To Sleep, Perchance, To Get Brain Damage?

April 17, 2015

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When I was in training, people would talk about “brutane” being their preferred agent for keep a child still during a procedure: hold them down by brute force. We didn’t have a lot of great options for sedation for relatively short procedures, so the choice might be knocking the child out for hours, or just getting it over with. We often went with the latter.

In hindsight, it sounds primitive and inhumane. (You are probably wondering if I studied with Hippocrates, and carried leeches around in my kit. No, and no.) But in the last 25 years, newer short-acting analgesic and sedative agents have been developed and approved. During that same time, there has been an increased understanding of the long-term effects of inadequately treated neonatal and early childhood pain, including changes in the brain’s structure and responsiveness and the immune response. Among pediatric specialists and subspecialists, use of analgesics and sedation for even minor procedures is now exceptionally common, and is in many cases an important quality differentiator.

OK, the sound you hear is that of the pendulum swinging back and getting ready to hit you in the head. In the past 5 years, there has been a growing body of literature demonstrating that the anesthetic and sedative agents we use to treat and prevent procedural pain in infants and children may themselves cause adverse effects in the developing brain. Most of the evidence comes from effects in baby animals, though there is some (albeit still incomplete) data on effects in humans as well. Some professional organizations and the FDA have begun to raise a red flag and suggest that at least some elective procedures should be deferred until after age 3.

There is evidence that pain is bad, and that preventing pain is bad. Now what? Do we go back to brutane? And more importantly, how can we help parents make sense of the options and make the best possible choice for their child.

First, this is a great illustration of the principle that children are not just small adults. Providers with the extra expertise that comes with subspecialty training are in the best position to understand the data and interpret it for families. The evidence for some agents being harmful is stronger than for others, and some have not been linked to these side effects. Pediatric subspecialists are also more likely to be familiar with and have access to the full range of alternatives. For example, sucrose solution (i.e., sugar water) has been shown to provide adequate analgesia and sedation for many minor procedures in infants, but is unlikely to have the kind of adverse effects seen with other agents. My anecdotal experience is that non-pediatric physicians are not as familiar with this option. Non-pharmacologic measures, including swaddling, or distraction and other techniques provided by child life specialists, may also be effective for babies and young children.

While the experts try to sort out the data, I may think twice before automatically giving a strong sedative. I’ll think carefully about the alternatives. And I’ll certainly try to keep up on the literature and emerging guidelines.   But I don’t want to go back to the brutane era. I still have images of children struggling mightily to break free of the 2 or 3 large adults holding them down while I tried to put stitches in or remove a bead from the ear; I have to imagine those kids have even worse memories of it than I do. They deserve better than that. They deserve the best.



The Essentials

April 9, 2015

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I don’t know exactly what a prayer is.

I do know how to pay attention, how to fall down

into the grass, how to kneel down in the grass,

How to be idle and blessed, how to stroll through the fields,

which is what I have been doing all day.

Tell me, what else should I have done?

Doesn’t everything die at last, and too soon?

Tell me, what is it you plan to do

With your one wild and precious life?

-Mary Oliver, “The Summer Day”

It’s virtually impossible to go a day without asking someone how they are doing, and receiving the reply, “Busy.” It’s often implied that this is both good and bad; while we complain about being overwhelmed, we say it with a certain pride, busy-ness indicating success. This mixed message comes not only at the individual level but as a society. Commentators who lament the frenetic pace of the world also imply that this is unique in human history, an unintended consequence of the immense progress in our era. With the explosion of knowledge and technology, we have more options than ever before – how could we not be overwhelmed. More specifically, it arises from the globalization and connectedness begat by the Web. We are advanced, therefore we are busy.

Except this anxiety over lack of time goes back a long way. Back in 1910, Arnold Bennett wrote a small book called “How To Live On 24 Hours A Day.” He points out that people often try to live within a monetary budget, but that time is actually a more finite and therefore precious resource. “The supply of time, though gloriously regular, is cruelly restricted….We never shall have any more time. We have, and we have always had, all the time there is.” Time mis-management is a long-standing feature of our species.

The problem isn’t that we have too many choices now. It is that we are challenged to prioritize among them. This is true whether there are 12 TV channels or 1200. One way of looking at our choices is to categorize in two dimensions: timeliness (urgent vs. non-urgent), and significance (important vs. unimportant). Urgency too often trumps importance.

Greg McKeown, in his book Essentialism: The Disciplined Pursuit of Less, stresses the need to focus on significance, and to identify those things that are truly the most important. Essential. This, of course, sounds far easier than it is. None of us lives in a vacuum, and we do not have complete control over what we need to do. When a Joint Commission surveyor shows up at our hospital, my opinion about whether they are “important” or not doesn’t really matter. I know what I’m going to be doing the next few days.

