A Heated Argument About…Pens!


By:  The Musing Medic (@TheMusingMedic)


So I took a look back over my previous entries as well as those from other authors and it occurred to me that we could use a moment of levity. Allow me to address a topic that is both light and refreshing yet pertinent to all my colleagues.


A Heated Argument About The Right Tool For The Job


This is a hot topic in my workplace, particularly with physicians. The idea for this post came to me the other day when an attending and myself got into a heated discussion over what pen was the best type to use in our particular department. Now to many of you this is a moot point as EMR has become quite ubiquitous. But sadly, we continue to use paper charting (at least for the next few months). So choosing the correct writing utensil, in this case a pen, is actually pretty important.


I suppose a number of my colleagues will pick up whatever black or blue pen is stocked in the supply cabinet. Usually these are ballpoint pens with a cap rather than the click-type pen. These are not usually of the highest quality and are purchased in bulk. If one gets lost or covered with some bodily fluid, just chuck it in the garbage and grab another. But I have to say, the writing experience over the course of a twelve hour shift is terrible. These pens drag and blob, leaving unsightly marks all over the place. Additionally, the ink can wash out and be removed from official documents fairly easily so there is a security factor to consider. I can’t say I have much love for these all-too-common office staples.


On the other end of the spectrum are gel pens. Typically these pens are smooth and reliable. Very little residual ink stays on the tip of the pen and most are safe enough to use on official documents without risk of washing the ink out. I can see why those with the ability to prescribe prefer to use these. My only complaint is the ink runs out quickly and they are a bit more costly. Still, they are leaps and bounds above ballpoint pens.


There are a few other types of pens that exist but are less common. One is of course the classic rollerball pen. Think of a Pilot Precise V5 or V7. The ink is nice and dark with smooth writing. But these tend to feather or leak and are not safe for airplane travel as the pressure change causes the pen to leak ink all over the place. The other type is a fountain pen. I know a few people who use these but considering the cost and efficiency of using one in a busy ED, I think there are much better choices out there (however, I do use fountain pens away from work).


If I Had To Choose Just One Pen

If I had to choose one pen to write with it would be an advanced ink pen. These pens combine ballpoint and gel ink together. What you get is a smooth writing pen with dark ink and security. They cost a little more but the ink cartridge lasts a good while. These are fairly new on the market but a few of the most well known are the uni-Ball Jetstream, Pilot Acroball, and Papermate Inkjoy. But I don’t use any of these on a regular basis.


No, I use the Cello Topball 0.7mm in black ink. These pens are designed in Germany and manufactured in India. The pen is lightweight and has a needle tip. This allows for fine, precise writing. The ink is smooth and dark, composed of the advanced hybrid ink I previously mentioned. They are hard to find in the U.S. but can be ordered online.


I can’t believe I just wrote a whole article about pens but I think a little levity and banality is a welcome distraction from our normal topics.


Please share your favorite pen in the comments section.


Next week’s article will focus on Trendelenberg position and its utilization.


Till next time


The Musing Medic


Let’s Analyze Your Data


By:  DMKashmer, MD MBA MBB FACS (@DavidKashmer)


Do you remember Mark Twain’s three categories of falsehood?  Mr. Twain described these as “Lies, damn lies, and statistics.” (I’ve also seen the quote attributed to Benjamin Disraeli.) Well, no matter who said it, the bottom line is clear:  we need to be very careful with statistics.  So, if you’re performing a quality improvement project for your system, what are the pitfalls of data analysis.


Just Having Data Is A Good Start, But Isn’t Enough


Up front, let me take a moment to compliment you, again, on even getting data for your quality project.  Deciding to make decisions based on your team’s data rather than your gut or your own feelings will get you a lot farther down the path to success.  Yes, your colleagues may be worried, initially, until you show them that the data in your project are not assignable to any one person.  (It’s team and system performance–not individual based.) However, let me share with you that I’ve been in organizations which try to use their gut or feelings or some other whimsy to make decisions.  Over time, you’ll come out way ahead with data…you’ll make constant improvement and you’ll be able to show those improvements over time.  You’ll know if you’re doing better or worse.  Not so with organizations that practice by whim or feelings.  (Feelings have a real value, don’t get me wrong, but feelings without data are like lost children.)

So, congrats on even having data.  But, my colleague, you need to go further to have a successful, high quality program:  you need to analyze those data effectively (and correctly) to avoid basing your decisions on damn lies (!) So this brings us to the next step of a sound quality improvement project:  analysis.


Pitfalls of Opening Pandora’s Box


You see, one of the pitfalls of making data-driven decisions is that you need to be able to correctly analyze the data…and that’s no easy task.  Six Sigma practitioners are trained to use standard statistical tools to demonstrate the valid, meaningful conclusions you can make based on your data–and let me share with you that, prior to my training, I had no idea of what needed to be done to understand and demonstrate meaning from data.  To my medical colleagues:  yes, we take biostatistics classes and these make us conversant in techniques; however, going from sample design to data collection to meaningful conclusions is NOT what I’d seen in medical school or elsewhere.

For example, take this example of the perils of using data distributions:  click here.  Or check out some other pitfalls here.


A Few Tricks of The Trade


In reality, there are more than a few tricks to the trade.  You’ve seen, in the links above, how important it is to decide whether you data are normally distributed (and what to do if they’re not).  You’ve seen, again above, some of the relevant ideas about how to collect data (and what type of data) to make later analysis much more straightforward.

