Done and done

Today is my last day on the job. Tomorrow I'm off on a week-long vacation with my family Vermont, and med school orientation starts as soon as I get back. It's a pretty exciting time. Hopefully I'll have some time to catch up on posting from VT, but I make no promises. Happy Friday.

Quick pix

Crooked and blurry as it might be, this picture made me smile broadly when it arrived in my inbox late last week. The e-mail this photo was attached to was sent by the main secretary at the McCord Hospital in Durban, South Africa -- where I worked in 2007 -- and included a request for the name of the then-med student on the far left. In writing my response to Geraldine, I was overwhelmed by how much I miss Durban and all of the people I worked with at McCords. It's going to be very hard to resist the urge to go back during the summer after my first year in medical school. Hmm -- I was planning on writing a bit more about South Africa, but I think I'll just stick with nostalgia for the time being.


Big ups to Drs. Richard Murphy, Ingrid Bassett, Helga Holst, and Janet Giddy for featuring so prominantly in this picture. And why do I look like a giant? Weird.

Sim City

I'm about to go spend the rest of my morning playing with SimMan, a life-sized mannequin/patient simulator, with realistic anatomy and clinical functionality. I am really hoping to get a lesson on how to perform an intubation or, better yet, a cricothyrotomy. It's cool to know that these sophisticated educational tools are around to teach us noobs these extremely important clinical skills in a non-patient environment. Performing your first intubation on a real patient is a terrifying experience, I'm sure.

Also, because there hasn't been a post up here without some mention of health policy in a long time: here is a recent interview from the Brian Lehrer show on WNYC with analysis on Massachusetts' move towards universal healthcare. I must admit that I haven't listened to this piece myself just yet, but one of the participants is Dr. Stephanie Woolhandler -- a woman I admire tremendously, and who has incredibly persuasive and smart things to say (to Congressmen no less!) about the disastrous state of healthcare in America.

I've got to run off to play with my oversized doll. Lata', all.

30 Days

It's t-minus one month until the start of medical school. I am as excited and nervous as ever --but mostly eager to meet my new classmates and get this show on the road. There are lots of fun orientation activities planned for us the week before classes start. At the moment I plan on strategic attendance of these events to make friends without being too overly enthusiastic about the Manadory Fun. I'll leave that to the 21- and 22-year olds. Although, I must admit, I have only the fondest memories of my college orientation week (described at the time – and quite accurately in retrospect – as Camp Amherst) those 7 long years ago.

Also, I just received my new mailing address, effective August 25:
435 East 30th Street
Room# 726
New York, NY 10016

Hope you all are enjoying your respective summers so far, and keeping out of trouble as best you know how. Check back soon for new content, as I'm trying to keep my readership from flagging as has been suggested by the Google Analytics and Feedburner software. Hopefully, I can keep you interested. Holler.

Reading matériel

Things have gotten busy at work -- hence the lack of new content. But I have been doing a lot of reading, and would love to point you all towards some of the more interesting things I've come across in the past few days:


A fascinating study conducted by the Kaiser Family Foundation, in conjunction with NPR and the Harvard School of Public Health, takes an in-depth look at the impact of heath care costs and the economy in two of the most important swing states in the upcoming election: Florida and Ohio. I highly recommend you click through to take a look at the analysis of the surveys and at the NPR news coverage, providing insights into the way health care costs currently affect people's daily life decisions in these battleground states.

An article in The New Republic written by a health policy junkie by the name of Don McCanne, MD on the importance and inevitability of stand-alone single payer health care system in the US.

And finally, two articles of note from this week's New England Journal of Medicine:

The first is about "Nontraditional Medical Students" (this includes myself!!) and the future of medicine, written by the young and exciting physician/author, Sandeep Jauhar, who is currently the director of the Heart Failure Program at Long Island Jewish Medical Center.

The second is about the current state of premedical education in the United States, and was written by the dean of medical education at Harvard Medical School.

Hope you find some of these pieces interesting, and I'll hopefully be able to holler back at y'all with some new content before the weekend is out.

First I have to finish up this document outlining the tentative purview of the Executive Quality Council for the hospital. Maybe I'll even share some of the work I've been doing here with you guys as it gets closer to completion.

