Alpha and Omega

“After all, what’s a life, anyway? We’re born, we live a little while, we die. A spider’s life can’t help being something of a mess, with all this trapping and eating flies. By helping you, perhaps I was trying to lift up my life a trifle. Heaven knows anyone’s life can stand a little of that.”

– Charlotte the spider – Charlotte’s Web, by E.B. White

Birth and death are both part of any physician’s career.  While the newness of taking part in either wears off over time, the uniqueness of the experience doesn’t.  Holding ultimate responsibility for another human being’s life in your hands is a hard experience to describe.  It’s sort of like an all-encompassing weight – not a physical weight, like trying to hold something heavy in your arms or slung over your back.  It’s more like a mental weight – a crisp, sudden heaviness that comes with the realization that what you do in this moment is going to irrevocably deflect the path of another person’s life.  It fills your body and your mind with a powerful yet dizzying energy.  While I’ve come to expect and even anticipate this in practice, there is nothing else in life that ever comes close to replicating it.

My first clinical experience with death was seventeen years ago, when I was a 19-year-old emergency department (ED) technician in Worcester, Massachusetts.  I’d gotten my Emergency Medical Technician (EMT) license as a freshman in college and that summer, thanks to the incredible generosity of my neighbor and mentor Dr. Mary-Ellen Taplin, I got a job working in the Worcester Medical Center ED.  I’d been there a few weeks when an ambulance brought an elderly patient in with full cardiac arrest.  Her heart had stopped, she collapsed, her family called 911, and now the ambulance crew had brought her here.

As an ED technician I couldn’t start an IV, I couldn’t give any drugs, and I didn’t know how to implement the Advanced Cardiac Life Support protocol that practically everyone else in the room had trained in.  But I was an EMT and I did know how to do CPR, though at that point despite compressing the chests of more mannequins than I could count I’d never actually done it on a person.

So after we transferred the woman from the ambulance’s stretcher into the ED bed I climbed up a small step-stool, grasped the knuckles of my left hand with the palm of my right hand, and began giving a real patient CPR for the first time as the entire ED team tried to save her life.

We didn’t.

After twenty minutes of resuscitation, during which I learned exactly how hard it really is to give good quality chest compressions to an actual adult human, the ED physician called the code and declared her dead.  I was drenched in sweat, physically exhausted and had no idea what happened next.

As it turned out, my job as an ED technician also involved helping prepare the elderly woman’s frail body after death.  We cleaned the blood from her IVs, changed her sheets, dimmed the lights and allowed her family to stay with her for what seemed like a long, long time.  When they were ready to leave, I remember being surprised at how quickly the warmth had drained from her body.  We fastened a body tag to her toe to supplement the ID band around her wrist, moved her body to the box-like morgue stretcher, and draped it with a clean white sheet.  A more experienced ED technician led the way to the morgue where we opened a small door the size of a college dorm-room refrigerator, transferred her body to a metal slide, pushed her inside, closed the door and affixed another label to the door’s tag slot.

That was it.

We left the morgue, washed our hands, walked back upstairs, and went back to work.  I have no recollection whatsoever of the rest of my shift that day, but will never forget the woman, her family, the morgue, or the tag.

My first clinical experience with birth (not counting my own) was thirteen years ago, when I was a 24-year-old medical student in Durham, NC.  I was a little over halfway through my second year of medical school, the year that Duke medical students rotated through all the basic medical and surgical specialties.  It was spring and I was excited to start my rotation on Labor and Delivery because medical students on Labor and Delivery got to deliver babies.  Not stand to the side while the real doctors delivered babies – I mean actually deliver the baby with your own two hands while a resident stood directly over your shoulder, gowned and gloved and prepared to intervene at any moment.

I remember cleaning my hands with the betadine scrub brush, gowning and gloving just like I’d learned on my surgery clerkship, and sitting on the metal stool at the foot of the soon-to-be mother’s bed with the dutiful resident hovering over my left shoulder.  It wasn’t this mother’s first baby and we expected her to deliver pretty quickly.

The mother-to-be (again) was already in the stirrups of the specialized Labor and Delivery bed ready to push, and by the time I was on position the baby’s head was already crowning.  The resident coached me through how to carefully deliver the baby’s head, checking to ensure his umbilical cord hadn’t slipped around his neck and making sure the shoulders didn’t follow too quickly.  There’s sort of a pop when a baby’s head completely delivers that I remember seeming a little shocking, but the resident didn’t look worried so I made sure to hide the fear from my face as well.

With his head safely delivered and no evidence of a nuchal umbilical cord the resident talked me through how to gently tilt the soon to be newborn’s body so we could deliver one shoulder and then the next… and that’s when I realized exactly how slippery a baby can be.

His first shoulder delivered just as expected, but as his second shoulder emerged the rest of the baby followed with a speed I hadn’t appreciated was possible during childbirth.  I managed to catch his tiny butt with my right hand while the resident flipped the rest of him up onto my left forearm and into a stable position.

Pound for pound, at that moment my adrenaline level and the newborn’s adrenaline level must have been just about the same as the fact that I almost (but didn’t) just drop a baby sank in.  But thanks to a quick hand (all that baseball I played as a kid had finally paid off), a superbly mindful resident, and a whole lot of luck, I didn’t – and now this new person was alive, screaming, pink, and pooping right in my hands.  I handed him to his mother and she smiled, his slippery little body now nuzzled against her outside in much the same way he had been nuzzled against her insides for the last nine months.

