Longwoods Essays

Degrees of Separation: Do Higher Credentials Make Health Care Better?

noreply@blogger.com (Longwoods) — Thu, 05 Nov 2009 21:23:00 +0000

Lewis, Steven

Somewhere around 2050, the last registered nurse without a university degree will ride off into the sunset. Manitoba had gamely held out as the last province to retain the diploma option, but it, too has thrown in the towel. Raising entry-to-practice credentials (ETPC) in health disciplines is the new pandemic. Among recent developments:

Nursing: decades-long evolution from hospital-based to college-based diplomas, and then baccalaureate degree ETPC
Medicine: lengthened the family medicine residency to 2 years from 1 in the early 1990s; major cause of subsequent doctor shortages
Physiotherapy: conversion to master's-level ETPC almost complete
Occupational therapy: ditto
Pharmacy: talk of moving to a PharmD ETPC; the University of Toronto has pitched it to the Government of Ontario, and Quebec has made similar noises
Various technologists and technicians: regular push for baccalaureate ETPC

In a world that values education as an intrinsic good, these have to be admirable developments. Professions devoted to the public good and humbly aware of their limitations raise their ETPC as part of the journey to continuous improvement. Higher ETPC has to create better-prepared graduates, improved system quality, and a better patient experience. If a diploma is good, a degree is better; if a baccalaureate is adequate, a doctorate is superior.
Sounds sensible, right? Let's examine what we've learned about this phenomenon over the years^[i]. First, no one can pin down where raising the ETPC starts. Many have looked, and more knowledgeable and savvy people than I cannot trace a change back to its origins. The best guess is that the movements begin in faculty lounges or around the board tables of professional associations. While we don't know how the credential upgrade begins, we know how it doesn't. Employers never demand increased ETPC; on occasion they explicitly oppose it. No one has ever produced evidence that those practicing with the about-to-be-abandoned credential were harming the public. Governments never instigate the changes.

Second, increasing the credential does not necessarily mean more training. Take the therapies. Until recently, you got to be a physiotherapist by taking a 4-year university degree in, sensibly, physiotherapy. Now you take a 2-year master's program following an undergraduate degree in anything. Same with OT - my brilliant and talented niece got her MSc on top of her architecture degree, consisting of about a year in the classroom and a year of practical experience. We are to take it on faith that we get a more capable entry-level therapist in half the time it used to take, armed with a degree that sounds more advanced.

Nursing has been even more artful. First, it bid adieu to an intensive, roughly 23-month diploma program in favour of the 4-year, but less jam-packed baccalaureate program. The degree students actually spend less time in practice settings during their training. The transition to a degree-only program predictably reduced the numbers of graduates. Employers and governments grew alarmed at forecasts of a 100,000+ shortage of RNs on the horizon.

No worries, responded the universities. We've got a solution. Presto - there are now 11 programs across the country that will give you a nursing degree on top of, say, a fine arts degree in 2 years! Follow the bouncing ball: two years wasn't sufficient to turn out a competent entry-level nurse fifteen years ago, but now it is again. Excellent. (Advice to students: demand a master's degree for your troubles, just like the physios and OTs. Of course, this would confuse regulators, irk nurses with 4-year baccalaureate degrees, and cause riots among nurses with real master's degrees. The physios and OTs had the good sense to eliminate the undergraduate option altogether.)

Third, at least in some jurisdictions, universities, wielding their academic freedom, have acted with remarkable vigour to satisfy professions' aspirations for increased ETPC. The University of Saskatchewan - my alma mater and annual recipient of my donations, in case this essay prompts it to withdraw my degrees - decided on its own not to enrol a new class of physiotherapy students a couple of years ago, as part of its campaign to adopt the MSc as the ETPC. It somehow forgot to notify the government or obtain its permission, although it invoked the Cool Hand Luke defence. One might think the Premier or Minister of Advanced Education might have called up the President to inform him that this ringing exercise of institutional autonomy suddenly made a few million dollars vanish from the university's budget. Nah; bygones.

Fourth, the ETPC movement has created subtle changes in the meaning of advanced degrees. I believe the technical term is "phoney baloney." These so-called professional master's degrees and doctorates require none of the rigour, research, or external scrutiny that used to be hallmarks of advanced education. While purveyors of these degrees acknowledge that they are different in important respects, they know full well that the public makes no such distinctions. The biggest assault on standards is where the advanced degree sits on top of an undergraduate degree in a different discipline. The master's-level PT and OT training has to be basic because no one has any grounding in the subject matter prior to entry into "graduate" studies.

Fifth, no one seems to know or care about the practical consequences of raising ETPC. People will disagree about the wisdom of the nursing conversion, but shouldn't we at least be curious about the consequences? (I'm not picking on nursing here; it's just that nurses outnumber the other professions combined, so the implications are huge.) For example:

How much did it cost? The transition reduced supply, which shifted bargaining power to nursing unions and led to bidding wars among the provinces. Every higher-than-normal contract settlement produced a domino effect across the country. I'm all for paying nurses well, but no one consciously decided that we ought to spend several billion dollars to make nursing more lucrative. Is it several billion? Well, if 200,000 nurses are getting 20% more than they would have had the diploma option remained in place, and the average nursing salary is $60,000, that would be $12,000 more per nurse x 200,000 nurses = $2.4 billion annually.
Is nursing care better? We have no clue. There is some (largely American) research that attributes hospital care outcomes to RN staffing levels, but the studies have deliberately avoided comparing diploma vs. baccalaureate degree nurses. Hint: you can read a tonne of quality improvement literature without coming across any references to ETPC as a key factor.
Are nurses happier? I hope not, because they remind us weekly of their collective misery and plummeting morale, so it would be terrible if this reported malaise is actually an improvement over their state of well-being prior to degreeing up.
Has the class structure of nursing education changed now that the profession is degree-only? Are fewer working class kids inclined to choose a career in nursing because it is much more expensive and time-consuming to acquire the credential? What about Aboriginal peoples, recent immigrants and other minorities?

You would think that public policy makers might be interested in some case studies of the consequences of these decisions. Uh-uh. A number of us have proposed a research agenda to get to the bottom of these monumental changes and produce real evidence to resolve the ongoing debates. It might cost a few million dollars to do the work comprehensively, but we're dealing with multi-billion-dollar issues. The failure to commission the research betrays not just a stunning lack of curiosity; it is wilful ignorance that will condemn decision-makers to the same sort of ad hoc, ill-informed choices that have created the current mess.
But, one might counter, even if the ETPC changes were in a sense unnecessary, there are worse sins than overeducating the health care workforce. Not so fast. One of the reasons professions raise ETPC is to increase their status and credibility in the academy. They do this in part by developing complex theory and creating specialized identities. Merging these identities into unified interprofessional teams is a challenge under any circumstances; even stronger and more fragmented identities forged in longer education programs will hardly make this easier. Furthermore, graduates with higher credentials will expect to work at a higher level and many will be disappointed and bored by the everyday but important work of patient care.

All that said, there is no definitive proof that increasing ETPC has been a colossal mistake. I'm saying merely that it might have been, but we know embarrassingly little about the consequences. And if we're going to require more education for health care newbies, we need to debate the form that education should take. Too many practitioners know nothing about the social determinants of health, health systems, policy, economics, and the arts of citizenship. Maybe they need to broaden their educational horizons rather than deepen their discipline-specific identities. That nurse with a BFA and a two-year nursing degree may indeed turn out to be admirably educated for the challenges of working in a variety of contexts. But let's not confuse that prospect with the ETPC essential to making health care better.
-------------------------------------------
^[i]Before I get into the analysis, full disclosure: as a public representative on the Canadian Nurses Association Board of Directors in the early 1990s, I cast the lone vote against what was then known as the BN 2000 resolution. For the past 6 years I have sat on the federal-provincial-territorial Coordinating Committee on Entry to Practice Credentials (we have a gift for catchy titles). So I have been around this topic for some time, and while it cannot compete with my obsession with baseball statistics, it ranks right up there among my day job preoccupations.

What Elinor Ostrom can Teach Healthcare

noreply@blogger.com (Longwoods) — Wed, 21 Oct 2009 13:36:00 +0000

by Neil Seeman

Remember the "tragedy of the commons"? I learned the concept in first-year economics class at Queen's University - not in real economics class, but in the dorm room. The cleaning staff fluffed the pillows and vacuumed the carpets each Monday. Students would raze the place over the ensuing days. By Thursday the place was a pigpen.

We undergraduates lived the tragedy of the commons. Acting independently in our own self-interest, we destroyed the shared but limited resources of the common area: the pull-out sofa bed for out-of-town guests; the dart board; the ping pong paddles. In the hierarchy of student needs, these things ranked very highly; yet we ruined them. Why so?