We’ve discussed, in earlier entries, the idea of what to do when data aren’t normally distributed.  Take a look here.


Get Professional Help


With all that in mind, it’s no wonder people seek professional help!  Allow me to recommend, here, that you either develop the in-house expertise necessary to analyze and obtain data effectively or you find someone who can.  (Just email the team at info@thesurgicallab.com for our recommendations and ideas about where to go for more info.)


Some Parting Thoughts


If you’ve made it through the Define & Measure phase of your quality project, and you have data you’re looking to analyze, allow me to compliment you again.  You’re miles ahead of what I’ve seen in some organizations, and are on your way to looking at yourself squarely and both characterizing your system’s current performance as well as improving it over time.  Nice work–you’re miles ahead of others and miles further on the journey to excellent performance.

Now it’s time to focus on specifics of data analysis and some examples of how these tools come into play.  Stay tuned for the next entry on data analysis with examples from projects gone by.

Questions, comments, thoughts?  Let me know beneath.

The Surgeon’s Ego Has A Purpose


By:  The Generation Y Surgeon (@GenYSurgeon)


I’m Interested In The Surgeon’s Ego…

Social sciences fascinate me.  Social psychology, influence, compliance gaining, emotional intelligence, interpersonal dynamics, how to lead change…all of these topics run rampant in our workplace.  It’s no wonder why there are so many medical and hospital dramas on television.  Our workplace, including the hospital as well as pre-hospital workplaces, medical school, academic labs and private practices, abound with pathological behaviors and interactions.  Some of which are purposeful and useful, others of which are clearly not.  Stereotypes abound: the outwardly loving yet passive-aggressive pediatrician, the lifestyle-obsessed and distracted emergency department doc, the painfully awkward yet brilliant physician-scientist and my personal favorite, the egotistical, over-confident, sharp-tongued surgeon.  The surgical ego is one of my favorite subjects and I have many thoughts on how this came about as well as why it continues to exist.

(Pre-hospital staff, nurses, administrators and ancillary staff….you’re not off the hook.  I see you and your time will come–I will be writing about you as well!  This blog post however is dedicated to my fellow physicians, specifically my surgical colleagues.)

The Stereotype Of What It Is

The stereotype: inappropriately confident, stern and unwaivering, ruthlessly focused on the task at hand…and ignorant of the surrounding emotions of other people–or just not caring what they may be.  Surgeons thrive on chaos and adrenaline and they’re proud of it. 

Everyone knows surgeons have big egos.  What you may not think about is why.  I will offer this: the surgical ego has a purpose, and that purpose is to protect the surgeon.

Here’s Why It Exists…

Medicine is hard.  Doctors struggle to stand out in undergrad, struggle to succeed in medical school and struggle to remain standing upright throughout residency.  Physicians sacrifice years of their lives, putting off high incomes, personal growth and even family until they emerge as an attending.  And even then they work obscene numbers of hours in high stress positions.  Yes, the work is personally and (eventually) financially rewarding; however, the cost of getting to attending-hood is often underestimated.  

Surgeons undergo the longest and most rigorous training.  Residency teaches more than knowledge; it’s about decision-making, leadership and technical skill.  The environment is high stakes for teacher, patient and learner alike.  That’s where the surgical ego comes into play.  And the ego is shaped by the environment in which it must exist.  

IQ and emotional intelligence are often in conflict.  Pitting these against professional duties in a hospital?  Well this is where even the smartest and most socially adept doctors begin to fail.  Before we get to the pathology associated with the surgical ego, let’s talk a little more about what the most emotionally intelligent physician may look like.

Let’s Go To The Books

In Daniel Goleman’s famous book Emotional Intelligence, emotional intelligence is defined and broken down into five domains:

1. Knowing one’s emotions. This is self-awareness, the ability to monitor feelings from moment-to-moment and stand confidently behind your decisions.

2. Managing emotions.  This is resilience, the capacity to deal with how your feel and manage what comes next.  

3. Motivating oneself.  Controlling emotions for productivity, creativity, mastery and attention.  This is how you achieve the “flow” to continue with outstanding performance. 

4. Recognizing emotions in others.  In other words, empathy.  

5. Handling relationships. Popularity, leadership, interpersonal skills and mastery of labile social situations.  

Now imagine you are a trauma surgeon and you are leading the resuscitation of a young pregnant woman who was stabbed by some low-life outside the grocery store.  The patient is about to die, and so is the baby.  The injury is severe & it requires a procedure that you’ve only read about before.  The trauma bay is chaos and the staff are clearly upset about the scenario.  You can hear family members wailing outside.  What do you do?  How do you act?

Let’s Apply Our Definition

Let’s put this in the context of emotional intelligence.  After all, we just read about it above.  Think about the definition of emotional intelligence:

Know your emotions.  Easy, you’re scared, likely tachycardic, unsure of yourself and your ability.  But you cannot show it because…

You must stifle your feelings because someone’s life depends on it.  The only way you can manage is to ignore the fear and….

Motivate yourself.  You think hard and develop a game-plan for the operating room.  You quickly prioritize what must be done and there is no time for…

Other people’s emotions.  The family, the nurses, the onlookers, they are about to decompensate into puddles of tears, frantic with emotion so you…

Manage the room with firm leadership, loudly commanding the staff with clear, unwaivering words in an effort to get this patient to the operating room and save a life.

