Starting With Curious

People often ask if my kids are pursuing a career in medicine.  As it turns out, neither of my sons is going into anything even remotely related.  They’ve never really had the inclination, and I’m certainly not the type to push them into anything.  But when someone learns that my boys aren’t following in my footsteps, the follow up statement is often something along the lines of “I hear a lot of doctors are pretty unhappy with how things are going, and say they wouldn’t do it again. I guess it’s not surprising you would discourage your children from being a physician.”

That’s when I get defensive.  I actually love what I do!  If anyone has an interest in medicine, I would absolutely encourage them to pursue it.  After a number of these conversations, I started to wonder if I was crazy.  But now there is data to suggest I’m not alone.  A recent survey, the Gallup-Healthways Well-Being Index, shows that physicians rank highest or all occupations in terms of overall well-being.  (It’s like we’re the Denmark of occupations.)  The findings are based on over 170,000 interviews in 2012 with working Americans.  Physicians had the highest overall well-being index (78.0 on a scale of 100), followed by teachers at 73.5.  The survey includes 55 items measuring respondents’ physical, emotional, and fiscal well being.  Physicians scored highest (95%) in their belief that they “use their strengths to do what they do best every day” (followed by nurses at 92.7%), and near the top in being treated by their supervisors as a partner.  Physicians also scored at or near the top in measures of physical health, such as exercise, healthy food consumption, obesity.

This is not to deny that physicians are under a great deal of stress as we move through as rapidly changing healthcare environment.  Moreover, dissatisfaction appears to be particularly high in certain specialties, where changes in work patterns and reimbursement may be leading to lower pay and more difficult working conditions.  But overall, the evidence is that for the large majority of us, we still find that being a physician remains a rewarding way to fulfill our goals of making a difference in people’s lives.

I’m not disappointed that my kids are following different paths – I’m thrilled they have passions and they are pursuing them.  But I’m certainly not sorry with the path I’ve chosen, and I’d gladly do it again.

If medicine is a team sport, then integrity is the force that holds the team together.  In our statement of core values, integrity is characterized as “We build confidence and trust in all interactions.”  Integrity is often defined in terms of trust or honesty.  But it is really much more.  The word derives from the Latin root integer, meaning whole, or complete.  Integrity embodies the concept of consistency, the parts being in harmony with the whole: for example, consistency between words and actions.  In that sense, the link to honesty is clear, and is exemplified in the associated behaviors “I follow through on commitments,” and “I give and receive feedback honestly.”

But how does this notion of integrity as honesty explain “I listen to others to gain understanding,” or “I am committed to service excellence”?  This follows from a more expansive view of consistency, not only between words and actions, but between our actions and our inner principles, beliefs, and values.  Integrity is the pillar that supports our other values of purpose, collaboration, health, and innovation.  If we act with integrity, then what we do is motivated by our devotion to these other values, by our vision of the children in Wisconsin being the healthiest in the nation.

We cannot collaborate if we do not listen for understanding, if we do not assume good intent.  When we fail to assume good intent, then our action is not consistent with our values – we lack integrity.

A key behavior is “I treat others with dignity, compassion, and respect.”  Doing this, in turn, requires understanding those with whom we interact.  It means trying to put ourselves in their place, trying to see the world through their eyes.  This is particularly critical for our patients and families.  Acting with integrity requires empathy.  For a compelling look at approaching others with empathy in a health care setting, see this Cleveland Clinic video.

Integrity doesn’t just apply to us as individuals.  Our organization must also have integrity.  Patrick Lencioni, in his book The Advantage: Why Organizational Health Trumps Everything Else, states “An organization has integrity – is healthy – when it is whole, consistent, and complete, that is, when its management, operations, strategy, and culture fit together and make sense.”

For us as individuals, and collectively as an organization, integrity is absolutely critical.  Lack of integrity leads to failure – it is, literally, dis-integration.  “A house divided against itself cannot stand.”  But we can also look at this more positively.  When we have integrity, we are whole, we are healthy.  As Gandhi said: “Happiness is when what we think, what we say, and what we do are in harmony.”

For some time now, those interested in promoting safety in healthcare (such as our recent visitors from the Solutions for Patient Safety collaborative) have recognized that creating a high reliability environment and a culture of safety require a focus on the systems within which people operate, rather than on the individuals themselves.  Checklists, hard stop alerts, pre-filled syringes, all are examples of system design that “nudge” us (gently or firmly) away from things that might harm patients.

