Il coraggio di parlare: gerarchie, checklist e sicurezza

Da Biblioteca Medica Virtuale: http://www.bmv.bz.it/j/index.php?option=com_content&view=frontpage&Itemid=1&lang=it

Su BMJ Quality and Safety in Healthcare due articoli sull’adattamento di checklist e programmi per la sicurezza a diversi contesti culturali.

L’aviazione è una continua fonte di insegnamenti per la sicurezza in ambito sanitario. Su Outliers(Fuoriclasse. Storia naturale del successo) Malcolm Gladwell ha raccontato come tra le cause dei numerosi incidenti sulle linee aeree coreane ci fosse una comunicazione indiretta e ambigua nella cabina di pilotaggio, anche in situazioni critiche: una eccessiva deferenza nei confronti dell’autorità del pilota si traduceva nell’incapacità  di evitare il disastro aereo. Tutta colpa di una marcata gerarchizzazione della società: usando la terminologia del sociologo olandese Geert Hofstede, tutta colpa di un’elevata “distanza dal potere”, “la misura in cui gli individui meno potenti di un’organizzazione accettano che il potere sia distribuito in misura diseguale al suo interno”. Si va da un punteggio di 40 per gli USA e 11 per l’Austria, a un punteggio di 80 per la Cina, 50 per l’Italia. Se un’organizzazione è fortemente gerarchizzata, le persone ai gradini inferiori hanno forti resistenze a mettere in discussione l’operato di chi occupa posizioni di leadership. In tali contesti può risultare difficile l’applicazione delle checklist che hanno tra gli elementi chiave la comunicazione tra tutti i membri dello staff. Ne parla Karthik Raghunathan, anestesiologo statunitense di origine indiana, su BMJ Quality and Safety in Healthcare: forte della sua esperienza cross-culturale, dice che le checklist per la sicurezza “possono rendere più semplici le negoziazioni ostacolate dalla distanza dal potere, fornendo un contesto standardizzato simile a quello usato in aviazione e democratizzando l’ambiente”, tuttavia, “comprendere la cultura è cruciale per adattare gli interventi per migliorare la sicurezza in setting diversi”.
L’argomento è ripreso da un altro articolo sullo stesso numero della rivista, di cui è coautore Peter J Pronovost, il creatore della check list per la prevenzione delle infezioni del sangue legate all’uso di cateteri venosi centrali, che con cinque semplici regole ha salvato, e continua a salvare, migliaia di vite. Nel suo articolo si legge: “managers e medici senior non devono rimproverare infermiere/i e medici junior che esprimono le loro preoccupazioni, e ognuno deve sentirsi a proprio agio nel dare voce alle proprie opinioni di fronte a una situazione rischiosa per la/il paziente”.
Infine: in un suo recente discorso Atul Gawande (chirurgo, autore di best seller come Checklist e direttore del Global Patient Safety Challenge dell’OMS) racconta di un intervento chirurgico su una donna anziana, con una grave complicazione, risolta grazie all’intuizione di un giovane interno, a ulteriore conferma della validità del nostro proverbio “sa più il papa e un contadino che il papa solo…”

Fonti:
Jeong HJ, Pham JC, Kim M, Engineer C, Pronovost PJ.Major cultural-compatibility complex: considerations on cross-cultural dissemination of patient safety programmes. BMJ Qual Saf 2012; 21: 612-615
Raghunathan K. Checklists, safety, my culture and me. BMJ Qual Saf 2012; 21:617-620 Published Online First: 4 April 2012 doi:10.1136/bmjqs-2011-000608
Gawande A. Non tutto è  perduto. Internazionale 954, pp 56-58, 22 giugno 2012.

Live & Learn

If you are a Mr. Bean fan and you tuned in for the opening ceremony at the London Olympics, you will be nodding your head in agreement with the chart.  Mr. Bean stole the show playing Chariots of Fire.  If you missed the show, you can catch it on this NBC Olympic video clip.

 

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Chart Source: ilovecharts

Related Posts: The ultimate repeated-note technic @ LaDona’s Music Studio

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Live & Learn

 

 

 

 

 

 

 

 

 

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Source: abirdeyeview via jorthomas149

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SIHTA

“Le decisioni per la sostenibilitàdel sistemasanitario:
HTA tra governo dell’innovazione
e del disinvestimento”

Roma, 22 – 24 novembre 2012

V ° Congresso Nazionale  SIHTA
Società Italiana di Health Tecnology Assessment

Scelta tempestiva del tema congressuale. Ecco un articolo appena apparso sull’International Journal of Technology Assessment in Health Care

http://www.slideshare.net/carlofavaretti/hta-e-disinvestment

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Hey Doc, do you know how much that test costs? @drsilenzi @muirgray @Medici_Manager @agnescheer

By Jeremy Petch & Suzanne Turner JULY 16, 2012

TAGS: Choose Wisely, Cost Savings, EMR, innovation, Test Costs

For our health care system to remain sustainable, scarce resources must be managed effectively both at the system level and on the front lines.  In health care, decisions by doctors have a major impact on resource management in front-line care.  But our health care system does not provide doctors with all of the information they need in order to manage front-line resources effectively.  Specifically, our system does not provide doctors with information about the cost of medical care.  We believe that providing physicians with accurate information about costs, and particularly the costs of diagnostic tests, is an important piece of the sustainability puzzle.

The first thing to realize is that doctors do not know how much diagnostic tests cost the health care system. A Canadian study of emergency room physicians revealed that they have limited knowledge of the costs of the diagnostic tests they order every day, and tend to significantly underestimate the costs of diagnostic imaging.  A systematic review of physician knowledge of diagnostic testing costsfound the accuracy of physician estimates to be low, with fully 50% of the estimates ranging from 50% to 200% of true costs. The review included studies of physicians in a number of different specialties and at different levels of training, including many who had completed their training.  It didn’t matter how much they had trained or what specialty they were in – estimates of true costs were wildly inaccurate.

