Starting With Curious

“Defensive medicine” has long been a favorite rationale for our health care costs.  Indeed, in a recent survey of physicians in JAMA, trial lawyers were assigned the greatest responsibility for reducing health care costs:  60% of respondents thought they had a major role, followed by insurers (59%), pharma and device manufacturers (56%), hospitals (56%), and patients (52%).  In contrast, only 36% of physicians thought physicians had a major role in cost control.

I’ve never been a huge fan of the defensive medicine hypothesis.  First, several studies have suggested that only a very small percentage (around 3%) of total health care spending can be attributed to malpractice.  Second, poor outcomes and allegations of malpractice can arise from errors of commission as well as of omission.  A fatal allergic reaction to an antibiotic prescribed unnecessarily for a viral illness could as easily open a provider up to a liability claim as not doing an unnecessary CT scan for a child with trivial head injury, so I would imagine someone fearful of a lawsuit would hesitate to do both.  Most important, in my own experience (admittedly skewed by working in academic centers), overuse appears to be driven far more strongly by factors such as the desire for more complete information before making decisions (more on that in a subsequent blog), and by financial incentives.

A recent study, though, provides what appears to be compelling evidence of the effect of fear of malpractice on use of diagnostic tests.  An article in the August issue of Health Affairs linked physicians’ responses regarding their levels of malpractice concern as reported in the 2008 Health Tracking Physician Survey to Medicare Parts A and B claims for the patients they treated during the study period, 2007–09, focusing on use of various diagnostic tests for complaints of chest pain, headache, or lower back pain.  The investigators found higher rates of imaging by physicians who had reported high vs. low concern about malpractice on the survey, although the magnitudes were modest.  This would suggest that defensive medicine may be a significant contributor to overall healthcare costs.  However, the study undercuts the assertion that moves to limit malpractice claims would help – there was no association between diagnostic testing and various measures of actual state malpractice risk, only with the physician’s reported subjective level of concern.

Which raises several questions.  Where does the fear arise from, if not from the actual climate of the state within which the physicians practice?  Is it truly a fear of liability, or is that just an expression of an underlying tendency to place a premium on diagnostic certainty?  Providers tend to fall into one of two camps – “test minimizers” and “risk minimizers” – based on their tolerance for uncertainty.  In either case, if individual provider attitudes override public policy, how can we address this factor in the effort to control costs?  At the very least, it suggests that the doctors have at least as much responsibility as the trial lawyers.

This song about burnout on the job was quite popular in 1977 (original version by Johnny Paycheck; subsequently also recorded by Dead Kennedys).  While many of you are not old enough to have been assaulted by the recording on AM radio, the sentiment probably isn’t at all foreign.  The phenomenon of burnout among medical professionals has been the subject of both serious research and discussion in the lay press.  A 2012 study in JAMA Internal Medicine revealed high levels of self-reported burnout among physicians, especially in “front-line” specialties such as family practice and emergency medicine, where over half of physicians reported some form of burnout.  (Fortunately, both primary care pediatrics and pediatric sub-specialties had below average rates.)  Also, physicians had higher rates of burnout than the general population.  (There are studies showing similar statistics for nurses, but I haven’t been able to find any studies specifically dealing with burnout among advanced practice providers.  I think we can assume it’s fairly similar.)

Burnout is defined as “a syndrome characterized by a loss of enthusiasm for work (emotional exhaustion), feelings of cynicism (depersonalization), and a low sense of personal accomplishment.”  Effects of burnout include symptoms of depression and/or anxiety, loss of empathy and objectivization of patients and co-workers, unprofessional behavior, and high rates of error.  It can also lead people to leave the profession.  Thus, burnout is a problem for the physicians, for their patients, and ultimately for the system.

While a good bit has been written about the prevalence of burnout, there seems to be little data on what can be done to prevent it.  It doesn’t appear to correlate with hours worked, income, or satisfaction with work-life balance, but data are limited.

In the meantime, try this two-item screening tool for identifying burnout:

How often do you agree with the statement “I feel burned out from my work”?

