Health Courts – A Reasonable Answer to the Malpractice Problem

I met a new patient last month that came to me because she needed to find a new internist.  When I asked why she responded, “Because I have to sue my last one.”

 

I’m sure it doesn’t surprise you to know that this is not the quickest way to endear yourself to a new doctor!  But as I always try to practice Stephen Covey’s advice to “seek first to understand and then be understood” I asked about the specifics of the situation.  As it turns out, this poor 59 year old woman was advised by her internist to have a mammogram performed.  Some of you may remember the controversy over whether annual mammograms were cost effective given how many “abnormal” mammograms turn out to be nothing but radiological artifact.  These “false positives” result in many healthcare dollars being spent in unnecessary evaluations and lots of emotional angst on the part of the women involved, but when you do catch an early breast cancer that saves a woman’s life, the joy is so profound that it’s hard to focus on economic practicality.

 

But as usual, I digress!  After this woman’s mammogram was found to be abnormal her internist referred her on to a surgeon for a biopsy, per the usual protocol.  The surgeon presumably evaluated the flim and performed an FNA (fine needle aspiration) in the office.  With every abnormal mammogram the following decision tree is faced in a surgeon’s mind….

1) Am I worried enough based on the radiologic appearance to just cut the whole thing out? (Which requires outpatient surgery in the hospital, anesthesia, recovery from surgery, and a permanent scar….)

2) Am I a little worried such that I will do a stereotactic biopsy with ultrasound guidance (Which requires assistance from a radiologist, an invasive biopsy with a large bore needle requiring more significant anesthesia, and more post-op pain…)

3) Based off the picture on the film I am not too worried and I will do the procedure with the least cost and least trauma to the patient (FNA) and follow the abnormality every 3-6 months with repeat exams and mammograms.

Perhaps this seems like an easy decision for some of you, but I assure you there are many shades of grey (pun intended!) and the decision is always tough.  As a woman who has had two breast masses and has had to personally undergo this decision tree knowing way too many scary things, I will share that once I chose excision, and once I chose FNA.  Never an easy choice.

 

In this woman’s case, FNA was advised and follow up was prescribed. Unfortunately, before her prescribed follow up, she noticed that the lesion seemed to have changed and was definitely larger.  She went back to the surgeon who now excised the lesion and found an advanced, aggressive cancer that had already invaded four lymph nodes.  This poor woman now had to undergo a complete mastectomy, chemotherapy, and radiation, and still has to live with the possibility of a recurrence.

 

Is the surgeon at fault in this case?  I honestly have no idea.  I never saw the original film, and I didn’t watch him perform the FNA.  Does this woman have the right to investigate whether she is the victim of malpractice?  Absolutely.  Was this more likely a case of playing the odds and losing?  Probably.  But what I was more confused by was the internist’s role in this story.  The woman admitted that she thought her old internist was great, always reminded her to get an annual mammogram, sent her right back to the surgeon when she voiced her concern, but “my lawyer told me I had to sue him”.

 

This, my friends, is the crux of the problem.  When a lawyer takes a case they drag EVERY physician involved in the patient’s care because then they can access more money for the client by cashing in on each doctor’s insurance policy.  It’s not about who’s right or wrong.  In too many cases it’s about how the lawyer can secure the biggest reward for themselves (and by trickle down, the patient).   In my last posting I aligned myself with the Democrats in terms of health care, but will now share that I am very disappointed that they will not embrace tort reform.  Historically physicians (and Republicans) have been asking for a cap of $250,000 to be placed on non-economic damages.  Traditionally, Democrats have opposed placing any sort of caps on damages, supposedly because they believe this will inhibit injured parties from receiving the just compensation they deserve, but the reality is that many of the elected candidates from the Democratic party made their money from malpractice litigation, and they are not going to bite off the hand that’s fed them.  So I swallow this.  I support the Democrats because their health plan is getting us headed in the right direction, but tort reform has not been addressed at all.

 

The American College of Physicians recognizes that this is a serious problem and drafted a “Health Courts Rescue Act of 2012” that provides a framework for legislation that authorizes a national pilot of no-fault health courts.  A section by section summary of the framework can be found at http://www.acpservices.org/leadday12/agenda/10.pdf

 

No-fault health courts would provide a new system to resolve medical malpractice claims by utilizing an administrative process and specialized judges, experienced in medicine and guided by independent experts, to determine cases of medical negligence without juries.  The idea that an average citizen, untrained in medical language let alone medical knowledge, can decide if there has been malpractice is ridiculous.  Even judges, who pass a certain intelligence criteria by graduating from law school and passing the bar, cannot be expected to be medical experts! We already have specialized judges in tax court, bankruptcy court, and family court.  Why don’t we have specialized judges for health courts?!  This not only better protects good doctors, but also protects patients.  In today’s system, two patients with the same story can have wildly different outcomes based on which jury and/or which judge their case is heard by.

