A Christmas Toast

Dearest family,

I am so thankful to be here with those I love.  It has been a difficult year and the messages of the months just past are grim, indeed.  We are embattled with Nature.  A "storm of the century" did unprecedented damage to our homes leaving too many of our Long Island neighbors without a place to stay.  Much of the repair and restoration still lies ahead and will take a long time.  But we will never restore the lives lost to the storm, and these also included some we know by name.  We have so rarely felt so vulnerable.  And what is worst perhaps is that this nightmare may be the "new normal,"  a result at least in part of human activity, an environmental injury to which each of us contributes every day.  

We are embattled as well with one another. I am reminded of the description a recovering addict once offered to describe how he reached bottom:  "I reached a state of degradation that surprised me by being even lower than my rapidly declining personal standards."  And so it was in Connecticut when twenty young children were murdered in a sudden, random and awful act.  No doubt mental illness played a role.  We must believe this because to believe that a sane human being could do such a thing would be to accept an account of human nature that is beyond our imagining.  

Too many Americans are following too many elected leaders toward a state of paleolithic tribalism fueled by the basest of instincts.  The marketplace of ideas is noticeably unpopulated.  Deliberation is out; ad hominim attacks are in. Take-no-prisoners politics has eroded our ability to respect divergent views, to find common ground, to solve problems together. 

We come together around this Christmas table despite these sorrows...to share what is still beautiful in our world -- this meal, a gesture of affection, your laughter, the Overture to Messiah, a December sunrise over Northport Harbor...and in doing so to stake a small claim to a different future, a better way forward.  Whatever the circumstances of the real, historical Christ child, we believe that He represented the idea that a single soul can re-create the world in ways that defy probability and common sense.   In our modern parlance, what I am describing, family, is your goodness going viral.  

As Andy Warhol noted "They say time changes things, but actually you have to change them yourself."  God bless us every one.

    

Whose body is it, anyway?

A study reported recently in the Journal of the American Medical Association found that three strategies for regulating long term asthma medications produced similar results.  One of these involved symptom diaries, while a second used sophisticated nitric oxide exhalation testing.  The researchers found that neither produced better results than a third strategy, which was simply to suggest that patients regulate their own medications based on symptoms.  

Two things struck me about this study.  One was that simple solutions turn out to be best more often than we may expect.  The second was what the authors said about their findings:

“The data from the study are reassuring that we’re doing no harm in allowing this flexibility.”

Allowing this flexibility?  First, I hope these academics know that patients regulate their own medications - for asthma and a host of other conditions - with or without permission.  Second, and more fundamentally, this inadvertent expression of paternalistic medicine sounds weirdly out of synch with the contemporary movement toward collaboration between care providers, families and patients.  After all, the person with a chronic disease will only enjoy the best possible health if she becomes as expert in her own care as her physicians.  Or more so.

Which is not to say that I favor the practice of laying out a smorgasbord of choices for those who come to us for care.  (Back pain?  Tell me what you'd like - an X-ray?  An MRI?  Referral to a chiropractor?  How about a nice spine surgeon?)  While this latter approach, which has become common in some quarters, seems to empower the patient and support her autonomy, it deprives the person seeking care of what is most helpful, and that is the thoughtful and informed opinion of the physician.  

But some raise an objection here.  Bioethicist Robert Veatch has suggested that since literally every medical decision is value-laden, and for the most part physicians do not and cannot understand their patient's values, it is impossible even in principle for the physician to make medical judgments in the "best interest" of the patient.   One treatment carries more side effects but the alternative costs so much that I'd need to sell my house.  What textbook tells my doctor which one is "right for me"?

When I pick a primary care physician to supervise my health I want him to have the right knowledge, skill set and dedication to do a really good job.  I'll also want to make sure that he's flexible enough to work with me when I need to call the shots,  but confident enough to tell me what he thinks is best.  It's a tall order.

How Your Doctor Can Provide Safer, More Effective and More Efficient Care: The Role of Clinical Decision Making

During the last decade, health policy experts have devoted much thought to faulty "systems" and their influence on healthcare quality.  The idea is that even very qualified and devoted professionals will fail if the infrastructure of the healthcare system fails to promote effective information management, communication and coordination, while creating safety nets for high risk situations - like surgery and medication delivery - that keep inevitable human errors from actually harming patients.

This represented a significant departure for the medical profession, which for generations had focused single-mindedly on the individual physician as the unit of quality. However, as we confront run-away costs and uneven quality at a level that constitutes a national crisis, our focus must shift once more.   The safety agenda circa 2000 was about executing on the physician's plan of care.  Now we must re-direct our attention to the way physicians create that plan, and indeed to the way physicians diagnose and treat.  We need to think about thinking.

The "Medical Student Write-Up" was the place where past trainees (like me) first practiced diagnostic thinking and patient management.  It begins with a series of steps which, truth be told, physicians practice and, one hopes, improve upon over many years.  The patient arrives with "complaints" - like fever and abdominal pain - and the physician decides what other information is necessary to narrow the list of possible causes.  These "hypotheses"are then tested against the physical examination which may reveal findings (like right sided tenderness) that increase the likelihood of some diagnoses while ruling out others.  It is only at this point that additional tests, if any, are considered.  The thoughtful practitioner selects each test because the result - whatever it may be - materially changes the relative likelihood of one diagnosis as opposed to another. Additionally,  tests are prioritized based upon the urgency of the particular diagnosis under consideration (appendicitis, for example), the invasiveness of the test (like radiation from a CT scan), and, possibly, but not usually, its cost.

Here's the thing.  Busy, experienced practitioners see patients with certain complaints often enough that the sequence of steps becomes (somewhat) predictable.  And if the test is done often enough in a particular setting, it becomes a "standard of care" whether for the doctor individually or at the level of his peer group.  Sometimes this is a good thing, especially when the benefit of a test easily exceeds its risks and costs. There is a problem, however.  The more often such decisions are placed on "automatic pilot," the more removed the physician becomes from engagement with the facts of the case, hypothesis testing and critical thinking.  Over-use, diagnostic errors, over-exposure to harmful studies and excessive cost are ALL side effects of over-reliance on the "automatic pilot".

How do we know when doctors are on auto-pilot?  The fact is that it can be hard to tell.  And the reason for that is that many physicians have fallen away from the habit of recording their thought process in medical records.   Production pressure is one reason for this. Another is a misplaced notion that writing less is protective against medical malpractice (it isn't).  And paradoxically, the advent of electronic health records has made the situation worse, at least temporarily, as practitioners try to figure out how to use a combination of point-and-click, drop-downs and "free text" to replace what they once wrote with a ball-point pen.

The next time you see your doctor with a problem that needs diagnosing and she orders a battery of tests, ask the question.  What will this blood test or that MRI tell us?  Will it change the treatment?  Good diagnosticians have a reason for every test they order.  So if the answer is that "these are just the routine tests we do," think about another physician.  One who can share her thoughts and has thoughts to share.

      

Getting through the storm

Superstorm Sandy.  The waters have receded and the roads are (mostly) cleared.  But our homes are still largely dark and cold, and many have been rendered homeless.

I am writing this evening from the Riverhead, NY residence of my very generous father-in-law, who has opened his home to my wife and me, my mother and several friends.  Meanwhile, back at the hospital, nurses and physicians, ancillary staff and administrators are still working round the clock in the face of high volume in the ED and an overcrowded facility.  Why?  We can't discharge patients to unsafe conditions at home.  We can't discharge patients to long-term facilities and nursing homes that won't accept them, because their facilities are dark and their workers stranded.

Gridlock.

I have to say that like many, I have done my share of eye rolling when, in previous weeks and months, our COO called special meetings about disaster preparedness.  When the facility is humming along, the skies are blue and a dozen other challenges call out for attention, preparing for hypothetical catastrophes just doesn't seem like a good use of limited time.  We all feel differently now.

