Book Review-Uncaring: How the Culture of Medicine Kills Doctors and Patients

It is not that they set out to be uncaring.  Quite the opposite.  Doctors, most of them anyway, got into medicine because of their concern for others.  That’s what makes the fact that modern medicine, particularly in the United States, isn’t as good as it could or even should be for patients or doctors.  In Uncaring: How the Culture of Medicine Kills Doctors and Patients, Robert Pearl pulls back the covers on the systems that drive our modern healthcare industry and what’s wrong with them.

I’ve read and reviewed Pearl’s previous work, Mistreated, and have fallen into the awareness that he and I can correspond from time to time on the problems with healthcare and the associated public health issues.  I deeply respect Pearl’s perspective and wisdom about how the systems work – and how they don’t.  Uncaring is no exception to this general regard I have for his work – it provides a clarity into what ails the system – even if he cannot offer any specific remedies.

The Long History of Bad Practices

It was Ignas Semmelweis who is credited with the beginnings of our awareness that would ultimately become germ theory.  What’s not commonly known is that Semmelweis was dismissed and nearly unemployable.  He died alone in a mental institution.  So much for the embrace of new and improved techniques to move forward the practice of medicine.  Unfortunately, his experience was far from unique.

The process of bloodletting involves removing blood from an infected individual with the thought that the four humors are out of balance.  It’s believed that this killed George Washington – yes, that one.  Of course, he was already suffering from some ailment, but the degree of blood loss due to the bloodletting could not have helped.  And still, bloodletting remained an acceptable medical practice even through 1923, when it became a published practice.  This is nearly 100 years after the harmful effects were established.

What’s important here isn’t that there were practices in medicine that were ultimately discovered to be harmful – there’s a long list of them.  The point is really the time between when a practice is determined to be bad and the time it takes for that information to permeate the practice.  Pearl cites the often-mentioned statistic that the average time for a medical innovation to reach practice today is 17 years – this is, I suppose, better than our history, but a far cry from what we can and should do.

What You See Is All There Is

Daniel Kahneman in Thinking, Fast and Slow describes it as What You See Is All There Is (WYSIATI).  Pearl describes it as a cultural insistence that doctors must follow their instincts in their practice rather than the data.  From the very beginning, they’ve been taught that they’re special, and it’s their powers of observation that save patients.  However, the problem is the data doesn’t support this conclusion.

Atul Gawande proposed bringing checklists to the operating room in The Checklist Manifesto.  This was in part to neutralize the power dynamics of the operating room so that staff could speak up, but in another way, it was the application of a proven practice to medicine that has struggled with reliability.  Gawande’s book was published in 2009, and to my anecdotal knowledge most operating rooms do not use checklists – and some that do use them do in a rather perfunctory way.

The data can tell you whether something works or not – if people are willing to look at the data.  Ivermectin, a veterinary anti-parasitical, was recommended by some as a solution to improving outcomes for those with COVID-19 – except it’s wrong.  There’s no data.  What people said is that 100% of the people they treated with Ivermectin got better.

The problem with this thinking is that it ignores base-rate.  The base rate of mortality – and even hospitalization – with infections from SARS-CoV-2 is relatively low.  (I’m not going to quote them here because the rates keep changing with each new variant.)  The highest probability for a small clinic that treats as few hundred patients is that all their infections will get better – working treatment or not.  Similar arguments were made about former President Trump’s suggestion that hydroxychloroquine sulfate (HCQ) and chloroquine phosphate (CQ) would be effective at improving COVID-19 outcomes.  These anti-malarial drugs were proven ineffective – but not before many people tried them – many of whom were written prescriptions by their family physicians.  (Ivermectin wasn’t approved for human use, so it wasn’t the physicians enabling this behavior, even if they were encouraging it.)

The problem is that, when there’s a low base rate of mortality, if you try something – and no one dies – you assume it was effective when it wasn’t.  Similar problems happen when people start thinking about surgeons.

Practice Makes Perfect

Anders Ericsson and Robert Pool explain in Peak that the best in every world of performance get better by purposeful practice.  Whether you simplify this to 10,000 hours, as Malcolm Gladwell does in Outliers, the point is that more purposeful practice is better.  With dedicated surgical centers performing the most common surgeries repeatedly, you get better results.  That’s easy to see in the data about outcomes.  However, that doesn’t fit with the surgeon’s ego that says they get the best results.  They systemically discount their bad outcomes, ignoring them or explaining them away.  It’s what Thomas Gilovich explains in How We Know What Isn’t So.  When you know that more than 50% of surgeons believe they’re better than average, as professors and high school students did, someone has to be wrong.

What does this mean?  It means that physicians need practice and experience with a procedure to get good – and to remain good.  As a pilot, I must do so many take offs and landings in a given period of time before I can carry passengers.  Surgeons don’t have to do any specific number of appendectomies to be able to do one – but I’m not recommending they operate on themselves.  Specialization of surgeries to surgical centers allows for better outcomes.  Specialization among practice members for different kinds of surgery allows better outcomes for the entire practice.

Hope, At Any Cost

Nearly a decade ago now, I got to play a role in a drama at a pediatric hospital M&M (Morbidity & Mortality) session.  It was centered around “everything possible.”  It is a phrase that parents of children often use when speaking with the care team about what they should do to protect the lives of their children.  It’s also wrong.  The point was that there are some things that only extend pain and torment without adding any potential value to a child’s life – but are sometimes done anyway.  The point was to teach those in attendance that it wasn’t a literal plea but was rather a starting point for a discussion.  In pediatric and non-pediatric situations, people are often willing to give up more than they should for more time, because they can’t bear the loss.

Doctors are encouraged to provide hope when it’s not impossible and to offer ever life-extending options even when those options don’t increase the quality of the additional life but instead spread the misery longer.  They’re supposed to be the consummate professionals, being unwavering in their faith in new treatment options and their own skills.  However, the unfortunate truth is that, too often, we extend lives and try procedures that we would have been better off not doing.  “Everything possible” isn’t the right standard, but it’s the one that is often used.

