Dr. Abelson Connects

Breaking the Silence: Boston Marathon bombings

Sun, 05 May 2013 00:01:19 -0400

I recently published a blog on the Boston Marathon bombings. Like many people, I have personal connections to Boston. My son was near the finish line when the bombings occurred. I was spared the anxiety of having to wait for information about his safety. I found out about the bombings at the same time my daughter texted me to say that Michael was safe.

Scores of others were not so lucky, however, and had to wait anxiously for hours or longer to find out if their loved ones were okay. One of those people is an emergency physician at Massachusetts General Hospital, Leana Wen, MD, who is also an author and essayist as skilled with words as she is with a scalpel.

Dr. Wen’s husband was at the Boston Marathon finish line. It took hours for Dr. Wen to receive confirmation that her husband was safe. All that time as she was treating victims of the bombing, she was terrified that her husband might be her next patient. When she finally spoke with her husband, she felt a mixture of relief and guilt – guilt because, as she put it “What kind of person was I to wish this horrible suffering on someone else’s family instead of mine.”

In several published articles, Wen vividly describes her experience in the ER that day. First, they transferred most of their patients to other parts of the hospital to make room for the wounded.

“Moments later, the doors flew open,” she writes. There were ambulances as far as I could see. The first patient: pulseless, not breathing, both legs blown to shreds. The second: covered with blood, no blood pressure. The third: covered in soot, one leg gone.”

Still waiting to hear from her husband, Dr. Wen describes her mounting anxiety.

“An hour passed. Friends called me to say they were OK, but nothing from my husband. I kept texting: Where are you? I love you.

“Two hours later, a cellphone rang. A nurse, a surgeon and I all reached for our pockets, but it wasn’t ours.

“The phone was in a pile of clothes in the corner, in the tan slacks of my patient who had gone to the operating room to complete his amputations. I picked it up and saw the message that had come through: ‘Where are you? I love you.’”

Dr. Wen admits that the experience has given her nightmares.

“At work, I feel numb to my patients’ suffering,” she writes. “At home, I break down and cry. Then I feel guilty. Who am I to have these emotions, when so many others suffered so much?”

Dr. Wen was brave to publicly address an issue that most healthcare professionals want to keep hidden: clinician grief. Many clinicians still feel there is an unwritten code that you must keep all feelings of sadness and grief to yourself. That was my understanding as young physician.

One of the most searing emotional experiences I’ve had as a physician occurred early in my career when I was still a medical student. I was doing a pediatrics rotation at Hennepin County Medical Center when my call beeper went off and I ran to the Emergency Room. The resident was already there trying to revive a four year old child who had darted into the street and was run over by a car. The child was crushed by the car and we could not save him. After the child died, I went to the family room with the resident to deliver unfathomable news: their child was gone. Their wails of pain and sorrow pierced my soul. To this today, I still have occasional flashbacks of trying to resuscitate the child and I can still hear the anguished cries of his parents.

I have written about this topic previously. In my blog post from June 2012, “Clinician Grief,” I shared some other personal experiences and discussed a clinical study on grief among healthcare professionals.

I commend Dr. Wen for her candor in sharing her personal feels about a public tragedy. If you would like to share your experience of dealing with grief in your professional life, please feel free to comment below.

End of Life

Sat, 20 Apr 2013 09:48:44 -0400

Tuesday was National Healthcare Decisions Day. The day serves as a reminder to answer the question of who will speak for you regarding important medical decisions if you cannot speak for yourself.

Planning for end of life entails conversations with loved ones about your preferences and values that will help guide medical decisions at the end of life. You should also select a substitute decision-maker who knows your preferences and values and can make decisions in accordance with your wishes if you are unable to communicate. These preferences and values are generally written into a document called “advanced directives”- directions to your loved ones in advance of needing them.

This day reminds me of John, a patient of mine who also became a teacher to me regarding how to be clear about preferences and face the end of life. I met John when I was an intern on the oncology service. John had lymphoma that had progressed despite all treatment. He had large disfiguring nodules on his face and body and the nodules were filling his lungs. He knew he would not leave the hospital alive. John was a few years older than me with a son about 5 years older than my newborn son. John and his wife were immensely likeable and during quiet on call evenings I found myself drawn to his bedside to talk.

John knew that modern medicine could not halt the lymphoma that visibly grew on his face and invisibly inside his body. His wish was to have as much lucid and comfortable time as possible with his family. He did not want resuscitation and appeared at peace with his looming death. He and his wife spent their time together admiring their son and making arrangements for after John died. At the time home hospice was not known but I am sure that he would have preferred to die at home if hospice was available.

John made me promise that when his “time was near” he would not be in pain. He feared being overwhelmed by a sense of anguish in his final days. I promised and dutifully wrote the orders for morphine which I knew to be the best pain killer.

At this point in my career, however, I did not understand the difference between pain and anguish. This was an important lesson that I learned from John. “Pain” was the intense physical symptoms caused by John’s illness. “Anguish” could range from breathing problems to the emotional and spiritual feelings related to dieing. Feeling anguish would interfere with John’s ability to spend time with his family as he approached the end of his life. During his last days of life John was comfortable. I kept my promise to him; morphine relieved the anguish and he died peacefully.

John’s frank conversations with me and his family made a difficult time more bearable. As his physician, I knew his wishes and felt like a partner in helping him achieve his wishes. His loved ones could focus on the moment rather than worry about what he wanted when he could no longer express himself. John demonstrated care for his loved ones by being clear about his wishes.

Please use comments below to describe how conversations about end of life wishes and advanced directives represent caring for loved ones.

Terror

Wed, 17 Apr 2013 23:21:45 -0400

Monday started as a usual day. At 3:36 my daughter texted me the following message:

I don’t know if you heard about the Boston Marathon explosion, but Michael is fine. I think they might have shut down phones so if can’t call him that’s why, but he posted on face book.

My son Michael was at the finish line waiting for a friend to complete the race. Within minutes of my daughter’s text the phones of my immediate family began buzzing as we called and texted each other that Mike was not injured.

My first feeling was relief and gratitude. My relief was quickly displaced by the thoughts of friends and families across the world that would hear that their loved one was injured or dead. I felt the fragility of life and how in an instant lives change.

Working in healthcare we stand witness every day to this fragility. We are privileged to engage with patients, members and families as they courageously struggle when their lives are changed in an instant.

Please use comments below to describe your thoughts about the recent tragedy in Boston or how you deal with the possibility of life changing suddenly.

Empathy

Sun, 07 Apr 2013 06:13:00 -0400

I’d like to share a fascinating video with you. In it, a camera tracks through the hallways and rooms of a hospital in real time, capturing the actions and interactions of 38 people (and one dog), in four and a half minutes. There are no spoken words – only written captions that appear over peoples’ shoulders indicating their private thoughts. Some of the captions express joy (“first vacation in years”), while others express fear (“too shocked to comprehend treatment options.”)