 

Health courts would provide fair compensation for injuries caused by medical care, reduce costly and time-consuming litigation, reduce malpractice liability costs, provide guidance on standards of care, reduce the practice of defensive medicine, and improve patient safety.  The health court model is predicated on a “no fault” system, meaning compensation programs that do not rely on negligence determinations.  The central premise behind no-fault is that patients need not prove negligence to access compensation.  Instead, patients must only prove that they have suffered an injury that was caused by medical care, and that it meets the severity criteria.  The goal of the no-fault concept is to improve upon the injury resolution of liability.

 

So when I was in Washington last month, we actively sought a member of Congress in both chambers to introduce the ACP’s Health Courts Rescue Act of 2012.  We believe that authorizing a pilot on health courts provides an opportunity to break the gridlock in Congress concerning medical liability reform.  Before I close, since I did imply that some powerful Democrats refuse to cap noneconomic damages for self-serving reasons, I also feel compelled to inform my readers that President Obama is not included in this group.  In fact, President Obama included funding for pilot projects for health courts in his Fiscal Year 2012 budget.

 

So if this post has moved you, please write to your congressmen/women and ask them to introduce the ACP’s Health Courts Rescue Act of 2012.  Every trip I make to Washington confirms that the key people making the key decisions do not even know where to look all the time for revolutionary ideas.  I do think the aides read their email, and you never know when your plea may land on the right eyes or ears at the right time!

 

 

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The Affordable Care Act and Landmark SCOTUS Decision Explained

What an exciting week with the SCOTUS decision regarding the personal mandate! To summarize for those not glued to the coverage of this event, the Supreme Court decided that the Affordable Care Act, including its individual mandate that virtually all Americans buy health insurance, is constitutional.  The penalty that an individual who chooses to go uninsured must pay is considered to be a kind of tax that Congress can impose because of its taxing power.  Because the mandate survived, the Court did not need to decide what other parts of the statute were constitutional, except a provision that required states to comply with new eligibility requirements for Medicaid (covering everyone that is below 133% of the poverty level) or risk losing their funding.  On that question, the Court held that the provision was constitutional as long as states would only lose new funds if they didn’t comply with the new requirements, rather than all of their funding.


I personally believe that since all citizens will utilize healthcare at some point in their lives, all citizens should have to contribute to the healthcare spending pool.  It’s no wonder our system can’t pay for services when so many healthy people are choosing to not buy insurance out of the misguided hope that they will not need to utilize healthcare at some point.  The analogy I always make is how long would a home owner’s insurance company stay in business if only people planning on burning their homes down this year buy a policy?!? We need those NOT immediately cashing in on the system to be paying in so that there is money to pay for those who are using it.  When these same “investors” ultimately need healthcare, those who are healthy will in turn fund their care.  It is the ultimate “pay it forward” philosophy.


But obviously NOTHING is ever this simple.  In addition to providing access to care, we need to make sure we are training an adequate number of qualified physicians to meet this need.  We need to make sure these doctors are coming out trained to manage a complex healthcare delivery ecosystem where understanding the needs and expectations of the consumer (aka “patient”) is as important as knowing how to treat the disease process.  As Atul Gawande says, physicians can no longer operate as cowboys, they need to function in the health care arena as an efficeint pit crew, which requires understanding their roles and responsibilities as part of a team, not as a savior.  In the words of healthcare cousultant Paulo Machado (@pjmachado), doctors now need to function as health care sherpas – badass mountain climbers with backs like armadillos that can use their knowledge of the healthcare system to lug the patient and their family up the mountain towards maximal health and wellbeing.  Like the sherpas in Nepal, this is not a glamorous job.  Nepalese sherpas are rarely on the camera in National Geographic films and do not get to stay in comped hotel rooms like the researchers they are serving.  But lugging all that gear is one of the most critical jobs!


Physicians are used to the limelight.  Historically, we’ve made an excellent living and have enjoyed our position on the pedastal society has placed us on as the Kings and Queens of the healthcare world.  So it’s no wonder that the shift to a team based mentality could be hard for those with particualarly big egos to swallow.  It’s a paradigm shift to understand that we have to engage our patients to achieve the best outomes.  It is the sum of these individual outcomes that leads to overall improved population health.


Of course, in addition to an insured population and well trained physicians we also need tort reform, system delivery reform, and outcomes research to ensure that our limited health care dollars are spent most effectively.  Two weeks ago I was asked to summarize some of the problems the healthcare system is facing and how the ACA is starting to address these issues to a group at UIC.  Below I have provided the slides from my talk.  I hope this is helpful to those of you doing your best to understand the complicated health care landscape.  After reviewing the slides, please post any additional questions you have below, and I will do my best to answer.  My ultimate stance, which is also shared by the American College of Physicians, is that the ACA is NOT perfect and still needs to be improved, but repeal at this point would have devastating consequences that many citizens are not even aware of.  I do not agree with every philosophy the democratic party espouses, but when it comes to healthcare, they’re miles ahead of the republican party when it comes to addressing pressing healthcare issues.  If these important issues are not addressed, our country will surely go bankrupt as a result of runaway health care costs.  When it comes to the ACA, we cannot afford to throw the baby out with the bathwater. 