Okay, so the research shows that doctors don’t know how much tests cost.  So what?  Well the research also shows that when doctors are educated about the costs of tests they order every day, they start ordering fewer tests.  A study in Israel examined laboratory testing habits of physicians at a single hospital for one year following an education course on costs of diagnostic testing. The study showed an overall reduction of 19% in laboratory tests performed at the hospital in the year following the educational program. Another Israeli study involved a system for ordering tests for an internal medicine department, in which notes were placed on the order form about the laboratory costs and diagnostic accuracy for blood testing. The study showed significant reductions in tests per visit, with no difference in the readmission rate or in the number of diagnoses of conditions based primarily on blood tests, between the study group and the control groups. A Swedish study showed similar results in a primary care setting.

We know you’re thinking “I’m not sure I want my doctor to know how much tests cost… what if they didn’t order an important test and my care suffered as a result?”  But there’s a very important detail about those studies: they show a modest but significant reduction in tests with no measured negative effect on patient care.[i]  This research suggests that when doctors are informed about the costs of tests, they still order all the important tests; they just stop ordering the ones they know won’t tell them anything important.

Now, maybe you’re thinking this wouldn’t really save the system that much money.  Not so fast. Canada spent about $200 billion on healthcare in 2011.  Diagnostic tests account for about 10% of health care spending in hospitals.  Assuming that trend is roughly the same in community care, that means Canada spent about $20 billion last year just on tests.  If we can figure out how to bring that number down by even 10%, significantly less than the amounts seen in those studies from Israel and Sweden, then we could be talking about saving the Canadian health care system billions every year.  That should be enough to get our attention.

Of course, the challenge is how to provide this information to doctors in a way that is both accessible and useful.  Doctors already have to keep pace with breaking developments in medicine and there’s not much room left in the medical school curriculum for robust education about costs.  And doctors are under so much pressure for their time that they’re not going to be able to look up the cost of a test they don’t order very often.

The answer, we think, is to put this information at doctors’ fingertips: build it right into the electronic medical record system they use to order tests.  When doctors click the box to order a test on their computer screen, they would see the cost of the test right next to the box (and why not information about test accuracy and clinical guidelines while we are at it?).  They instantly get the information they need, right when they need it.  This doesn’t stop them from ordering the tests they want to; it just provides them with all of the information they need to act as both clinicians and responsible front-line resource managers.

This isn’t a completely new idea – a group of American researchers attempted something similar using clinical practice guidelines instead of test costs. They incorporated practice guidelines for routine laboratory and chest radiographic testing directly into the electronic ordering system of a cardiac care unit, and provided education on these guidelines to house staff and nurses. Their research showed an estimated reduction in expenditures for “routine” blood tests and chest radiographs of 17%, with no significant changes in health outcomes.  This suggests that putting information at doctors’ fingertips right when they need it can promote more effective, more efficient care.

Of course, as with any innovation there are challenges associated with this idea.  Many physicians do not currently use EMRs, so this idea could only spread as fast as EMRs are adopted across the system.  As a result, not all of the potential cost savings could be realized right away.  It’s also important to acknowledge that costs in health care can be difficult to estimate accurately, can vary across regions, and can change as technology advances.  Care would have to be taken in developing accurate estimates and keeping these estimates current.

We don’t want to suggest that this is some kind of silver bullet for sustainability.  But what is exciting about this idea is that we might not need endless committees to start reducing unnecessary tests, we might just need to empower individual clinicians by giving them the information they need to choose wisely.

[i] It should be noted that these studies were relatively small (and thus underpowered), so until larger studies are conducted or a systematic review is performed these results should be treated with some caution.  However, these initial results are promising enough that we think they indicate larger Canadian studies are warranted.

Jeremy Petch is a policy researcher and the opinions editor of healthydebate.ca.

Suzanne Turner is a family doctor.

Is rationing necessary to reduce health care costs? @GIMBE @drsilenzi @kevinmd

by STEPHEN C. SCHIMPFF, MD | in POLICY http://www.kevinmd.com/blog/2012/06/rationing-reduce-health-care-costs.html

Healthcare costs keep rising. Your insurance premiums go up, your deductible and co-pays go up, pharmacy benefits go down. Despite the high cost you get little time with your physician, insurance statements are complex beyond belief and “customer service” seems to be a foreign concept. To combat high costs we are often told that rationing will be necessary. Is that true?

Why are costs so high in this very dysfunctional healthcare delivery system?

There are many reasons. New technologies and drugs are often cited as major culprits. There is some truth to this of course but the real culprit here is inappropriate use. Think of the stomach acid blockers for reflux (heartburn). Good drugs for sure but maybe some lifestyle changes such as less caffeine, less alcohol, raising the head of the bed and waiting a few hours after dinner before going to sleep will work just as well with no cost whatever.

Worst yet is when an expensive test is ordered when diagnosis could have been figured out through a careful history. Did you need an endoscopy with its negative results when the reflux would not abate? Or did you really need a careful history that figured out you were sensitive to gluten? A dietary change solved the entire problem; no pills or procedures needed.

Our lifestyles are a major reason for the escalation of costs. As a society we eat a non-nutritious diet and far too much of it, we are sedentary, we are chronically stressed and 20% still smoke. The results are complex chronic illnesses such as diabetes, cancer, heart disease and stroke. These are lifelong once they develop, difficult to manage and expensive to treat. The real answer is to adjust our lifestyles and to prevent the epidemic of obesity which is a precursor to many of these illnesses. But until we do, costs will escalate rapidly as more and more individuals develop these chronic illnesses – which are where about 70+% of health care claims paid go.

The population is aging as well and with aging come problems such as visual and hearing impairments, joint dysfunction and Alzheimer’s disease. These too incur substantial expense.

There remains in healthcare delivery far too many preventable errors with probably 100,000 individuals dying each year and an equal number dying of hospital acquired infections. Dealing with these two problems will not only markedly improve quality but will also save billions of dollars each year.