In one scene, we watch a clinician taking his place beside two other people in an elevator. On the left, with his back flat against the wall, an elderly man with a furrowed brow twists his hands anxiously and looks straight down at his feet. The caption above his shoulder reads: “Wife had a stroke. Worried about how he will take care of her.” An arm’s length away, a middle aged woman in a white lab coat stares vacantly in a different direction; the caption above her shoulder reads “Recently divorced.” And in the opposite corner, a young, bearded clinician with a stethoscope draped around his neck looks bewildered and happy all at once as he looks straight ahead and smiles. His caption says “Just found out he’s going to be a dad.”

This poignant video is called “Empathy: The Human Connection to Patient Care.” It was produced by the Cleveland Clinic and opens with this quote from Henry David Thoreau:

“Could a greater miracle take place than for us to look through each other’s eyes for an instant?”

The video triggered in me a flood of thoughts and emotions that reflected my different roles as a physician, a health care executive, a concerned family member and a patient with several chronic illnesses.

I am blind in my left eye. As I watched the video with my sighted eye, I gratefully recalled the empathetic connections I feel when people supporting me understand my fear of going blind when I experience something unusual in my lone good eye. As a husband and a father, I thought about the physicians and nurses who interact with my wife and how they understand that every time she experiences a symptom she is concerned that her cancer has returned.

I also recalled my own times as a practicing physician and the satisfaction I felt when I tried to see the world through the eyes of my patients. And I remembered times when I was less than perfect in empathizing with my patients and instead thought about other tasks, rather than being present for the person in front of me. And, ironically, after feeling those memories, I had to be empathetic with myself and forgive my lapses that occur in a busy, multi-tasking environment and remind myself that maintaining empathy is a practice requiring constant vigilance.

The video also reminded me of something said at a recent Schwartz Rounds, a forum for discussion of the ethical and personal issues surrounding healthcare. Shannon Cooksley, a Methodist Hospital Cardiovascular RN said “I try to be the nurse that my patients need me to be.” In other words, Shannon does not use a “one size fits all” approach as she interacts with patients and families. She uses empathy to sense the inner stories of her patients and shapes her interactions with them to best meet their needs.

Opportunities to show empathy go beyond the patient bedside and extend throughout our organization, from explaining insurance benefits to an anxious family member, to giving directions to someone in a hallway, to smiling when we stand in line next to a stranger. Every interaction in healthcare creates an opportunity to benefit our patients, families and our co-workers.

As the video concludes, the following question appears on the screen:

“If you could stand in some else’s shoes…Hear what they hear. See what they see. Feel what they feel. Would you treat them differently?”

Would you?

Please use comments below for your thoughts about the importance of empathy.

Being "present" saves lives

Sun, 31 Mar 2013 00:01:00 -0400

The simple act of one human being “present” for another saves lives. According to a fascinating New York Times column, simple listening could contribute to solving the Medicare cost problem. In this time of spiraling health care technology costs, we overlook simple but profoundly effective activities.

These radical statements echoed in my mind as I attended an event to recognize volunteers in the Hospital Elder Living Program (HELP) at Methodist. Approximately 25 volunteers attended, ranging from young adults to retired seniors. The event also included team members led by Paula Duncan.

HELP is an approach to prevent delirium in hospitalized patients. Delirium describes acute confusion and attention problems occurring most frequently in elderly patients hospitalized for other problems. It may complicate elective procedures like a joint replacement or may occur in patients admitted for acute problems. Delirium is life threatening. Patients with delirium have a 25% to 70% higher chance of dying during the hospital stay compared to similar individuals without delirium. For those who survive, up to 63% will die in the next 12 months compared to 17.4% for a similar group without delirium. After an episode of delirium, functional dependence triples and institutionalization doubles. An episode of delirium expands length of stay and may increase the costs of a hospital stay by tens of thousands of dollars. (Many of these statistics are highlighted in a second New York Times column on hospital delirium linked here.)

HELP prevents delirium in many at risk patients. The approach is simple. Once a patient is identified as at risk, a volunteer sits at their bedside, listens and sometimes talks. The simple act of one human being who happens to be a volunteer connecting with another human being who happens to be a patient prevents the chance of a patient developing delirium by 30-40%.

The highlight of the HELP event was hearing the responses to the request to “tell me about a special moment you have had as a volunteer.” One volunteer after another talked about what it meant to simply be present and listen. John described how rare it is to really listen to another person. He said that more often than not “listening” really means being conscious of time and when it is your turn to tell your story rather than simply being present for the other person’s story. John also painted a profound image about how we are constantly changing roles in our lives — sometimes we are at the bedside of a patient and other times we are the patient in the hospital bed. He described how, as he sits volunteering at the bedside of a patient, he often sees himself as a patient.

As I listened to the “special moments” of the volunteers, I glimpsed how important the experiences were to them. Could it be that the volunteers were enhancing their own longevity by being present at the bedside of patients and listening? Daniel Buettner describes the characteristics of “Blue Zone” communities — geographic pockets marked by unusual longevity. The features include a sense of purpose (why I wake up in the morning) and belonging. In Wellbeing, the authors describe five categories of wellbeing based on years of Gallup Poll surveys. One category is “community wellbeing” including volunteer activities.

We learn from HELP about the power of healing relationships. Everyday miracles occur when one human being is fully present and connects with another. Delirium is averted, lives are saved, healthcare costs are reduced and the connection enhances the wellbeing and perhaps even the longevity of the volunteers.

Please use comments below to describe how the power of “being present” and simply listening helps you at work and/or in your personal life.

Team work and a culture of safety

Sun, 24 Mar 2013 00:01:17 -0400

Katie Goehner, RN has been part of the Methodist Hospital team since she was born 30 years ago. Her father, Dick Barrett, worked in the Methodist Safety and Security office when Katie was delivered more than a month prematurely by emergency C-section with very immature lungs and weighing just 2 pounds, 11 ounces. Katie’s Dad used to go upstairs to help feed her during his work breaks as she slowly gained weight and strength.

Katie went home a few months later and soon began to thrive. In her first week of kindergarten, she drew a stick drawing of herself standing in front of a nursery incubator and told her teacher she wanted to be a nurse.

Katie went through the St. Anthony school system, where she was on the Student Council and the marching band in high school. Katie received her nursing degree from Winona State. Methodist hired her in 2004 and she was trained in her new job by some of the nurses who helped deliver her two decades earlier.

Sharing her story to help others

A mother of two children herself (three and five year old girls, also born at Methodist), Katie loves her work at the Family Birth Center. When she helps care for premature newborns, she sometimes shares her own personal story with anxious parents. If it looks like they need encouragement, she flips over her employee ID badge and shows them her kindergarten drawing that she laminated to the back of her badge when she started at Methodist.

“They usually smile when they see the drawing and it helps lighten the mood,” she says. “It helps give them perspective. I try to give them reassurance and stay positive. I tell them I hope their baby will come back and take my job when I’m ready to retire, just like I did with the nurses who delivered me.”