More typically referenced examples of the tragedy of the commons tend to involve natural resources, like fish. If everyone in a village who fishes has equal rights to eat out of the same lake, human behavior (even if everyone in the village is kind-hearted) will lead inevitably to a disappearance of stocks. How do we regulate this?

Thanks to the influential article by the late biologist Garrett Hardin in Science in 1968, the paradox of the "tragedy of the commons" - Hardin used the example of herders sharing a common plot of land and then eroding its value due to individual self-interest - has flummoxed economists for the last 50 years.
The tragedy-of-the-commons problem is highly relevant to not-for-profit hospitals and public sector healthcare: how do we align collective self-interest to support public goods?

Elinor Ostrom, 76, one of this year's Nobel Laureates in Economic Science (shared with Oliver E. Williamson), devoted her career to cracking this riddle. A researcher at the University of Indiana and Arizona State University, Ms. Ostrom's work as a "collective action scientist" well preceded what we now call "good governance". Just as intriguing as her research is the way she went about attacking the problems she sought to solve.

Practical Economics

Economist David Henderson has described Ms. Ostrom's Nobel as a victory for "practical economics" as opposed to abstract formulas. Public reaction to her award, as measured by my quick sentiment analysis on Twitter, the social network, has been highly positive (try this: log on to Twitter, and search for "Congrats" and "Ostrom"). (Compare this to negative sentiment, and shock, registered in response to President Obama's Peace Prize win.)

Lost in the media parade over Ms. Ostrom on account of her being the first woman to win the economics Nobel has been her work itself. ("The important thing about Lin Ostrom," 2002 Nobel laureate Vernon Smith said, "is not that she is the first woman to win the prize but that she richly deserved it.") Ms. Ostrom challenged the tragedy of the commons as an absolute rule, and, upon reviewing dozens of governance case studies, discovered cases of communal ownership in poor regions that worked smoothly - i.e., where people's interests in the "commons" were aligned, and as a result the common resources did not disintegrate.

Among the case studies she uncovered that worked were those that had a manner of property rights system in place, despite the lack of private ownership in the resource itself. This led her to propose a series of rules for governing commonly pooled resources. These included the idea that rules should clearly define: who gets what; good conflict resolution methods; that people's obligations to keep the resource in good condition be proportional to the benefits they reap from the resource; that monitoring and punishing be done by the users or someone accountable to the users; and that users should be allowed to participate in setting and modifying those rules.

The Power of the Case Study

One lesson to be had from Ms. Ostrom's work is the power of case studies. Her practical case-study approach and field work led her to attack the paradox of the tragedy of the commons methodically, and in ways that economic theory never could.

In real life, Ms. Ostrom found, the tragedy of the commons theory did not unfold the same way all the time. She examined user-managed fish stocks, pastures, woods, lakes, and groundwater basins. Some common resources were overused and depleted, but some were managed well. She set forth her findings in her 1990 book, "Governing the Commons."

What is the secret to successful management of the commons? "One of the most important factors is whether local people monitor each other," Ms. Ostrom said in a news conference after her award was announced. "Not officials, locals. I'm not denigrating that officials can do something very positive. But what we have ignored is what citizens can do, and the importance of real involvement of the people involved…". This, to me, sounds like a good argument for involving every responsible citizen who consumes publicly funded health care to formulate its ethics and rules. In a word: engagement.

About the Author
Neil Seeman is a writer, and Director and Primary Investigator of the Health Strategy Innovation Cell at Massey College at the University of Toronto.

The End of Healthcare Consultese?

noreply@blogger.com (Longwoods) — Mon, 10 Aug 2009 18:50:00 +0000

By Neil Seeman

A new motion passed unanimously by the British Medical Association urges the NHS to scrap management jargon. For example, physicians have been asked to use “patient” and ditch “client” and “service user.”

People who thirst for plain English in healthcare and in all service sectors – I count myself among them – have been losing this battle. In a journal article in 1994, Richard Peck described the then-“adjectival All-Star” of healthcare: “seamless.” He wrote: “Virtually no one attending a healthcare conference in the ‘90s will avoid hearing the word “seamless” at least a few times. It is the Holy Grail of would-be managers of the healthcare system, an ideal: patients moving effortlessly from one level of care to another, as necessary and without a hitch – without doubt, without misadventure …”.

Fifteen years later, “seamless” still reigns. According to the British Medical Association, management-speak dehumanizes health professions: “performer” (aka “doctor”); “efficiency savings and disinvestments” (aka “budget cuts”); and “service user” instead of “patient.” The UK-based Plain English Campaign promotes clear language in all public communications, noting that language confusion among doctors and patients can be a life-or-death issue.

The Plain English Campaign states: “Since 1979, we have been campaigning against gobbledygook, jargon and misleading public information. We have helped many government departments and other official organizations with their documents, reports and publications. We believe that everyone should have access to clear and concise information in plain English.”

Some NHS hospitals and trusts have received the Plain English Campaign’s annual Crystal Mark for clarity, while other institutions have been shamed with its opposite, the “Golden Bull” award. The Campaign’s medical writing course teaches “writing short sentences; using bullet points; being ‘active’ not ‘passive’; and using verbs to emphasize action.” Sessions feature lessons on how to craft hospital appointment letters and patient information leaflets.

What People Want

There are legitimate arguments against so-called “plain language”: sometimes what is straightforward to one is offensive to another (e.g., the word “blind”); hence words such as “non-sighted” emerge. Language, especially English, is like an arctic floe – slow and serene, and then disruptive. This year Miriam-Webster added many jargon-laden words that address concerns about the environment (carbon footprint), medicine (cardioprotective), pop culture (flash mob), and, in particular, online activities (sock puppet, vlog, webisode).

Given the natural drift of language, especially in healthcare, can we learn from patients to determine which words they prefer? I think so.

We can learn from online analytics – looking at the actual language people use every day – found in millions of postings scattered on the World Wide Web. When talking about their real healthcare experiences, people describe themselves as “patients” about five times more frequently than as “consumers”; and people call themselves “consumers” about seven times as much as they call themselves “clients”.

Most of the objections to the word “patient” seem to come from academics who decry the supposed paternalism associated with the word; or from those who prefer “consumer” on principle – they don’t like the “medical model” of health. My interpretation: Regular people overwhelmingly prefer “patient”.

This is just one example, and not scientific. (For what it’s worth, this approach seems to confirm small studies. In one such study, 75% of 133 people in community care preferred to be called “patient” by their GP – vs. “client” or “service user”. In another study, the author surveyed 101 people attending a back-pain clinic and found that 74 preferred “patient.”)

Words such as “client” and “consumer” and “service user” have been thrown about in conferences and vision statements for many years, but they don’t stick with the public. When a word doesn’t stick, we should shelve it.

It would be helpful if dictionaries would expunge stale meanings with the same vigour with which they embrace new ones year after year. Then, perhaps, the experience of patients everywhere might be a bit more seamless.

About the Author

Neil Seeman is a writer and Director and Primary Investigator of the Health Strategy Innovation Cell at Massey College at the University of Toronto.

Bird Flu, Mad Cow Disease, and other Biological Plagues of the 21st Century

noreply@blogger.com (Longwoods) — Tue, 04 Aug 2009 14:10:00 +0000

Andrew Nikiforuk

On October 17, 2004, a Thai smuggler wrapped the two small crested eagles from Tibet in cotton cloths. Then he placed each bird into a 60-centimetre (24-inch) wicker tube, making sure the raptors had room to breathe. With the tubes hidden in his hand luggage, the avian transport boarded Eva Airways Flight BR0061 from Bangkok to Vienna, along with 128 other jet-setters.

The smuggler was on a business trip. A Belgium falconer had ordered the birds for $17,000 and the avian entrepreneur had promised to make the delivery in Antwerp. But a random drug check at Zaventern airport in Brussels uncovered the illicit cargo. Given that bird flu had already killed 32 peasants and chicken handlers that year as well as millions of chickens and 83 tigers at Thai zoos, customs officials quarantined the birds and tested them. When both eagles proved positive for H5N1, authorities slaughtered 700 parrots and canaries in quarantine facility. Authorities then tracked down the smuggler (importing diseased species is not a crime) and put him in an isolation ward at the Antwerp University hospital for four days. The veterinarian who tested and killed the infected eagles developed conjunctivitis, a common flu symptom, just two days later. Doctors put his entire family on anti-viral drugs. "We were very, very lucky," admitted Renee Snacken at Belgium's Scientific Institute of Public Health in Brussels. "It could have been a bomb for Europe."

See: More.

