Starting With Curious

As I often do, I had a wonderful run early this morning on the Hank Aaron State Trail!  Extending 12 miles from Lakeshore State Park, just south of Discovery World, to 124^th St (the portion west of 94^th is unfortunately closed during the Zoo Interchange construction), the HAST provides a vital east-west link in the 117-mile Milwaukee County Oak Leaf Trail system.  While there are many wonderful trails in the Milwaukee area (as described by the Journal Sentinel’s talented outdoor writer Chelsey Lewis), the Hank Aaron is one of my favorites.  Love the combination of seeing the Menominee River, the historic Soldier’s Home, Miller Park, and the now re-industrialized Menominee Valley.  One of the joys of being out on the trail is seeing the vibrant mix of bicycle commuters from Tosa and the east side of Milwaukee (including at least a few Children’s Hospital providers and staff!), along with the predominantly Latino and Hmong families from the near south side neighborhoods through which the trail passes out recreating on the trail, all living out our value of health.

To support that value of health, Children’s Hospital of Wisconsin is a sponsor this year of the annual Friends of Hank Aaron State Trail 5k run, on Saturday, August 6^th.  Proceeds from the run support not only trail maintenance and enhancements, but also programming such as the free Bike Adventure Camps for disadvantaged children from the adjacent communities.  It’s a great way for Children’s to partner with other community organizations to provide opportunities for kids in the area to become the healthiest in the nation.

As part of our sponsorship, we have a limited number of complimentary entries for the run.  If you are interested in joining, please contact Robin Pitts.

Several years ago, we had an exchange student from Norway who needed to see a specialist periodically to have a cyst drained.  The day before a big school dance, she told me she needed to go get it taken care of before the dance.  As in, that afternoon!  I explained to her that in the US you can’t simply see a subspecialist to get a non-emergency procedure done at a moment’s notice.  We have these things called appointments.  And you have to make them.  In advance.

Was this just a cultural difference in expectations based on better medical care access in Scandinavia?  (It turns out you can’t just waltz into the ENT office same day in Norway, either.)  Or was it typical Millennial insistence on instant gratification?  Either way, she asked if maybe she could find someone else to do it.  I then explained that her doctor was one of the best, and no, we weren’t going to find just anyone, who might not do as good a job – quality is worth waiting for.

A lot of us in health care tend to rationalize this way.  Quality is most important; convenience is just a frill.  We feel pretty good if our time to next appointment is “only” a week or two.  Yet I routinely get requests from people inside the system who have to wait that long for a family member to see if there is anything that can be done to get them in sooner.  I heard a colleague at another hospital talk about how nearly every day she helps friends and “important donors” get quicker access.  Not only does this create a two-tiered system of easy access for those with connections while regular folks have to wait, it belies the assertion that convenience isn’t important.  Timeliness is one of the six domains of quality espoused by the Institute of Medicine. And while we tend to associate such impatience with the Millennial generation, it appears to be pretty important to the Boomers whom my colleague keeps listed on her phone.

Data from a Healthgrades survey in 2014 suggest that in choosing a physician or hospital, convenient location and hours were cited as factors far more often (56-62%) than outcomes (22-30%).  While this may be accelerating, this has been true for some time: a 2000 study from University of Nebraska of factors used in choosing a primary care physician found that wait time for an appointment was as important as whether she/he had any malpractice history, and more important than factors such as the doctor’s training or years of experience.

To the extent that the prioritization of convenience is a bigger issue for the Millennial generation, then those of us in pediatric health care need to be especially ready to address this, as the Millennials are the parents of our patients.  And they aren’t willing to wait for what they want.

The first time I saw a TV ad for a prescription medication (direct-to-consumer advertising was made legal in 1985), I was appalled.  Not only because of the long list of potential side effects – which as I recall included both flatulence and death) – but the whole concept that companies would try to market something as complex as a drug the same way they would treat floor wax or breakfast cereal.   Health care is not a consumer good!

Well, it’s become clear that health care is, in fact, a consumer good, and those of us who provide health care need to accept that and understand how consumers make decisions about it.  Even when we grudgingly admit that people may be doing some “shopping” for their medical care, we tend to think that health care is still very different.  In some ways that is certainly true.  For example, measuring and reporting on quality is far more challenging in health care.  And there is considerably less ability for consumers to get information on medical cost than for almost any other product or service.  But as a 2015 McKinsey study showed, the factors used by consumers to rate health care and non-health care companies are nearly identical: the top 4 were (in order) customer service, “delivering on expectations,” convenience, and “offering great value.”

It may be that these other factors are merely proxies for actual quality measures.  As noted in a Deloitte report:

Quality tends to be defined with professionals in mind. In lieu of understanding clinical quality, consumers may substitute cost, convenience, and customer experience for quality. Consumers may well equate quality with cost, assuming a direct relationship between the two.