Never

Less than once a month

A few times a month

Once a week

A few times a week

Every day

How often do you agree with the statement, “I have become more callous toward people since I took this job”?

Never

Less than once a month

A few times a month

Once a week

A few times a week

Every day

If, after that, you need a little pick-me-up, watch this – a good reminder of our value of health.

The teen had been referred to the ED for evaluation of a mediastinal mass found on a chest X-ray; he and his mother both knew his primary physician was worried about cancer.  We performed a CT and a slew of lab tests.  The lab tests were pretty non-specific and not overly concerning.  As we reviewed the test results with them, the patient said, “Yeah, but I’m gonna die, aren’t I?”  At that particular moment, when we didn’t even have a diagnosis, much less a prognosis, I was more focused on whether he had laboratory signs of blood stream or organ involvement.  He couldn’t have cared less about a white count or liver enzymes – he wanted to know if he was going to live.

Providers often find themselves focusing on things that are at best of indirect interest to our patients.  Nobody cares what their hemoglobin A1c or HDL level is (except for a few hypercompetitive types who brag about their biometrics after their screening), except to the extent that they are indicators of what truly matters – mortality or morbidity.  People don’t want a healthy blood pressure, they want a healthy life.

Why have we not paid more attention to these patient-centered outcomes?  One thing is, we like to measure what we can affect.  I may be able to improve someone’s pulmonary function with an inhaled steroid; the link between the prescription and their overall quality of life is more tenuous.   It’s also more difficult to measure something as abstract and multifactorial as “quality of life.”  At the very least, tools for determining patient-centered outcomes can be more time consuming to use, and if not properly developed may be less valid and reliable than “hard” measures such as lab results.  There is a developing science around measurement of patient-oriented outcomes.  The Patient Centered Outcomes Research Institute (PCORI), created under the Affordable Care Act, serves as a promoter and funder of efforts to advance such measurements.  But, while there are a growing number of tools for measuring both disease-specific and generic quality of life across the age spectrum, such tools are not incorporated into routine clinical care.

There has been much discussion of “meaningful use” of the EHR.  But if you look at many of the measures, one can ask, meaningful to whom?  Documenting BMI, keeping INR in a certain range for patients on warfarin, prescribing steroids for patients with asthma – I doubt very much that our patients care about these in and of themselves.  If we want the EHR to be truly meaningful, we should think about incorporating patient-centered outcomes into the record.  This would promote discussion of these outcomes with patients and families, and allow us to determine how effective our care is in improving them.

It’s pretty clear that by looking only at conventional measures of effectiveness, we are missing a big part of the picture, the part that matters most to the people we are trying to help.  A conventional measure of success of ED treatment of acute asthma is discharge to home (with a prescription for systemic steroids), and no unscheduled return visits within a set period (usually a week).  By that measure, the ED where I used to work did a good job.  But when we looked at patients “successfully” discharged to home, we found that nearly half had either prolonged symptoms, substantial missed school or day care, or significant activity limitation.  While we were congratulating ourselves for keeping these children out of the hospital, they were sitting at home coughing and wheezing and being miserable.

If we are going to act in the service of children and families, we need to understand and measure what is important to them – to have a mutual understanding of what constitutes “success.”

I recently recounted for someone the story of how, during the oral exam for my surgery rotation in medical school, one of the senior attending physicians made me cry.  Literally.  He belittled and humiliated me, and what was worse, he seemed to be enjoying himself.  Now, I don’t think there are very many true sadists in the healthcare profession, but we have to admit that, in the grip of the intensity of what we do, we sometimes lack a certain amount of sensitivity and civility.  We are not always respectful.

Sometimes it’s directed toward patients.  Not necessarily as overt rudeness, but more subtly, such as keeping people waiting without apology, not introducing ourselves or addressing people by name, etc.  Other times it’s a lack of respect for our colleagues.  A recent study from the Journal of General Internal Medicine revealed the extent to which physicians criticize other physicians to patients, often with inappropriate language (e.g., “This guy’s an idiot!”).   The situation is no better when it comes to relationships among other members of the healthcare team.  While perhaps 5% of physicians can be described as chronically disruptive, disruptive behaviors are well documented among both physicians and nurses.