The Care Guide

It was the late 1990s, and we did something revolutionary for a clinical study.  I played a small part in bringing best practice diabetes care to a primary care setting.  The program took in data and from it made recommendations about patient care based on the best practice standards at the time.  Spearheaded by a visionary endocrinologist and paid for by Roche (then Behringer-Mannheim), the program made a real difference.  The key difference, though, was the way that the recommendations were provided to the physician.  We gave them broad categories, and they either filled in the details or used the research and recommendations provided to them by the trained nurses – nurses they trusted.

The result was a success because we weren’t telling them exactly what to do, we were nudging them into the right direction and allowing them a bit of choice.  (See Nudge for more about this idea.)  We built trust with the providers.  We made the system work by playing into the culture instead of trying to work against it.  However, too often today, doctors feel like the systems are dictating care – and they’re no longer able to be doctors.

Doc-in-a-Box

It’s a rather derogatory way of referring to the nurse practitioners and physicians’ assistants who offer up care in pharmacies and standalone urgent care clinics.  It refers to their need to follow the rules and do basic urgent care.  Come in with a cough, and leave with a prescription for antibiotics.  It’s the extreme form of what physicians fear.  The responses are largely scripted.  Nurse practitioners and physician’s assistants in most states work in a collaborative practice agreement with a physician who supervises the care they provide – and who is presumably their backup for problems that they can’t handle.

This has dramatically improved healthcare access in many ways – and it’s led to the over-prescription of antibiotics and, by extension, the emergence of multi-drug resistant bacteria.  People expect they can have treatment if they go to a doctor – even a doc-in-a-box.  As a result, many people leave with prescriptions that will do them no good.  Additionally, because they’re only taking prescriptions to feel better, they’ll often stop taking them before the infection is fully under control and will rebound with an infection that is mostly of variants of the infection that are least susceptible to the antibiotic – thus furthering the development of antibiotic-resistant bacteria.

Bias Toward Action

Built into our human psyche is a bias towards action.  There’s a bias towards doing “something” – even if that something ultimately turns out to be harmful.  Nassim Nicholas Taleb explains this in Antifragile, and it resurfaces everywhere.  We’re notoriously bad about waiting for things to play out.  As a result, we prescribe medications that do no good.  But more than that, surgeons can take an old saying to heart.  “A chance to cut is a chance to cure” is a common refrain from surgeons that exposes the belief that surgery is always an option to cure – even when it isn’t.  It may help the surgeon feel good that they’ve done “everything possible,” but that doesn’t mean it’s right.

Doctors Disconnected from the System

For most of us, we’ve got a positive view of our personal doctor.  We believe they’re competent above their peers, and we’re lucky to have them.  We also simultaneously believe that the healthcare system is broken.  We accept the gap between these two, even though our doctor is a part of the system.  The truth is that we treat our doctors like they’re separate and apart from the system they operate in, but that’s neither real nor reasonable.

Primary or Specialty?

It’s a simple pyramid.  There are lots of people at the bottom and few people at the top.  Fewer physicians/specialists and fewer patients.  If you want to make a big impact, where should you focus your energies?  Most people realize that the answer is the bottom of the pyramid.  It’s the day-to-day interactions with healthcare that are the opportunities to improve preventative care – but that’s not the way most healthcare systems prioritize investments.  Investments are made with specialists because they can charge premium rates and generate premium revenue.

Of course, working on the primary care isn’t fun or sexy.  It doesn’t necessarily feel like you’re making that much of a difference.  It’s small, incremental improvements, but those improvements are multiplied across many physicians and can make a huge impact.  The point isn’t the impact, the point is that it doesn’t “sell well,” either internally or externally.  There’s no marketing message to most efficient primary care – because patients don’t care about that.  There are messages to be sent about cutting edge procedures – that most people will never need.

Equal Treatment

In medicine, like justice, we expect that everyone gets the same treatment – that there are no biases.  However, the data says otherwise.  Just like we know that judges aren’t impartial, physicians aren’t either.  This is particularly true for physicians in ER settings, where triage is an expected part of the job.  In law, numerous sources (including Thinking, Fast and Slow, Complications, When, and Pre-Suasion) speak to the fact that judges are less likely to grant parole right before lunch, and, often, the more you appear like the judge, the more likely you are to be treated more leniently.  We like to believe that physicians are different, but the data says differently.

Capitation

One of the central problems with the spiraling healthcare costs is the lack of a focus on prevention.  In a fee for service model, you get paid for doing more, and therefore there’s a negative incentive to work on preventative medicine.  This was a problem in the 1930s, when the Committee on the Costs of Medical Care (CCMC) met to discuss solutions.  They proposed capitation.  That is, they’d give physicians or medical systems a fixed fee per patient per year.  With large enough populations, the extreme cases are weighed out by people with little or no need in a year.  The incentives would then shift strongly to physicians doing preventative care, which is generally less expensive in the long run.  They’d make more money when they managed their patient population health well.

The problem is that nobody wanted it.  The physicians didn’t want their income tied to the behaviors of patients.  As we learned in Change or Die, as much as 80% of healthcare costs have behavioral roots, and changing behaviors isn’t something that physicians were trained for.  The resulting compromise was the Social Security Act – a far cry from what was intended but a win for citizens nonetheless.

When you create cultures and set up systems such that people are incentivized for the wrong things, you create bad outcomes.  It’s not that you’re getting the law of unintended consequences, as explained in Diffusion of Innovations, rather it’s that you’ve designed the system for bad outcomes.  Sometimes, those outcomes are a system that seems Uncaring.