Unintentional Observations about Poker and Pandemic Planning

noreply@blogger.com (Longwoods) — Tue, 28 Jul 2009 00:16:00 +0000

Two weeks ago. Visit my own clinic and am stopped at the front door, separated from staff by a two metre glass wall. Questions. "Do I have a fever, cough or sore throat?" Signage reinforces the interrogator. "No". A sanitizer dispenser is right in front of me. "Please clean your hands and go on in." I am monitored as I follow her instructions.

One week ago. Visit the lab at my own clinic. Its a repeat performance. Stopped at the front door I was separated from staff by a two metre glass wall. Questions. "Do I have a fever, cough or sore throat?" Signage reinforces the interrogator. "No". A sanitizer dispenser is right in front of me. "Please clean your hands and go on in." I am monitored as I follow her instructions. Consistent. I appreciate the diligence.

Yesterday. Accompany an adult to a three-physician practice. No signage, no sanitizer, no questions. Doctor shakes my hands and we chat. He joins the patient in his office. I wonder about the patient who just came out of his office.

Yesterday. Accompany the same adult to a lab - one of many outlets of a very large corporation. Lots of pandemic related signs -- I count at least three on the counter alone -- saying: Stop - Clean Your Hands. One sign asks about symptoms: If you have a cough or shortness of breath (especially if new) - please report and wear a mask. At least 22 other people walk in while I wait. Just two people use the obvious bottle of sanitizer. The crowd includes a young father with a three-day-old child. The visit, the father tells me later, is for the child. No preferential treatment provided. No one from staff asks any one any questions about their general health. Or their throats or coughs. No one is monitored to see if they sanitize their hands. One lab technician is wearing a plastic face shield. Two others are not. Everyone who enters stands in front of the signs to announce their arrival and is told to take a "number" -- a piece of plastic about the size of a Bicycle Poker Card. Everyone does. The baby is in arms as dad holds the card. [Gee they are beautiful at that age and dad is doing a pretty good job despite her fussiness.]

One man (about 75 years old) sits and waits, keeps coughing one of those deep gurgling coughs. He tries to stifle them and turns his face to the right. Now his seat mate is in the direct line of fire. A few times he puts his right hand to his mouth as he coughs. In this same hand he is holding his "poker card." His plastic poker card. When his number comes up he walks to the counter and returns it to the card dispenser - ready for the next patient. Glad he didn't leave before the baby arrived.

Beside me is a play area for children. It's mostly full of red, yellow and green blocks but no children. Good thing. I can imagine where each one of those blocks would be if there were children in there. I silently dub this the little spittle flu box.

The patient with me is done. We leave and decide to walk down the stairs. The elevator is half full. Full enough. No need to play the odds.

Share your own stories here.

Why consultants use PowerPoint … and other pearls of wisdom from 26 years in the healthcare management consulting industry.

noreply@blogger.com (Longwoods) — Tue, 09 Jun 2009 00:41:00 +0000

Neil Seeman interviews Neil Stuart . . .

Why consultants use PowerPoint …

With a newly minted PhD in health policy from Brandeis University, Neil Stuart joined Price Waterhouse as a fresh-eyed consultant in 1983. “It seemed like a good place to be for a short while – I’d learn a lot and maybe figure out how I could get a ‘real job’.” Twenty-six years later he would emerge as one of Canada’s most respected strategic advisors and health policy visionaries. The world of consulting has changed dramatically since 1983, Neil Stuart recently told a large gathering of former colleagues, clients, and mentees upon his retirement from IBM Canada’s healthcare consulting practice. (We would have needed a Hubble-powered fisheye lens to jam every well-wisher there into a single photograph).

1. How would you define the business of “healthcare consulting”?

Neil Stuart: “Any consulting to health care organizations that in some ways is about the business of health care or health care delivery – assisting with studies, plans, reviews, evaluations, solving problems, designing or implementing new approaches.”

2. What sorts of character traits make somebody well-suited to the healthcare consulting business? Who is not suited for it?

Neil Stuart: “To be a good consultant, exceptional analytical, problem-solving and communication skills are essential. But the thing that really distinguishes a great consultant from the rest is an ability to see things from the client’s perspective to understand their issues – the consultant who really figures out what the client is looking to deal with and focuses their energies and imagination on this. In my experience, one of the most common scenarios for consulting jobs getting off track is when a consultant gives a client something they did not ask for or sets out to solve the wrong problem.

If someone is the kind of person who already has the answer or who is “on a mission”, they might find consulting a frustrating path to take.”

3. How has the business changed over the last 25 years – for the better, and for the worse?

Neil Stuart: “The big consultancies have become much more sophisticated with well developed consulting methodologies and more refined tools for running their business. Twenty-five years ago, consultants were more likely to be ‘flying by the seat of their pants’. The contracts and scale of projects have grown too. A lot more of the work is related to information technology. Twenty-five years ago much of what consultants did was advisory in nature, e.g. reviews that led to recommendations. Today, there is much more hands-on work with bigger projects where consultants are involved in building and implementing large solutions and helping to manage associated change processes.

With bigger consulting projects, bigger teams and bigger practices, the roles in these consulting practices have become more specialized – with some individuals focused just on selling consulting work, some on project management, some on change management, some on process redesign, some on IT architecture and so on.”

4. How do these changes affect how and when healthcare organizations should hire consultants?

Neil Stuart: “Health care organizations need to be clear on why they need the help of a consultant. Is it for an independent or expert opinion? Is it to do a job for which they lack the specialized resources internally? Is it because they are in ‘trouble mode’ and need outside help? There are many different kinds of consultants and consulting skill sets. Health care organizations should make sure they are clear on what they are looking for and be sure to hire the consultant or consulting team that can meet their needs. If in doubt, would-be clients should check with others who have used consultants recently for similar work and learn from them.”

5. How do you respond to the critics of healthcare IT consulting who complain about some projects going over-time and over-budget?

Neil Stuart: “More often than not these situations could have been avoided if there was greater clarity on the project requirements. It is true that some times when consultants are competing to win projects, they can over-promise. This is where the client has to be crystal clear on what they are looking for and what they are contracting for.

In the case of IT related projects, it is really important that there be a clear focus on the health care benefits of the IT. There must be meaningful business reasons for introducing new IT. The health care leaders (not just the people in the IT group) must be involved in and driving these initiatives. They have to believe that health care itself will be improved by the IT. And as the IT solutions are being designed, built and implemented there must be an overriding emphasis on realizing these health care benefits.

Ontario is currently poised to try a very different approach to procuring large e-health solutions. They are looking to Infrastructure Ontario to help channel such procurement through consortia that include the IT vendors and consultants, but also include a party who will finance the project. They have called this approach Alternative Financing and Procurement (AFP). It offers a way of addressing many of the risks traditionally associated with big IT initiatives.”

6. In all your years as a trusted advisor to healthcare leaders, what qualities do you think make the best leaders shine?

Neil Stuart: “Vision, an ability to inspire their team, a grasp of the critical strategic issues – all have to be at the top of this list. Many of these qualities touch on being able to anticipate new opportunities and mobilize organizations to prepare for the future.”

7. What qualities make for dysfunctional healthcare leadership?

Neil Stuart: “Maybe the biggest pitfalls lie in becoming too focused on the narrow interests of one’s own health care organization and losing sight of what is good for patients and what the bigger health care system needs to be taking on.”

8. Why do consultants use PowerPoint presentations so often? Will the madness end?

Neil Stuart: “You have a point – no pun intended. PowerPoint has been a great tool to help consultants quickly summarize their analyses and findings and pull together a presentation. But PowerPoint can also be a real handicap if people rely on decks that are just an amalgam of slides originally prepared for other purposes. And there are some downsides in getting caught presenting from slides someone else has prepared. PowerPoint is often a used as shorthand to frame a richer, more detailed story. The presenter has to have the story and if they don’t, PowerPoint will not give it to them.”

9. What was your best experience as a management consultant and leader in the industry?

Neil Stuart: “Consulting gives one an opportunity to assist client organizations at some of their most exciting and formative moments, as well as sometimes their most vulnerable moments. Consulting can sometimes give one an opportunity to contribute to breakthrough changes and real innovation. This can be very fulfilling. But the consultant’s role is often beneath the radar. It will always be the executives in the health care organizations, or sometimes government, who own the initiative and deservedly wear the success.”

10. Would you recommend consulting as a career or even a career step for a young professional entering the health care world?

Neil Stuart: “Absolutely, I can think of no other place a fresh MBA or MHA graduate could go where they could get the same variety of experience, the insights, the chance to be part of so many innovative projects, to be in an environment that so values learning, and (if they are good) to move ahead so fast.”

Neil Seeman is Director and Primary Investigator of the Health Strategy Innovation Cell at Massey College, University of Toronto.

