Sunday, September 25, 2011

An ounce of prevention

My sons' tastes run to the macabre.

We were on holidays in Newfoundland in August, and climbed Gros Morne Mountain.  As we were scrambling up the scree, they began to discuss the chance of an avalanche.  Specifically, they wondered about the possibility that we would be trapped by boulders.

"Hey, it would be just like that guy who got trapped when he was hiking and he had to cut off his own arm with a pocket knife!" said one.

"Yeah, he's famous now," replied his brother.  "They just made a movie about him."

In 2003, Aron Ralston had gone hiking alone in Utah without telling anyone where he was going.  After having his arm pinned by a dislodged boulder and spending 5 days (the movie is called 127 Hours) without food or water, he freed himself by amputating his forearm.  He was found by other hikers, and taken to safety.

I remember thinking back then, as Ralston was celebrated as a hero on TV news and talk shows, that although he had showed incredible will and courage, perhaps his ordeal could have been prevented or shortened if he had taken the elementary precaution of telling someone where he was going, and when he could be expected to return.

An ounce of prevention...

This story came to mind again at the end of our holidays when we were visiting in Newmarket, Ontario.  I was walking by Southlake Regional Health Centre and saw these signs:

Before I go any further, let me make this clear: I am not making light of the contribution of this Health Centre.  I am not minimizing any illness that the pictured lady or any other patient suffered, nor the important role medical care plays in treating and curing serious disease.  These signs are representative of many others used in hospital fundraising campaigns across the country.  I am not singling out Southlake; it was just a coincidence that I was passing by their hospital while thinking about this issue.

In healthcare, most of our attention is on acute and chronic care: heart disease, cancer, diabetes and trauma, for example.  Our taxes and charitable donations build hospitals and furnish them with the latest technology.  We pay specialists handsomely to perform complex, life-saving procedures.  We marvel at the latest advances in medical science.

Many people will say, "Of course our attention is on acute and chronic care! What else is there?"  There is Acute and Chronic's demure sibling, Prevention.

It's often said that prophylactic measures, such as clean water and vaccinations, have had more impact on improved health than any other intervention.  But, how many $500 a plate dinners raise funds to promote eating more fruits and vegetables?

Prevention gets less attention for a number of reasons:

Its beneficial effects are not seen for many years, making it difficult for us to link preventative measures to beneficial outcomes.  Those in charge of health care budgets may find it difficult to allocate scarce funds today, when the benefits will not accrue for decades.

Its value is measured across populations. When individuals enjoy good health, it's seen as a normal, baseline state, and not because of some intervention on their behalf. 
The least economically and politically powerful among us may be the ones who benefit most from preventative measures such as smoking cessation, and education about diet and exercise.  

I've heard acute care medicine (derisively) referred to as "rescue medicine".  The point is that health care systems include the maintenance of healthy populations in their mandate, yet they spend many of their resources saving people whose disease could have been prevented in the first place.   What if that kind of contrarian thinking became the norm?  What if we noted the known risk factors for every condition that forced someone's hospital admission, and so kept a running tally of the daily cost of each risk factor?  We would expect hefty government investment in smoking cessation, and promotion of healthy diet and exercise, as a start.

Perhaps the information on Southlake's signs ("40,000 patients and counting") should be seen as a sign of our health care system's failure to prevent disease, rather than a rallying cry to promote expansion of health care facilities.

Wednesday, September 21, 2011

Full awareness at work

I was walking home after a run last week and decided to take out my earphones.  I usually keep a podcast playing until I walk in the front door of our house, but this time, I thought I would let my own thoughts keep me company.  I was struck by what I noticed when I didn't have something playing in my ears.

I keep the volume low so I can hear bike riders coming up the trail behind me.  Even so, as soon as the earphones came out, I was acutely aware of sounds I had been missing: wind blowing through tall grass, and a small animal in the underbrush.  Hearing the sounds didn't surprise me, but the change in my overall awareness did.  Without earphones, I paid more attention to things I saw along the trail, in addition to things I heard.  Listening to something in earphones had turned my attention inward more than I realized.

I mention this because of a conversation I had last week with a health administrator from another province. We had both noted how some medical personnel seemed to be distracted at work by their various electronic devices.  I have particularly noted that, in Saskatoon's hospitals, some of the housekeeping staff wear earphones while performing their duties.  She told me that the practice had been banned in her health region.

