Holiday enlightenment

Christmas holidays enlightened me about a couple of things.


My usual practice while on holiday is to spend some time every day answering work-related emails, reading professional papers, or just contemplating clinical or improvement work.  I decided to try something different last week.  Over the Christmas break, our family spent 4 days at Elkridge Resort, near Prince Albert National Park, and I deliberately disconnected from work.  I left my laptop at home. There was no Wi-Fi in our cabin.  My cellular network doesn't reliably cover that part of the province, so I couldn't sneak email peeks on my phone.

When we first arrived, my kids rapidly assessed the telecommunication situation.  No Wi-Fi for 4 days! Barbaric.

"Looks like you'll have to walk up to the main hotel lobby to check your emails," my wife told me.  I guess my holiday routine was predictable.

It was surprisingly difficult to give myself permission to slack off.  It wasn't a problem while we were outside tobogganing, skiing or hiking.  But inside the cabin, I had a nagging feeling that I should be doing something... productive.   If I would have had my laptop or other work paraphernalia with me, I'm sure I would have succumbed to the temptation!  Instead, I played board games, watched TV and read a book.

Lesson learned: I have to work at relaxing.



During the school year, our home life is very busy (our own doing!).  Much of our time in evenings and weekends is spent rushing to children's activities, then back home to get ready for the next day.  This can lead to some stressful family interaction (Hurry up! We're going to be late!).

Even on holiday, old habits die hard, and we over-schedule our vacation activities. (Get your boots on - we're going tobogganing at 2:45.)  I surprised myself a couple of times when the kids weren't ready to head outside, by flopping back down on the sofa rather than cracking the whip.  We got to the sledding hill eventually, and everyone was in a better mood when we got there.

I also enjoyed a switch in some traditional family roles.  We decided to try cross-country skiing - which I hadn't done for over 20 years.  After we rented the skis, one of my sons announced that he had been skiing at school recently and showed me how to clip my boots into the bindings.  It was a very satisfying change in our usual parent-child / mentor-student relationship.

Lesson learned: There are other ways of being that are hidden by the self-imposed flurry of daily life.


Back to work tomorrow - I hope these lessons stick with me.

Improving healthcare by learning about hotel management - IHI Forum Excursion

Who would have thought that you could improve healthcare by learning about hotel operations?

The organizers of IHI’s 24^th annual National Forum, that’s who.

The Forum Excursions are a very popular item on the menu in Orlando this week.  I had the chance to visit behind-the-scenes at the Marriott World Centre, with the intent of linking best practices in other service industries to healthcare.  (Yes, we are a service industry!)

A few lessons learned:

Visual management –  hotel staff used visual management extensively to relay information such as daily guest volume, special events and that day’s guest service focus (that day, it was “anticipating guests’ needs).  There were no fancy computer displays, just white boards, markers, colored paper and tape. 

Eliminate variation – at a buffet service, every item – right down to bread and salad – is placed at the same location, every time.  This makes it easier to tell at a glance when items need to be replenished and makes it less likely that a certain dish will be overlooked.  Staff can work together more efficiently as each person knows ahead of time where their partner will be placing the dish that they are carrying.  Less confusion and rework.

Relations with staff – Marriott staff are called “associates”.  Managers all said the same thing: Take care of your associates and they will take care of the guests.  I asked if the hotel was unionized.  It isn’t.  One manager commented “If we look after our associates, there’s no need for 3^rd parties to be involved.”

Standard work – A great quote from the executive chef: Open the kitchen with a list; Close the kitchen with a list.  He told us that staff were required to use a series of lists for every aspect of running the kitchen.  Even if a cook had worked in the same area for 20 years, they would still use a checklist to start the day, and be accountable for each task by initialling it. 

The most surprising insights about hearing the customer’s voice came from an unlikely area – Lost and Found.  These associates gather, store and (hopefully) return items found on hotel property.  The manager told us that they keep every (legal) item no matter how worn out it looks.  She gave the example of a scrap of worn and stained blanket that had been left in a room.  Frantic parents called the hotel looking for their young daughter’s special “blankie” and were thrilled to hear that Lost and Found had it.  The manager told us that only the customer could decide the whether an item was valuable or not. 

We asked whether the hotel staff telephone guests to let them know that an item was found in their room.  We were surprised to hear that they don’t do this.  The manager explained that, if they were to call a guest’s home and say “This is the Marriott in Orlando.  We found your cellphone in your room,” the spouse answering the call might be surprised to find out that their partner had been in a hotel room – without them.  Calling the guest’s home seemed like it would be an innocent and helpful thing to do, but hotel staff realized that it was a potential violation of privacy.

Forum Excursions – highly recommended!

Show me that you care. With sticky notes!

I knew I was in good hands when I saw this on the table:

"Yay! Sticky notes! Today is going to be a good day."

I was only half-joking to my table mates as I sat down to start a day-long meeting.  In the centre of the table was a plastic bin full of coloured sticky notes and marking pens.  And the sight really did give me a warm feeling.

Sticky notes and marking pens mean that audience participation is planned. Usually, participants are invited to write comments and contributions on the notes, then post them on a flipchart where they form the basis of, well, just about any kind of planning work. They also usually indicate that there will be discussion and debate.  That's fun.  (Also, occasionally, productive.)

But most importantly, their presence means that someone prepared for this meeting.  Somebody thought about what needed to be accomplished and how the attendees could be active participants.  Somebody wanted to hear our opinions.

Somebody cared about the day's outcome.

That's the real reason I was excited; the sticky notes were just an indicator.  An epiphenomenon.


The meeting's closing speaker related a story that linked my sticky note experience to my daily clinical work.  She told us about a man who had gone through 2 joint replacement surgeries.  At the first surgery, he remembered that the OR staff had been laughing and joking when he entered the room and he felt that they weren't paying attention to him.

Several years later, at the time of his second operation,  the surgical safety checklist had been used.  Staff all stopped what they were doing and focussed on hearing the plan for his surgery.  The man related that he felt everyone really cared about what happened to him that day.

Completion of the surgical safety checklist didn't guarantee a better outcome for him.  But he (rightly) interpreted its use as an indicator that someone had put effort into planning for his safe care.


What other indicators - positive or negative - are patients reading as they traverse the healthcare system?

Making it easier to do the right thing - Is there an app for that?

I was out running this morning and came across this:

A beer can on the road.

I'll pick up the occasional piece of garbage while I'm out and about, but I don't want to lug it all the way home with me.  I definitely didn't want to run very far carrying a beer can because, you know, people would talk.

I happened to be on a familiar path and knew that there was a garbage can right around the next corner, so:

That made me think that there must be plenty of like-minded people walking around Saskatoon, that is, people who will pick up a piece of garbage, but only if they know a garbage can is handy.  They may be motivated to do the right thing (clean up their neighbourhood) but need a little help to follow through.

Here's a suggestion for some entrepreneurial programmer:

Smartphone app that people activate when they are in an outdoor public space.  The GPS-enabled phone signals when a garbage can is within X metres (X varies according to individual preference).  Maybe there would be a recorded voice encouraging the user to "Pick it up" or "Let's clean up".