Certainly, health providers like to think that when it comes to picking a doctor or hospital, quality is most important and trumps everything else.  But maybe not so much.  Another McKinsey study found that although patients stated that clinical outcome was most important to them, experience was actually more highly correlated with willingness to choose that provider again.  And cost is increasingly a factor.  In a 2015 survey by FAIR Health, 48% of all respondents indicated they always or usually considered cost when selecting a doctor.  And despite a widespread belief that cost is no barrier when it comes to health care for children, it actually appears to be more important for the generation with kids.  In this survey, cost was more often cited as a key factor for those age 18-44 (58%), those with children (56%), and women (53%).

We can wish away consumerism (and TV ads).  Or we can deal with it.  That doesn’t mean sacrificing quality.  We need to maintain our commitment to the best and safest care.  At the same time, we also need to address families’ real concerns about cost, convenience, and experience.  It starts with one element of our service promise: “I will strive to understand what matters most to you.”  If we don’t know what consumers value, we can’t provide it, or help them navigate the choices they must make.

Our chief nursing officer used this phrase to summarize the profession of nursing at an event for Nurses’ Week, a time to celebrate that profession and the individual nurses who practice it.  In honor of the occasion this year, I have invited a guest blogger – our patients’ families!  Here is just a very small sample of the comments about our nurses from our patient and family experience surveys (names removed for privacy).

• After rushing to the ER and getting admitted right away, we had an amazing nurse who I will never forget, his name is XXX! He cared for my son so kindly, kept me calm and tried to keep my son comfortable while providing care – although he is too young to understand Nurses and Doctors are the good people trying to help… We talked about my son’s favorite things, his family and his kids. After leaving the room XXX later came back with a Mickey Mouse toy (his favorite character lately) for my son. He told me he holds onto toys until he feels that a child needs it after a rough night in the ER. In that moment I was thankful for the pick me up and an exceptional nurse. Thank you for calming me and providing compassionate care for my son in that moment, you’re an amazing Nurse!

• This was our best hospital stay yet. Everyone worked as a team & we felt included.  We felt like everyone listened to us.  The nurses treated our daughter like a child, including her and allowing her to make choices & be heard.  We really appreciated the care!

• The ER staff were ALL absolutely amazing! Nurse XXX on W-10 was the BEST!  She worked all night and stayed another 4 hours and took awesome care of our son.  She spent time talking to him about things he loves.  She spent 15-20 min talking and sharing with him.  Priceless!!

• As we left the hospital, my son said I feel like we are leaving good friends behind. That is how connected he became to the wonderful nurses who took care of him.  Children’s Hospital became a haven for us in the midst of his scary medical condition.  I cannot thank the staff enough!

• There was a nurse in training. I wish I could remember her name, who came in on our last day, she sat & rocked and sang to my baby for several hours so I could rest.  She was very kind & I wish she knew how thankful I was for her time & gentleness with my son.

• Every person who entered our son’s room was an angel of healing. They made a very scary situation manageable + helped us to find peace + healing.  They recognized that our whole family was part of our healing team, and we went home with a healthy child.  For that we will be extremely grateful.

• No parent wants to see their child go through surgery, but w/ the awesome staff we had & of course all our prayers we were truly relaxed & extremely grateful! The nurses were beyond WONDERFUL!  There were two nurses who stuck out to me during my daughter’s stay – ones name was XXX & I wish I remembered the young RN who never stopped smiling or asking how we were doing or if we needed anything!

• I just have to say that the nurses were amazing and caring and put you at ease during a very scary time. We were never left hanging and they always kept us informed, amazing care!!

• Two nurses on 10 West deserve to be acknowledged & credited for their excellent care. They should get employee or nurse of the month awards.  They are so compassionate about their jobs & the care they give.  Absolutely best experience of our lives.  Thank you Children’s Hospital!

• Very impressed with the level of care provided and quite impressed, truly, with the obvious strong line of communication amongst all caregivers. I’ve never seen this level of effective and efficient communication at any care facility, ever!  Hats off to your entire staff.

• My son’s nurse XXX was amazing. I always looked forward to the evening shift when she showed up.  Evenings were hard as the rest of my family had to leave.  She made my evenings a lot better.

Hmm, communication, calming, caring, compassion.  That pretty much sums up Children’s nurses!  They are the best – because kids deserve the best.

It’s usually a throwaway question, the answer being “Not much?  How about with you?”  But after spending the last few days at the annual Pediatric Academic Societies meeting, I’d answer “A ton!”.  Besides renewing a bit of a connection with my clinical and academic roots, I heard a lot that reinforced our value of innovation, including over 100 presentations by Children’s Hospital of Wisconsin and Medical College of Wisconsin faculty, trainees, and staff.  Over the 25 years I have been involved with this meeting, it has continued to evolve for the better.  A great deal of what is presented now falls under the rubric of quality improvement, demonstrating that we can always find ways to provide care that leads to better outcomes, lower cost, and better experience, and that we are always getting better at getting better.  I left with a long list of new ideas we can consider at Children’s.  And some of my colleagues learned from what we are doing and shared at the meeting.