Neil Stuart may be reached at: neil.stuart@sympatico.ca

This Just In: Systems Designed to Fail, Fail

noreply@blogger.com (Longwoods) — Wed, 03 Jun 2009 13:44:00 +0000

By Steven Lewis

First there is the disaster that comes to light long after the fact. Then there is the inquiry. Then there is the scathing report that meticulously unearths the causes of the disaster. Then there is the apology (they’re allowed now – it’s the law!). Then there is restitution. Finally there is the commitment: never again. And then the same thing happens, somewhere else, again, and again, and again.

Canadian medicine – it is quite different in some other jurisdictions – is organized around four fundamental premises. First, doctors are highly trained professionals whose license to practice needs no expiry or renewal date. Second, initial certification exams are reliable guarantors of lifelong competence and consistent, high quality practice. Third, it is both unnecessary and unsporting to subject the autonomous judgments of professionals to rigorous and regular scrutiny. Fourth, professional self-regulation is the ideal mechanism for preventing harm.

To quality improvement and harm reduction experts in every other industry, these premises are not merely dubious, but laughable. Yet they persist in medicine, and the inevitable result is that people get hurt. Radiology and pathology are high-stakes diagnostic professions where errors can kill. When massive failures occur, as in the Newfoundland and Labrador breast cancer testing debacle of 1997-2005 (!), or the Charles Smith forensic pathology fiasco of 1981-2005 in Ontario (!), the root causes turn out to be depressingly pedestrian. That’s what makes them as pathetic as they are tragic.

Even more damning is the repetition. The lid has just come off Quebec’s breast cancer diagnostic breakdown. Saskatchewan is cleaning up after a pathologist who may have put thousands of people at risk over 5 years. It will cost millions of dollars to have every one of his 70,000 images reread out of province, and perhaps tens of millions to settle the malpractice claims (the notorious Regina lawyer Tony Merchant has already launched a class action suit). The only difference between these jurisdictions and those so far untouched by the contagion is that the time bombs are on different schedules.

Despite the repeated revelations of system errors that demand system solutions, nothing has fundamentally changed to guarantee safer health care and prevent the birth of gestating misadventures. When push comes to shove, the right to practice shoddy medicine trumps public safety; no one gets to cancel the flight or shut down the assembly line without definitive proof of repeated incompetence. A health region or regulatory body that moves aggressively to suspend a practitioner pending investigation of suspicious results will be harassed and condemned for violating due process. The first reflex will not be to acknowledge the problem or seek mentorship; it will be to lawyer up. The medical association with go to bat to keep the practitioner in the saddle. Physicians and others in the know who would not send their own kids to an incompetent colleague either can’t or won’t stop yours from ending up in his care.

It’s not just a conspiracy between the guilds and the law; it’s a systematic failure to manage risk. Built in redundancy, rigorous peer review, structured continuing education, and mandatory recertification are cornerstones of safety. The higher the stakes, the greater the need for vigilance and tightly organized quality control systems. Geographically isolated professionals are obviously at risk, and many will fail without carefully designed, reliable supports in place. But everyone needs audit, feedback and peer support to perform reliably over time. In medicine it is well-documented that performance declines with age. The response to this chilling reality has been to let the chips fall where they may – the pathology of denial.

The Saskatchewan case is especially instructive. There were suspicions about the radiologist’s competence 3 years ago. With the regulatory noose tightening around his neck, he volunteered to go for remedial education. No educational program in western Canada stepped up to the plate. After he spent 3 months at McMaster, the Saskatchewan College received a perfunctory and brief report on his progress and skills that it rejected as inadequate. He returned to practice, and on the evidence to date, his interpretation of every 20^th image may have put someone at risk.

The system is designed to fail, and it must be redesigned to succeed. The solution is not to expect physicians to look furtively over their colleagues’ shoulders and snitch to the authorities. The remedies must be systemic, obligatory, and woven into the fabric of medical education, ethics, and organization. Among the obvious requirements are:

Mandatory review of randomly drawn samples of diagnostic interpretations. The frequency and intensity of the scrutiny should be commensurate with the complexity of the practice, known error rates, and the consequences of mistakes.
A formal, standardized protocol for addressing competency problems. The first signs of problems should trigger mandatory supervision and intensified case reviews until performance is demonstrably up to snuff.
Beyond certain thresholds of error, automatic suspension followed by the launch of a remediation algorithm.
Specific additional support, review, and continuing competency assurance procedures for isolated practitioners.
Transparent reporting to the public of performance results.

It is delusional to believe that everything is now out in the open, with nothing more to uncover. It’s not just the outliers who cause harm; because medicine is so fraught with unjustifiable variations in practice, it is certain that the errors resulting from “satisfactory” practice far outnumber the misdeeds of the visibly incompetent. The graveyards are filled with anonymous victims whose stories will never surface in a public inquiry. Until professionals take their collective obligations seriously and embrace a culture of safety, prevention will fail, detection will be late, and the victims will pile up. If they view peer review, recertification, and remediation as violations of sacred entitlements, sleepwalking through mandated processes won’t accomplish much.

Sad to say, for radiology and pathology our salvation may come from machines. It is foreseeable that computerized pattern recognition software will be able to diagnose more accurately and consistently than specialists in all but the most unusual of cases. If that day comes, we can be sure that these highly reliable machines will be programmed to self-diagnose and identify anomalies in their own findings and performance at regular intervals, and will be examined, refurbished, and re-tested according to strict protocols. In other words, we will treat them and their needs with care and respect, governed by the duty to put patients first. Too bad that we don’t do the same for fallible diagnosticians and their victims.

Don’t Make Me Gag

noreply@blogger.com (Longwoods) — Thu, 28 May 2009 19:31:00 +0000

By Steven Lewis

Would you commit in writing not to slag your physician on the internet? A US company called Medical Justice (MJ) is hawking a waiver form that gets patients to foreswear anonymous posts to doctor rating websites. I'm your doctor, you're my patient. If you have problems with me or my staff, tell us, tell your friends and family, tell anyone you want through the usual channels. But put it in writing that you won't post it to the internet.

The internet is a pretty big windmill to tilt against, but MJ claims 1000 doctors have signed on. The pitch is that the muzzle pact protects doctors from anonymously posted and inaccurate portrayals of their courtesy, promptness, morals, and clinical skills. The lawyer in the MJ website video recounts the story of an anonymous post implying that a physician was a child molester. Though the post was a malicious plant from a competitor, not a patient, apparently US law exempts Internet Service Providers from liability in such cases, and they cannot be compelled to remove the alleged defamation.

This is ugly and outrageous stuff. But the proposed remedy is ethically objectionable in principle and foolish in practice. The flaws are as follows.

First, Medical Justice argues that rating doctors is not the same as rating barbecues. This is formally true: I cannot libel the barbecue, and in any case the barbecue doesn't care. (The manufacturers do, but somehow they have not yet demanded censorship in return for the privilege of purchasing their goods.) MJ goes on to describe the doctor-patient relationship as a precious union of equals whose sanctity and trust are violated by the specter of anonymous rating. This is patent nonsense: there is a major power imbalance between the parties. The rating sites are popular precisely because the vast majority of patients don’t have the nerve to challenge their doctors face-to-face and fear the consequences if they do so.

Second, the internet free-for-all has been with us for a decade, and it has created an endless stream of opinion, advice, and rating. Of course it is full of garbage, lies, rantings and ravings. It is also a treasure trove of facts and shrewd observations that skewer privilege and reveal truths absent from the increasingly concentrated mainstream media. The bees have burst from the hive and there is no getting them back inside. There is no better advertisement for doctor rating sites than the attempt of doctors to suppress them.

Third, like Othello and Lear, MJ mistakes a friend for an enemy. Most people think better of their doctors than their doctors' performance warrants. The overwhelming proportion of assessments on www.ratemds.com are positive. An avalanche of evaluative literature shows that overall physician performance is in fact mediocre by the standards of evidence-based practice. Misprescribing is rampant, it takes weeks to get an appointment, adverse events abound in hospitals, and mental health problems are underdiagnosed and ineffectively treated. Physicians come off far better on the web-based rating sites than in scientific practice profiles. They should be demanding patient ratings, not proscribing them.

Fourth, the public can learn something from the ratings. Themes tend to repeat in both the critical and laudatory commentary. When 8 patients tell you that doctor X prescribes penicillin for everything, I doubt they’re lying. When 20 of 40 assessments of doctor Y mention misdiagnosis, I’d bet the farm that there’s a lot of misdiagnosis going on. When every one of 32 posters says Dr. Z cares, listens, and explains, I believe that of Dr. Z. Many of the postings are balanced, nuanced, and thorough. The critics in particular tend to give reasons for their judgments. Some are scathing and even cruel, but the savage commentary is usually reserved for those who have committed truly barbaric acts.