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The Awkward Adolescence of Healthcare IT

No one can deny that healthcare is at a crossroads.  Current thought leaders like Atul Gawande  and Richard Baron have proposed that history will label our current time period as the “healthcare revolution”.  The introduction and adoption of electronic medical records will have an impact no less powerful than the cotton gin had during the industrial revolution.


If you are working in the medical field you have no doubt felt the tension between the “change-makers” and the “change-resistors”.  Depending on which camp you are in, you tend to either love or hate what’s happening in the field of medicine.  If you talk to anyone in healthcare these days about EMR, mobile health, payment reform, or ICD-10 you’re bound to get a passionate response – sometimes positive, sometimes negative.  Much like our political system, the two camps sometimes face gridlock.


To help me understand the conflict going on in healthcare right now, I’ve looked to Dr. Helen Fisher’s Personality Type Study which describes four broad basic personality types.  She uses her data to help people find love on her internet dating site Chemistry.com.  I propose that this same framework can help those working in healthcare to find common ground as well.  After all, like marriage, we’re all in this field for better or for worse, so we might as well figure out how to live together so that we can navigate these choppy waters and not capsize the ship!


Per Dr. Fisher, the two most basic personality types are “Explorers” and “Builders”.  Explorers are driven by the neurotransmitter dopamine which imbues these individuals with enthusiasm, heightened energy, curiosity, creativity, spontaneity, optimism, and the propensity to seek novelty and take risks.  Builders, on the other hand, are calm, social, cautious, persistent, loyal, fond of rules, facts, and orderly.  These individuals are driven by the serotonin system.  Given these biologic facts, it’s obvious that Explorers are more likely to be “change-makers” and Builders are more likely to be “change-resistors”.  Asking an Explorer to be more like a Builder or vice-versa is like asking a zebra to change its stripes to spots – it’s not going to happen.


Dr. Fisher’s study shows that in the romantic world explorers are attracted to other explorers and builders are attracted to other builders.  We see this in the world of healthcare too.  Explorers are the ones driving the healthcare revolution, and the builders, given their much more calm and cautious nature, are putting on the breaks.  Evolution has shown us that both character sets are important.  Without the explorer’s impulsivity, tendency to value rewards more than fear consequences, and propensity to try new things, we would not continue to evolve.  Although it is true that Explorers often win big, they are also much more likely to suffer disastrous consequences.  Explorers are the group most likely to come up with revolutionary ideas that lead to big changes or big business rewards, but a much higher percentage of Explorers than Builders may lose big too.  We need the Builders’ caution to balance the Explorer’s impetuousness, but at the same time we can’t let the Builder’s sometimes excessive caution and fear of change allow us to stagnate. 


I’ll reveal that I’m an Explorer that lives and works in a Builder’s world.  This unique, but sometimes lonely position, has given me the ability to truly understand what motivates both camps.  A “radical academic” by nature, I came to the suburbs at the beginning of my child bearing years thinking I wanted to focus on motherhood and just be a “regular doctor”.  This suited me well when high levels of estrogen, prolactin, and oxytocin induced by my four pregnancies suppressed my drive to explore new territory.  But when my hormonal induced fog began to clear, the “change-maker” area of my brain reactivated and healthcare IT became my new drug and obsession. 


What I’ve learned during my time in the suburbs is that most private practice physicians, especially primary care doctors, are Builders, which makes perfect sense.  Builders tend to be affable, tactful, careful, orderly, precise, detail oriented, persistent, patient, conscientious, and have exceptional managerial skills.  This absolutely sounds like the skillset I’d like my doctor to have!  But this same group of people, while amazing providers, can be a nightmare to those trying to encourage healthcare reform or the broad-scale adoption of HIT because they like routine, predictability, tend to be frugal, and are wary of fast changes.  Builders are more likely to hold tightly to the “right” way of doing things and can be closed-minded and stubborn.  The Builder’s realism and caution can also sometimes morph into deep pessimism or fatalism, which leads them to strongly believe that nothing will ever change for the better.


As I began to see the revolutionary changes EMR would bring to healthcare, I initially suffered from many delusions.  I believed that with the right product and optimized workflow scenarios any physician office could successfully implement the new technology.   I mistakenly thought that the ability to do away with paper, collect structured data, and ultimately reduce costs while improving outcomes would automatically appeal to everyone!   As I reflect on my actions during that time period, I can only laugh at my naivete.  I was completely oblivious to the fact that many of my fellow physicians were NOT exhilarated by this opportunity for change, and actually dreaded it.  But like a bull in a china shop, I was going to prove how wonderful it was.  Needless to say, my first big exercise in change management could have gone better. L


An entire industry of “implementation specialists” has evolved to help manage the pain that comes from transitioning from a paper based to an electronic healthcare system.  What many of these experts forget, though, is that effective change only happens when the system is ready to embrace it.  Large corporate organizations have recognized this and actually employ many people in full time “organizational readiness” positions.  But with healthcare being so strapped for financial resources, this critical piece of the journey is not often put in place even when monumental changes are anticipated.


