Update Your Medical Knowledge Base!

By:  The Musing Medic (@TheMusingMedic)


Medicine is a fickle creature. It is equal parts art and science. The idea of perfection in the field is quixotic. Yet we continue to move forward with research and adapt our practices to the evidence…or at least we should.

Unfortunately, as we continue adding years under our belts, we move away from reading and updating our knowledge. I think this is true of any profession outside of academia. We become complacent to a degree. The only time we change our thinking is every four years or so when our certifications are in need of renewal. New information presented in the renewal course is blended into our practice. But outside of that and the occasional trade publication, we move along and do what we know. Is that ok?

Modern research has led to the revamping of many practices that were once considered dogma in clinical medicine. Two of my favorite ones that should have gone by the wayside (but have not) are the use of Trendelenberg positioning and the consistent use of supplemental oxygen in acute coronary syndromes. Evidence collected from completed and ongoing research has indicated both of these time-honored treatments, as benign or helpful as they may seem, are in fact detrimental to patients and influence morbidity and mortality rates.

Now I could have easily provided information regarding the aforementioned studies but since this is an article dedicated to keeping oneself updated, I think it would be hypocritical…and so I’m stopping here.

This, then, is your challenge:  go and find the information for yourself. Brush up on those research skills.  Tell me if you agree or disagree with my thoughts on Trendelenburg and supplemental oxygen in ACS as described above.

Surgeons: Don’t Ignore This Severe, Treatable Disease!

By:  The Generation Y Surgeon (@GenYSurgeon)


With all of the media hype regarding Robin Williams’ suicide, I thought it appropriate to bring up a topic that I find quite important. Physician suicide.  If you think that’s not a good blog topic, or that we shouldn’t talk about it–or even that you don’t want to hear about it–then you are DEFINITELY the person who should read on.


Mental illness knows no boundaries.  Whether you are a famous actor, a child, a homeless person or even a physician, depression and suicide destroys lives. Why is this in a blog regarding business models and hospital systems? Because this is an example of a way we can improve our system. Any profession that allows the loss of one of its own can be improved. I don’t know how to fix it but I hope someone else does. In the meantime, let’s start a conversation about it…because awareness is a good start.


A Setup For A Bad Outcome

For (at least) five years, “the future”meant “next weekend”. Knowing your call schedule for the month before the month started was a luxury, and even then it could change at any minute. Financial planning consisted of paying your bills and keeping your bank account above zero. Living a healthy lifestyle meant having (not necessarily using) a gym membership and sleeping for more than 4 hours on six out of seven nights. The future meant surviving each shift by looking forward to your sacred 24 hours off, and not much else. Emotional stability meant you showed no emotion.


Physicians, and especially surgeons, do not do a great job of caring for themselves. During our training we defer our salaries, postpone our personal goals, set aside social commitments and are often forced to plan our lives month by month. Residency is consuming and exhausting and seeing beyond graduation is enough of a challenge, seeing to the ends of our careers is nearly impossible.


Surgeons Do Very Little To Protect Themselves

For all of the emphasis on anticipation and prevention in surgery, for as hard as we work to protect our patients, surgeons do very little to protect themselves. Surgery is emotionally and physically draining. The burnout rate for surgeons is abnoxiously high and likely underestimated. And the physical cost of long hours, late nights, navigating large hospitals and hands-on patient care is not insignificant. Due to the training required and the intensity of the job, surgical careers start late and end early. And we do very little to protect ourselves from, well, ourselves.


Ut Oh:  The Facts Of The Matter Make Us Pay Attention

Here are some alarming facts courtesy of the American Society for Suicide Prevention:

  • In the U.S., suicide deaths are 250 to 400 percent higher among female physicians when compared to females in other professions.
  • Among male physicians, death by suicide is 70 percent higher when compared to males in other professions.
  • In the general population, males complete suicide four times more often then females. However, female physicians have a rate equal to male physicians.
  • Women physicians have a higher rate of major depression than age-matched women with doctorate degrees.


This makes me sad. (Don’t worry…not that sad.) We spend our days and nights and weekends snatching people from the jaws of death, yet we let our own people die the most painful deaths? Think for a moment about what it is like to suffer so much that you take your own life…what terrible suffering that must be. To know that physicians, strong and intelligent and persevering people like yourself, have taken their own lives? The loss of life, of talent, of influence in a community….truly a waste.


Focus On Surgery

Physician suicide is a problem across all specialties, but I want to talk specifically about surgery. Surgery is a tough sport because it preys on weakness and always finds our weakest point.  Long nights, high stakes life-or-death situations, empty stomachs, harsh critics and strict deadlines. As a surgeon, the amount of stress we face on a daily basis is already too much. Add to that the emotional stress of seeing people die and families mourn, the associated accountability and feelings of guilt, and the “extras” like M&M, ABSITE/boards and interviews which get tacked onto the “side.” The life of a surgeon is unforgiving to say the least and our training prepares us for much of this, but it doesn’t make us immune to stress and depression. As much as I hate to admit it, surgeons are just people…and we have limits.