Book Review-No Time to Teach: The Essence of Patient and Family Education for Health Care Providers

Sometimes you pick up a book because someone recommends it, and it changes the way that you view a topic – and it changes the way you view the person who recommended the book.  No Time to Teach: The Essence of Patient and Family Education for Health Care Providers is one of those books.  Fran London is at the end of her career as a nurse educator and wrote the book to implore nurses and other providers to recognize the value of education – and to share what works.

Contradictions

It started early.  I started disagreeing with London’s perspectives.  Not just because it didn’t match my experience, but it also didn’t align with the best practices in training.  Focused on one-on-one, face-to-face communications, London discounted the value of supporting materials.  We know, for instance, from Job Aids and Performance Support that it’s worth assessing what is needed and what the best answer to that is – whether it’s training or a tool for getting the job done.  In The Checklist Manifesto, Atul Gawande explains the value of checklists (a kind of performance aid) to the performance of all kinds of tasks.  London tries to explain that you should individualize teaching – which is supported – but in a way that neither recognizes the ability to get leverage nor addresses the fundamental process of assessing what the patient and family know.

In The Art of Explanation, we learn that people can learn within a range.  If the gap between their current knowledge is too great from what is being taught, it will be lost.  That matches Malcolm Knowles et al.’s understanding of The Adult Learner, who needs to connect what they’re learning with what they know.  Efficiency in Learning provides a path for developing materials to support teaching that can be used by people with varying experiences for effective learning – efficiently.

Ultimately, layered learning is the best approach.  Learners’ current knowledge is assessed, and they’re given a set of resources and instructions that match their level – and provide the ability for self-reinforcement.

Assessing Knowledge

Too many professionals lead the witness when they ask if someone knows something.  “You know how to take care of a wound, don’t you?” will lead to the obvious response, “Of course.”  This response has nothing to do with the awareness of the needed skills but rather reflects the desire to not be perceived as stupid.  I learned decades ago the best questions have “no” as the correct answer.  They’re best, because in situations where understanding isn’t good or where shame or embarrassment may be a factor, people will default to a “yes” response.

There’s more to assessing knowledge than just a yes/no question.  The next step is breaking down the knowledge they need to know into a set of specific skills that must be used – including the skills related to decision-making about situations and potential problems.  Simple boundary conditions like “If they have trouble breathing, go to the emergency room immediately” or “If you don’t have a bowel movement in the first 12 hours, start with Miralax, and if you’ve not had a bowel movement in the first 36 hours, call the office to let us know” are great ways to help identify when action is necessary – and what the actions are.

You’re Not Too Stupid

People have a high degree of anxiety when interacting with health professionals.  While they may be competent or even exemplary in their day-to-day jobs, often, the general public knows far less about health than health professionals believe.  (They have the curse of knowledge.)  It’s easy for the patient or the family to slip into thinking that the health professional is saying, “You are too stupid to understand this,” when that’s not what they’re trying to convey at all.

Whenever you’re struggling to communicate a set of skills to a patient or the patient’s family, it’s the teacher that is failing, not the student.  The teacher needs to try harder – and to apologize to the patient for not making it easier to understand.

The Need to Teach

Too often, medical professionals see teaching (or even communicating with) the patient as secondary to their roles.  Nothing could be further from the truth.  The provider or nurse will see the patient for a limited time, but they’ll be with themselves for their entire life – and the families will spend substantially more time with them than they’ll ever get with a healthcare provider.  The more these critical folks know, the less likely they are to have a negative outcome – or need to come back to the healthcare provider.

In the end, it’s only if bad outcomes are desired should someone say that they have No Time to Teach.

Book Review-Cleaning Up: How Hospital Outsourcing Is Hurting Workers and Endangering Patients

One of the challenging ethical dilemmas that faces physicians is when parents of a child tell them to do whatever they can to keep their child alive. The problem is that, no matter how painful it is, there are some situations where death is the right answer. It’s not an easy call, and no one involved likes the answer, but sometimes there are no real chances for a meaningful recovery. The dilemma for the physician is how much to do and when is the time to compassionately tell the parents it’s time to end the suffering – even if there are technically more things that can be done.

One thing that shouldn’t require this degree of struggle is having a clean – and disinfected – hospital room for the care of patients. However, the research is clear that most rooms aren’t cleaned well. Things are missed and patients are getting sick because of it. Dan Zuberi believes that at least part of the problem is the outsourcing of environmental services workers. In Cleaning Up: How Hospital Outsourcing Is Hurting Workers and Endangering Patients, he lays out the case that something must be done to improve patient safety.

Healthcare Associated Infections

To understand what’s at stake, it’s important to realize that healthcare-associated infections (HAIs) account for additional suffering for around 2 million Americans each year. Of those, roughly 100,000 will die. HAIs are infections that you didn’t have when you arrived at the hospital but that you acquired during your stay. While some progress has been made on reducing HAI rates, they remain strikingly high.

Based on many factors, including the region you’re in, the socioeconomic factors of patients, and the kinds of care that a hospital provides, there’s an expected rate of HAIs. These expected rates are baked into the way that the Centers for Medicare and Medicaid Services (CMS) pays hospitals. Hospitals are not reimbursed for the care that they provide related to an HAI. Additionally, when a hospital’s rates are poor compared to others in the industry, they face penalties that can be millions or even tens of millions of dollars. A single infection can cost a hospital over $100,000 dollars but may be as low as approximately $13,000. Collectively, the costs of the infections and the penalties are staggering.

Despite this, the expected rate is generally around 0.12 percent per patient per day. So, it is expected that for every 1,000 patient-days in the hospital, there will be 1.2 infections. This doesn’t sound all that substantial until you realize that an expected rate like this creates a greater than 50% chance that someone will have contracted an HAI in your room in the preceding year.

The cost in human suffering and finances to the healthcare system are substantial, and they should be unacceptable. If the airline industry had a similar failure rate, no one would fly or there would be a monumental outcry. However, because HAIs are hidden and distributed across the world, there is no uproar.