Calling the team to action

Fortunately, retirement is a long way off for this very active nurse, who recently received the Good Catch Award from the Minnesota Hospital Association for recognizing a serious situation with a newborn baby. Katie’s concern and quick action triggered the Family Birth Center team to save the life of the newborn. The incident is an important reminder of the essential relationship of teamwork, culture and patient safety in providing care, which Katie describes in her own words:

When I came across that baby in the nursery I first noticed how pale he was and instinctively decided to do an assessment on him, just because he did not look “right.” My assessment revealed a lethargic, pale infant with a swollen head that extended to his ears. Basic vital signs were stable, and I was assured that the doctor had ordered a morning hemoglobin, but that was to be done 6 hours later and I knew he couldn’t wait that long. My basic thought was that I knew someone had to see him, even if he had been seen an hour before I knew his condition had likely worsened and would likely continue to do so. I announced that I was going to take him to the special care nursery to have him looked over, and that if all was well he would come right back. I figured I had nothing to lose, and that more importantly this baby had everything to gain. Most importantly, I knew that the culture here is so team centered, that I wasn’t afraid to ask for a second look, even if I had been wrong. It was the team that worked together, quickly, that was able to get him transferred in just under an hour, and it was a team that I feel honored to be a part of, every shift, every day.

Thank you for promoting that team mentality, I think it meant all the difference that day.

Speak up for safety

A culture of teamwork prevents harm and saves lives. After listening to recordings of crashes in which co‑pilots or others sensed danger before accidents but did not clearly communicate their concerns, the airline industry changed its culture by creating the expectation that everyone speaks up if they have a concern. The deck of an aircraft carrier resembles healthcare in that there is life threatening danger with unpredictable and constantly changing factors such as weather or waves. Safety depends on everyone on deck having “situational awareness” moment by moment and clearly communicating with each other.

The Minnesota Alliance for Patient Safety (M.A.P.S.) cites evidence that workplaces with high scores on surveys assessing a culture of safety are safer organizations. In other words, maintaining a culture of safety enhances patient safety. Our culture of Head+Heart, Together encourages a safety culture by promoting team work and by creating an environment in which everyone feels comfortable speaking up. That said, we must always look for ways to improve.

Looking Backward, Looking Forward

Sun, 06 Jan 2013 00:01:18 -0500

On January 1, 2013, Park Nicollet and HealthPartners officially combined. How appropriate this event occurred in the month of January. The ancient Romans named January after Janus, the god of beginnings, transitions, gates, doors, endings and time. In Roman mythology Janus has two faces, one looking back at the past and one looking ahead to the future. The image of Janus simultaneously peering back while gazing at the future continues to describe our behavior despite the thousands of years which separates us from the ancient Romans. During January, the media summarizes the “year in review” while we look ahead and make New Year’s resolutions.

In Janus, the Romans captured human beings as narrators. With one face looking backward, we weave stories about the past using a common thread of meaning. With the other face looking ahead, we tell stories about the future. Fearing an unknown and uncertain future, these stories may be full of anticipatory dread about all the unfortunate things that may befall us. In contrast, we can use stories to create and shape the future by describing a vision.

What story line do I select looking back at Park Nicollet? Park Nicollet developed over the years from multiple combinations of entities which were dissatisfied with the health care status quo and subsequently found ways to improve upon the standard. St Louis Park Medical Center and Nicollet Clinic were created by individuals who knew that a group practice could provide better care than solo practice. As a result, they were shunned by their colleagues in private practice. Methodist Hospital, wanting to be close to the community it served, was the first Twin Cities hospital to move to the suburbs. Park Nicollet Clinic and Methodist Hospital merged and demonstrated that care integrated across the clinic and hospital was superior to the usual fragmented version. In order to support this vision of integration, Park Nicollet became one of the first healthcare systems in the country to implement an Electronic Medical Record that spanned clinic, hospital and home-care. The excellent reputation of Park Nicollet attracted talented and dedicated people who furthered the outstanding care to patients and families.

What story do I want to choose in order to create the future? Patients, families and members will be better supported in what they live for because we can do it better together. Together, we will support health by working with patients, families and members so the quality of our care and the experience and affordability of that care is exemplary. Despite a harsh and unpredictable healthcare environment, we will thrive and become a national model of how healthcare should be implemented.

Combinations create uncertainty. The healthcare environment is uncertain. We have a choice through the stories we tell to ourselves about how we deal with uncertainty. We can tell stories that dwell on uncertainty and amplify anxiety or we can use stories to shape our future.

I choose the latter.

Please use comments below to relate the stories you tell yourself looking back at Park Nicollet and looking ahead at a combined future.

Pay it Forward

Sat, 22 Dec 2012 00:01:30 -0500

DrAbelsonConnects is on vacation during the holidays. We hope you’ll enjoy this post originally published in October 2010.

The film, “Pay it Forward, depicts young Trevor McKinney, engaged in an intriguing assignment from his new social studies teacher, Mr. Simonet. Trevor must create an opportunity to make a positive difference in the world. Trevor conjures the notion of not “paying back” a favor, but “paying it forward.” He intends to repay one good deed, by generating several new ones on behalf of three new people. Trevor’s efforts reverberate, not only in the close circles of his life which include his mother, and physically and emotionally scarred teacher, but in widening ripples of people completely unknown to him

Recently, Methodist experienced “pay it forward.” The following story is true with the exception of altered details to protect confidentiality. This summer, a 90 year old retired accountant working at a local store, sustained 6 hours of chest pain before taking a bus to the Methodist Emergency Room. Arriving early in the morning at 6:45 a.m., he remained resolute in desiring a rapid evaluation enabling him to return to his work shift. The Emergency/Observation Center team scrambled to honor his wishes. Discharged by 12:50 p.m. he completed a full evaluation including a stress test. Appreciative of the team’s assistance in helping him meet his work obligations, the professor, sent a check for $1,000 allocated to aiding less fortunate individuals unable to afford emergency care.

His generosity paralleled attempts by the Emergency Center and the Pharmacy at Park Nicollet Methodist Hospital to identify ways to fund low cost or free prescriptions for patients unable to afford discharge medications. Emergency Center team members, inspired by the generosity, donated $7,000 through matching gifts.

The Emergency Center team “paid forward” a good deed to the patient by honoring his desire to return to work in the afternoon. The patient “paid forward” with a donation for those unable to purchase prescriptions. His gift prompted a cascade of others “paying forward” with matching donations.

Please use comments below to reflect on the relationship between “paying it forward” and our work

Dealing with Tragedy: Remember What You Live For

Sun, 16 Dec 2012 00:01:00 -0500

“What do you live for?” is an important question at Park Nicollet. The question embodies the “noble cause” of health care. Living for something is an essential part of wellbeing. Our role at Park Nicollet is to support wellbeing by enhancing the ability of people to participate in life as fully as possible. We’ve made the question the theme of Park Nicollet’s marketing campaign with billboards that feature patients and families saying what they live for.

