Tuesday, November 19, 2019

Intercepting the Asinine

My New England Journal of Medicine still arrives each week.  I pay for the subscription so I feel obligated to read two articles from it each week, roughly 100/yr, even in retirement.  They tend to be cases of the week or a review of something related to endocrinology, but I am as interested in the changes of how we practice, having lived through it.  One element that exploded during my final years as a clinician has been the number of directives and processes that differ from what an experienced physician would likely devise on his own.  Now, I may have gotten in on the ground floor of this, starting my post-residency career as a VA physician.  These guys didn't have the insight to allow me to receive a flu vaccine in my non-dominant shoulder.  One kabooby from the lab ordered, who didn't know what a patient looked like prior to autopsy, ordered that all the lab slips be placed in the chart without having been seen by the ordering doctor first, where they ended up in somewhat random order.  They used to transport World War I veterans 100 miles each way for their appointments, paying $700 dollars to the driver of a Ford Pinto that just squeaked by state inspection.  I had the transportation director price the cost  of a limo for the same trip.  For one-third of that, the old warrior could have travelled the breadth of New Jersey in style.  He would have to pay for what he took from the back seat bar, but if he drank too much, the VA would dry him out for free and hire the Pinto back to take him home.

On graduation to the university and private sectors, directives declined in number.  I am pretty hard pressed to come up with anything that matched the VA encounters.  Scheduling made sense.  Rules on charting were understandable.  We got our own parking spaces and as security became more important, ID tags enabled access to the places we needed to be to provide patient care.

And then came HITECH and the computer.  It all changed.  In an inner city area, it was common for patients not to keep appointments.  Any number of schemes were devised to either reduce the no-show rate or compensate for it, with scheduling bedlam when everyone came.  There was a directive to see everyone within seven days of discharge.  A schedule does not expand indefinitely, not everyone really needs to be seen sooner that three months by the consultant, and thinking about appropriate post-hospitalization is part of the competence that the residents are expected to acquire.  Meetings to discuss quality addressed non-problems to the neglect of what really needed more attention.

Intercepting the asinine seemed hopeless in this era of an expanded middle layer of managers charged with doing things that they don't really have the insight to do because they seemed like a good idea at the time.  Once there, they have a life of their own until the hospital is forced to reconsider by either legal allegations or loss of revenue.

It came as a welcome though unexpected surprise to learn that all elements of the inane did not have to become immortal.  A NEJM Sounding Board essay described an algorithm that can be computerized to identify and intercept the dysfunction, though not until it has become dysfunctional.

Based on importance, these mavens at NYU targeted processes that had no real basis but were intended to solve a problem.  If they didn't solve the problem, they were identified and sent back for rethinking.

Do we really need a computer algorithm for that or would a simple anonymous suggestion/complaint box suffice?  The big corporations probably addressed this decades ago.  A directive would come by or a customer would complain.  The VP's would hire people to address the concerns or deal with an external regulation.  Before you know it, you had people with significant salaries tweaking what would be better neglected.  Somewhere around the time of the 1992 election, they figured this out and pink slipped the capable high salaried people whose work wasn't worth doing.  Medicine has always lagged behind, which is why we are now being pummeled by insurers and product manufacturers.  They had their restructuring.  We have not.  If the algorithm really intercepts the many asinine processes imposed upon us, we might have a chance of catching up.

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Sunday, November 10, 2019

Harvesting the Old Office

It seemed like an essential need for space at the time.  Like many physicians or our era, by the close of the  last decade, a solo practice became nonviable.  Net revenues dropped far below what I could make as an employee, to say nothing of the burdens of operating the practice and investing in expensive computing capacity for what would likely be less than ten more years as an active physician.  An attractive job offer came my way and I accepted it.  After eight years in the new location I retired.

Ownership creates freedom, but it also creates expense.  A costly tail premium got paid.  Records went to storage with a monthly fee that became non-activity after about two years.  At the end of the legally required seven years retention, I arranged destruction, which priced at about another year's rental.  And twenty years of practice generates stuff, most of which could not be transported to my new digs.  As a result, my cleanout specialist recommended a nearby storage unit to house payroll records, old tax forms, a huge bookcase that cost $400 from IKEA, a laser printer, enough stationery to supply quite a number of poor children at back to school, a coat rack, and nearly 20 years of Franklin Planner refills in their annual storage binders.  The monthly fees came out of autopay so I didn't really notice it.  When I retired, more stuff from the final eight years belonging to me personally found it's way there.

