Starting With Curious

This from the Washington Post: The parents of two children, age 10 and 6, were investigated by child protective services after their children walked home alone from a park near their home.  Several years ago,

Since many of you are mandated reporters of suspected abuse and neglect, I may be putting myself at risk by admitting the following:

• Our kids walked to school since first grade – without their parents
• When our son was 7 we allowed him to be in the house by himself when we ran around the block
• At age 10, our older son was given the chore of doing his and his brother’s laundry, which of course meant pouring laundry soap into the machine
• By age 12 our younger son regularly took the Milwaukee County bus to his guitar lessons
• All of us regularly walk barefoot in the yard, eat outside, and pick up trash and recycling we find as we walk

Without realizing it, we were in the vanguard of what is becoming known as the “free range kids” movement, a reaction to the notorious “helicopter parenting” trend of the past decade or so: the notion that kids must be protected from all known risks by hovering over them constantly and intervening should any danger such as a pedestrian, a mosquito, or a jellybean dropped on the floor get through the layers of virtual bubble wrap in which those kids are cocooned.

This is, perhaps, a bit harsh.  I don’t mean to suggest we should be cavalier about safety, and I recognize that the fact that I walked to school in first grade, stayed home alone briefly after school, and rode New York City public transit when I was 12, means that everything we did back then was a good idea. (Our kids did not ride in the back of pickup trucks.)  But we tend to overemphasize risks and safety, at the expense of allowing children to experience – and yes, at times fail.  Take stranger phobia; the evidence is that abductions and other crimes involving children are actually less common, though you’d never know it from watching Nancy Grace or other TV “news”.

There is a down side to this sheltering.  Overprotection of children makes them less able to deal with problems when they are adults.  Here’s one example: Boston College has seen a doubling of emergency calls for minor issues like being called a name by a roommate or finding a mouse in the dorm.  So the helicopter continues to hover.  NPR reported a couple of years ago about parents who show up at their children’s job interviews.

I’m all for insisting on kids wearing bicycle helmets.  But at some point you have to take off the training wheels and let them go around the neighborhood on their own.  Just hope someone doesn’t call CPS.

“It’s worse than that – he’s dead, Jim,” Dr. McCoy would solemnly intone, after waving a small handheld device over the motionless figure in the red velour shirt.  Of all the gadgets in the Star Trek universe – some of which (warp drive, transporter) remain science fiction, while others are already passé (communicators like 1990s cell phones, 3” square computer disks) – the one I found most fascinating was the tricorder.  Imagine waving something the rough size and shape of a salt shaker over someone and getting a reading of their vital signs, blood chemistries, and even a diagnosis.  If you had one of those, who would even need a doctor; you could hold it in front of your own face and figure out what was wrong, and then ask the computer what you should do about it.

Until recently I assumed the tricorder was more like the transporter than the communicator – unrealistic fantasy rather than established technology.  Perhaps not.  A raft of devices designed to allow people to monitor their own health and self-diagnose is coming to market, some already here.  (Google “medical tricorder” and one of the first hits is the Scanadu Scout™, which measures and records vital signs by scanning your forehead.  For real.)  According to a new book called The Patient Will See you Now from Dr. Eric Topol, a cardiologist and “Professor of Innovative Medicine” at the Scripps Institute, as well as long-time proponent of personalized medicine, the future of medicine lies not with physicians, but with individuals armed with smart phones, miniature electronic sensors, and terabytes of genomic and other data about themselves.

Others, while not disputing the usefulness of some of the new technology, are less certain how soon they will revolutionize health care in the way envisioned by Dr. Topol.  For one thing, data are not information: raw data must be processed to be actionable, and context is important.  While automated language translation programs are certainly getting better, anyone who has used one knows that communicating to a native Mandarin speaker requires more than drawing on a database of Chinese ideograms.  Similarly, humans are more than the sum of a set of physiologic parameters.  The best providers don’t treat numbers, they treat patients.  Besides, despite all the incredible hassles they complain about, patients seem to value seeing their doctor, which may explain why the annual physical remains a popular ritual despite the lack of evidence for its benefit on health outcomes.

What is missing from the patient-as-own-doctor model is the element of empathy, the communication, caring, and connection that characterizes the ideal of the provider-patient relationship.  The tricorder-like gizmos may eventually be able tell you what is wrong with you, but they can’t hold your hand, or give you words of encouragement or sympathy.

As technology advances, the medical profession has an opportunity to increase their value to patients.  We like to blame technology – especially the electronic health record – for interfering with the relationship between patients and providers.  But it can also be liberating.  As rote memorization and manual dexterity, keys to success in medicine in the era before handheld computer devices and robotic surgery, become less important, we can select for and spend more time developing communication and interpersonal skills.  Some innovative training programs have shown promising results.

