Cleaning the Graffiti in Healthcare

 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

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

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

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

What Not to Wear: Hospital Edition May 2010

Personal Statement Do’s and Don’ts July 2010


What Not to Wear: Hospital Edition

At a recent meeting I attended, a vigorous discussion broke out about what medical students, residents and attendings should wear, and more importantly what they should not wear.   Interestingly, patients have been asked to weigh in on this discussion.  What to wear is also on the mind of many current second year medical students who may find themselves trying to take study breaks from USMLE1 to go buy clothes for the wards.  I also remember doing this as a rising third year student and wondering what to get.  Here are some tips from our Associate Dean of Student Advising and Professional Development Dr. Shalini Reddy (@md2b_advisor).

  1. Don’t break the bank. Stores like Target, Marshalls, Sears or JCPenney are all fine places to get clothes for the hospital. You’ll be wearing your white coat over your clothes.  Save your money for your fourth year interview suit.
  2. The hospital is a messy place. Buy clothes which you wouldn’t mind throwing out if you were drenched in body fluids. (Not likely to happen but would be devastating if you’re wearing Prada or Valentino).
  3. Buy comfortable shoes.  You’ll be on your feet most of the day. There are actually studies that demonstrate that residents (who you’ll be following around) may walk up to 6 miles when on call!   It’s hard to answer “pimp” questions if you’re developing bunions and wondering when the heck you can take off those shoes. You’re feet will thank you…
  4. Get a waterproof, inexpensive watch.  You’re going to be washing your hands a lot. Being late to rounds is never good, but you may also lose your watch after you take it off to scrub in. A watch with an alarm can be very handy when you have to get up at 4 in the morning to pre-round for surgery. 
  5. Scrubs are for the hospital not for home.  As a New York Times article pointed out, no one wants to sit next to someone on the subway wearing scrubs, particularly those with uncharacterizable stains on them.  Scrubs are there, in part, to keep you from taking hospital germs into the community. It’s also hospital policy.  Unless a resident or student is staying overnight or involved with procedures, scrubs are a ‘dressed down’ look. So plan to change from scrubs to regular clothes before you wander around outside the hospital.
  6. Stock up on detergent, soap and deodorant. You’re going to be getting up close with your patients and if your clothes (or you) smell, they will feel even sicker than they already do.
  7. Buy a bleach pen.  This is very helpful for spot cleaning blood stains until you can get your coat back to your house for laundering. Peroxide works too.
  8. White coats (and ties for men) are still part of the uniform. Yes, there are studies showing white coats and ties spreading infection.  In the UK, they are already banning white coats.  However, for now in the US, they are considered part of the standard attire for physicians and medical trainees and what patients have come to expect.  In addition to washing your coat often, washing your hands is the #1 thing you can do to prevent infection.
  9. Wash that white coat. Those aforementioned uncharacterizable stains are really gross on white coats. Not a great way to instill confidence in your abilities with patients…or attendings.
  10.  No perfume or cologne. Remember the triggers for asthma? Perfume is one of them. Stick to “eau de soap and water.” Beware the overly scented deodorant too. Unscented soaps are typically the best for combating malodors while avoiding elicitation of bronchospasm.