One of the most stupid expenditures is to pay a monthly fee for stuff you don't want, which is virtually everything there.  Financial forms have passed their statute of limitations.  Our state will shred two boxes of paper a month, so I have become a regular at the site adjacent to the landfill the first Wednesday of every month.  Appointment and payroll logs gone.  Tax submissions now unreadable.  At the rate of three storage boxes a week, I should be done by year's end.  I can finally see the floor.  Copier cost $500 but it's bulky, missing a key tray and could be replaced for a lot less than I pay to store it.  Off to the state's electronic recycling bin.

Some stuff has personal value.  I had carefully wrapped a series of mugs in newsprint.  They are mementos, logos of my alma maters and places I visited with my son when we toured colleges.  I should be able to run them through the dishwasher and line them up for display in My Space.  I bought a big globe at a yard sale.  That will find a home in my house.  Along the way, I purchased three pre-insulin medical texts from book clearance sales.  Probably have little monetary value but tell me something about my medical roots.   Those come home.  And the big IKEA bookcase will fit just right in my bedroom, which never has enough shelf space.

There was a show on TV called "United Stuff of America", a series of mini-documentaries on how various usually unimportant museum artifacts summarize key events in history.  My son's college tour is in those mugs.  My interest in diabetes includes times before I was part of that care.  The countries on the globe were not there when I learned the geography of Africa at Kakiat Junior High School.  All moments of my adult life.  None worth a monthly storage fee.

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Thursday, November 7, 2019

Psychiatric Stigma

Among my courses at the Osher Lifelong Learning Institute is a weekly discussion group where each of the dozen participants is assigned a topic one week per semester to lead a discussion.  Medical related topics crop up, and even non-medical subjects often benefit from the expertise or experience of the doctors in the room.  One lady, now retired like the rest of us, was raised amid severe psychiatric illness with a father displaying bizarre and often controlling, paranoid behavior and the next generation including a sibling with a less clear diagnosis but chronic personal and social instability.  She is a survivor who could have escaped through bitterness but took a path empathy which has served her well, though from the discussion, maybe less efficacious for the two patients than it could have been.

Endocrinologists like myself are the most frequently consulted specialists in a psychiatric unit where the nursing staff cannot avoid bedside glucose monitoring and occasional lithium generated thyroid, calcium and electrolyte dysfunction.  All this needs to be coordinated with the psychiatric needs, always usually severe enough to require hospitalization beyond the 72-hour form #302 involuntary diagnostic commitment allowed by the Commonwealth of Pennsylvania with a subsequent length of stay, sometimes voluntary, sometimes court approved, that far exceeds length of hospitalization on other medical units.  I never saw any families there when I did my consultations and periodic follow-up rounds, though undoubtedly the psychiatrists and social workers would regard the impact on family as a core part of their medical advice.  I was shielded, making the discussion from a family perspective an interesting revelation for me.  I also have a medical perspective, noting what could have been many lost opportunities to achieve a better result for her father, her brother, and her family.  And as happenstance would have it, a review of schizophrenia, with a brief section on non-medical psychosocial support, appeared in the New England Journal shortly thereafter.


As the doctor in the room among the dozen discussants in the room, my focus immediately gravitated to the medical, with some resentment on her part.  Like it or not, as the NEJM review indicates, the fortunes of these people depend on how well the medicines are managed, both their therapeutic benefits and the undesired effect.  If you pick up one end of s stick, you pick the other one up as well.  The obligation of the physician is first to the one designated as ill.  The family becomes a form of collateral damage, something to be addressed though not necessarily by the medical expert.  As she noted in her presentation, the medical community was not a reliable source of empathy or family repair.  These patients can function surprisingly well at the workplace, as her father did with a perceptive supervisor who minimized the employee's tenuous social interactions, focusing on productivity at work.  He supported a family economically for an entire career but inevitably the household lacks the resources of a medical institution or a major corporation so disruption emerged.

People with bizarre affect, socially marginal behavior, or atypical appearance get noted.  They also get avoided, and as my OLLI classmate noted, the close family gets avoided as well.  That aspect has not done as well as modern medical care.  She is a survivor, though not unscathed.  Her father has passed away, late life divorce for her mother's safety.  His death, found alone and unresponsive, took its toll on her, probably more than on him.  A sibling drifts along, unstable socially, managed professionally by the medical and correction communities, but leaving the lingering impression on her that her brother was basically written off for lack of the employable skills that her father had acquired that secured a better level of protection for him, if not for the other family members.

While the treatment of schizophrenia has advanced and the chronic psychiatric hospitals that functioned more as a warehouse have waned, the people are still amid the public, identifiable as outliers and largely avoided by those who do not have a direct professional or family responsibility for their welfare.  Good medical care, as her discussion noted, does not fix that.

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Thursday, October 31, 2019

Jargon of Medical Enterprises.