It is on days like Friday when we are powerfully reminded of the important things we live for.

Tragedy in Connecticut

I am sure that all of you share in my deep sadness and sorrow following Friday’s shootings at Sandy Hook Elementary School in Newtown, Connecticut.

At this writing we know that 28 people were killed, 20 of them children between the ages of 5 and 10. The 20 year old gunman also shot and killed his mother and killed himself.

Like many of you, one of my first reactions was to think of my own family and loved ones and to be grateful they are healthy and safe. President Obama, in addressing the nation about the shooting, had a similar response.

“I react not as a President,” he said, brushing away tears, “but as anyone else would, as a parent. I know there’s not a parent in America who doesn’t feel the same overwhelming grief that I do…our hearts are broken today…Our hearts are [also] broken for the parents of the survivors as well. As blessed as they are to have their children home tonight, they know that their children’s innocence has been torn away from them too early and there are no words that will ease their pain.”

Emotional costs of responding to tragedy

We all pay a cost when we confront tragedy. Something or someone we value has been taken from us and we must find a way to move forward.

This circumstance confronted my own family and community last September when a friend of mine was killed along with four others in an act of workplace violence. (I wrote about this in a previous blog entry.) My friend left behind his grieving wife, children and grandchildren who must find a way to carry on with their lives. I was moved by the strength of my friend’s wife, who visited with the families of the wounded at a hospital less than two days after the death of her husband. This terrible event hit close to home and was a reminder to all of us to be grateful for the things we live for.

We also confront these issues in our professional lives. First responders, police officers, firefighters, emergency response personnel and those of us privileged to practice medicine know what it is like when you have to set aside your personal feelings and treat the victims of tragedy.

On Friday, as police officers were still searching the school, victims were transported to Danbury Hospital, just eleven miles away. The hospital was forced to go on lockdown and activate their emergency response team to quickly react to this unforeseen and unimaginable tragedy. As victims were brought into their emergency room on stretchers, I am sure they had to suppress their own emotions to treat these children under challenging and stressful circumstances.

Keeping families connected

Here at Park Nicollet Methodist Hospital, we have our own emergency preparedness plan that is ready to be activated in the event of an emergency. In fact, our team has spent the past two months working with regional hospitals, Minneapolis Police, Minneapolis Public Schools and the American Red Cross to create plans and procedures for how to reunite parents and school children after a mass casualty event, such as happened Friday.

Park Nicollet and other health systems do this because we know what our patients, families and communities live for: the health and well being of each other.

I am glad we prepare for such emergencies, but I pray that we never have to respond to something as tragic as the school shootings in Connecticut.

What do you live for?

I live for the well being of my family and friends. I live for making an impact in how healthcare contributes to well being —including affordability.

We all live for things that are important to us. Please use comments below to share your feelings and tell us what you live for.

Touch and Technology in Patient Care

Sun, 09 Dec 2012 00:01:19 -0500

At one clinic, an experienced physician uses the tips of his fingers to probe a patient’s neck and feel for any abnormalities. At another clinic, a young physician uses the tips of his fingers to launch a smart phone app that details the symptoms of thyroid disease.

Which physician is practicing the most effective kind of medicine?

The tension between touch and technology in healthcare is a familiar problem that has become more acute with the ability of app designers to make sophisticated diagnostic resources available to clinicians at the tap of a finger on portable mobile devices. Does the use of smart phones and tablets by clinicians improve the care they provide, or does it put a barrier between them and their patients? Does it create a generational divide between colleagues? Does it take us farther away from one of the first things we learn in medicine, the laying on of hands?

I experienced a similar generational divide 40 years ago during my medical training. My cardiology mentors received their training before the advent of echocardiograms. They spent many minutes bent over patients, carefully listening to subtle heart sounds to find evidence of valvular heart disease, congestive heart failure and pulmonary hypertension. I could never hear what they heard and instead relied on the results of phonocardiograms and echocardiograms. My endocrine mentors diagnosed thryroid disorders from the speed of ankle reflexes; I used blood tests. Other mentors, trained before the advent of C-T scans used palpation (touching the patient) and plane XR’s to diagnose- I relied on C-T scans. At the time, I did not understand how listening and touch contributed to healing- I only focused on how much more efficiently I could diagnose by using new tools. Only later in my practice did I come to appreciate the importance of touch (as I described in my earlier blog post, “Rituals”)

A recent New York Times story took this issue a step further and looked at the generational divide that some feel is developing over the use of mobile technology in patient care. In her article “Redefining Medicine with Apps and iPads,” reporter Katie Hafner creates a fascinating juxtaposition of two physicians at the University of California, San Francisco Medical Center who share the same goal of providing outstanding patient care but with from different perspectives. I encourage you to read it.

The story follows a third year resident in Internal Medicine, Alvin Rajkomar, as he uses his iPhone and an app called “MedCalc” to help him provide patient care. The story also focuses on a 66 year old physician at the same hospital, Paul A. Heineken, who worries that younger physicians may be losing the ability to rely on human touch to treat and comfort patients.

For Dr. Rajkomar, according to the reporter, mobile technology is “a black bag of new tools: new ways to diagnose symptoms and treat patients, to obtain and share information, to think about what it means to be both a doctor and a patient.”

But Dr. Heineken says “’I tell [residents] that their first reflex should be to look at the patient, not the computer…’ And he tells the team to return to each patient’s bedside at day’s end. ‘I say, don’t go to a computer; go back to the room, sit down and listen to them. And don’t look like you’re in a hurry.”

My feeling is the best approach lies somewhere in between. Personal contact and human empathy are essential to patient care and must not be overlooked – nor should we overlook the value of medical and mobile technology to aid in care and to give us more time to be with our patients.

Personally, I like what another physician quoted in the article says: “Just adding an app won’t necessarily make people better doctors or more caring clinicians…What we need to learn is how to use technology to be better, more humane professionals.”

In other words, we should use technology not just to find answers, but to help us become more humane to our patients and to ourselves.

In other words, we must use Head + Heart, Together.

This article and the issues it raises are perfect examples of why we need our internal culture of Head + Heart Together. We must use the evidence-based medicine and technological resources that are in our Heads and combine them with the healing relationships and compassionate care that come from our Hearts, and bring it all Together to create experiences that benefit our patients, families, teams and communities.

Be it technology, experience or generational divides, we can bridge any gaps when we all share the values of Head + Heart, Together.

Please use comments below to share your experiences with using technology to improve patient care and to improve the quality of time that you spend with patients or supporting patient care.

Curiosity

Mon, 03 Dec 2012 10:12:00 -0500

Today, NASA scientists are announcing the latest findings in their search for life on Mars, reporting data from the “rover” that travels the surface of the planet looking for signs of life. What is the name of NASA’s rover? “Curiosity,” named after the force that sends people forward in life to ask questions and search for answers.