I confess to being guilty myself.  As time goes on, I find it harder to get back on task when I am interrupted.  It shouldn’t be a surprise that interruptions are very common in the emergency department.  But I find that when a nurse “interrupts” something I am doing because there is something that she interprets as more urgent, I sometimes – especially if my perception of the urgency is different – react in a manner that is curt or dismissive.  It makes me come across as difficult to approach, which has a negative impact on our ability to work as a team, and ultimately perhaps on the effectiveness and safety of our care.  (And needless to say, I am not always correct in that relative perception of urgency.)

Even little things, things we may not ourselves perceive as disrespectful, can damage the team relationship.  For example, in a recent survey, only 4% of physicians agreed with the statement that nurse practitioners should be paid the same as physicians when providing the same services.  Now, this is certainly a complex issue, but consider what it sounds like to a nurse practitioner to hear that she or he should be paid less for doing the same thing.

Fortunately, a little respect goes a long way.  When wait times in the ED are long, trying everyone’s patience, I’ve seen the simple act of apologizing and recognizing the inconvenience to the family melt the icy stare that greeted me when I walked in the room.  Thanking a nurse for alerting us to a monitor alarm, telling a physician assistant “nice job” when she picks up an exam finding we missed, talking candidly but with respect to a consultant with whom we may disagree on a management plan – these are all ways of living our value of integrity.

Two years ago, I was having trouble finding time to get over to employee health for my flu shot.  One day I went to Walgreens for something, and realized I could get it right then and there, so I did.  I admit, I felt a little tainted, like I was aiding and abetting the enemy.  But it was quick, cheap, and convenient – hard to argue with that for a simple flu shot.

A recent article in JAMA talks about the “convenience revolution,” the innovative options for treatment of low-acuity conditions, including store kiosks and retail clinics, employer-based clinics, “clinic in a car,” and e-visits.  These are examples of the kinds of “disruptive innovations” than Clayton Christensen talked about in “The Innovator’s Prescription.”  It’s easy to be dismissive of these as a “doc-in-the-box,” but we need to be mindful of why they have been growing.  For many conditions, especially in pediatrics, it’s frankly difficult to demonstrate much of a difference between providers and settings in the quality domain of effectiveness.  Let’s face it, most of the time kids with simple illnesses are going to get better no matter what.  So from a consumer perspective, if effectiveness is the same, then the other domains, especially efficiency (i.e., cost), timeliness, and patient-centeredness (i.e., service) are going to be more important.  There is no difference in how well protected I was against the flu by my Walgreen’s shot than by one administered by MCW Employee Health.  But I didn’t have to make an appointment or walk across campus to get it – I could do it when I happened to need to go to the drug store to buy razor blades anyway.

OK, perhaps a flu shot doesn’t matter.  But even something as simple as a sore throat – will the provider at Target perform a strep test correctly?  (Answer: Probably – it’s really not that hard.)  Will she be able to recognize the rare case of epiglottitis or diphtheria? (Answer: Is that a serious question?)  And what happens if everyone starts going to retail clinics for routine things, and only come to their pediatrician or Children’s for things that are more complex?  Or worse, those “convenience clinics” start dealing with some of the more complex things, where there may be a difference in effectiveness or safety.

The answer to those questions is, we can’t let them.  I don’t mean we lobby for restrictions to prevent it – that probably won’t work.  I mean we have to outcompete them.  We must acknowledge the importance of those other domains – service, cost, timeliness – and provide a similar level of convenience.  What kind of “disruptive innovation” can you think of in your area.

And by the way, last year, employee health came to me.

This week’s post will be short, as I am living out our value of Health, specifically, “I am an active participant in my own health and lead a healthy lifestyle.”  In other words, I’m on vacation, and I mean really on vacation, as in no cell phone and no email.  (I wrote this last week.)  I’ve written previously about the work showing a link between rest and rejuvenation and increased quality, productivity, and satisfaction with work.  As anyone who has tried to schedule a meeting over the summer knows, many people do take vacation.  But are you really gone?  Try it out.