Environmental Cleaning

Most of the focus on environmental cleaning surrounds the so-called “terminal” clean. This is supposed to be a complete cleaning and disinfection of the room, and it’s supposed to happen between patients. The problem is that the research shows less than 50% of the high-risk objects (HROs) are cleaned in an average terminal clean. HROs might also be called “high-touch” objects, because they’re the things that are touched all the time. They’re bedrails, light switches, doorknobs, tables, and so on. The result of this poor cleaning is there’s a 40% higher chance of catching an HAI based on the person who had the room before you having that particular infection.

Zuberi pins the problem of poor cleaning on the movement to outsourcing environmental services, though my own research indicates that this is at best an aggravating factor rather than a smoking gun.

Outsourcing the Source of Evil

Outsourcing is done to reduce costs. The general idea is that another organization can run a function better than you can run it in house. You pay them for a service, and they can deliver it at a lower cost. It’s a standard approach across all industries. Relatively universally, it has challenges.

The winning bidder is often unprepared to deliver the service at the level of delivery that the organization is used to getting. Whether we’re talking about help desks or facilities maintenance, often the “savings” are due to a lower quality of service. Even when they want to maintain quality standards, they’re forced to pay less and offer fewer benefits to extract the profitability necessary to pay for the management and sales overhead. The push to lower pay results in higher turnover and therefore increased training costs.

Management at the outsourced contract provider are constantly trying to manage their cost profile to ensure that they remain profitable while sometimes making decisions that hurt them in the long term.

Aligning Metrics

The key to effective outsourcing is to align the incentives for everyone such that the situation is a win/win or lose/lose rather than win/lose or lose/win. When metrics aren’t designed well, situations arise where what is in one party’s best interest is not in the best interest of the other party. Such is the case with most environmental services contracts.

Even when metrics are aligned correctly, the necessary work to collect and verify the metrics isn’t done – because that adds additional costs to the system. As a case in point, there are sometimes – but not always – performance guarantees. However, these require audits of performance, which, because they’re awkward and difficult, are rarely done.

More perversely, rarely are environmental services organizations held accountable for any degree of increased HAIs – even when it’s possible to nearly directly associate those infections with poor cleaning practices. As a result, organizations are incented to reduce the cost of cleaning by reducing time, labor costs, supplies, or any other means necessary – irrespective of whether those decisions negatively impact the patients or the hospital system with whom they’re contracted.

The Working Poor

The result of wage pressures means that the workers are working – sometimes two or three jobs – for such little money that they can barely make ends meet or are slowing falling into an economic pit that they can’t recover from. This is while they’re facing challenges that put them at risk every day. They carry high degrees of stress that compromise their immune system’s capacity to combat the pathogens they encounter daily. (See Why Zebras Don’t Get Ulcers for more on the impact of stress to the immune system.)

In the struggle to make ends meet, they’ll change jobs for a small increase in pay, because the risk of changing jobs is smaller than the impact the pay increase can mean to their family. Zuberi contends that the wage of workers was nearly cut in half when environmental services were outsourced. This pressure means there’s a scramble to recover the wages they once had. The resulting turnover increases the non-compensation costs of the organization, applying more pressure to the managers to cut costs.

Non-compensation costs include the cost of recruiting, hiring, training, and managing payroll for the organization. Consider the initial recruiting, setup, and training costs for an employee might be $4,000. When wages for the employee are in the $12/hour range, the training and setup costs are roughly 20% of the first-year wages. When turnover is greater than 50% per year, this creates more than 10% of the total cost of the employees. Additionally, the constant turnover creates chronic shortages, further reducing the quality of the cleaning.

Fixing a Broken System

For us, Terri and I, we want to reduce HAIs. That’s why we pursued the patent on the moisture indicating IV dressing. It’s also why we’re making a substantial investment into the development of an augmented reality environmental services training program (AREST). We want to teach environmental services workers how to clean in a way that works for them, is effective, and isn’t expensive. In a sense, we’re trying to do our part to start the process of Cleaning Up the challenges with environmental services. Maybe you can do your part: start by reading Cleaning Up.

Book Review-Better: A Surgeon’s Notes on Performance

I’m sometimes a hard guy to impress. Sometimes, I strive for excellence and look for ways to get better, and I forget to appreciate that good is good enough. Maybe that is why I appreciated Better: A Surgeon’s Notes on Performance so much. It certainly doesn’t hurt that I’d previously read and reviewed Atul Gawande’s Checklist Manifesto and Being Mortal. However, in the end, I think what I recognize in Gawande is that passion for making things better, because better is possible.

Medical Advances

From the dawn of medicine until relatively recently, doctors largely did their patients more harm than good. Techniques like bloodletting weakened patients when they needed their strength the most. Sometimes, even when advances were possible to move medicine forward, they were resisted. Ignac Semmelweis discovered the basis for germ theory in 1847 and the need to wash hands after working on cadavers or before helping mothers deliver their babies. Today, it’s positively obvious, but back then, it was unique and different.

There are numerous accounts for why Semmelweis was so ineffective at convincing his peers that germs existed, and that handwashing was sufficient to stop (or at least hinder) their spread. Most of them involve what are described as “personality defects.” Gawande reports that Semmelweis refused to defend or support his germ theory and instead resorted to personal attacks – which didn’t win him friends. (See Mastering Logical Fallacies for some of the techniques that may have made it difficult to take Semmelweis seriously.)

Handwashing and Antibiotic Resistance

Over 150 years after Semmelweis’ discovery, we still struggle to wash our hands effectively. Depending upon whose numbers you want to believe, handwashing compliance in acute care settings (mostly hospitals) is somewhere between 20% globally and between 50-80% in the United States. And we’ve tried everything to get those rates up. We’ve put alcohol stations at every door. The WHO has spent countless millions on campaigns like the “The 5 Moments” to teach providers when to wash their hands, and we’ve barely moved the needle. More importantly, we’ve not managed to improve patient outcomes – not one iota.

