Thursday, March 05, 2015

Unasked questions about global payments

The Boston Globe reports that Blue Cross of Blue Shield of Massachusetts is expanding its capitated, or "global payment," form of medical reimbursement.

The Massachusetts health care industry’s traditional system of paying doctors for every office visit, test, and procedure may be nearing its end.

Blue Cross will essentially pay doctors a set amount to care for their patients but payments will ultimately be tied to how well doctors and hospitals score on a variety of quality measures.

The company CEO is quoted:

“This is definitely a new phase. It’s a very important signal to the community and to the market that we want to continue to advance payment reform, promote accountability for quality and costs, and continue to move away from the fee-for-service system.”

The story takes as a given the possible benefits of this approach, but gives short shrift to any alternative points of view.  Beyond that, with all the encomiums included in the story, it lacks any mention of some very important unanswered questions. I've noted these before, with reference to issues that ought to be reviewed by the state's Attorney General:

[BCBS of MA] also acted to increase the disparity in payments among hospital networks, even after those disparities were documented by the previous AG as being one of the major causes of health care inflation in the Massachusetts. A study commission is supposed to review this issue of disparities and make recommendations to narrow them.  What's the AG's role in that process?  Might she, for example, pursue a reference pricing approach that would require an insurer to justify payments rates outside of a normal band? 

BCBS of MA has also persuaded the state to adopt a policy that shifts risks from the insurance company to doctors and hospitals but has made no adjustment to its capital structure to compensate for that savings. Will the AG consider clawing back excessive earnings given the company's new risk profile? 

All other financial service industries have been able to reduce administrative and transaction costs over the years.  What is it about this company that gives them a pass? As premiums rise, the percentage the company keeps for administration and profit stays the same. Here's another area worthy of attention by the new Attorney General.  Shouldn't we expect some technological improvements and the resultant savings to passed along consumers?

Wednesday, March 04, 2015

Are you a clumper or a splitter?

The Economist reports about an experiment in the National Health Service:

On February 25th it emerged that local authorities, clinicians and George Osborne, the chancellor of the exchequer, were proposing to transfer control of the £6 billion ($9.3 billion) of public money spent on health care in Greater Manchester to local hands. They want to create a health and wellbeing board, made up of NHS and local-government representatives, to administer a single budget for the conurbation. A trial version is expected to take shape in April. 

The city region’s doctors and hospitals will still be bound by national targets for things like waiting times, and subject to national regulations and inspections, but the board is a welcome idea nonetheless. It is bottom-up, pushed by local figures rather than imposed by the government, and it advances two positive trends.

The first is the integration of health and social care. Long-term conditions like diabetes, dementia and depression are now responsible for 70% (and rising) of Britain’s state health-care spending. They require a mixture of medical and non-medical attention.  

The second positive trend is that regional conurbations are becoming more powerful. Manchester has led the way: in 2011 ten local councils in and around the city formed a “combined authority” to manage services and infrastructure jointly.

But the initiative will also test Britons’ willingness to tolerate regional variation (or “postcode lotteries”, as tabloid newspapers call it). Andy Burnham, the opposition Labour Party’s shadow health secretary, warned that Manchester’s proposals could turn the NHS into a “Swiss cheese”, with some parts more autonomous than others; taking the “national” out of the National Health Service. 

The newspaper concludes:

Public services can be nationally uniform or locally accountable. They cannot be both.

Whether you live in the UK or not, what's your take?  Is this a good approach or not?  How would you measure success? Does it matter whether we consider the short term or the long term?

Tuesday, March 03, 2015

Darzi fellows at Royal Brompton

It was such a pleasure to meet four of this year's holders of Darzi Fellowships in Clinical Leadership, a program named in honor of Ara Darzi, one of world's leading surgeons at Imperial College London, who also devoted time during his career to the public service, as noted here:

In December 2006 NHS London asked Darzi to "develop a strategy to meet Londoners' health needs over the next five to ten years" and so his report Healthcare for London: A Framework for Action was published on 11 July 2007. Largely implemented, it recommended the development of academic health science centres and the introduction of more primary services in one place: polyclinics. The plan for moving care from hospitals to GP-led polyclinics was largely thwarted by GP opposition, but his call for trauma, acute stroke and heart attack services to be centralised in specialist units achieved was seen as successful and was widely copied.