And at end of life, often there is a decision made by either patient (or patient’s loved ones) or recommended by the physician to “do one more thing.” All too often this is a mistake with no real benefit to the patient and often more time spend with distress. It is much better to have a realistic discussion between patient (and or loved ones) and the physician and from that a realistic plan for care. This, I hasten to add, is neither a “death panel” nor does it mean no more care and attention. What it does mean is that the care going forward will be just as complete and compassionate but with the more realistic goal of best quality of life possible for as long as possible. Here again, quality ends up costing less.

These are just some of the most notable reasons for rising costs. Many, perhaps most with the exception of those that come with aging, could be addressed with changes in lifestyle, good preventive medicine, attention to quality and more emphasis on patient-physician interaction rather than on testing and referrals to specialists. Add to this good palliative care at the end of life and a very substantial amount of money could be saved while providing better quality.

Physicians can take the lead by agreeing to eliminate those tests and procedures that are often done but which have not been found to add much to the care of the patient. A good approach to this has been presented by Dr. H Brody in the New England Journal of Medicine which was followed up in the oncology field by Smith and Hillner also in the NEJM . The basic concept was that each specialty society create a “top five list” of those tests or procedures that offer little or no benefit to most patients. In Smith and Hillner’s article they suggested – just one of their  examples to reduce costs in medical oncology -that no patient (other than certain well defined exceptions) should receive chemotherapy if he or she was unable to walk into the clinic unaided, there being good data that such patients rarely benefit but often suffer adverse consequences.

Rationing is not necessary. We need to correct the dysfunctional delivery system so it can offer higher quality care at a reasonable cost. It is not impossible to do and no rationing is required.

Stephen C. Schimpff, MD is an internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center and consults for the US Army, medical startups and Fortune 500 companies. He is the author of The Future of Medicine – Megatrends in Healthcare andThe Future of Health Care Delivery, published by Potomac Books. 

Adding Value to Healthcare by Eliminating Waste @muirgray @drsilenzi

Written by Kathleen Roney | July 20, 2012

Becker’s Hospital Review

Tags: Gary Kaplan | hospital CEO | hospital CEO Q&A | Virginia Mason Medical Center

Gary Kaplan, MD, has been chairman and CEO of Virginia Mason Medical Center in Seattle since 2000. Dr. Kaplan is also a practicing internal medicine specialist at Virginia Mason’s clinic in Kirkland, a Seattle suburb. During Dr. Kaplan’s tenure as chairman and CEO, Virginia Mason has received significant national and international recognition for its efforts to transform healthcare. Awards and distinctions include Top Hospital of the Decade by The Leapfrog Group, 2012 Top Hospital — for the sixth consecutive year —and a grade “A” patient safety rating by The Leapfrog Group, a 2012 Distinguished Hospital for Clinical Excellence and Patient Safety Excellence Award from HealthGrades and a 2012 America’s 100 Best Specialty Excellence Award for Overall Cardiac and Gastrointestinal Care from HealthGrades.

In 2002, Virginia Mason embarked on an ambitious program to adopt the principles of the Toyota Production System as its management system. The Virginia Mason Production System, or VMPS, is a system-wide management system that improves patient safety and quality, reduces cost and the burden of work for the health care workforce.

Here, Dr. Kaplan discusses how VMPS helps Virginia Mason eliminate waste — one of the biggest challenges he feels the healthcare industry faces today — to focus on the patient, his perspective on partnerships and how leadership means going against the grain to make the tough calls.

Question: Hospitals pursue partnerships or mergers for a variety of reasons. In February, Virginia Mason and Kirkland, Wash.-based EvergreenHealth approved a strategic partnership. How did you approach that partnership?

Dr. Gary Kaplan: While it is not our first partnership, the EvergreenHealth partnership is important because it was developed and executed at a time when many others, including some in this the market, were consolidating or merging to get bigger, grow market share and enhance pricing power.

Our partnership with Evergreen is predicated on a shared vision and shared goals as well as a belief that a thriving respectful partnership between like-minded organizations makes more sense than a medical arms race.

Q: What would be your advice for other CEOs to ensure a beneficial partnership?

GK: I would advise other hospital CEOs to remember that culture and shared values are just as important as other considerations, such as size and market power, for a potential partner.

We are supportive of a collaborative approach that doesn’t need governance or a balance sheet merger to succeed. I am not saying those things are inherently bad, but I am saying that the recent rapid market consolidation is not necessarily in the best interest of patients and communities. Partnerships need to be complementary to be successful, and our partnerships are great examples of that.

Q: What challenges currently face Virginia Mason Medical Center? How do those compare to current national challenges? 

GK: Our greatest challenge is the same challenge that everyone faces, although they may not all agree it is the greatest challenge. For us it is: How do we create even greater value in our marketplace? We do that here by eliminating waste. We think that [waste] is an enormous problem. That which adds no value is how we define waste. Donald Berwick, the former administrator of CMS and founder, former president and CEO of the Institute for Healthcare Improvement, called waste the “quality dimension of our time.” He is a quality guru, and over the past 20 years, he has come to see how [healthcare] can focus on eliminating waste and how it will add tremendous quality and safety to our healthcare processes and outcomes.

Even though the challenge of waste continues, we feel we are in a good position. Our staff is trained to focus on eliminating waste every day; it is a mindset that exists among our staff. Some estimates say that 30 to 40 percent of what we spend on healthcare today adds no value. When you think about that estimate, it is as much as a trillion dollars of waste, which includes all categories of healthcare: administrative, clinical decision making, overuse of diagnostic and therapeutic interventions, inventory, facilities and more. The areas that may be adding no value are huge opportunities for us to improve.

Q: You mentioned that the Virginia Mason staff is trained to think about eliminating waste every day. How have you made a “waste elimination” mindset a fundamental part of the hospital? 