I think I delivered at least one more baby on that 24-hour shift and assisted with several more over the course of my rotation on Labor and Delivery, but this first experience with birth is what’s stayed with me.  The look on his mother’s face when she held him, the intense fear of almost dropping a baby as slippery as a greased pig, the hands of the resident imperceptibly hovering then shooting forward at just the right moment, and the silent reassurance I gave myself that the resident’s deftness must have been a sign that it wasn’t the first time she’d had to help a hapless medical student not drop a newborn.  All in all, it was truly like nothing I’d ever experienced.

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Would you read this book?

I’ve been playing with a book idea for a few months, writing and re-writing the introduction and toying with different ways to shape the chapters.  It’s still not fully baked, but the concept at least is formed enough to see if it would resonate…

So, in the spirit of leveraging all the 21st century has to offer in the way of crowd-sourced feedback: Would you read this book?  Feedback of all kinds welcome in the comments, and please Like/Share with anyone willing to send their thoughts this way!

-Chris

__________________

Introduction

Throughout the world, thousands of patients will experience an event today that divides their lives in half.  Before and after the birth of a child.  Before and after the death of a parent.  Before and after the heart attack.  Before and after cancer.

For most of us these events are exceptionally rare.  But physicians play a role in shaping them for their patients many times a day, day after day, often for decades.

Medical school and residency equip us with the knowledge we need to identify and treat even the most seemingly insurmountable diagnoses, and superior clinical performance is crucial to being a great physician.  What medical school doesn’t do is prepare us for how a life spent repeatedly bearing witness to these inflection points in other peoples’ lives will forever shape our own.

Imagine standing in cramped hospital room where an incredibly premature infant is dying.  He’s barely 12 hours old and you’ve spent every one of those 12 hours trying to save his life.  You have come to know his mother and father by first name and they know you by yours.  Even in this short time they have grown to trust you, to depend on you, to celebrate with you, and to cry with you on a rollercoaster of emotion unprecedented in their lives.  But not in yours.

You’ve prepared them for this moment since the beginning, and when an hour ago his blood pressure kept dropping no matter how many drugs you pumped into his (quite literally) pint-sized body, you told them his battle was nearly over.  And – no matter what you or God or anyone else did next – he wasn’t going to win.

You managed to keep him alive long enough for his parents to fill the room with family-members crowded around in uncomfortable chairs.  Grandparents, uncles, aunts and friends all without any idea of what to say or how to feel.  Except sad.

After everyone has had a chance to hold him, nuzzle him, hug him and kiss him, his mother brings him close to her chest.  You lock eyes and share a moment that makes it clear now is time.  The rhythmic bounce of his chest stops as you gently remove his breathing tube, allowing his mother to see his face unencumbered for the first time.  You both cry.

Within minutes he’s lost his pulse and you place the bell of your impossibly small stethoscope on his impossibly small chest for a full 60 seconds just like you learned in medical school.  With no breathing and no heartbeat you again look up into his mother’s eyes and let her know that he’s gone.  Time of death 2:37AM.

You all grieve together and then you leave so his family can grieve alone.  In any normal universe you’d then wake your kids up on FaceTime to make sure they all still have a pulse and know how much you love them and process your own sense of loss, of failure, of grief.

But you can’t.

Instead your pager goes off and, without missing a beat, you run to another room where a new family is delivering another premature baby.  A tiny baby girl joining the world 4 months before she was supposed to and whose entire life relies on all the skill, training, and expertise you and your enormous team of partners in caring can muster.  You cannot stop – this baby and her family deserve your very best, and no matter what happened in the room you’ve just left you cannot let your best be any less for this baby.  If anything, you feel a burning need to somehow be more.

Physicians fool ourselves into thinking we can live like this at work, go home, and then live our lives like normal people.  Engaging deeply with each individual patient while having a deep enough well to move from patient to patient, from inflection point to inflection point, without carrying the weight of the last one.  And the one before that.  And the hundreds upon hundreds before that.  This is what the profession demands, but it comes with both incredible cost and incredible reward and fundamentally shapes and reshapes who we are as people.

We don’t talk about this with our patients.  We barely talk about it with each other.

So I will.

Each chapter in this book centers on how it really feels to practice medicine and a different way being a doctor shapes who you become as both a physician and as a person.  The loneliness that comes with the responsibility for making life and death decisions, the deep humility that sinks in with the recognition that sometimes disease will win no matter how good you are, and the incredibly powerful sense of purpose and triumph of just making it through the night and keeping everyone alive.

In the end, writing this book is as much a personal journey for me as it is an effort to provide you a window into a world you’d otherwise never experience: what it’s really like to be a doctor.

__________________

Elementary School, Insurance, and the Free Market

As part an “Insight Council” survey I was recently asked:

“If you had a magic wand and could change *only one thing* about health payment reform what would it be?”

Now let’s be clear – picking just one thing to fix about how America pays for healthcare is like trying to find and fix only the worst-looking shingle on this roof:

We have government payers that reimburse less than cost yet have ongoing unfunded mandates that measure in the trillions of dollars.  We incentivize “doing more” rather than “staying healthy” and thus both cover and reimburse total knee replacements far better than chronic disease management.  Our uninsured rate is at historic lows and yet hundreds of thousands of Americans will still declare medically-related bankruptcy this year and every year into the foreseeable future.

The choices are plentiful.

But being forced to choose just one I went with this:

Decouple preventative/routine, catastrophic/emergent, and elective care into separate payment models.

Think about it.  In what other part of our lives do we try to fund routine maintenance, optional upgrades, and urgent repairs out of one general program?  It’s like trying to bundle regular gas station fill-ups, oil changes, towing packages, leather seats, emergency roadside assistance, and collision repair into one global car insurance program.  No one would ever agree on what to include in it!  While everyone has to regularly fill-up with gas and everyone needs routine oil changes (whether they actually get them or not) not everyone wants to tow a boat.