It Makes Sense, Doesn’t It? 

To the fly on the wall you are inappropriately confident, stern and unwaivering.  You are ruthlessly focused on the task at hand, ignorant of the emotions surrounding you.  You thrive on the chaos and adrenaline and you’re are proud of it.  Wait….isn’t that how we described the stereotypical egotistical surgeon at the beginning of this blog?!  Think about it. 

I’m not saying that we should excuse all of surgery’s pathologic behavior, the point is to understand why some of these behaviors exist.  To bring this back to the theme of the website, systems matter.  When a surgeon exists in an effective system that eliminates uneccessary stress and tension between staff, they are less reliant on the surgical ego for protection and productivity.  Surgeons have often grown into the surgical stereotype because they have no other choice.  Where they perceive threat or challenge they fall back on what they know and the ego defenses appear.  After all, it works in the high stress situation of the trauma bay. 

In an ineffective system, the stereotype becomes necessary and after a short while the surgeon is unable to snap out of it.  It becomes a way of life and they identify with it.  Remember, surgeons spend years to get where they are and it comes at great personal sacrifice.  Even so, there is always room for improvement.  How do we get ourselves and our colleagues to identify when the situation is different and it’s time to drop the surgical ego for a bit?

I’m NOT saying the ego is inherently bad or useless.  In fact, as we described, sometimes it’s necessary and adaptive.  The question is “how do we teach and learn when it’s time to shut it off for a while?” Surgeons are smart (but often tired) so how do we learn when the situation requires different tools and instruments?

The surgical ego is one of my favorite subjects and I have many thoughts.  There will be much more to come in future blog entries.  Until then, stay curious and stay objective.  So, what are your thoughts on it?  Let me know beneath.


Distance Education Is Legitimate


By:  The Musing Medic (@TheMusingMedic)


Hey, Much Of Education Is Inefficient


Let’s cut right to the chase and admit that education is inefficient. The amount of time spent on non-productive activities is staggering. In my experience, most of the wasted time is spent in the actual classroom setting. The reasons for this are varied, but addressing these issues is most likely an exercise in futility. What we can discuss, however, is the adoption of the ever-growing trend of distance based education and its appropriate utilization.


Distance Education Isn’t The Correspondence School You May Remember…


We all remember correspondence courses offered in fields such as medical transcription and private investigation. Late-night television was littered with ads for learning “horticulture at home”. Most of these courses were not for college credits and were generally not of the highest quality. Now fast-forward to the modern day, where we find that a number of reputable universities are offering college courses in an internet-based format. Some of these universities are regional, lower-ranked schools while some are Ivy-League, such as Harvard and Princeton. So how do these internet-based courses differ from the traditional brick-and-mortar classroom?


They Are No Different.


Okay , okay–so that may not be entirely true in the literal sense. Students enrolled in distance learning courses do not travel to a campus or sit in a classroom for a lecture. Nor do they have face-to-face interaction with professors or other students outside of the online video chats or virtual classrooms used by some programs. Outside of these few differences, there is almost nothing to distinguish between the two learning environments.


Consider how internet-based courses rely heavily on recorded lectures and textbooks. Professors generally will provide lecture notes in PDF files or powerpoint slides. Usually there is a class discussion board where students are required to discuss topics addressed in the course. Quizzes are taken online with some being open book and some are not. Also, assignments are e-mailed to the professors if required. As for exams, they are administered via proctor. This proctor can be at a local college or through an online proctor that utilizes a webcam to make sure no cheating occurs. The takeaway point here is that the material presented is exactly the same regardless of how the course is delivered, and modern courseware allows for both interaction and discussion.


As a student who has taken numerous internet-based courses, I think there plenty of advantages. Since some of these courses have no concrete class times, there is more flexibility.  That makes for a great option for those of us who are working adults or deal with the chaotic schedules seen in healthcare. There is no travel time which saves fuel and money. Professors that are boring or talk slowly–no problem! Just play the recorded lecture at 1.5x the normal speed. And no need to worry about in-class distractions such as texting or whispering. Just set up a home office and you’re good to go.


If there is a downside, it is that students need to be self-motivated and disciplined. Students need to setup a workspace that is conducive to learning. Eliminating distractions such as cell phones, televisions, etc., is key for success.  Additionally, a schedule must be created and adhered to strictly. Getting behind in a distance course is not going to lead to a good grade, or, more importantly, good learning.


Now Why Did I Bring This Topic Up On A Medical Blog?


…because medical education, at least the didactic portion, is no different. There is this old-wive’s tale that students can only learn when presented material in live lectures. This is absolutely not true and potentially detrimental to retention. Studies have shown that most students have an attention span of only twenty minutes before knowledge retention falls off precipitously. Unless professors in a traditional classroom are going to give breaks every twenty minutes, they are wasting a lot of their energy. And since this isn’t likely to happen, traditional lecture-based courses are somewhat ineffective. With all this being said, I realize that some medical schools have no attendance requirement. All lectures and lecture slides are provided on a centralized server for download and viewing. This allows for a better utilization of time and resources.


All of this comes down to one thought for me:  the delivery of educational material should come in multiple formats. Be open to the various methods of learning and good things will come.