GK: It goes back to the strategic plan we developed around 2001, which helped to clarify the question: Who is our customer? Everyone says the customer is the patient, but in reality that is not always the behavior of those of us in healthcare. We have designed our systems and processes around us — the physicians and nurses. Instead, at Virginia Mason we have focused on developing systems and processes around the patients. That led us to our core vision and core strategy. Basically, we bet the farm on a quality strategy more than 10 years ago. We wanted our core business strategy to be quality rather than size and market power, and in doing so, to create value for our patients and our communities.

The way we chose to do that was by adopting Toyota Production System principles. We have been applying it consistently longer than anyone in healthcare in. Every one of our employees is trained in its methods. Several thousand members of our staff have participated in improvement events over the past decade. It is a way of life — it is our philosophy and management system. We focus on the belief that we can mistake-proof our processes and get closer to zero defects in the healthcare we deliver to our patients by eliminating waste. It has been a remarkable 10 years centering on this quality strategy and applying the specific methods that we borrowed from manufacturing.

Q: You mentioned that a quality focus and the Toyota Production System influenced Virginia Mason’s philosophy. How do those elements of your philosophy inform your goals for Virginia Mason or where you’d like to see the medical center progress?

GK: Our vision is to be a quality leader not just in Seattle but everywhere. That is what we aspire to be. We also want to help transform healthcare. The way we have chosen to do that is by striving to create a perfect patient experience at Virginia Mason — every patient, every time. We strive to show a great patient experience is possible without building unnecessary facilities and having dominant market share. The patient should not have to wait in the emergency room or on the phone. We strive to give the patient everything they need and only what they need. We want to show that a hospital can succeed in patient experience and thrive economically. Our aspirations are about our patients and about our community.

Q: Can you share one piece of advice or one lesson you’ve learned throughout your career?

GK: I would start by saying that it is important for leaders to have passion. Leaders need to care and to feel emotionally connected with their work and their vision. They need to share that passion and inspire others by appealing both to the head and the heart.

Healthcare today is hard work and it is complex. As senior leaders, we have a responsibility to inspire our people and lead our people, but we need to appeal both to the intellect as well as to the emotions or heart of our people. We need to never lose sight of why we went into medicine.

For me that is part of who I am; I am passionate about Virginia Mason’s vision and what we are working on. I have come to see over time that the combination of intellect and passion will best inspire others to  achieve what is necessary for large scale change at an organization.

A lot of individuals make rigorous intellectual arguments but can’t move organizations forward. Just appealing to the heart without a rational and intellectual foundation is also not the ultimate or best leadership approach. You need both.

Q: Who has most inspired your personal leadership style? What did he/she teach you?

GK: There are many individuals I have been very fortunate to have as mentors. I have also tried to be a student of leadership, constantly watching others and learning every step of the way.

However, my father heavily inspired my personal style. He was a businessman and still is at age 87. I grew up working in his hardware store. I learned about customers and how listening carefully, maintaining a sense of humor and having optimism are really important tenets in leading either a small business or a healthcare enterprise.

Q: Do you have any personal routines or guideposts when you come to difficult decisions? How do you handle that pressure and come out with a no-regrets answer? 

GK: I think it starts by listening carefully rather than having my mind made up and shutting down. I think that may be a pitfall that many leaders fall into. Another would be doing my homework [before a decision]. Leadership is hard work, and you need to take it seriously, which means doing research, talking to many stakeholders and listening to diverse viewpoints. I want to surround myself with people who present varied points of view and not those that just agree with me.

If a discussion is going in a certain direction and even if I agree with it, I will ask for someone to present an opposite point of view so we can hear it and make sure we present all alternatives. After we review and make sure there is fair process for all stakeholders, someone has to make the call. I try not to shy away from making those decisions. You have to make sure that a decision is fairly communicated and you can execute the strategy or tactic.

I also reserve the right to be smarter today than I was yesterday. That may mean we change our minds. When all is said and done leaders today need to have what I think many call managerial courage. We need to be able to sometimes go against the grain, go against the flow and make tough calls.

More Articles on Virginia Mason Medical Center:

10 Things to Know About Virginia Mason Medical Center 
How to Get Hospitals to Think ‘Lean’: 5 Key Principles 
Evergreen Healthcare, Virginia Mason Approve Strategic Partnership 

Health promotion needs to start in medical school

by RICH JOSEPH | in EDUCATION https://carlofavaretti.wordpress.com/wp-admin/post-new.php

I recently took an exam focused on the pathophysiology and clinical risks factors of cardiovascular disease, the number one cause of morbidity and mortality in the developed world. Atherosclerosis, hypertension, and smoking were all there, front and center. Ironically enough, since it was the final exam of our first year of medical school, the instructors decided to reward us with dozens of Krispy Kreme donuts to enjoy during the exam. I tried my very best to see this for what it was, a well-intentioned congratulatory treat, but I could not get past the hypocrisy.

As I interpreted ECG’s with ST-elevation and discussed clinical management of acute coronary events, I looked around the room to see many of my classmates going for second and even third helpings of the donuts. Talk about an innovative way to provide early clinical experience—self-experimentation with risk factors!

I often wonder how the very essence of health can get lost on the front lines of health care. At its very core, medicine is about health promotion whether this happens upstream via disease prevention or downstream via treatment.  It would only make sense that physicians and allied health professionals embody and exhibit the same health behaviors that they strive to instill in their patients.  Shouldn’t those in the health care field be the healthiest employees around? Wouldn’t you think that health care institutions would prioritize wellness? Isn’t the culture of medicine would be rooted in the tenets of healthy living?

The unfortunate reality is that the culture of modern medicine often breeds, perpetuates, and exacerbates unhealthy habits. True, there are the unavoidable periods of sleep deprivation, IV-drip levels of caffeine consumption (although this may not be so bad based on recent studies!), limitations on social life, and hit to one’s love life. Many of these are unavoidable consequences of the intensive, yet necessary training. Certain sacrifices come with the territory.

