Free Range Kids

January 26, 2015

CHW LogoThis from the Washington Post: The parents of two children, age 10 and 6, were investigated by child protective services after their children walked home alone from a park near their home.  Several years ago,

Since many of you are mandated reporters of suspected abuse and neglect, I may be putting myself at risk by admitting the following:

  • Our kids walked to school since first grade – without their parents
  • When our son was 7 we allowed him to be in the house by himself when we ran around the block
  • At age 10, our older son was given the chore of doing his and his brother’s laundry, which of course meant pouring laundry soap into the machine
  • By age 12 our younger son regularly took the Milwaukee County bus to his guitar lessons
  • All of us regularly walk barefoot in the yard, eat outside, and pick up trash and recycling we find as we walk

Without realizing it, we were in the vanguard of what is becoming known as the “free range kids” movement, a reaction to the notorious “helicopter parenting” trend of the past decade or so: the notion that kids must be protected from all known risks by hovering over them constantly and intervening should any danger such as a pedestrian, a mosquito, or a jellybean dropped on the floor get through the layers of virtual bubble wrap in which those kids are cocooned.

This is, perhaps, a bit harsh.  I don’t mean to suggest we should be cavalier about safety, and I recognize that the fact that I walked to school in first grade, stayed home alone briefly after school, and rode New York City public transit when I was 12, means that everything we did back then was a good idea. (Our kids did not ride in the back of pickup trucks.)  But we tend to overemphasize risks and safety, at the expense of allowing children to experience – and yes, at times fail.  Take stranger phobia; the evidence is that abductions and other crimes involving children are actually less common, though you’d never know it from watching Nancy Grace or other TV “news”.

There is a down side to this sheltering.  Overprotection of children makes them less able to deal with problems when they are adults.  Here’s one example: Boston College has seen a doubling of emergency calls for minor issues like being called a name by a roommate or finding a mouse in the dorm.  So the helicopter continues to hover.  NPR reported a couple of years ago about parents who show up at their children’s job interviews.

I’m all for insisting on kids wearing bicycle helmets.  But at some point you have to take off the training wheels and let them go around the neighborhood on their own.  Just hope someone doesn’t call CPS.

The Age of the Tricorder

January 22, 2015

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“It’s worse than that – he’s dead, Jim,” Dr. McCoy would solemnly intone, after waving a small handheld device over the motionless figure in the red velour shirt.  Of all the gadgets in the Star Trek universe – some of which (warp drive, transporter) remain science fiction, while others are already passé (communicators like 1990s cell phones, 3” square computer disks) – the one I found most fascinating was the tricorder.  Imagine waving something the rough size and shape of a salt shaker over someone and getting a reading of their vital signs, blood chemistries, and even a diagnosis.  If you had one of those, who would even need a doctor; you could hold it in front of your own face and figure out what was wrong, and then ask the computer what you should do about it.

Until recently I assumed the tricorder was more like the transporter than the communicator – unrealistic fantasy rather than established technology.  Perhaps not.  A raft of devices designed to allow people to monitor their own health and self-diagnose is coming to market, some already here.  (Google “medical tricorder” and one of the first hits is the Scanadu Scout™, which measures and records vital signs by scanning your forehead.  For real.)  According to a new book called The Patient Will See you Now from Dr. Eric Topol, a cardiologist and “Professor of Innovative Medicine” at the Scripps Institute, as well as long-time proponent of personalized medicine, the future of medicine lies not with physicians, but with individuals armed with smart phones, miniature electronic sensors, and terabytes of genomic and other data about themselves.

Others, while not disputing the usefulness of some of the new technology, are less certain how soon they will revolutionize health care in the way envisioned by Dr. Topol.  For one thing, data are not information: raw data must be processed to be actionable, and context is important.  While automated language translation programs are certainly getting better, anyone who has used one knows that communicating to a native Mandarin speaker requires more than drawing on a database of Chinese ideograms.  Similarly, humans are more than the sum of a set of physiologic parameters.  The best providers don’t treat numbers, they treat patients.  Besides, despite all the incredible hassles they complain about, patients seem to value seeing their doctor, which may explain why the annual physical remains a popular ritual despite the lack of evidence for its benefit on health outcomes.

What is missing from the patient-as-own-doctor model is the element of empathy, the communication, caring, and connection that characterizes the ideal of the provider-patient relationship.  The tricorder-like gizmos may eventually be able tell you what is wrong with you, but they can’t hold your hand, or give you words of encouragement or sympathy.

