I believe in the principle behind practice guidelines. That is, I believe there is value in compiling the best available evidence related to treatment options for a particular condition and synthesizing it into a series of recommendations for clinicians. There are certainly potential pitfalls in developing guidelines, but I still think that a high quality guideline, applied critically and with respect for patient preferences, can improve care.
One objection that clinicians often raise about guidelines is really not about the guidelines themselves, but rather about being judged on the extent to which their management matches guideline recommendations. The argument is pretty straightforward: management depends both on the physician’s recommendations and the patient’s adherence, and physicians can’t control the latter. I have argued that physicians have more influence on adherence than they may care to be accountable for, but the point is well taken. There are limits to how much physicians can influence patients’ behavior. Are there other means for improving adherence?
A novel collaboration between the American College of Cardiology (ACC) and Google is based on the assumption that patients can be engaged and activated if they have easier access to high quality information.
Continue reading Patient Engagement
My mother died last week. This is about her.
She was born in New York City, raised as an only child on the Lower East Side, and was the proud product of city public schools and City College. She was an accomplished student and, as was common in those days, was accelerated through grade school, so that she graduated high school at the top of her class at age 16 and college at age 20. As was also common in those days, she married my father of blessed memory the same year she graduated from college, in August of 1949.
She and my father lived with her parents for a bit, with her teaching in the NYC public schools and then went off to Boston, where my father went to graduate school, and she taught 2nd grade in the Brookline public schools. When her father – a grandfather I never met, and for whom I am named – became ill, they moved back to NY, eventually becoming part of the great migration from the LES to Kew Gardens, Queens, and then, in 1960 with 2 little boys to Merrick, Long Island. She used to like to tell the story that she voted for JFK in the morning, and moved in that afternoon.
Continue reading Charlotte Nash
Perhaps you have heard the rather grim joke about how doctors don’t know when to stop treating patients who no longer benefit. It goes something like this: The oncologist goes to the cemetery to find (and treat) Mrs. Jones, since she hasn’t “seen” the latest chemo-cocktail for her recently fatal malignancy. When he asks the grave-digger why she isn’t in her assigned plot, he is told that she is off getting dialysis. Bah dum bump. OK, so it is crude, but everybody “gets” it, because it is just an exaggeration of the kind of aggressive, low-utility care that we often see (or “provide”) at the end of life.
Readers of this blog know that I believe that we, as physicians, often fail our patients by doing more than we would want done for ourselves. I have generally considered this a distinctly “American” issue, fueled in part by unreasonable expectations of the utility of medical interventions, the entrepreneurial nature of a lot of US health care, and the prevalent American sentiment that death is somehow “optional,” or at least to be opposed vigorously at all times regardless of the circumstances.
A recent paper in Heart provided a little international – and, alas, cardiology — flavor.
In it, researchers from the UK, Israel, and France reported on their experience performing primary percutaneous coronary interventions (PCI) for acute ST-segment elevation myocardial infarctions (STEMI) in nonagenarians. It was a retrospective analysis of a series of 145 patients with no control group, which almost certainly means that there was a strong selection bias toward treating only “the best” nonagenarians. The principal finding was a 24% in-hospital mortality, with a 6 month mortality of 39% and 1 year mortality of 47%. Here is what the survival curve looked like:
Continue reading No Way Out
There is a deadly explosion of opioid addiction in the United States. While it is clear that nothing this complex or widespread can have a single cause, it is also clear that American prescribing habits have been a significant contributing factor.
According to the Department of Health and Human Services more than 240 million prescriptions for opioids were written in 2014, and it is well established that prescription oral analgesics are the principal gateway for heroin and other injection narcotics.
It is also true that use of narcotic analgesics is much higher in the United States than in other countries. Here again, the difference between the US and the rest of the world probably has multiple causes, including pharmaceutical marketing, and the easy availability of drugs. Recently, CMS implicitly acknowledged another cause: the creation of patient expectations around pain control, and the subsequent pressure that has had on US physicians’ prescribing habits.
Continue reading It’s a Start
Northwell Health aspires to be among the best places to work, and our efforts to make it so are closely linked with a broad institutional effort to improve the experience of our patients. The theory goes – and I believe – that it takes engaged and committed employees to provide great care. To that end, we survey our employees regularly to gauge our progress and to identify opportunities to improve their work life.
I am proud to say that my team, the roughly 100 people who make up the administrative core of Northwell Health Physician Partners, is a highly engaged bunch, but we recently instituted two programs that I hope will make a good situation even better.
Continue reading Management Experiments
Mental illness causes great suffering for the afflicted, profoundly affects families and loved ones, and is highly prevalent. As I share stories of my own family, I am routinely struck by how many people have similar stories of their own to tell – really heart-wrenching stories about their children, or their parents, or their siblings, which have shaped their own lives as well as the lives of their loved ones. And yet, we don’t much talk about it. It is like a great shared silent burden. Keeping these stories in the shadows compounds the pain of those affected and further stigmatizes mental illness and its sufferers.
Fortunately, I have seen recent signs that this conspiracy of silence is starting to change. Maybe it is a consequence of the “radical sharing” of the Facebook generation (no, I still don’t have an account), and partly a consequence of more effective treatment for serious mental illness. Whatever the cause, people are starting to talk. Here are a couple of examples, just from this last week.