The stages of change are often described as pre-contemplative, contemplative, preparation, action, and maintenance.  I think many working in healthcare these days are frustrated because attention is not being given to the necessary elements for successfully navigating each stage.  So much has been written about change management, but I’ve gained my deepest knowledge of the process from the Harvard MBA professor Dr. John Kotter who wrote Leading Change.  It’s a great place to start for those trying to steer healthcare innovation.


The inspiration for this posting came from watching my twelve year old daughter experience the turmoil of a middle school girl.  Adolescents are so awkward because they are changing so rapidly.  We’re seeing the same in healthcare.  Some days are exhilarating, and some days everyone wants to regress and throws tantrums.  As a mother and a healthcare “change maker”, my hope is to continue to study, learn, and help others develop the skillsets to navigate this choppy time.

 

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The Birth of How To Be Healthy MD

To those new to my blog, welcome!  To those longtime followers, after one year of blogging, I want to thank you for your support.  I started this blog with no purpose other than to communicate to my patients the developments within my fledgling practice.  But as I started to write, I found myself driven to explore broader topics that relate to health, and our delivery system. 


What does it mean to be healthy?  I’ve come to believe that the answer to this question is different for each individual, but the answer definitely does not lie in physical health alone.  To me, “healthy” is a state of mind and is going to look very different from one person to another.  I watched one of my “healthiest” patients die of ovarian cancer this year.  Unfortunately, I also see many patients every day with no true physical ailments, but who are very unwell.  So in our quest for health, what areas do we have to consider?  I have framed my ideas around the book Wellbeing written by Tom Rath and Jim Harter http://www.wbfinder.com/home.aspx but have added one additional category that I think they missed – spirituality.


·        Physical Wellbeing – Do you have health and enough energy to do what you want to do every day?  Do you fuel your body with healthy nutrition, exercise, sleep, and keep toxins to a minimum?

·        Emotional Wellbeing – Do you have strong relationships and love in your life?  Are there unresolved tensions with your spouse, parents, children, friends, or work colleagues?

·        Financial Wellbeing – Do you feel secure in your ability to cover the basic needs of food, shelter, clothing, and education?  Does the way you use your non-essential income bring you joy?

·        Community Wellbeing – Do you take pride in your community?  Do you contribute in some way that helps others in your world to thrive because you care?

·        Career Wellbeing – Do you like what you do every day, be it at home or in an official work place?  Do you wake up every day excited to take on the next challenge in your “job”?

·        Spirituality – How do you refuel yourself?  What feeds your soul?  This can come from an official place of worship, or from another activity that brings joy and re-energizes your spirit like nature, music, writing, etc.


When I’m inspired to write, it’s with these categories in mind.  Sometimes I also explore how our broken healthcare system can change to better serve the wellbeing of the community as a whole, without going bankrupt.  So after my infancy as a blogger, I think I’ve finally figured out what I’m about and what the theme of my social platform will be – How To Be Healthy.


Careful readers of my blog may pick up that I’m mimicking my social media idol, Baratunde Thurston, author of How To Be Black. http://howtobeblack.me/htbborder  In reading his book, I realized that although we have different platforms and objectives, we share the common idea that there is no one way to “be” anything.  Although one may assume that his book prescribes a certain ideal for “blackness”, his thesis is actually that “blackness” is whatever a black person wants it to be.  In his very funny way, Baratunde satirically puts forth a few models of “blackness”, but he ultimately admits that his book is really about “How To Be Human”.  


Similarly, there is no one model for successfully navigating the path of “wellbeing”.  Our physical health can dramatically change in a moment due to illness or injury, but we can always strive to achieve our own maximal fitness.  One can be emotionally well within all sorts of different frameworks – married, single, childless, with kids, large friend networks, a closely held few.  In addition, every relationship looks different.  What matters is the degree of connection and the love that is felt.  Financial wellbeing will look different depending on the community one chooses to live in.  Spirituality can take innumerable forms, and so on.  What matters is that a person lives their life authentically, with their own inner voice as their guide.


So welcome to HowToBeHealthyMD.  I hope my readers will appreciate that my strong science background and training in evidenced based medicine enables me to judge new medical and nutrition information and provide a reliable interpretation of the implications.  But I also hope my followers appreciate that I am a “radical academic” (also coined by Baratunde on that roof top bar in Austin) that isn’t afraid to stand in the face of commonly held beliefs if they just “don’t make sense”.  I feel well poised to talk about issues of balance and wellbeing, because as a mother and an American, I’m struggling with the same issues you are.  So here’s to being healthy!  I hope you’ll continue the journey with me to higher and higher levels of personal fulfillment.