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Vice President, Performance Excellence - Mid Atlantic Region

Executive Management

The institution from which I retired and regard with great fondness posted a recruiting ad which came to me passively via Facebook as a subscriber to the organization's postings.  I clicked the bold print title which took me to the parent institution's Job Opportunities.  The job expectations and requirements took about half a page.  Even though I have forty years experience with patient care and I thought a good grasp of when we excel and when we fall short, apparently Excellence that we strive for could use a task master to achieve.  And all this time at all the Physicians Network quarterly meetings they made me attend lest I forfeit my achievement bonus, they told us collectively what a great group of physicians we were.  And I think the conveyed assessment was correct, there are no grander, more dedicated and reasonably knowledgeable group of medical school graduates that I have encountered.  But apparently we still underperform, or do we?

So here's the description, with the organization's identity omitted, with the assumption that this could be anyplace in contemporary consolidated medicine.

The Regional Vice President, Performance Excellence will assist the Chief Executive Officer and Regional Leadership Team in change management, process improvement, lean implementation, Operational Excellence Improvement (OEI) and Transforming Operations (TO).
The Regional Vice President Performance Excellence has accountability for the oversight of performance improvement activities within <identity omitted> and will lead the organization's implementation of a lean management and production system. This role will assist senior leaders in the strategic deployment that propels <identity omitted> to top tier operational performance. The Regional Vice President Performance Excellence will support operational leaders and clinical units in the development of high performance operating plans and efficient deployment of resources. The individual who holds this position will exemplify the <identity omitted> mission, vision and values and acts in accordance with policies and procedures.
? Master's Degree in Systems Management or Business Administration with a minimum of five years' experience in complex industries such as healthcare, manufacturing, etc.
? Leads the development of performance improvement plans and collaborates with departmental leadership to develop operational goals linked to the performance improvement plans
? Fosters a culture of shared ownership for outcomes-driven improvement.
? Provides leadership for design and implementation of an effective and ongoing program to monitor, evaluate and improve the financial performance, efficiency and growth initiatives for the region
? Provides leadership for the system performance improvement program, including performance management and improvement training and operational excellence initiatives
? Creates a system-wide "lean" and/or other process improvement culture and is dedicated to coaching and driving operational efficiencies.
? Partners with clinical and non-clinical leadership across the enterprise to identify opportunities for greater organizational efficiency and process improvement
? Drives lean improvement initiatives in concert with leadership partners including initiatives related to waste and/or cost reduction.
? Establishes national benchmarking standards to improve operations by identifying best practice methodologies from within healthcare and other high performance industries.
? Integrates innovation into the redesign of systems and processes to ensure optimal outcomes and value
? Serves as a member of various organizational work groups, committees and teams to include serving as a member of the Regional Leadership Team
? Serves as a change agent and champion to drive organizational transformation in alignment with strategy and vision

 Now I am a college graduate with a solid if not spectacular verbal SAT score who endured many a class that required composition directed at making me proficient at expressing myself in an understandable way.  There is not a single word in this description that I do not understand as vocabulary..  About half the phrases I do not understand are those otherwise familiar words are strung together in sequence.  Could use a little help here, either from other experienced though likely younger doctors or maybe from people who thing they are qualified to pursue this opportunity, which I suspect pays more than they paid me.  My gestalt, shaded by modern experience, is that this is the update of what 1970's era physicians were taught as Buff & Turf.  Make the patient seem healthier than they really are, or in this case create the illusion that the doctors were more effective than they really were.  Oh, and do it with fewer doctors and nurses.

Did I come close?

Too many analysts and overseers, not enough value to those of us who contact the patients skin to skin, or even blue vinyl to skin.

Friday, October 18, 2019

Doctors in the Wrong Half


I try not to merge my personal blog with my medical one, or even immerse myself in political positions, but the intersection here was just too inviting.

For whatever reasons, I am situated in the prosperous part of America as are my children.  We have professional degrees, economic stability, take personal and political positions that are in strong opposition not just to depravity itself but to its enablers.  It's part of the politically Blue America with little crossover and barriers to entry to those not already there.

Many doctors seem to have averted this intersectionality.  Sermo in my opinion has deteriorated, not just changed, into an echo chamber of thought that the posters probably wouldn't want on their office doors with their real names and Photo ID's.  Yet they have my same education, most a higher income if not greater net worth.  I don't know any of these frequent right wing posters personally, and very few in my professional interactions.  I suspect they are not the cohort that gets invited to present at national meetings, as medicine has its upper and lower hierarchy just as medicine does.