The first was a two-part podcast produced by WNYC as part of the “Only Human” series that explored intergenerational conversations about mental illness. Part one focused on immigrant communities, and how children raised in America faced difficult conversations with their parents raised in other cultures. Part two was about a medical student who challenged her school and her teachers with an open approach to her own mental illness. Both are well-worth listening to, and may challenge your own thinking.
The other was a video produced by the Washington Post about a young composer, Rachel Griffin, who is developing a musical about mental illness to de-stigmatize her own story. I am proud to say that my daughter, Emily Nash is in the cast, and helping to bring the work to life.
These seem to me to be good signs of progress on a long road. What do you think?
The Hofstra Northwell School of Medicine recently graduated its second class. The commencement was a wonderful “feel-good” event, complete with beautiful weather, happy graduates and proud families. The ceremony closed with the newly minted physicians rising to their feet and reciting the oath of the physician. In a nice touch, the other physicians in the audience were invited to renew their commitment to the profession by joining in. I found the whole thing joyous, and the opportunity to publically take the oath again was a moving reminder of what doctoring is all about.
Coincidentally, I also had the opportunity this week to lead one of the sessions in Northwell’s Physician Leadership Development Program, part of a half-day session with Sven Gierlinger, our organization’s Chief Experience Officer, and Jill Kalman, the Medical Director of Lenox Hill Hospital, devoted to the voice of the patient. My bit was about our “transparency project”to publish our physicians’ patient experience scores on our public website. I used the story of how and why we did that as a case study that tied together the themes of physicians driving change and of improving the care we provide to patients and their families.
It was only after the fact that it occurred to me that there was a profound connection between the two events.
Continue reading Hippocrates and the Internet
I am reading a really interesting book entitled Team of Teams written by (naturally) a team, which includes retired United States Army General Stanley McChrystal. McChrystal, you may recall, was the commander of US and coalition forces in Afghanistan before he got sacked for comments he and his staff made to a reporter for Rolling Stone. Prior to taking command, he served as the head of US Special Forces in Iraq during the Sunni insurgency, and this book is about how he and his deputies restructured that “Task Force” to meet the unprecedented challenge they faced.
Early in the book, he discusses the rise of “efficiency” as an organizing principle for industry and, by extension, other forms of human endeavor. He tells the story of Frederick W. Taylor who, late in the 19th century, introduced the idea of organizing activities in a factory so that the workers could produce “more, faster, with less.” Taylor also popularized the means of doing so by standardizing processes to reduce wasted time and effort and by optimizing each element of production. He was, one could say, the Lean production maven of his day. Here’s the passage from McChrystal’s book that really caught my attention, describing Taylor’s experience in a factory in 1874:
Taylor became fascinated by the contrast between the scientific precision of the machines in the shop and the remarkably unscientific processes that connected the humans to those beautiful contraptions. Although the industrial revolution has ushered in a new era of technology, the management structures that held everything in place had not changed since the days of artisans, small shops, and guilds: knowledge was largely rule of thumb, acquired through tips and tricks that would trickle down to aspiring craftsmen over the course of a long apprenticeship.
That transformation from artisanal workshop to organized enterprise, and from “tips and tricks” learned through apprenticeship to standardized work that can be specified and taught, sounds to me exactly like what medicine is going through today. In fact, the changes in medical practice that have been advocated as the pathway to better, less expensive care have been described using the very same language.
Continue reading Sound Familiar?
I had a great time at the national meeting of the American College of Cardiology (ACC) this past weekend. I hadn’t been to “the meetings” in a few years, in part because my professional focus is no longer primarily clinical and well, I never really liked going even when it was. I generally believed (and still do) that I get more valuable information about new developments in cardiology by reading journals than by shlepping around some gargantuan convention center and listening to a few talks while dodging the barrage of drug and device manufacturers. Now that the results of “late breaking” clinical trials are instantly available (complete with slides and expert analysis) within hours of their presentation, I find the whole convention thing even less compelling.
So (with a nod toward the upcoming Passover holiday) why was this meeting different from all other meetings?
First, I had the pleasure of hearing my brother, David Nash, founding Dean of the Jefferson College of Population Health, deliver the Simon Dack lecture. As I said to him when he first told me he was invited (and wanted to know if it was a big deal), this is a big deal. It is the opening keynote for the conference, and is intended to set a tone or theme for the meeting, which draws almost 20,000 people from around the world. Here is a picture of him being introduced by the President of the ACC:
Continue reading Population (Heart) Health
Policy makers who are responsible for shaping how the federal government (the country’s biggest payer of health care services) pays physicians are pushing CMS on a rapid path away from traditional fee-for-service (FFS). As I discussed last year, CMS intends to have 50% of its payments flow through “alternative payment models” such as ACO’s and bundled payments by 2018, with nearly all of the rest of the FFS payments linked to quality measures.
While I believe this is generally a good thing, I pointed out recently that changing how the dollars flow is not the same as changing how the care gets delivered. Changing payment models facilitates redesigning care, but it doesn’t automatically create new care models. That only happens when physicians, liberated from the constraints of FFS, lead the way to do the right things for patient.
Continue reading Capitation? What Capitation?