However, it seems that even in cases when a choice is available, the unhealthy option often prevails.  Even though we pay lip services to the detrimental health consequences of poor diet and physical inactivity, we often do not heed our own advice.  We are trained to ask patients about their smoking habits, alcohol intake, and stress levels. We inquire about their dietary habits (even though we lack adequate knowledge to provide follow-up suggestions). And we encourage them to get exercise on a daily basis.

Meanwhile, we spend nearly all of our waking hours in a stressful setting, living a rushed existence that is inherently imbalanced. The “grab and go” diets reflect this hectic bustle as we hoard, guzzle, and inhale any and every piece of sustenance that we get our hands. Often, this is the birthday cake for a colleague, the soda from a vending machine, or a bag of chips from the cafeteria. We are too busy to sit and eat like civilized folk much or strategically plan well-balanced meals. Time to prepare meals, eat at regular intervals throughout the day, exercise, meditate, and rejuvenate the soul are all luxuries in the medical profession.

My own struggle to maintain a healthy, balanced lifestyle this past year leads me to believe that this imbalance starts at the very outset, in medical school. Now that I am living it, it is clear why medical students demonstrate more significant reductions in wellbeing, and higher levels of depression and burnout than those in other academic disciplines. I feel very fortunate to attend a medical school that is committed to its students’ physical and mental health. I live in one of the most health-conscious areas of the country and this has successfully penetrated the medical culture.

We have access to farmers markets, a med-student only gym, free personal training sessions, a wellness coach, top-tier athletic facilities, and outdoor adventures. The students here take their personal health very seriously, and many can be found exercising at lunchtime, standing and stretching during lectures, and tossing the football at any free moment. The administration has taken note of this and responded in kind by instituting a Wellness Committee and creating a WellMD newsletter. Although I feel very blessed, I feel for and speak on behalf of those at other institutions who do not have access such facilities and opportunities. Given our mission and the message we carry, this should be the bare minimum, and even here, we could be doing better.

Please do not misunderstand this message. In no way is this an incrimination of or a crusade against those who do struggle to maintain a healthy lifestyle. And in no way am I proposing low-carb, no sugar diets with mandatory Iron Man training in medical school. I am simply voicing a concern on behalf of the many medical students out there who are health conscious, yet feel frustrated by the absence of health promotion in medical training. For those of us who have even the slightest inkling towards the healthier choice, it does no good if that choice is not even on the menu.

Most of the time, our brainpower is solely focused on the task at hand—trying to cram in as much information as possible to pass the next exam. It is unreasonable to expect us to devote our valuable mental resources to seeking healthy options, cooking meals, planning workouts, etc. Healthy living is a commitment that requires dedication and energy.  Yet this commitment should be facilitated by an environment that provides an unconscious nudge in the direction of the healthy choice. Medical schools and medical facilities in general should have workout facilities onsite with locker rooms and showers. Cafeterias, kiosks, and vending machines should provide ready-made, well-balanced, and portable meals and snacks. All medical students should be provided with sample meal plans, simple recipes, and tips for cooking in bulk for maximal efficiency. All lecture halls should have areas with standing desks or even treadmill desks so that students are not sitting for 8 hours each day. If I am expected to spend 10-14 hours of my day in one building, I think it is fair to expect that building to support my lifestyle and provide the comfort and amenities of a home.

Medical schools are the settings in which the new cadre of physicians is currently in training. Health promotion must start here. Healthy lifestyle is not s skill set that can be transmitted didactically in a few lectures on nutrition and cardiovascular health sprinkled here and there in jam-packed curriculum. Healthy lifestyle is learned through experimentation, trial and error, goal setting, competition, and hands on interaction, and direct participation. My challenge to the medical schools of the 21st century is to design ways to create unconscious, simple nudges towards healthful choices as part of education process.

Rich Joseph is a medical student who blogs at Progress Notes.

Why does a twittering doctor tweet?- note from ASME 2012 @richard56 @drsilenzi

Interessante messa a punto di Anne Marie Cunningham su che cosa dovrebbe twittare un medico che twitta!

Include una presentazione. Illustra 10 finalità dell’uso professionale di Twitter.

http://wishfulthinkinginmedicaleducation.blogspot.co.uk/2012/07/why-does-twittering-doctor-tweet-note.html

If the government was a physician @drsilenzi

by JORDAN GRUMET, MD | in POLICY http://www.kevinmd.com/blog/2012/07/government-physician.html

If the government was a physician, it wouldn’t be an ordinary doctor like you or I.

It would be a sexy actor like the ones we see on those medical melodramas that have become so popular over the last few years.  His hair coiffed, his jacket pressed and free of stains, and his manor confident he would rush into the trauma bay.  As the beeping monitor flat lines, he would sweep the nurses and residents out of the way, grab the paddles, and shock the poor patients heart back to life.  The wife and children would rush in and profess love to their newly awakened father.  And the super cute head nurse would glance appreciatively at our hero and wink with not so subtle romantic overtones.

Of course, any one remotely involved in health care knows that this is a farce.  Wipe away the syrupy made for TV moment and what we are left with is one simple medical fact.  You don’t shock asystole, it’s useless.  Such subtleties are often lost on those who shape today’s health care policy.  And who could blame them?  Most are politicians, administrators, or physicians who have long forgotten the practice of medicine.

Given the set of circumstances, the ACA is more sophisticated than it first appears.  In fact, much credit must be given for the emphasis on demonstration projects.  This is basic scientific method at it’s best.  Try a bunch of ideas and see which stick.  I couldn’t be more in agreement.

To Medicare’s great embarrassment, recent demonstration projects have shown little measurable benefit for the lynch pins of health care reform: pay for performance and patient centered medical homes.  There is no doubt in my mind that the same will eventually occur with ACO’s.  The problem arises, however, that in Washington, political expedience often carries more weight than courage.  In other words, it may be of no benefit whatsoever to shock asystole, but when the film is rolling, the defibrillator paddles are charged and ready.  It’s a million dollar fundraising moment.  Politicians like these.