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An Explorer’s Delight

Sxsw

Two weeks ago I broke out of my comfort zone and attended an amazing conference in Austin called South by Southwest (SXSW).  Although this conference is better known for its film and music components, there is also an “interactive” session which brings together 15,000 of the most amazing social media, entrepreneurial, and IT minds in the country from every industry.  As the picture above suggests, this festival of creativity is quite a scene!  During these five days, innovators from every realm take the city of Austin by storm.  Everywhere you looked, people engaged every imaginable piece of technology to blog, tweet, post, or link the latest information hitting the scene.   

I chose to attend this conference because of a confluence of several interests that all emerge from my desire to understand why people do what they do.  Through my work, I strive to influence others to make choices that promote both their own wellbeing, as well as the physical and psychological health of the community as a whole.  I went to Austin with the hopes of discovering tools to encourage positive behavioral changes in both my weight management and general medicine patients which I found in the work of Noreen Kamal @noreenkamal at Vivospace. http://www.magic.ubc.ca/pmwiki.php?n=Projects.E-HealthCare  Through my experience in health IT, I know that mobile health will play an increasingly large role in facilitating and improving patient care.  

The Mobile Health Revolution

In my affluent community in the northwest Chicago suburbs it seems that almost everyone owns a smartphone.  In a few short years, this perception will be the reality.  In fact, sixty-five percent of the population is predicted to own a smart phone by the year 2015.  The power of this vehicle to collect data and influence people has the attention of every industry, including healthcare.  In collaboration with Technical Doctor http://www.technicaldr.com/tdr/, Dr. Blodgett of the Thompson Memory Center http://thomsonmemory.com/, and Dr. Arora @Futuredocs of the University of Chicago, I have spent the past two months developing two unique mobile health solutions.  One application will enable us to evaluate therapies for Alzheimer’s and link caregivers and patients into a support network.  The other application will support better transitions from the hospital to the outpatient setting for patients with chronic diseases requiring frequent hospitalizations.  Today fifteen billion dollars is spent on patients who are readmitted to the hospital within 30 days of their discharge.  Twelve billion of this is thought to be preventable with better follow up care in the outpatient setting.

Startuphealth

In this photo you see me at SXSW with a few of the most inspiring people I’ve come across in the mobile health scene.  The two gentlemen in the photo, Steven Krein @stevenkrein and Unity Stoakes @unitystoakes, are the two co-founders of StartUpHealth. http://www.startuphealth.com/  This company’s mission is to improve healthcare in America by providing health and wellness entrepreneurs with inspiration, education, and access to customers, capital, and other critical resources.  With this help, startups can innovate more quickly and build new solutions that will improve care and reduce out of control healthcare costs.  I’m excited to share that I may apply to their StartUpHealth Academy to facilitate the promotion of my unique ideas. 

The woman in the photo is Dr. Jennifer Dyer who is a pediatric endocrinologist and social media queen better known as the @Endogoddess.  Love it! http://endogoddess.blogspot.com/  This inspiring woman has developed several mobile health apps to improve care for diabetics and is a fashionista to boot!  I am so honored to have both her friendship and her mentorship as I explore the world of mobile health and social media, but I’ve told her to give up on me in terms of high-end fashion! J 

Behavioral Genetics

As a student of molecular biology, neuroscience, and human behavior, I have come to believe that each of us is a walking clinical trial in regards to our genetics, physique, lifestyle, consumption, location, and relationships.  At SXSW I was somewhat alarmed to learn that corporations are gathering data on every purchase we make, giving them insight into very personal areas of our lives http://www.dailymail.co.uk/news/article-2102859/How-Target-knows-shoppers-pregnant–figured-teen-father-did.html.  My Facebook friends may also be surprised to know that CEO Mark Zuckerberg can determine by a person’s Facebook postings with 33% accuracy when a couple will break up!  Also shocking was that the popular app Foursquare can actually predict with amazing accuracy where a person will go next.

I’m currently reading Thinking Fast and Slow http://www.amazon.com/Thinking-Fast-Slow-Daniel-Kahneman/dp/0374275637 by the brilliant Princeton psychology professor Daniel Kahneman.  This book describes the “instinctual” part of our nature (System 1) which drives most of what we do.  On some level, the entire concept of “free will” is questioned.  In a prior post http://karanancemd.posterous.com/its-the-little-things-that-matter I wrote about how the trait of “altruism” is actually genetic.

At SXSW I attended many talks that highlighted other behaviors that we think of as “choices” that actually have a genetic basis or are very predictable when you use data to determine what a person, or certain demographic of the population will prefer.  Most inspiring was the talk by Dr. Ravi Iyer @ Ravi_polipsych, the Founder and Data Scientist of www.YourMorals.org with whom I was lucky enough to share a margarita and some conversation with as pictured below.