There have been positives.  On a personal level, I have been gratified to have opportunities to spend time with people one-on-one that I would not ever have had otherwise.  (Having spent Monday morning to Tuesday night in the hospital through the heart of the storm, I found many chances to engage my colleagues in discussions we would never had had under other circumstances...)  And then there was the camaraderie, the high spirits despite fatigue and the sense of shared purpose.  When every thing is going well we can be pretty self-centered.  The sommelier telling us that the Pinot Noir is unavailable becomes A BIG DEAL.  It takes a little disruption to set us straight.

There was one other lesson.  We have been conversing as a healthcare community about the issue of waste.  Unnecessary CT scans,  unwarranted consultations, inappropriate consultations. Under conditions of duress, these problems are magnified.  When the scanner is down, it MATTERS that we not order tests thoughtlessly.  And so, at a recent meeting of hospital leaders, I suggested that we keep this experience in mind when the dust settles, and get busy with the problem of eliminating waste from healthcare.  More on that next time.

To those of you in the path of Sandy, please accept my most sincere wishes for a safe recovery.  Keep the faith.

By my side

The federal Center for Medicare and Medicaid Services has enacted new rules for hospitals to ensure the right of every patient to have someone - such as a spouse, relative or friend - to help them make medical decisions and to provide emotional support.  This is a very good thing.

The experience of serious illness carries with it not only the crisis of confrontation with our own mortality, but also, all too often, alienation and a sense of powerlessness.  Our hospitals and medical profession have, in the past, done much more to exacerbate this kind of suffering than to address it.  From Doctor's Orders to Visiting Hours, it is no wonder that in his role as a terminal patient in "The Bucket List" Morgan Freeman's character talks about "busting out" of the hospital.  Indeed, leaving "Against Medical Advice" is as unsanctioned (and liberating) as a jailbreak.

Persons receiving hospital care have the right to appoint a "representative." The healthcare team, led by the physician-of-record, communicates with this individual just as it does with the patient himself, and so allows the patient the opportunity to share decision-making with another trusted person.  The new rules also provide for a "support person" who may or may not be the representative.  This person helps with visitation, ensuring that anyone the patient wants to visit can do so while also helping to protect the patient's privacy by limiting visitation in accordance with the patient's wishes.  

Among the traditions that may be most offensive to the autonomy of hospitalized patients is that when certain procedures are undertaken, the patient's visitors - even a spouse - may be asked to step out.  This goes on regardless of the patient's wishes.  A variety of explanations are offered: the procedure will be too upsetting for the visitor, or the visitor may faint, or the staff will be distracted.  None have ever been studied scientifically, and to the extent that unrestricted visitation has been evaluated, we know that it is helpful to patients.  Moreover, it is their right.

When I need the services that can only be provided in an acute-care hospital, I will want my wife or my children there.  I will understand that the number of visitors may need to be limited if I have a room mate, although I think that double rooms are a questionable practice and need to be abolished.  I will probably ask my wife to be there if I need a tube inserted into my stomach or chest, unless I am asleep for the procedure.  If I have grandchildren at that time, I will decide with my wife whether it is in their best interest to come into the hospital, and not leave that decision to hospital staff.  And if I become unable to make decisions on my own behalf I will expect my physicians to treat the decisions of the person I have pre-appointed as though they were my own.

Surely not all patients will want the same things or decide in the same way.  This is very much to the point.  But every patient will have the right to decide how they decide and how they live within the walls of the hospital, walls that we can hope will represent not incarceration, but patient-centered care.

 

What IS Romneycare? And can we possibly afford it?

With the rhetoric flying in every direction in this pre-election season, separating fact from fiction is a daunting task, especially in the complex world  of healthcare delivery and finance.  Figuring that his party's own websites would provide the most favorable take on Mitt Romney's healthcare position, I visited www.mittromney.com/issues/health-care.  This is what it says:

"On his first day in office, Mitt Romney will issue an executive order that paves the way for the federal government to issue Obamacare waivers to all fifty states. He will then work with Congress to repeal the full legislation as quickly as possible.

In place of Obamacare, Mitt will pursue policies that give each state the power to craft a health care reform plan that is best for its own citizens. The federal government’s role will be to help markets work by creating a level playing field for competition."

Certainly this is consistent with the Republican platform.  The fix for unemployment: less government.  For the environment: less government.  For energy: less government.  For education:  less government.  

Here are my concerns.  

1.  Policy analysts and experts from many quarters - the Institute of Medicine, National Quality Forum, Institute for Healthcare Improvement, academic centers, various professional societies and others - have weighed in.  To the best of my knowledge, no credible expert has made the claim that "less regulation" is the key to reversing our spiraling healthcare costs. 

2. As we all know by now, the US pays more for healthcare than any other nation in the industrialized West with poorer outcomes than most.  Now, how many of these more successful nations provide examples of the Romney philosophy succeeding in reducing cost and improving quality?  Answer: none.

3. The Romney philosophy fails on the level of principle.  The unsustainable hyper complexity of the private market has been a part of the problem; it can't also be the solution.  So has a fee-for-service market that pays for interventions rather than outcomes.  The predictable result has been a vicious cycle of "more" - more tests, more images, more operations, more hospital admissions - more than are good for us and more than the best medical scientists recommend.  

Mitt ought to have asked some doctors.  Believe me, we understand over-regulation.  But in the doc's Main Street office, it's not "gumment"  that's the bogeyman.  Talk to the staff - multiple individuals in each office - who spend all day, every day interacting with multiple insurance companies (the folks that Mitt is counting on to fix the problem).  Each one has its own separate rules.  What tests require "pre-authorization" (by a clerk).  What antibiotic your doc can order.  What screening tests you can have.  And every time any insurer says "yes" to anything, it is eroding its own profit structure and harming its shareholders.  This conflict of interest is not theoretical.  Your doc feels it.  Every day.

Free markets work exceedingly well in so many areas of our economy.   But even the framers of our Constitution favored public libraries; and (public) fire departments were established in Colonial America to serve the common good.  Romney-style private competition as mis-applied to our national healthcare system not only leaves unperturbed the cycle of spending, complication, quality problems and waste, but worse yet throws gasoline on the conflagration.  Cooler heads must prevail.  

[DISCLAIMER:  the foregoing comments are the private views of the author and not necessarily those of Huntington Hospital or the North Shore LIJ Health System.]

Flu shots for hospital staff -- should they be mandatory?

Backed by a number of studies, healthcare policy experts at the CDC and elsewhere have advocated for some time that all healthcare workers be immunized against influenza.  There are two reasons for this.  First, during an epidemic, an infected healthcare workforce can dangerously strain our national infrastructure at a time we need it most.  Secondly - and this is the major argument - infected professionals can unknowingly transmit this virus to susceptible patients with potentially serious consequences.  This is especially true when the patient is an infant or an individual of any age who is debilitated by chronic disease or an impaired immune system.

Is there any plausible counter-argument to mandatory, universal immunization for hospital staff?  One might doubt this, when experts recommend a flu shot (with rare exceptions) for every healthy child and adult, every year, and when hospitals will immunize their staff members on site and for free.

And yet, predictably, there are naysayers.  This is not a scientific controversy, but a disagreement over the rights of nurses, respiratory therapists, and even doctors as regards a health intervention with a non-zero risk.  (The benefits of the vaccine, which in its most common form contains no infective material, are believed to far outweigh the remote possibility of severe allergic reaction or neurological side effects.)

Whose rights prevail - those of the many (the patients) or of the one (the professional)?   This is no more or less than the familiar red/blue debate of our day.  In the current instance, however, it is colored by other considerations.  How far does our professional obligation go in compelling us to sacrifice for the good of our patients?  "Professionalism" clearly mandates physicians to place the patient's interest before all others.  Does this extend to flu shots?  And does it extend to the rest of the team?  The boundaries of professional obligation (and perquisites) are determined jointly by society and the profession itself.  What do YOU think?  Write a reply and share your thoughts.  And, by the way, don't forget to get your flu shot this Fall.