But when the lights are turned down and the cameras shut off, we are left with a doctor who knows nothing of the practice of medicine and a health care system wrought with perverse incentives.

We need the real thing.

Not just someone who plays a doctor on TV.

Jordan Grumet is an internal medicine physician who blogs at In My Humble Opinion.

Medical education needs to get a passport

by MICHAEL MANK | in EDUCATION http://www.kevinmd.com/blog/2012/07/medical-education-passport.html

I participated in a medical mission to Haiti with the Hope for Tomorrow Foundation. The trip only lasted a week, but the impression it made will stay with me forever. I experienced a culture shock stepping off the plane: “tent cities” sprawled the streets, sewage and garbage piled up to no end, and the people had nowhere to go.

Upon arriving to the hospital in Les Cayes, there were hundreds of people waiting there for days for our surgical group. The first day of patient screening was hectic and dysfunctional — there was a mad rush to see a physician, women were handing me their children without apprehension hoping that I would cure them, and the line of patients had no end in sight. I was seen as a doctor to them because I was wearing a pair of scrubs. They did not know any better. They only wanted help.

There was a consistent theme: routine and vital services were unavailable to these people. Their conditions progressed much further than medically appropriate. They were suffering from disorders that became complex due to years of not receiving care, and now they could not be resolved with conventional protocols. Sadly, we were only able to help so many. We were limited in the supplies that we packed and the resources that were provided by the hospital, which were bare minimum at best. We were only able to perform procedures that did not require follow-up, and turning those away that did not qualify never got any easier. We needed to triage, and we needed to move onward by performing the procedures.

In the operating room, the surgeons faced a whole different animal. There were only three tables, much of the equipment did not work, and there was minimal help with organizing the rooms. However, due to innovation and personal drive, the surgeons were able to perform about one-hundred surgeries in their short stay. I was able to assist in several procedures ranging from hernia repair, removal of masses, to even an orchiectomy. Many of the extensive surgeries I assisted in consisted of procedures performed in combination that are usually performed individually, and all of these operations could have been prevented if the patients had been treated earlier. I feel that I did more during this week than I have done my whole life.

This experience is one that I do not believe many medical students have encountered, and I think that is a shame for the US medical educational system. Not only would medical students be able to serve indigent and needy populations in remote and isolated areas around the world, but I think they would be able to participate more extensively in medical care than they would otherwise. When I was assisting in the operating room, I had not even stepped foot into medical school. Regardless, I was using scissors, retractors, and even the scalpel — I sliced living, breathing tissue (under the supervision of an experienced surgeon, of course).

I can only imagine the possibilities for actual medical students as they will be able to use their current education and continue to learn more as they work with what seemed like an endless line of patients. Furthermore, the patients I encountered had not received any sort of care in years. In fact, the hospital we worked at had not performed a surgical procedure for four years prior to our arrival. The educational opportunities, along with the ability to enact great change, are endless in underserved countries. The US medical education system needs to get a passport.

Michael Mank is a medical student.

Will recommendations from Choosing Wisely ever be followed? @drsilenzi @kevinmd

by WILLIAM SULLIVAN, DO, JD | in PHYSICIAN in http://www.kevinmd.com/blog/2012/07/recommendations-choosing-wisely.html

Choosing Wisely is the new campaign advocated by the ABIM Foundation to help physicians “be better stewards of finite health care resources.” The recommendations in the campaign have been published in Consumer Reports and has been distributed to AARP members.

At first glance, the campaign seems to make sense. Limit unnecessary testing and decrease costs. However, I predict that the Choosing Wisely campaign will also have many less desirable effects. I picked out a few random examples of current Choosing Wisely recommendations to illustrate some of the problems that I perceive will occur.

The American College of Physicians recommended that we, ”Don’t obtain imaging studies in patients with non-specific low back pain.” Notice how the ACP didn’t describe how to classify back pain as non-specific prior to testing? Third party payors will be citing this recommendation routinely. Any back pain imaging that shows no pathology is likely to be retrospectively labeled as unnecessary because the back pain was non-specific. What if a patient has urinary retention with his acute back pain? Would anyone argue that an urgent MRI wasn’t indicated? However, the MRI shows nothing but an enlarged prostate and the urinary retention was probably just caused by the opiates the patient was taking for the pain. Retrospective diagnosis: Unnecessary test. Doctor should have known better. Patient gets stuck with bill.

The American Society for Clinical Oncology recommended that we, ”Don’t perform surveillance testing (biomarkers) or imaging (PET, CT, and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent.”

Isn’t the idea of cancer survival to catch things early? By the time we wait for an asymptomatic metastasis to become symptomatic so that testing is appropriate, the cancer will most likely be too late to treat. Using this recommendation, third party payors will refuse to pay for follow up screens because they are unnecessary. Patients won’t get the testing, and more patients will die from cancer recurrence.

Are most surveillance tests normal? Of course. But instead of having a group of stewards act as barriers to testing, patients should be presented with data regarding the effectiveness of the testing and then make an informed decision as to whether they want to have the testing performed. If ASCO truly believes that surveillance testing is inappropriate, it should check its own web site. The recommendation against surveillance testing isn’t even one of its own clinical practice guidelines for breast cancer. And if you look at ASCO’s recommendations for use of tumor markers in breast cancer, the Society does recommend use of some tumor markers which seems to contradict their own Choosing Wisely recommendation (“The following categories showed evidence of clinical utility and were recommended for use in practice: CA 15-3, CA 27.29, carcinoembryonic antigen, estrogen receptor, progesterone receptor … “).