The main concern was around workplace safety.  As I found out after my run last week, not only is your hearing affected, but listening through headphones impairs your overall awareness of your surroundings.  She also mentioned that, even though they are not considered "clinical staff", housekeepers work in patient care areas and may hear (and then respond to) patients in distress.

I wonder if workplace headphones also have a less obvious opportunity cost.  Housekeepers perform an essential role in keeping our facilities clean, safe and functional.  In order to do that, they need access to all areas of the hospital.  As such, they regularly cross paths with staff and patients.  They have the opportunity to greet visitors, answer questions and give directions.

However, if I see someone wearing headphones, I take it as a sign that they don't want to interact.  They're sending a message that they prefer solitude.  I suspect that patients and visitors will make the same assumption if they see hospital staff wearing headphones.  They may hesitate to ask for help.

This no-headphones rationale won't resonate with staff unless they've been explicitly given permission and encouraged to interact with patients and visitors.  Unless housekeeping staff see themselves as goodwill ambassadors, it won't matter whether they wear headphones or not.   And if they don't see themselves in that role, then staff are missing opportunities for joy and satisfaction through richer interaction with our clients, and we're missing the chance to use our staff's talent to full advantage.

Monday, September 5, 2011

Long wait times for surgery? Never again!

There is absolutely no inevitability as long as there is a willingness to contemplate what is happening.

- Marshall McLuhan

When someone decides they want to have surgery performed, they usually want to know details: What will happen? Will it be painful? What are the complications?  But, even if they don't have a lot of questions about How and What, they almost always ask about When.

And that is often an awkward question to answer.

Our surgical booking system divides patients into 4 categories: emergency,cancer, urgent and elective.  While the first 3 categories denote pressing need for surgery, "elective" surgery indicates that the procedure can be delayed without significantly compromising the person's health or chance for a good outcome.  It's an arbitrary definition, and varies from surgeon to surgeon.  The perception of what should be considered "elective" certainly varies between surgeon and patient.

The Saskatchewan Surgical Initiative's (SkSI) goal is that, by 2014, all patients will have the option to have their surgery within 3 months.  ("Option", because some people may choose to delay their surgery until a more convenient time).  By the end of 2011-2012, the goal is to reduce all surgical wait times to less than 12 months.

A 12 month wait for surgery is shocking, and some people wait 18 months or longer!  The amazing thing about that is that we (patients, surgeons, administrators) have accepted this as inevitable.

But, we won't accept these waits for much longer.  Take a look at this trend: 

This is the number of people waiting longer than 12 months (top line) and 18 months (bottom line).  Over the last year, the numbers in each group have been halved!  While this trend had started (due to other provincial initiatives) even prior to SkSI's formal start in 2010, it has been bolstered by SkSI.  Additional OR time, as well as more effective use of that time, are helping to clear the "long wait" backlog.

This success isn't without a cost.  In our practice, we've been assigned additional OR time to provide service for our patients who have been waiting for over 12 months.  This means that the urologist will not be available to provide other important services, such as office consultation or cystoscopy clinics.  As such, wait times in those areas have increased.

There's nothing magical about how this wait time success is being achieved.  Health system leaders decided that this would be a strategic priority, and put attention and resources toward fixing it.  Leaders and managers are accountable for achieving targets.  With this approach, SkSI will meet its goals - whether by 2014 or not is just a quibble.  Then, once the SkSI goals are met, our healthcare system can focus on another strategic priority.

And that's when all SkSI's work will be in danger.

We can only concentrate on a few major initiatives at a time.  A fairly small number of people are involved in moving these projects ahead, and only have so much time and attention to go around.  Once we declare "Mission Accomplished" on surgical wait times, and move on to, say, Primary Care Reform, surgical wait times may creep back up.

In addition to reducing the surgical backlog, we need to build in sustainability, such as ongoing surveillance and transparent reporting of wait times.  More important is a critique of current practices - keeping the effective parts and redesigning the rest.  We need to create processes (e.g. pooled referrals, assessment and treatment pathways) that will survive the inevitable dimming of the spotlight currently illuminating the surgical system.  We can't rely on the hyper-vigilance associated with being the provincial priority du jour.

I look forward to the day when, as I hold forth in front of a group of medical students, they shake their heads and smile wryly at the old-timer's tall-tales of surgical wait lists longer than 3 months.