Maintaining a sense of curiosity is an attitude that enhances our lives. Being curious implies withholding judgment and being open to new ways of thinking. Life is about learning when we are curious. Every interaction is an opportunity to learn.

This outlook is summarized well by Shynru Suzuki, a Zen monk whose own sense of curiosity led him to found the first Buddhist monastery outside of Asia and help popularize Zen Buddhism in the United States. In his book “Zen Mind, Beginners Mind” he wrote:

“If your mind is empty, it is always ready for anything, it is open to everything. In the beginner’s mind there are many possibilities, but in the expert’s mind there are few.”

The etymology of the word “curiosity” derives, in part, from the Latin root “cura,” which means to care. We care when we are curious.

Curiosity will be a great asset for us as we approach January and start bringing two thriving cultures together and begin integration with HealthPartners. What can we learn from our HealthPartners team members? What can we do better together?

I learned this personally from my own family’s experience with HealthPartners. My son, daughter-in-law and their two children live in St. Paul. They are HealthPartners members and receive their care at a nearby HealthPartners clinic. Dan and his wife glow when they talk about their experience at HealthPartners, describing it as “hassle free.” He says he is never told that “you need to check with your insurance company” before he and his family receive care. It’s a process that leaves them raving about their experience.

I am grateful that my family is treated well by HealthPartners. (After all, I am a member of HealthPartners health plan, as are most of you.) But it was also eye opening for me to realize that my son does not differentiate between his experience as a patient and his experience as a member. It is a fully integrated process that occurs seamlessly and behind-the-scenes; all he knows is that he and his family have a great experience from start to finish.

Dan’s views helped me overcome the blinding biases of my “expert mind” and realize I had much to learn about the benefits of integrating care with financing (health plan functions). This is one small example of how maintaining an open mind and a sense of curiosity will help us realize our full potential as we move forward with HealthPartners in the New Year. I hope you will join me in the excitement of discovering the new things Park Nicollet and HealthPartners will be able to do as a combined organization.

Please use comments below to describe examples of blind spots from your “expert mind” or instances of when you learned through adopting the attitude of “beginners mind.”

Thanksgiving: What a difference a letter can make

Wed, 21 Nov 2012 15:35:00 -0500

A recent article, published in the Journal of Clinical Oncology by our own Steve Duane M.D., brought tears to my eyes. Steve is a physician in the Park Nicollet Hospice Program. In his article, Steve movingly describes his experience with junior high students in the “Growing Through Grief” program sponsored by the Park Nicollet Foundation.

Growing Through Grief is a school based program that offers grief support and education to children who have experienced the death of a loved one. The program provides grief support groups, individual counseling and continuing education for staff and the community. (Click here if you would like more information about Park Nicollet’s Growing Through Grief program.)

In his article, Steve tells the story of a sixth grader reading a letter from his mother (which he keeps on his smartphone). The boy’s mother, who died of cancer when he was 5 years old, wrote the letter prior to her death.

The article prepared me for Thanksgiving as I consider the many Park Nicollet team members who have died this year and am aware of additional losses and tragedies suffered by co-workers. As I read Steve’s story, I feel grateful for my health and the health of those I love. Please feel free to use the comment box below to share your thoughts on the things for which you are grateful on Thanksgiving.

Here is Steve’s article.

What a Difference a Letter Can Make

by Steven F. Duane ⇓

I learned an important life lesson recently from a sixth-grade student: a letter from your mom can make all the difference.

All too often, oncologists find themselves in the difficult position of sitting across from a dying patient who is also the mother or father of young children, discussing end-of-life care. In my practice, such conversations usually involved young women with metastatic breast cancer. When the delicate topic of the patient’s children was broached, tears were inevitable. There is perhaps no greater sadness than that of a mother who is about to leave her children behind forever.

After allowing time for the patient to cry and to say whatever she felt up to saying, I often talked gently about ways that I hoped might help my patient and her children cope a little bit better with such an unthinkable loss. One idea that I sometimes suggested was for the patient to write letters to each of her children to open on special occasions in the future, after the patient was gone—letters for certain birthdays, graduation, or a wedding day. Despite making this recommendation, to me the act of writing such letters had always seemed impossible. And I also often wondered how these letters would be received by the child—would the communications from a long-gone parent be eagerly anticipated and prized, or would they instead be dreaded, summoning ghosts and painful memories of a desperately sad time? Whenever I imagined that future birthday or wedding day, I could see an image of the letter being opened and read, but my thoughts were unable to go any further.

Enter the sixth grader who taught me just how important those letters can be to the recipient.

I was asked to attend a support group for kids who had lost a loved one. This group is open to sixth through eighth graders and meets weekly in a local junior high school. The two group facilitators had been inundated with medical questions from the students, and the counselors asked me to attend one of the group meetings to help answer some of these queries. I accepted, but I had some reservations about talking with junior high school students, especially as it has been almost half a century since I was that age myself.

I arrived at the meeting early and was led to a room that was near the school principal’s office. The room was large and stark, making it seem more suited for detention than for baring one’s heart. The kids filed in slowly; eventually, six students comprised the group. They looked so young as they talked about band practice, compared homerooms, and speculated about this evening’s basketball game. “So, are you the doctor?” one boy eagerly asked. “Yes,” I said, knowing that my gray hair and necktie had likely already answered his question.

The facilitators began by asking each student to introduce themselves and briefly recount the story of their loved one’s death. Cancer was the common theme. Questions quickly followed. Initially, these questions were easy, straightforward ones that I had answered many times before. How did the cancer get to my mom’s brain? Why does chemotherapy make a person so sick? But soon the questions began to cover more uncomfortable matters. What does it mean that I dream about my dad? Is it OK that I am mad at God for taking my mom? It quickly became clear to me that these kids had been forced to grow up faster than children should, and they were demonstrating maturity and wisdom well beyond their years.

One young boy grew quiet, and the counselor noted his bowed head looking down. “Are you OK?” she asked. His soft response was, “It’s just not fair. Sometimes it makes me so angry that my mom had to die.” The counselor repositioned herself, now sitting next to the boy with her arm around him. (There are uncelebrated heroes on this earth, and I realized that I was witnessing one of them in action). “What do you do when you feel this way?” she asked him.

He looked up, paused briefly and said, “I read my mom’s letter. I was reading it just now.” He volunteered, “Would you like to see it?” After a few questions from the group leaders probing whether it would be OK, we collectively asked the boy to share the letter.

He explained that his mom died of cancer when he was 5 years old and she had written this letter just before her death. He had not been given the letter until he was 8. Now, he keeps a copy of his mother’s letter on his smart phone, along with her picture.