Photo_10

Dr. Iyer gave a compelling presentation that highlighted why emotional profiles are more important than demographic profiles, and astutely pointed out that we live in an age where consumption is about values (e.g. Whole Foods) and happiness (e.g. Zappos) rather than survival.  I encourage each of you to contribute to his research and better understand your own moral psychology by participating in the free surveys on his website.  Most interesting from his talk for me, though, was how we can use social networks to form moral agreement amongst people from different cultural backgrounds and ideologies.  This tied right in with my other new SXSW discovery, the politically-active, technology-loving comedian and Director of Digital for The Onion http://www.theonion.com/, Baratunde Thurston.  Baratunde gave an inspiring keynote speech about the role of technology, comedy, and satire in transforming the world around us.  An audio link to his talk is available at http://schedule.sxsw.com/2012/events/event_IAP992055

Born into a “neighborhood just like The Wire” in Washington DC, Baratunde grew up surrounded by drug dealing, police brutality, and murders.  Despite living “in a black neighborhood under siege” Baratunde was blessed with an amazing mother, Arnita Thurston, who as a widow provided her son the opportunities and structure to ultimately lead to his graduation from Harvard University in 1999.  In his book, How To Be Black http://howtobeblack.me/htbborder, Baratunde thanks his mother for helping him to survive his childhood.  As a result of her efforts and tutelage, Baratunde describes himself at twelve years old as “a bass-playing, tofu-eating, weekend-camping, karate-chopping, apartheid-hating, top-grade-getting, generally trouble-avoiding, agent of blackness.”  LOL!

Through a random twist of fate, I was lucky enough to engage this thoughtful, fun “agent of blackness” in a conversation at an Austin rooftop bar. 

Baratunde

After a freewheeling exchange of ideas that included Obama’s Accountable Care Act, race relations, and social media, I downloaded his book and have been enjoying every minute!  I think Baratunde’s book is a “must read” for every white person that doesn’t interact with the black community on a regular basis.  It’s one thing to study African American history, but yet another to understand the misperceptions between races that can lead to strain and even violence, as highlighted by the Trayvon Martin tragedy.  After reading Baratunde’s light-hearted but poignant book, I’m proud to report that I’m much “blacker” than I was a month ago! 😉

So those are the SXSW highlights I’ve finally found the time to share.  Although I was initially intimidated by the size and intensity of this fast moving scene, I’m happy that I strayed from my typical “doctor” conferences to learn some completely new things.  I’ll close with my favorite (and only!) Japanese Proverb brought to my attention in one of @DrHelenFisher’s books (another personal idol I met at SXSW!) “Let us not follow where the path may lead.  Let us go instead where there is no path, and leave a trail.”

 

 

 

 

 

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All You Need Is Love

Grandad

Today’s posting is in honor of one of the most incredible men I’ve ever known, Lt-Col Thomas Martin Scott Junior, my husband’s 96 year old grandfather.  Grandad currently lives in an assisted living facility for retired military in San Antonio, TX.  After having not seen Grandad for almost two and a half years, we travelled with the kids last month for a visit.  Although arthritis prevents him from navigating the world as nimbly as he would like, I was amazed to see that Grandad remains as sharp as a tack, and is a true testament to a life well lived.  At 96 years old Grandad still uses his computer where he reads email, skypes with his family, and just discovered Facebook!  His latest joy is the Kindle Fire, which he received as a gift from the family this past Christmas.  The ability to enlarge the print and have the text read out loud as he follows along has again opened up the world of literature to Grandad.  Once again he’s tearing through books.

 

So as our children played board games, cards, and pool in the community room, I talked to Grandad about his life story.  Born in Ellsworth, Kansas, Grandad attended the University of Missouri where he excelled in ROTC.  He remembers a certain army captain that he admired and respected, who encouraged him to make a career in the service.  After a few years in the army Grandad was stationed in Fort Des Moines, Iowa, where he met and fell in love with Colin’s grandmother, Margaret “Dusty” Wallace.  Their relationship was a true romance.  Although I only knew Grandmaloo for a short time before Alzheimer’s set in and she died in 2007, I remember how lovingly she and Grandad treated each other.  They had one daughter before Grandad had to leave his family for three years when he served in Europe during World War II.  Upon his return they had two more daughters and raised a lovely family.


Grandad reflected happily on his many years in the service.  He appreciated the “congenial” community, where newcomers were always welcomed with social calls within 24 hours of arriving to base.  He enjoyed the “exactness and challenge” of the army and the rigid demands of military life did not bother him.  Towards the end of our visit I asked Grandad what he felt the biggest factor to a life well lived was.  Without a moment’s hesitation he answered with one word – love.  In addition to having a great love in his life, Grandad was blessed with a loving family, loving friends, and a loving community within the military.


As I celebrated yesterday’s holiday devoted to love, I found myself reflecting on why some people accrue so much love in their lives, while others leave this world very alone.  I think many of the answers are described in Dr. John Townsend’s book, “Loving People”.   To have good relationships a person must know both how to give, and how to receive love.  When someone grows up surrounded by love, these behaviors can come quite naturally.  But for those that haven’t been loved well, both learning how to love others and learning how to let oneself be loved may require conscious effort.