P.S. I should mention that I have contacted a number of medical school admission offices to ask their opinions on distance education. A resounding number had favorable opinions and were no less likely to reject a student because of it. Which is a good thing to me as an applicant as more than one of my prerequisite courses was taken via distance education through an osteopathic medical school (!)


Questions, comments, thoughts on distance education and it’s place in healthcare?  Let me know!

Let’s Talk About Data


By:  DMKashmer, MD MBA MBB (@DavidKashmer)



A Car Isn’t Just About The Wheels…But It Needs The Wheels To Go.


We have spent a great deal of time running through the background of a typical Six Sigma project. This is because I have heard colleagues estimate that 80% of the Six Sigma process is about the people and the teamwork, and that seems about right to me.  Without a supportive team and a receptive administration, the Six Sigma pathway is slow to succeed if it succeeds at all. However, despite the fact that much of Six Sigma is not about the mathematics and statistics, the mathematics and statistics are a huge difference maker. Alone they are not sufficient for project success; however, they are a necessary ingredient. After all, a lot of the car is not about the wheels–yet you absolutely need the wheels. Now let’s take the time to discuss Six Sigma data collection plans and other important considerations so that we can get those wheels turning.


West Meets East


There are some important differences between classic Western management styles and Eastern management styles, and these play into what we do with data. First, as we have mentioned, the rebuilding of Japan post World War 2 allowed Western modern management thinkers to implement advanced techniques in a receptive culture. (West went East, and it flourished.)


This deployment resulted in an interesting blend of statistical process control and Eastern philosophy. Western classic management, by contrast, is very person and individual focused. It has often been described as being less data driven. Of course, counter examples spring to mind immediately. Instance, time-motion studies performed in early America, Henry Ford’s production line, and multiple counter examples clearly exist. We are speaking in generalities here not hard and fast rules.


That said, modern Western management styles are incorporating data driven decision making more and more. Not only is “big data” a catch phrase, but Six Sigma and Lean deployments have really changed the face of what we describe as Western management philosophy. Here, let’s describe some of how adding a data layer to your project really gets it moving in the right direction.  Let’s go to the nuts and bolts.


The Data Collection Plan Is Based On The SIPOC Diagram


We have previously discussed the SIPOC diagram as a high level process map (and beyond) for which ever process you are trying to improve. We mentioned the SIPOC diagram as one of the Six Sigma tollgates in the define phase. Now let’s move on to how this SIPOC diagram is woven into creating a data collection plan.


No Matter Which Data Points You Choose To Collect, Get The Data Right From The Process


First, some broad philosophic points. When we collect data for Six Sigma projects, we recommend avoiding the use of data from data warehouses or trauma registries whenever possible. Why? This is because data in warehouses and similar registries has often been cleaned, edited, or otherwise filtered. Whenever possible, we recommend getting data directly from the process. Spending time ‘on the factory floor’ is useful in that it leverages the Hawthorne effect and gives the team (as well as managers) a real feel for how the process works. We recommend going to the gemba whenever possible.


Let’s take a moment to continue the philosophy of why we collect data that way we do. First, the question has often come up of whether leveraging the Hawthorne effect is appropriate for these projects.


The answer:  we will take quality improvement anyway we can get it….as long as it is sustainable.


Hawthorne Effect?  We’ll Take It!


Let me explain what I mean. We don’t mind if the Hawthorne effect is a driver for quality improvement, as long as this quality improvement is sustainable. That’s why, whether the Hawthorne effect is at play or not, we look for improvement that is quantifiable, reproducible, and persists in the control phase (a later Six Sigma project phase) and beyond. We don’t care if the Hawthorne is one of the players that improves things; however, we want to make sure this is sustainable. So, the first two philosophic points are: 1. Take data directly from the process in real time if possible and 2. Hawthorne effect? So what…if it’s sustainable!


Specific Nuts And Bolts


Next let’s move into the nuts and bolts of how to turn your SIPOC diagram into your data collection scheme. Remember, the SIPOC diagram highlights Suppliers, Inputs, Process, Output, and Customer. In general, to fully characterize your system you will require six or seven endpoints. (Yup.  That’s it.  NOT 20 data points.  NOT 400–just six or seven for quality improvement projects.  We’re not talking about getting novel insights from data a la “big data” here.)


This is includes one or two input endpoints, 1 process endpoint, and two or three output endpoints. These endpoints are key to adequately describe your system.  Where do you get them?  You look at the SIPOC diagram to see each element of the process, and you choose endpoints that the group agrees have meaning for that element.  In healthcare, we suffer from an issue here:  we often can’t believe that (with all the data we see and track) that we need so few endpoints to make dramatic improvement.  Guess what healthcare colleagues:  we don’t need to be data rich and information poor for our quality improvement projects…even though we may be used to it in the rest of our work.  It’s always a challenge to focus healthcare teams on narrowing our view to the six or seven required endpoints.  It’s challenging…but rewarding when the project succeeds.


Another important note:  sometimes, we are able to ‘double dip’.  “Double dipping”, here, is a term used when one endpoint can actually represent two elements of your system. Yes, sometimes we do need to use trauma registry data or other data that has already been collected (because it’s very handy, easy to get, and does what we need.) Sometimes an element from the registry can serve as an input measure and a process measure.  Again, we try to avoid registry data whenever possible…yet, sometimes, not only do we use it but we allow it help us double dip.