The consequences are terrifying. We’ve become so reliant on antibiotics that when antibiotic resistant strains of bacteria emerge, we’re caught flat-footed. In 1988, a Vancomycin-resistant enterococci (VRE) strain infested a renal dialysis unit in England, and by 1997, 23 percent of ICU patients were infected. Vancomycin is a go-to drug for infections, and when VRE adapted, we didn’t know what to do. In healthcare, we assume our antibiotics will save us – but when the bacteria adapt, we don’t know what to do. SARS (severe acute respiratory syndrome) was primarily spread through healthcare workers.

We fail to realize that the scary things that we must combat today aren’t fixable by an antibiotic. Take MRSA (Methicillin-resistant Staphylococcus aureus). Methicillin is another go-to drug that a bacterium found a way to resist. What’s scarier is that the newer strains – the ones that haven’t made the news yet – are resistant to not just one of our antibiotics but multiple of our wonder drugs.

When It Doesn’t Work

Medicine has changed war. Medicine has dramatically reduced the death toll in war. It’s reduced the mortality of both mother and child during childbirth. It’s made conditions that would have been fatal into outpatient surgery, yet it’s not enough. “The paradox at the heart of medical care is that it works so well, and yet never well enough,” writes Gawande.

It’s hard to have conversations in a group of people and not have someone tell a story of a loved one who died of a health issue. Too many of these stories involve complications that happened as a part of the medical care itself, whether it was an infection they didn’t have when they came in, a medical error, or just something that wasn’t an expected outcome.

As much as we have made progress, we’ve not been able to deliver the best care consistently.

It’s a Business

While it’s nostalgic to think of the doctor who serves a community, accepting livestock and services in trade for the healing he can offer, that’s not the world of today. Healthcare is a business – a big business (as is pointed out by Mistreated). As a business, doctors need to do what is necessary to keep the business going, and that may mean they stop helping people when doing so means you can’t afford to be in business.

The reality is that the skill of a surgeon in the operating suite has almost nothing to do with how much money they’ll make. Their ability to make a business run will drive their revenue and their professional survival as a doctor.

Follow the Rules and Innovate

It’s a double bind. On the one hand, we know there’s not enough application of the best practices that have been demonstrated through research. On the other hand, there’s no way to innovate if we don’t break some of the rules – in a controlled way – to see if we can make things better. This is the central concern at the heart of making medicine better.

On the one hand, we want doctors who read the latest journals and follow all the latest advice. On the other hand, we’ve seen research be reversed as new information is gained – and that information is only gained when we stray from the rules.

Clearly, the difference is that, in the one case, doctors fall upon the norms of their groups and just do what they’ve always been doing, even when there is research saying it’s ineffective or there are better approaches. It’s just too hard to override your experience. You’ve done sometimes hundreds of these procedures with only a few complications. Why should you have to learn something new? How many injuries would it really save? We don’t believe the research; we believe our personal experience.

So, we have to encourage consistency and simultaneously find ways to carefully try new ideas to see if we can get even better.

The Ego and the Average

At the end of the day, being better is about elevating yourself above the average. The only way to know if you’re making progress is to measure your performance, and that comes with a great risk. You may discover, much to your dismay, that you are only average, despite your striving and struggle. Despite the trials and the conquests, your performance is only average. While this may be, on the surface, bad news, it does at least let you know where you are. If you want to become better – as a surgeon or just in life – perhaps you should read Better.

Book Review-Mistreated: Why We Think We’re Getting Good Health Care—and Why We’re Usually Wrong

It’s no secret that the American healthcare system is broken. While there have been great advances in healthcare that saves lives and improves the quality of lives for so many people, it is still broken. The problem is that we can’t take a step back and fix it because it’s still saving lives every day. Mistreated: Why We Think We’re Getting Good Health Care—and Why We’re Usually Wrong walks through the details of our healthcare system from blind spots and misperception to motivations that are out of alignment with what’s best for the public.

Confronting the Truth

It’s a convenient belief that we have the best healthcare system in the world. It’s convenient, because it fits the facts that we have the most expensive healthcare system in the world. More expensive means better, right? It’s convenient to believe we have the best healthcare system in the world, because we send our loved ones to get healed here, and we want the best for them. We ourselves get our care here, and why wouldn’t we want the best?

The problem is, while it’s convenient to think we have the best healthcare system in the world, that’s far from true. We have “the highest infant mortality rate, the lowest life expectancy, and most preventable deaths per capita” of the modern world. While we spend the most on healthcare, our results are far from the top of the pack. Instead, our system invites waste, greed, and poor outcomes, all the while believing the care we receive is good. At some level, we know that this is lunacy, but it’s a convenient thought that keeps us from confronting the truth. Seventy-six percent of people describe the quality of their care as good or excellent. This statistically can’t be true.

Affordable Care Act

The Affordable Care Act (ACA) is the most sweeping set of healthcare reform that has been done in decades. While focused on making it easier for every American to have access to healthcare, it was able to address some other issues as well. No longer would people be denied insurance because of a preexisting condition. Preventative care was made nearly or completely without cost to the consumer.

While this was important legislation, it didn’t strike at the heart of the structural problems healthcare faces. We pay for services instead of paying for health. We’ve not been able – yet – to transform the relationship to one where the consumer only pays for results. This change can make all the difference.

Unnecessary Surgery

If pain is the symptom, surgery rarely has better outcomes than alternative treatments. Yet we perform surgery to repair a torn meniscus and place stents in people’s arteries at great cost with little or no actual health benefit. The results are in – and they say we shouldn’t do them. Like dozens of other treatments that are ineffective, we still do them because it’s standard practice or because they’re marketed aggressively.