While you’re checking out, check out this item about how giving is the key to getting.  Specifically, organizational psychologist Adam Grant, at the Wharton School of Business, has written a book describing how framing work as altruism can lead to improved productivity and satisfaction as well.  In his view, there are 3 kinds of people: takers (those who always seek advantage), matchers (people who give in expectation of a return in kind), and givers (those who give – especially of their time and attention –  without expectation of immediate gain).  While most people are matchers, givers are overrepresented at both extremes of success – they can be taken advantage of, but they are also among the highest achieving leaders.

We speak of the gift of time.  Try giving it to yourself and to someone else.  It could be the gift that keeps on giving.

In a recent post, I talked about the growing interest among our patients and families – driven by increased cost sharing – in understanding what care is costing them, and the difficulty in answering that question.   A recent study in Pediatrics illustrates the problem.  Residents and attending hospitalists at Children’s Hospital of Philadelphia were surveyed about their knowledge of costs, charges, and payments for a range of common tests and treatments.  The respondents were not confident in their knowledge: only 13% of attending and 3% of residents rated their understanding of hospital finances as at least moderately adequate.  The large majority of both groups expressed a desire for knowing more.

It turns out they need to.  The median percent error was 75% for attending and 80% for residents.  Only 15% of estimates were within 25% of the actual value, and the magnitude of errors were similar for costs, charges, and payments.  However, both groups tended to overestimate costs, while underestimating charges and payments.  Arguably, the latter two are what matter most to patients who will have to pay at least a portion of the bill.  In addition, there appeared to be a certain tendency toward the middle: overestimates were more common for the least expensive items, while the costs and charges for the most expensive items tended to be underestimated.

If our patients and families are becoming more price-sensitive, and are asking more about what services will cost them, we need to prepare providers to deal with that.  Moreover, we know that making clinicians aware of costs can reduce unnecessary “routine testing” and other resource utilization.  This study shows that we have a long way to go in terms of getting accurate information into the hands of providers.  One of the advantages of an electronic health record is the ability to embed that information into the ordering process.  Interestingly, the Pediatrics study was done at an institution using Epic; it’s not clear whether they include any price information to the ordering provider.

Transparency, anyone?

There are a number of striking features of the American healthcare system compared with those of other developed countries: the huge percentage of our GDP that goes to health (currently at 17.9%); the enormous gap between our spending and health outcomes (i.e., the apparent lack of value); and the tremendous health disparities in this country compared with others.  We have recognized these disparities as a particular problem in Milwaukee, and one of our strategic priorities is to address those disparities in our community.

Our approach has been essentially two-pronged.  We are addressing access to care in a variety of ways, including directly providing medical and dental services in underserved communities (e.g., Next Door Foundation), providing school nurses, and a CMMI-funded initiative to provide community health navigators and other wrap-around services.  We are also working with community partners to address risk factors for poor health outcomes as varied as obesity, bullying, and unsafe sleep practices.

Increasingly, though, there is evidence, as summarized in a recent Robert Wood Johnson Foundation report that health disparities are not the result only of differential health care access among the poor, but of poverty and racial bias themselves.  There are several lines of inquiry.  One is the role of environment (and specifically prenatal exposures) on epigenetic effects.  Adverse effects believed to be related to epigenetic changes that are more prevalent among infants of poor women include obesity and psychiatric, behavioral, and learning problems.  Another is the role of “toxic stress,” which is the result of repeated, unmitigated stress responses in infancy and early childhood – stresses that may result from both conditions of poverty or racial discrimination – leading to long-lasting effects on physical and mental health.  The AAP has identified both of these as strategic focus areas.

Even more intriguing is evidence that while poverty may be a contributing factor, the level of income inequality is more important than the absolute amount of poverty.  In other words, while poverty does lead to less health care access, less health care utilization, and more exposure to risk factors, these factors combined account for only a portion of the observed disparities.  Indeed, higher degrees of income inequality appear to predict worse health among not only the poor, but among the wealthy.  At least part of this seems to be related to the fact that when there are big gaps between the rich and the poor, the very phenomenon of feeling poor contributes to the toxic stress.  At the same time, the wealthy tend to be more resistant to public expenditures that benefit poor and rich alike.