But we do have a certain amount of discretion, which we fail to fully utilize. And it isn’t just a matter of doing things more efficiently to get more done. Paradoxically, focusing on the essential requires a certain investment of time into doing, well, nothing. More specifically, thinking rather than doing. McKeown emphasizes that determining what is essential takes some discipline itself. It isn’t necessarily obvious, and may not already be known. Taking time to explore and ponder options, time for discernment, is a critical part of essentialism.

Our leadership team, which has been reading McKeown’s book together, is experimenting with some things to help us move ourselves, and the organization, toward an essentialist mindset. One thing we’ve done is commit to building “thinking time” into our schedules. Time for reflection, time for discerning what are those most important things we should spend the rest of our time on. It may not involve kneeling down in the grass, as Mary Oliver’s poem suggests, but it does involve paying attention. How else are we to know what to do with our one wild and precious life?



Cleaner Air, Deeper Breath

April 2, 2015

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It sounds like a plot for a corporate thriller: an industry that poisons people and then profits from selling the antidote.  In a sense, though, this could describe health care.  As one of the most energy-intense industries – hospitals account for 8% of all US energy use – health care facilities are an important contributor to both air pollutants and greenhouse gas emissions.  Those pollutants are an important cause of respiratory illness, especially in children.  We could, unintentionally, be contributing to adverse health effects for the children in our community.  That undermines our values of purpose and health.

Many hospitals, including Children’s, are taking steps to address this.  Our hospital actually already compares favorably to others in its energy footprint.  This year we will be installing new facility operations software that will further reduce our energy consumption.  And the thermal plant on Watertown Plank Road, which provides Children’s and the other facilities on the Milwaukee Regional Medical Campus with steam and chilled water for heating and cooling, is being converted from coal to natural gas, which will decrease both carbon and particulate matter emissions.

The good news is that efforts like these will lead to improved public health.  A recent study from the New England Journal of Medicine showed that in southern California over a 13 year period, pollution reductions as a result of regulations under the Clean Air Act were associated with improvements in lung function in children.  This affirms findings in other studies showing a link between improvements in air quality and overall life expectancy across the US.  Clean air is good.

Other hospitals are going even further.  Gundersen Lutheran, in La Crosse, WI, became the first hospital to go carbon neutral, getting all of its energy from wind, geothermal, solar, and other renewable sources.  That’s a stretch.  But even the steps we are taking will help.  And as individuals we can help to reduce the energy intensity of the organization by turning off lights and computers, using stairs, and other small things that will add up to less waste and healthier kids in our community.


March 27, 2015

CHW LogoI’m a bit of a Cold War nerd.  I loved the novels of John le Carre, and can still recite the list of leaders of the Soviet Union from the pictures that hung on the walls of my 10th grade social studies classroom.  In some ways, the world seemed simple.  There were two big alliances: NATO and the Warsaw Pact.  The world could be divided into East and West.  While these blocs came to represent competing ideologies and politico-economic systems, the original purpose was to assure mutual defense through shared, coordinated military effort. Over time, it came to seem that not only could the world be divided into two camps, but that it had to be.  You were either East or West.  Yet we forget that the majority of nations in the world, especially in Africa but even in Europe, the epicenter of the Cold War, were part of the non-aligned movement.

Health care in 21st century Wisconsin is coming to resemble mid-20th century Europe.  Two large state-wide alliances of health systems are emerging – Integrated Health Network (IHN) and abouthealth.  The former includes, among others, Froedtert, MCW, Wheaton, Ministry, Dean, and HSHS, while the latter counts Aurora, ProHealth, UW Health, ThedaCare, and Gundersen Lutheran among its members.  Such accountable care organizations (ACOs) are an approach to managing health for populations.  Alliances of providers (including physicians, hospitals, and others) jointly take responsibility for both the costs and outcomes of care.  The specifics can vary widely, but some of the common principles include:

  • The providers take on some or all of the financial risk for providing care. Rather than payment for volume, there is payment for value.  Better quality and lower cost are rewarded; poor quality or high cost put the provider at risk.
  • Value is driven by coordination of care, emphasis on prevention, and use of shared data to drive informed decisions by both clinicians and administrators

While this sounds appealing in theory, it is difficult in practice.  Studies of ACOs to date show that achieving the desired combination of improved outcomes and lower cost is challenging at best, with many performing below expectations.  Scale seems to matter, as does expertise.  And most of the experience to date is with adult populations (especially Medicare).