How Much Data Do We Need?


The next question is how much data do you need? We have included sample size equations for discrete and continuous data here. These equations can help you determine how much data you will need to characterize your system in order to detect a certain size change. It is useful at this point to calculate what sample size you will need and to determine how small of a change you would like to be able to find. Figure those things out before you collect data.  Of course, positioning a sample to detect a smaller change means you need many more data points. Read more about it here.


The next important philosophic take home message is we try to use continuous data whenever possible. Why do we use continuous data? Read more about it here. As mentioned in that post, we can do a lot more with a lot less continuous data as opposed to discrete data. We encourage the use of continuous data whenever possible. And, if need be, it makes sense to turn your discrete data endpoints into a more continuous type of data with something like a Likert scale.


That’s The Setup, & More To Come


So, now you have the setup. You need to take your SIPOC diagram and establish which endpoints have meaning for you. It is a great idea to take endpoints that are easy to collect right from your process. This often makes data collection obtainable. All of that said, there are some other challenges to data collection.  More on that in the next post!


See you soon.  Questions?  Comments?  Let me know beneath.




Cover Your…The Idea Of Defensive Medicine

Cover Your . . . The Idea Of Defensive Medicine


By:  The Musing Medic (@TheMusingMedic)


Let me preface this article with a disclaimer:  I am not a physician nor do I claim to be one. The thoughts in this article are based on anecdotes and experience. My current education and training do not qualify me to do anymore than make observations. Hopefully this article will spur some discussion on the topic.


So What’s The Topic?  Defensive Medicine, a.k.a CYA Medicine.

After almost four years in a busy suburban ED, I have been witness to multiple instances of physicians practicing defensive medicine. Let me tell you, it doesn’t take a physician to witness what constitutes defensive medicine. But it may take a physician to know when defensive medicine is justified.


My Question Is:  “When Is Defensive Medicine Justified?”


I always thought the gold standard was to be evidence based medicine (EBM). After doing a little research, the actual percentage of EBM utilization hovers between 15-30%. That means more than 70% of clinical decision making is not evidence based. Why is this? Is it due to the litigious nature of modern Medicine? Is it the fear of missing a diagnosis resulting in a poor outcome?


These are questions that many of the ancillary staff ask ourselves, amongst ourselves. We discuss them in hushed tones, though some may be more willing to ask the physician “why’d you do that?” But, in my experience, many physicians view this as questioning their decision making or clinical prowess. That isn’t the idea behind the question though. Medicine is a complex amalgam of science, psychology, business, and customer satisfaction. Those of us without the medical school education and residency training are not privy to this information but we still want to know why. I think communicating these thoughts and ideas are beneficial to all involved.


Let Me Provide An Example From A Recent Case…


(If you don’t speak Medicine for some reason, ask a friend to translate.)


63 y/o F presents with left sided rib pain and left shoulder pain that worsens with movement x 24 hrs. States she fell while playing with grandchildren, landing on left side. PMHX of HTN, hyperlipidemia, and COPD.


Attending MD orders workup for r/o MI with admission to chest pain unit. Admission is out in prior to any testing.


Testing was within normal limits. ECG was NSR with no ST changes from previous ECG. Enzymes were all normal. CXR was that of a COPD patient. No rib or shoulder injury noted on films.


Never once did I get the impression this patient’s complaints were cardiac related. My thought was the patient suffered a MSK injury due to the fall. The onset of pain coincided with the fall. The pain worsened with movement and was localized to a very particular area. The patient had no other symptoms such as nausea, diaphoresis, etc.


When I asked the attending why the patient was being admitted to the hospital for r/o ACS, he stated “I have no way to tell if this pain is from the fall or not”.


Horses–Think Horses!

…Actually, you do. The puzzle pieces add up. Like I mentioned before, think horses when you hear hoofbeats not zebras. There were a hundred pieces that fit together. But he went another route and I am still asking myself why? What did he see or think that I didn’t?


But if I had to guess, he was practicing defensive medicine. Maybe that was the safe choice. I can’t answer that. But would’ve practicing EBM here resulted in a different disposition. I think it would.


This is a topic with no black or white answers. But discussion is possible. Feel free to leave some comments and provide your own thoughts, stories, or criticisms.


Till next time,


The Musing Medic

Orientation Or Disorientation?

Orientation Or Disorientation?


By:  The Generation Y Surgeon (@GenYSurgeon)


I recently graduated and transitioned into my fellowship. As most physicians know, part of transitioning to a new hospital is enduring the necessary mandatories and introductory sessions; however, as a small percentage of a large number of incoming physicians, I was grouped with the interns for orientation. This was painful for a number of reasons.  However, what made me buck was much more subtle.