He showed us what the letter looked like and then started to read it. It was clear from the sound of his voice that he had read it many times before. The letter was brief, encouraging, sad, loving—and obviously deeply treasured by the boy. He shared with us that whenever he feels really down or angry, he rereads his mother’s letter. “Reading it always makes me feel better, more relaxed. I feel connected to my mom.” As he pocketed his phone, I could see a noticeable change in his expression and his posture—calmer and more settled. Fortified by his mom’s courageous letter, the young man now appeared ready to move ahead, both with the rest of his day and with the rest of his life.

A deep uneasiness stayed with me for days following this experience. My thoughts bounced back and forth between my previous conversations with dying parents and what I’d heard that afternoon from the group of young students. I felt a great sadness reflecting on the profound losses that they had experienced, and yet what kept resurfacing was appreciation of the courage and resilience that I had witnessed. So, bravo to that dying mother who somehow found the courage to write a critical letter to her 5-year-old son. Bravo, too, to that resilient young man, whose mother is now memory, but who is using her words to help him find his way in life, just as she had hoped he would. What a difference a letter can make.

Irritability and Compassion

Wed, 21 Nov 2012 00:01:30 -0500

Most interactions between staff and patients and their family members go well. Occasionally, we disappoint. A colleague recently told me the following poignant story about Janet Stensgaard, a parking lot attendant on the Park Nicollet Methodist Hospital campus. The story illustrates how each of us has the potential to reach out to patients and improve their outcome even after they feel dejected and disappointed.

Today I had a phone conversation with a patient who had a very poor experience in one of our specialty departments. There was one little bright light…

As she left the parking lot, the patient obviously was in distress. The parking attendant [Janet Stensgaard] recognized her unhappiness, and asked her what was wrong. The patient told her that she had just had a miserable visit with a doctor and was really upset. The attendant then said “well then you surely shouldn’t have to pay for the parking,” voided the parking ticket,and then wrote down the number for patient relations and gave it to her.

That attendant is a hero, demonstrating sensitivity, compassion, initiative and courage.

I spent time with Janet to learn more about the interaction. Janet told me about the disturbing personal news she received herself on that particular day. As a result, rather than causing her to feel irritable and oblivious to the plight of the woman in front of her, her own struggles triggered a sense of compassion. “Perhaps this lady also received bad news,” said Janet.

Janet’s words made me look at myself. How do I interact with others when preoccupied by my own personal issues? Often I react with irritability rather than compassion. Meeting Janet was the highpoint of my week. Her actions and words inspire me to improve how I deal with others when I am distressed.

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Please feel free to comment. We encourage a free exchange of ideas but, as always, we reserve the right to remove comments that make personal criticisms or attacks on individuals or specific businesses.

Medical Ethics and the Flu

Sun, 11 Nov 2012 00:02:04 -0500

I’d like to share with you a blog post I recently sent to all Park Nicollet team members regarding the importance of vaccinating healthcare workers against the flu.

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“Beneficence” describes our ethical obligation to act in the best interest of others; non-maleficence denotes our ethical duty to “do no harm” (a common principle in healthcare). Patients and families trust that we act in their best interest and we avoid harming them.

We place patients in harm’s way, thus violating our ethical principles, when we in healthcare do not immunize ourselves against influenza. As individuals we have a duty to our patients to receive influenza immunization. As a healthcare leader, I have an ethical obligation to assure patients that Park Nicollet will not harm them by exposing them needlessly to influenza.

According to a study in the Journal of the American Medical Association, influenza kills an estimated 36,000 people each year in the United States (although the actual total can vary widely). Most of these deaths occur in individuals who are in compromised health from age and chronic disease. Because of their compromised health, these individuals end up in our hospitals and clinics where we have the obligation to protect them from being exposed to life threatening influenza.

According to the National Foundation for Infectious Diseases: “Healthcare professionals are frequently implicated as the source of influenza in healthcare settings. [Horcajada, Salgado, Harrison] This is particularly troubling for the high-risk patients in their care, who may be at increased risk of severe complications, including influenza-related mortality. Outbreaks have been documented in high-risk patient care areas, including organ transplant units [Malavaud], long-term care facilities [CDC 1992], and neonatal intensive care units. [Cunney]

We in healthcare don’t do an adequate job of preventing the harm of transmitting influenza to patients. A recent survey by the Centers for Disease Control found that only 66.9 percent of healthcare professionals reported having influenza vaccination for the 2011-12 season. The national goal is 90 percent.

Many healthcare organizations approach their ethical duty to not transmit influenza to patients by making yearly influenza vaccination a condition of employment (or masking if there is a legitimate medical or religious reason to not receive the vaccine). This is similar to our requirements for proof of Measles/Mumps/Rubella immunization, Hepatitis B protection and regular Mantoux testing looking for evidence of tuberculosis. The Centers for Disease Control (CDC) found that 95 percent of workers in hospitals that required vaccinations got them compared with only 68 percent in hospitals without such a rule. [MMWR, 9-28-12]

Critics of organizations that mandate influenza immunization generally cite lack of 100% effectiveness of the vaccine and also raise issues about personal choice. I don’t buy either argument. Even if influenza immunization is less than 100% effective we still have a duty to do everything we can to not transmit influenza to our patients. U.S. Supreme Court Justice Oliver Wendell Holmes, Jr. summarized the fallacy of the personal choice argument. Known for his blunt opinions, Holmes said: “The right to swing my fist ends where the other man’s nose begins.” In other words, autonomy of choice does not imply the right to hurt others.

Park Nicollet does not have mandatory vaccination, but we do make it easy for you to receive vaccine at no cost at all of our hospital, clinic, specialty centers and office locations. I hope Park Nicollet can achieve a 95 percent rate of influenza immunization using our current voluntary approach.

Our patients entrust their lives with us. That trust drives a sacred duty for us to receive influenza immunization.

Unwavering commitment to patients, community

Tue, 30 Oct 2012 13:32:26 -0400

As I watch news reports of the devastation caused by Hurricane Sandy on the East Coast, I feel sorrow for the human suffering and continued concern for people who live in the path of the storm, including some of my own relatives and friends who live on the Eastern Seaboard. I’m sure that many people reading this also have relatives and friends who live in affected areas of the East Coast. My thoughts go out to you and your loved ones.

I am also deeply affected by the brave response of healthcare workers caring for patients at the center of the storm. New York University’s Lagone Medical Center evacuated more than 250 patients throughout the night, carrying them down as many as 15 flights of stairs with only flashlights to guide them. Nurses carried four newborns from their Neonatal Intensive Care Unit, pumping air bags by hand so the babies could breathe as they descended the stairs and were transferred into waiting ambulances. This work of astonishing heroism represents the best of our profession.

While very different and not nearly as damaging, I remember with pride the response of our Park Nicollet team members during the December 2010, 17 inch snowstorm with strong straight line winds that brought the Twin Cities to a halt, closed the Metro Transit system and collapsed the Metrodome roof. Methodist Hospital and Park Nicollet Clinic staff went through extraordinary efforts to keep our hospital and clinics open. Many team members had remarkable stories of driving or walking through the storm so they could get to work (one team member skied 8 miles on unplowed roads to get to his shift on 2 North). Clinic staff cared for patients and shoveled walkways to keep our Urgent Care centers open. More than 65 clinicians and staff stayed overnight at Methodist to make sure essential services were provided without interruption.