 And some more tips especially for women

  1. Save the ‘Hospital Honey’ look for Halloween: Buy clothes for the hospital, not for going out: cover your cleavage, make sure your skirts reach at least mid-knee when you sit; shirts and pants/skirts should cover your midriff even when you raise your arms above your head.  Remember, you are not dressed to kill, but dressed to heal.  A patient actually called one of our attendings out for wearing loud, high heeled boots. An embarrassing reminder that we’re dressing for our patients not for each other.
  2. Minimize jewelry.  Make sure you don’t wear anything too expensive to work especially if you know you’ll have to take it off (e.g. engagement ring gets taken off whenever you put on gloves). Get a safety deposit box if you’re worried about leaving your jewelry at home. Stay away from hoop or dangling earrings. Your stethoscope will pull off the hoops and kids will pull off the danglers. Besides, you’ll get germs on anything that’s not attached closely to your body (e.g. stud earrings).
  3. Wear OSHA compliant Shoes (no open toe).  We know this is especially hard in the summer, when all the high fashion sandals and pedicured feet aching to show themselves.  Do everyone a favor and keep your toes covered and save your fashion forward footwear for an evening out with friends.  One of us actually took care of a female healthcare worker who had an IV pole run over their foot and contracted a MRSA foot infection – not fun!   As a result, every summer, we are on the hunt for comfortable but good looking pair of “OSHA shoes”- it’s harder to find that it looks!   DSW shoe warehouse is a good bet and won’t break the bank.  Dansko clogs are also a safe bet and Crocs are now making comfy shoes without holes. Stay away from Crocs with holes which just provide pores for body fluids and needles To get to your feet.
  4. Hold off on the fancy manicures. Your nails have to be short and you’ll be washing your hands often. Nail polish does not stand up well to frequent hand washing/Purell.

Lastly, for all the 2nd year medical students out there, good luck on Step 1 and starting the wards!

 Dr. Shalini Reddy & Dr. Vineet Arora

Mean Girls in Medicine? Time to Get SMARTer

meangirls11I recently moderated the women’s networking luncheon at the American College of Physicians with Temple Program Director and dynamo Darilyn Moyer, whose enthusiasm is infectious.  In planning this luncheon, I began to think are these things necessary?  Females now account for nearly 50% of entering medical students.  I don’t think I ever really thought about going to a luncheon like this until this year – and it happens to be the year that I am going up for promotion and thinking about being a women hoping to rise up the academic ranks.  Of course, there is still a glass ceiling, especially in academia, and women are underrepresented in the upper echelon of faculty – like Professors and Department Chairs.  In my department, there is one female division chief.  While one could presume that say this will correct in time with all those younger women entering the medical workforce, many believe that this is not happening and women are being left behind. To make matters worse, new research suggests academic medical women work more but also make less than their male counterparts. 

So what can women do?  Well, Darilyn had some great tips for women who were negotiating to make us Get SMARTer.  (She apparently loves acronyms as much as I do).

S is for Strategic– timing, understand how the other party negotiates, choose battles wisely, get unfulfilling work off plate

M is for Mentors– use them, internal/external, personal/professional

A is for Achieve– common ground, a successful negotiation requires give and take with no party feeling smug at the end! Remember your BATNA (Best Alternative To a Negotiated Agreement)

R is for Rehearse– your negotiation with your toughest critics who know the other party and can anticipate responses

T is for Timeout– plan a pager/bathroom break about halfway through, timeout to check on short- and long-term goalsa set time as a ‘safety net’  (yes we have all done this)

In addition to negotiation, I also highlighted the need for women to celebrate each other’s accomplishments in the workplace since women don’t usually brag.  All too often, I also observed women undercutting each other and NOT being nice.  Apparently, I was not the only one who thought this – several women came up to me after and thanked me for brining this up, including the president of AMWA (American Medical Women’s Association) who said we definitely need to be nicer to our female counterparts.  So, I got to thinking why do women do this and when does it begin?  Every women has high school tales, but I distinctly recall being the sole female intern with all male interns, residents, and attendings in the ICU with – you guessed it female nurses.  I felt like I was not going to have as an easy of a time as my male counterparts, so I tried to stay under the radar, learn from the ICU nurses who knew way more than I did, and generally ‘kill them with kindness’ as a close friend says. 