People Smarter Than I

Julie Solomon, author of the new book Hospital: Man, Woman, Birth, Death, Infinity, Plus Red Tape, Bad Behavior, Money, God, and Diversity on Steroids, has been doing some guest posting over at the Freakonomics Blog on the New York Times website. She is an excellent journalist and is interested in many of the same health related issues that I spend my time thinking about. Here is a great excerpt from her first guest post entitled, Common Sense Health Care:

Our market economy approach to medicine has to change. There is “a fundamental illogic to trying to contain costs in a market-based system,” writes Dr. Marcia Angell in a thoughtful article about health reform in the April 21 issue of The American Prospect.

Dr. Angell, a senior lecturer at Harvard Medical School and a former editor-in-chief of The New England Journal of Medicine, was called “an unlikely muckraker” by The New York Times in 2004, when she published a powerful expose of the drug companies.
Her position on health reform appeals not to corporate interests but to common sense and the desire for good medical care, making it appear radical:

“The only workable solution is a single-payer system (there, I said it), in which everyone is provided with whatever care he or she needs regardless of age and medical condition,” she writes. “There would no longer be a private insurance industry, which adds little of value yet skims a substantial fraction of the health-care dollar right off the top.

“Employers, too, would no longer be involved in health care,” she continues. “Care would be provided in nonprofit facilities. The most progressive way to fund such a system would be through an earmarked income tax, which would be more than offset by eliminating premiums and out-of-pocket expenses.”

Brilliant (and ballsy) stuff, right? Thanks to my darling poet 2.0 Ms. Fjeld for tipping me off to these posts. I'll be back with another installment of my open letter to Edward shortly. Happy Friday, and I hope everyone has a wonderful weekend. Holler.

On Healthcare in the United States: an Open Letter (Part 1)

On Mon, Jul 7, 2008 at 1:25 PM, Eddie Bearnot [redacted]@gmail.com wrote:

benny -
i am lost as to what we need in regards [to] healthcare reform. talk to me. you can't possibly be that busy.

e

//

My little brother is quite right, if somewhat rude - there's no particularly good reason I haven't gotten back to him more quickly. I have plenty to share on the subject, and more time on my hands than I will at any point in the foreseeable future. In light of this, what follows is the first installment of what will be a serialized open-letter response to Eddie’s questions on healthcare and healthcare reform in the United States.

//


Yo Ed –

Thanks for being so persistent. Part of my reluctance in getting back to you has been the magnitude of the questions you are asking. I am very excited that you have been asked to think critically about the healthcare system in the US since arriving in Washington D.C. several weeks ago - but healthcare and related biomedical science are issues of particular significance to me, and I would be disappointed in myself if I supplied incomplete answers.

Because of the scale and infinite complexity of these topics, I will do my best to provide you with some concise answers in a format that you will hopefully find readily accessible. It’ll probably take me a couple of installments to get all of the salient points down, but I encourage you to ask for clarification whenever necessary. It’s important that I learn to write lucidly about these topics as well. Let’s get started then, shall we:

The most disheartening piece of the healthcare crisis in the United States – and the component that I will focus on for you here – is the system’s gross inefficiencies. The US spends approximately 15% of its GDP on healthcare each year. In 2006 this sum eclipsed $2 trillion, or $7,000 per American. And while this percentage and absolute total are the highest in the world by a significant margin, the United States lags behind many other developed countries in basic metrics of nationwide health (average life expectancy, infant mortality rates). This is even more problematic when coupled with the observation that there are still nearly 50 million Americans living without health insurance. In short: we are paying significantly more for our care while missing out on the benefits of this spending.

So, if this $2 trillion (that’s 2 followed by 12 zeros) isn’t going towards the provision of the best possible care, where is it going? Here is a partial list of the most conspicuous answers to that question as our health system is currently structured:

Expensive drugs and devices researched and developed by pharmaceutical companies. Because of the way US patent law works, these corporations have every incentive to charge usurious prices for these products during the finite number of years in which they are protected by patent. And while astute advocates of free-market economics correctly point out that these big paydays make it possible for big pharma to lavishly spend on the expensive basic science to develop and trial new and wonderful discoveries, many of the products brought to market are debatably superior to the preexisting drugs/devices in their class, while costing many times more.

Health Maintenance Organizations (HMOs). These private companies were originally designed to prevent unnecessary healthcare spending, pooling risk while simultaneously encouraging the “health maintenance” of policy holders by covering preventative care costs. But because these HMOs are private corporations, responsible to shareholders and board members, they are driven by their inherent profit motive to keep costs down and maximize income. This has resulted in systematic attempts to reject legitimate reimbursement claims submitted by physicians and patients, refuse coverage to patients deemed high risk, and to provide substandard compensation for the primary care physicians who act in the essential role of gatekeeper for further medical services – causing an increasing number of physicians to enter more specialized fields where they might be compensated more fairly.