On top of the stress inherent to the job, societal stresses and double standards have further isolated us emotionally. For example, take the snide comments regarding our paychecks. I’ve been told by more than one patient that doctors make too much money, and I’ve admittedly felt a little ashamed. However these patients don’t know that most medical students have over a quarter million dollars of educational debt, that residents can’t always pay all of their bills, that our “huge”paychecks don’t start rolling in until we are in our 30’s. To be attacked by the very people you are trying to help is an added stress and it takes an emotional toll whether conscious or subconcious.


Another issue is our lack of support from the public, other hospital staff and even our own families. The truth is that no one truly understand what it costs to be a physician. We sacrifice our 20’s to school and eventually to residency, we work when our patients need us and sacrifice our own lives for their sake, we endure years and years of stifling training and sacrifice time and youth inside the hospital…and yet no one really understands.


Is what I’m saying making you uncomfortable? Unfortunately, that’s how it goes when we stop and look at what we do.  Probably still worth it to look at what we do instead of ignoring our situation.  After all, maybe if we acknowledge the challenges we can work to avoid those preventable deaths.


The Paycheck Issue & Lonely Days

Truth is, no one offers any sympathy because all they see is the big paycheck, the fancy car and the letters behind our names…and they forget that we have earned it. The luxuries we afford ourselves have been delayed by years and even those luxuries are used against us in underhanded ways.


Surgery, specifically residency, is also a lonely time. Even though we work with people every day, we lack the time we need to build and sustain healthy relationships with family and friends. Our work schedule prohibits the downtime that is need to maintain stability. For those of us that are married, we take time from our families and give it to strangers. For those of us who are not married, an empty house and a limited social life is expected. For for the women who deal with the stigma of being unmarried, or being child-free while living and working in a male dominated field…well, I’m sorry you have to deal with that.


The truth is, surgery is isolating and dangerous. It is a setup for depression and suicide, yet at times it seems we have done little to prevent it. All surgeons go through the same trials, some face more difficulties than others, and even the “easiest” of careers is maximally stressful compared to the general population. I would venture to say that most of us, somewhere along the way, have dealt with some degree of depression. But why don’t we talk about it? Depression and suicide are taboo, especially in surgery. And talking about it (or trying to get help!) can hurt your career…a very dangerous situation.  And that’s why we’re discussing it here.


As Surgeons We Spend A Lot Of Time Looking For Less Common Diseases…

As surgeons, we spend a lot of time and money preventing adverse events in our patients. For example, CTAs for blunt cerebrovascular injuries (BCVIs). BCVIs have a low incidence yet morbid consequences…but nowhere near the rate of physician suicide! It’s unacceptable. Let’s be scientists (& doctors!) about this and start paying attention to this problem. After all we spend a lot more time looking for things MUCH less common than depression.  Depression is treatable and many suicides are preventable. So next time you see someone who may be struggling, become their doctor and save a life. We owe it to our patients, our loved ones, ourselves to prevent the loss of more surgeons. And most importantly, we owe it to our colleagues who are suffering with depression.

Let’s Staff Hospitals Correctly


By:  David Kashmer, MD MBA MBB (@DavidKashmer)


Sometimes you get locked into a certain way of thinking without even realizing it.  For example, you may think hospital infection surveillance staff, case managers, and even hospital attorneys are all useful positions…

Guess what–they’re not.  And here’s why:


60% Of Costs To Run The Hospital Are Staff

Yes, that’s right…it’s not the DaVinci robot or the physician’s use of Factor 7 that end up being the major portion of the overhead in running a hospital.  It’s the staffing.  I was amazed when I learned this as part of an MBA course, and now I’ve seen it repeated across organizations.  What does that have to do with my claim above about case managers and hospital attorneys not being so useful?  Read on.


Value Added Time and DOWNTIME

Isn’t it amazing how education frames things we thought we knew in a way that sometimes flips them on their heads?  Let’s talk a little about some Lean concepts that reframe how to think about hospital staffing.  First, consider Value Added Time (VAT).  VAT is the amount of time in a system spent adding sometime of value to the eventual output for which the customer will pay.  In healthcare, we have a special problem in applying the definition of VAT to what we do.  (More about that here.) After all, we are adding value to the patient, yet it isn’t that patient who pays.