As technology advances, the medical profession has an opportunity to increase their value to patients.  We like to blame technology – especially the electronic health record – for interfering with the relationship between patients and providers.  But it can also be liberating.  As rote memorization and manual dexterity, keys to success in medicine in the era before handheld computer devices and robotic surgery, become less important, we can select for and spend more time developing communication and interpersonal skills.  Some innovative training programs have shown promising results.

Sir William Osler said “a physician who treats himself has a fool for a patient.”  Perhaps a patient who treats herself has a fool for a doctor.  But if we can’t figure out and demonstrate how providers can add value in a world of Scanadu™ and Siri, many patients will take their chances without us.

Worried Wellness

January 9, 2015

CHW LogoI signed up for the 2015 “Healthy Rewards” (the Children’s Hospital of Wisconsin workplace wellness program) within about five minutes of getting the email that it was available.  Aside from the fact that I’m a bit on the competitive side, I figure the only thing better than having good health care when you’re sick is staying well in the first place.  For employers, a healthy workforce should have all kinds of benefits,  including lowering their health care costs, which helps explain why Children’s, along with over half of all US businesses, offers a wellness program (with larger companies more likely to have them).  In fact, workplace wellness is a $6 billion a year industry.  Must be a smart investment, right?

That’s not entirely clear.  A recent NY Times article, citing several reports and systematic reviews, called into question the health and financial benefits of these programs.  At the risk of oversimplifying, here’s a summary of the salient points from those articles:

1)  Studies of the impact on employee health are generally poorly designed and have mixed results.  Better designed studies (i.e., randomized trials) are less likely to show benefits, but still half of these have demonstrated that wellness programs lead to improvements in some aspects of health including exercise, weight management, and smoking cessation.

2)  Programs that are focused on disease management (e.g., targeting employees with chronic conditions and incentivizing them to better management and preventive care) have a generally better impact than those focused on more general lifestyle management or screening.

3)  The overall benefit of these programs is probably muted by the fact that on average fewer than half of eligible employees participate, with some evidence that those most likely to benefit are the ones who are opting out.

4)  Overall wellness programs seem to save employers money, but part of that is from shifting costs to employees (e.g., higher premiums for those who do not meet screening criteria).  Most studies showed a positive return on investment, but the quality of these studies was low.

5)  Key facilitators of success include making wellness activities convenient and easily accessible for employees, and making wellness an organizational priority among senior leaders.

So yes, the jury is still out; it’s not a slam dunk that these programs are all they are cracked up to be.  But if half the randomized trials indicate a positive benefit, I’d say the glass isn’t half empty, it’s half full – of clean, non-bottled tap water, of which we ought to drink 64 ounces a day.  In the meantime, go ahead and sign up.

The Year That Was

January 2, 2015

CHW LogoPicking a top 10 list is like deciding which of your children is your favorite.  So, at the risk of omitting some very important and meaningful people, events, programs, or accomplishments, here’s my list (in no particular order) of the top 10 happenings at Children’s Hospital of Wisconsin in 2014.

  1. CHW was verified by the American Nursing Credentialing Council as a Magnet hospital for the third straight time, a distinction placing us in the top 1% of hospitals. This is a recognition of many aspects of quality, but especially the level of nursing care.
  2. For the first time, CHW was ranked in all ten specialties evaluated by US News and World Report, including a number 5 ranking for our Herma Heart Center. Others include diabetes/endocrine, gastroenterology, neonatology, nephrology, neuroscience, oncology, orthopedics, pulmonology, and urology.
  3. Our neonatal ICU was featured in a cover story in Time magazine.
  4. A multidisciplinary team from the Fetal Concerns Center completed the first ever in utero repair of a myelomeningocele (aka spina bifida) in Wisconsin, making us one of the few centers in the country performing this sophisticated procedure.
  5. There was a groundbreaking for the Sojourner Family Justice Center, a collaborative effort with numerous community partners and the state of Wisconsin. Hailed as a national model, this innovative center will bring together shelter, community, and legal services for women and their children who are victims of domestic violence and child abuse into a single location, improving access for those in need.
  6. The first phase of our new NICU opened, providing private rooms and incorporating a variety of new technologies to improve quality of care and family-centeredness.
  7. The latest step in our commitment to provide care closer to home was the opening of our Delafield clinic in December, with primary and specialty care services.
  8. In July we overhauled our clinic fee structure, which greatly reduced costs to families for outpatient care.
  9. A variety of steps to improve access for families. This includes an expansion of our access center which coordinates visits for patients traveling from outside the area for care; the initiation of the Wisconsin International Patient Program, with a focus on patients from the Middle East needing some of our highly specialized services not available elsewhere; the expansion of the Ronald McDonald House, an important partner that provides accommodations for families from out of town; and the reopening of  Watertown Plank Road (a blessing for everyone!).
  10. Many of our staff relocated to space at the Summit building in West Allis, consolidating those staff into a single (and quite lovely) location.

