Picture This

September 22, 2014

CHW LogoA neurosurgeon, a minister, and a nurse walk into a bar…. (There’s no punch line, though I invite suggestions for a good joke.)  I’m willing to bet that in picturing the scenario the vast majority of you imagined two men and a woman.  I’d even go so far as to say that the woman was the nurse.  It’s an example of how our thinking is influenced by our most recent experiences.  If you work at Children’s Hospital of Wisconsin, the last nurse you met was very likely female, and the last neurosurgeon was certainly a male.  It is what is referred to in the psychology of decision making as the “availability heuristic”: when we make judgments without complete information, we tend to refer to our most recent experiences, relying on the information we have available by easy recall to fill in for the information that is missing.  (A heuristic is a mental shortcut – there are many types, this being just one.)  Not knowing the sex of the characters, I draw on the most recent prior information I have about the sex of a neurosurgeon or a nurse.

Short cuts like this evolved as a way for our minds to function more efficiently.  When asked “Think of a common man’s name that starts with P,” it is far easier for me to conjure up the last man with that name that I interacted with (Peter) than to call up in my mind the complete list of men’s names beginning with P (Paul, Philip, Patrick, Pedro, Pradeep, etc.) and thinking about how many people have each of them.  In many circumstances, the availability heuristic works well and allows us to act on incomplete information.

You could argue that it’s simply a matter of playing the odds.  In the US, the majority of neurosurgeons and ministers are men, and the majority of nurses are women.  But research shows that we actually are not all that good at thinking statistically, and that playing the odds is often trumped by recent experience.  When recent experience is not representative of reality, this mental shortcut leads to bias.  For example, we recently had a patient in the ED who had just arrived from Liberia with high fever and upper respiratory symptoms.  Which is the most likely diagnosis: a) malaria, b) a cold, c) Ebola?  If Ebola even crossed your mind then you are displaying the availability bias; a cold is several orders of magnitude more likely based on actual prevalence.

Non-representative recent experience can steer us wrong in many ways.  It’s a common problem in medical diagnostic decision making, especially among non-experts.  I remember as a fellow seeing a teen with severe abdominal pain, to the point that he was irrational.  I had recently read about acute intermittent porphyria, which can cause abdominal pain and altered mental status, and promptly ordered a urine porphobilinogen level to test for it.  Never mind that it has an incidence of around 1 in 50,000.  Not only was I wrong, it delayed me from treating his pain and making the actual diagnosis (kidney stone, incidence about 1 in 10, though less common in teens).  I suspect the availability bias explains a good deal of the higher cost of care provided by medical trainees.  The first time a resident sees someone with a rare illness, they start to evaluate more patients for that problem.  It’s also a culprit in driving some utilization by patients.  When the media run sensational reports about uncommon conditions, people overestimate their risk and often seek unnecessary medical care.

The availability heuristic also leads to broader bias in society.  For instance, young blacks are arrested for marijuana possession at much higher rates than young whites, despite having a similar frequency of drug use.  Blacks thus have higher rates of incarceration, and news stories about drug arrests are much more likely to feature African-Americans.  As a result, people (both blacks and whites) overestimate the proportion of criminals that are black.  In one study, 60% of viewers of a crime story without a picture of the suspect falsely recalled seeing one, and 70% believed that the suspect was African-American.  After all, the last news story they saw about crime was likely to have featured a black suspect: availability bias.  Similarly, low income individuals are more likely to be prosecuted for child abuse, leading us to believe – incorrectly – that those who are more well off are unlikely to maltreat their children, and potentially missing an opportunity to intervene when necessary.

There are many examples of how our use of this mental shortcut can lead us not only to misrepresent how common or uncommon something is across a group, but also to misapply the most readily recalled information about groups to individuals.  Even when the most recent image is truly representative (e.g., most nurses at Children’s are female), it may not apply to a given individual.  (Just ask any of the 3 male nurses I worked with in the ED yesterday!)

The availability heuristic is just one of the filters we all see the world through.  Like other filters, it’s not necessarily either good or bad, but it is something to be aware of.  When we make a snap judgment without having all the information, we need to be aware that we are overly influenced by our most recent experience and by the way things are portrayed – correctly or not – in society at large, and be willing to reshape our initial image as we get more information.  And while some people cry “political correctness” when we use gender-neutral language or multiracial images, a non-biased environment is an important way to make our mental images more accurate.  I know more than a few women neurosurgeons, female ministers, and male nurses who would appreciate it.

Relax, This Won’t Hurt

September 12, 2014

CHW LogoI’m overdue for one of the rituals of middle age in 21st century America: the screening colonoscopy.  Now this may have been a rationalization, but just after my doctor referred me for one, I changed employers, and therefore insurance plans (moving into a high-deductible plan), so I needed to see what the coverage would be.  Of course, it’s taken me 2 years to do it.  Can’t read the fine print too carefully, I always say.