If this is even partly true, it suggests that addressing health disparities will require addressing income disparities.  Talk about a Herculean effort! We’ve always recognized that we cannot solve the problem of health disparities alone, which is why we have partnered so broadly in that effort.  But how can any organization, or even a coalition, hope to make a dent in the basic American economy and culture?

That’s why I found this article on newborn care in Finland so intriguing.  It suggests that small efforts to level the field can matter.  Basically, all new mothers in Finland receive a maternity package.  Unlike in the US, where kits may be given out by hospitals but vary widely, it’s the same for all Finnish moms.  The kit comes in a box and includes breast feeding information, along with bodysuits, a sleeping bag, outdoor gear, diapers, bathing products for the baby, as well as bedding and a small mattress – the mattress is designed to go into the box, which serves as a crib!  And the culture is such that everyone uses it.  Mothers have a choice between the kit and a 140 euro cash grant; 95% choose the kit.  Imagine how things might be different if all babies in the Milwaukee area, whether they live in Lindsay Heights or Whitefish Bay, napped in the same type of box.  Of course, that would require a cultural change that could be even harder to achieve than income redistribution.  The Finns note that part of the appeal of the maternity kit is the fact that it symbolizes equality.  But when it comes to children, there is a strain of American culture that supports that: for example, the traditional commitment to universal public education dating back to the first years of the Republic.

Our health disparities are a daunting problem.  Could the answer lie in a box?

When I came here in 2000, we had two physician assistants working in the emergency department (one of whom recently retired).  A couple of years later, I hired the first nurse practitioner. (She’s still with us, and recently got her Doctor of Nursing Practice degree.)  We now have a dozen advanced practice providers in emergency medicine, and they see roughly 20% of our patients either alone or together with a physician.  Our APPs not only provide excellent patient care, but they participate in the education of students and residents.  Our approach has been one of a team of professionals, with complementary if somewhat overlapping roles.  This growing role of APPs is paralleled in the practice as a whole.  One-third of the CSG membership now consists of advanced practice providers.  In many of our specialties, they are a critical part of our workforce, a great example of our values of collaboration and innovation.  Nationally, nurse practitioners, physician assistants, pharmacists, and other providers are increasingly seen as a way to address shortages of physicians, and to attempt to maximize value by providing high quality care at a lower cost.

Interestingly, despite our commitment to innovation, academic centers in general, and children’s hospitals in particular, seem to have been slow to adopt this innovation.  About five years ago a colleague did an informal survey of nine academic pediatric EDs.  We were one of only five that used APPs at all, the only one that used them in both the main ED as well as a “fast track,” and had 50% more APP coverage than the next highest.

The growth of the APP role has not been without controversy, both in our practice and in the larger community.  There has been a good deal of media discussion lately about scope of practice, quality, cost, and other issues related to the appropriate workforce composition.  Two recent articles shed some light on some of the tensions involved.  A paper in NEJM reported on a survey of nearly 1000 primary care providers, approximately equally split between physicians and nurse practitioners.  They appeared to do similar work:  when asked about the services they provided, NPs and physicians generally reported a similar distribution except that physicians were much more likely to provide care of patients with chronic conditions that were not yet well controlled. Yet there were large differences of perspective between the groups.  For example, while large majorities of both agreed that NPs should be able to practice to the full extent of their training and education, only 17% of physicians believed NPs should lead medical homes, vs. 82% of NPs.  Physicians were far more likely to endorse the concept that physicians provide a “higher quality of examination and consultation”; 66% of physicians agreed with this statement, while 75% of NPs disagreed.   And on the issue of pay, only 4% of physicians believed that NPs should be paid the same as physicians for providing the same services, compared with two-thirds of nurse practitioners.