Yet this is exactly what we do in healthcare.  No matter your insurance carrier (with the exception of Medicare’s semi-artificially divided “Parts”) I can say with nearly 100% certainty that you pay one premium for a mishmash of coverage that includes relatively cheap primary care visits, relatively expensive emergency room visits, some checkerboard of drug coverage, and heaven only knows what if you actually got sick and needed long-term intensive treatment for a serious disease.  Plus, if you have a high-deductible health plan its likely that none of that coverage kicks in until you’ve spent several thousand dollars out-of-pocket first.

This is why it’s nearly impossible to come to consensus in America on how to “fix” the crisis in healthcare – we’re largely arguing about the wrong thing.  Instead of asking whether America needs one government insurance program or lots of private insurance programs we should instead acknowledge that health insurance isn’t now and never has really been “insurance.”  Once we do so we can finally get to the real crux of the matter and instead address who should be paying for what and how should we be paying for it.

Let’s start with preventative/routine care.  If a nation with nearly $19 trillion in GDP is going to cover the cost of anything for anyone related to healthcare, it first and foremost needs to be preventative/routine care.  Staying healthy is both better and exponentially cheaper than treating disease, and yet today we pay Medicare (through payroll taxes) to dole out billions of dollars treating chronic diseases and late-stage cancers once Americans reach the magic age of 65.  Doing so costs the United States $646 billion each year, while younger Americans skip the vaccines, screenings, and early-stage treatments that could have prevented disease in the first place.

From a purely long-term financial perspective, we should never want Americans – no matter their age – to skip vaccines, breast cancer screening, or autism screening because they cannot afford them.  Doing so only ultimately increases the nation’s healthcare expenditures because in the long-term Medicare winds up paying to manage disease instead of preventing it.

If we’re ever going to really bend the cost-curve in this country, its time we stopped treating routine/preventative care like “insurance” and start treating it like elementary school education.  Everyone needs it, we strongly incentivize everyone to get it (though how they get it can vary), and we strongly dis-incentivize trying to avoid it.

Second, cancer should never bankrupt a family.  Nor should MS, or a massive heart attack, or a horrible accident.  Emergency and catastrophic care in this country really should be covered through actual insurance, because while everyone needs coverage not everyone will wind up using it.

In 48 states drivers are required by law to purchase the equivalent of such coverage in the car insurance market, providing some minimum amount to cover personal and property damage resulting from a collision.  With a population as large as America’s, where the “community rating” reaches the hundreds of millions, we can and should create real insurance to cover emergency and catastrophic care.  Doing so will ensure no American is bankrupted by paying for their child’s chemotherapy ever again.

Now things get a little more interesting – what about care that’s neither preventative/routine nor truly catastrophic/emergent?  This is exactly where the free market works best!  While our model treats preventative/routine care like elementary school education and emergency/catastrophic care like real insurance, it’s this in elective space where a robust free-market can create value through differentiation.  Let insurers compete for consumers with whatever kinds of chrome, bronze, silver, gold, platinum, and super-platinum plans they’d like, providing combinations of real insurance and bundled/discounted coverage for services that don’t fall into the preventative/routine program.  There’s an enormous space here for competition on price, access, quality, and experience to let the market work its magic, and that’s exactly what we want it to do.

So would it really work?

The short answer is I think it would be incredibly hard to get from here to there, especially with a Washington that’s great at cutting deals to divide the pie but not so great at fundamentally restructuring nearly 20% of our economy.

That said, I’m told the Elder Wand is pretty powerful, so perhaps it depends on what kind of magic wand the “Insight Council” had in mind…

Uncertainty

Leaders prove their worth during times of great uncertainty.

We live in uncertain times.  Multiple fundamental aspects of American life all face a crossroads… and healthcare is at the top of the list.

With this in mind, I had the great fortune today to share my thoughts on navigating the enormous change in healthcare with NEJM Catalyst.  In the piece I highlight the four grounding principles I believe are most important to leading quality in healthcare during this period of great uncertainty:

http://catalyst.nejm.org/changing-quality-leaders-population-health/

What are *your* grounding principles for leading yourself, your team and your organization through uncertainty? 

Please Like/Share/Comment and contribute your thoughts to the thread!

Burnout… and a Moat of Resiliency

I remember it as vividly as a childhood nightmare.  The sense of vacuum when I’d go to the well and find nothing there.  The deep-seated feelings of ineptitude for all things personal and professional.  Exhaustion as thick as Appalachian fog.

I didn’t have a word for it at the time but I was experiencing burnout.

Burnout in healthcare has reached epidemic proportions.  This isn’t hyperbole – according to the CDC’s Principles of Epidemiology, an epidemic refers to:

An increase, often sudden, in the number of cases above what is normally expected in [a] population.

Few would argue that the explosion of evidence around burnout in healthcare falls short of “a sudden increase.”  In truth, the only part one could reasonably argue with is whether recent data are in fact an increase “above what is normally expected” or whether burnout has in fact been endemic but unmeasured in healthcare for centuries.

Things don’t start this way.  It is common for caregivers of all kinds to describe having felt somehow “called to serve” a greater good in healthcare.  They begin their careers as bright-eyed health professions students on any one of a number of different paths.  I know – I was one.

IMG_0090.png

A newly minted Dr. DeRienzo circa 2008 (note the distinct lack of gray hair and/or wrinkles…)

Actually heeding that call however is no small task.  Training is often grueling and can last well over a decade.  To become a neonatologist I first spent 4 years in medical school, then 3 years in pediatric residency, then 3 more years in neonatal-perinatal fellowship for a grand total of 11 post-college years of medical education.