And the winner is...

Earlier this week, US News and World Report published its most recent ratings of hospitals nationally.  And my hospital made the top ten list - twice!  Huntington Hospital in Huntington, NY, a member of the North Shore LIJ Health System, was ranked 9th in the metro-tristate area and an impressive 7th among all hospitals in NY State.  And as number 1 though 6 were large university medical centers, I can say accurately, and with much pride, that we were the top-ranked community hospital in the state.

Which raises the question, what does it mean to be a "better" hospital?  The answer is as hard as "what makes a better university"?  Or a better community?  US News looks at a range of data, from nursing ratios to medical equipment, complication rates to patient satisfaction, and importantly, "survival" - or what we call the "risk-adjusted mortality index."

One concept that fascinates me is standardization in healthcare.  Quality gurus from the halls of industry have migrated to healthcare to spread a religion that makes holy war on "variation."  Variation causes inefficiency and errors, and is to be suppressed.  This is not so odd as it at first seems.  If three patients in the ER are being admitted with the same kind of pneumonia, why should they receive three different drug regimens, just because their various physicians were "trained that way." Surely this drives up cost (while driving harried nurses up the wall).

And even more important, with all these differing orders to keep straight, this kind of random variation taxes our limited resources, slows down care and even increases the likelihood of an error.  So you can keep your doctors' prerogative and your "autonomy."  Pass the standard order set, and if it works for my patient, I'll sign it.

But can we embrace standard protocols while also paying close attention to each patient as a unique individual?  Whose illness experience is her own?  Can we adopt an industrial model of patient "throughput" while also making certain that NO one refers to the kidney infection in Bay 6? This is Medicine's other great challenge.  And if it's me in the hospital bed, I hope my team can be scientific, a little OCD, and possessed of hold-my-hand warmth and connection, all at the same time.  That's a great hospital.

The Medical Home: More Credo than Blueprint

The speaker at this morning's Grand Rounds invited us to stop her with questions or comments at any point and so I did.

She was an expert from a nationally recognized healthcare think tank and her topic was the "Patient Centered Medical Home" and she had just finished mentioning that the concept came out of Pediatrics, and that in her opinion the defining characteristics of this model were the availability of a database to follow populations with special problems and teams of advanced practice nurses to do patient education.  I disagreed.

The field of Pediatrics did not invent or discover the patient-centered medical home.  Rather, our leaders described what we already did and gave it a name.  Its underpinnings are not about "processes" but about a culture and a shared set of beliefs about where the obligations of the patient's primary care physician begin and end.  At its center, the pediatric medical home is a place where physicians, nurses and other team members take responsibility for the whole child and her family.  What the consultant says, what the surgeon recommends, what the school needs, whether the medications from two specialists are compatible, what the insurance company will or will not do, how mom and dad and the siblings are coping - it's all our concern.  Not because a federal program has offered to compensate us according to some new and innovative formula, but because it's our job.

Not that I am opposed to innovative compensation mechanisms that promote this work. I have no illusions.  In the world of child healthcare we can afford to do this precisely because most of our patients don't need it.  As the population ages, however, and more and more baby boomers find themselves caught in the maze of contemporary medicine, ricocheting between the endocrinologist, the cardiologist and a variety of other specialists, our colleagues in adult primary care will need to find imaginative ways of keeping up with the care coordination needs of these individuals.

This will not be free, but it will be much, much less expensive in financial and non financial ways than the (current) alternative.  Welcome home.

Embracing uncertainty is the defining feature of Medicine and of all good Science

A front-page headline in yesterday's New York Times announces an apology to the gay community authored by an aging giant in the field of Psychiatry.

Dr. Robert L. Spitzer has retracted the findings of a study that he published in 2003 which evaluated the effect of "reparative therapy," a technique aimed at "reorienting" gay individuals to heterosexuality.  Although the methodology of this retrospective inquiry was criticized as deeply flawed by his peers, the key finding - that reparative therapy seemed to be effective in "curing" homosexuality in some cases - influenced the national conversation on gay rights in ways that were offensive and damaging to  the gay community.

For me, this retraction is important and relevant.  Most obviously, because it is welcome news to a minority that, despite progress on many fronts, still faces societal discrimination, especially from the religious right-wing. At another level, however, it says something about the way good Science, and good scientific Medicine work.

Despite the widespread use of the term "scientific certainty" to denote significant surety,  this use of language reflects a misunderstanding of the scientific method and the nature of scientific knowledge.  The opposite of "Science" is superstition, while the sine qua non of Science is what philosopher Carl Popper called "falsifiability."  (More on what this means next time.)  Suffice it to say that falsifiability means, among other things, that a scientific claim is, by definition, one which can be overturned with evidence or, in many cases, with a more careful analysis of existing evidence.

Which in turn means that the process is self-correcting in a way that dogmatic thinking is not. This may unsettle individuals who perceive that the house of Medicine is like a pinball, ricocheting incessantly from one position to another.  The better metaphor, however, is probably that of a seagoing vessel guided by a skilled but invisible captain who counters the currents and shifting winds, bringing her direction through small but frequent corrections closer and closer to the desired course.  That course refers, of course, to verifiable truth; in the present case it means a clearer understanding of sexual orientation, not a concept retrofitted to accommodate someone's ideology but one arrived at through the collaborative scientific method, and for the benefit of all, regardless of health status, race, gender or sexual orientation.




  

Autism, Obesity and the Metabolic Syndrome

AUTISM.  No childhood condition is more complicated or less understood.  We're not even sure how to talk about it.  Is it a "condition" at all, or more like a symptom pointing to other underlying problems?  And if the latter, what kind of problems? And perhaps most vexing of all: Is the prevalence of autism increasing?  The is very good reason to believe that some of the apparent increase is the result of better detection among mildly affected children; reclassification, or what some call "diagnostic substitution" seems to be at work as well.  But is there more to the story? We don't know.

One thing is clear.  We will never understand autism until we understand its causes.  And such causes appear to be numerous and diverse. Researchers are reasonably certain that autism has a strong genetic basis, but that "environmental" factors play an important role as well.  Does this kind of thinking make sense?  Skeptics argue that this is just a lot of mumbling among scientists, and a sophisticated way of avoiding the difficult admission that we are in the dark.  Before tuberculosis was found to be the result of infection with a special bacterium, "experts" blamed it on multiple causes, like climate and crowded conditions.  

However, autism is probably more like cancer than tuberculosis.  Meaning that it simply isn't a single condition, but a whole host of conditions, with separate causation, prevention, symptoms, outlooks and treatments - hence the "spectrum."  And these conditions may have very different causes.  This isn't good news of course - its much easier to tackle a single condition than a "category" of disorders.  

In the May issue of PEDIATRICS,  a team from UC Davis and Vanderbilt University report on their evaluation of more than five hundred children on the autistic spectrum between 2 and 5 years of age, comparing them with 172 others with developmental disorders and 315 age-matched controls.  A major purpose of the study was to see whether the parents of affected children were any more likely to suffer from "metabolic" conditions, including obesity, diabetes and high blood pressure.  They were.  For families with a child on the spectrum, the odds of a mother having one of these conditions was 1.6 times higher than for a "control" family.  What does this mean?

On the one hand, a case-control study like this needs to be interpreted cautiously.  Did the mother's diabetes or obesity cause autism?  Or are these conditions all the result of the same common (genetic) factor?  Other kinds of investigation will be needed to confirm the association and better work out the matter of causation.  On the other hand, these results may turn out to be very significant, especially given the rising incidence of type 2 diabetes and hypertension, which are both consequences of the obesity epidemic.  Additionally, some experts have suggested that an association between these conditions and autism may be explained as the adverse effect of elevated blood sugar, or "hyperglycemia."  We know that excess glucose causes a range of disturbances at the molecular level and that some of these could plausibly impact nervous system development in utero. This realization proves nothing, but "biological plausibility" is an important consideration for an candidate theory about autism. 

