Cleaning the Graffiti in Healthcare

24 07 2013

 I just left the most unusual conference I have ever attended.  First, it was small – 25 people.  Second, it was all women.  Third, it was all senior healthcare leaders who have done amazing things…make that trail-blazing things.  Moreover, I found myself surrounded by women who were journalists at major news outlets, retired military officers from the highest ranks, senior leaders (in some cases the senior most leader!) at major federal and state healthcare agencies, Fortune 500 companies, large health systems, healthcare foundations, national advocacy organizations.   It’s no surprise the name “Amazon warrior” resonated with this group!  Finally, the conference was all about identifying our “living legacy”.   Legacy seems like a strange word when you are living…it’s even stranger when you feel like you haven’t don’t anything yet!  So, how did I get invited you (and I) are wondering?  After all, I was the youngest person in the room, which as an aside, is a very unusual context when you work with students and residents for big chunks of the day.  So, believe it or not, I was invited by in large part due to my… social media presence!  After reviewing the list of participants, the organizers realized something was missing, and that something was someone younger who also had a social media presence.  And whoever said tweeting is a waste of time?

While there is much I could say, one of the group exercises on the last day of the conference is worth sharing and involving others in.  We were asked to examine “broken windows” in healthcare.  A broken window is a symbol of something smaller that is part of the context to a larger problem.  As Malcolm Gladwell popularized in his book, the Tipping Point, New York made a dent in the big problem of crime by tackling smaller problems, such as cleaning off the graffiti from the train every night.  By changing the context, people started to “own” the subway and report crime instead of expect it.  An excellent video summary is here.

So, how does this apply to healthcare?  While there are criticisms of the broken window theory, what a boon it would it be if we could locate something small in healthcare to fix the very large complex problems facing healthcare.   So, our group only had a short amount of time to pursue identifying broken window in healthcare.   While it sounds easy to come up with broken windows, it is much harder than it looks.   Interestingly, the healthcare problems here are so large, that the broken window may not be as simple and elegant as the graffiti example, but represent an easier place to start.  Here are three examples broken windows that we came up with.

  • Media portrayal of healthcare, especially related to resuscitation – By correcting the media portrayal of resuscitation, the public might have fewer unrealistic expectations of life sustaining therapies at the end-of-life, which could result in fewer people opting for futile measures.   By the way, researchers have even studies this (watching episodes of ER for research!) and have demonstrated the problem in a New England Journal article.   Imagine tackling this problem with media tools to demonstrate to people what a “good death” is.
  • Patient gown – While patient-centeredness is the new buzzword in our world, can we really say the system is patient centered?   Take the simple example of the patient gown which represents a loss of control and source of embarrassment to patients.  Could it be that when patients are in the gown, they feel to disempowered to engage in their own healthcare?  Could changing the gown empower patients to take a larger role in their healthcare?   In case you are wondering, there are many stories and efforts that have been undertaken to redesign the hospital gown – my favorite is the collaboration by Bridget Duffy, former Chief Patient Experience Officer at Cleveland Clinic, with fashion designer Donna Karan.
  • The Word Healthcare – It is well accepted that our healthcare system focuses on “healthcare” and not “health”.  Prevention and health promotion takes a back seat to intensive healthcare interventions.  It’s easy to resign that this will never change due to the payment system, or that return on investments in prevention are only realized in the long-term.  But, what if we could change the dialogue by using the word “health” instead of healthcare at every opportunity and juncture.  By changing the dialogue, can we change the context enough to create a change in the system?  I’m not sure, but at this point, I will say it is certainly worth a try.

There could be other examples of graffiti in healthcare.  By continuing the dialogue, hopefully we can locate the most promising levers for change.

–Vineet Arora MD

Special thanks to Dr. Joanne Conroy from the Association of American Medical Colleges for organizing the conference, our facilitators from the leadership consulting group Sunergos, and support from the Robert Wood Johnson Foundation to make it happen.





Vampires and Urban Legends: Teaching Residents about Healthcare Costs

24 05 2011

This past weekend, I gave a talk at the Committee of Interns and Residents, the largest housestaff union in the United States.  The most inspiring moment of the meeting that I witnessed were the 2 standing ovations earned by Dr. Koffler for advocating for residents to get paid in 1936 (her first paycheck was 15 dollars a month!).   How could I follow that…especially with a talk on how to train cost-conscious physicians?   Those who know my work well may even wonder how I got invited to talk about this.  Well, earlier this December, I wrote on the blog about my holiday wish list for medical education and #2 was a curriculum on cost conscious practice for medical trainees.   In addition to lack of a formal curriculum, there were several other barriers on teaching residents how to practice cost-conscious medicine that I discussed.

  • Faculty are not trained.  The largest barrier of course is that faculty don’t know how to do this.  A study in Journal of Hospital Medicine showed that faculty physicians could not identify what things cost.
  • No one knows what the cost of anything is.  Because each hospital negotiates its own prices with suppliers, it is very difficult for residents to know how much things cost.  In trying to find out how much your hospital charges for various tests, you may end up on a wild goose chase until you find the helpful person who may or may not even be in your state!
  • Bad systems promote costly workarounds.  Most of the time, residents are too concerned that they won’t be able to get a test or worse, it will delay a patient’s discharge.  The system is set up to order the test even if the attending thinks about it.  Some of our own data shows that interns learn during internship to misrepresent tests as urgent to get the job done.
  • Rumors and hospital legends spread quickly.  The highly connected residency program can actually spread rumors about how much things cost or give rise to urban legends when patients actually pay and don’t pay.
  • Underordering, not overordering, is penalized.  Due to the highly litiginous environment, most attendings encourage residents to err on the side of getting a test since the biggest fear we all have is of missing the ‘can’t miss’ diagnosis.  More reasons doctors over-order tests here.