Turns out, I’m not atypical.  A study in Medical Care looked at people who were switched from an HMO to a high-deductible health plan (HDHP).  Compared with those who stayed in the HMO, people in the HDHP tended to use fewer low acuity services (such as non-urgent ER visits).  Interestingly, women had similar rates of use for medium- to-high acuity services, while men reduced their use across all levels of acuity.  It appears that women are better health consumers than men, wisely saving resources for services that are more necessary.  Men are either just cheap, or looking for an excuse not to go to the doctor.

There are many myths and uncertainties surrounding HDHPs.  More and more Americans are enrolled in them – including an increasing share of employees at Children’s Hospital of Wisconsin – so it’s worth addressing a couple of those.  First, preventive care (including, if it’s coded right by the provider, screening colonoscopies) is generally covered at 100% and not subject to cost-sharing.  So don’t skimp on the check-up and vaccines; you’ve already paid for them through your premium.  Second, research has shown that for most people, HDHPs lead to more rational use of health resources (that is, avoiding unnecessary treatment while preserving needed treatment), with no worse health outcomes compared with forms of insurance that do not require the patient to bear as much of the cost.  There is an important exception: the RAND Health Insurance Experiment showed that lower income people deferred both needed and unneeded care similarly, and had some worse health outcomes associated with that.  (And maybe stubborn men, as well.)  That said, making good choices requires some guidance.  It’s not necessarily easy for people without medical training to distinguish low-value services from those that are necessary.  A key principle is to ask questions.  Is a brand name drug necessary, or would a generic do?  Or what about no medication at all – would the condition get better on its own?  How will doing a diagnostic test change what the provider will recommend in terms of treatment?  There are many sources of information on line, many of which are of dubious quality.  A particularly reputable one is Choosing Wisely, where you can find recommendations from the leading medical professional organizations about services that are generally agreed to be low value.

When used well, high deductible plans are nothing to be afraid of, and may have the potential to decrease costs with as good or better outcomes.  I guess the same is true of colonoscopy….

It Takes a Village

September 5, 2014

CHW LogoMy older son spent the first year and a half of his life in Falls Church, VA.  Based on data from the Robert Wood Johnson Foundation, his life expectancy is 83 years. (Don’t worry, buddy – they go fast but you have plenty left.)  But if he had been born three Metro stops away, in Washington, DC, his life expectancy would be 7 years shorter.  The situation is even more striking in New Orleans, where the difference in life expectancy across the metro area is 25 years.  As an article in Health Affairs put it, Zip code is more important than genetic code when it comes to health.

It’s easy to write this off.  Different communities, different people.  While there are undoubtedly differences in population between neighborhoods – including racial and ethnic differences that may include a genetic component – the strongest association is with poverty.  Poor people have worse health regardless of their race or culture.  Moreover, a 2011 study published in the New England Journal of Medicine showed that when people who began in a poor neighborhood were randomly assigned to receive housing vouchers allowing them to relocate, those who moved to low-poverty areas subsequently had lower rates of obesity (19% lower) and diabetes (22% lower) than those who either stayed or moved to another high-poverty area.  It appears the real estate people are right: it’s all about location, location, location.

The exact factors about a neighborhood that lead to adverse health impacts are unclear.  Possibilities include: physical infrastructure (e.g., parks, sidewalks, safe streets) that allows and promotes physical activity; access to healthy food; low crime and attractive environment that decrease chronically elevated levels of stress hormones.

As an organization committed to making the children in Wisconsin the healthiest in the nation, Children’s Hospital recognizes that we can’t simply provide excellent health care.  We must partner to influence all the other determinants of a child’s health, including the state of their community.   A recent article in the New York Times highlighted a Philadelphia program of community health workers: individuals from target communities, hired by a health system and trained to work with other families in those communities to address health needs and connect with needed resources.  This is very similar to Children’s’ own community health navigator program in three neighborhoods in central Milwaukee.  Health Partners, an integrated health system in the Twin Cities, has adopted what it calls a “community business model,” whereby they invest in activities and partnerships that are designed to improve all of the modifiable determinants of health, not just medical care.

Kids on the near north side of Milwaukee deserve to have the same life expectancy as those in Wauwatosa.  To get there, it truly takes a village.

Spring Cleaning

August 29, 2014

CHW LogoWe got our house back last week.  Our sons, who have been storing most of their belongings in our garage and basement for the better part of the past three years, both settled in to new apartments, taking their stuff with them.  Now we just need to sweep up the debris and voila!  No more squeezing past a futon to get my bicycle, or climbing over cartons of books to get to the rake.  It’s like pouring Drano into a clogged sink.