Fifth, physicians should welcome the feedback, especially if it is anonymous. Patients are disinclined to ruffle their doctors' sensibilities. I like my family doctor, Mick Jutras of Saskatoon, as do 29 of 32 raters here. He is intelligent, thoughtful, and a good communicator. I did not change my mind because one patient wrote, “He sucks. Totally ignorant. Rude.” But I have never had the jam to tell him that same-day access should be the norm*, that the lab test result communications are erratic, or that it is perplexing that Toyota summons my car for screening but his highly automated practice doesn’t invite me for the tests that are supposed to be so vital to my well-being. (My optometrist and dentist pester me relentlessly.) Nor has he ever surveyed me. Both he and I have let him down on the quality improvement front. If I thought he and his partners would read the internet ratings carefully and recognize that the negative feedback is the wellspring of improvement, I’d log on and write.

MJ claims to be in favour of objective physician rating systems, meaning, no doubt, rating systems that they control or endorse. Their real fear is that patients will pay more attention to each other than to the insiders’ guild. Don’t pay attention to the unwashed who have the gall to write about a condescending ass who interrupts after 20 seconds and can’t tell a virus from a bacterium. We’ll do the rating and ranking of our own.

But what about malicious content? Yes, it's a problem, and potentially harmful to the innocent. There are remedies aside from squashing your patients' freedom of expression. The rating sites open their doors to physician comments and rebuttals. Smart ones, like Saskatoon urologist and medical blogger extraordinaire Kishore Visvanathan, have actually embraced the concept and the technology as a learning tool. Patients can respond to others’ posts. Site surfers should be invited to report suspicious content to the administrators or directly to their doctors.

Above all, keep some perspective. False positive opinions far outnumber false negatives. A patient bent on vengeance has many ways to sully a reputation. And the public are not idiots: if they are at all open-minded about the merits of a doctor, they will read all of the posts and judge on the basis of the body of evidence presented.

If I ran a doctor rating site, I would add a new category: has your physician ever asked you to sign a MJ-type gag order? If the answer is yes, go elsewhere if you can.
________________
* Except for the time we were both at a fundraiser with excellent and abundant alcohol

The End of Professional Snobbery

noreply@blogger.com (Longwoods) — Wed, 27 May 2009 21:57:00 +0000

By Neil Seeman

Imagine if no prestige attached to professions. Nobody cared about old-world credentials…MD, PhD, JD, MBA, MPH, MHSc: the letters would mean nothing, zip, in this alternate world.

It’s not so far off. Welcome to 2015, the year the Facebook generation is married with kids. This is when Mark Zuckerberg, 24-year-old billionaire, Facebook founder and Harvard dropout, turns 30.

The era of post-professional snobbery will be a very agonizing time…for boomer-generation grandparents. How will they boast about their over-educated children’s accomplishments as quantifiably as they can today? For the rest of society, it will mean a boon to human creativity.

The End of “Perfect Outputs”

In one of the most downloaded videos on the Web – Sir Ken Robinson explains, to roaring applause at a TED conference, how our educational system kills creativity in young people. Our system, he says, is geared to producing one “perfect output”: the university professor. Robinson blames the post-industrial age educational model for vaporizing creativity from children, promoting a culture where test-taking ability, rather than intellectual agility and ingenuity, reigns.

Young people under 30 – the Google Generation, the Facebook Generation, whatever title you fancy – really are different. They care more about social good, and less about status. This is not an original hypothesis. Leading thinkers on innovation - Gary Hamel, Don Tapscott and Jeff Jarvis – have written books on this. What has been less explored is what this means for healthcare.

In the era when newspapers drove the climate of public opinion – about two years ago – OpEds on healthcare were written by PhDs and MDs. Nowadays patient-experts write many of the most popular blogs (with clinically accurate content). Google controls health-seeking behaviour, with at least 70% of all searches on healthcare information originating from the Google search box.

When MDs and PhDs carry less prestige…

Today, the only job titles that earn real respect at cocktail parties are “social entrepreneur” and “artist” (though I admit I attract a fair deal of intrigue when I tell people that I’ve taken up boxing). Why does this matter for healthcare? Why does it matter for governments?

As Gary Hamel has trenchantly written, “Thanks to Enron, WorldCom, Adelphia, FEMA, Lehman Brothers, AIG, Fannie Mae, et al, the generation now joining the workforce has an extraordinarily jaundiced view of authority. They are deeply (and often rightly) suspicious of large organizations and those who run them. In their view, it’s not titles and credentials that make a leader worth following, but mission, self-sacrifice and world-class competence.”

Line management in both the delivery and organization of healthcare will need to get flatter. This means wider scopes of practice – for all members of the care team, which includes patients and their families. Further, CEOs will need to learn how to admit their mistakes. This is the signature virtue of the Facebook generation: humility. I always laugh when people tell me that social networks such as Facebook and MySpace and micro-blogging tools like Twitter show that the “younger generation” is self-centered. In fact, the average age of a user on Linkedin is 41; Linkedin is the fourth-most popular social networking site on the World Wide Web, with 40 million users. People under 30 demonstrate both humility and ego in equal measure. These are not mutually exclusive personality characteristics.

They can chest-thump like the rest of us (witness the scores of Facebook pages boasting about winning beer-chugging contests). But they can also confess to being wrong. Mark Zuckerberg, Facebook’s CEO, did exactly this when he responded to a storm of user protest and removed Beacon, a Facebook application. Zuckerberg famously wrote on his blog in December 2007:

“About a month ago, we released a new feature called Beacon to try to help people share information with their friends about things they do on the web. We've made a lot of mistakes building this feature, but we've made even more with how we've handled them. We simply did a bad job with this release, and I apologize for it. While I am disappointed with our mistakes, we appreciate all the feedback we have received from our users. I'd like to discuss what we have learned and how we have improved Beacon.”

…we will start to measure innovation and good governance differently

Today, we measure “innovation” through reference to numbers of publications, the impact factor of journals, academic citations, numbers of degrees after one’s name, and other proxies of knowledge translation. But if ingenuity and agility are what matters – we are currently preparing our children for jobs that may not exist as we know them. The US Department of Labor predicts that the average learner will have 10-14 jobs by the time they are 38. Niche licensing, already commonplace in healthcare, will intensify. At the same time, there simply won’t be enough people with the requisite prescribed credentials (e.g. health records, information management, and health information technology) to satisfy the HR managers.

And so we will need to recruit very differently. Memo to management: drop the “fast-track executive model”; reward the curiosity-seekers, even if they fall flat-footed on their first, second, or third time round. Beware job applicants who have had perfectly linear career paths.

What is more, we may need to measure innovation capacity in the workplace differently, especially in healthcare (where the jobs will be) by qualities such as tolerance for failure; willingness to admit mistakes; and, most crucially, ability to learn from those mistakes.

Few will ever accuse Facebook’s Mark Zuckerberg of modesty, but his apologia for his Beacon debacle is emblematic of the new age. Imagine if a hospital admitted in a CEO’s blog that its big-budget technology implementation failed miserably? And then have the CEO tell her clients how she had learned from her mistake? That is good governance, Facebook-style.

About the Author

Neil Seeman is Director and Primary Investigator of the Health Strategy Innovation Cell at Massey College, University of Toronto.

It’s Good to be Alive: Limericks in Bloom

noreply@blogger.com (Longwoods) — Tue, 19 May 2009 00:25:00 +0000

By Neil Seeman

The economy crashes, and falters, and fails
You utter the wildest, most hair-raising wails,
“Should I buy, should I sell?”
But there’s no one who’ll tell.
It’s chaos around you and panic prevails.

Yet holiday weekends were meant to have fun
To warm weary bones in the heat of the sun
To soak aching toes
Forget all your woes
And bask in successes laboriously won.

Forget the travails; you are, thank God, alive
You know that, no matter, you’ll always survive
You know you have friends
Who will go to all ends
To be there for you till your spirits revive.

I’d always liked poking some innocent fun,
Joking when others were morbidly glum.
My friends would be crying
I’d smile at their sighing
And tell them that grieving was clearly “too dumb.”

So welcome the spring, when the world is ablossom
The view from my window’s amazingly awesome
Pansies, impatiens
In stunning variations
I think I will go and attempt now to grow some.

It’s spring, and you look, and you can’t fail to notice
That purple-blue buds have come out into focus
When the first bluish hue
Makes its yearly debut,
It’s time to rejoice at the birth of the crocus!

I exult at our hedge with its gorgeous azalea
It brightens our garden in splendid regalia
It’s pink, red and milky
Luxuriant and silky,
Each spring it parades its new paraphernalia.

