Happy Nurses Week!

May 11, 2017

 

By his own admission, it took Arnold Relman, former editor of the New England Journal of Medicine, until age 90 to realize the importance of nurses in providing quality medical care. It took me until a week after starting my internship.  My first rotation was on 3 Orange, the unit for medically complex children (including many ex-preemies).  In many ways, medical school had not prepared me well for residency.  I had never ordered feeds for a healthy baby, much less one with a 27-item problem list.  My first night on call, covering the entire team, I was asked to order a refill on a medication for someone else’s patient.  I checked my sign out list and wrote (with a pen, on paper) the order; 10 minutes later, the nurse paged me to double check whether that was really what I wanted to order.  It wasn’t: I had mistakenly ordered a soundalike medication, at a dose that would have been harmful if administered.  Embarrassed, I returned to the unit to correct the order.  I made some comment about making a rookie mistake.  The nurse just smiled and said, “It won’t be the last, but don’t worry because we’re all looking out for each other.”

Relman, after being hospitalized for 10 weeks after a fall, wrote a column for the New York Review of Books about his experience, in which he said, “I had never before understood how much good nursing care contributes to patients’ safety and comfort, especially when they are very sick or disabled.  This is a lesson all physicians and hospital administrators should learn.  When nursing is not optimal, patient care is never good.”

Amen. Over the years, I (and my colleagues) have been bailed out by nurses on occasions too numerous to count.  Mostly not because they caught errors – though in the era before computerized order management that was certainly important.  It’s the subtle change in a child’s behavior pattern that made the nurse call me to re-evaluate a patient who was developing hepatic encephalopathy.  It’s the funny movement that the consultant dismissed, which turned out to be decorticate posturing in a post-craniotomy patient.  It’s the question about why I selected a particular test that made me think through and decide on a different one that was just as good but less traumatic for the patient.  It’s putting a teenager with perplexing symptoms in a room and commenting, “She’s acting just like the aspirin ingestions we used to see,” arriving at the correct diagnosis hours before the physicians.  It’s the insight about family dynamics that allowed me to address concerns I might never have identified on my own.  The list is long.

It’s impossible to overstate my gratitude for all that the many nurses I have worked with over the years have done for our patients. Their job is intellectually, physically, and emotionally challenging, with rewards that are hardly commensurate with the demands.  And I also appreciate what they have done for me: for my education, my professional development, and my job satisfaction.  We share food on the night shift, we laugh and cry together, we brag about and complain about our families, we encourage each other, we look out for each other.  Those interactions, those shared experiences, illustrate what Join Together and Be Remarkable really mean.  Nurses are the embodiment of the Children’s Way.


Comfort Promise

May 8, 2017

No doubt Dr. Aziza, my pediatrician as a kid, was a nice man. But my main memory of him, 50 years later, is of having a tantrum and having to be dragged into his office when I realized I was going to get a shot.  Seriously, I still have a vivid recollection of my terror of that needle. (My mom probably does, too.)  I used to think it was me, that I was particularly fearful of sharp objects and pain.  But I now know that this is actually pretty normal.  What we healthcare providers like to call “iatrogenic pain,” which is a typically obscure way of saying “pain caused by us,” is a significant problem in pediatrics.  Even the youngest infants not only have a predictable negative physiologic response to things like needle sticks, but they have lasting effects as well, including aversion to subsequent healthcare encounters and behavioral distress. In other words, when providers do nasty things to kids – and needle sticks for immunizations and blood draws are the most common nasty thing we do – kids get scarred by it and act out.  (Sound familiar, mom?)

Fortunately, awareness of this problem is growing, and many people are doing something about it.  I am proud to note that Children’s Minnesota has developed what we call the “Comfort Promise.”  This is a commitment to offer all children and families at least one of several evidence-based interventions to minimize the pain of needle sticks when they come to our hospital or clinics.  These interventions include topical numbing medicine, positioning, and behavioral soothing measures.  For young infants, sugar water is also offered.

It does take a little extra time and effort for staff.  But when surveyed, children and families said needle pokes were the most unpleasant part of coming to the hospital. So living up to our values “Listen, Really Listen,” and “Kids First,” in the past couple of years we’ve managed to do this for over 90% of patients in the hospital, and we are now spreading it out to the outpatient clinics.