As a beneficiary of America’s medical trainee work-hours restrictions my stories aren’t nearly as insane as those who trained before me, but here are just a few to provide some insight into what “grueling” looks like in real life:

On one medical school clerkship I worked 12-14 hours a day for 26 days straight (a privilege for which I paid over $60,000 in tuition/fees that year).

  • My longest week in the hospital as a trainee after medical school lasted 95 hours – two 30 hour “full calls,” one 24 hour “weekend call” and one “regular” 10-hour weekday.
  • As a resident I started listening to books on CD (in the days before Audible) while driving home so I could be certain I hadn’t fallen asleep at stop lights.

After training the challenges do not relent as our nurses, therapists, physicians and surgeons are met after commencement with:

  1. Equally grueling ongoing work schedules as full-fledged professionals,
  2. An ever-changing and increasingly hyper-regulated work environment,
  3. Crushing student loan debt that ranges from $30,000 for bachelors-prepared nurses to well over $170,000 for physicians, and
  4. An American healthcare system that neither consistently supports nor nurtures personal or professional resiliency.

Layer these challenges onto a field that by its nature demands an emotional well markedly deeper than most (see On Hubris and Humility) and one wonders why it’s taken until now for burnout in healthcare to hit the national consciousness.

So what’s the answer?

Tasting the bitterness of burnout has made me a strong supporter of efforts to both prevent it and to help others coping with its necrotic effects.  I’ve also come to believe that there is no one “fix”– rather, turning the tide against burnout will require building caregivers a moat of resiliency that has at least three layers of defense – one that supports our work, one that supports our teams, and one that supports ourselves.

Any one of these layers is individually necessary but insufficient to keep burnout from storming the castle walls.  But as a triumvirate they can become nearly impenetrable.

Layer 1 – Teaching, Resourcing, and Empowering Continuous Improvement

In the outermost ring, we must inculcate continuous improvement into every aspect of caregivers’ work, an effort Mission Health is driving through Mission reNEW.  The ability to directly influence our daily work is deeply linked to magnifying joy at work, and joy is a powerful deterrent to burnout.

But continuous improvement is like fishing – to become a great fisherman you first must have some understanding that you need to fish.  Then you need a fishing pole and someone to teach you how to use it.  Finally, you need to be empowered to actually go fishing and receive some recognition when you catch something.

While continuous improvement methodologies have permeated healthcare for years, few centers can say that every caregiver everyday has the combination of tools, teaching, and empowerment to make continuous improvement an integral part of his or her everyday work.  As leaders we can and must change this.

Layer 2 – Amplifying the Power of Teams

Moving further inward, the next layer of our defense must magnify the power of “belonging” to a team.  I’ve been on many teams in nearly 20 years in healthcare, from the Worcester Medical Center ER team where I got my start as an ER technician to Mission Health’s senior leadership and NICU follow-up clinic teams today.  The best teams have reminded me of playing sports as a kid.  I was a baseball player, and anyone who played little league (or any kids recreational sport for that matter) remembers a game when the whole team pulled together, motivating each other to perform well beyond each player’s baseline potential and, under the most exigent circumstances, reached for and grasped improbable success.

We’re all at still little-leaguers at heart, and the team bond is no less powerful now then it was when we wore rally caps and screamed “hey batter batter” at the tops of our lungs.  Visionaries like Marcus Buckingham have recognized this and are facilitating better teamwork through strengths-based programs like TMBC’s StandOut (a program Mission has had in place for over a year with some exceptional results).

I strongly anticipate that before the decade closes programs like these that tap into the resiliency-building power of teamwork will be essential to any leading health system’s arsenal to prevent and combat burnout.

Layer 3 – Nurturing Personal Wellbeing

In perhaps the greatest commencement speech in history, President Kennedy told the graduates of American University in the summer of 1963 that:

…in the final analysis, our most basic common link is that we all inhabit this small planet.  We all breathe the same air.  We all cherish our children’s future.  And we are all mortal. 

At our core all caregivers are just people.  People who come to healthcare with our own stories and our own scars.  We are only human and as humans we must support and nurture each other’s personal wellbeing with the same intensity we use to build any other layer of defense against burnout.

Enormous bodies of research have shown that personal wellbeing is a muscle we can consciously strengthen over time.  As an industry we’ve barely scratched the surface on ways we can support the growth and development of this muscle in each of our caregivers.  Mission has partnered with the Life-XT team to pilot their combination of techniques from the book Start Here (basically the programmatic equivalent of P90X® for personal wellbeing).  Other early-days thought leaders in evidence-based personal wellbeing include Bryan Sexton and his “WISER” work at Duke and Albert Wu’s “Caring for the Caregiver” efforts at Hopkins.

We cannot shy away from this intensely personal but intensely important work – without it we ignore the most powerful and last line of defense against burnout.

Concluding Thoughts

In one of my favorite episodes of The West Wing (S2-E10: Noël), Leo tells Josh a story about a man who fell in a hole:

This guy’s walking down the street when he falls in a hole. The walls are so steep he can’t get out.  A doctor passes by and the guy shouts up, ‘Hey you. Can you help me out?’ The doctor writes a prescription, throws it down in the hole and moves on.  Then a priest comes along and the guy shouts up, ‘Father, I’m down in this hole can you help me out?’ The priest writes out a prayer, throws it down in the hole and moves on.  Then a friend walks by, ‘Hey, Joe, it’s me can you help me out?’ And the friend jumps in the hole. Our guy says, ‘Are you stupid? Now we’re both down here.’ The friend says, ‘Yeah, but I’ve been down here before and I know the way out.’