Finally, we must keep in mind that even if a causal relationship between metabolic conditions and autism is found, the majority of mothers of affected children are not hypertensive, diabetic or obese, suggesting that important as this association may be, it accounts at best for a fraction of children and families afflicted with this challenging developmental problem.

  

It's Ten PM - Do You Know Where Your Doctor Is?

Genomics.  Robotic surgery.  Implantable cardiac assist devices.  The list of innovations that have extended life and health in the last generation reads like a sci fi novel.

And yet, patients nowadays find themselves missing out on a critical element of excellent healthcare: their doctor.  More and more patients lack a primary care physician.  They have a cardiologist who manages their heart condition.  They have an endocrinologist who manages their diabetes, and maybe a pulmonologist who expertly cares for their chronic emphysema.

But when they run a fever on a Saturday evening, whom do they call?  Of course, many patients still have a real primary doc - an internist or family practitioner.  But it is far less likely in 2012 that the physician is in a solo practice.  According to a report by the NY Times, that chance was 58% forty years ago.  Today it is mere 18%.  And the rest?  They are in larger group practices with teams of physicians.  At a recent medical meeting, a colleague complained that it is a "miracle" if a patient happens to reach his own physician after hours.  Much likelier she will reach another member of her physician's "coverage pool," which may include anywhere from a few to a few dozen physicians.  And what if you reach a physician "on-call" for, say, 20 colleagues?  If the problem involves anything more complicated that the common cold, the answer will be predictable - "head over to the Emergency Department and the doc there will take care of you."

Nothing the matter with that except for long waits and large copayments.  Well, maybe a few other things.  Like the fact that this doctor doesn't really know you or your history, or whether you will come back for followup.  To make matters worse, hospitals are measuring ED docs on their "throughput time."  And if after sending you home, you need to return within 72 hours a black mark goes next to the doc's name.  So we, the hospital leaders, are sending signals that say to this ED physician, decide fast but decide right.  And if you're not 100% sure, admit the patient.  And while you're at it, do a blood count and a slew of other tests.  If there is pneumonia, don't rely on your stethoscope.  Get a chest x-ray.  And while you're at it, don't rely on the chest film either, send the patient back for a thoracic CT scan.  And now that you have much more data than you know what to do with, get the internist who will admit the patient...and call an ID consult (because pneumonia is an infection), and a pulmonologist, just in case.

Americans are looking on in alarm as our nation is embroiled in a debate about the future of our unsustainably inefficient healthcare delivery system.  Some conclude the efforts to fix it will imperil choice and create long waits for needed services.  Others of us have a different vision.  One that includes much better care coordination and that reestablishes the critical role of the primary care physician.  One that reemphasizes the need to weigh more carefully the benefits of individual tests and treatments, and that acknowledges the principle that simpler care is not only less expensive, but often more timely, less error-prone and more accurate.  And one that will allow patients once again to know how they can get their doc on the phone, even if it is 10 pm.

Treating patients like persons - why we don't always do it and how we can change

Last evening I put aside the urgent matter of getting my taxes done to attend a truly inspiring committee meeting. I know, I know...that sounds like an oxymoron.  But our Health System's new Narrative Medicine committee is truly exceptional. Populated with a diverse group of professionals - social workers, nurse practitioners, art curators, medical school faculty, a "quality" expert, chaplains and physicians from specialties as diverse as opthalmology and pediatrics - this working group shares a passion for putting the "care" in "healthcare."

As I drove home last night, I wondered: "why are we necessary?"  By this I mean, why is it not automatic for health professionals to bring all that they are to the bedside of every patient?  I believe there is no single answer.  What we know is that empathic capacity among physicians and nurses has been measured and tracked, and that it declines during training.  The more time we spend with patients, it seems, the more insulated we become from their experiences of isolation, fear, anxiety and loss of control.  The evidence is clear: without heroic countermeasures, the more expert we become, the more we disconnect from the human experience of illness.

And so we find ourselves in a conference room snacking on nectarines, potato chips and Pelligrino water (true story!) swapping ideas about interventions and research projects that might bring the perspective of "narrative medicine" to bear for the benefit of wounded patients and wounded providers of care.

"Tell me everything you feel I need to know about you" to understand you, to address your fears, to respect your values...in short, to provide you the care you need.  This is one message of Narrative Medicine.  Another, equally important stream is directed at the wounded caregiver: what are you feeling?  What fears, what resentment, what kinds of inadequacy have you locked away in order for you to do your job...to get through your day?  And how can we use words and written expression to unlock those hidden recesses of our psyche, and to purge the toxins from the culture of healthcare?    

I am very hopeful.  The antidote to burnout is not less work.  It is the chance to participate in meaningful work, and to know in our bones that our labors are worthwhile.   Half a century of progress has provided technologies for extending life and health that would have been unimaginable to our forefathers.  We stand at the frontier of a new country...one that values these advances, while also bearing witness to the human act of caring, and honoring in a way that is very new and very old the act of one vulnerable person caring for another.

Would you like to be resuscitated?

I was honored this week to deliver a Grand Rounds lecture to our Department of Medicine on the topic of "advance directives."  This was curious, in a way, since I am expert in neither the law nor bioethics.  But I do see physicians and nurses and patients and families struggling with end-of-life care, and I have participated in many organizational efforts to assist all of them in what are inevitably gut-wrenching decisions.  In all but a few cases the issue is the same - how to do the right thing in the face of radical uncertainty.  When is intervention heroic, and when is it ill-advised?  What do we mean by futile care?  When does prolonging life become prolonging death?

In the last thirty years, a sea change has come over American healthcare that involves the concept of patient autonomy.  "Autonomy"-- the recognition that all persons have a moral right to self-determination including the absolute right to decline any medical intervention -- stands beside two other dicta: to do always what is in the patient's best interest, and finally the Hippocratic proscription against doing harm.  An "autonomy movement" has gathered momentum in recent years for a variety of reasons:  our changing understanding of medical error and potential harm, the commercialization of healthcare, a consumerist movement and growing concern fueled by sub specialization that the doctor doesn't always "know what's best" for me.

Promoting autonomy is the basis for all informed decision making.  It is also the basis for those efforts at end-of-life planning that include recording our wishes (I do not wish to be resuscitated, or intubated, or to undergo tube feedings, etc...if doing these things will prolong my death, but not my life...) or delegating the authority to make those decisions in the event that I cannot make them myself.   Examples of the former include, of course, the Living Will and, more recently, MOLST (standing for Medical Orders regarding Life Sustaining Therapies).  Creating a Health Care Proxy, by contrast, serves to identify a healthcare "agent" who is in possession of knowledge about my values and goals and is formally empowered to act on my behalf.  Many advance directives actually combine these two approaches.

These efforts have not been without their difficulties.  Only a minority of individuals execute such advance directives; many are vague or contradictory.  Appointed healthcare agents, often close family members, are often disinclined to carry out the wishes of their loved one when that means limiting end-of-life interventions.  And too often, such wishes and preferences were never discussed.  In a thoughtful paper entitled "Controlling Death:  the False Promise of Advance Directives" (Annals of Internal Medicine 2007),  Dr. Henry Perkins suggests that these are no mere technical shortcomings.  Rather, he suggests, they are fundamental to the radical unpredictability of life and death.  Perkins writes:


Because advance directives offer only limited benefit, advance care planning should emphasize not the completion of directives but the emo- tional preparation of patients and families for future crises. The existentialist Albert Camus might suggest that physicians should warn patients and families that momentous, unforeseeable decisions lie ahead. Then, when the crisis hits, physicians should provide guidance; should help make decisions despite the inevitable uncertainties; should share responsibility for those decisions; and, above all, should courageously see patients and families through the fear- some experience of dying.