Now if only we could do something about those nasty swabs to test for strep throat….


Race to the Bottom

April 21, 2017

I had the good fortune to hear Dr. Steve Nelson give an eloquent and impassioned talk about equity and racism yesterday, which led me to want to reprise this blog from a few years ago.

I am a racist. There, I said it.

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.


That Costs How Much?

April 7, 2017

My wife was recently trying to book a flight for business travel. The price of the flight on one airline from Minneapolis to DC varied from $700 to $2000.  How is it possible for the cost to vary three-fold?  The answer is, it doesn’t.  The cost depends primarily on how many people are needed to staff the plane, and how much fuel is used.  The cost of those flights was exactly the same.  It is the price that varies.  The point is, we often say that the $2000 flight costs more, but it depends on what we mean by cost.  The cost to the airline is the same.  The cost to my wife is very different.

The same is true when we talk about costs in healthcare. When you read about healthcare costs, it’s often a challenge to figure out exactly what is being addressed.  Do we mean the cost to the hospital to provide the service?  The cost to the patient?  The cost of the insurance?  Any can be true depending on the context.  However, in the end, what someone (whether a patient family or an insurer) pays for healthcare is ultimately tied to the cost of providing that care.  Just like the cost of a plane ticket is at root tied to the cost of staff and fuel.  Other factors, especially supply and demand, affect the price, but it starts with the cost of production.  So if we want to address the high cost of healthcare – whatever that means – we have to address the high cost of healthcare.

Like any other product, the cost of providing a healthcare service can be broken down into its parts. As in most service industries, labor is the biggest part of the cost.  Doctors, nurses, social workers, interpreters, pharmacists, etc.  These are highly trained individuals, and thus not easily replaced with cheaper labor.  Moreover, much of their work is not readily amenable to automation or outsourcing (though there are numerous examples of both).  Economist William Baumol refers to this as the “cost disease” that helps explain why healthcare costs (along with those of education and live entertainment) tend to rise faster than the cost of other goods and services.  Other main drivers of healthcare costs include equipment (which is typically expensive and rapidly obsolete) and supplies, especially pharmaceuticals.

To figure out the cost of providing a particular service – say, an MRI – you need to know the unit cost of each of the components, and the number of them you use. Unit cost might include a certain number of hours of nurse, radiation technologist, and physician time, a portion of the depreciation of the scanner itself, and medications for contrast or sedation.  You can bring down the cost of the MRI by getting cheaper components (for example, paying the radiologist at a lower rate, or using a less expensive contrast agent), or using fewer of those components (for example, not using contrast).

One more thing. The total cost of providing care is then the sum total of the cost of all of those particular services. The cost of caring for a child with appendicitis, for example, is the sum total of the cost of the various diagnostic tests, medications, and other therapies.  You can lower the cost of an appendectomy by making a CT scan cheaper to do, or you can lower the cost by doing fewer of those CT scans in the first place.  This is the heart of efficiency which, along with effectiveness and safety and patient-centeredness and equity, is one of the core domains of healthcare quality.

Why does this matter? The overall amount of money spent in the US on medical care continues to rise.  For individual families and for society as a whole, medical spending is starting to crowd out other priorities.  Families must choose between medical care and clothing.  States must choose between medical care and education.  You can’t open a newspaper or go on the Internet without hearing that people are unwilling to continue to spend more on healthcare.  Which means we in healthcare need to figure out how to lower the cost of that care.  Not lower the price.  Lower the cost.  We need to be compensated fairly for the service we provide, but we can’t simply advocate for more. We must become more efficient so that we can continue to provide care, and so that our patients and families will continue to be able to access it.  Otherwise someone else – likely someone who is not as knowledgeable about what it takes to provide excellent care, and someone with less personal investment in the outcome of the care – will do it for us.  And we won’t like the result.

But we can do it. Health professionals are smart, creative, and committed.  As an industry we have made healthcare more effective and safer than ever.  We can also, without sacrificing those other domains of quality, make it more efficient.  Otherwise people will forego it – just like my wife declined that $2000 flight to DC.


Let’s Dance

March 29, 2017

Diversity is being invited to the party.  Inclusion is being asked to dance.