As we work to figure this out in Wisconsin, Children’s is poised to be one of those non-aligned nations, working with both alliances to advance the health of children in our state.  With our scale and expertise, not only in specialty and primary care, but also with care management and coordination (as in Children’s Community Health Plan, our Medicaid HMO), we are uniquely capable of taking on the task of managing the health of the population of the children in the state.  We like to say kids are not just small adults.  This is as true when it comes to managing their health as when managing their illnesses.

Which is why you didn’t see our name listed in either of the two statewide alliances listed above. We do, and hope to continue to, work with both.  There are only about 1.5 million kids in Wisconsin, spread out among many different health systems.  If we are forced to pick one side or another, it is likely that neither of them will have sufficient scale and expertise to do the best job of managing the population of children, in sickness and in health.  I hope the health care equivalent of the Berlin Wall doesn’t get in the way of our vision of the kids in Wisconsin being the healthiest in the nation.

Say That in English, Please

March 16, 2015

CHW LogoObserving on rounds one morning, I could see the patient’s mother’s brow furrow and her eyes narrow as the resident presented.  “…Respiratory-wise, she’s tachypneic but sats are good, so wean the O2.  FEN-GI-wise, we can try something PO, then decrease the D5….”  After the presentation the attending physician, sensing the mother’s confusion, said gently, “That’s great.  Now let’s just summarize the plan for mom so she can understand what to expect.”

One of the domains of quality health care is patient-centeredness.  Including families on rounds and accounting for their preferences in decision-making are important steps toward that.  But it is all for naught without effective communication.  Patients and families differ in their health literacy, the degree to which individuals can have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.  It depends on education, prior experience with medical care, culture, and a host of other factors.  But health care providers often make it more difficult by the language they use.

Language is meant to convey information and achieve mutual understanding.  In medicine and many technical fields, precision is critical, so words should be chosen to maximize it.  While medical jargon, typically derived from Latin and Greek roots, is much maligned, a good deal of it is intended to increase precision.  Sometimes the word “skin” suffices, but if it is important to differentiate the layer involved, we might use the terms “dermis” or “epidermis.”  Blister is a lay term that describes a fluid-filled lesion on the skin but it gives no sense of size; the more jargon-y terms “vesicle” and “bulla” describe blisters that are small (<5 mm) or larger.  So using those terms actually adds to meaning.

Too often, though, it simply confuses.  “Tachypneic” means “breathing fast.”  They are interchangeable.  Using the term “tachypneic” doesn’t add to the precision or convey any extra information.  Almost everyone understands “breathing fast”; few people who are not medical professionals, regardless of their educational attainment, know the word “tachypneic.”  So if the words are interchangeable, why not use the simpler, more widely understood term when talking with families?

Some of many examples of non-value added medical terms include:

Erythema (redness)

Chalazion (stye)

Urticaria (hives)

Eructation (burping)

Sometimes a term doesn’t necessarily add precision, but it is more efficient.  One of my favorite (albeit obscure) examples is “photoptarmosis”: sneezing due to bright light.  A whole concept in one word!  But in each of the above examples, the medical term is actually longer than the lay one.  No greater clarity, and more effort.

Abbreviations sometimes fall into this category.  We love our TLAs*.  They can be handy when writing long hand.  It is certainly easier to write or say “T&A” instead of “tonsillectomy and adenoidectomy” (or even “removal of the tonsils and adenoids).  And in the correct context, one is unlikely to confuse “T&A” the medical procedure for other meanings of “T&A.”  But abbreviations can be confusing.  Is BMT “bilateral myringotomy tubes” or “bone marrow transplant”?  Therefore, they should be used cautiously.  The advantage when typing or dictating is probably not worth the confusion.  And there may not even be any savings when speaking.  “PO” is a term that means “by mouth.”  Two letters vs. seven.  But both are two syllables.  So when talking to a parent, why not say “give something by mouth,” instead of “give something PO”?  When you factor in the extra explanation required, it’s clearly not worth it.

It’s great we have interpreters for patients and families whose primary language is not English.  We shouldn’t need them for everyone.

*Three-letter abbreviations

Safe or Out?

March 9, 2015

CHW LogoTo commemorate National Patient Safety Week, I am reprising this column from a year ago.

The only apparent sign of spring around here is the fact that the baseball pre-season has begun.  Now, I’m not a member of the “baseball as a metaphor for life” school of thought, but it does seem that baseball is in some ways a lot like medical care.  Both involve a large team of people with specialized jobs who spend most of their time in what I would term “anticipatory inaction” (i.e., standing around and waiting for something to happen).  And when they do go into action, the goal is to get someone to home.  (One could also add the unexplained ridiculous prices – a $9 Miller Lite is even less defensible than a $25 Tylenol.)

