Recovering Paediatrician

Blogging 365

In any given month I travel anywhere from 2000 to 3600 km in the relentless pursuit of medical administration and medical quality. This translates to an average of 40 hours a month driving. Often I spend this time thinking about the problem I'm traveling to solve, but just as often I'm listening to CBC Radio (English and French) or to podcasts.

So yesterday I was traveling back to Kamloops from Osoyoos and was listening to a podcast series called the Accidental Creative. The host was interviewing Noah Scalin, the author of 365: A Daily Creativity Journal. Noah's premise is that if you do something daily for a year, you've got to get better at it. That even if what you produce on any given day is garbage, it will build skills and give you material to work at a second time. It all makes sense. Noah's one year project was to make a different skull every day. I've had a look at some of them, and they're really quite neat.

So I'm not a sculptor or a (great) visual artist. I'm a physician and a bureaucrat. I look at problems and try to think of creative ways to solve them. I write a lot - and would like to be better at it. I'm going to try blogging every day. That's a challenge for someone who sometimes doesn't tweet daily, but it's a challenge I'm going to try. Sometimes the blog post will just be a picture and a note. But hopefully it will be more than that. And I'll be counting on you to help me by commenting.

So that's the grand announcement. Watch this space for more to come. Have ideas on what I should be writing about? I'd love to hear. Think the article was great or just plain sucked? I'd also like to hear. The nice thing about blogging is that it's a two way exercise - a conversation. I'm looking forward to it.

 

Leadership Development

We held our first physician integrated leadership residency this weekend. Last May, we had the kickoff event, helping our co-management teams to understand each other better, and to understand the power of personal stories. This last session was aimed at helping our leaders deal with two of the most intimidating and yet important aspects of their jobs - running meetings and dealing with colleagues whose behaviour has become disruptive.

The first day was led by Eli Mina (go to www.EliMina.com). Eli is a registered parliamentarian. He is a very soft spoken man, yet he kept a room of 90 people on task and in the end, helped them learn that leadership requires an understanding of the rules, the courage to stand by them, and the humility to treat people courteously.

The second day was led by Dr. Paul Farnan. Paul is registered in addictions medicine, and teaches a physician manager institute course on disruptive behaviour. He began by stating that if we were out to punish people, we had come to the wrong place. All behaviour happens for a reason - part of the trick in dealing with disruptive physicians is to help them and us learn what those reasons are, and to find constructive ways of accomplishing the same ends. The other part of the trick is to be clear on the consequences of not finding constructive ways. It's safe to say that this isn't as easy as it sounds. Nonetheless, we all left feeling that our organization is headed in the right direction.

Our next residency will take place in February and will cover quality and media relations. In between that time, we will be working on developing an online curriculum to cover other aspects of leadership.

I'm excited by these programs and how they are helping our leaders grow into their jobs. More on this will surely follow. My postings will be sporadic between now and October 11th as I take holidays and move into a new city, but they will continue to flow. I'll see you around.

 

The Day Freedom Died a Little More

A lot is being said today about the anniversary of the attack on the World Trade Centre. My memories are the same as most who were not actually there, but I place a different significance on them. 

That morning, I was doing rounds in the Neonatal ICU. The TV was on - which was unusual, and the nurses were distracted. They mentioned that aircraft had crashed into the towers. I pushed that information into a compartment of my mind for future review; there were patients to care for.

The attacks were dreadful. But we adults made them worse. We allowed our children to watch the horror over and over on television that day and in the days to follow. In the months that followed, I often saw children whose nightmares involved the Twin Towers - or whose stress hormones flowed whenever they saw or heard an airplane.

I remember thinking that the world had changed, and for the worse. The next night, Mr. George Bush confirmed my fears. In a televised address he spoke of the "first war of the 21st Century" as if it were something to celebrate, as if there hadn't already been enough suffering. He and his band of cronies used the horror as an excuse to attack Iraq, and to pass laws curtailing liberty in the name of freedom. George Orwell would be proud.

In the years that passed we have not become a bit safer. We have allowed ourselves to be terrorized. We have used slogans (support our troops, if you're not behind our troops, you should be in front of them) to deflect attention from misguided politics. We have learned to use the excuse of fighting terrorism to get past rights and freedoms. We have become xenophobic. Fear has become patriotic. To avenge the three thousand who died on September 11th, 2001, we have killed at least a hundred thousand more, most of whom were innocent of any crime. We are dancing to the tune of the attackers. 

