama” v “Southern Man”): we Southerners are best judged individually, just like every other American.  I imagine Neil would agree today.

lies straight from the pits of hellNevertheless, it pained me to hear Georgia Congressman (and physician) Paul Broun say last month “… what I was taught in school … evolution, embryology, The Big Bang Theory … are all lies straight from The Pits of Hell!” (see recent YouTube video from the Liberty Baptist Church, NE Georgia).

renaissance man, leonardo's sketch

His words pain me because I am a proud Georgian.  And a proud Man of Science – indeed, a physician.

So for those of you who live in other areas of the country, and doubt the intellectual and creative capacity of your Southern Brethren, hear me when I say … don’t make the same mistake Neil Young made 40 years ago … Paul Broun does not define Georgian men, nor Georgian physicians.  Let’s hope not anyway.

 

Responsibility to Self v Group

Recently I’ve written about the societal tension between The Individual v The Group, when dealing with: (a) limited agricultural and healthcare resources (“The Tragedy of the Commons, Revisited“), (b) environmental stewardship (“Selling Environmental Stewardship“), and (c) medical practice (“The Ongoing Debate for EBM“). If one were to summarize the research and observations that led to those posts, I suppose it could be “Humans in general, and Americans in particular, prefer actions that more directly benefit Self, rather than Group”.

gullivers travels

I’ve also written about the new and expanding trend of employers implementing financial penalties, rather than incentives, for employees failing to pursue healthy behavior (“Where’s the Line Between an Owner’s Right and Individual Liberty?”).

individual v group incentives for weight loss, April 2013

So how shall we interpret the research published this month in Annals of Internal Medicine (Kullgren JT, et al. Individual v Group-Based Financial Incentives for Weight Loss. Ann Intern Med 2013;153:505-514), which showed group-based financial incentive was more powerful than individual incentive at achieving weight loss among obese employees?

In other words, how do we reconcile the preference to reward Self (see first paragraph), with the preference to suffer with Group (see the Annals study)?

running in a groupHeck … that’s easy. Its harder to disappoint teammates than self. We hominids learned hundreds of thousands of years ago that Group is important for safety, food and love, in that order (Maslow’s Hierarchy, anyone?). That’s why civilization and culture developed. The Self was more likely to live and reproduce if he/she remained a part of The Group. Thus, we apply more discretionary effort to team-based pain than individual pain. Or if you prefer, our tolerance for suffering is greater when suffering in Group. Think about your effort when running with mates, rather than alone. In which context do you push yourself harder?

individual fish jumping into fish bowl

We doctors should use this insight into the Human Condition. Not for our patients – Lord No – rather for one another, and for the profession, ultimately benefiting the patient.

Tell me how by leaving a comment.

 

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.

 

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?

 

March 30, 1933 – Winder GA

Mrs. Eudora Almond, wife of Dr. Charles Almond of Winder GA (approximately 50 miles northeast of Atlanta), witnessed firsthand the sacrifices made and empathy felt by her husband toward the good people of the county. Presumably he set their broken bones, diagnosed their maladies, reassured the anxious and comforted the dying. Presumably she felt the need to honor his unwavering commitment and humble service to the people. And so the first Doctors Day observance was held on March 30, 1933 in Winder, Georgia, that date chosen to commemorate when a fellow Georgian physician, Dr. Crawford Long, first used ether as anesthetic for surgery in 1842. From red carnations placed on the graves of deceased physicians to Starbucks Gift Cards mailed today, the country has acknowledged our service ever since.

Although we still have the day of observance, have the people lost some of their respect toward us in these 80 years? Or even worse, have we lost some respect for one another, or our profession? In the time that has elapsed at least some of our public identity has changed – from the wise, community servant consistently focused upon the patient to the business-owner preoccupied with self. I’m not saying that is us, I’m saying we need to mind our public Brand as a profession, particularly during this time of industry turmoil.

There are at least three ways we can protect and promote our professional brand: (1) start every conversation about Healthcare Reform with how to make the outcome best for our patients, rather than best for us, (2) change our compensation system from “fee-for-service” to something more aligned with the interests of the patient and our country, and (3) lead the redesign of American healthcare to produce more effective, more humanistic and lower-cost care.