Each city would need to enter the locations of garbage cans.  This could be done by municipal employees who geo-locate garbage cans, once again with GPS-enabled phones.  Or, public users could contribute the locations.  This might be a revenue source for the app developer, as each city would need a unique database of garbage cans, licensed on the developer's server.

Individual users could record their contribution by logging the number of pieces of garbage they pick up.  Nothing like a little competition to encourage participation!  Users could submit pictures of the trash they pick up, with prizes for the most unusual object.

I'm not sure if there are researchers studying trash, but if there are, they could ask users to log the type of litter they find (e.g. fast food packaging including the restaurant name) to better understand the source of the garbage, and lobby the responsible businesses to reduce packaging.

Anyone up for this?

Wasting time and money on a long weekend

I often hear stories about physicians repeating lab tests or x-rays because it's inconvenient to get results from other hospitals or physician offices. I flatter myself that I'll make a concerted effort to track down test results before subjecting patients to repeat testing. Sometimes however, "the system" will not yield.


Here is a little story:

Earlier in the week, I saw a lady who was passing a kidney stone. We agreed that she would give it a few days but if the pain continued, we would do emergency surgery over the holiday long weekend. The complicating factor was that she lives in a community that is more than a 5 hour drive away from Saskatoon and she didn't want to come to Saskatoon if she didn't have to (that is, if she passed the stone in the meantime). For that reason, she had an x-ray done in her home community late in the week. The written x-ray report came down to me by fax and there was no mention of a kidney stone. (This can either mean that the stone is gone or that the radiologist has not noticed the stone on the x-ray.) Also, she was still having some discomfort, making us both suspicious that the stone might still be present. I needed to compare the x-ray to the one she had done earlier in the week to see if the stone truly had passed.


The challenge was that her home community is not connected with our electronic access system for x-rays (PACS). PACS allows online access to x-rays done in many places around the province as soon as they are completed. This innovation has markedly improved the speed with which we can make appropriate diagnosis. In her case, however, she would need to have the hospital make a CD with her x-ray on it and then send the CD to me. With this being a holiday long weekend, it would be well into next week before I could make a diagnosis.

She called me back to let me know that her plans had changed and she was planning to come to Saskatoon for the long weekend. She would drop a CD off at one of the hospitals when she arrived and I would pick it up in the morning.

The next morning turned out to be a vignette of frustration.

I searched around the department where my patient said she had left the CD but no one knew where was. I called her to check that she had actually dropped off and she assured me she had. I returned to the department and someone remembered where it was. I tried to open the x-ray files on a computer but was unable to do so. (Usually, loading the CD on a computer automatically opens the x-ray pictures.) I hunted down the on-call radiologist to see if he could open the pictures. He spent 10 minutes trying but was also unsuccessful.

I called my patient and told her we would need to repeat the x-ray. She came to the emergency department and registered herself. She had the x-ray repeated and I checked the results. After comparing to the previous x-ray, I could see that the stone had actually passed. I met her in the emergency department and gave her the good news.

I estimate the time I spent with phone calls, searching for the disc, and trying to open it with the radiologist was about 30 minutes. That's 30 minutes of completely non-value added time.

Also, there is the real cost of registering my patient in the emergency department, doing another x-ray, paying the radiologist fee for interpreting the x-ray, and paying my bill for seeing the patient in the emergency department.  (I've ignored any patient costs...)  If I would have had access to the x-ray electronically, I would have phoned her and the additional cost to "the system" would be zero. There is also a non-tangible cost of frustration both on my and my patient's part. When a similar situation comes up in the future, I'll be tempted to make things easier for myself by insisting that the patient come to Saskatoon to have another x-ray done.

Multiply these costs by the number of times similar scenarios play out across our health care system and you begin to see the money and resources we are squandering by not having a fully integrated electronic medical record. What a waste!

Asking family physicians how we can help them provide care

We've been working on improving patient care and access for over 5 years.  While we continue to improve processes in our practice, it's been frustrating to see that, after our initial success in improving access, patients have been waiting longer over the last 2 years.  This is partly because of reduced manpower in our group (retirements and semi-retirements) and a shift in focus of urologists' time (provincial emphasis on reducing surgical wait times takes urologists away from office consultations and puts them in the operating room).

Wait times have crept up enough that patients and referring physicians are feeling a strain.  We recently received several calls from family physicians commenting on our wait time and the problems it's causing.  Not only do patients have to put up with the anxiety and suffering from their medical condition, but family physicians have to spend more time reassessing patients and then sending "re-referral" letters to us.  Sometimes these letters are indicating a change in the patient's condition and asking for a more urgent appointment.  Sometimes these letters are just checking that our office has actually received the initial referral.  Either way, it's more work for the GP, the urologist (who has to reveiw the second letter) and our respective staffs.

Last week, I visited one of Saskatoon's large family physician group practices.  I attended their regular practice management meetings to acknowledge the difficulty they were having in getting access to urology services and to ask for their advice.  They had some useful suggestions:

While they would prefer to have rapid access for their patients, if there is going to be a wait, they would like to be able to give their patients an accurate idea of how long the wait would be.  They felt that this would reduce anxiety and the number of repeat phone calls from patients wondering when their appointment would be.  One doctor commented that, when our urology clinic had initally improved wait times, family physicians had become used to the rapid access and were still telling patients that "it shouldn't be too long to get in".  Unfortunately, this isn't consistent with our current access, so patients become concerned when they don't get a prompt appointment.

The family physicians were interested in a more collaborative approach to the consultation process.  They asked if we could provide guidelines to help them carry out appropriate investigations prior to their patient seeing the urologist.  I mentioned our hematuria evaluation guidelines (requesting that the GP arrange an ultrasound and certain lab testing, so that we can arrange a "one-stop" consultation for the patient to undergo cystoscopy/bladder examination) and they agreed that more of the same would be useful.  They suggested a urology referral template that would list common conditions and symptoms along with suggested pre-consultation testing and management.  They could load the template onto their EMR for easy access.

One of the senior group members made a frank observation.  He said that, over the years, he's come to rely on our practice to manage his patients' urologic conditions, so much so that he may have become a little "lazy" in managing some of the conditions himself.  He wondered if he could have a "refresher" about common urologic conditions, such as erectile dysfunction and enlarged prostate.   Several of the clinic members agreed that they would like to have guidelines on how to manage these common problems in primary care.  

They also made an interesting observation about the utility of clinical guidelines.  Many guidelines and protocols are available from various sources, including family physician and specialty organizations at both the local and national levels.  The GPs indicated that the multitude of available guidelines becomes confusing for them and their patients.  They were particularly conscious of the fact that if they chose to follow a legitimate national guideline in managing say, bladder infections, and later refer their patient to the local urologist who follows a different guideline, their patient may be distressed and question the GP's aptitude.  For this reason, they preferred that any guidelines bear the "stamp of approval" of local specialists so as to take into consideration local practices and resources.  This doesn't mean that we would have to generate recommendations independent of national standards, but rather that we would review available practice guidelines, and adjust appropriately for local practice before disseminating them.

They also suggested that a variety of continuing professional development tools would be helpful.  In addition to having specialists make presentations at local family practice conferences, opportunistic instruction ("teachable moment") could also be used.  For example, if our urology clinic received a referral regarding a patient with a common condition that can be managed by the primary care practitioner (recurrent bladder infection, for example), rather than making the patient wait to hear the treatment advice from the urologist, we would fax back to the referring practitioner a treatment algorithm, along with an educational module and patient information. 