Osama bin Laden chose his opponent well. George W. Bush did more to strengthen Al Quaida than he ever did to weaken it. You have to wonder how Jimmy Carter would have done differently. An article in today's Guardian suggests he would have taken a different approach. We will never know.

Some remember this date as one where almost three thousand innocent civilians died in an act of war. I remember it as a day of murder, and the day where freedom died a little more.

Blogging 52

Life has gotten a bit hectic lately, so I've decided that what is needed for the near future is a commitment to keep blogging, while making sure that I can focus on what's important. I won't be posting daily, but will post more than once a week. 

In the meantime, what do you want to hear about? I'll look forward to your thoughts.

Ten Thoughts for the New Physician Executive

I've been doing administrative work for the better part of my career, but it's only been the last four years that it's been close to a full time pursuit. With that in mind, here is some advice for physicians entering administrative medicine.

1. You will not be right all the time. Accept this. Embrace it even. We will allow you to be wrong.
2. Sometimes even when you're right, you won't win the day. Don't let it burn you out. Plan how to achieve the same ends using different means.
3. Related: Administration is a team sport. You need to collaborate. Even if you disagree with a team decision, you need to support it moving forward unless it clashes with your deeply held values.
4. If you find yourself in a position where a team decision offends your values, you need first to declare that, and if the decision holds, you need to resign.
5. Values are not the same as beliefs.
6. Most of the time, change happens slowly. Use the time well.
7. You have to be a genius to make an original mistake. Treat your medical and employed staff accordingly.
8. Everyone one will want to make appointments to see you. Make appointments with yourself to get other work done. I schedule a full day every week where the only person who can make an appointment with me is my boss.
9. You have a boss. This is a new phenomenon for most of us. Your simplified job description is to make your boss look good. Sometimes that means helping the boss see pitfalls, usually it means negotiating a set of objectives you both agree on.
10. Administration is the perfect gas. It expands to fill available space, and being heavier than most things, displaces them. Make the important things in your life heavier than administration. Family and your health need to be protected.

As always, I look forward to your thoughts and comments.

VM -- Never Events? Well, Hardly Ever., Sep 11 ... Virtual Mentor

The well-bred Captain Corcoran of the HMS Pinafore was clear in his intent and could be forgiven a bit of braggadocio, but his affectionate crew was quick to remind him of his flaws and get him to be a touch more modest. Likewise, we can be sure that surgeons who perform medical procedures are clear in their intent—avoiding harm to patients. But their performance, too, belies this intent more often than we would like.

via virtualmentor.ama-assn.org

It's worth remembering that you have to be a genius to make an original mistake. If we make a mistake we need to remember that other people can make the same one if we don't share the learnings.

Crew resource management is another way of saying good communication. It's hard to argue with that.

Rural Issues 365

I guess it's not really 365 anymore since I missed two days, but those two days have been spent incubating this post. This post is about the changing landscape of rural medicine and how it's colliding with the increased expectations of rural communities.

My career as an independently practicing physician began in 1982 with a posting to Canadian Forces Hospital Cold Lake. It was a posting that I'd asked for - 3 hours north east of Edmonton. I'd asked for it because unlike the occupational medicine practiced in most Canadian Forces Bases, Cold Lake looked after dependents. We had a fifty bed hospital, one general surgeon, one anesthesiologist, one psychiatrist and six general practioners. As a GP in that hospital I covered the emergency room, assisted at surgery, delivered babies and looked after my own practice of servicemen and dependents. I even used forceps, and once repaired a fourth degree tear into the rectum, rather than send a new mother by ambulance to the referral hospital three hours away. I made about $30,000 a year and thought it was a pretty good gig. I don't think that this was unusual for physicians of my vintage. Several members of my class ended up in rural medicine.

A lot has happened since then. Fifty beds for a community the size of Cold Lake was not unusual in the 1980s. Now we have 1.6 beds per thousand population on average in British Columbia. That would translate to about 13 beds now - with about four of them being in a tertiary facility. The people who end up in those beds these days are much sicker on average than the folks we practiced on back then. That's just one change.

There is also a generational shift. Back then I worked 80 hours a week - and being young, keen and a boomer - loved it. You won't find many new physicians willing to take on that kind of work load. Over half of today's graduating classes are women - and they have other duties to worry about. We may have made strides towards sexual equality, but we're not there yet. Women still have the lioness's share of domestic and child rearing duties. Medicine is a field where, being self employed, they have the option of changing the rules.