I heard this phrase at a recent half-day training in diversity, inclusion, and equity as part of my new employee orientation at Children’s Minnesota.  What a great metaphor for how we need to approach these issues!  By virtue of my status as a white, heterosexual, professional male, I rarely have to deal with exclusion on the basis of the typical “checkbox” categories.  But even the most privileged of us have all experienced occasions where we were somehow not included – where maybe we’ve been invited to the party but no one asked us to dance.  It reminded me of being a public high school graduate at a selective Ivy League university club.  The door wasn’t barred, but never having golfed or been a varsity athlete or summered on the Cape, I didn’t exactly fit in, and no one made much of an effort to make me comfortable.

I’m not sure any of those preppies worried about it, and honestly after about 10 minutes neither did I.  But the stakes were pretty low.  There were plenty other places to drink beer.  But when it comes to making decisions about healthcare for children and families from a plethora of backgrounds, or good leadership choices for a nearly billion-dollar organization, a narrow perspective can literally be deadly.  Diversity – inviting people with a full range of backgrounds, experiences, beliefs, and skills to the table – is necessary, but not sufficient.  Diversity is a start, but without true inclusiveness, it’s just window dressing.  Checking the boxes.

Which may be part of why diversity programs are at times viewed skeptically. Without a commitment to being not just diverse but inclusive, a team or organization can’t expect much to change.  This is a commitment to being not only proactive in seeking diversity of all kinds, but active in promoting inclusion of all in the decision-making process.

The fact that Children’s Minnesota chooses to devote fully one-third of its new employee orientation to this is a strong statement that we recognize how important inclusiveness is to our success, and to the health of the patients, families, and communities we serve.  It opened my eyes to the fact that as a leader, I have to invite a lot of different people to the party.  And then I need to ask them to dance.


Resegregating our Schools

March 7, 2017

Because of the historical racial patterns of church-going, it has been said that the most segregated time in America is Sunday morning.  Thanks to changes being pushed by, among others, Secretary of “Education” Betsy DeVos, that is likely to change to Monday morning, when school bells ring.

House Bill 610, in the words of its sponsor, “repeals the Elementary and Secondary Education Act of 1965.”  This 50 year old law, the backbone of American education policy through Democratic and Republican administrations, is being scrapped. The new law sharply limits the authority of the Department of Education, which is reduced to administering block grants to states.  More importantly, the law establishes a national voucher program allowing children to attend any public or private school, including home schooling, at taxpayer expense, and it requires states to allow complete school choice as a condition of receiving any public education funds. (As an aside, this seems to me to be exactly what the original Affordable Care Act tried to do to force states to accept the Medicaid expansion; it will be interesting to see if any progressive states choose to challenge this “coercion” under the Supreme Court ruling that invalidated that portion of the ACA. Turnabout is indeed fair play.). It will obliterate this nation’s long-standing commitment to public education.

As with health care, the forces behind this change are obsessed with free markets and choice as the answer to, well, everything.  They believe that competition is the only way to improve the quality of education, and that the public school monopoly is the root cause of our troubled education system.  The evidence does not support this.  I should note that finding unbiased research is challenging – for those who want to go straight to the sources, the nonpartisan National Center on School Choice has a comprehensive compendium of studies.  However, my admittedly brief review shows mixed evidence, with some studies showing choice is helpful, some showing it is neutral, and in some studies harmful. It seems fair to say that if 3 decades of research have failed to demonstrate a conclusive benefit of choice on education, it isn’t a slam dunk that choice is THE answer.  One issue is that choice can mean many things: choice among public schools, or charter schools, or vouchers to be used in non-public settings.  It’s therefore hard to draw a firm conclusion about “choice” overall.  But the evidence about vouchers specifically – the centerpiece of HB 610 – is less mixed.  It’s negative.  The largest, best designed studies have consistently shown that voucher students do worse than those who stay in traditional public schools.  The reason is unclear, but it would certainly seem to warrant caution before unleashing it on millions of American students.

If it were simply a matter of mixed evidence, this move to privatize education would be perhaps understandable as a reasonable gamble, a decision that could be refined with more and better research.  But at its heart, this privatization scheme is a radical undermining of core principles of American democracy.