None of these ideas is earth-shattering, but they demonstrate family physicians' genuine appetite to break out of the current consultation model in which we are stuck, and is not serving our patients well. 

Leaders' work: Removing barriers to success

Don't it always seem to go 

That you don't know what you've got 

'Til its gone

Big Yellow Taxi

Joni Mitchell

This summer, I rediscovered the joy  of cycling.

Last weekend, I went for a long ride with my neighbor, an experienced cyclist. As we were returning home, it began to cloud over and the wind picked up.

"Why don't you try riding about 8 inches behind me," Bruce suggested.

As I experienced drafting for the first time, I immediately found that riding was easier. Because Bruce was blocking the wind for me, I went faster using the same energy.  I realized how much extra effort it had been to fight the head wind.

It was a much more enjoyable ride after that.

This week, I rediscovered the joy of using technology in my work.

Our urology clinic has used electronic medical records (EMR) for many years. Among the many benefits, having remote access to our records is one of the most useful. This is particularly helpful for specialists who split their time between various physical sites such as an office and  the hospital. 

Prior to converting to using an EMR, we would transcribe notes from the paper chart in our office so that we could refer to them the next day at the hospital. (We had a policy prohibiting removal of paper charts from the office, both to maintain chart security and also to give our office staff access to the charts for record keeping and billing purposes.) Not only was this time-consuming, but we had no access to the original chart once we left the office.

Now that we have remote access to our EMR, we can check patient information, lab results and staff communication from any site. We even have access using our smart phones.   This has become such an integral part of our practice that it's hard to imagine what work was like before the EMR. That is, until the technology fails.

Over the last few months, remote access to our EMR has been painfully slow.  At a typical cystoscopy clinic at the hospital, I would see up to 15 patients during the course of a morning, each scheduled in a 15-minute slot.  That 15 minutes includes time for preparing the examination room, greeting the patient, discussing their problem and the cystoscopy procedure, performing the cystoscopy, discussing the results and treatment, dictating a consultation letter to the referring physician, then reviewing the next patient's records.  

My laptop connects to our office via the hospital's wireless network to the internet and then to our office server.  When something is awry in that connection, loading each patient's record can take several minutes.  No amount of hammering on the keyboard changes this.  Many times, the nurse will already have brought the next patient to the cystoscopy room, at which time we all wait for the EMR to work its laborious magic.  At one point, I reverted back to old-fashioned note-making the night before a cystoscopy clinic.  (Blasphemy!)

During the summer, we overhauled our office's computer system with a faster server and upgraded laptops.  This seemed to make a difference initially, but then the problem recurred.  Two weeks ago, in a last ditch effort, we replaced our modem.  Hallelujah!  We now have remote EMR access at almost the same speed as when we're plugged directly into our office network.  Now, I can review my next patient's chart and still have time to review incoming labwork, reports and consultation requests - all while the nurse prepares the cystoscopy room and brings in the next patient.  

Once again, it is a pleasure to let the EMR make my work easier.

On our bike ride, Bruce recognized that, in order to reach our goal (get home before it started raining), we needed to move faster.  He could have encouraged me to work harder and pedal faster, but I was already tired and wouldn't have been able to maintain additional effort.  Also, I would have felt badly for letting him down.  Instead, he found a way to remove the barrier that was preventing me from achieving our mutual goal.

That's great leadership!

Perverse incentives - Don't shoot the messenger!

I don't follow international badminton as closely as perhaps I should, but maybe we've all been a little guilty of that.  However, the recent disqualifications of Olympic players got my attention.  It seems that some top badminton teams were blatantly trying to lose their matches.

Puzzling, huh?  It is until you read about the tournament system and strategy around match play.  It seems that the top-ranked teams don't want to face each other until the finals, and so they conspire to throw preliminary games so that they are matched with less expert opponents.  This strategy improves their chances to make the finals, and end up with a medal of some sort.  When you think of it like that, it makes sense, except that it was so obvious to spectators and officials that the teams were flubbing games, that they were disqualified for not living up to the competitive Olympic spirit.

I wonder what the athletes were told before they left for London: Your country expects you to give your best in ever match, or Your country expects you to bring home a gold medal?  Even if it wasn't explicitly voiced, I suspect the second is strongly implied.

Commentators pointed out that the format of the tournament - round-robin - encouraged this type of "cheating" as athletes knew that this would be their best chance to win a medal.  So who is to blame?  Is it disingenuous of Olympic officials to expect athletes to give their all in every match when it could deny them a chance at a medal?  Why do the Olympics only recognize the three top teams with medals if grit and determination are more important?  This is a classic perverse incentive.

It made me think of the current fee-for-service remuneration system for physicians.  Provincial health insurance plans "reward" us for providing more visits and procedures, yet at the same time, we're told we need to provide better quality of care (which sometimes means doing fewer interventions...).  At present, our monthly billings are the only scorecard we have, yet health care commentators ask us to "give 110%" to patient-centred care.

If physicians can legally maximize their billings without compromising patient care, then it's only natural that we will do so.  (Note that there is a difference between passively "not compromising"- i.e. status quo - and actively optimizing care.  The latter is preferred, but needs an incentive...)  In the same way that the Olympic officials should consider the influence of tournament structure on player behaviour, officials responsible for maintaining the current physician incentive structure should do the same.

Leaving a dysfunctional structure in place is not a passive choice.  It is an active decision to avoid taking the steps to make a positive change.

Don't shoot the messenger!

Drone on! Making standard work standard

A couple of months ago, a colleague told me that he had watched the video of my presentation at the BCPSQC Quality Forum.  In it, I had highlighted the detrimental effects of variation in clinical practice.

"Pretty good," he said, "but I'm not sure that everyone should do things the same way.  I mean, I didn't study for all those years just to be some kind of drone!"

It's interesting to hear this free-wheeling sentiment from surgeons.  I can't imagine any health professional more fussy about consistent practice than surgeons. (Why aren't all the scalpels pointing due north!?)  We develop a reliable method though training and experience, and we like to stick with it.  We know we're more prone to mistakes when we deviate from habit.

Coincidentally, my colleague had just completed 2 somewhat finicky procedures that day.  Actually, it was the same procedure performed on 2 different patients.  The operation required specialized equipment, nursing expertise and patient preparation.   Quite sensibly, he likes to do the procedure the same way every time.

I asked him how the cases went.  He saw where I was going.

"I do it the same way every time because that's what works for me.  I don't want to have to do it your way," he said.

He genuinely wants to give patients the best care he can, and uses his experience to best advantage.  From the viewpoint of his own practice, his personal "standard work" serves him fine.  He's convinced about the value of intra-practitioner consistency.

How to convince him that inter-practitioner consistency can further improve quality and safety?

As we discovered in our practice (see the video), demonstrating to practitioners that there is significant variation in clinical practice is illuminating.  (There's no shortage of variation to measure!) Approach the information with curiosity rather than judgment.  In most cases, physicians will have never seen this aspect of clinical work, that is comparisons between practitioners.  For us, it lead to sharing our individual "best practices".

