Starting With Curious

Remember when cigarette ads featured physicians smoking?  Well, I don’t either; I’m not quite that old.  But I do remember in the 1980s, numerous patients I encountered at medical school in North Carolina believed – in some cases based on doctors’ advice – that smoking was healthy because it exercised the lungs and soothed the throat.  Moreover, we sold cigarettes in the hospital (this was North Carolina, after all), and many providers and staff smoked.  People are influenced not only by what doctors and nurses say, but what they do, when it comes to advice on health behaviors.  For example, one survey showed patients had less trust in health advice from overweight doctors than from those of normal weight.  (Although another study showed that overweight patients were more confident in dietary advice from doctors who were also overweight.  I guess we sometimes listen for confirmation rather than for understanding.)  We can also influence our colleagues through our “shadow of leadership.”

If we want to promote our value of health, we can’t just talk about it.  We need to model it.  On the positive side, a Gallup survey shows that Wisconsinites are above the national average in terms of exercise and eating fresh produce, though granted the national average isn’t all that great.  But there’s a lot more we as individuals can do, starting with small but meaningful steps:

1)       Literally, take steps.  Use the stairs.  While I am admittedly a fanatic who acts like I have an anaphylactic response to elevators, even pledging to use stairs whenever you are going 2 floors or less would have a big impact.  Each minute of walking up stairs burns about 7-8 calories (unless you’re eating a donut while you’re walking).  And it frees up the elevators for patients and families who really need them.

2)      As John Cleese once said, “You should eat more fresh fruit.”  We are fortunate around here to have an abundance of farmer’s markets in the area – including one on the CHW campus later in the summer – where you can get locally grown produce, supporting not only your personal health but the health of the community.

3)      Get out of the car.  In US metro areas, nearly half of all car trips are less than 3 miles, and 28% are less than one mile.  In fact, 2/3 of all trips less than a mile are made by automobile.  I can’t imagine driving less than a mile.  It’s easy to avoid the car if you live in a dense area like the east side of Milwaukee or Wauwatosa, but even if you live in the exurbs or the country, it’s likely that once you’ve driven to a destination for shopping, for example, you could get around more on foot while you’re there.  To start, think of 1 or 2 times you get in the car each week that you might walk or bicycle instead.  If you get really ambitious and start cycling everywhere, join the Children’s Hospital of Wisconsin team for the National Bike Challenge.

4)      Enter the cone of silence, at least email silence.  Thanks to Henry Ford and various unions, the five-day work week has been standard in the US since the 1920s.  At least until the 1990s.  With the rise of computing and communications technology allowing constant accessibility, there has been a trend toward longer hours and seemingly continual connectivity.   This, studies show, is bad for health as well as for productivity.  In other countries, governments and large corporations are instituting restrictions on access to email during evenings and weekends.  This is, I admit, easier said than done.  But I try to set aside at least one day a week where I do not look at my work email.  And I am trying to avoid sending email to others on the weekends, lest people feel I expect them to be looking at it and responding.

We don’t see doctors and nurses walking the halls of the hospital with a Chesterfield dangling from their lips anymore.  That’s progress.  Now let’s see more people taking the stairs, eating local produce, and relaxing on their days off.  The first steps on the road to health can’t be taken in a car.

A bunch of years ago, as part of religious education teacher training, we were given an exercise: sitting in a large circle, each of us was to take a lump of clay, close our eyes, imagine what is in the clay, and then mold it, allowing the clay to “express itself.”  After about five minutes we all opened our eyes.  Everyone else had beautiful sculptures of varying degrees of complexity and intricacy.  I had an ashtray.  It was the only thing I could imagine was in that clay.

I’ve not generally considered myself to be a very creative person.  I have no artistic ability whatsoever, challenged to draw even a stick figure dog or tree.  While I perform music, I am in awe of anyone who can create even the simplest three-chord tune.  And when asked to do the sort of mental exercise like “come up with as many different uses for a bar of soap as you can,” my list typically consists of “wash hands, wash face, wash neck, wash table, wash dishes…”

So I was really struck by an article in the April edition of Southwest Airlines’ magazine (thanks to Juliet Kersten for calling my attention to it), entitled “Chasing Beautiful Questions.”  It tells the story of Van Phillips, who as a young man lost his leg in an accident.  Not content with the prostheses available, he invented the springy scimitar-shaped prostheses made famous by Oscar Pistorius (“The Blade Runner”).  The key to this and many other innovations is a series of three questions:

• Why…?  This can take the form of challenging the status quo (“Why are current prostheses so stiff?”), or simply wondering about an interesting phenomenon (“Why do cockleburs stick so tenaciously to clothing?” – the question that led to Velcro).

