A Global Force for Good

A few years ago, the United States Navy launched a new recruiting and marketing campaign using the slogan: “America’s Navy – a global force for good.” The line was apparently a flop, and the Navy threw it overboard for “protecting America the world over,” but I liked it. I thought it captured a deep truth about the Navy, which is that it is undoubtedly a “global force” and that the force exists for a good purpose, but I guess most people thought that it made the Navy sound too much like a bunch of social workers.

I was reminded of the phrase, and of an experience I had while serving in the Navy Medical Corps, when I read a recent article in the Annals of Internal Medicine.  A Navy physician retold the story of a mission he was on to a remote village in Honduras. He and his team were flown into small villages, where they would “see dozens of patients each day and dispense an assortment of symptomatic medications” and where “the most practical health benefit that we provided villagers consisted of hundreds of tooth extractions.” He further noted that “although advertised as humanitarian missions, these exercises provided US military personnel with experience working with military and civil authorities from host nations.”

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Shared Accountability

There are plenty of good reasons why thoughtful physicians are often unhappy with the current approach to measuring the quality of care they provide. Some, of course, object to the whole notion of quality measurement, but I believe they are in a shrinking minority clinging to an anachronistic mental model in which each physician defines for himself what constitutes high quality care. I have addressed this previously. But even those, who like me, believe it is essential (and possible) to measure quality, can point to legitimate shortcomings in the way it is done.

Among these shortcomings is the imperfect process by which individual physicians’ “results” are “adjusted” to account for differences in the patients they care for. In the simplest case, when the quality of care is judged by looking at patient outcomes, this risk-adjustment is meant to reflect the fact that clinical outcomes reflect both the baseline characteristics of the patients being treated and the treatment they get. For example, if one were to use in-hospital mortality rates to assess the quality of care for acute myocardial infarction, it would be essential to know “how sick” the patients, on average, were on presentation. A 50 year-old man with a small inferior wall MI is likely to live even in the absence of good care (or any care for that matter), whereas a 90 year-old woman with cardiogenic shock from an anterior wall MI is likely to die even with state-of-the art care. Any attempt to assess the quality of care for a population of MI patients must take this into consideration.

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Residency Ratings

I have been a big proponent of seeking the feedback of our patients regarding their experiences with our care, and of pushing our organization to be more transparent about the results. I believe that sharing performance motivates everyone to raise his game, and that we should embrace valid ratings on specific measures. On the other hand, I have always thought that global “rankings” divorced from specific performance measures make little sense.

As Malcolm Gladwell pointed out in the New Yorker a few years ago rankings of complex, multidimensional things like cars or colleges are inevitably flawed, because they don’t account for the fact that different people will value various attributes in different ways. There is no “best car” since I may value handling and acceleration, and you may value styling and safety. Likewise, there is no “best college” because one student may value class size or athletic facilities while another values research opportunities and proximity to a large city.

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Patient Safety, Swiss Cheese and the Secret Service

I was listening to the news on my way to work last week, and heard a story about the review conducted after the well-publicized security breach at the White House. Like many people, I was shocked when the story of the fence-jumper first broke. How was it possible that some guy with a knife managed to get over the fence, cross the lawn, enter the White House and get deep into the building before he was stopped? The answer, according to NPR’s reporting of the Department of Homeland Security investigation is that a whole sequence of events made it possible:

It turns out that the top part of the fence that he climbed over was broken, and it didn’t have that kind of ornamental spike that might have slowed him down. Gonzalez then set off alarms when he got over the fence, and an officer assigned to the alarm board announced over the Secret Service radio there was a jumper. But they didn’t know the radio couldn’t override other normal radio traffic. Other officers said they didn’t see Gonzalez because of a construction project along the fence line itself. And in one of the most perhaps striking breaches, a K-9 officer was in his Secret Service van on the White House driveway. But he was talking on his personal cell phone when this happened. He didn’t have his radio earpiece in his ear. His backup radio was in his locker. Officers did pursue Gonzalez, but they didn’t fire because they didn’t think he was armed. He did have a knife. He went through some bushes that officers thought were impenetrable, but he was able to get through them and to the front door. And then an alarm that would’ve alerted an officer inside the front door was muted, and she was overpowered by Gonzales when he burst through the door. So just a string of miscues.

The explanation rang true. Of course it was no “one thing” that went wrong; it was a series of events, no one of which in isolation was sufficient to cause a problem but, when strung together, led to a catastrophic system failure. The explanation also sounded familiar. It is a perfect example of the “swiss cheese” conceptual model of patient safety.
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Sometimes “Sorry” is all it Takes

In my administrative role, I have the great pleasure of signing thank you letters to patients and family members who have acknowledged the great care they have received by one of our physicians or other caregivers. It is a nice way to tell the patient “we got your note” and to simultaneously recognize the provider by copying her or him. The best part is that I get to read the patients’ letters, which are filled with gratitude, and remind me of the great privilege we have to make a positive difference in the lives of our patients.