As I conclude this post, I am struck by the coincidence involved.  I had not intended to address this topic during the observances of Easter and Passover - each of which focus on life and death, transition and spiritual transcendence.  But what existentialists see as courage in the face of life's "absurdity,"  others would experience as faith in an ineffable purpose and Reality.  Putting this author's point more broadly, it would seem that the proper role of health professionals is to find patients and families "where they are" and provide attentive presence at the end of life.  Perhaps the timing of this post is not accidental after all.  Happy Easter and Happy Passover.

Is the Affordable Care Act on the Ropes?

The Supreme Court has concluded its deliberations on three issues linked to the 2010 Affordable Care Act.  Optimistically, I am taking the position that the nine justices will be deliberating about the constitutionality of this sweeping legislation, and not about its strengths or weakness - issues for the legislative branch and decidedly not for the court.  As I understand it, they will be answering three key questions.  First, does the commerce clause of the US Constitution empower Congress to mandate every American to buy health insurance whether they want it or not.  Second, if the answer to the first question is "no," does the entire law fail, or is this provision "severable"from other sections that are arguably unrelated.  And finally, is the law's requirement that the states participate in its various provisions in order to receive support for Medicaid coercive in effect.

I am no scholar of the law, and what I know about constitutional law would fit on a three by five card.  However, I am struck by the central irony of this entire discussion.  The Obama administration backed away from the single-payer solution because it was seen as too radical a departure from a system of healthcare delivery in which private insurers were such important players.  Thus, the "mandate" that persons obtain health insurance in the private sector was created to find a solution that would be more palatable to free market advocates.  An expansion of Medicare for the purpose of capturing the uninsured would face no such constitutional hurdle.  Make no mistake: the ACA presented a very complicated solution, but it was a centrist solution.

One more thing.  If we get healthcare coverage taken care of, the job will be only half done.  In fact, less than half done.   Because the skyrocketing costs of US healthcare are NOT just due to an encumbered and expensive insurance industry (which they are) or to fraud and abuse (which represent only a sliver of the pie) but most importantly to patterns of medical practice and over-use that will be very challenging to address.  The psychology and sociology of this phenomenon runs very deep in US medicine and in our culture at large.  More next time.

Myths, obstacles and snafus - why children with asthma don't always receive the right care

Asthma affects about one in twelve children, making it the most common chronic disease in pediatrics.  Much more is known than ever before about the genes and molecules that make it happen, and expert guidelines provide a roadmap to care.  Newer agents and delivery systems promise improved efficacy and safety.  As such, we ought to be really good at diagnosing and treating it.   And yet, serious gaps remain.  Here's why.

First, asthma is a "sneaky" condition.  It would be great if every child with asthma, and only those with asthma, came to the doctor with cough, chest tightness, and wheezing.  Mission accomplished.  Good job everyone.  Next case. But that's not the reality.  According to studies, half of all children have one wheezing episodes by 36 months of age, but only a fifth of them will turn out to have asthma.  Further, young children don't complain of chest discomfort; they just get cranky.  On the other hand, recurrent cough and wheeze at any age requires an explanation, and as a matter of fact, a "cough history" is one of our most important tools for sorting out the thorny problem of diagnosis.

When I say that asthma is "sneaky," I also mean that the symptoms can increase so gradually that parents can easily overlook the fact that something is amiss.  One of my favorite diagnostic encounters was with a wonderful parent from whom I was getting some historical information.  In connection with her four year old son, whom I was seeing for the first time with shortness of breath, I asked "does Johnny have trouble with coughing?"  Her answer was incredibly helpful: "No, just his normal cough."  You see, this boy's symptoms had emerged so insidiously that it became this family's new "normal."

Here's another reason.  Neither pediatricians nor parents like to see children taking any more medication than necessary.  Ok, I know this is a generalization.  But when it comes to chronic medication, we're squeamish.  Which is really dysfunctional, since we ought to be more concerned about unnecessary antibiotics, decongestants, antihistamines and other commonly prescribed medications where over-prescribing exposes children to risks that exceed the benefits. (See my previous posts on inappropriate antibiotic use!)   When it comes to asthma, evidence-based guidelines highlight the role of airway inflammation and the central role of every-day inhalation of anti-inflammatory medications for all children with "persistent" asthma.

Finally, we need to take asthma seriously.  For children with the most severe forms, this is easily done - when a child gets very sick from asthma it's impossible NOT to see that this condition requires diligent, ongoing care.  My concern here is with children with mild and moderate asthma who suffer unnecessary loss of sleep, discomfort, missed school, exercise intolerance, restricted play and the like.  They, too, are at risk for more severe exacerbations leading to an ED visit or hospitalization.  But aside from this, they are suffering needlessly.  These children and their families need good primary asthma care, including a partnership between the care provider, child and parent.  They need to know what causes asthma, what avoidable triggers (like tobacco smoke) make it worse, how to use their medications properly, how to self-monitor and when to seek assistance.  They need periodic asthma "check ups" to adjust medications and review control.

Fortunately, more and more pediatricians are getting involved in quality improvement work around conditions like asthma that ensure that the care we provide is standardized against the best science, and also individualized to meet the need of every child.
 

One Child in Twelve: Asthma and Allergies

I'm scheduled to do an interview with Newsday this week.  The question we will discuss is this: "will the warm winter cause an unusually severe allergy season?" The problem with print media is that the readers can't see you shrugging your shoulders.

There are few scientific studies to inform the answer, but lots of educated guesses.  We are already seeing and hearing signs of Spring.  There was a blazing cardinal on my front lawn this morning and yesterday a visit to Planting Fields Arboretum rewarded us with a feast of colors not at all typical for March.  As a result, there should be an early rise in the levels of pollen - the stuff that trees and grasses produce to reproduce.  And so, those individuals whose immune systems mistake this material for an invading organism will mount a vigorous counter attack that works, biologically speaking, like a circular firing squad.  We call such individuals "allergic" and their dysfunctional responses, "hay fever" and "asthma."

Hay fever is the quintessential misnomer, having little to do with hay and nothing to do with fever. Those of us who get it (around 10 - 30% of the population) experience itchy eyes and noses, congestion and discharge.  The allergic swelling of our nasal passages also blocks up the outlets of our sinuses, predisposing us to sinus infections, also called "sinusitis."  Many experience lack of sleep and the symptoms are both uncomfortable and distracting.  Nonetheless, hay fever is a minor affair when compared with what happens when the same kind of irritation and inflammation take place in the bronchi (the branching network of conduits that transport gases to an from the lungs.)  And this more serious condition, of course, we call "asthma".

Asthma has been understood and misunderstood for centuries.  We currently know that asthma is a genetic disorder, usually appearing in childhood, often coexisting with infant eczema and nasal allergy, and involving constriction of muscles in the bronchial wall AND inflammation of the bronchial lining.  Although wheezing is a classic sign, not all wheezing is due to asthma, not all individuals with asthma wheeze, and most important, not all wheezing is detectable without a stethoscope.  As a matter of fact, most wheezing in children is not.  Consequently, this most common chronic disease of childhood remains under diagnosed and, when diagnosed, often under treated.  

What will this allergy season be like?  As Yogi Berra famously said, "it's hard to make predictions, especially about the future."  What I WILL predict is that we have much more work to do to effectively apply what we already know and what there is yet to learn to help individuals - and children in particular - to thrive in every way, even if they have asthma.

 

Customer? Consumer? Patient?

How did you feel about your last hospitalization?

Several years ago, the federal Center for Medicare and Medicaid Services began collecting survey data from patients, and publishing hospital report cards on patient experience.  Moreover, CMS began to tie incentives and penalties to performance, helping to drive patient satisfaction to the top of the priority list for hospital leaders.

