Tuesday, July 24, 2012

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!"


Monday, July 9, 2012

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.