Starting With Curious

My father used to make the rather ridiculous claim that children are always taller than their parents.  As patently laughable as that assertion is, others do not shy away from equally sweeping, and verifiably false, assertions about succeeding generations.  The most common tends to take the form of “kids have it so much easier than we do, and are so spoiled they don’t even appreciate how easy they have it.”  Each generation following the World War II “greatest generation” – the baby boomers, gen X, millenials – is purported to be increasingly self-centered and even narcissistic by the one preceding it.

In medicine, it’s not uncommon to hear “seasoned” (a.k.a. older) physicians (a category into which I, alas, fall) decry the ease of training in the era of resident work hour restrictions.  No doubt the life of a medical trainee is different, and yes, easier, now than 20+ years ago.  And I, too, share a certain nostalgia for the kind of camaraderie engendered by a shared survival of hardship, and for the nature of the doctor-patient relationship that may be unique to spending unsustainable hours together.  Perhaps that is the price one must pay for patient safety and a humane work environment.  But regardless of what one thinks of the merits of restricting work hours, we should not therefore assume that the current generation of students and trainees is any less motivated by commitment to healing than we were.  Choosing to value one’s health does not mean sacrificing purpose.

Indeed, there is some evidence that the millennial generation is, if anything, even more altruistic than ones before.  A recent report showed that “the no. 1 factor that young adults ages 21 to 31 wanted in a successful career was a sense of meaning.”  And the top choice for a place to work was a children’s hospital (St. Jude’s, to be precise)!  I see this in my own sons, 20 and 24 years old, who both made the decision to attend state university to avoid incurring debt, with the intention of entering some form of public service career.  Only one of them may have ended up taller than me, but both give the lie to the idea that altruism and service to humanity are waning characteristics.

“Better care for patients, better health for the population, lower cost”: this is the Triple Aim of health care.  Last week at the Institute for Healthcare Improvement Annual National Forum, there was a riveting panel discussion on “Environmental Sustainability and the Triple Aim.”  Don Berwick opened with a reflection on the huge environmental impact of healthcare, especially hospitals.  A few examples:

• Hospitals have 2.5 times the energy intensity and carbon dioxide emissions of other commercial buildings; they account for 8% of the nation’s energy use.

• Hospitals generate a daily average of 26 pounds of waste per staffed bed – 5.2 billion (yes, billion) tons of waste annually.

You get the idea.  Berwick posed the question, how can we create better health when we are creating an unhealthy environment?  How can we drive cost down with so much waste?  He suggested that paying attention to environmental sustainability was essential to driving the Triple Aim.

Four panelists highlighted some of the successes in promoting environmentally sustainable healthcare.  Jeff Thompson, CEO of Gundersen Lutheran Health System in LaCrosse, talked about their successes in their goal of becoming the first carbon neutral hospital in the US.  Although some of that has been through innovations in using alternative energy sources such as geothermal and methane from biodigesters, Thompson noted “conservation should always be your first fuel.”  He cited a $2 million dollar investment in energy conservation and waste reduction that has yielded $1.3 million in savings every year.  That’s a pretty spectacular ROI.  Another speaker discussed the Healthier Hospitals Initiative, which currently includes over 700 facilities and aims to increase that to 2000 in the next few years.  The model is that of the improvement collaborative, with hospitals helping each other figure out how to improve their sustainability in several areas, including energy, food, chemicals, and waste.

The final speaker was an architect who discussed the progress of thinking from “green buildings,” which have a less harmful impact on the environment, to “living buildings,” which have zero impact, to “restorative buildings,” which actually provide a net benefit to the environment.  That sort of thinking is somewhat visionary and aspirational; getting there can seem daunting.  But if a journey of a thousand miles begins with a single step, think about what we could do easily that would get us started.  I came in to the office last weekend, and was startled at how many computers were running, monitors ablaze.  Why? Think of how many disposable cups we use, how many documents we print (with multiple copies for people who already have one, or aren’t even coming to the meeting), how many supplies we simply throw away unused.

The panelists were asked how, at a time when we all feel overwhelmed by what we are expected to do with shrinking resources, can a hospital possibly hope to add yet one more thing to the list of “blue chips.”  This is a fair question.  The canned, and somewhat disingenuous, responses were that this is different – it’s really, really important – and that it’s “easy” to piggyback this with other priorities.  But let’s face it, there does come a point where you truly can’t fit even one more sock into the suitcase – it just won’t close (or the zipper breaks).  The fascinating response came from a panelist who talked about their recycling initiative.  They were looking for a group to lead it, and over 50% of the employees volunteered, including many who had never stepped forward into a leadership opportunity before.  His conclusion is that there is a hunger for this sort of effort within our organizations, it’s something people recognize as a shortcoming in how health care operates, and that those people will come out of the woodwork to participate.  By inspiring action, it actually increases the pool of resources available.  Imagine not trying to cram that last sock in, but getting an additional suitcase.

This is a season that, at least in the US, is a virtual celebration of excess and waste.  Then January comes and we all resolve to do better.  When you are making your resolutions, maybe you can include some that will move us closer to environmental sustainability and the Triple Aim.  The kids in Wisconsin can’t be the healthiest in the country if at the same time we are making Wisconsin itself less healthy.

Having come of age when nuclear disarmament and apartheid were the issues roiling college campuses, it’s hard for me not to reflect on the passing of Nelson Mandela.  I still get a little teary thinking of the image of him walking out of prison, holding his wife’s hand, smiling and waving – an image that 10 years earlier, when I was watching protesters urge our university to divest from companies doing business with South Africa, I never thought I’d actually ever see.  Part of what I so admire is the way Mandela was able to balance two contradictory strains, and in doing so accomplish more than he ever could have using either approach alone.  He was the epitome of the versatile leader.