A true human connection is at the core of a loving relationship.  Dr. Townsend breaks human connection into the following essential elements.

1. Feelings – The ability to share the emotions we experience about things and people, both pleasant and painful.

2. Dreams and Desires – Loving people can share their deepest longings and wishes with those they love, especially the things we keep protected and may even have a hard time acknowledging ourselves.

3. Fears – When we are connected we feel safe to share our fears openly.

4. Failures – No one is without mistakes, and when we connect, we let others in on the darker parts of our lives.

5. Our Past – When we connect with someone we bring them into our personal history, sharing both our losses and joys.

6. The Other Person – Loving people have the ability to honestly communicate to the other person how they feel about their interactions with each other in a way that does not threaten, but rather strengthens the relationship.


One of the most rewarding aspects of my job is the opportunity to connect with so many wonderful people through the art of medicine.  I know I’m doing my job well when patients share their feelings and fears regarding their current health issues with me.  When people open up to me, I know I’ve made them feel safe.  My weight management program has resulted in particularly satisfying connections.  By meeting weekly with people struggling with the very sensitive and emotionally complicated issues relating to obesity, we have the opportunity to develop a safe platform from which to discuss past failures, desires and dreams, and can develop the good communication skills required for a productive patient-coach relationship.  


Dr. Townsend points out that “the best connectors are the ones that have been on the receiving end of connection.”  I feel very blessed that I have been loved so well in my life.  When I encounter someone who is selfish, unkind, or hurtful, I try to react with empathy instead of anger, because that person is most likely acting “unlovable” because they are nursing an emotional wound from some prior relationship.  These are the people most in need of grace, acceptance, and understanding. 

 

Grace can best be defined as an undeserved favor.  Forgiving a person for behavior that they are not proud of is the most wonderful gift you can give a person.  Just yesterday I had a tearful patient in my office because she returned three months later than instructed because she was ashamed at her inability to meet her weight loss and exercise goals.  Her relief when I reached out and hugged her and said those magic words “it’s ok” was palpable.  I often hear from patients, “I was afraid you would be mad/yell at me”.  I always find this statement shocking because why would I scold when I know we all live with the most merciless critic of all – ourselves.  What people really need when they act in self destructive ways is support and forgiveness.  A person can break through the iciest shell with these methods!


So in this week devoted to celebrating love I will close with my favorite paragraph from Dr. Townsend’s book.  “Connected people are people who are grateful for what they have taken in and do not want to waste it.  When we use our connections good things happen.  Spouses feel like less of a failure, people take career risks that are fulfilling, kids move on from sports defeats, lovers develop closer bonds, single people resolve fears, and books get written.  Connection requires movement and response when we experience it.  Connection takes time and energy from someone you care about, even if it is freely given.  That is not a guilt motive; it is a reality motive.  Take ownership over connecting with others, and help it help you to be a better and more whole person.” – John Townsend

Please feel free to reach out to Grandad by email martys@satx.rr.com 

He’s always open to making a new friend!

Loving People, John Townsend, 2007, Thomas Nelson Publishing

 

 

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Desperate for Data

Ten days ago I returned from Washington DC where I attended the first Care Innovation Summit sponsored by the Center for Medicareand Medicaid Innovation. http://innovations.cms.gov/

 

I recognize we are living in tough political and economic times.  The national debt, unemployment, partisan conflict, struggling schools, and disenfranchised groups all come to mind when I think of serious political concerns.  But the problems in the healthcare system feed into many of the larger issues our country is facing.  Healthcare as it exists today is destroying American prosperity and the American dream.  With 17.9% of the GDP spent on healthcare, it is imperative that we jail break the health care system at a price we can afford.  We need to change the system so that value is incentivized over volume (i.e. how many patients are seen, how many tests are ordered, etc.) while keeping the patient’s personal experience at the center of all we do.


For such big problems there are obviously no easy answers.  The political gridlock we’ve seen in Washington in recent years contributes to the perception that everyone on Capitol Hill is motivated by personal agendas with little concern for the greater good.  But today I want to show you another side of what’s going on in Washington.  I want to familiarize my readers with the innovators in this country committed to reforming the healthcare delivery system, fixing the SGR, and reforming the way payments are made to reward quality and innovation.


The list of speakers that I had the privilege of listening to is much too extensive to cover here, so I’m choosing to highlight two amazing voices on the healthcare scene that left the strongest impression on me.  The first is Susan Dentzer, the Editor-in-Chief of Health Affairs http://www.healthaffairs.org/ which is the nation’s leading peer-reviewed journal focused on the intersection of health, health care and health policy in the US and internationally.  Susan used the words of the renowned writer from Stanford’s MBA school, Jim Collins, to talk about how we need a healthcare system that is built to last.1 


America is full of many corporate successes.  This is because our capitalist culture generously rewards true innovation that is successfully implemented.  Financial incentive encourages risk takers with boundless optimism and extraordinary creativity to come up with solutions to some of our toughest problems.  This drive to innovate is rooted in the American spirit.  Susan Dentzer pointed out that we need a partnership between the private and public sectors to come up with the best answers for the healthcare crisis.  By taking this approach we should be able to step away from the in-fighting in Washington because “innovation is not a partisan issue.  It comes in purple, not blue or red.”