I also realized that good ideas don’t matter if they aren’t put into action, and that takes advocacy.  Being with thousands of pediatric providers is a sure fire way to renew one’s sense of purpose.  A particularly inspirational moment was a talk by Dr. Mona Hanna-Attisha, the pediatrician who helped uncover the tragedy of lead in the water in Flint, Michigan.  Spurred by the needs of her patients and families, she did the research to demonstrate the reality that Flint’s children were being poisoned, and that it was due to lead in the water.  Then she advocated for action to fix it.  Neither was easy.  Fighting attacks from the authorities who were conspiring to hide the facts, Dr. Hanna-Attisha relentlessly pursued two things – truth, and justice.  All in the interest of improving the health of children.

One thing I took from it is that we are all advocates for children.  Advocacy is simply a call for action.  Those actions can range from public policies to address the social determinants of health, to better integration of children into school after a heart transplant, to a reduction in unnecessary X-rays in infants with bronchiolitis, to greater family and nursing involvement in patient rounds – all ideas presented by the CHW team, by the way.  Making a difference means turning those innovations into practice and policy, at all levels.  Advocacy is where the rubber of innovation hits the road to having the healthiest kids.

“Those who can, do; those who can’t, teach.”  That quote always ticks off teachers (and rightfully so.)  But the slur was actually aimed at bureaucrats: the complete quote ends with “and those who can do neither administer.”  As someone who has been both a teacher and an administrator, I naturally take exception to the sentiment.  Like most things, administration is inherently neither good or bad; it can be done well or poorly.  Increasingly I’ve come to understand the skills necessary for management.  And I appreciate those who master those skills.

Fortunately, there is a cadre of folks who dedicate themselves to mastering administration –  the administrative professionals.  In most organizations, they are the people who know how to get things done.  Without fanfare, and with little recognition, they ensure smooth operations, everything from juggling complex calendars to ensuring timely and effective communication, keeping everyone on track and on time (and in many cases fed).

The word “administer” appeared in English in the 14^th century.  It derives from the Latin “ministrare,” the same root as “minister,” meaning to serve.  And administration is about service.  For us, it is service not only to those who work at Children’s, but ultimately to those patients and families who benefit from a well-run hospital and health system.

So thank you to all those administrative professionals at Children’s.  I appreciate the myriad ways you make my job easier, and help our organization get closer to our vision that Wisconsin’s kids will be the healthiest in the country.  You can take pride in your role in that.  You not only can, you serve.

So said my niece Alice as we were planting a tree in memory of her cousin, Finley. Now I’m not one to argue with a 4 year-old with a romantic streak, but I’d put it differently, if more prosaically: where there is dirt there is life. No dirt, no plants, no food – no us. But dirt gets little respect.  Until our language loosened up in the 1960s, “dirty” was the 4-letter modifier of choice: dirty liar, dirty rat, dirty dog, dirty deed.  Today the word seems quite mild, even quaint, but there is still a huge phobia of dirt.

Dirt – the kind you dig in – is nothing more than decayed organic matter.  Leaves fall in autumn, and by the next year they have been miraculously transformed into a rich soil in which the tree’s seeds can germinate and grow.  All kinds of organic material can decompose into soil, including food scraps and paper.  By composting, organic waste becomes dirt; what is useless becomes useful.  As the saying goes, one person’s trash is another’s treasure.

Which is why I am excited that Children’s Hospital of Wisconsin just became the first hospital in the Milwaukee area to begin composting its food waste.  Starting in our Seven Sisters café, we will collect unused and uneaten food, paper goods, and compostable food containers.  Our partner is Compost Crusader, a local company that picks up compostable waste and turns it into fertile soil.  It’s a perfect example of the triple bottom line: less waste, better health, lower cost.  Here’s why:

• When organic matter goes to the landfill, it decomposes anaerobically, generating methane, which is a greenhouse gas 20 times more potent than carbon dioxide. Composting avoids this major contributor to climate change
• When compost is applied to gardens and farms it reduces or eliminates the need for chemical fertilizers, which are expensive and environmentally hazardous
• In part because the compost product can be sold, having food waste removed separately for composting is less expensive than including it in our usual waste stream. At CHW estimate we will save several thousand dollars annually.

Americans generate an estimated 133 billion pounds of food waste easy year.  (No, that’s not a typo.) This is almost 1/3 of all the food produced. Composting can have an enormous positive impact not only on our environment, but ultimately on our health.  So far with our trial we are on track to compost over 10 tons of food waste per year.