Telling stories about the negative side of clinical variation has been powerful in our practice.  Our staff told us that they found having 8 different ways (8 urologists!) of doing the same task was confusing.  They worried that patients might receive the wrong information or be missed for followup. Solution: Consistency.

Finally, doctors need to have a role in developing standard work.  Last fall, I heard a great comment from Intermountain Health's Chris Wood.  "Yes, it's cookbook medicine.  And you get to write the cookbook!"

 

What is "necessary" in health care?

It must be a tough time to be an American astronaut.  

Since the US Space Shuttle program shut down a year ago, their opportunities for spaceflight are limited to hitching a ride with the Russians.  It must be incredibly frustrating.  Consider the years of training, childhood dreams, and self-sacrifice - all for naught.  That is, unless they can convince the American government that space travel is a necessity, and a worthy recipient of public funding.

I imagine that US astronauts must be passionate advocates for funding space flights.  After all, their careers - and self-images - are at stake.

I don't think the astronauts would behave any differently than any of us, should we suffer a similar change in fortune.  A recent on-line conversation has me thinking about how professional self-image (or perhaps self-interest) affects what we consider "necessary" in healthcare.  The discussion started with a post on Healthy Debate (see the comments), then Irfan Dhalla and Mark MacLeod stepped outside.   To Twitter.  The discussion was about fee-for-service and whether it leads to provision of "unnecessary" services.  Dr. MacLeod, an Ontario orthopedic surgeon and OMA past-president, offered this tweet: 

@IrfanDhalla I open my practice completely to anyone who wants to come and tell me the services I provide that are not necessary. Anyone

It's a generous offer from Dr. MacLeod, but I'd rather explore whether or not I'm providing unnecessary service in my own practice.  I took a look at this 2 years ago in this post.  I reviewed 57 new consultations over a 2 week period and tried to judge whether or not they were "appropriate".  (To be fair, "appropriate" and "necessary" may be different classifications.  Read on.)  I judged that 8 (14%)  of the consultations weren't necessary, that is, the condition referred for wasn't serious, was for a false-positive test result, etc.

But, who should decide whether the consultation was necessary or not?  The various interested parties may have differing opinions.  I decided (according to a subjective review) that they weren't necessary.  The referring physician felt they were necessary (by definition, I think, otherwise he wouldn't have referred them...).  In most cases, the patient likely felt the referral was necessary but, for asymptomatic patients (in the case of the false-positive test result), the perception of necessity would have been influenced by the referring physician's appraisal.  How did our provincial health insurance payment agency feel about it?  I don't know, and I kind of hope they didn't read my blog post about it.

The point is that it is easy to make a case that any health service is "necessary", as long as someone wants it.  Patients may want the service to improve their health, relieve symptoms, or just give them reassurance that everything is normal.  Referring physicians may want the service because they have diagnosed a condition that is beyond their expertise to manage, or because they are uncertain of the diagnosis and/or treatment, or to satisfy a patient request to see a specialist.

That bring us to the consultants.  And the astronauts.

Both groups are highly-trained professionals who genuinely believe that their skills are necessary in society.  Naturally, either group would feel threatened if someone suggested that some of their services were not necessary.  Under those circumstances, a natural reaction is to be defensive and rationalize that one's services are, in fact, essential in society.

The debate will just deteriorate from there, with the main point of contention being the definition of "necessary service".

Perhaps we can avoid that divisive debate by rejecting the idea of necessity and instead considering value.  Let patients be the judges of how much value a given service if worth to them.  You might say that substituting "value" for "necessity" is just sophistry.  After all, if something is necessary, it will be considered valuable, and vice versa.  Well, let's go one level deeper to find out what patients are really seeking.

When a patient comes to see me with a kidney tumour, they may ask me to perform surgery to remove their kidney.  But, in truth, they don't want surgery.  After all, surgery is painful, stressful and carries significant risks.  What they really want is to have the kidney tumour treated and trust my advice that surgery is the best treatment.  They then reluctantly submit to surgery.

But, do they really want the kidney tumour treated?  Popular health culture dictates that cancers must be treated.  But, one of the vagaries of kidney tumours is that not all of them - even though they may be cancerous - require treatment.  For elderly patients with small tumours, the risk of surgery may vastly outweigh any benefit, and we often recommend observing the tumour.  This is because the patient's real goal is to preserve quality and quantity of life.  It's not always correct to assume that a kidney tumour will affect either parameter.  Yet, without a full discussion about the patient's desires (the patient is the expert here) and the medical facts (the doctor is the expert here), we can't truly know what course will be most valuable for patients (AKA shared decision-making).

In our practice redesign work, we've tried to think about what value we're providing for patients.  Back to that 2-year-old post.  Many men were being referred to us for "vasectomy reversal".  We found that the men would come for their consultation, listen to us explain the reversal procedure, then tell us they didn't want it done.   Some men were dissuaded by the fact that it is a non-insured procedure and they would have to pay for it.  Others were discouraged by the success rates.  Others were just interested to hear what the surgery involved.  In any case, many of them travelled up to 8 hours round-trip just for a 15-minute discussion.

The men, and their referring physicians, thought they "needed" a face-to-face urologic consultation.  But, when we dug deeper into it, we realized that the value was in the information, not in meeting the urologist.  We created an information pamphlet summarizing the vasectomy reversal information, and began sending men the pamphlet instead of booking a consultation.  We invited men to make an appointment for surgical consultation if they still wanted to go ahead after considering the information.  About 10% of men made those appointments.  They had their need addressed without having to travel.

I told you another (slightly discomfiting) story of poor patient value in this post.  An elderly man and his wife came to see me to get his CT scan results.  A medical student called me on the fact that they could have received the results in a different, more convenient fashion.  The system (my system!) had only provided them with one option - face-to-face with me.  It was a necessary service, but I could have given better value.

I suspect that most medical practices (perhaps even Dr. MacLeod's) would yield similar examples if subjected to scrutiny.  But such attention to other's work would be counterproductive as it would be perceived (correctly) as judgemental, and would lead to defensiveness.  I would rather encourage curiosity about how we can change our own practices to provide better value to our patients.  That also requires scrutiny, but we only need to open our practices completely to ourselves to achieve it.




American astronauts who see their mission solely to be to ride into space must be devastated.  But, those who see their mission to be to use their talent to serve society according to the public's need and desire, and are capable of adapting to fit changing circumstance... they will land on their feet.

What if we didn't care? (What really motivates healthcare workers?)

During my medical school application interview, I was asked why I wanted to be a doctor.  I gave the answer that I thought was expected of me: Because I want to help people.

I don't know what the interview committee thought about that answer.  Did they mentally roll their eyes as they listened to that rote response for the umpteenth time?  How can this 18-year-old kid know anything about caring for sick people?

If they wondered that, then they were right.  In retrospect, I had very little idea what I was in for, what a life in medicine would involve.  It's been a happy coincidence that I've found this career very fulfilling.  And I hope I channel that satisfaction into a genuine caring for the wellbeing of my patients.

But what if I didn't genuinely care about my patients?  Could I fake it?  Would it matter?

At many conferences and meetings, I've heard speakers remind us that "we all got into this job to care for people".  But, is it true?  I've never heard anyone publicly question it.  Imagine the horrified response if someone did take exception to that dogma!