Caregivers experiencing burnout need a friend who’s been there and knows the way out.  They need supportive leaders and systems that surround them with conscious and unconscious lines of defense against the attacking troops.  Their plight needs to be dragged out of the darkness and into the light.

Beating back burnout in healthcare will demand purposeful efforts to build our caregivers a deep moat of resiliency.  Resourcing must span all three layers of defense in order to ensure bulwarks won’t breach.  And caregivers can’t build it alone – we must come together as a community of patients, providers, advocates and leaders to build it for each other.

If not now – when?

If not us – who?

We are worth the investment.

On Hubris and Humility

There are times my words mark an inflection point in the lives of my patients and their families.  This recognition takes time to fully appreciate, and I will never forget the first time it hit me.

I was a resident working an evening shift in the ED.  The place was packed with a full waiting room and I was sitting in an incredibly uncomfortable chair staring at a computer screen.  Staring back at me was both exactly what I’d anticipated and exactly what I desperately hoped wouldn’t be there – a cantaloupe sized tumor.  In a kid’s belly.

You take a few minutes for yourself preparing for the conversation that comes next.  You rehearse what to say and how to say it, how to be compassionate while projecting the confidence needed to help someone step through the abyss and onto the path to healing.  All the while recognizing that after “cancer” these people’s world will turn sideways and you might as well be speaking Cantonese.

It was during those few minutes on that specific night that I realized for the first time I was about to divide someone’s life in half.  The first half was everything up to that moment – the second was everything that happened after they learned their child had cancer.  It’s the kind of thing you really, really don’t want to screw up.

Practicing medicine requires balancing a constant tension between two warring factions of the mind.  We’ll call the first side Hubris.  She bolsters your confidence and whispers in your ear that you’re an unstoppable force of clinical prowess and no one else in the world should be doing this thing (whatever it is) at this time other than you.  The other side we’ll call Humility.  She calls into your other ear with a reminder that – despite your delusions of grandeur – in reality you’re only human and therefore both fallible and penetrable.

Each of these muses is necessary but insufficient to both practice as an individual doctor and for doctors as a whole to advance medicine.  Without the Hubris, it would be impossible to both have anything resembling a heart and muster the level of confidence and compassion required to deliver the kinds of news we deliver on a regular basis.  The life-dividing kind of news.

Similarly, without this extreme level of confidence no human would have ever tried (much less perfected) the practices or procedures that advance all of medicine.  Michael E. Debakey, the first surgeon to successfully repair a dissecting thoracic aortic aneurysm (and then decades later have the procedure performed on himself by a surgeon he trained) once told Esquire:

It’s important for a patient to go into an operation with confidence… the operation I did in ’53 for aneurysm of the thoracic aorta gave me great satisfaction. It had never been done successfully before, and lots of doctors took the position that you shouldn’t try it. You’ve got to push ahead in spite of them.

I’m not a surgeon, but I am 100% certain it takes some serious steel to walk into an OR and believe that you and only you can save a person’s life when all other surgeons have failed.  And then do it.

On the other hand, without humility physicians would never acknowledge when we’re wrong (either individually or collectively).  We also wouldn’t be able to accept the inevitable times when – even if we were right – disease humbles our every effort to thwart it, and our service must redirect from seeking cure to seeking comfort.

I cannot count the number of times I’ve had to tell parents that – no matter what we do next – their baby will die.  The most painful of these conversations have been with expecting parents who are imminently delivering around 21 weeks gestation.  They are so close, yet on the wrong side of the fuzzy line demarcating when all of science’s advances can give a baby a chance… and when it can’t.

More than once my body has physically trembled saying something to the effect of “It is my job to bring all that medicine has to bear to save babies.  If there was literally anything I and the team of hundreds of NICU caregivers behind me could possibly do, I would do it.  But I can’t.  And I am infinitely sorry.”

There are few things more humbling than admitting you are powerless to change something.  These conversations have been simply the most humbling experiences of my life.  And I remember every single one of them.

Not too long ago a picture went viral of an ED physician crying in the parking lot after losing a young patient.  The sensation made it clear that the world rarely sees physicians when we’ve been humbled.  In part this is because life keeps moving.  The next patient is waiting, and he’s relying on us reassemble ourselves and both confidently and competently care for him no matter what happened in the room next door.

We have improved in recognizing the toll that this takes on us (e.g., in the form of burnout) and have many more support programs now than when I started medical school nearly 15 years ago.  But no program can change the reality that the practice of medicine will forever orbit between the dueling gravitational centers of unshakable confidence and earth-shaking humility.

Finding balance between these two great forces is what makes being a doctor both so incredibly fulfilling and so incredibly humbling, and why the pursuit of perfecting our craft has more than once been compared to seeking divinity.

In the immortal words of Cicero:

In nothing do men more nearly approach the gods than in giving health to men.

 

Musings from Europe

I just returned from a once-in-a-lifetime trip to Europe with my wife and kids – a truly awesome (and thoroughly exhausting) experience we’ve been planning for the last year.  In between seeing the old-world sites that make Paris and London ridiculously lucrative tourist destinations, I jotted a couple of healthcare-related observations I feel compelled to share here.

First, what’s the deal with triple antibiotic ointment? My wife was bitten by a spider on our first day in London – while the bite wasn’t bad, it’s the kind of thing your Mom would tell you to cover with triple antibiotic ointment and a Band-Aid for a few days “to keep from getting nasty.”  In the UK we had the choice of:

  1. Using the hotel’s antiseptic wipes,
  2. Buying Peppa Pig “elastoplasts” impregnated with silver, or

Image result for peppa pig

https://en.wikipedia.org/wiki/Peppa_Pig

3. Going to an NHS clinic to see a GP.

We literally give this stuff away to kindergartners in America but no British pharmacy would sell it to me.  Same deal with Children’s Benadryl – can’t get it.