When you see that your garden’s outfitted in frocks
Whose beauty just happens to knock off your socks
I bet that you’ve planted
Something enchanted -
Polychromatic and plentiful phlox.

Like gardens, we humans are, thank God, alive
We’re fruitful, productive and yes, we’ll survive!
We’ll laugh at our ills and our trifling distress
With humour and beauty we’ll battle our stress
It’s springtime, the season to thoroughly thrive.

It’s the springtime of hope and it’s time for good cheer
Now is the loveliest time of the year
Forget your finances
And broken romances
It’s time to rejoice with the ones you hold dear.

About the Author

Neil Seeman is Director and Primary Investigator of the Health Strategy Innovation Cell at Massey College, University of Toronto.

India On My Mind

noreply@blogger.com (Longwoods) — Tue, 12 May 2009 04:29:00 +0000

By Neil Seeman

I have never visited India. I know little of its culture, geography, history, or politics. One thing I know is that lots of smart people are writing about healthcare innovation in India. In Canada, more smart people have been thinking about how best to measure innovation. To be sure, measuring innovation is slippery: it’s hard to quantify “accidental triumphs” or “successful failures” in healthcare. We often revert to measuring interesting, but limited, output indicators: patents, publications, citations.

What if we could measure a country’s agility to innovate? This leads me to India.

India’s Healthcare Innovation Pivot

A pivot is the central point, or pin, on which a mechanism turns or oscillates in a new direction. Can we measure a region’s ability to “pivot” – to bridle the horse and gallop off in a new direction? The Indian healthcare economy is pivoting.

As the Wall Street Journal’s Peter Wonacott reported last month, rural India is defying the global economic slump. He wrote: “In poor and largely rural states from Orissa in the east to Rajasthan in the west, many new leaders have invested in health, education and infrastructure. That has set the stage for the creation of industry and consumer markets and enabled upward mobility.”

Nitish Kumar, chief minister of Bihar, India – where only one in ten people can read – has recruited private-clinic doctors from rich regions to public hospitals in the country’s poorest state. In an alliance led by his Janata Dal party, Mr. Kumar champions “Government 2.0” – the low-tech variety. He hosts Monday open houses at his home, where ministers must respond to public complaints. Bureaucrats travel with him to town-hall meetings across the most impoverished areas of the state, where they pitch tents in mud fields.

India’s economy is standing up boldly athwart the global downturn, and pockets of innovation in rural India are leading the country forward. Speaking at a recent meeting on “India's Future” organized by the Confederation of Indian Industry in Coimbatore, Gurcharan Das, author of India Unbound and former CEO of Procter and Gamble (India), said India’s economy will recover faster than others’. The International Monetary Fund projects India’s economy will grow 5.1% in 2009 (versus 0.5% for the rest of the world).

In Bihar, there are auspicious signs: The number of people migrating out of the state dropped 27% in the 2006-08 period compared with 2001-03, according to the Bihar Institute of Economic Studies. This, despite the fact that more than half of Bihar’s 83 million residents live below the international poverty line of about $1 dollar (US) a day.

Writer Vijay Vaitheeswaran has noted how India is better-equipped than many richer nations to embrace healthcare innovations. Fewer than 20% of US surgeons in America use health information technology (HIT). In contrast, according to Technopak Healthcare, a consulting firm, nearly 60% of Indian hospitals take advantage of HIT. India is fast becoming a hub for clinical research. Admittedly, India has a long, long, long way to go: tens of millions of Indians go without healthcare despite the country being a global hotspot for “medical tourism.” India owes much to its destitute: the level of malnourished children is higher than that of sub-Saharan Africa.

Yet, over the last decade, India has also emerged as the destination of choice for US healthcare organizations that take HIT seriously, in part because of India’s low-cost labour force – but also because of the ingenuity the country has shown in its embrace of new business processes. Recognizing the scarcity of trained e-health professionals in America, India has jumped in. The Nittany Institute in Chennai is suddenly overflowing with Indians taking courses in medical coding, IT Infrastructure management, even “e-talk” – the jargon of e-health.

The Diaspora Returns to Lead the Pivot

“India has always had access to intellectual capital,” says my colleague Amol Deshpande, “but it has lacked good infrastructure and abundant early capital funding.” Amol recently returned from Mumbai where he met Indian-born entrepreneurs at healthcare expos. He recalls some revealing conversations. “I was born in India,” conference attendees would tell him, “but I just came back after 12 years in Silicon Valley.” “The return of non-resident Indians with entrepreneurial minds, their own capital (from the US) and relatively cheap access to good technological infrastructure has begun to change the innovation landscape,” Amol tells me. “Combined with increased demand from a growing middle class and rising rural economy, innovation will begin to flourish.”

The Indian healthcare economy is pivoting thanks to money, brainpower and raw ingenuity. The poorest regions of India are leading this bottom-up revolution; they have the most to gain.

Can Canadian Healthcare Pivot?

It is the “bob and weave” of the Indian economy that impresses me. As the global economic punch arrives, India bends its legs quickly and simultaneously shifts its body. Will Canada pivot or buckle? I don’t know. Manny “Pac-Man” Pacquiao, the Filipino boxer who is emerging as the next all-time great, “slips” from opponents with beauty; hand-speed is what makes him special. Ali’s magic was in footwork, not his punch. My own boxing trainer, Theo Asante, always tells me “anyone can throw a punch”; it’s avoiding the punch that matters. People who measure innovation should consider how to measure agility. Look to India.

Some additional links of interest:

About the Author
Neil Seeman is Director and Primary Investigator of the Health Strategy Innovation Cell at Massey College, University of Toronto.

p.s. More on ‘I don’t Know’
Last week’s essay on “I don’t know” was “tweeted” on Twitter. Trisha Torrey, a globally renowned patient advocate and writer for About.com, picked up the discussion and asked her readers if their doctor had ever told them, “I don’t know”. See the results of the poll here.

The Power of “I don’t know”

noreply@blogger.com (Longwoods) — Mon, 04 May 2009 14:54:00 +0000

By Neil Seeman

Saying “I don’t know” can be a deeply liberating experience. People in healthcare – and in virtually all service industries – do not say this nearly enough. The client ends up suffering.

I learned the power of this phrase in law school; I hadn’t read the course notes, and, upon being fingered by the lecturer for an answer, I couldn’t fake it. Saying “I don’t know,” then pledging to the teacher to learn the answer, made me feel at once authentic and committed.

Trouble is, “I don’t know” is an alien phrase for many information elites – including everyone from lawyers to accountants to insurance salespeople to what Deepak Chopra calls “Medical Deities” (aka MDs). My colleague Carlos Rizo has suggested an entire course be taught in medical school on how and why and when to say “I don’t know.”

In a talk called “Empowering Patients” at a spectacular conference – “One Patient, One Record,” organized by Kevin Leonard and colleagues of the University of Toronto and patientdestiny.com – speaker Doug Gosling twigged me to the power of “I don’t know.” When chronically ill patients have access to their full medical record, Mr. Gosling explained, it is very hard to hoodwink them. If a clinician fails to say “I don’t know,” a patient detects evasiveness.

Perhaps “lie” is the right word. Lawyers will make a fancy case that in rare instances “saving” a patient from the truth is worth the lie. Maybe so. But here’s our reality: In 0.2 seconds – the time it takes to blink – it is possible for anyone anywhere with access to the Web to type in a health term into Google and for Google to send back a solid answer.

When you’re chronically ill, you are Googling about your illness several times a day. There are many who say we still need “information curators” to sift through the “noise”. Not always. I believe Google is making most of us a whole lot smarter about our healthcare. I think most people with chronic illness can learn enough accurate information online in 24-48 hours about any disease to be able detect whether their care provider is faking an answer.

An example: It is difficult at first to distinguish between obsessive compulsive disorder (OCD) and ritualistic behavior in young children. Many young girls (and boys) like to line up their dolls and pillows in a pre-ordained way every evening before bedtime. Insisting that food be organized in a circumscribed pattern on their dinner plate is also normal for a child. OCD is very different, and research published last year in the Journal of Psychopathology and Behavioral Assessment suggests the condition can develop in children as young as four.

When I asked a pediatrician to explain the difference to me one day, his eyebrows rolled sideways, he touched his left upper brow with his forefinger, and gave me a song and dance about how absurd it was to imagine that a four-year old could exhibit signs of OCD. I lost trust in him because he failed a basic humility test: to say “I don’t know but I’ll try to find out.”

Memo to doctors (and lawyers) everywhere: we pretty much always know when you don’t know (especially when it comes to our children or aging parents). This was probably true before 1995, when there were a few thousand websites, but far more so today when there are billions. And yet, in a paradox, many professionals today – perhaps to legitimize their existence in an age of ubiquitous information – feel they have to know *everything*. To say “I don’t know” is an unthinkable utterance, as if to break honour with a fraternal pledge of feigned knowledge.