I have no doubt that the majority of healthcare workers truly do care for their patients and clients.  


Wow - that sentence came out almost without me thinking about it.  It's so appalling to even suggest that healthcare workers might not actually care ("care" is written right into health care, for goodness sake!), that I reflexively wanted to avoid insulting anyone by even having suggested it.  But, after I read the words, I realized that I don't know how to judge if someone truly cares for a patient's wellbeing.

Let's say caring means a genuine concern about another person's welfare.  That's a state of mind.  We could measure "caring" by asking a person about their feelings or attitudes.  If they answered honestly, we could decide whether they were concerned about a patient's welfare.  But, if they thought they were expected to answer in a certain way, they might not be frank.

Perhaps their actions could be a surrogate measure.  If we observed them to be friendly, solicitous and gentle then we could conclude that they genuinely cared.  But, could they fake that?  And if they faked it, would it matter?  As long as the patient perceived the person as being caring, what difference would it make?

I think it is important to recognize how healthcare workers truly feel because it speaks to their real motivation to carry out their duties in a way that patients and clients want.  If we delude ourselves that everyone in healthcare is motivated solely by genuine caring for their patients' wellbeing, then we may be missing opportunities to unleash workers' potential.  And more importantly, we may be missing opportunities to let workers find joy in their relationships with their patients and clients.

My own motivation includes a mixture of (not an exhaustive list, and in no particular order...) financial reward, technical mastery, peer approval, and caring for others.

I don't know what my cutoff for remuneration would be before I decided to find another job.  I know I wouldn't sweat over a tough surgery or be on weekend call for free, but I get enough satisfaction from the job that I would likely do it for less than I get paid now.  (You didn't hear that from me.)  I suspect there is little direct relationship between remuneration and caring, as evidenced by some of the fabulous volunteers I know in our community.

For me, as with most surgeons, technical mastery is a tremendous motivator.  Last month, I was called on to repair an injury a patient had suffered during a previous emergent and difficult operation.  If I could fix it endoscopically, she would be spared an additional operation and weeks of recovery.  I cared about sparing her that additional burden, but I was also intrigued by the puzzle before me.  What instruments would I need?  What staff should be in the OR?  I visualized the procedure to decide how to arrange my instruments for easy access in the order I would need them.  When the challenging procedure went well and I was able to accomplish my goal, I felt tremendous satisfaction.  And, by another happy coincidence, accomplishing my goal meant that my patient would have a faster recovery.

Peer approval is a powerful force among physicians.  If, after I successfully complete a challenging operation or clinch an obscure diagnosis, one of my partners says simply "Good job", it's deeply rewarding.  When we've discovered variation in clinical practice among our group, there's been a desire to conform to the majority's behaviour.  If the majority are already performing according to best practice, then the task of standardizing behaviour is made easier by the outliers' desire to conform.

(Imagine what a crafty, yet well-intentioned, administrator could do with this information.  Just as one example, they could create easy access to performance metrics and encourage comparison between individual physicians and departments.)

Everyone will have their individual formula that motivates them to behave in a caring way.  (Note that "behaving in a caring way" is different from "caring", which presumes a state of mind.)  If we unquestioningly accept that all healthcare providers are primarily motivated by "caring", then we may be missing the chance to address all the other sources of motivation that could bring more joy to their work and greater satisfaction and better outcomes for their patients.

And, greater joy in work will lead to true caring.  As a friend recently told me, "You can act your way to a new way of thinking".

Or more plainly, "Fake it 'til you make it!"

Pooled referral gains momentum in Saskatchewan

Specialist "pooled referral" implementation is sweeping the province!  Here's a great story in the Prince Albert Herald about PA's orthopedic surgeons offering pooled access as of March, and general surgeons planning to implement it at the end of May.  The Regina Obstetrics and Gynecology department are also offering this option to their patients.

Pooled referral, also known as centralized referral intake (CRI), involves collecting referrals in a central location and then distributing the referrals so that patients have access to the specialist with the shortest wait time.  When our urology group implemented this system several years ago, the reception from referring physicians was very positive.  (Here's the post looking at wait times for pooled referrals.)  They liked the fact that they didn't need to do the "heavy lifting" of figuring out which urologist had the shortest waiting list, or which one of us subspecializes in a certain problem.  

When I have the chance to share our practice's learning and improvements, the idea of pooled referrals has an immediate appeal to both referring and consulting physicians.  However, physicians do have some trepidation about the system.

First, they're concerned about patients (and referring physicians) having the choice of which consultant they will see.  Our group's philosophy has been that patients and referring physicians have the choice of which urologist they see.  We don't require participation in pooled referrals, however, if someone "opts out" of pooled referrals, they may wait longer to see the urologist of their choice.

Continuity of care is also a consideration.  Physicians recognize that time and effort is wasted, and important clinical details may be overlooked, when patients switch between specialists.  A pooled system should try to maintain any previously-established patient-physician relationships (as long as the patient wishes to do so).

Finally, I'm often asked a very thorny question: How can a pooled referral system ensure that patients will have a consistent experience no matter which specialist they see (AKA not all docs are created equal)?  This applies to the interpersonal, as well as technical, skills of the specialist.  This is very difficult to answer as there is often no formal tracking and reporting of individual surgeon's treatment outcomes and complications.  Communication skills, empathy, and affability may only be judged through word of mouth.

This raises an ethical question: If we promote a new referral management system, and that system has the potential to adversely affect the experience and outcome of some patients, what is our responsibility to assess and improve the abilities of the specialists so that patients receive consistent, competent care that is constantly being improved?  

I think that, by its very existence, a pooled referral/CRI system begins to address this concern.  In order to implement this system, specialists must be prepared to communicate and collaborate, often to a degree that they previously didn't do.  This lets them share information about, and expose differences in, individual practices.  In our urology practice, learning about differences in our practice habits made us curious about what could be considered "best practice" and how we could offer more consistent care.  

Pooled referral/CRI has the potential to improve patients' access to specialist care, and make sure that they receive care from the appropriate practitioner.  However, it's not without drawbacks, and we must proceed with eyes wide open.

Great comment from a nurse about managing the drug shortage

This comment (made on the last post about the national injectable drug shortage) is great on several levels:

I am an Lpn at sch on the gyne ward.. I haven't noticed that my patients are suffering any more since the cut back on IV meds.. the use of gravol supps for nausea, regular use of oral analgesics and pain and nausea rating on rounds has I think ensured patient comfort..Patients seem hesitant at first but are reassured that if the oral or pr routes don't work we will go with the intervenous option. I wonder if Pre op clinic could instruct patients on the shortage so that they are less apprehensive post op when their nurse suggests something other than IV drugs..

• It's feedback from a front-line care provider telling us about how care-givers are perceiving the situation's effect on their patients' care.  

• The nurse tells us that pain and nausea rating is done in order to ensure patient comfort.

• We get some insight into how patients are being affected by the changes.  They may be anxious about the effectiveness of pain-killers or anti-nauseants being given other than intravenously.  The nurses on this ward are reassuring patients that they will switch to intravenous medications if the alternate forms aren't adequate.  I don't know if there has been formal training in a "script" to use when explaining the situation to patients, but I suspect that having such a script may be useful for nurses when counselling patients about these changes in practice.  This would also ensure that patients receive a consistent message across the entire health region.