The second speaker whose words I want to spread is Atul Gawande, MD, MPH who is a surgeon at the Harvard Medical School as well as a writer of three New York Times bestselling books2,3,4 and a public health researcher. Dr. Gawande contrasted the medical system in the pre-penicillin era5 to today’s much more complex environment.  One hundred years ago healthcare was cheap, but completely ineffective.  Dr. Gawande pointed out that today we have 13,600 unique diagnoses for human diseases, and 6000 different medications we can prescribe or operations we can perform.  Per his count we have 13,600 service lines that we are trying to roll out to every person in every community!


Dr. Gawande astutely concludes that the reason healthcare costs are so out of control is that innovations in delivery systems have not kept pace with the scientific and medical discoveries we can now leverage.  The old system rewarded the cowboys, physicians who could enter a room, take control, and do it all.  But the paradigm of individual clinicians trying to do it all on their own isn’t working.  Instead of cowboys, Dr. Gawande eloquently explained that we now need highly effective pit crews where humility, accountability, and self-discipline are what’s valued.


But how do we know if the pit crew is doing a good job or not?  How can the struggling crews identify the more effective teams and implement their secrets of success?  The answer lies in the ability to capture, analyze and report the DATA!!!  Without data we have no ability to recognize success and failure.  Dr. Gawande pointed out that at the turn of the century the American people were facing a crisis in the ability to produce and deliver enough food to its citizens.  At that point in history 40% of the family budget was going to food costs.  To address this serious problem the government collected data in the form of comparative effectiveness research and created regulations and incentives to encourage farmers to use processes that were proven to work.  The government also created the national weather service, which provided the farmers with important information to protect their crops.  Over the course of 20 years the percentage of the family budget that went towards food dropped from 40% to only 20%.  We need to do this in healthcare today.


The widespread adoption of electronic medical record systems (EMRs) by physicians has us on our way, but simply having a system doesn’t mean it’s being used in a way that provides structured data that can be studied.  CMS is trying to make this possible by demanding that physicians adopt CCHIT (Certified Commision for Health Information Technology) certified EMRs which use HL7 CCD (Health Level 7 Continuity of Care Document) programming to promote the exchange of health information between providers and facilities involved in a patient’s care.  This will lead to a profound reduction in healthcare spending because test results will be accessible, and expensive imaging studies will not need to be repeated.  Having access to the patient’s complete medical history will also help physicians to make accurate diagnoses and appropriate treatment plans.


In the words of Dr. Gawande, analyzing the data available to us today is like driving a car with a speedometer that tells us how fast everyone else on the road was going four years ago – not very helpful!  He pointed out that we know much more about how the crops and cows are doing in our country than the human beings.  We have a big problem in our healthcare system, and it needs to be fixed STAT!  Data is the oxygen for innovation, and right now we’re suffocating.  I feel strongly that patients should have a universal patient identifier (UPI) so that physicians don’t have to rely on having a conscious patient with a good memory and enough medical knowledge to understand what is or isn’t important regarding their past medical history.  I acknowledge that this is a controversial issue, and to see both sides of the story I invite you to read an article in the Wall Street Journal a couple of weeks ago that addresses both sides of the argument. http://online.wsj.com/article/SB20001424052970204124204577154661814932978.html?KEYWORDS=squaring+off+on+health+care

But I agree with Dr. Gawande that if we can’t access data on patient outcomes, it will be impossible to understand our current baseline.  Without this basic understanding, we will not be able to identify either problems we can fix in the current system, or opportunities to provide better delivery of healthcare to our citizens.  It is difficult if not impossible to set goals for improvement in medical delivery and quality of care without access to relevant and reliable data.  We also need data so that after implementing changes we can assess progress and identify teams who achieve superior outcomes at reasonable costs.


I share Dr. Gawande’s belief that we are fighting a war to preserve the soul of American medicine.  Regardless of political affiliation we all want people to survive and live their lives to their fullest potential.  I came home from Washington imbued with hope that if the citizens, the doctors, the innovators, and the politicians work together to capture the data floating around in our current healthcare system, we can achieve the goals of the three part aim – better health, better care, at reduced costs. 

1Built to Last: Successful Habits of Visionary Companies, James C. Collins, Jerry I. Porras, 1997 A Harper Business Book

 

2The Checklist Manifesto, Atul Gawande, 2011, Metropolitan Books

 

3 Better: A Surgeon’s Notes on Performance, Atul Gawande, 2007 Metropolitan Books

 

4 Complications: A Surgeon’s Notes on an Imperfect Science, Atul Gawande, 2002 Picador

 

5The Youngest Science: Notes of a Medicine-Watcher, Lewis Thomas, 1983 Penguin Books

 

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