Those who have seen my office know I can’t stand clutter.  This is as true of my virtual space as my physical one.  Which is why a recent article from the Economist resonated with me so much. “Decluttering the Company” describes an unfortunate tendency among business organizations to accumulate structures and processes that simply clog the place up, making it difficult to get anything of value done.  The author lists some of the usual culprits: committees and other governance structures, meetings, and emails.  The problem is not so much with committees or meetings per se.  All these things are to some extent necessary.  The problem is their kudzu-like indestructibility.  Once a committee is formed, or a meeting is scheduled, it is nearly impossible to get rid of.  The result is redundancy, wasted time, and excess complexity leading to lack of clarity about where responsibility and accountability lie.

Organizations that find themselves cluttered up should consider a spring cleaning.  Time to sort through the committees, governance boards, management layers, and standing meetings, and decide which ones still provide value, which ones need to go to the landfill.  Even better is to prevent the clutter in the first place.  Committee charters could include a planned sunset date, unless the members strongly believe that there is still value in it.  At the very least, organizations should build a regular spring cleaning into their processes.  A friend of mine who lived in the same apartment in Chicago for 20 years used to move out and back in again every three years, as a way to force herself to declutter.

Think about our organization.  We have a great deal of activity that creates value for us and for our patients and families.  But we have to admit we have a lot of clutter.  I still have work to do on my garage.  When I’m done, what should I work on next?

Decisions, Decisions

August 22, 2014

CHW LogoRaisin Bran or Honey Nut Cheerios?  Standing in front of the pantry, faced with five boxes of cereal, I was paralyzed with indecision.  I could not for the life of me choose which one to have when I got home from my overnight shift.  It was completely ridiculous: I had just spent nine hours effortlessly making, in some cases, literally life-and-death decisions in the ER, and now I pathetically could not pick among a few not-terribly-different, nutritiously marginal, food-like products.

It turns out, I was suffering from what has been termed “decision fatigue.”  Some really innovative and fascinating behavioral and neuroscience research in recent years has shed light on what is a common phenomenon, and one with widespread implications.  Perhaps the most famous study is one of parole decisions by Israeli judges: investigators analyzed over 1100 cases in a ten month period.  One of the strongest predictors of granting parole was when in the day the case was reviewed.  Prisoners whose cases were heard at the start of a session had a roughly 65% chance of being granted parole, whereas parole was almost never granted to the last cases reviewed.  Parole was far more likely at the start than the end of a session even after controlling for severity of the crime, length of time served, prior criminal history, and ethnicity.

Other research has demonstrated that after a period of repeated decision-making, subsequent decisions become harder.  This is manifest as either indecisiveness (e.g., Raisin Bran or Cheerios), or deferring a decision by defaulting to the fall-back position (e.g., not granting parole).  Not only do people with decision fatigue find it hard to make choices, they also show decrease in willpower, leading to bad choices.  It’s why we often eat or drink too much at the end of a tough day.  These findings are consistent with a theory first proposed by Freud, known as “ego depletion.”  In essence, voluntary mental effort, including making choices and resisting urges, draw on a pool of mental energy.  When that pool is drained, quality of mental efforts is diminished.  Intriguingly, food plays a role; decision fatigue is ameliorated by glucose.  (It’s not just the act of eating – artificial sweeteners do not have the same effect.) For example, parole rates for the Israeli prisoners went up after a morning snack, then drifted down again before lunch.  And back up again after lunch!

The notion of decision fatigue has numerous implications.  Most obvious is for the way we do our work.  Intellectual performance falls off after a period of time.  Potential remedies include frequent breaks; spreading meetings requiring decision-making over the course of a day rather than stacking them back-to-back; not trying to make critical decisions when you are mentally tired or hungry.

Another implication is a societal one.  Self-control is at a low point when ego depletion sets in.  Poor people, who frequently have to make trade-offs that those with more means don’t have to worry about, may be more prone to this.  They make more, and more challenging, decisions in a given day than others.  Choices that may seem trivial or irrelevant to me are depleting to someone who is counting every dollar.  Studies suggest that poverty is not caused by bad choices; rather, bad choices are a consequence of living in poverty.  But we are all potential victims.  It’s one of the reasons supermarkets put all that candy at the checkout line.  It turns out, shoppers who have just spent a half hour choosing among a dazzling array of products are much more prone to give in to the temptation.  (It’s also why, for example, car salesman offer the ridiculous undercoat protection after you’ve had to select the model, color, interior décor, sound system, and various other options.)

Well, picking a cereal for breakfast this morning was easy.  But deciding on dinner is going to be a challenge.