• Finally, what a great suggestion to prepare patients preoperatively!  Hearing about our change in medication practice in advance would certainly be easier than hearing about it when a person needs relief from pain or nausea.  Transparency? Check! Respect for patients? Check!

Sounds like the gyne ward staff at SCH have some great ideas.  Maybe a gemba walk is in order...

Variation in Clinical Practice revisited - the video!

How long have you got for lunch today?  37 minutes and 48 seconds? Perfect!

The latest work we're doing in our office (to improve care for patients with bladder cancer) inspired a post in March about variation in clinical practice.  It was also the spark for a presentation I had the pleasure to give at the BCPSQC Quality Summit.  Thanks to Christina Krause and her team for putting on a terrific meeting and for producing this video (37m 48s).

If you're not sure about investing 37 minutes, try the first 7 - that should give you a good idea what to expect from the rest.

(Yes, the screen shot could have been marginally less goofy-looking. Or perhaps not.)

Customer voice changes my thinking on changing our office practice

Last week, several of my partners and I had been talking about whether we should change a long-standing office procedure.  Most medical practices use a nurse or receptionist to show patients into examination rooms, where the patient waits until the doctor arrives.  In our office, we don't employ a nurse.  Instead, the doctor greets the patient at the entrance to the waiting room and shows him back to the consultation/examination room.

I'm sure that Lean practitioners would cringe to hear this.

Think about the steps in this procedure:

Doctor walks down the hallway from his consultation room to the examining room. 

Doctor calls the patient's name. (Repeat as needed) 

Patient packs up reading material, closes cell phone, removes and hangs up coat, etc. 

Doctor greets patient. 

They walk back down the hallway to the consultation room.

That takes from 1-3 minutes to complete.  It doesn't sound like much, but it's a significant proportion of our "standard" 15 minute visit.  It's time that could be spent finishing dictation of the previous consultation report, reviewing the next patient's chart, checking in-coming reports, etc.

I had recently read about the practice of "self-rooming", where patients are given instructions by the receptionist and then make their own way down to the assigned consultation room.  This would let our receptionist remain at her desk, save us the need to hire additional staff, and give the docs a few minutes of extra time between each patient visit.

What a great idea!  I ran it by a few of my partners and started thinking about how we could do try out the concept in our office.

Then, late last week, I met a man who changed my thinking entirely.

I was attending Saskatchewan's Health Quality Summit, and introduced myself to the man (I'll call him Ken) sitting next to me at one of the workshop sessions.

"Oh, yes," Ken said.  "I've visited one of your partners.  You know what impressed me about your office?  That the doctor actually came out himself to the waiting room to call for me."

What a coincidence, I told him.  We were just thinking about changing that practice because it's inefficient.  I explained the amount of time it took for doctors to perform that task.

He agreed that it may take a few extra minutes to do, but that he found it to be an important part of building the doctor-patient relationship.  He felt it showed a degree of respect and caring.

"When I meet a doctor for the first time, I make a judgment as to whether I can trust that doctor.  I think the first impression your staff make is a very good way to build that relationship," Ken said.

That was a very powerful thing for me to hear.  I have often commented to medical students and residents that specialists need to be deliberate about building a trusting relationship with patients.  Unlike family physicians who have years in which to develop a bond with patients, specialists have only a short time to do so.  This is especially important for surgeons, who may meet someone for the first time and, within the course of that visit, inform the patient about a serious diagnosis - such as cancer - and discuss performing a life-changing procedure.

Ken was telling me that the simple habit of escorting my own patients to my consultation room was a valuable step in building a trusting relationship.

That doesn't change the fact that the procedure requires an investment of time, but it does mean that, if we're going to make a change, we can't measure the outcome solely on the basis of time saved.  We would also need to consider the impact on patient experience.  As Ken went on to say, "Spending a few minutes more up front is probably saving you time later on because patients feel you are considerate and caring."

What a valuable lesson! (Even if I do have to keep learning it over and over again...)

"Doing the Wife's Tummy Tuck" - An informal survey of surgeons' reactions

About 2 weeks ago, an American plastic surgeon told the story of how he performed his own wife's "tummy tuck" - a cosmetic surgical procedure to remove excess, sagging skin from the abdomen.  The blog post is on the popular medical blog aggregator site, KevinMD, and also on Dr. Di Saia's own website.  Rather than having me recount the story, I encourage you to follow one of the links and read the brief post for yourself.  Reading it on Dr. Di Saia's website may give you a better appreciation of his practice context and expertise.

I shopped this story around the surgeons' lounge last week and the response was vigorous and unanimous: Bad idea.  The surgeons expressed several concerns:

First, while the outcome for the patient/wife was good in this case, any surgeon knows that this will not always be so.  In the rare case when things go wrong in the operating room, it becomes an extremely stressful and dangerous situation very rapidly.  In those cases, the patient's best asset is a calm, dispassionate surgical team that can think clearly and act decisively.  Every surgeon I spoke with admitted that their judgement would suffer if they were called upon to lead the team managing their loved one's surgical crisis.

Next, many of the surgeons wondered about the possible effects on a marriage if the results of the surgery were not exemplary.  Would the wife be comfortable in raising a concern to her husband?  If her own lifestyle depended on her husband's professional reputation, would she admit that she was dissatisfied with the outcome?  How would the surgeon/husband balance his professional appraisal of the cosmetic result against his personal satisfaction with his partner's appearance?

One surgeon commented that there is a ethical prohibition against physicians establishing intimate relationships with their patients, and wondered how that principle should be applied in this case.  The intertwining of professional and personal relationships can be messy.

During the discussions, almost everyone commented that they had, at one time or another, rendered some medical care to their family members: antibiotics for strep throat, sutures for a cut suffered while at the cabin, or various and sundry slings, splints and bandages.  And, most agreed that, in case of an emergency with absolutely no other suitable care available, they would operate on a loved one to save their life.  But this doesn't apply to a tummy tuck - the ultimate in elective, cosmetic surgery.

Some other comments:

How would Dr. Di Saia obtain full, informed and free consent to blog/tell the world about his wife's surgery?  

Was there any commercial incentive to perform this surgery, and then tell the story (i.e. "I'm so confident of my skills that I operated on my own wife!")?

Did the facility where the surgery was performed have any rules about this situation?  How did the rest of the surgical team feel about this? 

What do you think?  Are we over-reacting to this story?

Getting feedback on drug shortage - Do we need additional measures?

More on SHR's efforts to cope with the national drug shortage.

Last week, we received some positive feedback from our pharmacy about our efforts to conserve injectable medications:

The most recent review revealed an average 37% reduction in usage for the most affected injectable drugs.

That represents the combined efforts of both those prescribing/ordering the medication, and those administering them.  In our department, we've been conscious of the need to order both injectable and oral medications for postoperative patients, so that nurses can make the switch to oral medications as soon as it's appropriate, rather than needing to wait for new orders to be written.

It's encouraging to see this desired change, and I hope that pharmacy will continue to track the drug usage and report back to clinicians.  We're interested in a sustained change in practice, and will need to chart usage over time to see if clinicians need reinforcement, or perhaps some other intervention.

