PookieMD's Blog: Where Physicians Learn About the Business of Medicine

I am fascinated by mistakes–and why we make them.  What we do with mistakes is subject for another blog post, but I found some fun information from a couple of places on why we make mistakes.  (No comments, please, on how often I make mistakes!) The following are from the book Don’t Believe Everything You Think, by Kida, and from a  text on clinical informatics:

• We prefer stories to statistics.  Hopefully, we physicians are more focused on evidence based medicine, but there is the adage that we are only as good as our last (complicated) case.  This can also be described as availability–our estimate of the probability of something being true based on how well we remember similar events.
• We seek to confirm rather than to question our beliefs.  In other words, we look for information that confirms we are right.
• We don’t appreciate that chance and coincidence can shape events.  I don’t know how much this applies to medicine, as events usually aren’t coincidental.
• We over simplify.  Who doesn’t? Everything is so darn complicated!  I do wonder if there is so much information and options in medicine that it is too complicated for us to understand, so we instinctively try to simplify to better understand and manage problems.  We arrive on a particular diagnosis and this is the anchor.  We then adjust this anchor based on further information. However, we typically fail to reevaluate and underestimate the probability of a disease even when we have further information.
• We misperceive the world around us.
• Our memory is inaccurate.  Medicine is very much based on what you know, which is based on what you remember.  However, given the explosive rate of growth of information, perhaps as former Google CIO Doug Merrill points out, maybe it’s time we turn from memorizing information to becoming proficient on searching and finding relevant information.
• We classify data based on “representativeness”–e.g. in our experience, does this patient represent a patient with a certain illness?   This works when a disease is common, but fails when the disease is rare, the patient is atypical, or our previous experience was atypical.

If, at the minimum, we are attentive to these filters we place on our thinking, our error rates should go down.  And just for fun, check out the latest JAMA (June 23/30) article entitled “Adherence to Surgical Care Improvement Project Measures and the Association with Post0perative Infections.”  This article shows some errors in common thinking–especially over simplification!

From the ACQR website (Agency for Health Care Quality and Research, a government agency, under the auspices of HHS) is a list of 30 practices to promote better health care.

How does your hospital measure up? Here’s a partial list of outstanding items that hospitals/providers must:

• Institute adequate level of nursing (!)
• Management of ICU patients should be by critical care docs.  (Much disagreement in the literature about this one!)
• Have active participation by pharmacists in medication dispensing, use and monitoring
• Use standard abbreviations (I think we all had this beaten in to us!)
• Clearly document Patent’s “COR” status.
• Implement processes to prevent pressure ulcers.
• Implement DVT prophylaxis protocols — surgeons are you listening?!!!
• Monitor patients with renal insufficiency
• Do surgery on the right patient, and do the right surgery, and do the surgery right!
• Clean your hands.

Okay this is a summary.  But, truly, how well are we doing?  My hospital could use a little improvement on a couple–the COR status and the DVT prophylaxis, not to mention appropriate staffing by nurses.

I was getting a massage yesterday, and it struck me how simple the payment system was.  I paid for a twenty minute chair massage, told the therapist “my shoulders really hurt,” and away we went.  He worked the knots out, and I gratefully sat there in quiet bliss, face smashed against a paper towel on the massage chair.  At the end I said thanks, and gave him a tip.  I didn’t stop as I stood up and say, “But you know, I really hurt in my low back. Can you work on that too?”

Instead, I put my money in the tip jar, and listened as he told me to drink lots of water.  What if doctors were paid that way? What if the patient paid for a certain amount of time, and when it was over, it was over?  If the patient wanted more time, she would have to pay for it.  For instance, if I had wanted him to work more on my shoulders, I would have forked over the cash. Also, I made sure I was ready to start and didn’t waste time chit chatting.  Imagine: the therapist asks: “Are there areas you want to focus on?” and I answer, “well, yesterday, I was playing in my tennis league, and was serving really hard, and then didn’t stretch afterwards, but instead went right to the beverage table, and had snacks–and they were really good, they had those wraps with the turkey and swiss, and ranch, and I really love them. And then I had a glass of wine, red, I think, and then some of those brownies…And so my shoulder hurt, because it started to rain, and I didn’t have my jacket and the car was too far away to make it work my effort and then–.” You get the point.

And if I had chattered on, he would have taken it out of my chair time.

What do you think? A new billing system in the works?

In my last post, I was a bit dark with the factory worker analogy.  However, this is status quo for primary care.  But, given my promise that if I complain about a problem, I will seek to find solutions. So here goes:

Physicians must become leaders and team players.  Sometimes, when I am wearing my EMR consultant hat, I have to remind myself that I am not the boss, I’m a team member, and not necessarily the most important team member!  (I think we physicians love to be the boss–after I told my daughter what I did at work, she commented, “so basically, you bossed people around all day.”  Ouch!) Being the boss is not the same as being a leader!