They also share the concept of being safe, but here they diverge.  In baseball, “safe” is a result – one branch of a dichotomous outcome, the opposite of “out.”  But in healthcare, “safe” is much more complex.  It does involve good outcomes: one measure of safety is the absence of harm caused by the care provided, such as wound infections or pressure ulcers.  However, while such outcomes are an important measure of safety, and are necessary, they are not sufficient.  No wound infections can result from safety or from luck.  Safety is as much about the structures and processes that create a safe environment.  A car without airbags or seatbelts is unsafe even if you drive it many miles without getting injured.

I was thinking about this recently as we at Children’s increase our commitment to providing the best and safest care.  We participate in something called Solutions for Patient Safety, a collaborative of almost 80 children’s hospitals around the country.  The hospitals share data and best practices to try to eliminate patient harm.  When I have seen the data, on most measures we perform better than most, so it would seem that we are a “safe” hospital.  But even if we have a rate of 0, that by itself does not mean we are safe.  I used to have this argument with my son: I’d catch him riding his bike without a helmet, and tell him that wasn’t safe; he would argue that he hadn’t gotten hurt.  To which I would respond, “Yet.”

So while I feel good about our record, we can’t get complacent.  That’s why we are embarking on an effort to increase education among all of the staff and providers on what it takes to be a high reliability organization – the kind of place where not only do harmful events not happen, but they can’t happen.  It means having systems in place that make it easy to do the right thing and hard to do the wrong one.  Redundancy, double checks, alerts, standardized approaches, checklists, etc.

It also means having an environment and culture of safety.  This is an environment where people continually seek to improve by asking questions, raising issues, and intervening when there is a problem.  There are many elements critical to a functioning culture of safety, one of which is what we call “just culture.”  This means treating errors, when they do occur, as a system flaw, not a character flaw.  If I order the wrong medication, or forget to give someone a tetanus shot, it doesn’t mean I’m a bad person.  In a just culture, people are more willing to acknowledge errors, and more willing to point them out.

Creating a just culture and an environment of safety are challenging in practice.  For one thing, it requires overcoming the rather natural tendency to blame on the one hand, and to be defensive on the other.  It’s one thing for an organization to say “we’re not blaming you,” but only after an extended period of acting that way will people feel confident in the attitude shift.  In hospitals in particular, there is a traditional hierarchy that must be overcome.  It doesn’t matter how many posters we put up asserting “You have our permission to speak up,” it is never going to be easy for a nurse six months out of school to tell the chief of surgery that he or she is about to use the wrong instrument.  And it’s even harder if that physician makes it difficult by their response.

In recent years, physician performance has been defined around six core competencies.  Among these are medical knowledge and patient care, which are somewhat easy to define and measure.  Another key one, professionalism, has been shown to be a key element in creating the kind of atmosphere that promotes safety.  Much has been written about disruptive behavior –up to 5% of providers are estimated to be regularly disruptive.  But professionalism, and unprofessional behavior,  is much harder to measure.  It can range from an attitude of dismissiveness to frank verbal or physical abuse.  To paraphrase Justice Potter Stewart, it may be that you know it when you see it.  But the more objectively we can define it, the easier it is to identify when there are problems, to create actionable solutions, and monitor progress.  It allows for fair processes to hold people accountable and ultimately improve, which is the goal.  As difficult as it is to live out a “just culture” when it comes to things like medication errors, it’s that much harder when the “error” is a behavior.  It’s one reason we have moved away from the older language of “problem physicians” to “disruptive behavior.”

Not long ago, I was approached by my medical director and patient care manager with a concern about how I might be making the emergency department unsafe.  They told me that a nurse had indicated, in a survey, that “Dr. Gorelick is difficult to work with.  He is hard to approach with questions and dismissive of the nurses.”  I was absolutely floored.  I don’t consider myself to be a difficult person, and I pride myself on my respect for nurses and indeed all the members of the care team.  (My mother is a nurse, after al!)  But while I heard “Dr. Gorelick is a difficult person who disrespects nurses,” what was actually said was quite different.  It was about my actions, and a specific set of actions at that.  It caused me to reflect, and I realized it was true.  As I’ve written about before, I find it increasingly difficult for whatever reason (I’m sure it’s not aging…)  to get back on task when I’m interrupted.  So if I’m entering an order or writing a note and someone stops me to ask me a question, I do sometimes get snappy.  I worry that it will at least set me back in the task I was doing, and may even increase the risk of an ordering error.  In the parlance of our mood elevator, I go to the lower floors of judgmental and irritated.  But by being hard to approach, I was creating my own safety hazard.  The next time a child needed immediate attention, nurses might hesitate to seek me out, putting that child at risk.