The last change I'll consider (because there will be others) is the patient safety movement. Whereas people may have been tolerant of my lack of expertise in every discipline of medicine back in the 1980s, healthcare organizations can't afford to be so tolerant in the 2010s. More and more, physician and patient organizations are talking about a single standard of care, regardless of where that care is delivered.

All of this means that very few new physicians are willing to consider a career in rural medicine today. One of the rural communities I serve has not had a new Canadian physician join its medical staff in over ten years. This is a community, like Cold Lake, that is over three hours away from the nearest tertiary centre.

But these facts do not reduce the demand on the remaining physicians and nurses. Communities look at their truncated hospitals and believe that it is the lack of opportunity that is keeping physicians away. If only we had our operating rooms back the argument goes, we'd have physicians beating down the doors to work here.

Unfortunately, I don't think that's the case. I think the demands of rural practice, including the demand that a physician join the local hospital medical staff and cover the emergency room is part of what drives physicians away from rural care. From the point of view of the hospital administration, there also has to be attention paid to the quality of care delivered by its medical staff - something that perhaps wasn't that important in the 1980s. The end result is that rural hospitals end up restricting the pool of physicians that they'll consider - because such a broad skillset it called for.

So, what's the answer? This is only my opinion, but it's likely that in future rural physicians will be part of our employed staff - on salary, with benefits. They will be part of a team that includes nurse practioners and physician assistants. They will be paid to keep their skills up to date. More and more they will not be associated with hospitals, but they will be available after hours, backed up by a robust emergency transport system. There will be a network of tertiary sites backing them up. Telemedicine will play a large part in the rural health care system of the future. 

The biggest obstacle to making this happen is the willingness to recognize a complex problem for what it is. Once we can get past that - at every level of society, the solutions will come.

 

 

The Time I Almost Died « Thought Catalog

Two summers ago I bled out on a bare mattress in a foreclosed home in Miami. I’d been sick. I’d seen a doctor but, as an American without health insurance, I’d been able to afford only the diagnosis—not the solution. I went back to work.

via thoughtcatalog.com

Quality Measures 365

I've often thought it would be helpful to see how I compare with other pediatricians on indicators of practice quality. So it was interesting to read this article in the New England Journal of Medicine. The author feels that the report card she receives does nothing but demoralize physicians as she had seen no improvement in her indicators over two years and felt that the same was true for many good physicians. Demoralization is likely if there was no input from clinicians as to what they would find useful. It would be doubly true if these report cards were publicly reported.

In contrast, the authors of this article in the same issue of the New England Journal take an opposing view. They feel that you can't manage what you can't measure. They have shown an overall improvement in process measures since reporting became a requirement of the American Joint Commission. 

They go on to suggest criteria for process measures including:

• There is a strong evidence base showing that the care process leads to improved outcomes
• The measure accurately captures whether the evidence based care process was provided
• The measure addresses a process that has few interventing care processes that must occur before the improved outcome is realized
• Implementing the measure has little or no chance of inducing unintended adverse consequences.

It's hard to argue with these statements. There is no doubt that outcomes are a function of organizational structure and processes combined with individual competence. The literature suggests that the first two factors are the most important.

But let's consider the difference between the two articles. The first refers to reports on an individual physician's practice, the second on hospitals. It's fairly obvious that the hospital has much better control over patient behaviour/compliance than a physician looking after patients in a stand-alone office. There are a number of confounding variables including socio-economic status, culture, education, responsibility for children and so forth that an individual physician who is not gaming the system can not control. If we want to improve practice and not discourage physicians from taking high risk patients we must consider these factors.

Let's also consider the patient perspective. A diabetic patient probably doesn't care how often his or her hemoglobin A1c has been measured. Patients care about real life issues such as how healthy are they and is their health improving or declining. Those issues are not measured by indicators of process.

Going back to the issue of performance indicators for individual physicians, the problem in the first paper was not that there were performance indicators, but that they were the wrong ones. A managed care organization was trying to align the indicators used in hospital with those used in the ambulatory office. 

So, I'm going to suggest some criteria for indicators that can be used successfully in physician offices:

• The indicators should measure outcomes, not processes
• The outcome measures should be risk adjusted by postal code
• There should be strong evidence suggesting that the outcomes can be influenced by active provider input
• The measures should be discipline specific
• The indicators should be easy to report - they should not involve review of paper records
• Physicians should be involved in selecting those indicators
• We should not report individual statistics publicly, but we should consider reporting the outcomes of networks of physicians.