Again, I’m talking about Neosporin and Benadryl not Percocet and Xanax.  In a nation where 18 year-olds can buy Vodka and codeine is over the counter, we would have had to either beg a friend in America to AirMail us antibiotic ointment or buy it off eBay and hope the tubes weren’t refilled with either toothpaste or crystal meth.

You’d think we’re at a place globally where we could come to some universal concept of what over-the-counter means… until then, I’ll be packing a mini-pharmacy with me wherever I go from now on.

Second, while the spider bite improved and we never had to interact with a UK hospital or clinic we did interact frequently another industry in both France and Britain – restaurants.  It struck me that when it comes to restaurant service, America’s model is much closer to true value-based reimbursement than Europe’s.

What do I mean?

In America, our waiters’ compensation is (by and large) a function of the number of tables they serve, the size of each bill, and their level of personal service.  This is why people like my wife made for tremendous waitresses in high school (think the guy from Office Space with 37 pieces of flair) and I stuck to selling shoes.

On the other hand, every European café and restaurant we visited automatically included a “service charge” of 12.5% in the bill, guaranteeing the server a minimum tip with no regard to their actual performance.  And while patrons were “welcome to add additional gratuity” I got the sense that 12.5% was good enough for most of the folks we encountered and the focus was exclusively on speed, bill size, and volume.

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From Office Space (EW Online)

To be clear, I’m not calling European waiters mean or lazy people – human beings just act differently depending on the rules of the game.  It’s basic human nature to learn the rules and then do everything in your power (within legal and ethical bounds) to do as well as you can playing it.

In European restaurants that equates to churning volume and driving up the bill with as many add-ons as possible, accepting that with minimal additional service each table is at least worth 12.5%.  In America that model would backfire as restaurant-goers have the final say in whether and how much tip to leave – without strong personal service a waitress could end her night totally empty-handed no matter how many people order the Dom Perignon.  So while healthcare has learned LEAN from the engineering industry and checklist management from the airline and nuclear power industries, perhaps we have something to learn from food service as well as we complete our transition away from pure fee-for-service and into value-based and risk-bearing reimbursement.

In closing, I’d like the record to show that I did leave at least one French waiter a solid “additional gratuity” – he not only got our orders right, but he also brought my kids glowsticks and knew all the words to Hakuna Matata.

And while he didn’t have 37 pieces of flair I’m quite certain that old Stan would have approved.

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Stan from Office Space (NPR.org)

So now what?

  While Speaker Ryan has acknowledged that ACA will remain “the law of the land for the foreseeable future,” a looming question remains – what next?

For all the challenges with the now shelved AHCA – and there were many – Obamacare has never been perfect and is far from becoming perfect.  There are substantial structural challenges that must be dealt with ASAP, but with the White House vowing to “move on” from healthcare we’re left to wonder… what about the pressing problems that weren’t addressed?

Data from Kaiser shows that on the exchanges every state with a 5% or less premium increase in 2017 was matched by 2x as many states with a 20% or more premium hike.  For each of the 4 states who actually saw a drop in premiums (ranging from -1 to -4%) there were 3x as many states with a 40% spike or more (ranging from +40 to +145%).

Remember that – thanks to the ACA’s subsidies – these premium hikes are largely transparent to consumers… at least in the short term.  With subsides doubling, tripling, and even quintupling in at least one state, taxpayers will be funding subsides that are rising proportionately faster than the premiums themselves.  And with competition generally decreasing (from a mean of 5.9 insurers per state on the exchanges in 2015 to 3.9 in 2017) market pressure to control premiums isn’t likely to strengthen any time soon.

These math problems dwarf the even larger one associated with Medicaid expansion.  Over 14 million new Americans were added to the Medicaid program since implementation of the ACA (around 3 million of whom were actually previously eligible but hadn’t signed up), making Medicaid the largest provider of health coverage in America at over 70,000,000 covered livesWhile it still costs less than Medicare ($545B compared to $646B), Medicaid (as a combined state/federal program) is increasingly suffocating state budgets by consuming nearly 20% of all state revenues.

Republican or Democrat, liberal or conservative, the math doesn’t lie – these are fundamental problems of arithmetic that must ultimately be addressed.  Since AHCA’s chance to address them seems to have passed (at least for now) and the opportunity for large-scale reform in healthcare (e.g. revamping both the private/employer insurance market and government entitlement programs altogether to differentially address primary care, preventative care, emergency/catastrophic care, long-term care and truly elective care), the most pressing question is what can policymakers do now to at least stabilize the system in the short-term and avoid budgetary chaos in the long-term?

Here are two simple ways to start:

De-regulate (one of my Christmas Wishes from 2016).  Either as part of “one-in-two-out”or through separate legislation/regulatory actions, both Congress and HHS can provide significant and expedient relief to healthcare’s marmoreal regulatory environment.  The time for pruning is long overdue when even the federal judiciary acknowledges that:

Medicare and Medicaid are among the most completely impenetrable texts within human experience. Indeed, one approaches them at the level of specificity herein demanded with dread, for not only are they dense reading of the most tortuous kind, but Congress also revisits the area frequently, generously cutting and pruning in the process and making any solid grasp of the matters addressed merely a passing phase. (Rehab. Ass’n of Va. v. Kozlowski, 42 F.3d 1444, 1450; 4th Cir. 1994)

A few ripe targets?  Beyond the “impenetrable texts”of Medicare and Medicaid how about the antiquated Stark Law, widely acknowledged to make the kinds of interactions between hospitals and physicians that Obama era health reforms were intended to drive “remarkably difficult.” Another option would be the dense thicket of state medical license restrictions that makes providing tele-services across state lines both incredibly difficult and incredibly expensive.  The sheer volume of choices (catalogued here by Modern Healthcare) is prodigious, and few have defenders as vocal as their detractors (famously including Pete Stark himself).