As Warren Buffett said, “It takes 20 years to build a reputation, and five minutes to ruin one.”  My reputation was also at risk, and I needed to fix it.  The first step was acknowledging the problem, and owning it.  The problem was not the nurses’ inability to prioritize, it was my reaction to being interrupted.  Rather than being irritable, I needed to be curious – why does this person want my attention now?  If it turns out to be something that could wait, let’s have a respectful discussion about the risks of unnecessary interruptions, which could lead to a constructive solution (e.g., some way to let me know I’m needed soon but not immediately).

This sounds easier than it is.  I’m sure I still seem less than approachable at times in the emergency department.  As much as I’ve tried to objectify this and focus on my behaviors, it still feels like a questioning of my character.  And no doubt people’s perceptions are colored by my prior actions: even a slight hesitation in responding could be perceived as being “difficult” again.  But if I want to restore my reputation – and more importantly, contribute to the kind of environment that allows us to provide the best and safest care – I have to be accountable for my role.  Professional behavior is like an RBI, allowing our patient to get home safe.  Sometimes we have to attend batting practice.

EPILOGUE:  A recent article demonstrated a link between unsafe attitudes and negative safety outcomes:

Comparing Apples and Angioplasties  

March 2, 2015

CHW LogoConsumers seeking organic produce have, in the past, had few options.  Many communities had at most one purveyor of such products, and those stores could charge a premium.  (Hence the common nickname “Whole Paycheck” for Whole Foods.)  As more stores, including even Walmart, began to carry organic products, shoppers had choices and prices moderated.  Score one point for free market competition.

Many policy makers have argued that American health care needs a similar dose of market medicine.  More providers will lead to competition for patients, leading to increased quality and decreased costs.  While insurers and business leaders have tended to support such efforts, based on their experience in other industries, is health care different?  Empirical evidence is mixed.  Some studies have shown that in areas with more providers, prices tend to be lower.  Others, however, find higher costs associated with more duplication of services.  There are similarly contradictory findings on quality of care (though the studies that do claim to show higher quality have largely focused on things like wait times for appointments and patient satisfaction; safety and clinical outcomes actually appear to suffer from competition).

With regard to financial outcomes, it is very important to distinguish between price and cost.  Price (or charge), is the amount of money a provider of a product or service demands from the payer.  The cost to the purchaser, however, is a factor not only of the price, but also any negotiated discount, as well as the number of services consumed.  Let’s use the example of a car.  The car has a sticker price, but the cost to me depends on whether I can negotiate a better deal, and on whether I purchase any extras.

Hence the paradox of more competition leading to higher costs. In health care, competition among providers tends to drive down the prices, and it also allows insurers to negotiate better discounts.  However, the total cost can still go up, if people are using more of those services.  And that is where health care is different from groceries.  Consumerism only works if the consumers know the price, but also have information on quality, and can control the amount that is consumed.  In health care, even if prices were transparent, quality data are much more rudimentary.  More importantly, the consumer (patient) has very little real control.  If someone with chest pain is told by their doctor they need a nuclear stress test and a cardiac MRI they are unlikely to argue.  Decisions by physicians drive up to 80% of all spending; it has been said that the most expensive piece of medical equipment is the doctor’s pen.  (Or in the era of the electronic health record, her mouse.)

So while prices can go down, costs can go up.  There is evidence that when the price per unit cost of a health care service drops, providers may simply do more to make up the difference.  Similarly, when there are multiple hospitals in an area with duplication of expensive equipment and other infrastructure, the use of that equipment increases as the hospitals try to bring in enough revenue to pay for the investment.  The Institute of Medicine has estimated that 30% of medical spending – over $1 trillion per year in 2014 – is waste, much of it from medically unnecessary services.

The excess utilization doesn’t even need to be due to overt greed.  Physicians who are under more time pressure may feel a need to get more specialty consultation rather than spending more time themselves evaluating a patient.  Providers with lower levels of expertise – for example, a general emergency physician versus a pediatric emergency physician – may order additional tests or treatments due to a greater degree of uncertainty.  (Being a good pediatric specialist is as much about knowing what not to do as what to do.)

When it comes to groceries, competition can lower both prices and costs.  But when Walmart comes to town and Whole Foods lowers the price of organic rutabagas and tofu, if they get to fill my cart with whatever they want, I’m going to shell out at least as much money.  And as with medical care, more isn’t necessarily better.



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