Individual v Community Responsibility for Health

constitutional convention 1787

American culture is a lot about individualism.  From our country’s founding documents protecting personal liberty and property above all else, to our literary heroes (lonely cowboys, heroic soldiers, brilliant inventors, and even business tycoons [Steve Jobs]), to our favorite cinematic protagonists facing the bad-guys alone (James Bond, Indiana Jones, Luke Skywalker), we love celebrating the rights, achievement, and spirit of singular individuals.  Oh, and the more curmudgeonly, iconoclastic, and independent, the better.

 

jordan winning shotIt even shows up on the NFL field of play – an offensive coordinator can call the perfect play, the front line can block the pass rush, a quarterback can throw the perfect pass, but only One, the wide receiver, is permitted to dance in the end-zone.   I recall more of Michael Jordan’s iconic game-winners, than I do the first 47 minutes of team play that enabled him (or anyone) to win it.

 

stephen colbert, thumbs up

Ironically, while the Protection of Individual Rights is more often attributed to one political party, it’s the other party who more often protects and advances those rights (Brown v Board of Education, Civil Rights Bill, Roe v Wade, Same-Sex Marriage, etc).   Queue Stephen Colbert.  But, I digress.

 

So I totally understand when I hear that personal health is the primary responsibility of the individual.  Certainly, making better food choices, eating less quantity, exercising more, not using tobacco products are things each individual should do, and may do.  But is there a role for the community to make those behaviors more can do?

eastside trail ca Fall 2011For example, do we as communities provide enough well-kept green-space, enough public safety (pistol-carrying runners notwithstanding), enough sidewalks, public bike-rentals and planned development?  When will we halt the subsidization of high-fructose corn syrup in favor of a level playing field for fruits and vegetables?   When will we demand from restaurants they include calories and fat content on each menu (not necessarily mandate it, rather demand it, as consumers)?   Oh, and ketchup was never a vegetable.

 

beltline arboretum artist sketchYes, all of us, including me, must behave more responsibly as an individual when it comes to our personal health (eat less, move more, get our vaccines and cancer screening exams).  AND at the same time, we collectively can empower and enable individuals to behave more responsibly by providing more of a healthful infrastructure in our communities.  Join Park Pride, Trees Atlanta, Georgia Conservancy, Piedmont Park Conservancy, Atlanta Beltline, or any other noble organization trying to advance individual freedoms by providing and protecting collective-use environmental infrastructure.

 

The Face of Future Health Care

Journalist Reed Abelson begins his New York Times article today with “When people talk about the future of health care, Kaiser Permanente is often the model they have in mind.” Let’s examine the ‘why’ and the ‘how’.

We believe better-coordinated patient care leads to more rapid diagnosis, more rapid and effective treatment, through a more humanistic and holistic approach, individually tailored to the person before us. We achieve those superior outcomes first and foremost through (1) a culture of collaboration (highly-reliable team-care, Patient-Centered-Medical-Homes [PCMH]), (2) a culture of safety (best care, best time, best place, no errors), (3) a culture of continuous improvement, powered by (a) sophisticated technology (our exceptional electronic medical record – embedded with the latest best practices; analytics; and performance management systems), as well as (b) physicians and staff who confidently place the interests of the patient before all else.

We believe that physician pay should compensate for long hours of very intense work, devoted to the patient and family, simultaneously devoid of financial incentives of self-enrichment. That’s why our physicians are salaried, rewarded for individual or collective quality achievement, patient satisfaction, and keeping members optimally healthy. Traditional models of healthcare, particularly “fee-for-service” (FFS) models, lead to self-enrichment by maximizing testing, treatment, surgeries and hospitals, often without benefit to the patient (see Atul Gawande’s 2009 New Yorker article, or Steven Brill’s 2013 Time article, among many others).

We believe that physician leadership is a critical component of “re-engineering care” to make it more affordable, more highly satisfying, and more effective, as Mr. Halvorson states in the interview. To do so requires the sensibilities, experience and expertise of physicians. We provide the care in the exam-room, at the bedside, in the OR, after all. Our medical groups are self-governed, making ALL medical decisions with patient and family through a shared-decision-making process. What the Permanente physician establishes as medically necessary for that particular patient gets done, without ANY interference from the insurance end of the business. See my recent editorial in the Atlanta Business Chronicle for more information about the role of physician leadership in redesigning medical care in our country.

We are indeed the face of future health care, AND we have even more re-engineering work to do before we sleep.