The fellowship named in his honor:

is one of the most successful clinical leadership development programmes in London, with over 200 Fellowships having been awarded to date. This innovative programme provides a cohort of clinicians, who are typically in the early stages of their career, with a unique opportunity to develop the capability necessary for their future roles as clinical leaders.

Fellowship posts are twelve months in duration and require that time away from normal work or training.  Over that time fellows work on a major project (or in some cases a number of projects) covering service change, quality and safety improvement or leadership capacity building, under the guidance of a nominated sponsor - usually a Medical or Clinical Director or equivalent.

Seen above are the four fellows in residence at Royal Brompton & Harefield NHS Foundation Trust, where under the guidance of individual mentors and Dr. Libby Haxby, lead clinician in clinical risk, they are pursuing areas of interest to them and their hospital. They are an impressive group, who will surely be among the clinical leaders of the future.  From the left:

Julian Lentaigne, respiratory and intensive care medicine, whose project is "Improving communication and aftercare on discharge from intenisve care."

Andrea Fischer, pharmacist for critical care, whose project is "IT-system design across the hospital; improving digital care records."

Claire Boynton, anaesthetics and ICU, whose project is: "Customer service improvement in ICUs."

Elsa Ng, pediatric cardiac pharmacy, whose project is "Digital care records: Change management."

Monday, March 02, 2015

Buffett explains private equity

As I read this excerpt from Warren Buffett's annual letter to shareholders, all I could think of was the private equity acquisition of the Caritas Christi health care system.  As I have noted, this transaction will have a tail that will leave Massachusetts policy-makers with difficult choices.  Just think of the implications of a hospital system being considered "a piece of merchandise."  What plans are being made now to protect the provision of essential health care services in several Massachusetts communities?

When owners wish to cash out entirely, they usually consider one of two paths.  [A competitor or] the Wall Street buyer. For some years, these purchasers accurately called themselves “leveraged buyout firms.” When that term got a bad name in the early 1990s – remember RJR and Barbarians at the Gate? – these buyers hastily relabeled themselves “private-equity.”

The name may have changed but that was all: Equity is dramatically reduced and debt is piled on in virtually all private-equity purchases. Indeed, the amount that a private-equity purchaser offers to the seller is in part determined by the buyer assessing the amount of debt that can be placed on the acquired company. 

Later, if things go well and equity begins to build, leveraged buy-out shops will often seek to re-leverage with new borrowings. They then typically use part of the proceeds to pay a huge dividend that drives equity sharply downward, sometimes even to a negative figure.

In truth, “equity” is a dirty word for many private-equity buyers; what they love is debt. And, because debt is currently so inexpensive, these buyers can frequently pay top dollar. Later, the business will be resold, often to another leveraged buyer. In effect, the business becomes a piece of merchandise.

If patients only knew

Austin Frakt and Aaron Carroll offer this fantastic perspective on patients' lack of knowledge about the relative risks and benefits of common treatments.  The conclusion:

Even though some patients may benefit somewhat from being ill informed, it seems wrong to argue that we should keep them in the dark. Many of the studies in the systematic review show that people report that they would opt for less care if they better understood benefits and harms. Improved communication could better serve patients and might improve the efficiency of our health system if patients focus on getting the types of care for which the benefit outweighs risk of harm.

It’s also possible that unrealistic expectations of care help patients cope with disease or provide them with some sense of control. Feeling hopeful about one’s future is not to be dismissed. But those unrealistic expectations don’t come cheap. We should at least consider the price that we pay for being uninformed.

Brandi speaks out on heading in youth soccer

I've never met Brandi Chastain, but I've admired her playing for years, and now I have discovered that we agree on a major issue with regard to youth soccer--heading.  Her observations--that heading in soccer should be removed for players aged 14 years and younger, although training in heading technique could start at younger ages with appropriate pedagogy and protection--are a refinement on the points I have written about before.

Check out this PBS Newshour story here and watch her video interview here:

Sunday, March 01, 2015

Medical students see hospice up close

Photo by Gabe Souza, Portland Press Herald
Here's a wonderful story from University of New England medical school in Maine by Kelley Bouchard at the Portland Press Herald.  It relates the experience of pairs of medical students who chose to spend some deep immersion time at Gosnell Memorial Hospice House. (One of the students, Caitlin Farrell, is an alumna of the Telluride Patient Safety Camp.)