True knowledge begins with “I don’t know – but I’ll try to find out.” Ask a patient.

About the Author

Neil Seeman is Director and Primary Investigator of the Health Strategy Innovation Cell at Massey College, University of Toronto.

My Evening with the Future

noreply@blogger.com (Longwoods) — Mon, 27 Apr 2009 15:56:00 +0000

Steven Lewis

Throw away the crystal ball and spend an hour with Google Health: the future will be right in front of you. Providers who prefer the pedestal to parity and see themselves as traffic cops on the health information highway are in for the shock of their lives.

I intended to compare the on-line personal health records of both Google and Microsoft, but I couldn’t convince Microsoft that I was Phyllis Diller from Scottsdale AZ (you have to be a US resident to sign up). Google let me in, and in a few minutes I had my own record. Well, not quite my own. (Health record privacy purists, skip the next paragraph.)

Touch wood, I’m a healthy guy. I don’t have any chronic conditions (unless you count seasonal hay fever, a cat allergy and a severe reaction to sopranos), have never had surgery, take no prescription drugs, and, having read too much quality and outcomes research, am a bit of a fatalist. There will be no colorectal cancer screening bazooka shoved up my behind unless I get to watch a video of my doctor smiling happily through the procedure. With so little data to enter, I made stuff up – gave myself type 2 diabetes, angina, arthritis, and added 25 pounds – to test the ingenuity of the architecture.

Hello Frank Gehry. The software leads you through a consumer’s garden of neurotic delights – and I mean that in a good sense. You can input your own remarks and notes, set permissions for access, amend or delete entries. You can second guess the diagnosis or advice you got from your doctor in the seven minutes he spent with you. You can get drug price and therapeutic equivalence comparisons – your own reference based pricing program is at your fingertips. You can catch contraindicated drug combinations. You can learn your odds of falling prey to various health breakdowns by linking your profile to web-based risk calculators. You are handed the key to a cornucopia of safe information injection sites tailored to your profile.

But, dammit, this is America, and in America nothing good happens unless money changes hands. Some of the featured partner sites offer free advice, but they’ll also sell you drugs or other products. Others are more brazenly mercenary: at the Cleveland Clinic site it’s cash for counsel. Want a second medical opinion from MyConsult? That’ll be $565, and it’s not insured. The web site supplies a sample report so you can see what you’re likely to get: mainly of a summary of what the patient sent in, and a 3 paragraph opinion. I figure a good senior resident could knock one off in half an hour, an hour tops. Bargain-hunters can score a nutritional consult about your gout (honest) for a mere $95, or 2 sessions on high blood pressure for $165.

Perhaps you’re more inclined to Blueprint for Wellness, which offers a package of 29 lab tests, a wellness questionnaire, and a personal wellness report for $134. TrialX.org will match your condition to a database of 25,000 clinical trials and help you find clinical investigators expert in your condition – all free. It’s essentially a dating service for researchers and a potentially vast pool of trial recruits.

To those of us of a certain age for whom a long distance call was a special and costly luxury, this is all a bit disorienting, even creepy. Google has an incentive to choose its partners carefully – it doesn’t want to jeopardize its carefully cultivated we’re-not-like-the-other-megacorps image. No filter is foolproof, and no interaction is risk-free. Nonetheless, the methodologically innocent are far better off with Google as the quality control overseer than heading off solo into a cyberspace full of charlatans.

Still, there are reasons to pause and reflect. Will the model undermine the doctor-patient relationship? Will it fuel an even greater obsession with tests and assessments, luring millions more to the already-vast army of the worried well? What happens if providers act on inaccurate or misleading patient-created information? What jurisprudence will arise from the inevitable litigation when something goes wrong?

Yeah, whatever. Quibble all you want; it’s here, it’s growing, there will be no pausing and precious little reflecting. It’s a predictable workaround, an evening up of the odds against Fortress Healthcare that keeps patients in the dark and puts a firewall between them and their health record. Some enlightened health care organizations, such as Group Health Cooperative in Seattle, put patients at the centre of their e-health strategies. How strangely foreign to the Canadian Way.

Canada’s e-health leaders can either ignore it or embrace it. Ignoring it risks dooming the provider-oriented, paternalistic plans to rapid obsolescence. They should take what’s good about it – joint production and ownership of health information, the potential to create networks of trustworthy information sites, the linkage to self-management tools tailored to individual profiles, the fantastic communications capacity – and revamp their e-health plans, fast.

The democratization of knowledge and the desire to be treated like an adult in health care transactions are irresistible forces. It’s a near-miracle that Canadians for the most part continue to put up with the arrogance, inconvenience, secrecy, and error build into the existing system. We could have seen this coming a decade ago, but we are too often a nation of deer in a world of headlights. Google and Microsoft have set off the alarm. Pushing the sleep button won’t cut it much longer.

Pay for Performance: The Wrong Time, the Wrong Place?

noreply@blogger.com (Longwoods) — Tue, 21 Apr 2009 02:31:00 +0000

Steven Lewis

It sounds like such a good idea: don’t pay people to show up and scurry about, pay them for proven performance. It’s the new Big Thing in health care financing. As usual, the Brits have pursued it most vigorously. Some Canadian health care executives get bonuses for achieving certain targets. The US Medicare plan has quit reimbursing hospitals for the costs of dealing with avoidable mishaps such as falls and bed sores. Health care cheques should come with performance strings attached. About time, right?

Well, yes, if your overlook the P4P track record. Renowned British health economist Alan Maynard found lots to be cautious about in his review of experiences to date. The Hay Group believes that even 5% to 10% of income at risk is insufficient to produce a significant effect, let alone the 1% to 2% typically on the table in such arrangements. In the UK, the vaunted GP bonus schemes – which can add tens of thousands of pounds to physician incomes – have turned into base pay. The average GP practice scores 95% of the bonus-triggering points available and virtually all get 90% or more. But the number of complaints per practice – one reasonable measure of satisfaction – varies considerably.

On examination, the very essence of P4P is troubling. It is a profoundly pessimistic concept of what makes people tick in health care: we can’t rely on organizational culture, professionalism, devotion to public service, or commitment to excellence to get the desired results, so let’s just concede that it’s all about the money. Managers and practitioners are hardened cynics for whom pecunia vincit omnia -- cash conquers all. So let’s tell them what to accomplish, ring the economic bell and watch the Pavlovian throng stampede to improvement via the cash-stuffed trough.

Dishearteningly, P4P writ large becomes a self-fulfilling prophesy. Adopt its assumptions and fund or pay accordingly and you will indeed turn civilized people into econocentric shadows of their selves. Set up the game and people will learn the rules and play accordingly. Moreover, the game will inevitably lack sophistication, because to dole out the rewards, the goals must be clear and simple; the results easily measurable and immediate; and the reach modest (no one will play if it’s too hard to win). All nuance and complexity are obliterated by the basic algebra of the payout. So it’s hardly any wonder that British GPs are walking away with the dough. Ask not for what the bell tolls – it tolls for fee.

But what if we’re just learning, and eventually get it right, particularly if we learn from our masters in the private sector? You’re doubtless as inspired as I am by the corporate CEOs with incomes almost entirely driven by the value of their (occasionally back-dated) stock options and the quarterly earnings statements. They sure knew how to tally up the performance points. You get what you pay for, and the denizens of Wall Street decided to pay for scams so absurd that they make the Nigerian please-be-my-agent-for-millions howler look like Protestant-ethic capitalism at its sober best. IKEA CEO Anders Dahlvig refuses to take his company public precisely to avoid the tyranny of get-rich-quickism that makes a virtue of impatience and myopia and rewards Ponzi schemes over substance. But he never claimed to be as smart as the guys who ran Lehman Brothers.

For the hundredth time in a seemingly infinite series, the world is learning two key lessons: you don’t get something for nothing, and appealing to baser instincts will improve neither humans nor their achievements. Health care is a uniquely fraught enterprise that deals with uncertainty, vulnerability, tragedy, hope, and trust. Of course it involves great amounts of money and to which neither individuals nor organizations can be indifferent. Health care takes place in a messy world, not a monastery. But money is a resource for achieving other ends, and if it defines us or crowds out nobler preoccupations, the means become the end, the aperture narrows, and the golden calf beckons.

Doesn’t it seem odd that we would have to coin the notion of “pay for performance” in the first place? What the hell else are we paying for? When did “doing one’s job” uncouple from “doing one’s job well”? Suggesting that ordinary performance – not spectacular, but merely satisfactory, like being nice to your patients or doing Pap tests at the recommended interval – deserves a bonus debases the entire enterprise. It creates a cultural norm in which lousy performance is the natural state and the passable is redefined as extraordinary. It dumbs performance down and leaves out the hard parts.