Race to the Bottom

December 29, 2014

I am a racist.  There, I said it.CHW Logo

I don’t mean an Archie Bunker-type bigot who hurls invective and spews hate.  But view the world through the concept of race, the idea that characteristics are bundled together, and that knowing the color of someone’s skin can be informative about what is inside.  That is the essence of racism: the idea that race is determinative, that people of different color differ in other important ways.  (Some prefer to refer to this as racialism, but let’s just call a racist a racist.)

Now, I didn’t say I believe it; actually, I do not.  But being honest with myself, I’d have to admit that when I encounter someone I don’t know, I reflexively begin to make assumptions about them based on their appearance.  I do not consciously accept the concept of race, but my instincts are otherwise.  When I see a patient in the emergency department who is black, I make assumptions about the fact that they probably live in the city of Milwaukee, and they are likely to be insured by Medicaid.  I virtually always catch myself, and I work furiously not to allow that initial assumption to enter into my thinking and actions.  But no matter how good I am at suppressing it, I can’t deny it came up.

I’d be willing to bet a decent amount of money that everyone reading this is also a racist.  No doubt, you do your best, like me, to overcome it, and you probably don’t ever do or say anything that would be considered “racist” in the common use of that word.  But it’s probably inevitable.  In large part, it is a manifestation of the way our minds process information.  I have written previously about heuristics – mental shortcuts our brains use to reach conclusions more efficiently. These heuristics are based on our prior experiences and on statistical facts about groups.  When a child encounters a dog for the first time, she is unlikely to be fearful.  If her first experience results in being bitten, she will instinctively react with caution to dogs in the future.  Even those of us who have never been bitten are likely to be more leery around pit bulls, based on reports (which it turns out are probably wrong) that the breed accounts for the majority of bites.

We live in a society where, statistically, there is an association between, for example, race and poverty, or race and crime.  In that sense, the heuristic isn’t wrong.  It’s true that in our ED, black patients do largely live in the city of Milwaukee, and are disproportionately poor.  We run into trouble in at least two ways.  First is when we take a true fact about a group and apply it to an individual.  Even if it’s true that more blacks in this area are more likely to not finish school, it is an affront to the inherent worth and dignity of each person to make any assumptions about an individual black person’s educational level.   When we deal with a person, we cannot use mental shortcuts.  But to overcome them we must acknowledge them.

It’s also a short and slippery slope from seeing an association to seeing causation.  Many people are too willing to make the leap from “black people are more likely to live in poverty” (a true if unfortunate fact), to “black people are poor because they are black.”  Therein lies the kind of thinking that people commonly associate with the term racism.  And racism in this sense is still too prevalent in 2014.

Just six years ago, in the aftermath of President Obama’s election, we were hearing about how America had become “post-racial.”  Now, it seems that race relations are in the worst shape I can remember.  What went wrong?

If the first step toward a solution is admitting there is a problem, we have to accept that we are, nearly universally, racist.  It takes a lot of mental effort to override our heuristics.  Pretending racism is something that only overt bigots experience, it’s too easy to let down our guard.  It also closes off conversation.   The inherent racial thinking that we all have is pretty obvious to most members of racial minorities, but less so to those of us in the majority.  Denying it invalidates their experience and prevents us from building the kind of connections that might mitigate its effects.

I’d love to think we can actually get beyond the idea that skin color has anything to do with any other inherent characteristics – we don’t tend to draw the same conclusions based on hair or eye color, after all.  Not that there hasn’t been some progress.  Some medical journals, for example, will not accept analyses based on race unless there is a clear biological explanation (e.g., a study involving actual skin pigmentation).  Too often race is used as shorthand for socioeconomic status or educational status; such reporting simply reinforces the stereotypes and does nothing to contribute to our understanding.  But race seems such an entrenched part of the way of looking at the world, it’s hard to imagine a “post-racial society” anytime soon.

In the meantime, if rational thinking is to prevail over instinct, need to accept that regardless of our best intentions, we all view the world through the lens of race.  Go ahead, say it.

You Better Shop Around  

December 19, 2014

CHW LogoI found the same book on for prices ranging from ten cents to ten dollars.  All were new; the cheaper ones were publisher overstocks so they had a stamp on the inside front cover, but it was hard to argue that it was worth paying more than three times as much (after adding in the shipping) for something I would never notice in reading the book.  Even if I hadn’t been raised by an accountant, I would have picked the cheaper one (which I did).