“It’s Our Policy”…

When I showed up for orientation on the second day, one of the admit staff at the sign-in asked me where my badge was. Understanding how painful it is to replace a hospital ID badge when you haven’t memorized your employee number, my heart sank. How could I have lost that thing already?! So I looked down to my right hip, the place where it had sat for 5 years while I operated and rounded and….it was right there. The admin proceeded to tsk-tsk and point to her left shoulder. “It’s our policy..” she snapped in a sing-sing voice. Did she just scold me as if I were a child? Keep in mind that I was in the OR until after 8pm only days prior, had packed up and moved an entire apartment and was still answering calls about patients still admitted at my residency hospital. Lets just say that the response she received was not as benign as she would’ve hoped. And then I realized she didn’t know I wasn’t an intern…


Show Some Respect

I usually don’t snap at administrative staff; however, this interaction really struck a nerve.  What bothered me wasn’t that particular interaction as much as knowing that woman thought it was her right to speak to me like that. She wrongly assumed I was an intern and spoke at me disrespectfully as if I weren’t a physician at all. I am always respectful of the ancillary staff in hospitals, regardless of their positions. Without the techs, transport, cleaning staff, office staff, managers and administrative staff the hospitals where we work simply wouldn’t run. I will point out, however, that without physicians the hospital would be worthless and without residents (future attending physicians) the hospital would very soon be worthless.* And as such, providers should be treated respectfully, even in their earliest years.


The Interns Should Be Treated Like Adults…

Had this particular woman realized that I was in fact a board eligible surgeon, not an intern, I’m positive she would not have spoken to me in that way. I’m also positive that she had spoken to every other intern in that manner because she truly thinks they are beneath her. This make me angry for interns and for physicans in general. Let’s not forget that, by the time we entered residency, many of us were nearly one quarter of a million dollars into educational debt, 4 years of schooling beyond our bachelor’s degrees and already real, really tired. By the time we enter residency we have demonstrated commitment beyond our years and devotion to a noble profession. Interns should be treated like professionals, not children, because guess what…they’ve earned it.


…Even Though They Don’t Act Like It Sometimes

Now back to my real-life scenario. Thoroughly irritated, I looked around and much to my dismay, the interns were acting just like I had been treated. The room reeked of immaturity and bad behavior, all the markings of a group 10 years their juniors. The orientation had been set up much like college/university orientation and the new physicians were certainly acting the role. I wonder why the interns act like that, and whether it’s universal and what exactly happened during residency that pushes most people over the hump and into maturity. Would a different environment lead to different behaviors in these residents? Would they be treated differently by the admin staff?  Maybe all twenty-somethings are like that in every field.  If so, I guess I’m not as disappointed.


Don’t Accept It & Help Repair It

It’s important to think about what sort of environment we first expose our residents to because this first impression may have more profound effects than we realize. There are entire bodies of literature in business and management fields which outline how to create and model professional behaviors. Outside of Medicine, this is a huge deal and yet for some reason (probably because we are too busy and too tired!) physicians have let this aspect of the workplace slip. We would all agree that we have learned by modeling our seniors and conforming to the workplace norms, but what kind of norm have we set for the interns during their orientation? Should they expect to be treated disrespectfully? Should they accept that they are considered inferior to the ancillary staff during their entire first year? No, they shouldn’t. And neither should we.


Evolve Or Die

You may be wondering why I’m bothering to write about this issue on a blog about business models and innovation, and I’ll remind you that healthcare is in fact a business…and we are part of it. Don’t like it?  Well, guess what, denial of what it really is just got us managed by other people.  (Thanks a lot, dinosaurs, for that one.) The question is how to effectively take care of people in the current climate of Medicine and NOT to deny its realities or hope your denial and beliefs will somehow change it.  Evolve, people, or die.


And This Is Part Of That Business

Part of the business is building and maintaining an environment where the physicians can feel comfortable and empowered, and in this environment respectful communication is key. Somehow we have forgotten the importance of mutual respect and effective communication and our culture has shifted to the point where our incoming physicians are treated like scum. This is not how we should be ushering our interns into the hospital.


Where Can You Look For More Information?

As I mentioned before, there are entire bodies of literature on how to build effective workplace environments and how to communicate effectively. One free resource that I frequently use is called MindTools. I receive regular emails which outline different aspects of personal and professional growth, culture change, and common obstacles as well as some how-to guides for improving your workplace. I will challenge you to make small changes in how you model professional behaviors to the hospital staff and your mentees. With small, individual changes hopefully we will be able to change the maladaptive cultures that plague our field.


Disagree?  Have a different idea?  Let me know beneath.




*FYI:  Although I am writing specifically about physicians and residents, in spirit I mean to include all other providers…NPs, PAs, prehospital staff, etc.


Use A SIPOC Diagram For Your Next Quality Project




















By:  DMKashmer (@DavidKashmer)


Next Tollgates In DMAIC’s Define Phase

Previously, we have discussed the importance of the project charter along with a focus on the cost of poor quality. (All of that is available to you here.) Now, let’s turn our attention toward two other important components of DMAIC’s Define phase which include determining the nature of customer needs and making a process map.


The Voice Of The Customer (VOC)

Customer needs and requirements are key in establishing the endpoints for the rest of the project. In particular, one important question is ‘Who is the customer?’ Different projects have different customers, and sometimes who exactly the customers are is not intuitive. You may be performing a project to satisfy a state or federal regulatory bodies endpoints, internal customers such as people in your organization who receive output from a process, or even both. The importance of focusing on who exactly the customers are for your project cannot be overstated.


Once you have determined exactly who it is you are trying to satisfy, you can begin to see the Voice Of the Customer, or VOC, in your processes. The VOC is determined from customer driven endpoints. Sometimes, these are very obvious in that the state or accrediting body tells you what has to be done. They may say, for example, that 80% of the time a trauma surgeon has to arrive to the trauma bay within 15 minutes of patient arrival. This is a very straightforward voice of the customer for your project. Other times, and in less regulated fields, things may not be as clear. You may need to have small focus groups or otherwise spend time with customers with surveys or other tool in order to determine exactly what quality looks like to a customer and what elements they are focused on. However, realize that we must determine what quality looks like to a customer in order to progress in the quality improvement project.