Back to School

August 18, 2014

CHW LogoAt the ripe old age of 18, my mother was a newly minted RN, fresh out of a two-year diploma program.  Not too many nurses got bachelor’s degrees back then.  Years later – while continuing to work two jobs and raise two kids – she went back to get a bachelor’s (in psychology, not nursing), and eventually a master’s in health administration.  Why?  In large part, I think, because of new requirements.  I certainly don’t think she believed the additional years of school made her a better nurse (she was already an awfully good one).

A study published this year in the Lancet suggests otherwise.  Looking at 300 hospitals across nine European countries found two nursing factors that correlated most strongly with mortality rates.  One was the nurse:patient ratio.  The other was the proportion of nurses with a bachelor’s degree.

Knowing how important the quality of nursing is to the overall quality of care, this is perhaps not surprising.  Nurse education is one of the many criteria evaluated by the American Nurses Credentialing Center’s Magnet Recognition program.  (CHW was verified as a Magnet hospital for the 3rd straight time in 2014, a distinction held by only about 1% of all hospitals in the country.)  Over 76% of direct care nurses at children’s have at least a bachelor’s degree, and nearly a quarter have some form of national specialty certification.  Among our nursing leaders, 72% have a graduate degree.  This is one of the reasons we are able to deliver the best and safest care.

Not only are our nurses well educated, many of them are educators themselves.  I recently read through our annual advanced practice nursing report, which presents an impressive array of teaching and research being done by our many talented APNs.

The Lancet study doesn’t show why nurse education level is associated with better outcomes, but some speculation includes a greater ability of university-trained nurses to interpret sophisticated monitoring data, and a greater willingness to question the traditional hierarchy to raise safety concerns.

My mother is certainly proof that one doesn’t need a bachelor’s degree to be an excellent nurse.  (She’s also proof that you don’t need a degree to challenge authority.)  But when it comes to education for nurses, the data show that more is better – and kids deserve the best.

Do This, Or Else

August 1, 2014

CHW LogoA couple of years ago I was visiting another hospital.  In the course of a day, I separately witnessed two senior leaders stop to pick up a small piece of litter on the ground.  I was immensely impressed that a busy executive would literally stoop to that, and I told each of them so.  The first one replied, “I really can’t stand to see things like that.  I know it’s a little thing, but it feels good when the place looks neat and clean.”  The second executive said, “It’s important to set a good example for others.”

At the time, I thought both spoke to a commitment to excellence.  But now I wonder about the differences in motivation, and the implications for all of the work we all do.  The first response spoke to an internal motivation, self satisfaction, while the second was an external motivation – what others would think.  A lot has been written about the relative impact of different sources and modes of motivation, with an emerging consensus that much of what we do to drive changes in behavior is at best ineffective and potentially harmful.

As a clinical epidemiologist, I like to define everything in life as a series of 2 by 2 tables.  Here it is for motivation:

External Internal
Positive If you finish your book assignment, I’ll give you $20 I can’t wait to finish the book assignment – I love to read
Negative If you don’t finish your book assignment, you’re grounded this weekend I’ll never finish this book – reading is so boring

Conventional practice (at least in America) in business, and increasingly in education and other fields, is to rely on external motivations – rewards and punishments – to drive results.  Among external (also called instrumental) motivations, it is generally believed that positive is more effective than negative: you attract more bees with honey than with vinegar.  But increasingly, research shows that external motivations for individual performance are at best modestly successful.  One recent study of West Point cadets found that not only is internal motivation a better predictor of success than external, but that even among those with strong internal motivation (e.g., belief in service to country), the addition of an external motivation (e.g., wanting to please a parent, desire for free education) was correlated with worse performance.

In health care, there is a growing shift toward “pay for performance,” and results so far have been mixed.  Some even worry that adding this external motivation can undermine the intrinsic motivation to do the right thing for patients that virtually all providers embody as a core principle.

Rather than devising rewards and punishments for performance, we need to leverage the intrinsic desire to do good (benefit to others) and to do well (personal excellence) that most of us have.  It’s the difference between compliance and commitment.  But even the latter can be broken down further.  Fred Lee, in his book If Disney Ran Your Hospital, talks about a hierarchy of motivations.  At the lowest level is compliance: doing what someone makes you do.  Even doing something for a reward is a form of compliance, albeit one with a smiley face instead of a frowny one.  The next level up is willpower, or doing what you believe you should do.  This is what that second trash-cleaning executive did.  It’s a step toward commitment, but not as far as imagination, which is doing what you want because you feel like it.

The vast majority of people in health care are motivated by imagination, by deeply wanting to give our patients great care and a great experience.  Certainly we like to be recognized when we do good – it’s one way to know we are doing well.  But we must be cautious about using external motivators, whether positive or negative.  I want to be part of an organization where everyone would stop to pick up a piece of litter, even when no one is looking.


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