The American College of Radiology recommended that we, “Don’t image for suspected [pulmonary embolism] without moderate or high pre-test probability of [pulmonary embolism].” The actual incidence of pulmonary embolism in patients with a low pre-test probability of pulmonary embolism isbetween 4% and 15%. Adhering to ACR recommendations, doctors would miss up to 1 in 7 cases of pulmonary embolism. About one in three patients with untreated pulmonary embolism die, meaning that up to 5% of patients with low pre-test probability of a pulmonary embolism would die using the ACR recommendations. Even if we obtain a normal D-dimer assay in patients with a low pre-test probability of pulmonary embolism, the incidence of pulmonary embolism in patients is still 0.7% to 2.0%. There is no test that detects pulmonary embolism 100% of the time, but shouldn’t patients be making an informed decision whether or not they wish to have testing performed to help decrease the likelihood of this potentially deadly disease?

To push the steward envelope in decreasing the number of imaging tests being ordered, the American College of Radiology has even created its own Image Wisely campaign. However, radiologists aren’t the ones who get sued for failing to order imaging tests — they’re only liable for failing to properly interpret tests that other doctors order. By telling other physicians not to order that testing, the radiologists look like great stewards, but have no skin in the game. If the American College of Radiology wanted to have an impact upon the amount of radiologic testing being ordered, it would have created an Interpret Wisely or a Report Wisely campaign to deter its members from recommending low yield follow up studies on questionable x-ray abnormalities.

While there are many appropriate entries on Choosing Wisely’s list (we don’t need antibiotics in acute sinusitis, folks), many of the Choosing Wisely recommendations either have little applicability or are just too vague. Even recommendations that make good clinical sense don’t appreciably affect the project’s stated goals. How much of our country’s finite resources will be saved by refusing that unnecessary $4 amoxicillin prescription for sinusitis, anyway? Many of the recommendations in this project will give bean counters extra ammunition to use against us in determining our worth as physicians, in determining whether we are appropriately compensated for our services, and in shaping a negative public opinion about how uncaring physicians perform unnecessary and wasteful testing and treatments.

In addition, many of the tests that Choosing Wisely recommends withholding from patients have some element of physician judgment involved in deciding whether the test is indicated. See catch phrases such as “low-risk”, “asymptomatic” and “non-specific” within the current Choosing Wisely recommendations. These judgment calls limit the applicability of the recommendations, but don’t we see where this is headed? Like the non-specific back pain example above, once a test has been interpreted as being normal, third parties are going to retrospectively second guess the physician’s judgment in order to avoid paying for the test: “The doctor misclassified the patient as ‘intermediate-risk’ when the patient was really ‘low-risk’ and therefore [insert name of negative test] was not indicated.”

Insurance companies will have an incentive to use this discretionary language to refuse pre-authorization for expensive testing or treatments and to deny payment for tests that were performed.

Before any tests or treatments make the Choosing Wisely list, there should be proof that the involved activities are truly unnecessary and that no harm to patients will come from excluding those tests. If, instead, the tests are deemed low yield or discretionary an evidence-based assessment of the risks and benefits of the testing or treatment, including a summary with projected cost savings and projected morbidity and mortality, should be published along with the recommendation and the public should be allowed to comment on the summaries and recommendations. Using this information, patients could then decide whether or not they are willing to forego the testing and/or treatment based on their ownassessment of the risks and benefits of the testing or treatment. Doctors need to focus upon informed consent, not upon paternalism.

Choosing Wisely also needs to emphasize that many low-yield tests are performed due to a fear of lawsuits and that those discretionary tests might not be necessary if physicians were not held liable for failing to diagnose highly unlikely diseases or for failing to prolong the lives of terminally ill patients by a few months.

The Choosing Wisely campaign has good intentions, but isn’t a good idea. There isn’t a Suing Wisely campaign for attorneys and there isn’t a Legislating Wisely campaign for Congress. The amount of discretionary medical testing performed in this country is undoubtedly excessive, but in order to diminish the amount of discretionary testing, we shouldn’t erect barriers to performing those tests. Instead, we should help our patients understand that medicine will never be perfect and that sometimes doing everything or getting every test isn’t in a patient’s best interests. Until we impart this wisdom upon our patients, it is unlikely that any recommendations from a Choosing Wisely campaign will be routinely followed.

William Sullivan is an emergency physician and an attorney and who blogs at Dr. William Sullivan’s Med Law Chronicles.

Social Media Healthcare

Initially posted on the Society of Teachers of Family Medicine blog, July 16 2012.

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In this post, I described why I think physicians benefit from being active in social media.  The combined benefits of enhanced partnerships and new connections, keeping up to date with recent clinical and health policy information, and expanding one’s understanding of healthcare from the perspective of patients and other health care providers are valuable outcomes that all physicians should value.  After all, why do we read journals, attend CME, watch webinars and listen to conference calls?  To keep our clinical knowledge up to date in order to provide the best care for our patients and to learn from each others’ experiences.  Active participation in social media can provide those same benefits.

Over the last couple of years, I have seen more and more family physicians becoming active on social media, especially on Twitter.  I…

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The first step to changing the culture in healthcare @muirgray @drsilenzi

by VIPAN NIKORE, MD | in PHYSICIAN http://www.kevinmd.com/blog/2012/07/step-changing-culture-healthcare.html

“Look left, look right”, our group leader told us. No, I was not learning to cross the street. Rather it was my first day of employee orientation at the IBM Software Lab over a decade ago. I was fortunate that our CEO was Lou Gerstner, arguably one of the greatest CEOs who has ever existed. Gerstner stepped into IBM in the early 1990s when the company was struggling. One of the key changes Gerstner made was to change the corporate culture of IBM.

“Culture isn’t just one aspect of the game – it is the game,” he stated, and “looking left and looking right” was a metaphor for teamwork, for doing whatever you can to help others within the organization, no matter where they worked in IBM. Software development, marketing, sales, operations, consulting, and others were all united as one IBM. The end result was that Gerstner became a legend for bringing about one of the most remarkable corporate turnarounds in history, transforming IBM back into the powerhouse that it had been.