Sir William Osler said “a physician who treats himself has a fool for a patient.”  Perhaps a patient who treats herself has a fool for a doctor.  But if we can’t figure out and demonstrate how providers can add value in a world of Scanadu™ and Siri, many patients will take their chances without us.

I signed up for the 2015 “Healthy Rewards” (the Children’s Hospital of Wisconsin workplace wellness program) within about five minutes of getting the email that it was available.  Aside from the fact that I’m a bit on the competitive side, I figure the only thing better than having good health care when you’re sick is staying well in the first place.  For employers, a healthy workforce should have all kinds of benefits,  including lowering their health care costs, which helps explain why Children’s, along with over half of all US businesses, offers a wellness program (with larger companies more likely to have them).  In fact, workplace wellness is a $6 billion a year industry.  Must be a smart investment, right?

That’s not entirely clear.  A recent NY Times article, citing several reports and systematic reviews, called into question the health and financial benefits of these programs.  At the risk of oversimplifying, here’s a summary of the salient points from those articles:

1)  Studies of the impact on employee health are generally poorly designed and have mixed results.  Better designed studies (i.e., randomized trials) are less likely to show benefits, but still half of these have demonstrated that wellness programs lead to improvements in some aspects of health including exercise, weight management, and smoking cessation.

2)  Programs that are focused on disease management (e.g., targeting employees with chronic conditions and incentivizing them to better management and preventive care) have a generally better impact than those focused on more general lifestyle management or screening.

3)  The overall benefit of these programs is probably muted by the fact that on average fewer than half of eligible employees participate, with some evidence that those most likely to benefit are the ones who are opting out.

4)  Overall wellness programs seem to save employers money, but part of that is from shifting costs to employees (e.g., higher premiums for those who do not meet screening criteria).  Most studies showed a positive return on investment, but the quality of these studies was low.

5)  Key facilitators of success include making wellness activities convenient and easily accessible for employees, and making wellness an organizational priority among senior leaders.

So yes, the jury is still out; it’s not a slam dunk that these programs are all they are cracked up to be.  But if half the randomized trials indicate a positive benefit, I’d say the glass isn’t half empty, it’s half full – of clean, non-bottled tap water, of which we ought to drink 64 ounces a day.  In the meantime, go ahead and sign up.

Picking a top 10 list is like deciding which of your children is your favorite.  So, at the risk of omitting some very important and meaningful people, events, programs, or accomplishments, here’s my list (in no particular order) of the top 10 happenings at Children’s Hospital of Wisconsin in 2014.

1. CHW was verified by the American Nursing Credentialing Council as a Magnet hospital for the third straight time, a distinction placing us in the top 1% of hospitals. This is a recognition of many aspects of quality, but especially the level of nursing care.
2. For the first time, CHW was ranked in all ten specialties evaluated by US News and World Report, including a number 5 ranking for our Herma Heart Center. Others include diabetes/endocrine, gastroenterology, neonatology, nephrology, neuroscience, oncology, orthopedics, pulmonology, and urology.
3. Our neonatal ICU was featured in a cover story in Time magazine.
4. A multidisciplinary team from the Fetal Concerns Center completed the first ever in utero repair of a myelomeningocele (aka spina bifida) in Wisconsin, making us one of the few centers in the country performing this sophisticated procedure.
5. There was a groundbreaking for the Sojourner Family Justice Center, a collaborative effort with numerous community partners and the state of Wisconsin. Hailed as a national model, this innovative center will bring together shelter, community, and legal services for women and their children who are victims of domestic violence and child abuse into a single location, improving access for those in need.
6. The first phase of our new NICU opened, providing private rooms and incorporating a variety of new technologies to improve quality of care and family-centeredness.
7. The latest step in our commitment to provide care closer to home was the opening of our Delafield clinic in December, with primary and specialty care services.
8. In July we overhauled our clinic fee structure, which greatly reduced costs to families for outpatient care.
9. A variety of steps to improve access for families. This includes an expansion of our access center which coordinates visits for patients traveling from outside the area for care; the initiation of the Wisconsin International Patient Program, with a focus on patients from the Middle East needing some of our highly specialized services not available elsewhere; the expansion of the Ronald McDonald House, an important partner that provides accommodations for families from out of town; and the reopening of  Watertown Plank Road (a blessing for everyone!).
10. Many of our staff relocated to space at the Summit building in West Allis, consolidating those staff into a single (and quite lovely) location.