Starting With Curious

Remember when you could fairly easily disappear?  When I was a kid we’d go for long bike rides, and our parents couldn’t get a hold of us until we got home – and didn’t expect to.  Even during residency, I carried a pager, but I had to keep a quarter taped to the back so if I got a page outside the hospital I could use a pay phone.  Immediate connectivity was not part of the picture.

There are some real advantages to cell phones and other means of constant communication, but I don’t think it’s a secret that there are serious problems as well.  According to several studies, a large majority of American workers check email in off hours and on vacation.  Among the effects are decreased job satisfaction, personal and family stress, and burnout.  Not exactly what we aim for with our value of health.  What can we do to disconnect from time to time?  Some companies, beginning to recognize the downside of constant connectivity, are encouraging employees to refrain from email away from work, and implementing policies to reduce the volume of electronic communications  in off hours.  But as individuals we can take the initiative in reaching a healthier harmony between our work and non-work lives.  While I am no expert, I am pretty satisfied with my work-life balance, and here are a few things I’ve tried:

1.  Find, and schedule, leisure activities that require you to unplug.  Some of mine are exercising, playing music, and cooking.  It’s hard to check email or respond to texts when blowing a horn or stirring a risotto.  One caveat: many of us like to listen to music when working out, but if you’re using your phone as an MP3 player,  you run the risk of an interruption.  Try putting the phone on airplane mode – iTunes yes, text messages no.

2.  I’m a fanatic about to-do lists, both at work and at home.  I list my leisure activities on here right along with the chores.  When things are particularly hectic, I put “relax” on the list.  It may sound like an oxymoron, but it works.

3.  Let yourself be OK with not being available all the time.  I try to put some reasonable limits on the number of hours a day I’m available for non-emergencies.  If I’ve been in the office for 11 or 12 hours, I try hard not to do email after that.  If I have other things I need to do on my computer or tablet at home, I’ll turn off Outlook.  When I do look at email in the evening – and I do, if the work day was shorter, or there’s something pressing going on I need to keep an eye out for – I have become pretty disciplined about what I will respond to.  Unless it’s something that truly can’t wait until morning (which is frankly rare), I save it until the next day.  Responding to email at 10:30 in the evening only encourages people to send you more of them.

4.  When going on vacation for a week, it can be really tempting to just check the email to see if anything important came through.  Next thing you know, you’re reading all 200 messages that came in the day before to find the important ones, and responding to them.  I set up a separate email account that only my assistant knows.  When I’m away, she knows that if someone really, really, really needs to get me, she can send a message to that account.  I can easily see if there are any messages in there (so far there have never been any), and blissfully ignore the regular accounts until I get back.  If you can’t be disciplined enough to do that, go someplace without Internet or cell phone coverage.  (West Virginia is great for that!)

To avoid the “but there will be 2500 messages waiting when I get back and I’ll never get through them all so I better keep up” trap, schedule 2 hours when you get back to go through the backlog.  It never takes longer than that, since most of the messages are either junk in the first place, or will have been taken care of by the time you’re back.  One trick is to sort by subject, and start with the latest message in the thread.  You can probably read only the last one and delete the rest without opening.

5.  If you are away from the office now and reading this, turn off your device, and go for a walk.  Without your phone.

Picking up a medical journal can be humbling.  Easily ¾ of the medications and therapies I read about, including entire classes of drugs, didn’t exist when I was in medical school.  At the same time, the basics of what I do as a clinician, and what we do as a hospital, are fundamentally unchanged: patients come to us, we assess and treat them, and we bill for the services which are largely paid by some form of insurance.  But now that health care expenditures exceed 17% of GDP, a tipping point seems to have been reached, forcing changes in the basic model of health care.  While we are confronted daily with innovations in clinical care, most of the innovations in care delivery haven’t yet reached pediatrics, and certainly not our market.  But there are numerous novel approaches to delivering value in healthcare.  Here’s a brief view of some of what is happening elsewhere.

1.  Retail clinics.  CVS recently announced that they would stop selling tobacco products at its 7600 stores around the US.  The prime driver is the desire to be seen as a legitimate healthcare provider.  CVS, Walgreen’s, Walmart, and others already offer medical services, including both episodic urgent care and chronic disease management.  Such arrangements raise legitimate questions about continuity of care, but they have been highly successful.  The number of retail clinics climbed 8-fold from 2006 to 2013, with over 1600 such clinics today, and over 6 million visits in 2012.  The key drivers are convenience and access, though cost is also a factor.  In the US, only 35% of primary care physicians have after-hours care arrangements, compared with 95% in the UK and the Netherlands.  Retail clinics are simply filling an unmet demand.