I guess I’ll leave off here for now. Next time I’ll tell you more about the current state of medical malpractice and tort reform, the ongoing failure of Medicare and Medicaid to pull us out of this downward spiral, and expound further the intrinsic incompatibilities of excellent medical care and profit motive.

Hope you’re well and I can’t wait to talk with you again soon.

Love,
Ben

Oh, it's only a flesh wound. Pass me that plastic bear, would you?

From NYU's internal medicine blog, Clinical Correlations, a scientific update on the powerful but previously poorly-described anti-bacterial powers of honey:

Every once in a while when reviewing articles to be included in this section, I find one that makes me smile. An article featured in this week’s Clinical Infectious Disease was titled “Medical-Grade Honey Kills Antibiotic-Resistant Bacteria In Vitro and Eradicates Skin Colonization. The investigators studied Revamil, a medical-grade honey, to assess the in vitro bactericidal activity against S. aureus, S. Epidermidis, E. Faecium, E. coli, P. Aeruginosa, Enterobaceter cloacae and Klebsiella oxytoca in forearm colonization. After 2 days of application of honey, the extent of colonization was reduced 100-fold. Apparently, honey has other uses too and has been reported to successfully treat chronic wound infections that were unresponsive to antibiotics. Who would have thought? Perhaps this could have also made a ShortCuts section in the year 1776….

The article was published by a group of researchers in Amsterdam; somehow it makes perfect sense.

Lucian, you're like no other

Excerpts from an interview with Lucian Leape – an adjunct professor of health policy at Harvard School of Public Health – in a 2007 issue of Health Affairs.

[Buerhaus, Peter I. Is Hospital Patient Care Becoming Safer? A Conversation with Lucian Leape. Health Affairs. 26;6 (2007):687-96.]

Dr. Leape is well known for his ground-breaking research and thinking about patient safety, particularly on the need to focus on systems of care to prevent injury to patients, and, more recently on the need for full, open disclosure and apology when things go wrong.

///

On reducing medical error to 0:

The most exciting thing that has happened recently in patient safety--something that has truly changed our agenda--is that it is now apparent that we can use perfection as a benchmark. This means that we can stop talking about reducing medication errors by 50 percent or improving hand washing by 30 percent, and so forth. We now have convincing demonstrations that when the effort is made and new practices are implemented, we can actually eliminate certain adverse events. There is no reason to think that this cannot be expanded to the whole universe of adverse events.

On disclosure of medical errors and patient safety:

The need for full disclosure and compensation is finally on the patient safety agenda. Acknowledging mistakes when they occur, fully explaining what happened, apologizing for errors, and providing compensation for the cost of the injuries we cause are things that we have to do. Patients too often do not get the truth, the whole truth, and nothing but the truth, and it is time to stop that.

There are many reasons why physicians have been reluctant to be open and apologize after accidental injury, but a major factor has been bad advice from liability insurance carriers and hospital counsels, who have perpetuated the myth that informing the patient will increase the likelihood of being sued. There is not a shred of evidence to support this assertion--not a single study--yet the myth dies hard.

Although fear of litigation is very real, and understandable, I believe that a more powerful reason that doctors sometimes do not communicate fully with patients after a serious error is their sense of shame and guilt. Physicians hold themselves to high standards of performance. As a result, they find it difficult to deal with failure. And they get very little support, either from their colleagues or from risk management personnel. It turns out that full disclosure and apology when there has been an error are important for the physician as well as for the patient. We need to provide them with support to help make it happen.

On Pay for Performance (P4P) models of health care:

Essentially, it suggests that you can get quality by paying for it. The idea seems sound, but whether the results will confirm it remains to be seen. It certainly is a concept worth trying, given that our current system of paying for health care is rife with perverse incentives. As some wag observed, health care is the only industry where you get paid more for a defective product! But, it's true: Hospitals and doctors receive more income when things go wrong than when they go right. And it works both ways: You get paid less for good care. That is clearly not what we want.