How did this all come about?  One source was a 2001 report by the prestigious Institute of Medicine which made a compelling argument for the case that American healthcare fell short of meeting the needs of our citizens.  "Between the care we receive and the care we could receive" the authors wrote, "lies not just a gap...but a chasm."  Among those gaps was insufficient attention to "patient centered care."  Healthcare has spent the last decade - and longer - in an effort to understand what that means, why it is sometimes lacking, and what we can do about it.

Hospitals went through a stage where hotels and restaurants were felt to hold the answer.  According to the "Service Excellence" school of thought, if Ritz Carlton can make every guest feel special, why can't a hospital?  Meetings and posters referred to the "voice of the customer" and "exceeding expectations."  There was some merit to this approach: one way to disrupt entrenched thinking is to go outside one's own walls, and no culture is more insular than that of healthcare.  However.

This approach should have alarmed us on its fundamentals, and has by all accounts led to mixed results at best.   And so, from many quarters - purveyors of survey tools, the hospital industry and academia among others - another framework is emerging.  It is new and it is old and it is about one human being caring for another.  It is about recognizing what it is to treat the ill and injured, and what makes the health professional different from the hotelier.  And that is the solemn responsibility, and the unique honor, to care for those who are suffering.  This is a much higher standard, and one which is more authentic to those who provide, as well as those who receive, hospital care.

"Empathy based care" is a new term for an ancient idea.  More about how empathy is regaining our attention next time.
 

Blah blah patient safety blah blah

This is Patient Safety Awareness Week, an annual observance of the National Patient Safety Foundation. Every year my CEO raises the same objection: if we are all about patient safety, why do we need an annual observance?  If I were a patient, he says, I would hope that every week is "PSAW."

Good point.  The problem with a concept like "patient safety," however, is that with repetition the term can become leeched of all meaning.  It drives me nuts to hear someone being interviewed about this and offer that the point of patient safety is "to keep patients safe."  Bland platitudes are not what we need.

Not when the mandates of the 1999 Institute of Medicine report are largely unmet.  Not when checking into a hospital is roughly comparable to bungee jumping for "safety."  And certainly not when it is still all too common for healthcare professionals to inflict avoidable harm on patients.  When we talk about "adverse outcomes" in this context we need to be crystal clear - we are talking about something that we did to the patient, or failed to do correctly, that left them temporarily injured, permanently disabled or dead.  Something that was not the result of their underlying illness, but of our "care."

It is fair to say that we have made inroads.  The rate of some avoidable hospital infections has plummeted.  Physicians have begun embracing standardized order sets that help them not to forget things that ought to be part of the patient's treatment plan.  (This was no easy feat:  it took years for us to get over the loss of status.  If we're perfect, after all, why should we use such a crutch?  It's as insulting as asking the flying Wallendas to start using a net!)  We even use checklists in the operating room, just like cockpit crews.

Well, not exactly.  Unlike cockpit protocols, which have resulted in huge strides in aviation safety,  OR standardization has yet to bear the same fruit.   As a matter of fact, according to statistics maintained by the Joint Commission, the number of (reported) wrong-patient, wrong-procedure or wrong-side operations has only increased since such protocols were implemented.  It's not clear why.  The most cynical have suggested, however, that while surgeons may be adversely affected by operative accidents, there's nothing like being at the pointy end of a 100 meter projectile to focus one's attention on safety.

Personally, I don't buy this.  The fact is that Medicine is a very messy affair, and its practitioners are accustomed to this disorder.   Which means that it will take time and the work of provocateurs to keep us on the path to dramatic improvement and away from comfortable and familiar cliches like "patient safety."

Beautiful, tortured Tom Harrell

There could have been few better places to be on a recent Friday after dark than elbow to elbow with fellow disciples of jazz in the subterranean recesses of Manhattan's Iridium club.    The feeling was intimate, and the mood was warm.  The ensemble's lead was tall and gaunt, head flexed like a puppet revealing only what he wanted us to see, a dense mop of grey.   Standing statue straight and motionless in a rumpled back suit, he gave no hint that he was hearing the stream of sound, the cascade of notes and changing rhythms - not, at least, until he drew a pflugelhorn to his lips and began to play.  Neither did he let on that he was fighting down the voices, the scourge of those who suffer from paranoid schizophrenia.

Schizophrenia is, unfortunately, a fairly common condition, affecting more than 1 in 200 individuals overall.  Despite dramatic advances in the neurosciences, the causes of this disorder are only partly understood, and the mainstay of treatment - antipsychotic medication - mitigates symptoms but does not offer a cure.

Does the person own his chronic illness, or visa versa?  Our use of language has blurred this distinction for centuries.  Once there were consumptives and cripples; now there are asthmatics and diabetics.  There is a school of thought (to which I subscribe) which holds that terms like this submerge the person in the disease, are harmful for this reason, and should therefore be abandoned altogether.

The notes that flow out across the stage and over the audience make patterns within patterns, wild and unexpected scales, sliding and leaping beyond reason, making one excursion after another, traveling farther and father afield, notes that to the classical ear are crazy and dizzying, their thin tether to reality making a connection of delicate beauty.

Tom Harrell battles a brain disease. Listen to his new album, "The TIme of the Sun." Then consider whether one should describe him as "a schizophrenic."    

What's good and bad about modern healthcare? Ask mom.

I spent last evening in the Emergency Department of a regional medical center near my mother's home on Long Island.  She is a spry octogenarian who, wisely, can't stand doctors or hospitals (present company accepted, of course.)  Mom would be incensed to know I referred to her as spry. Suffice it to say that she had a little breathing problem.

Here's the good news.  The resident, the nurse and the radiology tech were fabulous. The latter came in smiling and asked "what is your name?  Can you tell me your birthday?" From mom's point of view this was a bit of a bore, since she'd been asked the same thing six times already.  Of course, this was for her own protection, since wrong patient events continue to plague healthcare, and rechecking before each intervention is protocol.  One check mark for safety!

The nurse was business-like, but polite.  It struck me, yet again, how different it is to be the one sitting at the bedside, waiting for things to happen.  I continue to believe that every physician and nurse should be assigned to this role, say twice annually, to be reminded how startlingly different the view is from this angle.

One notices, for example, that the Le Bon Pain coffee cup from the last patient was never removed.  And were private conversations going on between staff members, you can be sure that we would have heard them.  There weren't.

The resident was a blast!  He breezed in, took a look at the rings on mom's fingers and burst out, "Are you descended from royalty?"  It's funny how this sort of thing works, and part of the reason that we still refer to Medicine as an Art.  In the hands of some, a comment like that would raise suspicions that this doc was a nut job.  However, this particular young man carried it off brilliantly.  I know his program director and I've reminded myself to drop him a note of commendation.

The bad news?  It never crossed mom's mind to find out if her physician is available after hours, whom to call for advice if he isn't, or what to do if she needs a same-day appointment.  Nor, it seems, did the physician or his staff offer this advice preemtively. Knowing the answers would have avoided an ambulance ride, and a very expensive way to obtain two doses of a simple respiratory drug.  I'm not indicting the fellow: maybe mom was told but forgot.  However, I doubt it.

Bad news from the doctor: my child is eating a normal diet.

Over the years, I've told thousands of parents that "there's nothing less healthy than a good, hearty breakfast!"  By that, of course, I'm referring to the typical hotel breakfast buffet:  eggs in every style, pancakes, muffins, and toast accompanied by sausage, ham and bacon.


But one recent report takes us far beyond this catastrophe in a chafing dish. According to the National Health and Nutritional Evaluation Survey, the average US child consumes more fruit juice, starchy vegetables and white bread than recommended, and less in the way of fruits, dark green vegetables and whole grains. "Energy dense" foods like pizza, chips and desserts comprise almost twice the fraction of our diets that they did in 1980.  At the same time, sodas and other sugary drinks make up half of all beverages consumed by children and teenagers - dramatically more than ever before.