Our commitment to public education goes back to the early days of the Republic.  Thomas Jefferson was a strong proponent of education as the foundation of a free society.  He was so committed to it that his founding of the University of Virginia was one of only 3 things he wanted to be remembered for in his epitaph (the Declaration of Independence and the Virginia Statute for Religious Freedom were the other two; he left out being president, much less the size of his electoral college victory).  Jefferson and others understood that a sound democracy depends on an educated and enlightened citizenry.  Education should not be available only to those of means, nor should it vary based on those means.  One important function of public schools in a democracy is as a place where diverse people from different walks of life could mingle, interact, exchange ideas, and learn a common cannon of democratic principles.  It is an important basis of a level playing field in a free society.  (Granted, the diversity of schools in Jefferson’s day was lacking, but the idea is still valid.) Jefferson believed there should be a constitutional right to education, and while there is no such right in our national constitution (as there is in the constitutions of 174 other nations), every one of the 50 states does include such a right.

Jefferson had nothing against religious instruction; indeed, he believed it to be an important supplement to public education.  But not a substitute for it.  Sectarian separation of education would undermine the development of the American people, which required schools to be inclusive.  And in fact, the various waves of private and parochial school growth, starting with the Irish Catholic schools in the mid-1800s, through the segregation academies in the South in the 1950s and 60s, have been driven in large part by a reaction to this inclusivity.  This has also been behind many other forms of “choice” including suburban white flight starting in the 1970s (my own family was part of this in New York) and the more recent push to restrict busing and promote “neighborhood schools.”  This is the ugly truth behind most school choice – it has frequently been used as a means of re-segregation.  No doubt most parents who choose to move to less diverse neighborhoods with “better schools” or elect to send their children to private schools are motivated primarily by the desire to make sure their kids are well educated.  But some simply don’t want their children going to school with “those” children, and even those among the majority of the well-intended need to be aware of the segregationist effects of their choices.

If challenged by my many friends who choose to send their children to private and parochial schools, I would try to convince them of the value, to both their own children and to society, of a shared public education experience for all, supplemented by the religious education of their choice.  In a democracy we can’t force this, only try to encourage it.  But we shouldn’t be encouraging the dismantling of public education.  And we shouldn’t be paying for private goods with public tax dollars.

The sponsors of HB 610 state it is about the repeal of the 1965 education act.  But they should really be saying it is about the undoing of Brown v. Board of Education.  I can’t wait for the bill that reinstates Plessy v. Ferguson.


Nobamacare

March 1, 2017

We’re starting to see why those who supposedly hated Obamacare have been so reluctant to say what their replacement plan is.  It’s because it’s essentially Obamacare, minus the good things.  Their replacement is “Nobamacare.”  And it’s not likely to work.

First, let’s recall why health reform was such a big issue in the 2008 election.  15% of Americans were without health insurance at that point, the highest number since the creation of Medicare and Medicaid in the 1960s, and a figure that was increasing steadily over the prior 5 years. There are two basic approaches to trying to correct this.  One is a national health plan, where healthcare is either paid for (e.g., Canada) or provided by (e.g. Great Britain) the government.  The other is to work through the free market, using a combination of carrots and sticks to make private insurance more affordable, and incentivizing people to purchase it.  Over decades, and true to form, Democrats have tended to favor the former, while Republicans have promoted the latter.  Until, that is, Barack Obama was elected.  He essentially adopted the Republican idea of working through private insurance.  The Affordable Care Act – a.k.a. Obamacare – is almost exactly the same market-based plan as that instituted in Massachusetts by Gov. Mitt Romney (yes, the same Republican Mitt Romney who ran against Obama in 2012).  In fact, Democrats initially wanted to compromise on a hybrid where there would be a public option – that is, people would be able to choose among private plans or a public plan similar to Medicare – but that was dropped in a futile effort to get Republican legislators to support the Republican plan.

So, Obamacare was basically an effort to increase private insurance coverage (OK – there is one exception which I will get to in a minute). The reasons there were 48 million people without health insurance included that it was too expensive, that there were practices that prevented people from getting covered (e.g., companies refusing to give a policy to someone with a pre-existing condition), and that some people chose to take the risk of not having insurance. Trying to increase coverage through private insurance meant lowering costs, removing barriers, and incentivizing people who were choosing not to buy insurance.