From Villanova University Lean Six Sigma Course 2009
Figure 1:  House of Quality (Quality Function Deployment or QFD) From Villanova University Lean Six Sigma Course 2009




Some interesting tools have evolved, including the House of Quality pictured above (as Figure 1), to turn customer needs into defined endpoints. (We will discuss the House of Quality in an upcoming entry.)


Building Out A SIPOC Diagram

After you have determined exactly what quality looks like to your customers, and who your customers are, it’s time to focus on making a process map. A process map is often called a SIPOC diagram. SIPOC stands for Suppliers, Inputs, Processes, Outputs, and Customers. So with a SIPOC diagram, the focus is usually first placed on the mapping the process involved.


Figure 2:  Sample SIPOC diagram from a previous project.
Figure 2: Sample SIPOC diagram from a previous project.



If you have previously determined the scope of your project, as we advised you in an earlier entry here, you clearly know the bounds for the process. For example, you usually have determined a start and end time. These allow us to focus first on the P in the SIPOC diagram.


Take a moment to review the sample SIPOC diagram listed above as Figure 2. Once you have determined the bounds of the process, describe the process in five to six high levels steps. In healthcare, we typically try to be overly detailed with respect to this process map. As you perform more projects, you’ll realize we only require five to six high level steps for the process at this point. Usually this easily suffices for later work with the project. If you need to get more specific later on, there are many tools for that available.


Once you describe the process at a high level, it is time to focus on your suppliers and inputs. Often, for healthcare projects, we describe the input as a ‘packaged patient’.  A packaged patient maybe a patient who is completed several key steps and is now ready for the next system–the process on which you are working for improvement. ‘Packaged’, to us, means a patient who has had multiple things already occur such as having a history with physical exam, cervical spine collar applied, imaging studies, etc., etc. Depending on the process you are looking to improve, a packaged patient may mean something different.


We’ve constructed the ‘packaged patient’ over years of Lean and Six Sigma work because it is an easy concept for people in healthcare to understand. Further, it is often easy to measure with a Likert scale or similar construct. While at least one input to different processes is a packaged patient, there maybe other inputs depending on the process you are trying to reform. Again, the particular inputs are completely focused and contingent on what your process is. That’s why, again, we recommend working on the P in SIPOC first.


Who Are The Suppliers For Your Inputs?

Once you have the process and inputs laid out it is important to determine who the suppliers are for your inputs. From where does the packaged patient come? From where does the back brace come? Suppliers may include the brace company, the consultant who determines that a brace is necessary, and the emergency department or floor nurse who supplies the patient. Often, for trauma-type SIPOC diagrams, EMS is a key supplier.  Note, interestingly, that the concept of a packaged patient can be leveraged as an easily measurable input or output from the process.


Now that you have determined your suppliers, input, and process, it is time to determine the output. The output is often the packaged patient with some additional feature or value added. This maybe a patent with a brace to follow our example, or something similar.   The customers, however, can be more challenging. As we have described here, it is often very challenging to determine who the customer is in healthcare. The customer maybe a third party payer, the patient, other physicians, or EMS. Here the customer may be the trauma service. It may be that patient and also may be the social worker / discharge planning who receives the fact that the patient now has a brace and is ready to progress in their care. Physical Therapist and Occupational Therapy team may also be customers. Of course, Physical Therapy and Occupational Therapy may also be suppliers, in that they give an input to the system which is their evaluation and recommendation for bracing or further physical therapy etc.


Completion of A SIPOC Is Essential

Clearly, completion of a SIPOC diagram is essential for the Six Sigma DMAIC process.  Failure to complete a SIPOC diagram makes it much more challenging for the team when it decides what to measure and what must be measured in order to focus the project and achieve success.


So, the next step for the Six Sigma project is to utilize this SIPOC diagram in the next phase of your project:  the measure phase. We take the defined process map and use that to generate endpoints that the team agrees on as having meaning in your particular organization. This is part of the power of Six Sigma and Lean in your organization.


Six Sigma Vs. Just Trying To Do “What The Literature Says”

Let’s take a moment to talk about the philosophy behind what makes these projects more effective than simply trying to implement what the literature says. After years of performing these quality improvement projects one thing becomes very clear:  the literature may talk about best ways or best practices for different endpoints of patient care. I cannot impress upon you enough the fact that the literature often indicates a great result achievable at some center owing to its unique processes, people, and other strengths.  Can you do it at your shop?  Maybe…but odds are it will look different and be achieved in a very different way. The challenge lies in applying that literature to achieve excellent end points in your system.


This is what makes Lean and Six Sigma so valuable. They are processes by which we can improve our endpoints in our systems at our hospitals. Sometimes there are barriers to the process that are cultural in nature. However, if we implement the Lean and Six Sigma process we see improvement in our endpoints that have meaning. We see recouped cost of poor quality at our institution. See the difference? The difference is the tension between the findings related in the literature (contingent on all the vagaries at the centre at which it was generated) versus a culture change with rigorous statistics and decision making that is completely focused on our institution and doing better with our systems. Sometimes the Six Sigma process encourages us to completely change or revamp a system. Whether we revamp a system completely or tweak the one we have, Lean and Six Sigma are very different than simply trying to apply another center’s literature to our center.