Which leads me to one conclusion.  If we want to stay healthy, we have to eat differently than the average American.  If obesity, diabetes and heart disease are the "new normal," we had better commit ourselves and our children to an "abnormal" diet. 


Where is your family on the road from "normal" to healthy?

• Normal:  No time for breakfast
• Healthy:  Your family eats breakfast, and enjoys the energy boost!  No, not a donut.  Your M.O. is skimmed milk or non-fat yogurt, fresh fruit, whole grain cereal or a couple of egg whites.  
• Normal:  Pizza with pepperoni for lunch...and maybe a chocolate chip cookie for dessert
• Healthy:  You'll encourage your student to go for that slice once in a while, so long as he ditches the meat topping for veggies.  Most days, however, his backpack is transporting a whole wheat sandwich with a low fat cheese slice, tomatoes and sprouts.  Turkey or chicken show up from time to time.  
• Normal:  Snapple is a staple.
• Healthy:  "I'm sure our supermarket has a beverage isle; we just don't go there!"  (There IS a beverage that is sugar-free, caffeine-free, preservative-free and a great thirst quencher.  It's called water.)

Nutrition experts tell us that we can't get to healthy by way of self denial.   For most of us, eating is, and should be, fun.   Eating together as a family is good for many reasons (just as eating in front of a screen is bad for many reasons.)   Watch portion size, but don't just take away the fav's - find nutritious substitutes.  Remember that sleep deprivation makes us hungry for all the wrong foods.  And finally, during a winter as warm as this one,  go ride a bike or walk the dog or just go look at the clear blue sky.   It's all part of enjoying - and encouraging - good health.

The cure for normal infancy?

Just when I think I'm running out of less-is-more examples in pediatric healthcare, here comes a review of acid-blocking medications and their use in newborns diagnosed with "acid reflux."


What would cause one to consider the diagnosis of acid reflux (also known as gastroesophageal reflux disease, or GERD) in a newborn?  This entity is known to cause a variety of symptoms, from strange arching postures, cough and wheeze to apnea with blue spells.  But mostly, GERD is diagnosed in infants with spitting up, excessive fussiness and crying.  Hmmm.  How, you might ask, does one differentiate this condition from, well, normal infant behavior? 


As it turns out, not easily.  A lab test? There isn't one.  What about imaging?  Well, a barium swallow could help, but there's radiation and the study is hard to interpret.  So most pediatricians go with "empiric therapy" which is Greek for "let's do an experiment and see what happens."  The rationale for this stratagem is that acid blocking medications are basically harmless.


Except for the following.  As noted by Dr. Eric Hassall recently in the Journal of Pediatrics, these medications have now been linked to increase risks for pneumonia, candidemia, necrotising enterocolitis and C. difficile infection of the intestinal tract.  These are in addition to risks already documented in older patients including osteoporosis and impaired absorption of calcium and magnesium, minerals critical to health.  As it turns out, stomach acid is there for a reason, and eliminating it comes at a larger biological cost than most of us imagined.


I have been curious about this whole neonatal "reflux" thing for quite a while.  For one thing, we seem to have overlooked it for several decades without apparent harm.  It is also interesting that the diagnosis of "infant colic" has disappeared over the same time period that the incidence of newborn reflux has exploded.  Something, I dare say, is rotten in Denmark.  But maybe not so surprising.  How is colic different from reflux?  Simple.  One is treated with a car ride, the other with medication.  And if you wait a few weeks, both most often go away.   


By the way, I DO recommend pharmacotherapy for this condition:  my favorite regimen includes 4 oz of a chilled Muscadet per orum for each parent.

Taking on medication errors

One per patient per day.  That is the number of medication errors of all kinds that occur in hospitals, according to a 2007 report by the prestigious Institute of Medicine.  These include errors of omission and commission, wrong time, wrong dose, wrong route and wrong patient events.  The overwhelming majority are inconsequential; nonetheless, researchers have estimated that upwards of 380,000 to 450,000 episodes of medication-associated harm occur each year.

Opportunities to create - or prevent - errors occur at every step in the process from the time the physician orders a medication, through communication to the Pharmacy, dispensing, and administration at the bedside.  Some medications are more dangerous than others - those that are more toxic, more complicated to dose, those that look like or sound like other, dissimilar medications, and those prescribed for the most vulnerable patients (including children) deserve special attention.

Among our most serious challenges is addressing the risk of error when patients transition from one environment from another - home to hospital, or hospital to rehab, for example.  There is even a risk when the patient moves from one unit to another in the same hospital - ICU to floor, for example.

Yesterday I listened to two presentation from working groups within our Health System.  Their goal: figure out how to make sure that at the time of hospital admission, every patient's home medications are either continued, discontinued or modified as the result of a conscious action - rather than by accident.  The experience was inspiring and humbling at the same time.  Each team was comprised of the right people with the right tools.  Physicians. Nurses. Pharmacists. Experts in process design.  And all of them skilled, experienced and highly motivated. They had a year to work.  And their efforts were magnificent.  Nonetheless,  their statistical results told us that they were only modestly successful in reaching their goals.

Driving home, I had three thoughts.  First, a decade after the first halting efforts led to a national, and then an international movement to make healthcare safer, we still have a long way to go.  Second, as in every other aspect of patient safety, there is no substitute for patient and family engagement.  Hospitals and health systems can build databases and computerized decision support to try to prevent errors, but there is nothing like an involved son, daughter or spouse keeping careful track of what medications have been prescribed and in what doses, why they were prescribed, what side effects to watch out for.

Finally, and here's the pediatrician talking, it wouldn't be so darn hard to keep track of each patient's medications if we didn't prescribe so many.  This isn't so trivial a point as it sounds.  A number of studies have cited the untoward effects of "polypharmacy," especially in the elderly.  And investigators have found in these cases that a large proportion of medications could be discontinued without ill effect.  Yes, once again, in healthcare, less CAN be more.

Why be a physician?

There is a huge bouquet of flowers in our living room, and they came from a patient.  Not a patient of mine, mind you, but one of my wife's patients.  Well not the patient herself, actually (we're both pediatricians) but the patient's mother.  We say this a lot about pediatrics - we never treat one patient at a time.  It's the individual with the medical problem (in this case a teenage girl) and the parents.  And, sometimes other relatives as well.

Back to the bouquet.  It was the result of a series of fortunate events.  An adolescent comes to the doctor with a sore throat.  The sore throat is nothing much.  The doctor performs a very good physical examination and discovers a mass in the pelvis.  It is a tumor.  Imaging is performed, a surgical referral occurs, the mass is surgically excised and it is benign.  It could have caused problems, nonetheless, if not tended to.  The patient is fine and the parents are extremely grateful.  If the emotional life of a physician were a bank account, and late night phone calls, insurance forms and missed family events were small withdrawals, then a moment like this one would be like a windfall, a huge inheritance from a relative you've never heard of.  Moments like this are one of the reasons we become physicians.

Then there is the intellectual challenge.  I was reminded some years ago that doing a good job as a diagnostician doesn't necessarily get you a bouquet.  I was seeing a little boy, probably four or five years of age.  He had a lump in his neck, in the space under the chin and on one side that we call the anterior triangle.  I obtained a history: how long has it been? Does it hurt? Any fevers?  Do you have a pet rabbit? Any travel? And a dozen other questions.  I was on a quest, and although I may not have been conscious of it at the time, I was rather enjoying myself.  This is what it is like to be a diagnostic sleuth, a real-life House.