McVan and Farrell are among four students in UNE’s College of Osteopathic Medicine in Biddeford who, at their own request, spent recent weekends living and working at the home for terminally ill patients. The pilot Hospice Immersion Project provided unique exposure to end-of-life care in a nation whose medical schools are giving short shrift or largely ignoring a growing demand for training in long-term, palliative and hospice care. It also was an intense introduction to the realities of dying and death for students on the cusp of becoming physicians.

Admitted in pairs, the second-year med students spent two days learning from hospice staff and helping to care for patients and their families. They stayed in suites where people had died and their loved ones mourned. They followed nurses and physicians on their rounds and journaled about what they saw and heard. They got to know patients and their families and learned what it takes to care for people in their final hours.

There were some surprises:

“I was surprised how uplifting it was,” Gaul said. “Of course it was sad, witnessing the loss of each patient, but it also was a celebration of each patient’s life. The communication and the energy that each nurse and physician brought to each patient was amazing. It was beautiful to see.”

The students then reported back on their experiences to their classmates:

Farrell urged her classmates to be compassionate but honest with their patients when dealing with issues related to death and dying. And to embrace and promote hospice care as a way of experiencing death as a natural part of life.

“We don’t have a choice in this,” Farrell said. “We have to have these conversations. We as physicians can’t act out of fear.”

Pledging for quality in Australia

It's only 11 days, or 10 days, or 9 days till Change Day 2015 (March 11) in Australia.  I'm not sure how many days are left because that darned International Date Line always gets me confused.  (Maybe that's why Australia often beats America to the punch in terms of safety and quality improvement in hospitals: It has a one day head start!)

In any event, it's not to late to join in (locally or vicariously) with Mary Freer and the other organizers.  Well over 13,000 people have done so, and the range of pledges is remarkable.  Here's the gallery.

Here's a good personal one from Margie Grant in Victoria:

To always find out the “patient story.” Remember they are a person first and their illness is second.

In contrast, here's one from a big group:

The Australasian College for Emergency Medicine (on behalf of its 4265 Fellow and trainee members) pledges to promote the implementation of our Quality Standards for Emergency Departments to support EDs in improving the care they deliver to patients requiring emergency care in Australia.  

Alone or together, your ideas can make a difference to the quality of care in Oz.  Take a look and make a pledge.

Saturday, February 28, 2015

Lady, Janes is a winner

Way back in June 2012, I wrote about Sharon Linder's new company, GetJanes, which produces comfortable and appropriately fitted examination gowns for women.

It's time for an update.  Sharon writes:

Long story short...I have sold Janes throughout the country, they are featured on The Grommet ( and can be found in many VA Medical Center Women's Programs. Because Janes have given women so much comfort, there is nothing more rewarding for me. We continue to donate partial profits to fund free mammograms for under served women.

I'm so pleased, as this appeared to me from the start to be a great product.  Oddly, though, I don't hear about much use of them in Massachusetts hospitals, just a few miles from the company's Rhode Island headquarters.  I'd say this is worth a look by our local folks.

Meanwhile, for old times sake, check out this video:

Thursday, February 26, 2015

Beryl Institute surveys your experiences

The Beryl Institute are conducting their 3rd biennial survey on the topic of the “state of patient, resident and family experience in healthcare.”  They would love to spread the survey and get as much participation as possible from as many folks as possible – here’s the link.

Now seeking national nominations for compassionate caregiver award

It's time for nominations for the Schwartz Center's National Compassionate Caregiver of the Year Award.  Note the new inclusion of "national" in the title, as the center spreads its wings and offers this opportunity to people throughout the country.

Here's the description:

The Schwartz Center National Compassionate Caregiver of the Year (NCCY) Award is a national recognition program that elevates excellence in compassionate healthcare. Every year since 1999, the Schwartz Center has honored outstanding healthcare providers, who display extraordinary devotion and compassion in caring for patients and families.

This year’s expansion of the award coincides with the Schwartz Center’s 20th anniversary. Our two decades of growth and momentum has enabled us to expand our compassionate care community and grow the national movement to support and value compassion in healthcare.

The deadline for nominations is May 1.

