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.

At an American Academy of Pediatrics meeting recently, we had a debate over advertising of “junk food.”  While we agreed that promoting unhealthy foods to children should be discouraged, we couldn’t agree on how to define “junk.” Frosted Flakes might be junk, but what about Shredded Wheat, which may be less sweetened but still highly processed. I jokingly pointed out that my younger son would probably consider most of what I eat “junk” because I didn’t grow it myself.  That got me thinking about what we mean by “healthy” food.

In recognition of this week’s celebration of Earth Day, I’d encourage us to take a more expansive, ecological view of what we mean by health. The World Health Organization defines it as a “positive state of physical, mental, and social well being.”  I’d suggest that if we want to “eat healthy,” we need to think about not only choosing food that doesn’t harm us, but food that actually promotes wellness.  And not only our own personal wellness, but that of our communities and the environment.

One of our hospital’s values is, perhaps unsurprisingly, health. But if we want to aspire to be a true “health care organization,” one with a vision that the children of Wisconsin will be the healthiest in the nation, we need a similarly comprehensive perspective on health care. Care that not only cures illness, but promotes wellness – of individuals, of families, of communities, of the planet.

For those of you who work at Children’s, consider this:

• How often today did you smile at someone or greet them – patients, visitors, co-workers?
• Did you waste anything at work today?  Did you open something you didn’t use and throw it in the trash?
• Did you leave lights on in a room that wasn’t being used?
• How much of our supplies come from local sources?  How much of our food?
• Did you consider whether you really needed a paper copy (or 2, or 20) before hitting the print button?

Perhaps we can’t increase the percentage of locally sourced food or other supplies beyond the single digits.  And surely we will always have a few too many lights on for safety.  But everything we do to reduce waste, to support the community, to protect the environment, is a step closer to not just health care, but healthy care.

The only apparent sign of spring around here is the fact that baseball season has begun.  (And perhaps the Brewers’ 11-4 record is a sign of just what an unusual spring it has been.)  Now, I’m not a member of the “baseball as a metaphor for life” school of thought, but it does seem that baseball is in some ways a lot like medical care.  Both involve a large team of people with specialized jobs who spend most of their time in what I would term “anticipatory inaction” (i.e., standing around and waiting for something to happen).  And when they do go into action, the goal is to get someone to home.  (One could also add the unexplained ridiculous prices – a $9 Miller Lite is even less defensible than a $25 Tylenol.)

They also share the concept of being safe, but here they diverge.  In baseball, “safe” is a result – one branch of a dichotomous outcome, the opposite of “out.”  But in healthcare, “safe” is much more complex.  It does involve good outcomes: one measure of safety is the absence of harm caused by the care provided, such as wound infections or pressure ulcers.  However, while such outcomes are an important measure of safety, and are necessary, they are not sufficient.  No wound infections can result from safety or from luck.  Safety is as much about the structures and processes that create a safe environment.  A car without airbags or seatbelts is unsafe even if you drive it many miles without getting injured.

I was thinking about this recently as we at Children’s increase our commitment to providing the best and safest care.  We participate in something called Solutions for Patient Safety, a collaborative of almost 80 children’s hospitals around the country.  The hospitals share data and best practices to try to eliminate patient harm.  When I have seen the data, on most measures we perform better than most, so it would seem that we are a “safe” hospital.  But even if we have a rate of 0, that by itself does not mean we are safe.  I used to have this argument with my son: I’d catch him riding his bike without a helmet, and tell him that wasn’t safe; he would argue that he hadn’t gotten hurt.  To which I would respond, “Yet.”

So while I feel good about our record, we can’t get complacent.  That’s why we are embarking on an effort to increase education among all of the staff and providers on what it takes to be a high reliability organization – the kind of place where not only do harmful events not happen, but they can’t happen.  It means having systems in place that make it easy to do the right thing and hard to do the wrong one.  Redundancy, double checks, alerts, standardized approaches, checklists, etc.

It also means having an environment and culture of safety.  This is an environment where people continually seek to improve by asking questions, raising issues, and intervening when there is a problem.  There are many elements critical to a functioning culture of safety, one of which is what we call “just culture.”  This means treating errors, when they do occur, as a system flaw, not a character flaw.  If I order the wrong medication, or forget to give someone a tetanus shot, it doesn’t mean I’m a bad person.  In a just culture, people are more willing to acknowledge errors, and more willing to point them out.

Creating a just culture and an environment of safety are challenging in practice.  For one thing, it requires overcoming the rather natural tendency to blame on the one hand, and to be defensive on the other.  It’s one thing for an organization to say “we’re not blaming you,” but only after an extended period of acting that way will people feel confident in the attitude shift.  In hospitals in particular, there is a traditional hierarchy that must be overcome.  It doesn’t matter how many posters we put up asserting “You have our permission to speak up,” it is never going to be easy for a nurse six months out of school to tell the chief of surgery that he or she is about to use the wrong instrument.  And it’s even harder if that physician makes it difficult by their response.