Undoubtedly some people will be a bit squeamish about something as dirty-sounding as composting.  But think about it: how much worse is your uneaten pizza crust or unpopped corn kernels in a separate bin than mixed in with everything else?  I’ve been composting at home for decades and if anything, it’s tidier than having unsorted trash.

So when you see the new compost bins and signs, go ahead and pitch in!  We’re starting in one area to get out the kinks, with hopes to eventually expand to all of our food service areas.  It’s better for the earth, better for Children’s, and ultimately better for children.  As Alice would say, go ahead and create some love.

Despite its resemblance to a reality TV show, one positive effect of this year’s presidential campaign is that the issue of inequality in our society has been brought to the forefront.  In addition to economic polarization, there are persisting disparities in both health outcomes and the important determinants of health, especially for children and especially in urban areas like Milwaukee.  The vision of the children in Wisconsin being the healthiest in the nation can seem unattainable in the face of such gaps.  So I was especially heartened by a series of articles in the journal Pediatrics from the first few months of 2016, each providing a glimmer of hope that we may be inching closer to the goal of health equity for all children:

• The prevalence of asthma in the US, which doubled from 1980 to 1995 and continued to increase, with widening racial disparities, has flattened, and the racial difference stopped growing. Moreover, this is being driven primarily by a plateau in the rate of asthma among black children.
• A study of cigarette taxes over time across the US shows that higher cigarette taxes and prices are associated with a decline in infant mortality rates. This benefit was strongest among African-American infants. (Of note, Wisconsin has one of the highest cigarette taxes in the nation, 11^th highest at $2.52 per pack.  New York is the highest at $4.25, while the lowest is Missouri at $0.17.)
• Human papilloma virus (HPV), which causes genital warts and also accounts for the majority of cases of cervical cancer, is now preventable by a vaccine. Although there has been considerable controversy about the vaccine, there has been a 64% decrease in HPV prevalence in 14-19 year old girls following its introduction.  Since HPV disproportionately affects men and women of color, this benefit will be especially great for minorities.  (The HeLa cell line, now widely used in medical research, was obtained unknowingly from a black woman who was treated for and succumbed to cervical cancer at Johns Hopkins in the 1950s.   The Immortal Life of Henrietta Lacks recounts her story and is a fascinating read.)
• The lasting consequences of adverse childhood events – ranging from poverty to violence to family instability – are increasingly recognized, but little is known about how to mitigate the effects. An intervention among poor minority middle school youth in Baltimore schools demonstrated that mindfulness-based stress reduction techniques led to significant improvements in psychological and behavioral outcomes: less depression, somatization, negative coping, and post-traumatic stress symptoms.

There’s still a lot of work to do to erase the pervasive disparities in our community, but it’s great to get some encouraging news from time to time.

The Milwaukee harbor looked especially beautiful from the air as I flew above it today, bright blue and sparkling on this uncharacteristically warm and sunny February day.  Unfortunately, my enjoyment of it was marred by the knowledge that the harbor contained a particularly unsavory collection of bacteria – the kind of antibiotic-resistant “superbugs” increasingly causing hard-to-treat infections.  A recent study revealed that bacteria in water samples from that harbor had extremely high rates of resistance to multiple antibiotics.  In fact, bacteria in the harbor were far more likely to be multiply drug resistant than bacteria obtained from sewage samples or from hospitalized patients!  It turns out that antibiotics that get into the water – from being excreted in the urine of patients taking them, from unused medications being flushed down the drain, from agricultural runoff from farms that use antibiotics in animal feed – concentrate in the lake sediment.  This persistence of low levels of antibiotics provides the sort of selective pressure that, through natural selection, leads to the emergence of resistant organisms.

This is a striking example of the way our health care system, designed to heal disease and promote health, can have unintended negative consequences.  Overuse of antibiotics and other antimicrobial compounds (the kinds found in “germ killing” soaps, lotions, fabrics, etc.), and their improper disposal, is paradoxically creating a reservoir of bacteria that will be increasingly hard to destroy.  It’s like an antimicrobial arms race.  And the bacteria are winning.

Our value of health calls on us not only to take care of ourselves, but to think about the impact of what we do on the health of the environment.  After all, environmental factors have a bigger impact on our health than medical care does.   The antibiotic stewardship program at Children’s Hospital of Wisconsin promotes more appropriate antibiotic prescribing.  As individuals, we can also only take (or prescribe) antibiotics when truly necessary.  As tempting as it may be to flush that expired bottle of cefdinir down the toilet, take it to a medication collection station instead.  Consider purchasing antibiotic-free meat and dairy products.  The next time you drive by and admire the beauty of Lake Michigan, consider whether you are inadvertently helping create monsters lurking on the bottom.