But, is measuring reduction in usage sufficient?  Let's go back to that pesky Model for Improvement.

The Model's first question is answered in an aim statement.  I suggested that our aim statement might be something like:

We will ensure that patients receive appropriate care and access to necessary medication.  We will do this through careful management of the injectable drug supply and by use of alternative medications and administration routes.

The second question relates to how we measure progress.  We currently have one measure - an outcome measure - namely the usage of injectable drugs.  But, any time we change one part of a system, unintended changes may happen in other parts.   Perhaps we should also look at  these possible consequences of our conservation efforts with a balancing measure.  For example, could we be overzealous in our attempts to conserve injectable medication? What if patients had inadequate control of symptoms, like pain or nausea, because oral medication was being used when an injectable form may be more effective?

If you were the pharmacist in charge of this effort, you'd be gnashing your teeth right about now.  "We don't have the time and resources to do comparisons of patients' symptom control with and without injectable drugs," you might say.  That would be a lot of work, so perhaps we could start with a surrogate measure.  How about a survey of physician and nursing staff from various wards to see what their impressions are.  Do they notice a difference in patient comfort?  Are the oral medications giving prompt relief of symptoms?

If staff are noticing that oral medications are less effective, we owe it to our patients to investigate further. (Note: in my own practice, I have not seen any sign that patient care has suffered.  There you go, pharmacist, your first data point is collected!)



P.S. To the Anonymous commenter asking if SHR's medication substitution table is available for wider consumption, I haven't been able to find an external link for you.

Progress in managing the national injectable drug shortage

Yay for Saskatoon Health Region (SHR) Pharmacists! As I mentioned last time, SHR (along with the rest of the country) is dealing with a shortage of injectable medications.  Pharmacists have the task of managing our region's supply.  Right on schedule (March 13), they created a table of suggested alternative medications to address the shortage of injectable medications.  (Even though I advocated for this in my last post, don't give me any credit, because they were already in the process of creating the table before the idea occurred to me.)

The table has been circulated, posted on the SHR network, and has already been updated.  They also have a plan to track use of injectable medications that are in very short supply and have conversations with physicians using those medications to make sure that alternative administration routes are used as soon as appropriate.

This situation made me think of the Model for Improvement, a widely-used technique for process improvement.

The Model for Improvement has us ask ourselves 3 fundamental questions whenever we want to improve something:

What are we trying to accomplish?

How will we know a change is an improvement?

What changes can we make that will result in an improvement?

 In the case of the med shortage, the answer to the first question is obvious: We're trying to conserve the supply of injectable medications.  At least, that's how it looks from an operational point of view.  Our real aim is may be something like:

We will ensure that patients receive appropriate care and access to necessary medication.  We will do this through careful management of the injectable drug supply and by use of alternative medications and administration routes.

SHR Pharmacists have already given answers to the third question: What changes can we make that will result in an improvement?  They have notified all clinical staff of the shortage and have asked that we consider changes to practice that will conserve medications that may be in short supply.  Further, they've helped us achieve that goal with the alternative medication table mentioned above.  They will have individual conversations with practitioners, if there seem to be opportunities to appropriately change clinical practices.

It's the second Model for Improvement question I'd like to consider further: How will we know a change is an improvement?  This is about measurement.  Or, more accurately, measurement to enable change.

Pharmacists will be tracking use and supplies of injectable medication.  But, as they are not the ones using the medication, that information will have limited use if it's only in their hands.  Clinicians understand the importance of this initiative to appropriately use medication to preserve supply.  We can do a better job if we get feedback on our performance.

Show us whether we (individually, by department, or hospital ward) have made helpful changes to our practice.  Compare rates of use of injectable to non-injectable meds before and after this change initiative.   Have the reminders/exhortations from Pharmacy made a difference?  If so, plot these rates over time so we know whether helpful changes are sustained.  If not, then we need a different strategy.

Take advantage of positive deviation in practice.  Find out which departments/wards are making the changes more successfully and explore how they've achieved that.

Show clinicians that there actually is room for improvement.  I suspect that many docs had the same thought as me when I received the notification about changing prescribing behaviour: I'm already optimally using these medications.  This change doesn't apply to me!


What is the gap between current and desired prescribing behaviour?  If the gap is wide, then let's work to narrow it.  If not, then efforts to change clinician behaviour are a waste of time and we should pursue other change ideas.

Specific feedback will keep clinicians' attention on this important issue.  Without it, emailed updates will become background noise.  

Clinicians need help in order to conserve drugs in this time of shortage

Eliminate slogans, exhortations, and targets for the work force asking for zero defects and new levels of productivity

- W. Edwards Deming (10th of Deming's 14 principles of management)

I love it when 2 ideas smush together in a chocolate-and-peanut-butter way.

It happened for me this weekend.

On Friday, I had a great time at BCPSQC's Quality Forum.  In addition to attending some stimulating breakout sessions, I met Dr. Keith White, BCPSQC's Clinical Lead for Medication Reconciliation.  As he explained his work, he told me about the challenges that family physicians have in ensuring antibiotic use for patients with respiratory infections.

Most patients seeing their family physician about flu and cold symptoms have a virus, and antibiotics are not useful (and may be harmful).  Despite public education campaigns, some patients may still have an expectation that they will be prescribed antibiotics.   Public health organizations have exhorted physicians not to prescribe antibiotics in these situations, so as to reduce the risk of side effects and the development of antibiotic-resistant bacteria.

Dr. White explained to me that it's not sufficient to encourage this behaviour in family physicians; we need to provide the tools to help them.  He suggests using "scripts", or rehearsed responses, that address common concerns patients raise, such as "The last time I felt this way, the doctor gave me antibiotics", or "What's the big deal? It's just an antibiotic."

When prepared with responses to "frequently asked questions", physicians can confidently address common concerns and misconceptions that patients may have about antibiotic use in viral infections.  But, we can't expect that they will magically have these answers at their fingertips.  An initiative to curb inappropriate antibiotic use should include providing this resource to physicians, and showing them how to use it.

Make it easier for them to do the right thing.

That was the chocolate.  Here's the peanut butter:

Drug shortages have been in the news, and on the minds of health professionals across Canada.  Because of production problems at a manufacturing plant that supplies most of our country's injectable drugs, physicians are being asked to conserve supplies and consider using alternative medications via other administration routes.

Late last week, our health region circulated a memo asking nurses and physicians to "immediately change to oral equivalent medication to conserve the injectable drug supplies...".  Medications affected include common pain-killers such as morphine, as well as other commonly used drugs such as heparin.

All clinicians will recognize the importance of making these changes, where appropriate and safe for our patients.  We realize that we need to conserve injectable drugs so that they are available for situations where there is not good substitute.  But, good intentions may not be enough.  Perhaps federal, provincial and regional administrations should take Dr. White's advice and make it easier for clinicians to make these changes.

Specialists become comfortable and familiar with a fairly small palette of medications.  We know the dosage, side effects and indications.  We may occasionally use an alternate form (say, if our patient is allergic to the more commonly used drug), but don't necessarily have the same level of comfort.  It would be very helpful to receive specific suggestions on which drugs could be appropriately substituted, along with equivalent dosages (especially for narcotics!) and any special considerations or side-effects.