In short, what works at one center is unlikely to work at yours owing to how vastly different one place is from another. However, what Lean and Six Sigma generate will clearly demonstrate improvement or no improvement (and a continued need for improvement). These are very valuable and very different than trying to roll out whatever the literature tells us to do.  DMAIC, with its define step and team-based rollout, allows us to generate solutions and implement them as a team…even while we capture data to tell us whether we really are doing any better.


In conclusion, the define step is the first step forward to improving a system in your hospital or healthcare system. It requires team building, a project charter, and a clear path to be established including the Voice Of the Customer and a SIPOC diagram to map out the process for later improvement. All of this is done in the team context to focus on meaningful improvement that works at your center, rather than an often-doomed attempt to transport something the literature tells you is great directly to your center en masse.  Hope you find the SIPOC diagram and VOC elements useful as you work to improve the systems in which you practice.  Best of luck in your continued quality improvement journey and I look forward to hearing your thoughts in the comment field beneath.

Moving Forward: Legitimizing EMS

Moving Forward: Legitimizing EMS




By:  The Musing Medic (@TheMusingMedic)


Anyone who has spent time around me in the professional setting knows I am critical of EMS with respect to the education involved. Every shift I am constantly reminded of the problems with the types of paramedics we are churning out. But, until now, the most I have ever done is verbalize my thoughts to those around me. Well…that’s not totally true. I have also worked with paramedic students and tried to impart to them the necessity of taking their job seriously and doing it the right way. What other steps can we take to improve the level of professionalism and education while we advance the field?


 Increasing educational requirements is a start.

Currently, most paramedic programs are certificate or diploma programs. If we want to gain professional traction, we need to move towards at least an associates degree requirement. This would legitimize the profession a little more. Requiring actual college coursework such as anatomy, physiology, and other sciences would lead to an increased understanding behind disease pathology. Additionally, it would help push forward for an increase in salary.


Next would be recruiting and attracting the right types of people.

Talent management is key in any organization. We should be actively seeking persons who are not interested in being a hero but who are interested in treating patients, from the sick to the not-so-sick. I know many a student who is working on their paramedic certification because the fire service they want to work for requires it. Look, I don’t want these types in my field. If you are not interested in the medicine and it is not your passion, walk away.


Eliminate volunteer services except in underserved areas.

How often do you find nurses or physicians volunteering their services? Sure they may volunteer for special events, health fairs, or mission trips. But volunteer EMS agencies provide 24/7 coverage for certain areas. This is bad for business. What does it say about our profession if we can get people to do it for free? Moving towards all paid services is one way to help provide credence to our field.


I realize that some of these thoughts/opinions will be poorly received, but, frankly, it needs said. We in the EMS community continue to be our own worst enemy. Change will only come from within and there are enough of us to make that change.


Comments?  Ideas?  Replies?  Let me know beneath.


Let’s Celebrate July the 2nd!?


By:  David Kashmer, MD MBA (@DavidKashmer)


Adams Thought We’d Celebrate July 2nd…

Did you know that at least one of America’s progenitors was confident that we would be celebrating July the 2nd as Independence Day?  Well, I’m no historian, but…


John Adams’ famous letter of July 3, 1776, in which he wrote to his wife Abigail what his thoughts were about celebrating the Fourth of July is found on various web sites but is usually incorrectly quoted. Following is the exact text from his letter with his original spellings:

The Second Day of July 1776, will be the most memorable Epocha, in the History of America. I am apt to believe that it will be celebrated, by succeeding Generations, as the great anniversary Festival. It ought to be commemorated, as the Day of Deliverance by solemn Acts of Devotion to God Almighty. It ought to be solemnized with Pomp and Parade, with Shews, Games, Sports, Guns, Bells, Bonfires and Illuminations from one End of this Continent to the other from this Time forward forever more. You will think me transported with Enthusiasm but I am not. I am well aware of the Toil and Blood and Treasure, that it will cost Us to maintain this Declaration, and support and defend these States. Yet through all the Gloom I can see the Rays of ravishing Light and Glory. I can see that the End is more than worth all the Means. And that Posterity will tryumph in that Days Transaction, even altho We should rue it, which I trust in God We shall not. (The Book of Abigail and John: Selected Letters of the Adams Family, 1762-1784, Harvard University Press, 1975, 142).

Writing that letter was an act of celebration.

Above excerpt is from http://gurukul.american.edu/heintze/Adams.htm. You can find similar info all over the web on Google.  I first learned of John Adams’ thoughts on July 2 when reading his letter to Abigail as cited above.


The Players Involved Were People

I really enjoy historical instances that demonstrate how the people involved were human beings.  Have you heard of the one where, when crossing the Delaware, one of the participants (owing to his size) could have capsized the boat when stepping onboard?  George Washington warned him (Henry Knox, a man of considerable girth) not to get on too fast or he’ll “swamp [overturn] the boat.” (Washington’s actual words were much more colorful as the story goes.)


Instances, like these, demonstrate just how messy and human History can be.  So to all of the celebrators out there making history, and Mr. Adams too:


Happy Fourth of July.