Wednesday, February 25, 2015

Pediatrics on WIHI

Madge Kaplan writes:
The next WIHI broadcast — Topping the Charts in Pediatrics and Adverse Events Reporting — will take place on Thursday, February 26, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:
  • Adebisi Alli, DO, MS, Chief Resident in Quality & Patient Safety, Department of Internal Medicine, Banner-University Medical Center, Phoenix VA Healthcare System
  • Gareth Parry, MSc, PhD, Senior Scientist, Institute for Healthcare Improvement (IHI)
  • Lori Rutman, MD, MPH, Attending Physician, Division of Pediatric Emergency Medicine, Seattle Children’s Hospital
  • Angela Statile, MD, MEd, Attending Physician, Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center
Thirty-two abstracts and 56 posterboards were shared at IHI’s 20th Annual Scientific Symposium this past December. At the end of the day, the audience voted three of these as the best for clarity of presentation and strength of research. The leaders of the teams behind the winning presentations are gathering to talk about their work on the February 26 WIHI: Topping the Charts in Pediatrics and Adverse Events Reporting. We hope you’ll tune in.

IHI’s Senior Scientist Gareth Parry, who runs the Scientific Symposium, will kick off our discussion with some framing about the state of health and health care improvement science in the US and globally. He’ll also set the stage for us to hear about the three winning presentations of exemplar initiatives: a multi-year effort at Seattle Children’s Hospital to improve the care pathways for children suffering from chronic asthma; the successful implementation of new processes at Cincinnati Children’s Hospital Medical Center to reduce discharge-related waits and delays for children with complex medical problems and illnesses​; and the creation of a medical resident-led consultation team at a Veterans Administration Medical Center to increase the number of error reports submitted by residents and to ensure that safety concerns are addressed.

You’ll hear all the details on WIHI, including the most recent data about each improvement endeavor. As we’ll learn, the work continues to show gains and demonstrates how new processes and pathways can be sustained. Come treat yourself to some leading improvement science research, shared by some leading improvement researchers.

Riess delivers on empathy

Empathy is a fashionable topic, but the discussion surrounding it is often a bit touchy-feely, short on rigor.  In contrast, I recently came across this excellent TEDx talk by Helen Riess delivered at Middlebury a bit over a year ago.  It's 17 minutes are worth watching in several respects--thoughtful, understated, and substantive.

Helen is local, based at MGH, so I gave her a call and she told me about some of her activities.  With the encouragement of her hospital, she's started a firm called Empathetics, which is conducting training for clinicians based on her research. You see, empathy isn't just about feeling warmth and connection: The emotional connection also has roots in neurobiology and physiology.  Helen has taken what she and colleagues have learned about these aspects of empathy and have integrated them into a training protocol grounded in neuroscience that can achieve improvements in the clinical process and outcomes.  As noted:

Empathetics offers novel training based on the neurobiology and physiology of human interactions that improve interpersonal behavior benefiting both patients and clinicians. Empathetics training enables accurate interpretation and translation of emotional communications, resulting in greater trust, safety and satisfaction for patients and medical professionals.

For those concerned about the rate of malpractice asserts, it is worth noting, too, that, "Over 80% of malpractice claims are the result of communication failures, and the likelihood of an unhappy outcome is correlated to low physician empathy."

Helen is a scientist-clinician.  She put her approaches through a randomized control trial at MGH.  She concludes:

Providing empathic care does not necessarily increase cost or time with patients. In fact, empathic interactions with others can actually save time and be more effective using the techniques in our training.

I have no financial interest in this company, but it seems to me that the methods and approaches offered by Helen and her colleagues are worthy of consideration by a broad range of health care provider organizations.

Tuesday, February 24, 2015

A gracious witness dies

Every CEO knows that he or she is totally dependent on one's administrative assistant to get you through the day, the week, the year . . . and maybe your life.  Well, in my case, I also had an AA--Gail Serra--who had a remarkable ability to give me the most meaningful Christmas/Chanukah gift each year.

One of the best examples was in 2009 when she arranged with with Facing History and Ourselves for me to have a personal visit with Dr. Maurice “Ries” Vanderpol.  I later wrote about the visit on my blog, here.

I recently heard from Gail learned that Ries died this past fall, as noted by FH&O.