But when it comes to the effectiveness domain of quality, we still tend to focus on individual solutions – e.g., publishing systematic reviews or clinical guidelines, education – in the hope that providers will do the right thing. In reality, though, translating research into practice tends to be slow, sometimes painfully so.  Some recent publications shed some light on some of the barriers.  Pediatrician and New York Times columnist Pauline Chen wrote about barriers to clinicians acting on comparative effectiveness research results.  Citing a study in Health Affairs, she notes several factors that impede the ability of such studies to change practice: financial incentives that promote the status quo; limited applicability of study results to real world populations; ambiguity of study results (e.g., conflicting studies, subgroup differences); cognitive biases (e.g., the belief that more care or more expensive care equals better care); and limited use of decision support tools.

Changes in the health care payment environment may alter the financial incentives, and ongoing efforts to improve the design and conduct of comparative effectiveness research, such as those sponsored by the Patient Centered Outcomes Research Institute, will address the second two points.  Another recent article in Health Affairs sheds some light on the issue of cognitive biases.  Drawing on experience with behavioral economics, the authors discuss the two cognitive systems that affect behavior – the automatic and the reflective.  While the latter is driven by rational thought, the former is driven by heuristics, mental short-cuts that allow us to react rapidly to an onslaught of multiple, simultaneous inputs.  While they often serve us well and keep our brains from being overwhelmed, these heuristics are subject to a variety of biases and errors.  One example is “availability bias,” where things we have encountered most recently assume greater importance than they warrant based on actual probability.  The point of the article is that, if we hope to change clinical practice behavior, we cannot rely strictly on education – which utilizes the reflective system of processing – and instead use approaches that acknowledge and account for the biases inherent in the automatic thought processing we all use in our day-to-day practice.  For instance, behavior is often driven by perceived norms; we want to do what others in a similar situation would do. (“I believe most people would get a CT in a patient with a new onset seizure.”) The problem is, we don’t always know what those norms really are. (How often are CT’s actually done in such patients?)  If we knew what the norms are, we might be more inclined to change what we do to conform.  Another example is how our perception is altered by the messenger.  They cite a study where 82% of physicians said they trusted a guideline from their professional organization, while only 6% supported the same guideline said to come from an insurer.

One particularly important behavioral promoter of change is making the desired activity the default.  Enrollment in retirement plans and organ donation are both dramatically higher when someone has to opt out rather than opt in.  Similarly, generic prescribing is higher when that is the default.  This is a system change that can be used to drive evidence-based practice.  So is decision support, the fifth barrier to translating research into practice.  Building the evidence into the same tools we use for documenting and ordering is an important way to promote the use of that evidence.  Taking a systems approach will help as we attempt to improve quality in all of its domains, including effectiveness and efficiency as well as safety.

I’ve never been one of those people who really bought into the “baseball is a metaphor for life” thing.  But the longer days, melting snow, and opening day have got me thinking about one aspect of baseball that does resonate: teamwork.  While individual accomplishments are recognized, everyone on the winning team gets a World Series ring, even the guy with the lowest batting average, or the third left-hand reliever on the list.

As a team sport, even baseball pales in comparison to medicine, especially academic medicine.  Nothing we do can be done by one individual acting alone.  This is why one of our core values is Collaboration: “We work together to care for children and families.”  To be a team means more than just a group of people working in the same area.  Among the important things that transform a group into a team are common purpose, mutual respect, and collective responsibility.  All the members of the team are working toward the same goal – the health of a child, meeting the needs of a family, understanding a disease.  Sometimes it means putting off one’s own goals, at least temporarily, like a sacrifice bunt to advance another team member into scoring position.  It means each team member doing what she or he does best to lead to the shared outcome, regardless of the “credit” that may be given.  In turn, each team member respects the unique contribution of the others.  On a functioning team, diversity (of skill, talent, background, perspective) is a core strength.  An all-star team composed entirely of pitchers will never win.  In the end, all the team members share in the credit for success, or the responsibility for failure.  Members of teams don’t hog the limelight and they don’t point fingers.

Because we work in such a complex environment, we recognize the many teams each of us is on.  It might be the group of care providers in the clinic or OR.  It might be the individuals working on a research project.  The leadership team of a service line.  The members of a committee.  Leaders from our various campus partners like MCW, CHW, CSG.  The partnership between a family and a provider.  The list is nearly endless.  But all of these are teams, and all have in common those key features of collaboration: common purpose, mutual respect, collective responsibility.

So while I have always been terrible at baseball (I was actually held back in Little League!), I am grateful for the spirit of teamwork and collaboration I have found in academic pediatric medicine, and in particular here at Children’s Hospital of Wisconsin and Medical College of Wisconsin.