Opioids

There’s a bit of news now about how opioid manufacturers, particularly Purdue Pharmaceuticals, engaged in aggressive marketing of Oxycontin, which had a high potential for abuse but which the company routinely led physicians to believe was safe. Dreamland covers this aspect of our healthcare woes in detail. The short version is that we began treating pain as a vital sign, and physicians began getting more directly measured by their intentionality about treating pain. In most cases, this meant prescribing them a pill.

Pharmaceutical companies learned that, when marketed to them directly, consumers would ask their doctors for the medication. Often, they’d get what they ask for. Doctors are reluctant to deny their patients the medications they’re asking for – even when it’s not effective. Consider the over-prescription of antibiotics. A patient doesn’t feel well, and they make the decision to go to the doctor. They expect the physician will do something to make them better. They expect they’ll get a pill that will make them better. The physician, tired of explaining that an antibiotic won’t help, prescribes it anyway, knowing it won’t make them better. In the next week, the patient feels better and attributes their wellness to the drug – instead of to the virus running its course.

We see this desire of the public to just get a pill and fix it show up in every aspect of healthcare, including mental health, where it’s easier to take an anti-depressant than to deal with the underlying problem. (See Warning: Psychiatry Can Be Hazardous to Your Mental Health for more.)

Generalists and Specialists

The frequency with which you deal with a problem makes a big difference in your outcomes. The truth of the matter is that in medicine – like many other disciplines – you can’t get good at something if you’re never given enough time to practice and learn. Intuitively, it makes sense. If you do one gall bladder surgery a month, you’re not going to be as skilled at it as someone who does 100 a month. However, in most cases, the market doesn’t allow physicians to become hyper-specialized into a single kind of surgical procedure. Even our specialists cover a wide range of procedures and patient problems – too wide to drive the kind of volume in the procedure that would make them truly good at their craft.

What tends to happen is that a generalist treats a few patients a month and gets, at best, middling results from them. Even the specialist can’t afford to be hyper-specialized, because all the generalists are taking the cases they need to stay fully busy and get very good at what they do.

That’s not to say that generalists, like your primary care physician, are bad or not needed. It is believed (based on successes in other nations) that the best solution to the healthcare performance problem in America is to get primary care physicians better at preventative medicine – true health care – instead of trying to triage and route patients who are truly sick.

There’s a very old saying that “a stitch in time saves nine.” Meaning if we catch things early – like before they start – it takes very little to maintain or repair the situation. The later we catch a problem, the more challenging the recovery becomes – but that’s what we reward in our current system. Specialists (such as they are) are paid roughly three times what primary care physicians are paid. We undervalue the preventative measures that can have the greatest impact, and we elevate the heroic, last-minute attempts to help someone survive.

Undervalued

There’s a real soft spot in my heart for the understanding that we undervalue simple interventions that save lives and instead invest our money into technological marvels that have little or no real impact on outcomes. Another big marketing tool that healthcare systems are using is robotic surgery. Again, it makes sense. Doctors’ hands can be shaky, but robotic hands are not. However, the efficacy for robotic surgery isn’t any better than regular surgery – oh, and it takes longer. However, organizations are spending millions of dollars on these robotic surgery devices, which sit idle most of the time. Physicians want to have them but don’t see any need to make their jobs harder without better outcomes.

The soft spot for me comes because of our IV dressing patent. It’s simple. It’s straightforward. And we’re still trying to get the market to accept a change that may impact materials cost by $1 and may substantially reduce healthcare-associated infections (HAIs). It’s not sexy, but it seems to work. That may be why it’s not being used. Because, in the upside-down system of American healthcare, if it doesn’t seem like it’s cool, then it’s not worth doing.

Dr. Pearl shares his appreciation for information technologies and the ability for these simple technologies to improve outcomes.

Diabetes Advantage Program

It seems like a lifetime ago to me now. The study was being done in 1999, and the journal article was about the program titled “A Systematic Approach to Risk Stratification and Intervention Within a Managed Care Environment Improves Diabetes Outcomes and Patient Satisfaction” in Diabetes Care (Volume 24, Number 6, June 2001). The short version is we took patients with diabetes who were being treated by primary care providers, and we gave the primary care providers suggestions for the actions they should take to help their patient better manage the disease. We basically made it easy for the physicians to do the right thing.

The recommendations would print out to add another oral medication, the nurse would write a more specific recommendation in based on the physician and the specific drugs the patient was on, and the physician would sign the orders. The physicians quickly learned to trust the system (and the nurse). They realized the system was giving their patients the benefits of the best research on the disease without them having to study it.

The net result was about a 1-point drop in HbA1c values in 12 months. To put that in perspective, back then, the threshold for having diabetes was 6, and the threshold for uncontrolled diabetes was 8. (These values have been adjusted a bit in more recent standards.) So, a 1-point drop in HbA1c values was a substantial change. Most of that change is attributable to the system “reminding” physicians to do what the research suggested was best.

In short, helping caregivers with information technology works – and we’ve known it works for decades now.

Environment of Care

We tend to overestimate our rational rider and underestimate how much of what we do is shaped by the environments that we are in. Kurt Lewin proposed that human behavior is a function of both person and environment. You can’t predict what a person will do without understanding both. More recently, we’ve seen how people can be made to do awful things to other people with relatively little encouragement. The Nazi extermination of Jews was unfathomable. However, as both Albert Bandura (in Moral Disengagement) and Philip Zimbardo (in The Lucifer Effect) explain, it’s relatively easy to disengage our morality and cause people to behave in ways that don’t make rational sense. They both point to the work of Stanley Milgram after World War II, in which subjects were thought to be giving progressively higher voltage shocks to another subject in the next room. Most continued to give shocks that they perceived to be potentially fatal with little more enticement than knowing it was for the experiment.