The medical field could learn something from Gerstner. No matter what hospital you visit anywhere in the world, chances are you’ll see a distinct demarcation between various fields. As youth, most individuals are taught not to generalize people, but in the medical field I find that rigid generalizations about various professions are thrown around all the time, and there is a lack of respect between fields. There is even criticism between hospitals in the same field; “they screwed up the management there,” is something commonly heard. These criticisms are uttered despite the critics’ limited information of the particulars and despite knowing that medicine is an extremely complex field and decisions are rarely black and white.

I am in internal medicine, and I love and take pride in the field I chose. But I could not imagine what we would do without our surgeons who work their rear ends off into the late hours saving lives, I recognize the massive breadth of information that emergency medicine and family medicine physicians need to know, and I cannot thank our nurses enough for the bedside care they provide to patients. The list goes on and on, with pathologists, pediatricians, radiologists, physical therapists, psychiatrists, pharmacists, social workers, and others. And yes, I have had some extremely unpleasant encounters with certain individuals in many of the fields above. A handful of inappropriate individuals in a field, however, doesn’t mean you lose respect for all individuals in the entire field.

For those who work in healthcare, listen for one day to how many positive comments are made about those in other fields and how many critical comments or negative generalizations are made. Chances are the result will astonish you.

I wouldn’t be surprised if our culture of criticism is one of the worst in any field. But changing the culture of the entire healthcare system is not an easy task. I do not have all the solutions, but I think the first step to changing the culture in healthcare is awareness that it needs to change. People must consciously remember that every person has a different and useful role in the system. Changing how we are educated will make an impact as well. The more people in various fields collaborate, whether it be during the training years or even on the job, the more respect between fields will result. Why? Because when you know individuals in other fields on a personal level and you work together toward a common goal, you tend to respect them more.

The bottom line is that a change in culture that values respect and teamwork amongst health professionals will serve our patients better, and it will make the medical field a much more enjoyable place to work. We in healthcare can either work toward a culture change or stand still and become dinosaurs while the rest of the world reaps the benefits of collaboration and teamwork.

Vipan Nikore is an internal medicine resident physician and the President and Founder of the youth leadership non-profit Urban Future Leaders of the World (uFLOW).

You deserve superb integrative health care @kevinmd

by STEPHEN C. SCHIMPFF, MD | in POLICY

Is it possible that health care can become more effective, more personalized, more attuned to real health and wellness in a manner that truly benefits the patient as a customer/client?

The answer is “yes” but it will require understanding the dysfunction in the delivery system today, dealing with the growing shortage of primary care physicians and their non-sustainable business model, changing the insurance paradigm from prepaid medical care to (high deductible) true insurance for the catastrophic, and patients taking on greater responsibility for personal health and wellness.

There is excellent research and innovation along with superb providers is in this country. But the delivery system is dysfunctional and to date America has tolerated this dysfunction. It’s a medical care not a health care system. The emphasis is strongly on disease management and not disease prevention or health promotion. American medical care is very expensive, about $8,000 per capita, and yet outcomes are not what they could or should be. For example, America does not have the lowest infant mortality rate nor the longest life span. Other developed countries beat us on both counts. Medical care of acute illness is generally quite good in the United States but chronic diseases like diabetes, heart failure, chronic lung disease, etc. – of which there are more and more occurring – are not adequately cared for. The system is provider oriented rather than patient oriented and the patient is not the real customer of the physician or the insurer.

There is a shortage of primary care physicians and this is getting worse every year. Only 30% of American physicians are primary care physicians compared to about 70% in most other developed countries. Medical school graduates prefer to enter specialty practices. Those still in primary care practice often take less than adequate time for the prevention of chronic diseases. And too few appreciate or at least offer the time needed for chronic illness care coordination nor do they regularly integrate other options for care such as acupuncture, mind-body medicine, massage, etc.

Since today the patient is largely not the customer of the doctor, a good place to start is to change that paradigm. A high deductible health policy means that the patient will now be paying the primary care physician directly for care and thus this changes the professional-client relationship to a more normal occurrence. The physician will now become more attentive, allocate more time, offer more preventive care and will coordinate the care of chronic illnesses. True, the charge will be the same (unless the physician drops insurance entirely) which may not be any more adequate than before although the PCP should be able to save on the costs of billing and coding. When the PCP no longer accepts insurance and either charges fee for service or establishes a retainer based practice, the contractual relationship between doctor and patient is heightened.

Individuals also need to take more responsibility for their health and wellness directly. Attention to nutrition, exercise, stress and tobacco are key first steps. Work place wellness programs can materially assist. They can offer a health care premium reduction in return for engaging in added educational and action programs such as nutrition, fitness, smoking cessation and stress management to improve lifestyles.

Social networking can have an increasingly beneficial effect. Lifestyle changes are easier to accomplish in a peer group setting. Usually we think of this as a physical group setting but it can also be done through the use of social media. Groups help give a positive reinforcement for behavior change. Social networking through sites such as Facebook, Twitter or YouTube or others can be used to leverage the medical care delivery system to become more patient centered, more effective at the coordination of chronic illness, more attuned to prevention and responsive to true integrated medicine.

Everyone should have a primary care physician, one well schooled in the most current evidence-based care approaches yet who is attuned to the full gamut of integrative medical approaches such as chiropractic, nutrition, personal training, massage therapy, and acupuncture. You need to be sure that your primary care physician will spend the time needed to deal with health and wellness and not just disease. You may well need to pay your primary care physician directly rather than via insurance but the primary care physician will then be financially able to offer you the time you really need and deserve.

You deserve superb integrative health care but to get it you will need to take some action to obtain it. Call it a balancing of rights with responsibilities. It may cost you directly rather than via insurance but you may well find that the return on investment is well worth it.

Stephen C. Schimpff is an internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center and is chair of the advisory committee for Sanovas, Inc. and the author of The Future of Medicine – Megatrends in Healthcare and The Future of Health Care Delivery- Why It Must Change and How It Will Affect You from which this post is partially adapted.