As I look through my old blog post, I was struck by a comment from Patricia Ruane, about how Ries demonstrated that life experiences in one setting can be useful in another:

"Ries" brought his sage advice and wisdom to the aid of the principals and leadership team of the Brookline Public Schools, where he helped create a safe place for difficult discussion and conflict resolution. He invented a model of reflective practice that has been replicated by superintendent support groups throughout Massachusetts over the past 25 years. He is an inspiration and a resource for all generations.

I mourn his passage but I know I join many who were so grateful for the special times we had together.

The preemie grows up

One of my favorite blogs, going way back to 2007, was "The Preemie Experiment," written by Stacy Carney Harbst.  How could you not be engaged by this story?

The day my water breaks, with my first pregnancy, I was 23.0 weeks pregnant. The experiment begins as soon as I am admitted. I was told that I would go into labor within 24 hours. When that didn't happen a neonatologist came into my room to tell my husband and I that our daughter will never be normal if she is born before 26 weeks and that she would most definitely have disabilities. He told us that we should just hold her and let her die in our arms. He was even willing to make sure our wishes would be carried out in the delivery room.

When we refused to give up, I was moved to another hospital with a NICU that was able to care for micropreemies.  

The experiment received their next participant the day our daughter was born-at 25.5 weeks, weighing in at 1 pound 12 ounces and 13 inches long. Post natal steroids for her-not being sure on the dosage-they just guess (based on past participants). So many tests for her lead to many blood transfusions. X-rays, ultrasounds, exams... all part of the experiment. Central lines, TPN, IV's-all without any pain meds. Is this humane? Alarms blare, phones ring, people talk loudly around the babies. All part of the experiment.

That was 8 years ago. She walks, she talks, she is advanced in some areas of school. She is beautiful. Hardly an outward sign of her prematurity.

A success?

Not if you ask her. She is in physical pain daily thanks to mild cerebral palsy. Headaches. Seizures. Major sensory issues. Can't write long due to fatigue and pain in her hands. Severe OCD. Pain in her eyes from the scar tissue. Has thoughts of killing her parents and her brother, and even herself. Tics. Chronic constipation. Yellow adult teeth. Reflux that has put holes in her teeth. Years of physical therapy. More tests. Lots of blood tests. Etc... blah, blah, blah.

Our heart aches for our daughter. I don't know what life would be like without her. I just can't bear to think what life will be like *for* her.

Stacy's last blog entry was in November 2011, when Paige turned 13:

I did it! We celebrated Paige's 13th birthday and I didn't cry the entire day!

Well, this note arrived a couple of weeks ago:

Dear Mr. Levy,

We are high school students in a Health Informatics class doing a project on medical errors in healthcare. Considering your background, we have decided to email you to ask if you are available to Skype. Our names are Paige and Alex, and we know about your background through Stacy (Paige’s mom) blog and have decided to contact you to ask you about medical error situations and what your take is on how to fix them. Thank you for your time. 

Paige and Alex

So welcome to Paige at age 16! It was supposed to be a Skype call; but their teacher Karen Smith (a very accomplished nurse, by the way) is, in her words, "a rookie," and inadvertently locked herself out of the Skype account for 24 hours (!). So we used an old-fashioned telephone line, as seen here, from Shelby County Area Technology Center in Kentucky. (Alex, unfortunately was ill.)

The girls have started a blog about patient safety issues.  Check it out here.

We had a great talk, and I hope they find it to be useful material for their blog and beyond.  In the meantime, I am happy to report that "the preemie experiment" was a huge success.

Monday, February 23, 2015

$500K in medical waste--per week!

Here's what half a million dollars in medical waste looks like.

Shown below are the full page advertisements bought by hospitals in this week's New York Times Magazine. According to the current rate sheet, the cost per ad is roughly $100,000.

That's about $500,000 in useless expenses just in one week.  And it happens every week in this magazine.  Before you say, "Well, it must make business sense," let me assure you that, for the academic medical centers, they are mainly ego-gratifying sops for boards of trustees and doctors.

Time to nominate Sepsis Heroes

Its that time again, when the Sepsis Alliance is seeking nominees for its annual Sepsis Heroes awards:

Do you know of a person who deserves to be recognized for his or her work in raising sepsis awareness? Do you know of an organization that has gone the extra mile to help educate people about sepsis? If so, we want to hear from you!

The deadline for nominations is April 15.

Details are here.