It’s surprising how little factors can cause us to take different behaviors. Nudge uses numerous examples of how changing the easy or default answer changes the way people eat and save. When you look at the body of literature around change, you’ll find that, much of the time, making change work is about a few well-placed interventions. (See Switch, Redirect, Change or Die, Change Anything, Made to Stick for examples.)

These same factors hold true whether we’re talking about something truly evil or we’re simply talking about practices that aren’t effective. Once the group establishes a social norm, it’s hard for new people to adjust the norm, even when the new target has better demonstrated outcomes. In short, the team becomes fixed in their perspective and don’t accept the valuable input from the outside. (See Diffusion of Innovations and Hackman’s Collaborative Intelligence for more on the receptiveness of a group or team to outside influence.)

Sometimes, the best examples of what to do are sitting right under our noses. The Washington Post Magazine arranged for internationally-acclaimed virtuoso Joshua Bell to play his violin at a subway stop for spare change. The man who played for presidents and sold out concert halls earned a little more than $32 in his time at the subway station. The expectation that he was simply a street player led nearly everyone to treat him as one. The environment we’re in really does dictate how people respond to us.

Healthcare Is a Team Sport

In America, we’re enamored with the idea of a lone hero charging across the western plains to conquer a new land. The wagon trains of families banding together to face the hostile wilderness just doesn’t sell as well. We want to believe the surgeon has better outcomes while ignoring the impact of the hospital, the nurses, and even the janitors. In healthcare, janitors are called environmental services (EVS) workers. The painful fact is that most EVS workers clean somewhere between 30-50% of the things they’re supposed to clean between patients.

There’s a growing body of research that shows pathogens are being passed from one patient to the next because of improper or incomplete cleaning. Moving the needle from 50% to 80% of the objects cleaned can have a reduction in HAIs of about 20%. To put that in perspective, that’s more than one infection saved per EVS worker per year.

Nursing, too, has been shown to have a critical role in the outcomes for the patient. “Better” nursing care is associated with better outcomes. Subtle things like the degree of burnout nurses experience has an impact on the patient outcomes.

Everywhere we look, there is evidence that it’s more than the gifted surgeon that makes the difference in the outcomes. Now more than ever, healthcare is a team sport – and one that is sure to continue. The silent member of the team – but the one that is always present – is the patient.

Patient Non-compliance

One frustrating aspect of healthcare is that frequently the patient is non-compliant with the protocols they’ve been given by the healthcare staff. Whether that’s failing to take medications or it’s not doing the prescribed exercises, getting the patient to behave in their best interests is often a frustratingly difficult challenge. To be fair, most of the challenges here are ones that educational folks have learned to address but healthcare hasn’t picked up on.

Healthcare workers aren’t careful about educating patients and asking questions for which the correct answer is no. By default, humans will answer yes if we don’t understand. So, asking questions that have no as answers can help ensure the patient understands. (See Incognito, Predictably Irrational, and The Hidden Brain for more.) For instance, instead of asking “Do you understand that you should take this with a meal?” you might ask “So, do you believe you should you take this on an empty stomach?” Healthcare workers suffer from the curse of knowledge, which means they fail to explain in a way that patients can understand. (See The Art of Explanation for more.)

What’s more, healthcare workers haven’t been taught to give patients productivity aids to help make them more successful. (See Job Aids and Performance Support for more.) The handouts they give patients are largely unintelligible even by healthcare workers, and they aren’t inviting to someone who’s unfamiliar with healthcare and what’s happening to them. Beyond the paper they’re given, they’re rarely pointed towards tools that can help them be more compliant – like an application for their smart phone that will remind them when it’s time to take medications.

If we’re going to make healthcare better, we’ve got a long way to go. We’ve got to address the motivators that cause people to take advantage of others. We’ve got to move towards higher specialization and more preventative medicine. And we need to get everyone on the team – including the patient – so we can prevent more people from being Mistreated.

Book Review-Relationship-Based Care: A Model for Transforming Practice

Healthcare isn’t sausage-making. In sausage-making, “what’s in there” doesn’t matter. It’s simply that it tastes good. In fact, most people don’t want to know about the sausage-making process. However, in healthcare, we’re talking about people, and the process matters. That’s the heart of Relationship-Based Care: A Model for Transforming Practice – an understanding that the process of delivering care is important and the best way to do that is by recognizing the importance of relationships.

Three Directions

In the healthcare system, there are three primary kinds of relationships that a provider can have. First, there’s the obvious relationship to the patient – and their family. The second relationship is with the colleagues. Healthcare is a “team sport.” No provider can work alone. Finally, there’s the relationship to one’s self.

It may seem that a relationship to self is an odd thing to add; however, the truth is that the lack of self-care and self-awareness on the part of providers leads to burnout – and poorer outcomes for the patient. (See ExtinguishBurnout.com for more on burnout causes and resolutions.) The truth is that the relationship to self is the relationship from which the other relationships initiate.

Connecting to the Mission

Every day, care providers face new patients. They present with the same kinds of conditions and the same acuity as the day before and the day before that. There are variations to be sure, but the patients keep coming. It seems like the provider isn’t having an impact. The same patient comes back with the same problem, because they didn’t heed the provider’s advice.

It can be frustrating and demoralizing to realize that you can’t save everyone – that you can’t help everyone. As each day becomes more and more of a grind, it’s possible to lose your way – and wonder why you’re pushing yourself if you’re not seeing any results. That’s when it’s important to reconnect with the mission of the organization and to our personal mission.

Simon Sinek in Start with Why explains that connecting to why we’re doing something has a powerful effect on our productivity and our ability to continue in the face of adversity. In some cases, we know why we’re doing something – our personal and organizational missions – but we’re lost, because we don’t feel like we’re accomplishing the mission. Instead, we feel as if we’re engulfed in chaos, and we’re just trying to survive.