We all know the feeling of commitment to our patients and our community, and the effort that it takes to keep a health system running 24 hours a day, 365 days a year. I’m sure you will join me in expressing our admiration and support to all healthcare workers and all people who are affected by this catastrophic storm on the East Coast.

Teamwork essential in life and at Park Nicollet

Wed, 24 Oct 2012 00:01:00 -0400

Laura O’Donnell is a Certified Medical Assistant with Park Nicollet Senior Services. She has worked here for 11 years and also spent six years as an Air Force medic.

In her free time, Laura enjoys making jewelry and sometimes exhibits at local arts and crafts shows. In July, Laura was exhibiting at “River Town Days” in Hastings, a beautiful town encompassed by three major rivers. Suddenly, the tranquil sounds of a summer festival were replaced by screams.

A four year old boy walking along the shoreline fell into the Mississippi River. Laura immediately ran toward the screams and waded into the river where she joined a team that formed a human chain to reach the boy. Laura was waist high in water and right in the middle of the chain, flanked by two men on either side of her. They scooped up the boy and passed him from arm to arm until he was out of the water and safely reunited with his parents.

Laura did a wonderful and heroic act that day. It’s something I’m sure we’d all like to think that we would do under similar circumstances. But there’s one other factor that might have made other people think twice about jumping into the river.

Laura can’t swim.

Laura is very modest, avoids drawing attention to herself and is reluctant to share this story. But her coworkers at Senior Services and her friends are sharing her story with others. That’s how it reached me.

No matter what size, an organization must function as a team to succeed. Laura represents .0125% of our current work force. But she also represents one of the most important qualities that we need in every Park Nicollet team member to succeed — teamwork. Laura joined a larger group to accomplish something she could not have done alone. Not being a swimmer, she also left her comfort zone and relied on her other team members to help her achieve a very important goal.

Teamwork will be even more important as we join forces with HealthPartners in 2013 and begin to integrate our systems. While the size of our teams may expand, the success of our teams will still depend upon every individual combining their skills with other team members to achieve goals.

Some of us may have to leave our comfort zones to do this. Laura had to leave hers to jump into the Mississippi River. Laura became stronger, however, because she joined a team that combined their skills to accomplish something that none of them could accomplish alone. I am confident that our tradition of team work at Park Nicollet will provide us with important tools to succeed as a combined organization with HealthPartners.

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Best Care at Lowest Cost – new Institute of Medicine report

Wed, 17 Oct 2012 10:46:56 -0400

The Institute of Medicine (IOM), an independent, nonprofit organization that is part of the National Academy of Sciences, issued a major report recently called “Best Care at Lower Cost.”

At 450 pages, it’s a big report and it’s garnering big headlines in the news media – but not, unfortunately, a lot of insight. Most news coverage focuses on the IOM’s estimate of the amount of waste in health care: $750 billion per year. It’s an appalling number that we must not tolerate.

But what are some of the underlying reasons that we have a health care system that tolerates so much waste? Why does the United States spend more than any other nation on health care (18% of our Gross Domestic Product) and achieve poorer outcomes than much of the rest of the world?

Such a question is too complex for most news media reports. One of the reasons, according to Mark Smith, MD, Chair of the IOM committee that wrote the report, is…well…complexity. Speaking at a press conference on the day the report was released, Dr. Smith said:

“There are really two issues at stake. One is the cost, a problem well known to all of us. But part of what’s new about this report is our attempt to grapple with the issue of complexity, the complexity of health care, both in its biomedical and organizational aspects. In our view, trying to both acknowledge this complexity and come up with ways of dealing with it, both for individual clinicians as well as clinician organizations and for patients, is part of the path forward.”

The IOM identifies this problem on page one of their report, summarizing the issues at stake:

Health care in America presents a fundamental paradox. The past 50 years have seen an explosion in biomedical knowledge, dramatic innovation in therapies and surgical procedures, and management of conditions that previously were fatal, with ever more exciting clinical capabilities on the horizon. Yet American health care is falling short on basic dimensions of quality, outcomes, costs, and equity. Available knowledge is too rarely applied to improve the care experience, and information generated by the care experience is too rarely gathered to improve the knowledge available. The traditional systems for transmitting new knowledge—the ways clinicians are educated, deployed, rewarded, and updated—can no longer keep pace with scientific advances. If unaddressed, the current shortfalls in the performance of the nation’s health care system will deepen on both quality and cost dimensions, challenging the well-being of Americans now and potentially far into the future. (“Best Care at Lower Cost,” pg. S-1).

The report highlights some of the reasons for waste, many of which I have written about previously, such as unnecessary variation (see “Health Care and Zip Codes”), overuse of medical tests and diagnostic procedures (see “More is Magic” and “Unnecessary Tests and Treatments in Health Care.”) and lack of care coordination (see “Steve Jobs and Coordinated Care”).

Among the report’s recommendations are:

Clinical decision support: Accelerate integration of the best clinical knowledge (“best practices”) into care decisions.
Patient-centered care: Involve patients and families in decisions regarding health and health care, tailored to fit their preferences.
Community links: Promote community-clinical partnerships and services aimed at managing and improving health at the community level.
Optimize operations: Continuously improve health care operations to reduce waste, streamline care delivery, and focus on activities that improve patient health.
Digital infrastructure: Improve the capacity to capture clinical, care delivery process, and financial data for better care, system improvement, and the generation of new knowledge.
Data utility: Streamline and revise research regulations to improve care, promote the capture of clinical data, and generate knowledge.
Financial incentives: Structure payment to reward continuous learning and improvement in the provision of best care at lower cost.
Performance transparency: Increase transparency on health care system performance.
Broad leadership: Expand commitment to the goals of a continuously learning health care system.

The report says there are many stakeholders in our complex health care system that must find a way to work together to achieve progress, including patients, health care professionals and health care delivery organizations, professional societies, health insurance plans and other payers, government regulators, and private businesses that develop new medical products and technologies. The report states that “…achieving the vision of continuous learning and improvement will depend on the exercise of broad leadership by the complex network of decentralized and loosely associated individuals and organizations that make up the health care system.”

Or, as Dr. Davis put it bluntly at his press conference, “Health care now must be a team sport.”

What we must do as health care leaders is to embrace the findings of the report and work with patients and key stakeholders to bring about change so that we can improve the quality of care, improve the experience of our patients and make health care more affordable for everyone.

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Caring for Colleagues

Wed, 10 Oct 2012 00:01:29 -0400

It is very common for people who work in healthcare to receive their own care where they work. At Park Nicollet Health Services, most of our team members and their families receive their care from Park Nicollet.