So what can we do to teach residents about cost-conscious practice?  Well here are just a few of the things we can do..

  • Empower residents to find out how much their hospital charges for things.  As I said at the conference, we may need to start a support group for those that start down this daunting path – but it is the first step to understanding how to control costs.  Starting with senior leadership could be helpful – after all, how many C-suite leaders would not want to find out how to teach residents to control their costs? There is also a related movement to improve price transparency for patients.
  • Show residents how much they spend.  At least in the case of daily phlebotomy, a recent study dubbed “Surgical Vampires” (due to the daily blood draws ordered by the surgical interns) highlighted that letting residents know how much things cost actually reduced the cost of lab ordering per patient and resulted in 50,000 dollars saved over 11 weeks!  Studies with electronic health records at the point of care show even greater results!
  • Use unbiased resources that promote better cost-effective decisions.  Specialty societies like the American College of Physicians and the American College of Radiology are now starting to create guidelines that encourage cost-effective practice through more judicious use of imaging or other therapeutic modalities.   The popular 4 dollar list for medications is another example.
  • Incorporate discussions of costs into routine educational conferences.  At Harvard, one chief resident started a Hospital Bill Morning Report for the residents to review what a patient bill is like.  In our medical student lectures on radiology, the costs of the tests are also now discussed.
  • Educate patients that less is sometimes more.  Letting patients know about the risks of overordering tests- specifically workups of incidentalomas and pseudodisease may be helpful in explaining your new approach to cost-conscious medicine.   The pushback from patients may be the fear of rationing,  which is of course irrational since it already occurs.  A helpful summary for patients on high value cost conscious medicine appeared in Annals of Internal Medicine.
As with all things, there is the potential for unintended consequences in teaching cost-conscious medicine.  The most egregious of which would be to hide behind the veil of practicing cost-conscious medicine in order to shirk work and avoid getting an indicated test when needed.   This is especially important to watch out for as burnout sets in late in the academic year.  So, as we resist our inner vampire urge to order blood tests and uncover hospital urban legends and myths about healthcare costs, its equally important not to morph into the haphazard and dangerous cost-cutting monsters that we all fear most.
–Vineet Arora, MD




Blog ‘Paper’ Anniversary: Reflections & Top Posts of 2010

3 01 2011

It’s been one year of blogging or our ‘paper’ anniversary here on FutureDocs! 

I was reminded of this milestone with the receipt of the WordPress blog ‘report card’ below.   While I was excited to learn about the clean bill of health and intrigued by metrics related to shipping containers, I’m not going to lie.   It can be very challenging to stay fresh, write creatively, and keep up with posting while holding down an academic career.          

However, one thing I have learned (and confirmed by @MotherInMed who helped me get started) was that if you are inspired, the post will write itself (like this one).  Therefore, it is critical to pay attention to those moments you are inspired.  This gives rise to a somewhat startling personal observation– blogging can acutally improve your attention span and focus.  Sounds crazy, I know… But, unlike social media sites which can be highly distracting (Twitter or Facebook addicts anyone?), I find that I often pay closer attention to my surroundings so that I don’t miss the inspirational moment around the corner that I can share.   For example, in lieu of walking around aimlessly at medical conferences (a risk at any conference especially in medicine), I found myself taking notes and immediately reflecting on sessions to distill the most salient points, such as the oppressive nature of medical education or expert failure highlighted at the recent Association of American Medical Colleges.

In examining the report card below, the top posts on this blog are both predictable and surprising.  With the explosion of interest in technology and plenty of technophiles in the blogosphere, it is no surprise that posts about Twitter myths for docs and whether the iPad lives up to it’s hype on the wards are at the top.   The other 2 posts relate to career advising, which was a welcome surprise.  They also do reaffirm the need to continue to provide solid career advice to medical trainees, no matter how mundane (like what to wear to the hospital).   In addition to technology and career advising, I’ve enjoyed the ability to highlight various advocacy issues relating to medical education like healthcare reform, resident duty hours, the Match, and women in medicine.  Lastly, I must admit that I do enjoy writing for pure fun — like the posts on movies in medicine or healthcare phobias.   

Special thanks to uber medbloggers KevinMD and medrants who occasionally cross post or reference these posts and all those who subscribe and comment.   I was especially honored to be included in KevinMD’s top 10 posts of the year for this post on shadowing (which curiously did not make the WordPress list below).  

So here’s to more inspirational and informative moments of 2011, both in life and on the blogosphere.

–Vineet Arora, MD

***Blog Report Card From WordPress:

Fortunately, the stats helper monkeys at WordPress.com mulled over how this blog did in 2010, and sent me the following high level summary of its overall blog health:

Healthy blog!

The Blog-Health-o-Meter™ reads Wow.

Crunchy numbers

This blog was viewed about 20,000 times in 2010. If each view were a shipping container, your blog would have filled about 4 fully loaded ships.

In 2010, there were 30 new posts, not bad for the first year!  The busiest day of the year was March 5th with 304 views. The most popular post that day was Top Twitter Myths & Tips.

Where did they come from?

The top referring sites in 2010 were twitter.com, kevinmd.com, Google Reader, medrants.com, and facebook.com.

Attractions in 2010

These are the posts and pages that got the most views in 2010.

Top Twitter Myths & Tips February 2010
6 comments

Attending Rounds with the iPad – Hype or Hindrance? August 2010
13 comments

What Not to Wear: Hospital Edition May 2010
4 comments

Personal Statement Do’s and Don’ts July 2010
4 comments

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