Sadly, I also have to deal with the occasional patient complaint. Although these are clearly a lot less fun to address, they also point out the impact that we have on the lives of the patients and families that we serve.

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More on Ebola

With the first – and probably not the last – documented case of Ebola in New York last week, the reaction of State and local governments was big news, and the preparations of the North Shore-LIJ Health System kicked into a higher gear.

New York City Mayor Bill DeBlasio, flanked by the President of the city’s Health and Hospital Corporation, Dr. Ram Raju, and the city Health Commissioner, Dr. Mary Travis Bassett, gave a news conference. I thought they struck just the right balance of information and reassurance, and grounded their responses in what is known about the disease. In discussing the movements of the patient, a physician who had been working in West Africa with Doctors without Borders, prior to his admission to Bellevue, they repeatedly stated that he had posed no threat to the general public. Indeed, they cited the case of the man who died of Ebola in Texas, who had spent days living with family members at a much more advanced stage of his illness, and did not transmit the disease to any of them. Of course, 2 nurses who later cared for him did, but he was far sicker by then (which means he had a much higher viral load, and was correspondingly more infectious), and we now know they likely had inadequate training and personal protective equipment.

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Keep Calm and Carry On

Here are a few things that have happened since Ebola arrived in the United States:

  • CNN and other cable news outlets seem to have become “all Ebola all the time” with breathless reports about the latest twists and turns
  • A grade school banned a teacher from the classroom because she had visited Dallas
  • A photojournalist who had travelled to the affected area (and was well) was denied the opportunity to give a talk to a University audience
    Parents in Mississippi kept their children home from school because the principal had visited Zambia

People all across the country seem to be in a growing frenzy about the virus. On one hand, I get it. The disease is awful, the CDC seems to have fumbled in its management of the situation and in its messaging, and the disease rages on in a few countries in West Africa. On the other hand, a lot of this is just, well, nuts.

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The Good, the Bad and the Ugly

I had a recent conversation with an old friend about her elderly father that encapsulates a lot of what is both great and terribly wrong with healthcare in America today.

Here are the basic facts: the man is in his mid-80s, retired from teaching school, and is active and vigorous, living in the community; he is cognitively intact. He has a history of coronary disease and had an intracoronary stent placed some years back. He is asymptomatic on a typical “cocktail” of meds including aspirin, a statin, and an ACE inhibitor. Over the summer, he had a routine follow-up visit with his cardiologist, who detected a carotid bruit. After a duplex sonogram and a CT angio, a high-grade unilateral internal carotid stenosis was identified, and carotid endarterectomy surgery was recommended. My friend called me to see if I could recommend a surgeon in the city where she and her father both live.

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Over and Out

I highly recommend a provocative essay by Ezekial Emanuel that appears in the October 2014 issue of the Atlantic. Dr. Emanuel is a prominent academic who has also held important positions in government, including as a Special Advisor on Health Policy to the Director of the Office of Management and Budget and National Economic Council. He is also the eldest of the three impressive “Emanuel Brothers” that also includes Rahm (former White House chief of staff and now mayor of Chicago) and Ari (a prominent Hollywood agent). His piece is entitled “Why I Hope to Die at 75.”

OK, so the title is a bit over the top and meant to shock, and it is not even entirely accurate. But the message is really worth thinking about. Emanuel sets out why he wants to avoid the typical American approach to aging and progressive infirmity; he does not want to join the ranks of what he refers to as “American immortals.” Instead, he says that when he hits the admittedly arbitrary age of 75, he will no longer actively seek to prolong his life. No more doctor visits, no more “preventive” measures, no more diagnostic tests, no more interventions. Done. Whatever happens after that, well, so be it.

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Price Transparency

About a year ago, I shared details of my own out of pocket medical expenses and concluded that we have to have to be more transparent with our patients (and potential patients) about the costs they will face for our services. The urgency of price transparency as a business imperative and a professional responsibility has only increased since then.

Consider that we are now a year in to the implementation of the Affordable Care Act. Everything that I have read suggests that consumers were intensely price sensitive when it came to choosing which plans they elected. Well, duh! The benefits are defined by “metal” levels (e.g., Bronze, Silver, etc.), and there is almost no way for people to compare the quality of competing narrow networks or individual providers, so price differences drove decision-making. Likewise, the healthy people who bought insurance because they were compelled to by the individual mandate generally chose high deductible plans to minimize their monthly payments. This, in turn, makes them much more price sensitive at the point of care. That means that patients may resist recommended treatment. It also means that physician offices will face more challenges in collecting fees from patients who have not yet met their deductible for the year. At the very least, patients will be more interested in learning what costs they will be exposed to.

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