2.  Concierge medicine.  This term covers a wide range of practices, from One Medical group, encompassing 25 primary care practices in five markets, where patients pay $150-$200 per year for enhanced direct access to and longer appointments with their physician; to the $25,000 a year to be one of only 400 patients to have a physician essentially at your beck and call.  Again, the drivers are access and experience.  While the rise of these niche services raises questions of equity, in medicine as in so much of the rest of the economy there will undoubtedly be a role for services that cater to those who can afford them.

3.  House calls.  Remember Marcus Welby, black bag in tow, seeing patients in their homes? Increasingly, physicians or other providers are going back to the future.  Not only the old fashioned way, but also using phone or Web contact to bring care not only closer to home, but into the home.  Employers are also bringing healthcare into the workplace, with on-site primary care clinics for employees and families.  Wisconsin-based Quad Graphics, a large printing company, started this and now operates Quad Medical, which provides these services for other employers.  Access and experience, anyone?

4.  Price transparency.  Many elements of health reform, including high-deductible plans and healthcare exchanges, have the goal of containing costs by promoting price competition.  It’s hard to do that, though, if the person doing the buying has no idea what the price is, which has led to numerous efforts are making that information more accessible.  CMS, for example, has made publicly available charge data from Medicare providers on 130 common procedures.  Some hospitals are starting to do the same, publishing their prices up front. 

5.  On-line access.  My Chart, the patient portal for the Epic EHR, is only the start.  Other patient-centered innovations include free-standing patient health records (which are owned by the patient and pull data from all different sources), direct patient access to their records with the ability to edit them, provider-facilitated Web searches for health related information, and shared medical decision-making tools.  Interestingly, a JAMA study showed that access to such online tools actually increased patient visits, rather than supplanting them.

I’m not trying to suggest that all, or even any, of these is something we want to embrace.  We do, however, need to be aware of what is happening in the market.  At the very least, it tells us what our patients and families are seeking.  We, then, need to figure out how to meet those needs.  To do that, we need to be creative.  Selected for success in science and math, many of us in medicine are fairly “left-brained” types; creativity and original thinking often don’t come naturally.  We need to be more intentional innovators.  To do so, it will be important to think outside the clinic.  Leaders in healthcare need to look to other industries to identify trends and come up with new approaches.  We also need to tap into talent from outside healthcare.  The rest of the economy has been focused on value for a long time.  We have a lot to learn.

Picture this sampling of families one might run into in the ER or clinic:

A single woman with 6 children in the exam room.

A couple, both lawyers from Whitefish Bay, with their daughter who was injured in figure skating competition.

A teen couple with a three year old, and mother is pregnant.

You probably had an image of each of these families in your mind before meeting them.  You made some assumptions about their race, education, and social status.  And for most of you, I suspect that your image didn’t match the reality: the woman with the 6 children is a Latina, a PhD social worker with kids from 2 families who were involved in a car crash.  The couple from Whitefish Bay are an Asian and an African-American, both men.  And the pregnant teen mother with the three year old is the white daughter of a professor at an Ivy League school.

We are constantly making assumptions about people based on little to no knowledge.  Daniel Kahneman, in his book Thinking: Fast and Slow, refers to heuristics, the mental shortcuts we employ as a means of efficient mental processing.  This is the “thinking fast.”  When we look outside and see the vapor coming from the heat vent, we don’t first check the thermometer to make the assumption that it’s cold outside.  A barking dog with bared teeth elicits an immediate “I’m outta here” without waiting to see if he wants to play fetch.  The basic mental mechanism is an adaptive response; early humans whose brains were wired to assume that saber-toothed cats were dangerous and to be avoided were more likely to live to reproduce.

But what is beneficial in one context can cause problems in another.  Kahneman documents may examples where these heuristics lead to troublesome biases.  That’s why we have also evolved other mental systems – reflective, analytic, “thinking slow” – to question the snap judgments we make based on heuristics.  In the context of human interactions, this contributes to all kinds of biased thinking: racism, classism, sexism, etc.  As Kahneman shows, we often fail to call on our analytic side to question our biases.  Even when we think we are being objective and rational, we are more prone to bias than we realize.  While the specific biases are not hard-wired, the tendency toward them is.  It’s simply difficult to overcome assumptions.  But the cost of not doing so is high.  As individuals, it can lead us to make stupid investment decisions, choose poorly in everything from clothing to careers, and take both too many and too few risks.  For society, the costs are higher.

I learned an important lesson about making assumptions from a professor in medical school.  One day we had a prisoner admitted to the ward, and someone made an offhand and derogatory comment.  The attending told the team about the time he was attending a conference with colleagues.  In the evening they were walking on the boardwalk, casually dressed, when a police officer approached him, the only African-American in sight.  They were looking for a suspect in a crime, and he “matched” the description.  He described his complete humiliation as he was handcuffed, frisked, and released only when his white colleagues vouched for him.  “You don’t know this patient, and don’t assume you do.”

As the old joke goes, when you assume you make an ass of u and me.  Or perhaps far worse.  So if you have to assume, assume the best.