Incentivize innovation.  While significant enough de-regulatory efforts will in and of themselves spark innovation, we need explicit incentives to overcome the sheer inertia that’s barred real disruptors from accessing healthcare for generations.  We needed the Wright brothers, not the Vanderbilts, to imagine airplanes in an era of railroads.  We needed Steve Jobs to put a thousand songs in our pockets before we knew we wanted them there, and to create an iPad before we knew why we needed one.

We need innovators to have time, space, and resource to innovate – de-regulation will create the space, and while private investors will seize the opportunity to add resource the amount of incentives we can provide through revamped reimbursement mechanisms vastly dwarf venture funding.  Last year’s National Health Expenditures reached $3.4 trillion (over $10k per American), dominating all 2016 US venture capital investments by nearly 50 times.  Earmarking a mere 2.4% of what America spends on healthcare (or about 5% of what government alone spends) to fund disruptive innovation would beat out all U.S. venture funding across all industries… and still amount to less than half of the total increase in healthcare spending from 2015 to 2016.

We need real reform in healthcare and we need it faster than the political environment in Washington will support – until then, perhaps policymakers can at least move forward purposefully on these two fronts… even if the movement needs to begin subterraneously.

It’s time for government to govern.

How to *really* bend the cost curve

Healthcare is expensive.

And complicated.

Its current trajectory in America – one that yields an ever-accelerating rise in both cost and complexity – is clearly unsustainable.  This reality, combined with the outsized role government plays in regulating and paying for healthcare, presents Washington with an enormous policy challenge.

Healthcare’s web of interconnectedness means any change in one stakeholder’s business model – be it a hospital, physician practice, skilled nursing facility, device maker, pharmaceutical company, insurance company, etc. – is much closer than Six Degrees from every other business model across the delivery system.  Kevin Bacon can eat his heart out.

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Kevin Bacon – from the New York Daily News (Footloose)

Under the guise of “bending the cost curve” policymakers may be inclined to impose across-the-board cuts (like sequestration) in an effort to “finally get things under control.”  Instead of imposing blunt cuts that tell providers “just do less” – and potentially cut the exact kinds of care what we want to incentivize in a population health world – we need to use pay-for-value programs to drive a shift in the kinds of things we do.

CMS has experimented with this concept in both the Value Based Purchasing and ACO models (among others), using cost metrics to facilitate the move away from fee-for-service.  Now isn’t the time to give up on cost/utilization metrics – its time to double down and get real.

How?

Here’s my unsolicited advice for policymakers on how to keep driving the shift to population health *while simultaneously bending the cost curve in the short and long-term* through the thoughtful incorporation of cost/utilization metrics into their pay-for-value programs:

1. Use metrics that get at real under-utilization

Deming was right – driving quality decreases cost.  As our experience with “Core Measures” showed we have not and do not consistently perform evidence-based, low-cost preventative care 100% of the time.  These are basic things like prescribing aspirin at discharge for heart attack patients, *never* electively delivering a baby before 39 weeks, and universally screening for cervical and colorectal cancer.

Measuring and tying payment to these metrics drives performance, and providers have demonstrated the ability to rapidly top-out process measures at >99% achievement.  The temptation is then to “move on” to measuring something else… and this is where we risk missing the long-term cost impact.  We cannot lose sight of the tight relationship among ensuring the routine execution of evidence-based process, better outcomes, and lower lifetime cost.  However, since the cost impacts of many process measures (think high blood pressure control) are generally felt over multiple years (if not decades) we must maintain focus on inappropriate under-utilization to avoid “drift” once the Eye of Sauron has moved on to a new target.

2. Use metrics that get at real over-utilization

There is real waste on healthcare – that is, money we spend paying for diagnostic and therapeutic services that are either simply not indicated or where a different, less costly option would be equivalent.  Gawande wrote about this at great length (and with much greater eloquence than I can) in the New Yorker’sAmerica’s Epidemic of Unnecessary Care” so I’ll point you there for the full treatise.  Suffice it to say that we frequently “do too much” and we do so because of choices made at every level of the healthcare decision chain (including patients, providers, and payers).

So how to get at over-utilization within a metric program?  Rather than go after coverage (e.g., universally refusing to pay for certain services) we must begin measuring and reporting some of the examples discussed at Choosing Wisely – including:

There are literally hundreds of examples, each recommended by the relevant clinical specialty society (e.g. the American Academy of Pediatrics for the ear infection guidelines, the American College of Emergency Medicine for the ED guidelines, etc).  Yet we still do many of these things.

It’s time we measure, report, and expect explanations for over-utilization.

To be clear, I’m not saying payers should make either individual or universal COVERAGE decisions based on clinical algorithms… Choosing Wisely’s website itself actually states:

…recommendations should not be used to establish coverage decisions or exclusions. Rather, they are meant to spur conversation about what is appropriate and necessary treatment

Nor am I saying that practitioners must follow these guidelines 100% of the time (note the word routine in each of the examples above).  Instead, we need to be transparent with utilization metrics that are tied to real evidence, discuss them with our patients and incorporate their reporting into pay-for-value programs.

While there will always be exceptions to any clinical algorithm, we must begin asking clinicians to document (in an easy-to-use electronic workflow) their medical decision making that indicates antibiotic use for an uncomplicated ear infection or imaging for low back pain in the ED.  This in and of itself will be a critical first step towards decreasing real over-utilization and have an immediate impact on both short and long-term cost.