So what’s a physician leader? Here are things you don’t hear from a physician leader:

• “That’s not how we do things”
• “We’ve always done it this way.”
• “I don’t have time.”
• “You can’t teach an old dog new tricks.”
• “It will never work.”
• “That’s of no benefit.” (I think this was heard at the introduction of hand washing and sterilizing instruments!)

So what are what does a physician leader say?

• “Show me the data.” (We love data!)
• “How we will do this?”
• “Does it improve patient care?”
• “How much does it cost–in terms of time, money and will power, and what resources do we have for this?”
• “Who can I work with to get this done?”

So if you really want to stop being a factory worker physician, get out of your silo. Learn to lead, not to boss, open your mind to new ways of thinking and doing things, and learn to collaborate. And lastly, listen much, speak little!

Picture your average factory worker. She straps on her hard hat, strides to her place in the line, and begins to make widgets.  She does the same job everyday, carefully placing her part of the widget. To make her pay, she must place a certain amount of parts in to the widget.  Sometimes, if she’s not careful she may put her part in wrong, or not notice that something is wrong with the part someone else placed.  It’s hard to notice that things are wrong when she is trying to keep up.  And worse, if she does notice that something is wrong with the part, the whole factory line grinds to a halt.  No more widgets get made until the problem is solved, and other workers up and down the line are upset, because they are waiting for the problem to get fixed so they can get on with their part of making the widget. Finding and fixing something that is broken is disruptive, stops the entire line, and causes profits to fall.  The factory worker is not allowed to charge more because she fixes something–her wage is set and is inflexible.  There is no reason for her to look for problems–she’s paid to keep the line going, not to think about what is wrong.  

Medicine is similar.  The physician walks in to his clinic and has 22 patients to see, one every 15 minutes.  He must keep up his schedule to make his salary and support the staff, and keep the doors open.  He hopes that no one has a serious problem, because there is no time in the schedule to diagnose and fix the problem.  If he takes the time to diagnose and treat the problem, as well as actually talk to the patient, delays creep in to the schedule, and other patients become disgruntled as they are forced to wait.  Worse yet, if the physician makes a habit of taking more time with each patient, his revenues fall because he sees less patients.  He is not paid to think about what is wrong, he is paid to see patients quickly and move on to the next one.  He’s not allowed to charge more–his wages are set by the insurance companies, and the federal government.

And so each toils on–the the factory worker thinking that being a doctor just may be different from working on the line. But is it really? 

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On my quest to educate myself on the business of medicine, I picked up the April issue of the Harvard Business Review, which had a spotlight on health care.  Well, I want to fix health care as much as anybody, so I forked over the $16.95 for the issue.  Some of it was good (a review of Gawande’s Checklist Manifesto, already reviewed here) but other parts made my hackles rise.  (Yup, still got those hackles!)

Jeff Levin-Scherz, MD, MBA, assistant prof at Harvard Medical School and School of Public Health, was the chief hackle riser.He wrote an editorial on pages 72 and 73 on  5 items that “drives high health care costs–and how to fight back.”  Here are a few choice picks from his list:

• “Payment schemes that reward excess”: “he advocates that we all join HMOs because salaried physicians perform fewer procedures.  No matter that many patients and physicians hate HMOs and capitation. Dr.Levin-Scherz must not have practiced in these institutions.  Talk about another way to drive young doctors away from primary care! Practicing in capitated systems is very restrictive, and takes away a value that most physicians hold dear–autonomy! (Mentioned just earlier in the issue!)
• “Small practices, fractured care.” The good doctor states that small practices should  integrate in to large multispecialty groups to “improve communication and accountability.”  He also notes that such large groups are better able to leverage IT infrastructure, and use “non-physicians in a team approach.”  Basically, he sees the answer to rising health care costs is to make all physicians employees that can be forced to be the head of a “medical home” and supervise a group of health care extenders. (God, do I hate that word!)  Yes, large group have leverage in investing in items like EMRs (which by the way have NOT been demonstrated yet to improve health outcomes!), but the physician as employee model again shrinks one of  the hardest working, motivated, driven workers in the American system to that of line worker.  Physicians have huge intellectual capital, and minimizing that by enforced group membership lays waste to a huge resource.
• “A few patients cost a lot.” Yup, they do. He advocates that complicated patients go to”centers of excellence” to receive care from those with “disease specific expertise.”  Would those be the specialists that he says are costing too much money? (Yes, he decries specialists’ salaries, and suggests  that compensation be increased to “attract doctors to general medicine.” I am all for increasing internists and family practice compensation, but that is just one factor in why these specialties can’t attract young physicians.  To be honest, primary care can be a real drag, with relentless hours and countless regulations.  Dr. Levin-Scherz appears to ignore this fact.)

I do agree with some of Dr. Levin-Scherz’s observations and suggestions such as increasing transparency in pricing (a head ct in the US costs $950, but can be had in Canada for around $500.)  He also notes that the price of LASIK surgery has fallen because it competes on price. Dr. Levin-Scherz ignores the elephant in the room: Americans want “everything done”, and don’t care how much it costs, as long as it doesn’t cost them.  I am responsible for meeting this expectation, and am forced to abide by insurance regulations and malpractice pressures.  Dr. Levin-Scherz  neglects to mention that controlling these factors would go a long way toward controlling costs.

