Starting With Curious

So, the US lost to Germany, but still managed to advance out of the “Group of Death” in the World Cup by ending up above Portugal.  Lots of cheering and patriotic pride.  But right after the Facebook post of the photo of the American team and their fans celebrating were two other links that were rather sobering.

The first was the result of the latest Commonwealth Fund study showing that, once again, the US ranks dead last in health system performance among 11 advanced countries studied.  We’ve been in that position since the Fund first started doing these analyses in 2004.  Britain, Switzerland, and Sweden ranked first through third, respectively, on overall performance.  The highest score for the US was a 3 in “effective care.”  Interestingly, we ranked 5^th in “timeliness of care,” while Britain, with its much-maligned (at least in the American press) National Health System, ranked 2^nd in this measure of quality.  For access, efficiency, healthy lives (e.g., life expectancy), and equity – the US is right at the bottom.

Within our own country, the news for those of us here in Wisconsin was worse.  The Annie E. Casey Foundation released a report, “Race for Results: Building a Path to Opportunity for All Children,” on disparities in the US.  Based on an analysis of 12 different factors including educational attainment, socioeconomic status, and home life, Wisconsin was ranked the worst state in the nation for black children, and the state with the greatest disparities.  A few key data points:

• 77% of black children in Wisconsin (and 67% of Latino children) live in a household under 200% of the federal poverty level, compared with 29% of non-Latino whites
• Wisconsin scored lowest of all states (238) on its ability to prepare black children for educational and financial success; the average score was 345, while Hawaii had the highest score, 583. (WY, ID, VT, and MT, with very small African-American populations, did not have sufficient data for analysis.)  At the same time, Wisconsin was ranked 10th overall in its preparation for white children.

Knowing that socioeconomic and environmental factors are key determinants of overall health, these findings help explain some of the known racial disparities in health in our state.

Our vision for Children’s Hospital of Wisconsin is that the children of Wisconsin will be the healthiest in the nation.  Not only are we far from it, but even when we get there, is that enough?  Our health system doesn’t seem to be performing even as well as our soccer team.  According to the WHO ranking of all 191 nations, the US (at #37) is well behind Portugal (#12).  So much for making it out of the Group of Death.

When I was a resident, one of my least favorite things to hear from the parent of a patient was “Well, my mother thinks he has….”  The current equivalent is “I looked on the Internet and I found…”  Many of you know that fear of having to contradict grandma or Google, of the often lengthy and sometimes contentious discussions that would ensue.

Now along come new apps and devices that are only going to make this kind of conversation more common.  Examples include an iPhone attachment that turns the camera into an otoscope, and another that obtains an EKG.  In both cases, the image or tracing can be transmitted to a health care provider for interpretation, but naturally the patient and family have access to it as well.  Most electronic health records have some form of patient portal (such as Epic’s MyChart) that allows access to test results.

Health care, like many other sectors of the economy, is becoming democratized.  Patients are demanding a more active role in their care, a decades-long trend that is being facilitated and accelerated by advances in information and other technologies.  It is understandable that health professionals would, to varying degrees, lament or resist this change.  Our roles become, if not necessarily, harder, at least different.  I liken it to how the role of educators has shifted.  Teachers used to be the experts, valued for their ability to master a subject and convey information to passive recipients, usually via lecture and recitation.  In the early 20^th century, Woodrow Wilson introduced the concept of the preceptorial – education not as passive transmission of knowledge but facilitated discussion – which quickly became the dominant model at the university level.

Similarly, medicine is becoming less of a hierarchy and more of a partnership.  Providers need to be not only technically skilled, but able to serve as preceptors to patients who become active participants in their own health management.  We can bemoan or belittle the use of the Internet and other resources by patients and families seeking a greater role in their care, or the use of a smart phone to look in their child’s ears, but it’s not going away.  Our best bet is to guide them, so they can make good use of what can be at best confusing and at worst misleading information.  Last summer my son sent me this email:” I have a rash on my hands.  According to Google, I either have eczema or AIDS.  I hope it’s the former.”

At a national pediatric meeting a couple of years ago, one speaker contended that the area of “medical interpretation” – communicating medical concepts to the general public – would be one of tremendous growth in the next decade.  Undoubtedly there will be non-physicians who will do this, and do it well – I think, for example, of Rebecca Skloot, author of The Immortal Life of Henrietta Lacks – but it’s also part of our job as providers.  As an academic medical center, we embrace innovation and education; it should be just as true of our patients as our students and trainees.  As Sy Syms used to say, “An educated consumer is our best customer.”

James brought me a caterpillar the other day.  Never having met him before, I was impressed with this 10 year old’s gumption in bringing an insect on a milkweed leaf, unsolicited, to the office of the executive vice president of the hospital.  I was even more impressed when he started to talk.  James, who has spina bifida, has spent a lot of time at Children’s Hospital of Wisconsin.  But he’s pretty unimpressed with our clinics and operating rooms.  What gets him going is the park-like space across the street on the County Grounds.  Once the home of the Milwaukee County School of Agriculture and Domestic Economy, Asylum for the Insane, TB sanitorium, and poor house, among other things, the County Grounds is now largely occupied by the Milwaukee Regional Medical Center, UW-Milwaukee Innovation Campus, a golf course, and stormwater detention ponds.  But pockets of the grounds remain undeveloped, including the Monarch Butterfly Trail, where each year thousands of these beautiful and delicate creatures gather on their southward fall migration to Mexico.

James shared with me how he loves to visit the trail when he comes to the hospital.  It is a calming, healing place where he feels connected to the wider world.  It gives him energy.  As James’ mother said, “the County Grounds has become a refuge for our family.  Having a peaceful, natural place to escape to so easily has had a tremendous impact on the mental and physical well-being of everyone in our family.”  While the miracles of modern medicine have allowed James to walk, it is the miracle of nature that allows his spirit to soar.  James met with me to ask my support in developing a nature trail on the part of the county grounds nearest the hospital.  He described how kids like him would have a place to get away from the lights and sounds and smells of the hospital, and enjoy the trees, birds, and bugs, maybe even deer and coyotes!

There is a growing awareness of the power of nature to heal.  Children in particular seem to have a need for some “wildness” for their well-being.  Many hospitals have installed gardens: we have our own lovely Noel Family Healing Garden, for which many of our families are tremendously grateful.  Other hospitals have gone further, investing in more extensive adjacent nature trails. Mid Coast Hospital in Maine, for example, describes its 3300 feet of paths as a place of exercise and contemplation for patients and visitors (and staff).

James’ story rang true to me.  This week my dear niece, Finley Broaddus, succumbed to her brief and ultimately unsuccessful fight against liver cancer at age 18.  Always a passionate advocate for nature, she established Finley’s Green Leap Forward Fund, allowing family and friends to contribute to preserving and healing the planet in her memory.  A month ago, she left the hospital for the first time after six weeks.  When she went outside, she just sat in the grass and closed her eyes.  My mother-in-law described how she could almost see the Earth’s energy rise into Finley’s frail body, reanimating her and elevating her spirits.

I’m imagining a Wellness Trail, meandering through the woods and wetlands just a few hundred feet from the hospitals, and now easily reached by a pedestrian bridge.  A place where kids like James and Finley could wander, soaking up the healing energy of the natural world to complement the various therapies we provide.  And maybe seeing a hawk, or a deer, or a caterpillar.

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.