In recent years, physician performance has been defined around six core competencies.  Among these are medical knowledge and patient care, which are somewhat easy to define and measure.  Another key one, professionalism, has been shown to be a key element in creating the kind of atmosphere that promotes safety.  Much has been written about disruptive behavior –up to 5% of providers are estimated to be regularly disruptive.  But professionalism, and unprofessional behavior,  is much harder to measure.  It can range from an attitude of dismissiveness to frank verbal or physical abuse.  To paraphrase Justice Potter Stewart, it may be that you know it when you see it.  But the more objectively we can define it, the easier it is to identify when there are problems, to create actionable solutions, and monitor progress.  It allows for fair processes to hold people accountable and ultimately improve, which is the goal.  As difficult as it is to live out a “just culture” when it comes to things like medication errors, it’s that much harder when the “error” is a behavior.  It’s one reason we have moved away from the older language of “problem physicians” to “disruptive behavior.”

Not long ago, I was approached by my medical director and patient care manager with a concern about how I might be making the emergency department unsafe.  They told me that a nurse had indicated, in a survey, that “Dr. Gorelick is difficult to work with.  He is hard to approach with questions and dismissive of the nurses.”  I was absolutely floored.  I don’t consider myself to be a difficult person, and I pride myself on my respect for nurses and indeed all the members of the care team.  (My mother is a nurse, after al!)  But while I heard “Dr. Gorelick is a difficult person who disrespects nurses,” what was actually said was quite different.  It was about my actions, and a specific set of actions at that.  It caused me to reflect, and I realized it was true.  As I’ve written about before, I find it increasingly difficult for whatever reason (I’m sure it’s not aging…)  to get back on task when I’m interrupted.  So if I’m entering an order or writing a note and someone stops me to ask me a question, I do sometimes get snappy.  I worry that it will at least set me back in the task I was doing, and may even increase the risk of an ordering error.  In the parlance of our Mood Elevator, I go to the lower floors of judgmental and irritated.  But by being hard to approach, I was creating my own safety hazard.  The next time a child needed immediate attention, nurses might hesitate to seek me out, putting that child at risk.

As Warren Buffett said, “It takes 20 years to build a reputation, and five minutes to ruin one.”  My reputation was also at risk, and I needed to fix it.  The first step was acknowledging the problem, and owning it.  The problem was not the nurses’ inability to prioritize, it was my reaction to being interrupted.  Rather than being irritable, I needed to be curious – why does this person want my attention now?  If it turns out to be something that could wait, let’s have a respectful discussion about the risks of unnecessary interruptions, which could lead to a constructive solution (e.g., some way to let me know I’m needed soon but not immediately).

This sounds easier than it is.  I’m sure I still seem less than approachable at times in the emergency department.  As much as I’ve tried to objectify this and focus on my behaviors, it still feels like a questioning of my character.  And no doubt people’s perceptions are colored by my prior actions: even a slight hesitation in responding could be perceived as being “difficult” again.  But if I want to restore my reputation – and more importantly, contribute to the kind of environment that allows us to provide the best and safest care – I have to be accountable for my role.  Professional behavior is like an RBI, allowing our patient to get home safe.  Sometimes we have to attend batting practice.

With millions of people newly insured thanks to the Affordable Care Act, a lot of people will be seeking medical care for the first time in a while.  While many of these will be people with problems needing specialty care due to problems that have gone untreated, many others will be in search of primary and preventive care (most of which is not subject to cost sharing).  For several years there has been talk of a shortage of primary care physicians – seems that will only become more acute.

There has also been a lot of talk about increasing the supply of physicians selecting primary care specialties.  The pendulum swings back and forth.  But, as nicely summarized by Pauline Chen,  there has been no major, sustained trend toward more physicians going in to primary care, despite a variety of initiatives such as medical school expansions, dedicated primary care training tracks, loan repayment programs.  With many subspecialists enjoying shorter hours and much higher salaries – the recent release of data on Medicare payments to physicians was particularly eye-opening – simply creating more of the same doctors and asking them to pretty please go into primary care is simply not going to work.  We need to, as Steve Jobs said, “Think Different.”

1.  Expand the role of non-physician providers.  New York recently became the latest state to expand the ability of nurse practitioners to provide care independently by removing the requirement for a written practice agreement with a physician.  Nurse practitioners are already beginning to fill important holes in primary care in a number of underserved communities – including two inner-city clinics resulting from a partnership between Children’s Hospital of Wisconsin and Marquette University School of Nursing.  This model is very likely to be an important part of meeting the national primary care gap.  We need to commit to increasing the number of NPs, and to removing the unnecessary barriers to their ability to practice to the full extent of their training.

2.  Make primary care providers more productive.  Fields like education and medicine, being relatively reliant on the human element, typically have much smaller increases in productivity than industries like manufacturing that are amenable to automation.  That appears to be changing, with numerous actual or promised innovations such as remote sensors and other forms of telemedicine, better care management, and newer therapies that require, frankly, less skill.  By simply embracing innovations that promote efficiency – not to mention a shift in focus from medical care to maintaining wellness –  we should be able to get by with relatively fewer providers.