I suspect that we have slid in the direction of wage earners besieged and trying to hang on in an increasingly insecure professional world.  It comes not only at the expense of the autonomy which so many of us mourn, but also at the inherent dignity of medicine.  The posts that increasingly dominate Sermo are a too often long way from benevolent with virtually no one interested in refuting it.  If I, as a person loyal to medicine opt to walk away from this forum rather than stake my claim, it won't take long for the public to appreciate this as well and write us off as the Lesser Half of America. 

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Friday, September 27, 2019

My Turn to Present

To keep retirement from becoming too unstructured, I've enrolled in the Osher Lifelong Learning Institute, acronym OLLI, where I take classes two mornings a week and learn to play Mah Jongg late Wednesday afternoons.  One class, which I also took last semester, has the title Of Minds and Men.  At one time it was for men, but not wanting to jeopardize any access to funding, it has been co-ed for a while.  The enrollment is restricted to as many people as there are weeks in a semester so that each person leads the discussion one time.  I wanted to learn about Echo Chambers, but the sign up sheet got to me last.  Procrastinators being what they are, people captured their date from latest to earliest, leaving me with date at the beginning, which means picking a topic that already has familiarity.  Last time I chose exorbitant drug pricing.  This semester it's Electronic Medical Records.

It's one of those subjects that divides emotion and intellect.  It is hard to overlook the potential of maintaining data in an organized retrievable way.  With little effort I can see lab trends over years, know exactly which xrays are on file and review the reports easily and the images with a little more effort.  Calling up the notes, I know who saw each patient when, though the reputation of the note writer often screams Ignore this One.  Handwriting problems disappear.  Spelling is left incorrect so that future readers can figure out what I typed myself and what falsehoods were generated by the computer which performed better in spelling bee than I did.  Since most people have most of the elements of their exams normal and I pretty much examine everyone the same way, I can create a generic exam, leave what's normal, change what's not, and delete those things I did not examine on that individual.  I should be a great enthusiast, but like most clinicians, I am not.

It's tedious.  And since work is generally task based, the time distribution of the individual tasks that comprises with work day has redistributed in a less satisfying way.  I generally do not like telephone sessions for going over lab work or revising medicines.  The computer requires use of a template to document the call, expanding a one minute telephone encounter to a four minute telephone encounter, most of it filling out the template.  That means call time has to be more scheduled than previously, where a 1-2 minute span on the telephone could be squeezed into an odd moment, to say nothing of expanding the time that I like doing the least.  My records are not adequately maintained, particularly among shared users.  It is common to have a medicine list with three different doses of the same medicine.  The medicine list works on the Roach Motel principal, the pills check in but they don't check out.  Huge amounts of data to tease out successful from unsuccessful processes should capture my professional imagination, but that task and the design to do it goes to somebody else.

I do not know how much credibility I will have among the class, when the other doctor will not be there.  But I will convey the good, bad and ugly in its the most objective way that a person who sees himself as victim can overcome.

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Tuesday, September 3, 2019

They're Mostly Gone

Image result for under new managementIt had been a while since visiting the medical center from which I retired, maybe about six months when I attended a Grand Rounds there.  This time I dropped off school supplies purchased a little at a time at Back to School Sales over maybe twenty years.  As I organized My Space, loose leaf paper and binders at that volume would be classified as clutter.  The Sisters, though, collect stuff like this for the school children of the neighborhood so I transported a few boxes of this stuff to her.  The environment looked the same, not especially active but with enough people inside the building to require me to park on the garage's roof.  My old office had nothing going on other than a new neurologist joining in the previous month and one of the Medical Assistants nearing the completion of her pregnancy.  I learned that the hospital's CEO would be retiring soon and sent her a mixed congratulatory and thanks note when I returned home.

Recently the administrative alignment of the network subsidiaries had changed, an initiative of headquarters a few hundred miles away.  My guess is that it would make no difference to operations, as it is not the first shuffling, none of which have dripped down to the level of patient care.  However, among Physicians Network, the two head honchos had been figuratively beheaded.  Looking back, we've had several CEO's, Exec VP's, Chief Medical Officers for the network.  They seem to arrive as a group and mostly depart as a group, often suddenly enough to suggest the exit was not a voluntary one.  I suppose the salaries they pay are rather good but the duration of the salary not very long.  Moreover, nearly all who depart suddenly are at mid-career, or at least well short of customary retirement age.  I have no idea what type of Golden Parachutes are in their contracts but it would seem prudent to ask for one given the predictably short tenure.

The clinicians seem much more secure.  Since my exit, one hospitalist moved on, one orthopedist concluded his contract, and two more clinicians came aboard.  Perhaps we protest about the management more than we need to.  Time is on the side of the clinicians.