•  What if…?  This starts the process of imagining the alternatives.  What if a prosthetic leg didn’t look like a leg?  What if we could manipulate surgical tools remotely?  What if we could replace an abnormal gene with a normal version?

• How might…?  Here is where vision starts to become reality.  This question is often answered by making a leap from one domain to a completely different one, making a connection that others have not.  I might try shaping a leg like that of a cheetah in motion.  We might connect a scapel to a video-game style joystick.  Viruses insert their genes into cells they infect – perhaps we could use viral enzymes to do the same.

A few people – Thomas Edison, Van Phillips, Norman Woodland (inventor of the UPC bar code), Mary Anderson (inventor of the windshield wiper) – can ask and answer all three of these questions.  They become known as innovators.  But most innovation is the result of a team effort.  Almost all of us can do a decent job with at least one of these questions.  At Children’s Hospital of Wisconsin, innovation is one of our core values.  Our motto is “kids deserve the best,” and innovation is key to giving them that, by allowing us to constantly improve.  I think many of us think of innovation as something that a small group of people, the researchers, do.  Yet as long as all of us are asking at least one of those questions – Why?  What if?  How might? – we are all innovating.  Even if all we can make from a lump of clay is an ashtray.

Walk down the typical grocery store aisle, and the choice can be literally overwhelming.  Who knew there were so many ways to put sugar and a variety of processed grains and “food-like substances” together into so many different shapes and sizes, in so many different packages, taking up almost 1000 linear feet of shelf space?  But is that really choice?  All of them likely contribute to the high rate of type II diabetes, which is skyrocketing among children.  Does it really matter which one you pick?

Americans place a great value on freedom of choice; one of the huge criticisms of the Soviet economy was the lack of selection of consumer products.  But how much choice does one really need?  The real problem is the fact that what few consumer products were available in Leningrad were of poor quality.  Conversely, all those breakfast items are just variations on the same theme.  There is apparent variation, but little actual diversity.  We’d be better off with fewer junk cereals, and at least a few real foods.

Choice is emerging as a huge issue in health care.  Specifically, the move (blamed by many on the Affordable Care Act but in reality an acceleration of a long-standing trend) toward so-called “narrow networks.”  The idea is that an insurer will offer a narrower selection of providers (including doctors and hospitals), at a lower cost.  Because the plan only includes providers willing to accept lower payments, it can be offered for less.  It turns out, many consumers – not only those buying insurance on the new exchanges, but some of the nation’s largest employers – are making that trade-off of less choice for lower cost.

Hence the outcry from people like Dr. Monica Wehby, a pediatric neurosurgeon running for senate in Oregon under the slogan “Keep your doctor. Change your senator.”  It’s certainly understandable that individuals who have a long-standing relationship with a provider would be reluctant to have to switch because that provider is not included in a new health plan.  (Although I should point out that it’s no different than what happens if one changes jobs.  Someone really concerned about ensuring universal choice in providers would support universal health coverage.  Just sayin’.)  But how bad is it to have a narrower choice?  Emmanuel Ezekiel argues that in this case, choice among providers is not too different from choice among breakfast cereals.  There is little actual difference among most providers.  The real issue is to make sure that a network includes high quality providers.

To be included in narrow network plans, though, providers will need to be not just high quality, but high value.  Every insurance executive I’ve ever spoke to is willing to admit that while they care about quality, they’re really just looking for quality that’s good enough; what really matters to them is price.  At least they’re honest.

I consider providers like Children’s Hospital of Wisconsin and its doctors and nurses to be like the high quality, whole grain, unsweetened, delicious yet nutritious cereal frequently not found in the breakfast aisle.  They are often relegated to an “organic” specialty store.  So far consumer, and insurers, have recognized that we are indispensable to the community.  We’ve been there in the cereal aisle.  We need to make sure that we remain available in all the markets – which means being sufficiently competitive not just on quality but on price – so that families will have a real choice.