The Healing Power of Relationships

We think we’ve got the world figured out. We believe that our technology and techniques save lives – and to some extent, that’s true. Our technology does save lives, but there’s more to it than that. Aristotle knew that there was more than one way to know the truth. There’s the science – episteme – but there’s also the art – techne. The truth is that our technology and techniques are only part of the solution. (See Theory U for more about different kinds of knowing.)

In Being Mortal, Atul Gawande recounts research that assisted living facilities with patients who were given something to care for – a plant or an animal – lived longer than those who didn’t have something to care for. Our connection to other living things is a powerful tool for health.

Florence Nightingale knew this. She believed that the role of the nurse was to help patients attain the best possible condition, so nature could act, and self-healing could occur. The icon of nursing didn’t believe it was the nurse’s role to heal but rather to create the conditions for healing to occur, and those conditions seem to be found in caring, compassionate relationships.

Transforming an Environment of Care

Jayne Felgen developed a model, I2E2, for transforming the environment of care. The model is four concepts:

• Inspiration – How do you connect people with the things that inspire them – in other words, their mission?
• Infrastructure – The set of practices, systems, and processes that make the inspirational vision achievable.
• Education – The promotion of competence, confidence, and personal commitment through providing the knowledge and skills necessary to do the job.
• Evidence – Gut feel isn’t enough. In today’s healthcare world, it’s necessary to know for sure that the work being done is making a real difference.

The model encourages the tools that we know lead to change, including creating the initial pull to drive the change forward, supporting the individual both at a systemic and educational level to help them understand they can be successful, and providing continuing support in the form of demonstratable results. (See Diffusion of Innovations for more about motivating people to change.)

The Five Cs (Conditions)

In every organization, there are barriers to change. In fact, organizations, by their very nature, are resistant to change. The network of policies and procedures are designed to form a network that provides strength around unnecessary change. However, there are conditions that make it more likely that change can occur. They are:

• Clarity – When people know what’s happening at a deep level – both to them and to the organization at large – they can move forward with less fear. (See The Fearless Organization about the role of fear in organizations and Trust=>Vulnerability=>Intimacy, Revisited for more on the role of safety.)
• Competency – The more people feel competent, the more willing they are to step forward into the change. (See The Psychology of Hope for how waypower impacts a person’s ability to maintain hope.)
• Confidence – The feeling that someone knows what is being asked of them and has the skills to execute on that leads to confidence – or courage – to move forward. (See Find Your Courage for more.)
• Collaboration – Collaboration is the ability to work together towards a common goal. That’s essential if you want to transform an organization, because in all but the smallest of organizations, there are multiple people involved whom you need to work with. (See Collaborative Intelligence for a very detailed investigation in how to make collaboration work.)
• Commitment – Being “bought in” to a goal is critical to its success. Commitment carries the change beyond just doing it if it’s easy, and instead moves it to the world of grit, where there’s a burning desire inside the person who is willing to face adversity to accomplish the goal. (See Grit for more.)

Though the 5 Cs aren’t a rich model for organizational change, it does provide a good framework for some of the basics.

Person not Diagnosis

Diabetes in room 3. Stroke in room 4. Breathing trouble in room 5. It’s a quick way of communicating, but it’s not a respectful way. In healthcare, we’ve got HIPAA to consider, but we can’t use that as a shield for our thoughts and words. Everyone has a story. Everyone is a real person – and they’re much more than a diagnosis.

When we dehumanize people, as referring to them by their diagnosis tends to do, we make it easier to unconsciously treat them poorly. Stanley Milgram demonstrated that, given light environmental controls and encouragement, most people are willing to administer what they believe are life-threatening shocks to others – if they’re not in the same room. (See The Lucifer Effect and Moral Disengagement for more on Milgram’s experiments and the topic of dehumanization in general.) Though we don’t want to admit it, the more we fail to think and communicate about patients as real people with real fears, hopes, and aspirations, the easier we make it to discount them – and that’s the opposite of being in a relationship with them.

Leadership as Being in a Relationship

Joseph Rost laid out in Leadership for the Twenty-First Century how he believed all leadership is done in relationships – non-coercive relationships – and how everyone is a leader. Rather than believing there are two classes of people (separating people into us vs. them), Rost believed that all of us are in relationships with others and are capable of leading. The common thread is that the relationship is accomplished for a meaningful, mutual purpose. In healthcare, the well-being of the patient is a meaningful, mutual purpose.

Sometimes in leading recovery, the patient will lead, and other times, the nurse will lead. Sometimes, in healthcare organizations, the manager will be leading, and other times the nurse will be leading. Leading is, according to Rost, centrally focused on the ability to be in a relationship.

Most nurses recognize that their relationship with their patients, the ability to be with them at their times of such great vulnerability and need, is a sacred and privileged trust. This puts them in the position to lead the patient to better health – as non-coercively as possible.

Organizational Models

Relationship-Based Care spends a great deal of time investigating structural models of organization and approaches to how to deliver the best care. From the historically highly authoritative to the more collaborative approaches, the walk-through shows the progression from a very power-based approach to one that is more collaborative and focused on mutual relationships.

The concerns are addressed about how organizations can maintain consistency of delivery when the delivery is done in a more collaborative and relationship-driven way. The fact of the matter is providing professionals with more autonomy provides for better outcomes – when that autonomy works inside of a well-defined framework.

I’m reminded of Chris Lowney’s work, Heroic Leadership, and how the Jesuits learned which things couldn’t be adapted to fit a culture they were working with – and which could. This clarity about the things that were and weren’t negotiable made it possible to operate effectively in very different environments.

Reflection

Relationship-Based Care recommends reflection – and that’s important both at an individual level and at a level of process improvement. When we do institutional reflection like after-action reviews (see Lost Knowledge), more commonly seen as root cause analysis, systemic cause analysis, or morbidity and mortality meetings, we create the opportunity to learn from our mistakes and not repeat them.

Perhaps it’s worth some reflection to see if you are providing the best Relationship-Based Care.