Tackling these one by one, let's start with the suggestion that we measure outcomes. Why should we measure the number of times in a year that a patient's hemoglobin A1c is measured if that has no perceived value to a diabetic patient? Wouldn't it make more sense to measure the percentage of a physician's diabetic patients that progressed to renal dialysis? That's a number that the healthcare organization can readily access without increasing the burden on individual doctors. 

Continuing with that item, there's no doubt that most of us will serve our patients better if we follow protocols and guidelines. It's quite possible however that there are other ways of achieving the same outcomes. Should we be discouraging our physicians from developing their own evidence and processes to improve outcomes? This is obviously a rhetorical question.

We don't want our physicians selecting their patients by risk, and we don't want to penalize physicians who work with high risk patients. Most health care organizations have the ability to stratify risk by postal code. Doing that would ensure that physicians looking after the riskiest patients would not be penalized and might actually be rewarded for their efforts.

Clearly there's no point in measuring an outcome that's inevitable. Cancer of the pancreas for example has a very low cure/remission rate. Most chronic diseases however can be influenced by care; we should be measuring those outcomes.

There's a difference on what a general surgeon can influence compared to what a general practitioner can influence - the GP has much more health outcome influence overall. So it makes sense to ensure that the indicators are discipline specific.

Toyota refers to the waste of human talent as one of the wastes that must be eliminated. It wastes a physician's time to review records for process measures. Outcome measures can and should be trackable through administrative data.

If you want commitment to a practice, you need engagement and participation. For this reason alone, physicians should be involved in selecting outcome measures. They are a highly educated and professionally motivated group. Treat them that way, and be surprised by the outcome.

To the last point, we are trying to improve overall performance, not punish physicians. Individual physicians should know how their numbers compare with those of the discipline's average. The physician network quality council should also know. On the whole however, it takes teams to achieve outcomes, and to promote teamwork, only the team's indicators should be made public.

As always, I look forward to your thoughts and comments.

2011-09-01

No post today. Tomorrow I'll be looking at two views of quality measures

Degrees of Emergency 365

Are all emergency rooms created equal? Obviously they are not, but is that necessarily a bad thing? Consider rural medicine for a moment. It's not uncommon to have a small hospital, staffed entirely by general practitioners, where the nearest centre is over an hour away, where the emergency room is staffed by those same general practitioners. These men and women are the community's family doctors, but they also do obstetrics, some surgery, cover mental health issues - and the emergency room.

Thirty years ago rural emergency rooms were used primarily for life and limb threatenting conditions. The family physician on call would have an after hours clinic to care for the walking wounded. Outside of that clinic time, nurses would assess patients and direct them to the next morning's clinic if the condition didn't involve life or limb.

But community expectations have changed. Today in all but the smallest rural communities, the physician on call has to close his or her office to be available for a slow but steady stream of non life threatening illnesses. This has a financial cost to the fee for service physician who is seeing fewer patients and dealing with disturbed sleep. This physician also has to deal with the nagging feeling that the standards in this rural ED are not as high as those in an urban centre. Is it any wonder that we have trouble recruiting to rural areas?

Ideally there should be one standard of care for everyone, regardless of where they live. In the present environment that isn't possible. Larger centres will have better qualified practitioners because they will be able to divide work according to personal preference and academic qualifications. The rural physician doesn't have this luxury. This practitioner works with a broad base of skills. The ideal rural doctor is a generalist, comfortable with uncertainty and with his or her own limitations. This physician in many ways is superior to the urban generalist, for he or she has to be thinking several hours ahead of the patient's emergency - for that is how long it will take to get help from the referral centre.

If we are going to maintain emergency services in rural areas, we are going to have to accept some realities. The most important of these is that physicians are human. They can't be expected to do this kind of work for less money and less sleep. It wears them out and keeps them from performing well the rest of the time. It discourages others from trying rural medicine. We need to return to a model where only life and limb threatening illnesses are treated in the rural emergency room.

We are also going to need to invest in the training and maintenance of physician skills. As our older physicians retire, with fewer willing to replace them, we will also need to invest in physician extenders, physician assistants in particular. 

The world is changing, we won't be able to do things the way we always have. If we're smart though, we may do things differently, with better results.