Interestingly, there is a plethora of internet resources out there that highlight that women are not so nice to their female counterparts in ALL workplaces, not just the medical one.  A study by the Workplace Bullying Institute (who knew?) demonstrated that female workplace bullies (those who commit verbal abuse, sabotage performance or hurt relationships) target other women more than 70% of the time while males are more equal opportunity bullies.  To make matters worse, it’s not just at work either – women are equally mean to each other about motherhood as noted by CNN in an article that describes the “Mommy Mafia” quick to pass judgment about how others in the mommy brigade raise their kids, choose their childcare, and balance their work and life.  As one article so poignantly pointed out….

But to this day, a pink elephant is lurking in the room, and we pretend it’s not there. For years, I have heard behind closed doors from women — young and old, up and down the ladder — that we can be our own worst enemies at work.

So why do women do this?

Well, one theory is the scarcity excuse — the idea that there are too few spots at the top, so women at more senior levels are unwilling to assist female colleagues who could potentially replace them.  This could be especially true in medicine, given the lack of females at the top.

Another explanation is the D.I.Y. Bootstrap Theory,” which goes like this: “If I had to pull myself up by the bootstraps to get ahead with no one to help me, why should I help you? Do it yourself!”  Note that this theory is also often used to justify all of medical training to today’s younger hipper generation that values work life balance.

There’s even a biological explanation, which highlights that women may be uber-competitive with the other XX’s in the room during days 12-21 of their menstrual cycle, when their estrogen levels are the highest.  Apparently, in studies, women rated other women’s attractiveness much lower than when they were outside this phase of their cycle.

So, what should women in academic medicine do to avoid falling in to the mean girl trap? Here are some of the things that I have learned largely from trial and error in navigating this domain.

  •   Celebrate each other’s accomplishments.  Women are not good at bragging and can sometimes be perceived as arrogant or the ‘b’ word if they toot their own horn.  Pair up with female colleagues and let your friends know so they can brag for you.  Not only does it seem less weird, it also shows that you work in a collegial atmosphere.
  • Work as a team  Let’s face it – there is not enough time in the day to do the job in medicine.  Teaming up can not only boost your academic productivity but can also improve your morale since you’re not facing that uphill battle looking at the glass ceiling by yourself.  Moreover, when you work as a team, you can take turns taking the lead so that you’re not swamped all the time with all the hard work!
  • When in doubt, keep it professional Remember, you don’t need to be BFF with all of your female work colleagues.  You also don’t feel like you need to reveal EVERY detail of your intimate life to your work colleagues.  The more you keep it about work, the better you’ll feel.  It takes time to form true friends in the workplace so let time run its course to figure out who will help you out of a jam in the long haul.
  • Remove yourself from dangerous relationships  Some relationships are beyond salvage.  It may not be overtly obvious, but you probably have a ‘frenemy’ in your workplace.   If you find yourself in this situation, time to exit gracefully.   This can often be accomplished by letting someone know that you are swamped with work (usually not a lie), dealing with some family stuff or personal issues (code for need some time off), or taking another direction with your work.
  • Seek guidance from a mentor  Your mentor can be a man or a woman –but it should be someone who knows you, gives advice that you trust, and has your best interest at heart.  While many traditional mentors are very senior, they may be scarce so you may need to consider other types of mentoring (like mentoring from peers, groups, or teams) or even reverse mentoring (mentoring from a trusted junior colleague) for these issues.
  • Seek professional development opportunities The Executive Leadership in Academic Medicine (ELAM) (run out of Drexel University) and the Association of American Medical Colleges offer formal programs for women to enhance their leadership potential.  Many professional societies (like ACP) have resources for women in medicine like career profiles and tips for advancement.  Lastly, most academic institutions also have women’s committees to help promote networking with other women and discuss women’s issues.  The more secure you are in your own position in your organization, the better you’ll be able to help other women succeed too.

 After all ladies, if we’re not nice to each other, how can we expect anyone (especially the men on top) to take us seriously?   Despite the infamy, no one wants to work with a gossip girl.

–Vineet Arora, MD

For more detailed data see AAMC’s Women in U.S. Academic Medicine: Statistics and Benchmarking Report 2008-2009