3. Use metrics that actually drive change in care delivery… while resourcing the creativity, innovation, and investment required to achieve success

Driving accountability to the provider level for population health outcomes – e.g., preventable hospitalizations for ambulatory sensitive conditions like asthma or cellulitis – will require innovation, experimentation and investment.  It also presumes Americans are universally ready and able to accept it (see previous post for a longer discussion on this point).  While bundled service payments can simultaneously drive this innovation and fund it through reasonable target costs and bonus payments, we must drive deeper to meaningfully change our delivery system.

Cross-cutting metrics within broader pay-for-value programs can support the innovations needed to weather the transference of risk onto providers… but policymakers must be cautious.  There are very few if any providers prepared for the level of accountability that comes with metrics like those included in the Institute for Healthcare Improvement’s Whole System Measures 2.0 – including “unmet healthcare needs” and “disparities in high school graduation rate” in addition to preventable hospitalizations.  Incorporating metrics like these into pay-for-value programs transparently pushes the responsibility onto providers to chart the path to population health, and doing so must be coupled with the necessary resources to innovate, iterate, and ultimately broadcast the best interventions nationwide.

In the end, we can and will meaningfully impact the cost curve in American healthcare.  We simply have no other choice if we want to avoid bankrupting the country.  How we get there remains to be fully determined, and our window is small to drive policymakers towards programs that facilitate real changes in care delivery instead of wielding the sledgehammer of global cuts.

Unchaining the Blockchain

Perhaps the buzziest buzzword of 2017 (with the potential exception of “design thinking“) is BLOCKCHAIN.  Hailed as the answer to all our problems with IT privacy and connectivity across every industry worldwide, I’ve had more blockchain emails, articles, and messages hit my inbox in the last few months than all other “solutions of the future” combined.

Anyone in healthcare leadership whose email address has somehow found its way “into the ether” knows the experience I’m describing – the nonstop flow of messages from vendors, list-serves, and myriad other “experts” around new technologies promising to transform the world as we know it.

While these emails nearly universally wind-up in the electronic equivalent of the circular filing bin, those referencing blockchain have become increasingly interesting over the last six months.  Two of the best long-form posts I’ve read include this one from NEJM Catalyst and this one from Harvard Business Review.

I’ve become convinced that once vendors figure out how to operationalize blockchain – and stakeholders agree to both the costs and significant operational changes required to actually implement solutions based on it – the dynamics and flow of information through healthcare will be fundamentally changed in the same way Netflix permanently disrupted the home video business.

Here’s why… in as non-technical a way as I can describe it:

Our present world of information is built on the siloed universe of depots – segregated companies who own segregated data used for segregated purposes.  Myriad internal databases live within organizations and in many cases form the lifeblood of their ability to function (think a bank’s ledger, a physician practice’s collection of medical records, a grocery store’s inventory, and so on).

Each organization and each database within organizations have individual security and structure protocols, such that even within the same organization it can take an enormous IT lift for databases with complimentary information to interface at all much less in real-time.

In some cases this kind of database segregation is integral to an organization’s business model – the switching costs can be huge when you’re locked into one organization and its collection of databases, and are often large themselves to generate “loyalty.”  Think about whether you’re an Apple or a Samsung smartphone user – even if the alternative brand is cheaper or somewhat better, you’ve probably stuck with whatever personal brand choice you made a decade ago because the thought of rebuying all your apps, transferring your contacts, and figuring out a new operating system are so seemingly daunting.

Blockchain will (eventually) fundamentally disrupt this paradigm – at its core, technologies powered by blockchain free information from the shackles of individually locked systems by enabling real-time sharing, verifying, and updating across systems.  The authors of the HBR article I referenced above describe it like this:

With blockchain, we can imagine a world in which contracts are embedded in digital code and stored in transparent, shared databases, where they are protected from deletion, tampering, and revision. In this world every agreement, every process, every task, and every payment would have a digital record and signature that could be identified, validated, stored, and shared. Intermediaries like lawyers, brokers, and bankers might no longer be necessary. Individuals, organizations, machines, and algorithms would freely transact and interact with one another with little friction. This is the immense potential of blockchain. (Iansiti and Lakhani, HBR)

In healthcare, the applicability of a simultaneously secure and “shared” database updated in real-time across disparate entity platforms will be myriad.

Imagine how much greater our ability to respond to America’s opiate epidemic would be right now if we had instantaneous visibility into every narcotic prescription filled from every pharmacy for every patient across the country.

Imagine how much easier medication reconciliation will be when we have a master medication list for every patient with impenetrable fidelity across electronic medical records, pharmacies, insurance claims, and the patient’s own record-keeping.

Imagine the power we will have as patients when we become the masters of our own personal health records, granting certain levels of read-write access to our individual health blockchains for different entities (primary care, specialist, hospital, pharmacy, post-acute, health plan, etc…) with standardized “emergency access” fields for EMS or ED providers to use for saving our lives if we’re unconscious.

Much like the imaginary advances of the past -think flying machines, video conferencing, and autonomous cars – these too will become commonplace within the next decade.  Like every advance we’ve imagined as humans, they require both breakthroughs in technology and major adaptations in infrastructure to translate from imagination to reality.

Blockchain fundamentally changes the technology of database design – our ability to assimilate this advance in technology into solutions that disrupt the infrastructure of healthcare’s data and delivery systems will dictate whether and how fast these imaginary advances actually reach patients.

So what do you think?  Will blockchain live up to its potential or fizzle like other technologies (think the Segway) that promised to change our lives forever?