Who does pay?  The third party payor, eg Medicare or something else.  So, what if we treated the output of our systems as the note or documentation?  After all, isn’t that really what Medicare pays for?  Isn’t problems with documentation the sword that is used to NOT pay us despite our work?  (Don’t worry, the staffing issue is coming.  Hang in there.)


If we treated the note / documentation as the product we would re-align a lot of how we do what we do in healthcare.  Of course, we don’t want to commit fraud and so whatever we said we did for the patient in the note would actually have to be done.  The point here is that, in most systems (including healthcare) we spend less than 1% of the total time in a system as Value Added Time regardless of whether we consider the thing to which we add value as the patient or the documentation.  Amazing, and true.


What helps us find and label waste in our healthcare systems?  DOWNTIME.


Where Does The Time Go?

Much of the time, simply, goes to waste.  We usually categorize waste in eight buckets that, conveniently, spell the acronym DOWNTIME:


D = creation of Defects

O = Overproduction of things we don’t need to make

W = Waiting time, where patient / note is waiting to move along the stream

N = Non-utilized / under-utilized talent

T = Transportation that’s unnecessary

I = Inventory that’s just sitting around

M = Motion that didn’t have to occur

E = Excess processing (doing much more processing than required to get the effect)


Do any of these look familiar?  Of course they do.  We practically can’t walk around a hospital without seeing them everywhere.


Rework Is The Killer

Now imagine a system where DOWNTIME is minimized.  Less defects like wound infections?  Then not as much need for infection control.  The attitude in Lean (and Six Sigma) is that, if you get things right the first time you have MUCH less need to pay for rework elements.


What do rework elements look like?  Well, some are entire positions we’ve created because we haven’t been able to adequately get it right the first time.  Lousy quality of handwashing, vent weaning, or other issues?  Create an infection control department with five or six staffers.  Unable to get great outcomes and patient satisfaction?  Better have some patient safety staff and lawyers on board to help out.


Positions Built On Rework

The bottom line:  those positions are born from rework, and the attitude that rework is ok and expected.  Like many service industries, healthcare systems operate at around 1 defect per every 1000 opportunities at making a defect–and it’s lulled to sleep as it thinks that ok.  It’s not ok.  I’m not saying that lawyers, case managers, or infection control staff are bad people or useless.  I am saying that the fact we have them, and need so many of them, is a sign that the attitude toward quality is WRONG.  It’s expected that those positions exist.  Instead, it should be expected that those positions are minimized–because we get it right the first time.


Remember, the Cost of Poor Quality (COPQ) is created from four buckets:  prevention, surveillance, internal failures, and external failures.  (More on the COPQ here.) Many of those positions are owing to one thing:  surveillance or failures.  What if we had systems where quality was built in?  We’d have less need for after the fact surveillance or defect correction.  Often, those roles are misplaced resources.  It’s the bottom line.*


So, let’s address our title of this piece:  it’s not that the staff in these roles don’t do a great job.  In fact, lawyers, case managers, and infection surveillance really help people.  Yet these roles are useful only in the world of healthcare where rework and error correction is expected.  I’m not saying we should wake up tomorrow and eliminate these roles from our hospitals.  However, why not use what we know about quality to get it right the first time?  Why not re-focus healthcare from recovering from defects to eliminating their creation?  Let’s minimize re-work roles.


Think we can’t?  Think hospital systems are too complex to leverage the tools of Lean and Six Sigma?  Look around the blog–there are plenty of examples on here of how those systems work just fine in healthcare.




* oh, and by the way:  I’m not so extreme in this view.  Robert Chalice’s Improving Healthcare Using Toyota Lean Production Methods echoes this sentiment.  See page 105.

Without Data, You Just Have An Opinion

By:  David M. Kashmer MD MBA MBB (@DavidKashmer)


Do you agree with the thought that Six Sigma is 80% people and 20% math?  Whether or not you do, it’s important to realize that the 20% of the process which is math is VERY important.  As we discussed in other posts, the virtues of basing decisions on good data rather than your gut, social pressure, or other whims can’t be overstated.  As usual, we’re not saying that “feelings” and soft skills are unimportant; in fact, they’re very important.  Just as data alone isn’t enough (but is a key ingredient in consistent improvement) so too are feelings/intuition not enough when applied on their own.  Here, let’s explore an example of what good data analysis looks like–after all, without the engine of good data analysis, the quality improvement machine can’t run.


Starts With Good Data Collection

If the situation of your quality improvement project is not set up properly–well, let’s just say it’s unlikely to succeed.  We’ve discussed, here, the importance of selecting what data you will collect.  We’ve referenced how to setup a data collection plan (once over lightly) including sample size and types of endpoints.