So how can one justify the variability in costs for fairly standardized things in medicine, such as the more than ten-fold difference in prices for an echocardiogram, even within a metropolitan area?  Traditionally, providers of those services have relied on the fact that consumer choice was almost non-existent.  First, in the paternalistic world of medicine, patients frequently deferred to their doctor’s recommendation, asking few questions.  There was no incentive for shopping on price for those with insurance, and the costs were often too high for those without to even consider seeking care.  And even if one wanted to comparison shop, pricing information was at best difficult to obtain.

Recent studies provide a glimpse of the effect of consumerism – driven by the rise in high-deductible plans and other factors that have placed more financial risk on patients – on both prices and spending in healthcare.  A study in Health Affairs examined the effect of providing pricing information on MRIs without a connected financial penalty.  Members of health plans that provided price information on MRI options spent an average of $220 less than those who did not have access to the information.  Moreover, in those regions where the pricing transparency was implemented, the range in prices for MRIs among facilities in that region decreased by 30%, mainly due to lowering of prices by the most expensive providers.  No similar price change was seen in the control regions.  Another study in JAMA looked at variation in healthcare spending between people who did or did not use an on-line calculator to research out-of-pocket costs before seeking care.  Those who searched for information chose lower priced services for laboratory tests and imaging (but not for providers) than those who did not search for the information.  Interestingly, the difference was similar for those with and without cost sharing.  It was not clear that utilization was affected, only that given price information people seek lower prices.

These and other studies show that, despite what we providers might like to think, price does matter to patients, and even without punitive levels of cost-sharing, people will seek lower prices when they have the information.  But of course, price is not the only thing, or even the most important.  Quality matters.   In recent years we’ve referred to this as “the value proposition.”  But this concept has been around for a long time; the older and wonkier term is “cost-effectiveness.”  Which is why it is disappointing and puzzling that making data on cost-effectiveness available has been seriously hindered.  The ranting about “death panels” was a reaction to the idea that giving elderly patients information about cost-effectiveness of end-of-life options was at best “rationing,” and at worst one step away from the world depicted in the movie “Soylent Green.”  The Patient Centered Outcomes Research Institute (PCORI), established as part of the Affordable Care Act, was intended to be able to provide the sort of data to inform consumer choices in medical care.  Yet the law explicitly prohibits PCORI from funding or conducting cost-effectiveness research!  This is crazy.

Medical consumerism is here.  It is affecting the way patients choose, and it is affecting prices.  If people are to make good choices, we need more transparency, and more good data on cost-effectiveness.  If Amazon can do it, so can we.

A Medical Ferguson

December 12, 2014

CHW LogoDisparities in the criminal justice system have replaced health disparities in the headlines recently.  Is this because health disparities have improved?  Some recent articles confirm my suspicion that the answer is mostly no.

Two New England Journal of Medicine articles and one editorial examine this question.  In one article, researchers examined racial differences in performance on 17 process-of-care quality measures – for example, did patients with heart attacks or pneumonia receive appropriate medications.  In 2005, quality of care was substantially worse for black and Latino patients compared with non-Latino whites.  In 2010, the performance gap had improved substantially.  That seems like good news.  However, in another article in the same issue, racial differences in actual health outcomes (such as control of high blood pressure or diabetes) among Medicare recipients persisted from 2006 to 2011 nationally, though there were improvements in some regions.

How to reconcile these two reports?  Of course the populations and methods are somewhat different.  But a larger point is that reducing disparities in health care does not necessarily translate to reducing disparities in health.  Health care is one of many determinants of a person’s health, and only accounts for about 10% of health status.  The remaining 90% is due to genetics, behavior, and environment.  Improving health takes a lot more than improving health care.

Even in regard to disparities in care, the evidence is not necessarily encouraging.  The findings of an article in Pediatrics were fairly provocative.  Using national data, authors found that adherence to prescribing guidelines for otitis media was actually better for black children than non-black children, which seems like good news.  However, the difference was due to less prescribing of broader-spectrum, more expensive (and not recommended) antibiotics for black children.  These national data confirm early, localized findings from other studies.  While it would be nice to attribute this to more diligence by providers when treating blacks, a more realistic explanation is less parental pressure for expensive antibiotics – or more likely less anticipation by the provider of such pressure – for blacks compared with whites.  The authors of an accompanying editorial describe this as an example of “structural racism.”

Eliminating health disparities is going to take more than changing prescribing.  It will require addressing those behavioral and environmental factors that are the primary determinants of our health.  It means Ferguson, MO needs to have more in common with the nearby but much more affluent suburb of Ladue.



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