We already have some confusion in our urology department about whether we can continue to use injectable heparin in postoperative patients (to prevent harmful blood clot formation).  Surely, we can't be the only surgical department in the country with this issue!

Don't expect that busy clinicians are going to research each medication change.  We may just default to status quo, and continue using the same medications - via the same administration routes - that we're familiar with.

But, administrators can help us.

I suggest supplying each clinician with specific recommendations/options for substituting drugs and administration routes.  Give us the bare-bones information, but also a way to drill down if we want to explore in more depth.  A website would be good; an iPhone app would be better. (Seriously, this is an important problem; throw some resources at it.)  Ideally, we'd have national experts create specific guidelines that can either be sent directly to clinicians, or sent to health authorities to distribute after they review them for local relevance.

This needs to happen by the start of business on Tuesday, March 13.  

Yes, I realize I'm dreaming to think a national initiative could be mounted in 24 hours.  So, instead, let's see it happen in each health region.  This is an urgent situation.  Patient care is and will be affected.  The shortage may continue indefinitely.  The sooner we start making appropriate choices for drug use, the more medication we'll be able to conserve for patients who really need it.

It's a fairly short list of medications.  I imagine a hospital pharmacist could come up with a recommendation summary in one working day, and circulate it to clinicians by email.  Post it in all care areas where these drugs are commonly used.  Put a copy of it on the front of all inpatient charts.

Don't worry about making it perfect the first time around.  As long as it gives safe information, the first version doesn't have to be comprehensive.  Ask for feedback and we'll let you know what other information we need.

Make it easy for us to do the right thing.

Then, give us some feedback.  Report each ward's medication use before and after this intervention.  (N.B. Use charts, not data tables.  We like pictures!) We'll be curious to know how we're doing.  As this is an unusual situation, I doubt that there are published benchmarks for the conversion of injectable to oral administration routes.  But we can do internal comparisons (for example, between surgical units), to get a rough idea whether or not we're being diligent in making the requested changes.  "High-performing" units will be a source of ideas for their colleagues. But, this will work only if we know how everyone is performing.

Most importantly, make it clear to all clinicians that appropriate medication is never to be rationed to patients.  If the alternate drug or administration route is not suitable or effective, then our patients must receive the standard drug according to established practice.

Our health region memo goes on to say "If this voluntary conservation method does not maintain minimum supplies, stricter measures will be employed."  That sounds sensible and prudent to me, but let's make sure it doesn't come to that.

Don't just tell us what we should do.  Show us how to do it, and help us along the way.

Make it easy for us to do the right thing.

Variety is the spice of confusion and waste

Two months ago, a patient’s wife told me off before his surgery.

In the pre-op area, I was reviewing the planned surgery with them.  I mentioned that he would likely stay 1 or 2 days in the hospital.  Her forehead furrowed.

“Well, which is it,” she demanded, waving an information pamphlet in front of me.  “The nurse told us 2 or 3 days in the hospital.  This pamphlet says 4 or 5 days.  Now you say 1 or 2 days!”

I stood by my estimate, and asked to see the pamphlet.  While the information about the surgery and postoperative care was accurate, the hospital stay quoted reflected a practice that was about 5 years out of date.  I didn’t realize that this information was still being given out, and understood why she would be confused.

After a 2 day (phew!) hospital stay, he went home.  I called him the next week to discuss his pathology report.  After we had finished, I asked to speak with his wife.  I apologized again for the confusion about the length of stay, and told her that our nurse educator had made the necessary changes in the pamphlet.  I was interested to find out why it had bothered her so much.

“I wasn’t upset about how long he was going to stay in the hospital,” she replied.  “I was upset because I thought, if you people at the hospital weren’t talking to each other about a simple matter like how long someone stays in after surgery, maybe you wouldn’t talk to each other about how to look after my husband.  I didn’t know if I could trust you!”

From a minor (I thought…) and easily explained discrepancy, she had concluded that we were not a cohesive system, and was worried that her husband’s health might be in jeopardy because of it.  This small oversight had shaken her confidence in our ability to provide safe care.

I wish I could find fault with her reasoning.

 

Variation in clinical practice has been on my mind since a discovery several years ago.  My interest was reawakened recently due to our practice’s latest improvement initiative.

About 3 years ago, as part of our Advanced Access/Clinical Practice Redesign work, we found a wide variation in urologist practice regarding patient recall.  This 2008 post explains that, but in a nutshell, we found that the rate of patient recalls (internal demand) varied from almost zero up to 25%.  We realized that some recall visits are helpful, but that they also use capacity that could shorten wait times for new patient consultation.  For that reason, we worked toward reducing unessential recall.

We discovered, through group discussions, that most of the variation between our practices was “just because”.  That is, we recalled patients with certain conditions and at certain intervals because that’s the way we were trained and the way we had always done it.  We had never discussed “appropriate” recall as a group.  Once we recognized the variation, we developed methods (such as follow-up algorithms) to facilitate follow-up by the patient’s primary care provider.  Our recall rates dropped significantly over the 6 months after that initial discovery.

In that case, clinical variation was a marker for waste in our office system.

Our practice’s latest improvement initiative is around improving care for patients with bladder cancer.  Before Christmas, in order to explore what our current system looked like, I asked one of our office managers what she thought we could improve.  She had no hesitation in her reply.

“Get your act together with BCG,” she suggested.

BCG is commonly used chemotherapy treatment to prevent bladder cancer from returning.  Patients receive 6 treatments, started after their bladder surgery.  After that, they have regular endoscopic bladder examinations to detect any tumor recurrence.

That sounded pretty straightforward to me. I didn’t see much variation there.

She corrected my thinking.

“You all have a different way of ordering the treatment.”

She went on to explain that each of the 8 of us used a slightly different BCG protocol.  Each protocol was medically reasonable, but there was variation in the interval between surgery and treatment, between each of the treatments, and between the treatment and follow-up examinations.  Our staff had to keep track of each urologist’s unique habits (which occasionally changed from patient to patient!).

Staff had to be careful when explaining the treatment and follow-up schedule to patients as, if they gave the protocol belonging to the wrong urologist, the patient would be confused.  (And, have their confidence shaken.)

Also, our staff felt that a common protocol would improve patient safety. (Yes, we really do have amazing staff who think this way!)   Keeping track of multiple protocols increases the chance of confusion and the chance that we’ll miss scheduling important follow-up examinations.

Significant clinical variation had once again gone unrecognized.  (Well, unrecognized by me because I don’t see any variation in my own process.  And if my own process does vary, I convince myself that there’s a darn good reason for it.)

We physicians zealously guard our professional autonomy. We may see efforts to reduce clinical variation as a threat to that autonomy.  I agree that some variation is important to preserve, that is, variation related to each patient’s unique disease process, experience, needs and wishes.  But variation related to poor coordination of our healthcare system leads to waste, affects patient safety and erodes trust.

I think that much variation in practice is present not because practitioners are exerting their autonomy, but rather because we simply haven’t yet identified the variation and appreciated its impact on our patients.  If our healthcare system had methods to identify clinical variation, and encouraged clinicians to be curious as to its cause, clinicians would develop their own solutions to reduce it, and thereby improve our patients’ care.