What about patients and families?  A study in the June issue of Health Affairs examined preferences of 2000 adults, the vast majority of whom had had prior experience with both physicians and advanced practice providers.  When asked about which type of provider they would prefer if both were available, 50% had a preference for a physician, 25% for an APP, and 25% no preference.  Perhaps as a sign of evolving attitudes, younger respondents were more likely both to have had a prior experience with an APP and to prefer one.  And when specific clinical scenarios were probed, in which there was a trade-off in terms of timeliness – in one case, a choice between seeing an APP the same day or a physician the next day for worsening cough, and in the other seeing an APP the next day vs. a physician in 3 days for chronic persistent headaches – 60-67% preferred to see the APP sooner.  This all suggests that APPs are highly acceptable to patients, especially if it means more timely care.

Taking the holistic view of quality as care that is effective, efficient, timely, safe, patient-centered, and equitable, it appears that APPs have an important role to play in assuring that quality, especially in an evolving healthcare environment.  There are legal and attitudinal barriers to maximizing their potential, but I’m proud that CSG has been a leader among academic pediatric enterprises in innovating and embracing APPs as part of our team.

I will admit that over the course of my career, I have not always been compulsive about cleaning my hands on the way into and out of each and every patient encounter.  My “road to Damascus” moment came several years ago, when I was seeing a child with a hernia in the emergency department.  The visit involved not just our team, but some consultants as well.  At the end of the visit, the mother found me and said, “Congratulations.  We saw six different doctors, and you were the only one to wash his hands.”  All I could respond with was, “That’s truly appalling.  I’m very sorry for that.”  I wish I could have said I didn’t believe it, but sadly, it’s all too believable.  Our own audit data show that, while there is variability across types of providers and different settings, as well as over time, as an organization we consistently fall short of our target of 90%, much less 100%.  Admittedly we’re not alone.  Several studies have demonstrated compliance rates as low as 10%.  Still, our performance is disappointing.

I have to admit, I don’t get it.  First of all, I owe it to my patients not to transmit germs from one to another.  It’s a critical part of patient safety.  More importantly, I owe it to myself.  Just the thought of the billions of microbes crawling on every surface in our facility is enough to drive me to the nearest sanitizer dispenser.  Surely we all understand the importance; it’s not the days when Semmelweiss was trying to convince his colleagues that there was a link between hygiene and puerperal fever.

So what are the barriers?  In the past, there were some real issues.  Soap and water aren’t as toxic as the carbolic acid Semmelweiss used, but they can be very hard on the skin – I can recall days in the winter when I’d come home from a shift with my hands cracked and bleeding.  And sink placement wasn’t always conducive to “washing in” and “washing out.”  But with the newer generation of waterless sanitizers, and dispensers galore, it’s far easier for the providers.  It’s just not that hard.

Our improvement strategies so far have been focused on education and prompts.  There are signs, posters, pins, badge holders, screen savers, etc.   If anyone ever noticed them, at this point they are frankly part of the background noise.  For a while we tried to empower families and staff to remind providers.  Once or twice I’ve seen a parent ask someone to wash their hands, but it’s a rare occurrence.  (Several people have put out videos on the importance of handwashing.  While amusing, I have to question whether a YouTube clip, no matter how many hits, has ever changed behavior of a large number of people.)

Increasingly, hospitals are becoming more heavy handed in their approach to improving hand hygiene.  A recent New York Times article discusses the types of surveillance being used.  For example, at North Shore University Hospital in New York, a video camera is activated when someone enters an ICU room.  Hand cleaning is observed and monitored (from a video center in India!), and aggregate statistics on performance posted on an electronic board on the unit.  As reported in Clinical Infectious Diseases, compliance went from 6.5% to 89%!  A less Big Brotherish but high tech approach is used at another hospital, where a radiofrequency tag in each provider’s ID badge communicates with a sensor on the sanitizer dispenser.  If the wearer does not clean her hands, the badge vibrates to give a gentle, private reminder.

I’d hate to think that’s what it takes to get health care providers to wash their hands.  We all know it’s the right thing to do, and it’s been made as easy as possible to comply with.  Perhaps everyone needs to be mortified by a family’s reaction the way I was to imprint it on us.  In any case, please – WASH.  The infection you prevent may be your own.