It’s possible that the importance of setting things up properly can be overstated–but I think it’s very unlikely.  The key to the rest of the analysis we will discuss is that we have a good sample of appropriate size that collects data on the entire process we need to represent.  Yes, colleagues, that means data from the times it’s tougher to collect as well such as nights and weekends.


Requires A Clear Understanding Of What The Data Can (and Can’t) Say

The ball gets dropped, on this point, a lot.  In an earlier entry, we’ve described the importance of knowing whether, for example, your continuous data are normally distributed.  Does it make a difference?  No, it makes perhaps the difference when you go to apply a tool or hypothesis test to your data.  Look here.


Other important considerations come from knowing the limits of your data.  Were the samples representative of the system at which you’re looking?  Is the sample size adequate to detect the size of the change for which you’re looking?


You need to know what voices the data have and which they lack.


Nowadays, Often Requires Some Software

I’m sure there’s some value to learning how to perform many of the classic statistical tests by hand…but performing a multiple regression by hand?  Probably not a great use of time.  In the modern day, excellent software packages exist that can assist you in performing the tool application.


WARNING:  remember the phrase garbage in, garbage out.  (GIGO as it is termed.) These software packages are in no way a substitute for training and understanding of the tools being used.  Some attempt to guide you through the quality process; however, I haven’t seen one yet that protects you completely from poor analysis.  Also, remember, once the tool you are using spits out a nice table, test statistic, or whatever it may show:  you need to be able to review it and make sure it’s accurate and meaningful.  Easily said and not always easily done.


Two of the common, useful packages I’ve seen are SigmaXL and Minitab (with its quality suite).  SigmaXL is an Excel plug-in that makes data analysis directly from your Excel very straightforward.


Means You Need To Select The Correct Tool

We explored, here, the different tools and how they apply to your data.  (There’s a very handy reference sheet at the bottom of that entry.) If you’ve done the rest of the setup appropriately, you can select a tool to investigate the item on which you want to drill down.  Selecting the correct tool is very straightforward if the data setup and collection are done properly, because it’s almost as if you’ve reverse engineered the data collection from what it will take to satisfy modern statistical tools.  You’ve made the question and data collection which started all of this into a form that has meaning and can be answered in a rigorous fashion by common tools.


Allows A Common Understanding Of Your Situation Beyond What You “Feel”

This is my favorite part about data analysis:  sometimes it really yields magic.  For example, consider a trauma program where everything feels fine.  It’s pretty routine, in fact, that staff feel like the quality outcomes are pretty good.  (I’ve been in that position myself.) Why do we see this so commonly?  In part, it’s because services typically perform at a level of quality that yields one defect per every thousand opportunities.  Feels pretty good, right?  I mean, that’s a whole lot of doing things right before we encounter something that didn’t go as planned.


The trouble with this lull-to-sleep level of defects is that it is totally unacceptable where people’s lives are at stake.  Consider, for example, that if we accepted the 1 defect / 1000 opportunities model (1 sigma level of performance) that we would have one plane crash each day at O’Hare airport.  Probably not ok.


Another common situation seen in trauma programs concerns timing.  For instance, whatever processes are in place may work really well from 8AM until 5PM when the hospital swells with subspecialists and other staff–but what about at night?  What about on weekends?  (In fact, trauma is sometimes called a disease of nights and weekends.) Any data taken from the process in order to demonstrate performance MUST include data from those key times.  Truly most quality improvement projects in Trauma and Acute Care Surgery must focus on both nights and weekends.


So here again we have the tension between how we feel about a process and what our data demonstrate.  The utility of the data?  It gives us a joint, non-pejorative view on our performance and spurns us toward improvement.  It makes us look ourselves squarely in the eye, as a team, and decide what we want to do to improve or it tells us we’re doing just fine.  It puts a fine point on things.


Last, good data has the power to change our minds.  Consider a program that has always felt things are “pretty good” but has data that say otherwise.  The fact that data exist gives the possibility that the program may seek to improve, and may recover from its PGS (Pretty Good Syndrome).  In other words, part of the magic of data is that it has the power, where appropriate, to change our minds about our performance.  Maybe it shows us how we perform at night–maybe it shows us something different than we thought.  It may even tell us we’re doing a good job.


At The End Of The Day, Your Gut Is Not Enough

Issues with using your “gut” or feelings alone to make decisions include such classic problems as the fundamental attribution error, post-facto bias, and plain old mis-attribution.  It was DaVinci, if I recall, who said that “The greatest deception men suffer is from their own opinions.” We have tools, now, to disabuse ourselves of opinion based on our experience only–let’s use them and show we’ve advanced beyond the Renaissance.  So now we come to one of the “battle cries” of Six Sigma:  without data, you just have an opinion.  Opinions are easy and everyone has one–now, in high stakes situations, let’s show some effort and work to make actual improvement.