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As we get ready to celebrate the 40th annual earth day, I thought it would be fun to see if hospitals and medical clinics are going green.  At the two hospitals where I work, one recycles cans and uses washable isolation gowns, while the other is a dismal monument to a land fill.

Sigh.

But there are some steps that are being made.  Here is a list of “green” innovations that some hospitals and clinics are using:

• Collecting recyclables.  For pity’s sake–why isn’t this at every clinic and hospital?
• Reusable isolation gowns.  They are washed and then reused.  My hospital switched to this, not to be more green, but during the height of the H1N1 season, the hospital ran out of disposable gowns, and realized this was a cheaper option.
• Biodegradable bed pans and bed pan liners made out of recycled telephone books and beeswax.  Supposedly you just flush ‘emwhen you are done. (No, I’m not kidding!)
• Cotton insulation made out of recycled blue jeans rather than fiberglass.  How fire retardant is this?
• Reprocess items that were initially designed for single use.  This includes things like pulse ox finger sensors, SCDs, drills, saw blades and scalpel handles.  Reprocessing is regulated by the FDA, which requires a licensed reprocessing company to perform the reprocessing.  The reprocessed devices cost less than the new, and can constitue a large amount of savings for hospitals.
• Xeriscape planting rather than lawns.
• Low flow plumbing fixtures, non toxic paints, solar panels, and other “eco friendly” options are being used for new buildings.
• Changing to LED or fluorescent light bulbs.
• Using an EMR, which saves paper.

And lastly, as the Economist points out: keep people at home.  The fewer patients in hospitals the less waste created. Ah,why didn’t I think of that?

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Surfing the net aimlessly, I came across the following from Care Practice:

“We offer 24/7 Urgent Care and House Call services with an On Call Doctor available after hours and on weekends to meet patients that require Urgent Care services. Our office is open and staffed 365 days a year because patients don’t determine when they get sick.

It was a busy night at my local hospital.  I spent a lot of time in the ED, and the pager was in status.  The hospital I was at is a large tertiary hospital, and receives transfers from small mountain clinics that send us stuff like chest pain (easy) and hypertensive urgency/renal failure/barfing patients (hard.)  We get patched in to the Tiny Mountain Clinic Doctor, who gives us the skinny, and then we banter a bit about treatments etc, and then the helpful “connect” ombudsman arranges transport.

All good, so far. Except when the mountain doc wants to talk to me right as I am transferring a crashing patient to the ICU.  The helpful connect ombudsman calls me, and tells me that the Tiny Mountain Clinic Doctor needs to talk to me.  “I’m really busy,” I say, “I’m moving a patient to the ICU.  Can I call you back in 10 minutes?”  The helpful ombudsman agrees.  (BTW, our conversation is recorded, and we have all been warned to be polite as the powers that be will slap our hands if we are not.)

I’m busily assessing my patient, trying to get the transfer orders done, when the pager goes off again, not 5 minutes later.  It’s the helpful connect ombudsman.  “Tiny Mountain Clinic Doctor needs to talk to you,” she says.  Needless to say, Tiny Mountain Clinic Doctor takes first priority, even though I already said I would call back after the fire I’m putting out is taken care of.  (After all, we are being tape recorded!)

Oh how impatient we are.  But sadly, oh how impatient I am as well!  Could I just have a minute to think?

I don’t know how you feel about pain management, both acute and chronic, but articles like the recent one in Annals of Internal Medicine(“Opioid Prescriptions for Chronic Pain and Overdose” 1/19/2010, vol 152, #2, pp88) don’t make it even easer.

Basically the article said that 3% of adults are on long term opioids, and that the older the patient and the higher the dose, the higher the risk of overdose.  Add benzos in to the mix, and the risk goes up even higher.  Additionally, the highest chance of accidental over dose is upon initiation of the drug.  The situations that I think are potentially dangerous are the times you have a Little Old Lady right out of surgery, on her valium for sleep (“I’ve been on it for years, Sweetie!”) who now needs narcotics for her hip replacement. And yup,  the orthopods want you, trusty hospitalist, to manage her pain!

I hate PCAs. I really hate PCAs and Little Old Ladies.  (I don’t however, hate Little Old Ladies!)  So whenever possible, I nix the PCAs and try to convert patients on to oxycodone (no acetaminophen–I like to dose that separately), and occasionally on to ms contin with oxycodone for breakthrough.  The only issue I have with this is that nursing staff can get really busy and not get the oral analgesic to the LOL on time, and the pain level sky rockets, and LOL ends up with a shot of morphine or dilaudid.

So what to do?  Anyone know of slick tricks around this so that the  Little Old Lady has her pain managed with oral medications delivered on time?  (By the way, is not a rap on the hands of nursing–I just want to be realistic!) Let me know how you manage pain in this vulnerable population!