The ACA plan to increase coverage addressed each of those.  To attack the issue of costs, Obamacare sought to create a better marketplace.  The theory was that if you could increase competition, costs would drop and most people without insurance would be able and willing to buy it.  Adam Smith wins again.  So the ACA created an insurance marketplace (sometimes called the “exchange”).  People who did not have insurance through their employer would be able to go on line, compare several insurance plans with information on what they covered, which providers were included, and how much they cost – sort of an Expedia for health care – and competition would drive down prices.  Removing barriers meant preventing insurance companies from excluding those with pre-existing conditions, or placing lifetime caps on coverage which would toss many people with expensive illnesses like prematurity or cancer off the policy part way through their treatment.  And finally, incentives included both carrots – premium and cost-sharing subsidies for lower income people, allowing young adults to stay on their parents’ plan, and requirements that preventive care be covered without cost-sharing – as well as the stick of the individual mandate, which required everyone to have insurance or pay a fine. (Here is where that private insurance exception comes in.  The architects of the plan realized that some people were too poor to buy insurance no matter how many carrots or sticks were offered.  Therefore, one element of the plan was to expand Medicaid to make sure that all those below the poverty line were covered.)

OK, with me so far?  Obamacare was a Republican plan, implemented by a Democratic president, to expand health insurance coverage through the miracle of the free market.

So what happened?  Well, as far as the primary goal of increasing the number of people with health insurance, it was a big but not complete success, with some 20 million additional people covered by 2016.  Also on the plus side, the tens of millions of people predicted by naysayers to lose their employer-based coverage – that never happened.  Of course, that still leaves a lot of uninsured – over 25 million.  Of those, half cite cost as the reason they remain uninsured.  And this is not surprising, since after an initial flattening, health insurance premium costs have started to increase more rapidly again (though at a slower rate than before the ACA).  Why?  There are several factors.  Many insurance companies, in an effort to gain market share quickly, underpriced themselves in the marketplaces.  As competitors dropped out, they jacked up their prices.  Also, fines for not buying insurance under the individual mandate were very low, so lots of healthy people continued to forego insurance, meaning companies were covering a sicker and more expensive population than they expected. Finally, despite its title, the Affordable Care Act did little to address the root causes of high health care costs including private insurance overhead.

So what do the Republicans plan to do?  Instead of expanding health insurance coverage through the miracle of the free market, it appears they plan to expand health insurance coverage through the miracle of the free market.

Huh?

Yes, that’s right, the mainstay of Nobamacare is the insurance marketplace.  So what, you may ask, will be different?  That’s not entirely clear, but the main things seem to be changing the incentive system.  Rather than offering subsidies that vary based on income, Paul Ryan’s plan calls for tax credits and incentives to contribute to health savings accounts.  Both of these would be tilted toward those with higher incomes.  Moreover, the Medicaid expansion for the poorest would be reversed.  In other words, there would be fewer incentives for those most in need of incentive.  Given what we know about who is not covered – coverage increased least among the poor in states that did not accept the Medicaid expansion, and inversely proportional to income among those above the poverty line – that is simply not going to make things any better.  And like the original Obamacare, “Nobamacare” does virtually nothing to address healthcare costs.  If that were my plan, I’d be scared to release it too.

Now, I tend to agree that Obamacare has not lived up to its promise.  It has increased coverage, but less than hoped.  It has slowed healthcare spending, but less than hoped.  But the reason is not because it is insufficiently free market.  Rather, it demonstrates the limitations of the “free market” in healthcare.  Acknowledging the shortcomings in those ideas in the first place would be a start. Calling Obamacare something else because Republicans can’t abide the fact that a Democrat took credit for implementing their ideas isn’t the answer.  Maybe turnabout is fair play: today’s most prominent New York Republican, now that he realizes that healthcare turns out to be complicated, could steal the Democrats’ idea of “Medicare for all” and name it after the New York Republicans who also supported that idea in the 1970s.  He could really shake things up and introduce a single-payer Javitscare or Rockefellercare.  Now that would be interesting.  That would be progress.


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