Sunday, February 22, 2015

Wachter offers The Digital Doctor

Only a person with the experience, depth, and judgment of Robert Wachter could take on the task of summarizing the impact of the digital age on the practice of medicine.  But very few people who might have such experience, depth, and judgment would have pulled it off as well as he has.

The book is called The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine's Computer Age. It will be published in April, but you can pre-order it here, and well you should.  Bob is by no means a Luddite, but he is also not shy in presenting the disadvantages of the digital age. His goal, though, is to help us through this transition so medicine might actually work better in the future.

Read the summary over at Amazon.  Meanwhile, I'll give a few excerpts so you can get a sense of the substance and style--and the book has plenty of both.

On how computers in the exam room can affect the relationship between doctor and patient, he notes that several studies have confirmed that eye contact is associated with higher levels of perceived empathy and connection. To make the point, he gives the counter-example:

A colleague of mine, a successful physician-entrepreneur in his late sixties, recently told me about a visit to his primary care doctor after a long hiatus.  "I had seen him a few years earlier, and I like him," he said.  "But this visit was entirely different.  This time, he asks me a question, and as soon as I begin to answer, his head is down in his laptop.  Tap-tap-tap-tap-tap.  He looks up at me to ask another question. As soon as I speak, again it's tap-tap-tap-tap."

"What did you do?" I asked.

"I found another doctor."

On the effect of PACS, the computerized radiology imaging system--the first widespread adoption of computers in medicine--which led to isolation of radiologists.  Visits from other clinicians, once the norm, dropped to nothing. Indeed, interactions between and among radiologists themselves did likewise.

The radiologists were lonely, sure, but their situation involves something far deeper. Hari Tsoukas . . . highlights the distinction between "information" and "knowledge." Information, he wrote, "consists of objectified, decontextualized, time-less, impersonal, value-free representations," whereas knowledge is "context-dependent, personalized, time-bound, and infused with values." . . . The emergence of PACS left radiologists information-rich but knowledge-poor.

On the contractual hold harmless clause that exists in so many EHR business deals, rendering the companies virtually liability free even when their products may have contributed to patient harm:

The vendors' case seems like a version of the "guns don't kill people, people kill people" argument: errors reflect poor implementation practices or screw-ups by users. This is certainly true at times, but . . . there are scores of errors that are all but inevitable given clunky software, including poor user interfaces.  It seems right that the vendors would at least share responsibility if patients were harmed in such circumstances.

And on the nondisclosure clauses that prohibit sharing of defects and the like in IT systems:

EHRs are not simply business applications--they have become the tools that we use to take care of our patients.  It is high time we reconciled these conflicting worldviews and threw our weight behind the transparency we need to keep patients safe.

And, while giving great credit to both organizations and their contributions to the industry, on the current schism between Epic and athenahealth:

Epic and all the other vendors and providers need to be pushed toward a common standard that supports sharing, accompanied by a set of incentives and penalties to promote total connectivity. It should be easy for physicians to choose an office-based and relatively inexpensive EHR like athena and have it link up to their hospital's Epic system, or any of the equivalent inpatient products.  Today it is not.

And then, finally, the reconciliation between humans and machines, reflecting Bob's deep knowledge of clinical process improvement:

The measure of a safe organization is not whether the person who makes the great catch gets a thank you note from the CEO.  Rather, it's whether the person who sees something that seems to be amiss and decides to stop the line receives that  note . . . when there wasn't an error.  If the organization is not fully supportive of that person, it will never be completely safe, no matter how good its technology.

Bravo! Pre-order order the book now here so you can be pleasantly surprised by the package's arrival in April and so you can read it before your colleagues. It will be the talk of the town everywhere in the country, and beyond.

Saturday, February 21, 2015

Dear Mayo, Now let's look at your MS Google ad

A few days ago, I asked if the Mayo clinic was exercising any kind of quality control over Google health care search results, which are reportedly now part of a joint venture between the two companies.  As noted on the official Google Blog:

All of the gathered facts represent real-life clinical knowledge from these doctors and high-quality medical sources across the web, and the information has been checked by medical doctors at Google and the Mayo Clinic for accuracy.