3.  Rethink how we train physicians.  The current model of medical education – four years of college, then four years of medical school with two full years of basic sciences, followed by a minimum of three years of residency – is neither long-standing nor the international norm.  In most European countries, university and medical training are combined over a period of six years, and tuition is often free or far lower than in the US.  In the 1970s and 80s, a number of medical schools in the US experimented with alternative pathways, including 6 year combined undergraduate and medical degrees, or 3 year medical school.

The 3 year alternative is attracting new attention.  One important motivator is to allow students to graduate with lower debt, thus decreasing the barrier to entry into lower-paying primary care fields.  At the Medical College of Wisconsin, a Community Based Medical Education Program is being implemented, with satellite campuses in rural parts of the state and a 3-year curriculum.  The idea is that by attracting students with an interest in primary care in a rural setting, allowing them to decrease their tuition burden by 20-25%, and providing residency training programs in those communities, it is much more likely that they will choose to practice primary care in those areas.

I certainly hope this works.  But I think we need to use the opportunity to re-examine what is required for medical education.  In designing the community-based program, there has been a lot of thought to how to provide the basic science education (e.g., remote learning, offering some classes on local campuses, etc.).   I think the real question is how much basic science do you need, especially for a clinical (as opposed to research) career.  The opportunity to do less microanatomy and biochemistry, with earlier clinical exposure, may be even more appealing to those with an interest in primary care.

This borders on heresy in the world of medical education.  Without thousands of hours of basic science instruction, doctors will simply be “technicians,” no different than nurse practitioners!  Hmmm…..

The March 31 deadline for open enrollment in plans offered on the healthcare exchanges has now passed.  The original goal was 7 million enrollees.  And the actual number was … 7.1 million.  Whew!

Some of these are folks that had previously had insurance, and were simply exchanging one plan for another.  But a recent study from the Urban Institute Health Policy Center shows that the number of uninsured adults in the US decreased by at least 5.4 million since enrollment began in October 2013.  This represents a drop of 2.7 percentage points, or a relative decrease of 15%.

I say at least because the data come with 2 caveats.  First, it does not reflect enrollments in the last couple of weeks of March, when activity surged.  Second, it does not show the effect of other provisions that have been shown to increase coverage, especially the provision allowing young adults to remain on their parents’ insurance until age 26 (that number is estimated to be about 3.1 million).

This is a huge improvement in America’s shameful status among developed countries in providing healthcare coverage for its citizens.  The impact could have been even greater.  The drop in uninsured was less than half as big in the 24 states that opted not to expand Medicaid compared with those that did, leaving millions more uninsured.

BUT – I’m not giving 3 cheers yet.  The stated goals of the Affordable Care Act were to expand coverage (good start but more work to do), and to decrease costs (still more work to do).  In a previous blog I talked about how the ACA has likely already had a positive impact on healthcare spending.  However, now that there are millions more Americans with coverage, demand may start to increase, potentially reversing some of those gains.

Nevertheless, while the jury is still out, I think 8.5 million Americans with insurance coverage they didn’t used to have is something to celebrate.  I’m sure those people are celebrating.

In healthcare, experience matters.  And I don’t mean years of training or tenure – I mean patient experience.  For years we’ve resisted calling healthcare a “service industry,” and felt that “quality” was all that mattered.  If by quality we mean clinical effectiveness and outcomes, I’d argue it’s important but not enough.  Which is why the Institute of Medicine defines quality as having other domains beside effectiveness: safety, timeliness, efficiency, equity, and patient-centeredness.  This last dimension of quality includes incorporating  patients and families into the decision-making process and considering their preferences.  And patients are pretty clear that one of their preferences is to be treated with courtesy and respect.

There are now numerous sites where people can post ratings and comments about physicians, such as RateMDs.com.   The vast majority of comments are not about technical skill or knowledge, they are about listening, wait times, courtesy, bedside manner.  These things matter, especially as individuals are paying more of the very high cost of health care out of their own pockets, and demanding value for what they spend.  Not only consumers, but professional organizations such as the Robert Wood Johnson Foundation are leading efforts to make the health care experience more patient-friendly.

At Children’s Hospital of Wisconsin, we have long measured patient satisfaction and experience, but haven’t always been as focused on it as we should be.  This is changing, and with people at all levels of the organization starting to pay attention to experience, satisfaction is improving.  In some of our areas, like imaging, the emergency department, and the Surgicenter, our scores are now well above the national average for pediatric hospitals.  But we have a ways to go.  Eventually, we need to rethink many of our assumptions about how healthcare is different from other industries.  People used to think that cars, computers, and airline travel were different, too – too complex for the average person to evaluate on their own.  Yes, computers are complex; it takes as much education and training to build and program computers as it does to become a doctor.  But somehow even someone like me who has never taken a computer science class in his life can buy and use one without any specialized help.  Of course, when things don’t go right I seek expert assistance, but even there, I shop for that service the same way I do for everything else, judging them not on whether they can fix the problem (I expect that), but on how long it takes, whether they are nice or rude, how well they explain things, and how much it costs.

If you think experience doesn’t matter, watch this video comparing health care to the airline industry.  It’s funny and shameful at the same time.