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, are the up button on the mood elevator.

Kids deserve the best.  With our nurses at Children’s Hospital of Wisconsin, they have it.

I recently had the privilege of participating in a panel discussion for the medical students in the Quality Improvement Pathway at MCW.  One of the questions we were asked to address was “How do you anticipate addressing the need to provide point-of-service price information for healthcare?”

The four of us at the table in front looked back and forth at each other; clearly no one wanted to tackle that one.  How about a softball like “How can we completely eliminate medical errors?” or “What three simple actions will bring lasting peace to the Middle East?”  Seriously, point-of-service prices for medical care?

We know that consumerism in healthcare is increasing, thanks in large part to the exponential growth in high deductible health plans – a trend unlikely to be reversed any time soon.  With patients responsible for a larger share of costs, at a time when household income is basically stagnant, people are factoring cost into account like never before.  What are providers doing in response to that?  The answer, frankly, is not nearly enough.

There have been some efforts at transparency, sometimes in an attempt to gain a competitive advantage, sometimes in response to legislation.  But these have been pretty rudimentary.  List price, or the “charge master” price, bears a distant relationship to the amount a given patient actually has to pay.  And of course, the total cost of an episode of care depends on what happens during that episode.  Some pioneers are beginning to offer bundled prices for specific services or procedures – a fixed amount for, say, a routine checkup, or a tonsillectomy or knee replacement.  That gives the provider some element of financial risk: if the actual cost of performing that service is higher than anticipated, the provider loses.  It also makes it possible for prospective patients to comparison shop, at least on price.

But for many services, pricing remains a la carte, and therefore complicated.  Moreover, for most products and services – especially medical care – cost is not the only factor being compared.  Quality – and this includes effectiveness, safety, and experience – matters.  It’s really value that consumers are seeking.  That’s hard to do at the point of sale.  Nobody buys a car or a computer without doing some research.  I certainly hope no one ever buys a knee replacement that way.  What’s needed is information to allow prospective patients to determine and compare value before the point of service.

There are some initial efforts, all leaving much to be desired.  On the one hand we have the insurers.  Some already have tools to allow people to compare “value.”  On the plus side, someone can see what their actual out of pocket cost will be from a selected provider, based on negotiated rates and cost sharing specifics for the individual’s plan.  But the quality information is often suspect, frequently boiled down to a simple, and simplistic, 3 star rating system.  In most cases, that quality metric is heavily weighted toward what the insurer most cares about – cost.  There’s relatively little about outcomes or experience, the things that matter to patients.

On the other hand, we have information from the providers.  Many hospitals feature a quality section of their Websites.  Often the data are cherry picked, or are at best indirect measures of quality, such as the volume of procedures performed.  (McDonald’s sells lots and lots of hamburgers.  So what.)  And even when price information is provided, it’s still going to be difficult if not impossible for someone to interpret what that means to their bottom line.

The environment is ripe for a third-party source of information on value in healthcare.  Something like Consumer Reports.  And if we are serious about the value proposition, we should not fear this, we should embrace it and promote it.  What would the ideal value information look like?  Here are some elements:

• objective, neutral, trusted source, free of conflicts of interest
• validated, risk-adjusted quality metrics including the domains of effectiveness, safety, and experience, measured uniformly across providers
• cost information relevant to the decision maker – ideally, their actual out of pocket expense, though a reasonable substitute might be a relative cost (e.g., the ratio of payments to that provider from all payers for a given procedure, compared with the average payments to all providers in a region)
• footnotes to explain unusual variations
• unbiased explanations of terms and concepts

This last one is important.  I can look at a comparative rating of computers, but if I don’t understand what RAM does, or what a gigabyte is, it’s not that helpful.  A couple of years ago at a conference I heard a speaker claim that one of the big growth industries would be in “medical interpreting,” meaning the ability to write about complex medical care issues and explain them in a way that consumers can use the information to assess and compare.  I have to imagine that some of those medical students we spoke with may be poised to do exactly that.