And so, in an effort to be "informative" (but maybe just to show off a little) I heard myself reviewing a list of five or six diagnostic possibilities - what we call the "differential" in the jargon of Medicine - with the patient's mother, all the while writing out tests, a blood count, tuberculin test, various antibody levels and so on, that I recommended we obtain right away.  I felt very much in control of the situation and pleased to use a few more brain cells than are required to diagnose the common cold.

On the way out of the office, my nurse, a thirty year veteran, asked the mother in her typically kind way, "so is everything all right?  What did Dr. G. say?"  I was utterly surprised, but shouldn't have been, when the mom turned and said, "well, it seems he hasn't the slightest idea what it is!"

A dose of validation can do wonders for us, but a bite of humble pie is also therapeutic.  See you next time.

More on the art and science of healthcare

Yesterday I suggested that there is a role for measurement and standardization in our quest to make healthcare effective, efficient and safe.  This is Medicine's "left brain."  But leaving the issue there dooms us to healthcare delivered with "half a brain."

The fact is that without the "art," the "science" doesn't work.  The science doesn't address the question, for example, of how physicians make a diagnosis in the first place.   It remains true, even in the age of advanced imaging, that the most informative data for determining what is the matter with the patient come from the medical history.  The process by which the skilled physician obtains this history is highly individualized and nuanced.  It is a dance and an acrobatic balancing act.  If the physician interrupts too much, he prevents the patient from sharing key material.  If he doesn't ask questions at all, critical clues will go unreported.  More than a century ago, William Osler, a founder of modern American medicine said with deceptive simplicity: "listen to the patient and he will tell you the diagnosis."

I like to tell our students and residents that EVERY interaction with the patient, every word we say, in fact, is either therapeutic or anti-therapeutic.  There is no middle ground.  Medicine (and, for that matter Nursing) is an inherently relation-based endeavor.  How we greet a new patient ("what seems to be the matter?"), how we explain a finding, even how we frame questions.  Imagine palpating an enlarged lymph node in the neck of a teenager most likely suffering from a routine case of mono and asking while doing so... "any family history of cancer?"  You get the picture.

These interactions have effects, for better or worse, building trust, empowering patients, encouraging healthy behaviors, allaying anxiety - or the reverse of each and every one.  A re-examination of the relational nature of healthcare, and more exactly the role of "story" in healthcare, is at the center of an exciting new program now known as Narrative Medicine.  More on that soon.

The art and science of healthcare - and why we need both!

A cornerstone of the "quality" movement in healthcare is the idea that we can't improve what we don't measure.  This has led to any number of achievements that would have been impossible otherwise: reducing hospital infections, improving surgical outcomes and a host of others.  The concept is pretty straightforward.  Absent a good way to measure, reasonable clinicians can (and will) argue incessantly about whether any particular bad outcome was random, or something else.  (A surprising number of physicians - even some with a strong track record of secularism - will attribute the worst outcomes to "God's will."  Go figure.)  But if one hospital's, or one team's, or one surgeon's results are statistically different than another's - whether better or worse - well, then something interesting may be going on.

Another such hallmark is standardization.  Treating the same problem the same way seems pretty logical.  Even when there is more than one right way to do something, standardizing practice keeps down unnecessary complexity in the system, reducing both cost and the likelihood of error.  (For more on the latter, see my last post.) Like measurement, however, the idea of standardizing practices in healthcare brings surprisingly mixed reviews.   We've all heard the mantra:  "practicing medicine is an art."  This happens to be a true statement. However, there is a counter-statement that is just as relevant:  "all that is unscientific isn't necessarily art!"  What IS true is that providing the best healthcare requires that doctors adapt the treatment plan to meet the individual needs (and preferences and values) of each individual patient.   This is what I would call "beneficial variation."

Unfortunately, much of the actual variation in our healthcare system is not of this kind.  It turns out that when different doctors choose different antibiotics to treat the same kind of infection or suggest one operation over another, too often the reason has more to do with the doctor than the patient.  (Question to doc: "Why did you choose this approach?"  Answer:  "Well, that was the way I was trained."  Hearing this expression continues to cause my hair to stand on end.)

Is there, then, any room for "art" in Medicine?  Yes, and the need has never been greater.  More on that tomorrow.

Preventing harm from healthcare - where are we?

I'm reading Sorrel King's book "Josie's Story" about her beautiful little girl - less than two years old - who died at Johns Hopkins several years ago as the result of avoidable errors in her care.  This is a story that I have heard many times, including Ms. King's own account from the podium at large meetings such as those of the National Patient Safety Foundation. She has been a tireless advocate for patients and for making healthcare safer, a reminder to all of us that behind every statistic is not just a life but many lives, the brothers and sisters, mothers, fathers, sons and daughters of those who have suffered from medical errors and their aftermath.

I have been studying medical errors and patient safety for more than ten years, and I still don't understand it.  None of us do.  We know a lot more than we did a decade or two ago.  We know that medical errors and harm are not rare, comprising, in fact, a leading cause of death in this country.  We know that most occur while patients are receiving care from very well trained, committed and diligent professionals, and often happen in the nation's best respected Centers.   Meaning that everything we thought before - that such accidents are rare, and that they are generally traceable to "bad apple" doctors and nurses with deficient skills, an inclination to negligence, or both - that these assumptions were pretty much dead wrong.  

We also know that preventing healthcare-associated harm - from medication errors, missed diagnoses, delayed intervention, hospital infections, wrong site surgery and more - involves not one approach, but many.  Because the "war on harm," we now know, is a lot like the "war on cancer."  Just as "cancer" is many different conditions, so "errors" come in many forms, affecting patients in many ways.  And we are still learning about the causative factors, so that effective changes can be implemented, both locally and nationally.

Despite this complexity, however, we have learned to look at healthcare delivery in new ways that provide coherence to our War on Harm.  They involve how we design processes, the role of communication, organizational culture, the role of patient empowerment, and leadership.  More on this in future blogs.

Combining the past with the present to invent the future: your medical home

Can you reach your physician, or an informed and responsive surrogate, any time you have a question?  And if you need a same day visit, can you count on getting one?  Are you treated like a mature adult who is in charge of your own healthcare decisions?  If you are seeing one or more specialists, does your primary care physician coordinate your plan of care and help you understand it? Can you access your own records online?

Despite islands of excellence, contemporary healthcare falls short in providing the kind of patient-centered, coordinated, efficient and accurate care that our nation deserves and that is within our reach.  Not only do the current deficiencies frustrate patients and care givers alike, but our fractured system adds enormously to the cost of care. Ours is a high-cost, low-value system that many have criticized as being not a system at all.

Enter the "Patient-Centered Medical Home".

Arising from concepts first articulated by the American Academy of Pediatrics, PCMH is a model of care that describes a role for the primary care physician and his team that goes far beyond the "gatekeeper" economic model of the 1990s.  To be a PCMH, a primary care practice must provide comprehensive, team-based care that meets the large majority of each patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care provided by a cohesive team. 


This care must be coordinated across all elements of the complex health care system and connect patients to both medical and social resources in the community. It must include superb access to care that meets patients’ needs, including care provided after hours and by e-mail and telephone.  Finally, it must encourage self-care and empower patients and families to be active decision-makers to ensure that the healthcare provided is consistent with the needs, values and preferences of the patient.  


Why did this model originate in Pediatrics, when so many more adults than children have chronic diseases and the desperate need for this kind of care?  First, I think pediatricians have historically been oriented toward health maintenance, education and empowering families.  Second, and this is just my personal conjecture, when it comes to coordinating the care of patients under the care of one or more specialists, we pediatricians have been better able to practice to the "gold standard" if only because such a small fraction of our total population requires this intensive (and uncompensated) work.   


However it started, the PCMH concept is getting serious attention by thought leaders in Washington and across the healthcare scene.  At the risk of sounding like a pediatrician, it sure seems like a good idea to me.  Look for more details on the Patient Centered Medical Home at www.ahrq.gov.