Following that post, E-Patient Dave deBronkart offered a remarkable comment that dramatically expanded on my points. He noted:

Something is very wrong here, and after 15 minutes of digging, so far it smells to me like Google is playing fast and loose with the Mayo name. It almost seems willful to me, because Google is VERY conscious (at an expert level) of the power of what people see first. 

The wording "checked by Mayo" is fishy - as you say, it doesn't stipulate what that means, and as I say, Google is fully aware of the power of what meets a reader's eyes first.

Today over on Twitter, Elin Silveous (@ElinSilveous) pointed out another serious misrepresentation with regard to Multiple Sclerosis. Posting a screen shot (like that seen here) from her Google search, she noted:

More questionable Google health search: MS 200,000-3 Million U.S. cases/year. Not! 

I did a little research and reviewed the National MS Society website, where I found the following answer after the question, "How many people have MS?"

More than 2.3 million people are affected by MS worldwide (my emphasis.)

Veronica Combs (@vmcombs) watching this tweet fest, responded:

Interesting. But I suspect Google's motive is to increase targeted ad opps, not educate consumers.

Well, maybe so.  But this issue here really isn't Google, is it?  It is that Mayo Clinic is allowing its name and reputation to be used in a manner inconsistent with the high standard of medical knowledge and care for which it is rightly known. The search clearly says, "Sources: Mayo Clinic and others."  Mayo's business deal with Google gets it top billing on all these millions of searches. Google, in turn, gets the imprimatur of the Mayo name.

The question remains:  What's up?  Who's in charge of this over at Mayo? Why are they letting this happen?

Friday, February 20, 2015

CRE, ERCP, FDA, but not you and me

I was struck by the need for an FDA announcement to users of duodenoscopes—the endoscopes used in endoscopic retrograde cholangiopancreatographies, or ERCPs--that they should be extra careful about cleaning the scopes to avoid transmittal of drug resistant bugs.

So I asked a friend who is a world expert in ERCPs.  This MD said, "This is specific to ERCP scopes as an enclosed wire channel for the elevator makes access difficult despite following all manufacturer's recommendations.  We have been aware of this and very proactive for a long time."

Well, and now, according to an article by Steven Ross Johnson at Modern Healthcare, the folks at UCLA say the FDA recommendation may not do the trick:

The FDA advised that strict adherence to manufacturers' instructions would minimize the risk of infection.

But according to Dr. Zachary Rubin, UCLA Medical's director of clinical epidemiology and infection prevention, his hospital's bacteria outbreak and several others involving duodenoscopes suggest the problem may lie with the recommendations from product makers.

UCLA officials said their investigation found no deficiencies in the facility's internal cleaning processes for the devices and that the staff fully adhered to the manufacturer's recommendations on properly sterilizing them.

“The fact that we've identified this infection in a couple of different hospitals now suggests that the routine process we were using was just not quite adequate even though at the time they were FDA approved,” Rubin said.

After Jan. 28, the hospital began using more stringent sterilizing measures and has seen no subsequent cases of infection.

Wow.  The questions this raises go on and on.

How can the device have been allowed on the market by the FDA without a thorough review of this issue?  After all, it is well known that the scope is going to travel through the stomach and beyond each time it is used.  Why wouldn't the agency insist that the manufacturer's recommendation about sterilization at the time the product entered the market be sufficient?

If, as UCLA suggests, the the manufacturer's recommendation are not sufficient, why is the FDA not insisting on more rigorous approaches even now?

If some people in the field already recognized this problem, like my friend, why didn't the GI medical association promulgate the news to its members?  It just published this johnny-come-lately article.  This might be a good time to ask whether the AGA or its faculty receive funding from scope equipment manufacturers.  Of course they do, as noted here.

At what point should the FDA recognize a problem and send out an advisory?  It notes, "In total, from January 2013 through December 2014, the FDA received 75 MDRs encompassing approximately 135 patients in the United States relating to possible microbial transmission from reprocessed duodenoscopes." What is the appropriate standard of review and action in such matters?

The FDA said:

The agency is continuing to evaluate information about documented and potential infections from multiple sources, including Medical Device Reports (MDRs) submitted to the FDA, the medical literature, the health care community, professional medical societies, and the Centers for Disease Control and Prevention (CDC).