Here is a classic example: A doctor does a good job treating patients with asthma, teaching them to manage themselves, and the end result is exactly what we want--patients have fewer attacks. They are not going to the doctor's office as often, they are not going to the emergency room, and they are not being admitted to the intensive care unit and being intubated. But the net result is that both the doctor and the hospital lose money. That does not make any sense, and we need to change that. Our fee-for-service system also emphasizes providing services rather than providing care, and that also needs to be changed. We should pay for good-quality care.

On the major flaws of current - and potentially all - P4P proposals:

Pay-for-performance, though, has some major problems that we have to sort out. I do not know how they are going to be resolved, but let me at least briefly mention a few. The first is whether you should pay for process or for outcomes. Second, how do you pay: Do you pay a bonus for good care, or do you punish people who fail?

Let us say you pay a bonus for somebody who does a better job of making sure that all patients who have a heart attack get beta-blockers afterward. We have pretty good data that this makes a difference in outcomes, so one thing to do is say, "If you achieve a high level--say, over 90 percent of your patients get beta blockers--we will pay a premium." Or do you not worry about that and focus on outcomes?

I am also concerned about the possibility of perverse effects. Any time you change payment, you change behavior, and that often has unintended consequences. If we concentrate on paying for outcomes, will we in effect devalue and direct attention away from the "soft stuff" that means so much to patients: time spent listening to them, caring about them, communicating with them? If we do not pay for that, then is it going to be diminished? I would hope not, but one must be aware of that possibility.

On the power of data collection as an engine of change in health care settings:

The second [effective] approach [to progress in healthcare quality and safety], which is even more powerful, is data and feedback. Everybody in medicine, perhaps everybody in health care, thinks they are from Lake Wobegon--that they are "above average." It is very hard for any doctor, for example, to be called average. And when they find out from the data that they are below average, they begin to do something about it.

And finally, on one of the major shortcomings of the current state of medical education:

The third barrier is that students in medicine, nursing, and pharmacy receive insufficient basic education in quality and safety. At a minimum, in the first year of school, all of them should learn the basics of error theory, why people make mistakes, and how to prevent them. Later, they should learn how to analyze systems, how to identify systems' failures, and how to redesign systems. As we mentioned, they need to learn how to work in teams by doing it, and doctors especially need to learn the basics of leadership. They need to learn much more about how to communicate more effectively, how to handle their own feelings and concerns, and how to handle the shame and guilt they will feel when things go wrong, so that they can still be effective caregivers. They need to learn how to apologize. These are things that are currently not being taught to our budding doctors. That has to change.

///

Oh man -- Dr. Leape presents puts forward so many outrageously smart and forward-thinking ideas in this interview. I hadn't come across his work until I started working with the Patient Safety and Risk Management teams at this hospital, but some very similar thoughts have been fermenting in my brain (albeit, phrased far less articulately) since my time in South Africa - especially after my experiences working alongside members of the Institute for Healthcare Improvement's developing countries team.

Preemptive Strike

A brief preface to some of the constructive criticism that might eventually stem from my experiences working in a giant public hospital:

Running a good hospital system is an incredibly difficult proposition. This is due in part to the fact that providing excellent health care requires a lot of different things being done well in unison. This is, as we all know, one of the hard parts of making any big system run efficiently.

Moreover, this intrinsic problem has been increasingly complicated by the development and entrenchment of our current privatized health care situation in the United States. Most health care not provided by the US government is provided by "health maintainance organizations" (HMOs), who incentive the use of exorbitantly expensive diagnostic tools and treatments for a small subset of the population (mostly the wealthy), while disincentivizing the provision of basic primary care for the everyone else.

And while many patients entering city's public hospitals ARE NOT covered by HMOs and rely primarily on insurance plans managed and paid for by the government (Medicare and Medicaid being the main programs), the incentive structure has been sufficiently warped by the influence of the private sector so as to create a similarly wacky organization of publicly financed care. This is sort of a complicated point - one which it behooves me to flesh out for you guys more thoroughly in the future.

With all of that said, there is a small but growing group of physicians (and MPHs, PhDs and JDs - and all of those degrees in combination) who are committed to figuring out how to make these public and private health systems work properly, providing excellent care at a reasonable cost. I'm meeting some of these inspirational characters in person in the hospital and reading about many more as part of my background reading for this job. In fact, I'll post up some interesting exerpts from an interview with one of the figureheads of this movement, Lucien Leape, in the near future.

Alright, that's all for now. Keep your eyes tuned to this space for more riveting (ha!) insights into (public) health care. Hopefully we'll all learn something along the way. Peace out.