Mandela as conciliator.  Many have extolled his grace and magnanimity in victory over the apartheid regime.  Indeed, for many that is his defining characteristic.  One only needs to compare the violent conflicts in Zimbabwe, Algeria, or any of a host of other liberated colonies to the strikingly peaceful transition in South Africa.  It still defies belief that from the brutality that was apartheid, a multiethnic, multiracial society could emerge.  No one person can claim credit, but Mandela surely played an enormous role, though his leadership shadow – the shadow of integrity.  I don’t mean integrity in the sense of honesty and lack of corruption (though certainly he exemplified that, especially in contrast to the many other national liberation figures throughout the world who later succumbed to the temptations of power.)  I mean integrity in the sense of wholeness, or being true to oneself and others.  Mandela expected – demanded – to be treated as the equal of anyone else, even by his jailers and tormentors, but delivered no less himself.  During his many years in prison on Robben Island, he learned to speak Afrikaans, and encouraged his fellow Xhosa and Zulu-speaking political prisoners to do the same, so he could interact with his jailers as fellow humans.  This led to a mutual respect that paved the way for fruitful negotiation.  Mandela believed in the inherent worth and dignity of all people, neither allowing it to be taken from him, nor withholding it from others.

Mandela as fighter.  While the peaceful end of apartheid has dominated the remembrances, we can’t forget that it was the culmination of a decades-long and at times violent struggle, and Mandela was an advocate for and leader of that struggle.  His imprisonment was certainly a moral wrong, but he was not actually innocent.  After all, he was dedicated to overthrowing an unjust regime, openly so.  He never renounced or lost sight of that purpose.  He just remained flexible in his tactics.  Mandela didn’t learn Afrikaans to support the regime, but as a tool to subvert it.  He is revered as a pragmatist.  Pragmatism, however, is not an end, but a means.  Importantly, ending apartheid was only the first of many goals Mandela and his comrades embraced.  Once majority-rule democracy was established, Mandela fought for the welfare of those people who had been marginalized.  The post-apartheid constitution that Mandela helped craft enshrines a number of basic rights, including a right to education and to health care (something we could perhaps learn from).

Nelson Mandela was a man of great integrity and great sense of purpose.  Both are necessary to achieve great success.  As his example shows, even the most seemingly intractable problems can yield in the face of stubborn conviction coupled with an equally stubborn acceptance of the worth and dignity of each person, both ourselves and those who oppose us.

Here is one of my favorite songs, a musical tribute to Nelson Rolihlahla Mandela. 

It seemed so easy when Sgt. Joe Friday said it on Dragnet.  Why do we have so much difficulty in practicing medicine that way, based on evidence, on facts?  Here are some of the barriers, as I see them.

1.   Evidence generation.  This seems obvious, but evidence-based practices requires, well, evidence.  In many fields, especially pediatrics, there is a serious lack of evidence to support even treatments that are widely used.  One issue is lack of funding.  NIH funding, even before it began to decline due to the federal budget sequester, often goes preferentially to basic science rather than clinical trials, and to adult trials that address common, high-impact conditions.  While regulations about inclusion of children in research, the Better Pharmaceuticals for Children Act, and FDA incentives for industry to do perform pediatric trials to support patent extension have helped, funding for pediatric patient-oriented research continues to lag.  Pediatric trials are also difficult to conduct.  Many childhood diseases are sufficiently rare that they can only be studied in the context of multicenter trials, which are logistically challenging and more expensive to conduct (typically exceeding the level requiring additional scrutiny at NIH).

Nevertheless, generating evidence is absolutely critical.  When we do systematically evaluate treatments, as a study in Mayo Clinic Proceedings shows, the results often fail to support established practices.  Of 363 comparative trials of established practice reviewed, 40% showed that a standard practice was ineffective or harmful, 38% reaffirmed established practice, and the rest were inconclusive.

2.  Evidence dissemination.  Even when studies are done to critically evaluate a diagnostic test or treatment, the results may not be widely disseminated.   Publication bias – the tendency for authors to prefer to submit, or for journals to prefer to publish, studies with positive results, has been well described.   The reasons may include profit motive (for industry sponsored trials), legitimate concerns about negative results from underpowered studies, or sheer laziness.   The requirements by major journals to register trials before they begin as a condition for publication was supposed to help minimize publication bias, or at least enable  its detection.  But a study in PLoS found that only 46% of reportedly completed trials listed in ClinicalTrials.gov had been published.  Publication rates were lowest for industry sponsored studies (40%), followed by 47% for government funded studies and 56% for non-government, non-industry supported studies.

And of course, there is the sheer volume of stuff to read.  Medical and scientific journals have exploded in number; it is nearly impossible for a practicing provider to keep up with the literature.

3.  Knowledge translation.  Even when results are disseminated, the time for new findings to be adopted into widespread clinical practice has lagged.  It has been reported that innovations can take 10 years to become commonly used.  Reasons include entrenched interest in the status quo (which does not only apply to for profit industry – evidence questioning the utility of a procedure, for example, may threaten the specialists who perform it), and sheer inertia.  Physicians are naturally skeptical, and often question the data when it does not conform to their pre-existing beliefs.  This figure illustrates the gauntlet a study must run before it can be accepted as the basis for a practice change.

Evidence-based medicine has the potential to reduce the excessive variation in practice that has been widely described.  The goal is not to eliminate variation, only to minimize unnecessary variation.  Different patients with the same disease will differ in their exact biological needs as well as their preferences; these differences must be understood and accounted for.  But their management should not be based on which part of the country a doctor happened to train in, or what year she graduated from medical school, or her Myers-Briggs personality type.  We expect the legal system to operate based on the facts – the medical system should do no less.