Seeking healthcare from your own colleagues represents the ultimate in trust. When we go to our colleagues as patients, we signal our trust in their professionalism, skills, knowledge and compassion. But there is an additional vulnerability when we trade white coats for hospital gowns and shift from colleague to patient. This is true even with every day preventive health care. Stepping on a scale, having a pap smear or undergoing a colonoscopy entails making ourselves vulnerable as a patient with our own colleagues and co-workers.

As clinicians, we open ourselves up to the potential of loss and pain when we care for patients – a challenge we gladly accept in order to serve our community. The potential for loss is pervasive in healthcare. As professionals we feel loss when a patient dies. We feel loss when a colleague dies. And when a patient who dies is a close and beloved colleague, the pain and loss is compounded.

This is the vulnerability of living a rich and full life. We all face it. The more people you love in life, the more vulnerable you are to the pain of loss. There is no way to short circuit the process, although it helps me personally to find ways to honor the pain and the person by creating the space for grieving and by sharing with my colleagues.

What do you live for?

Wed, 03 Oct 2012 00:00:00 -0400

“What do you live for?” is an important question at Park Nicollet. The question embodies the “noble cause” of health care. Living for something is an essential part of wellbeing. Our role at Park Nicollet is to support wellbeing by enhancing the ability of people to participate in life as fully as possible. We’ve made the question the theme of Park Nicollet’s marketing campaign with billboards that feature patients and families saying what they live for.

Last weekend, the question “what do you live for” took on new significance for me and my family in light of the tragic shootings at Accent Signage Systems in the Bryn Mawr neighborhood of Minneapolis. Our dear friend Reuben Rahamim, the owner of Accent Signage Systems, was one of five people killed in an outbreak of workplace violence before the shooter took his own life. We did not know the others who were killed: Jacob Beneke, Rami Cooks, Ron Edberg and Keith Besinski, nor did we know the wounded or the other employees who will be changed by what they witnessed. We can only imagine the rippling tragedy and grief of all involved.

As I sat at the memorial service for Reuben held at Beth El Synagogue on Sunday, my heart ached for his wife, children, grandchildren and all lives forever changed by this horrific event. I was moved to learn that Reuben’s wife, Shireen, had visited the families of the wounded on Saturday morning at Hennepin County Medical Center, scarcely 24 hours after the tragic loss of her husband. I listened to his son-in-law Chad Blumenfeld describe Reuben as one of the “good guys.” At the service, people talked about how Reuben had two days of the week that were different from all other days, and in that way were sacred. The first was Saturday, the Jewish Sabbath, when Reuben would often spend time with his synagogue community and hosting people. The second was on Wednesdays, when everyone at work knew that Reuben set time aside to spend the morning with his two grandchildren.

Reuben lived for his family, his friends and for helping people find their way with his signs.

I knew there was no answer to why this “good guy” was senselessly struck down. But I sensed there must be a response. Listening to what Reuben lived for gave me that response — to continue to engage in the things I live for, even in the face of unexplainable tragedy. Further, listening to friends and families memorialize Reuben provided me a way to reflect on what I live for by answering how I want to be remembered.

I live for the wellbeing of my family and friends. I live for making an impact in how healthcare contributes to wellbeing- including affordability.

We all live for things that are important to us. Please use comments below to describe what you live for or how you want to be remembered.

Underuse, Overuse and the Triple Aim in Healthcare

Tue, 25 Sep 2012 23:56:22 -0400

I have written previously about the potential overuse of certain tests and diagnostic procedures in health care. In April, nine prominent medical society boards identified 45 common medical tests and procedures that they say are overused and, in some instances, may be unnecessary. In July, New York Times health care reporter Tara Parker-Pope wrote a compelling article about her own family’s experience called “Too Much Medical Care?”

One of my Park Nicollet colleagues, Dr. Dan Zapzalka, responded to this issue with a cautionary statement to “be wary of pendulum swing.” He wrote:

As I watch the news media address the topic of bringing complex medial issues to the masses in short sound bites, I get a bit worried. The news (and even Dr. Abelson) have written about the lack of efficacy of things such as PSA screening and now lack of effectiveness of prostate cancer surgery as examples of unnecessary tests and procedures in medicine. These examples trivialize very complex issues and give the impression to people at large (and who read this blog) that these are unnecessary tests and treatments that no longer need to be done. In fact, this is not the case and the issues surrounding these, and a lot of other tests, is really a much more complex and difficult one.

“Zap” got it right. Medicine involves complexity which precludes simple one dimensional solutions. Though we can predict how a population will do “on average” we can’t know how a given individual will do with approach A versus approach B. In addition to the specific benefits of clinical services, some patients may also have different psychological needs for tests and treatments and meeting these needs may influence their well being.

Zap also got it right because I emphasized only one side of the “coin”- overuse. The flip side of that coin is “underuse”- not providing what is known to be beneficial. Underuse may be an even larger problem than overuse. The New England Journal of Medicine published a study in 2003 showing that populations received only 54% of beneficial tests and treatments. We don’t see evidence that this has improved in the United States in the last decade, although data from Minnesota Community Measurement indicates that we have shown improvement here in Minnesota.

Screening for prostate cancer with a PSA blood test and treatment of prostate cancer demonstrate the complex relationship of overuse and underuse. For men who may benefit, not screening and not treating represents underuse. For men who will not benefit, screening and treating is overuse. The core issue with prostate cancer screening and treatment is that with the exception of advanced age, we don’t know which men will benefit and which men will not benefit. This complexity requires conversations with patients so that they understand these uncertainties.

As I consider this necessary complexity of overuse, underuse, patient differences and cost, I think of the “Triple Aim” developed by Donald Berwick, Tom Nolan and others from the Institute for Healthcare Improvement (IHI). Dr. Berwik articulated the Triple Aim as:

Improving the health of a population
Improving the experience of individuals
Reducing per capita health care costs for a population

Nolan also wrote:

The roots of the problem in health care is that the business models of almost all US heath care organizations depend on keeping these three aims separate. Society on the other hand needs these three aims optimized (given appropriate weightings on the components) simultaneously.

Until recently, patients could focus on their individual experiences without regard for cost as long as their insurance covered services. Large deductibles now encourage patients to consider cost as well as their individual experiences.

Park Nicollet remains a leader in incorporating Triple Aim thinking into our goals and strategies. Several years ago we established five year organizational goals related to excellent clinical care (measured at a population level), outstanding patient experiences and a lower per capita cost than our market. The Triple Aim also shows up at Park Nicollet when we talk about great care and great experience at an affordable cost.

The Triple Aim implies that in the face of the complexity of healthcare, it is not enough to take a one dimensional approach to problem solving. It is not even enough to take a two dimensional approach. We need at the least the three dimensions of health of a population, patient experience (and thus needs) of an individual and cost. At times these dimensions interact in messy ways. We must navigate this messiness as best we can using a combination of protocols when applicable, professional judgment and conversations with patients so that they are aware of the uncertainties and complexities of healthcare.

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