But here's a poster from the University of Pittsburgh suggesting that the usual level of disinfection was known to be inadequate.  Amusingly, one manufacturer, Olympus, suggested that the failure to clean was from use of a competitor's scope washer.  The investigators found, to the contrary, that this was not the cause, and that a higher level of disinfection than recommended by Olympus was necessary to avoid the transmittal of bacteria.

So, people knew about this problem:  MDs, the AGA, the FDA, the manufacturers.  Everybody but you and me.  If you go to Wikipedia, bacterial infection isn't even included as a common risk of the procedure.

I wonder if the "informed consents" used by GI doctors have included this other risk.  That University of Pittsburgh paper noted: "Post-ERCP bloodstream infections (BSI’s) and biliary tree infections are reported after 1-3% of procedures."

I fear we have been let down by the profession, the equipment manufacturers, and their regulators.

MIT SDM: Democratizing Innovation and Product Design

Webinar: "Democratizing Innovation, Product Design and Development, and Technology Strategy"
MIT SDM Systems Thinking Webinar Series
Ali Almossawi, Data Visualization Engineer, Mozilla; Author, An Illustrated Book of Bad Arguments; and SDM Alumnus

Date: February 23, 2015
Time: Noon–1 p.m. EST
Free and open to all

In this webinar, SDM alumnus Ali Almossawi will discuss the benefits of expanding the creative process through open-sourcing on the Internet, where there are more creators, fewer industry gatekeepers, and endless opportunities to engage directly with users. He will:
  • describe a model for open-sourcing the creative process and how it can be used to build a self-sustaining product or business;
  • outline the key players—often a combination of professionals with expertise in technology, business, and/or design;
  • discuss what is needed for team members to work together effectively—and the pitfalls to avoid;
  • provide examples of failure, success, and failure leading to success; and 
  • offer next steps that can be adapted and applied across all industries.

A Q&A will follow the presentation. We invite you to join us!

Thursday, February 19, 2015

Sshh: Moms and dads are resting

I really enjoyed this story by Steve Rukavina at CBC News about a Montreal hospital that has introduced "quiet time" in its maternity ward.  Perhaps this exists in other places, but I have not been aware of it if so.  It seems like a great idea to me.  Here are excerpts:

St-Mary's Hospital in Montreal will become the first hospital in Canada to implement a daily "quiet time" in its maternity ward to give frazzled parents of newborns a bit of a break.

The hospital is teaming up with researchers from McGill University to launch the project. The idea is to set aside 90 minutes each afternoon where lights are dimmed, the intercom is turned off, and visits from nurses, doctors and orderlies are suspended except for emergencies.

Here's an explanation from a student who's been working on the experiment.  Note the focus on both parents:

Over the last few weeks, Safina Adatia, a graduate student in family medicine at McGill and one of the researchers who's helping to set up the project, has been measuring decibel levels in the maternity ward.

Adatia says the World Health Organization recommends a level of 30 to 40 decibels for maternity wards — about the same noise level as a quiet street.  She says the maternity ward at St-Mary's regularly exceeds that.

"There's a lot of stress and anxiety when there's a lot of noise happening, so having an actual set amount of time will help show mothers that it's important to set aside an hour or two hours a day to make your own self-care really important," Adatia said.

"Reducing stress and anxiety during that time can lower cortisol (stress hormone) levels, and generally just improve the mood and create more bonding time and attention with the baby."

Mothers will be encouraged to schedule their feedings outside of the quiet time, so that they can be sure to dedicate that time to taking care of themselves, taking a nap, or having a nice uninterrupted cuddle with the new little one. Adatia says its important for new dads to take time out to rest as well.

Wednesday, February 18, 2015

The muscle of thoughtfulness

The New York Times' Frank Bruni offers a lovely column on the value of higher education (“College, Poetry, and Purpose"). Eschewing current trends that focus on the commercial value of college, Bruni returns to his favorite professor, Anne Hall, who, he recalls, taught that “with careful examination and unhurried reflection, we could find in Shakespeare just about all of human life and human wisdom: every warning we needed to hear, every joy we needed to cultivate.”  He now asks her, “What’s the highest calling of higher education?”

He reports, “She answered my question about college’s purpose, but not right away and not glibly, because rushed thinking and glibness are precisely what she believes education should be a bulwark against.”

Finally she says, succinctly, “It is for developing the muscle of thoughtfulness, the use of which will be the greatest pleasure in life and will also show what it means to be fully human.”