Show me a P4P system that rewards first class care of the frail elderly, life-enhancing management of multiple chronic conditions, reduced need for surgery fifteen years from now, or ending one’s career with sunny disposition and compassion intact, and I’m all ears. But in my preferred world, the first dollar and the last pay for excellence across the board, an ethos of care, devotion to the public good, and the perpetual search for knowledge. Pay individuals well and fund organizations fairly. Settle the money issues swiftly so all can focus on what the money is supposed to achieve. Do this well and we’ll have pay for performance – not as cause-and-effect, but as a harmonious feature of a thriving culture.

Providers who practice to chase income targets and dangled bonuses are different from providers who want a reasonable income to pursue their callings out of love for what they do and a drive to serve people better. For those who crave the buzz of the financial transaction, there is a vast world beyond health care to explore. Health care that takes its cues from the rantings of the Chicago School and the MBA culture imperils its values and its practitioners. If those twin intellectual frauds can take down an economy, they can easily corrupt health care. Health care culture needs more than a behaviourist tweak and tuck. The worst imaginable outcome would be that P4P as currently conceived actually worked as intended, for that would prove just how far we have fallen.

Bottom-Up vs. Top-Down Innovation – and Hot Air.

noreply@blogger.com (Longwoods) — Tue, 21 Apr 2009 02:28:00 +0000

Neil Seeman

“Hot Air” by Marjorie Priceman is a delightful children’s book about the first hot-air balloon – invented by brothers Joseph-Michel and Jacques-Étienne Montgolfier. In September, 1783 their Aerostat Réveillon reached 1,500 feet, its passengers being a sheep, a duck and a rooster. The Montgolfiers thought that smoke propelled the balloon. Years later it was discovered that hot air rises because it weighs less than cool air.

More than two centuries later, the debate over the source of innovation rages on: Does change come from daring researchers (the Montgolfiers)? From the throngs of people who cheer on the invention and send forth news of the sensation (in this case, to Paris)? Or from the monarch (it was King Louis XVI in 1783) who champions the invention?

Health policy wonks – especially those interested in the transformative power of health information technology (HIT) – are fixated on whether innovation comes from the “bottom up” (the patient/consumer) or the “top down” (government or the hospital).

Author Vijay Vaitheeswaran describes the bottom-up/top-down debate in the Economist Magazine’s current special report on health care and technology. Denmark is perhaps most cited as the showpiece for top-down HIT innovation, with almost all Danes having regular access to an electronic health tool to manage their appointments, track medications, and to ensure they don’t take the wrong kind of medication, too much medication or drugs that should not be used simultaneously.

So here’s one top-down formula for the successful adoption of HIT: Mandate common security standards, data-sharing protocols, and consistent interpretations of privacy law.

On the other side of the debate, many “health 2.0” or “peer-to-peer” enthusiasts tend to believe in bottom-up innovation: Give patients the tools (e.g., their complete online medical records), and the doctors and hospital CEOs and government leaders will step into line. I used to believe this. I now understand things are a bit more complex.

Too much focus on the bottom-up/top-down debate misses the real goal: making sick patients healthier faster, or managing and preventing illness altogether. This may happen bottom-up, top-down, or, more often than not in my opinion, by combination or accident. In many cases (as with the hot air balloon) we don’t really know why for years to come.

The management and health policy communities tend to ignore the reality of the happy accident. We are trapped in a cognitive bias: we think that if quality or outcomes improve within any organization, this must be by dint of “process improvement” or because of a charismatic leader who “just got things done.” From the hot air balloon to Twitter to Viagra, history abounds with accident as the seat of innovation. Perhaps the most we can do is make the ground fertile for more accidents to happen: hire lots of smart, diverse people willing every so often to bonk senior management on the head to experiment.

I don’t pretend to know the answer to why innovation and adoption of HIT takes off more quickly in some jurisdictions than in others. I am skeptical of those who think they know the answer to this very difficult question, given the deep socio-cultural differences among neighborhoods in the very same city, much less among countries or continents.

But I do say this: all the energy the academy, consulting firms, large companies and governments spend on debating this question could be channeled into something more productive: curiosity-seeking, idea-generation and free-form debate among patients and providers and others working in the system. Consider parking 15 percent of your organization’s time into tinkering with how to improve healthcare for everyone.

Sometimes a competitor will steal your idea. (Some claim that the hot air balloon was invented some 74 years earlier by the Portuguese priest Bartolomeu de Gusmão.) Sometimes a monarch or government official will take all the credit. Never mind. If just once we soar high, then it will all have been worth it.

Neil Seeman is Director and Primary Investigator of the Health Strategy Innovation Cell, based at Massey College at the University of Toronto. neil.seeman@utoronto.ca

The Obesity Epidemic and the Rise and Fall of Public Health

noreply@blogger.com (Longwoods) — Wed, 15 Apr 2009 13:55:00 +0000

David Gratzer
(HealthcarePapers, 9(1) 2008: 57-60)

"They don't understand how this could happen. I tell them that they have crushed their knees under their own weight."
-----------------------------------------------------

I'm at the annual meeting of the West Virginia Medical Association, and the conversation has turned to obesity. My colleague, an orthopedic surgeon with a local practice, explains how his clientele has grown younger with each passing year. Whereas he used to operate on people in their 70s for hip and knee replacements, he now sees patients as young as 40.

How can a 40-year-old ruin his knees? The doctor describes patients with body mass index (BMI) values of 45 - the equivalent of 152 kilograms (335 pounds) for a man with a 1.8-metre (six-foot) frame. No one at my dinner table is shocked. In West Virginia, such stories are too common. The state ranks as one of the fattest in America, ranked second overall for obesity. Whereas obesity rates in America are high, West Virginia is the ground zero of this ailment: 30% of the population has a BMI exceeding 30. And like the rest of North America, this is a new phenomenon: in 1991, no state's obesity rate exceeded 20%.

More troubling still is the fact that, on paper, West Virginia seems to have done everything right. For a generation, schoolchildren have learned about good nutrition - it is part of the curriculum. Public officials have gone as far as to study the use of video games such as Dance Dance Revolution in physical education classes. And politicians have implemented a variety of policies favoured by Seeman and Hobbs in their papers: bringing together stakeholders and nudging people in the right direction with everything from taxes on junk food to regulating school lunch options. Yet, it doesn't seem to matter. West Virginia's problems have been getting worse in recent years.

Is West Virginia the future of North America? It could be. How are we to avoid this fate? Start by looking at the rise and fall of public health.

A Brief History of Public Health

Dr. Sara Josephine Baker was a pioneer, helping to save the lives of tens of thousands. She did this without magnetic resonance imaging or even a computed tomography scanner.

Like many of the leaders of public health in the early 20th century, she focused her work on the poor. Among her initiatives was setting up a milk station in Hell's Kitchen, thereby enabling poor children to get clean, pasteurized milk. Dr. Baker didn't invent pasteurization, nor did she perfect it. Her work simply aimed at making basic food products safe and available.

For much of the 20th century, public health focused on a handful of goals to improve the environment people live and work in: sanitation, clean water and safe food. Across North America, Dr. Baker and her colleagues made it possible to grow up and grow old. Coupled with a long-standing commitment to immunization, public health officials can largely take credit for the incredible leap in life expectancy over the first half of the 20th century. Their methods may have been straightforward, but the results were extraordinary: the expansion of life expectancy during the age of Dr. Baker exceeded the expansion seen during the medical revolution of the latter half of the century.

But public health did relatively little to change people's behaviour. That is, until 1964, when a government committee issued a report and saved millions of North American lives.

In a balanced review, the Surgeon General's Advisory Committee Report Smoking and Health acknowledged the benefits of smoking (including its relaxing qualities); it also concluded definitively that tobacco is linked to cancer. The report had a profound effect. Today, people widely accept the connection between tobacco and cancer. In the 1950s, people were less certain - in 1958, only 44% of Americans saw the link.

Why? It wasn't for lack of evidence: by 1950, the Journal of the American Medical Association (JAMA) had shown in a large sample that 96.5% of the lung cancer patients were smokers." By 1958, JAMA published another landmark study showing that cancer and smoking go hand in hand. But the tobacco industry had been clever, buying advertising and physicians to contradict the evidence.

But the report of 1964 was a game changer. The committee members spent 14 months reviewing the world scientific literature and concluded that "cigarette smoking is a health hazard of sufficient import in the United States to warrant appropriate remedial action" (page 33). By the late 1960s, 71% of Americans believed that smoking causes cancer. And so began a decades-long fall in smoking rates. When the report was issued, roughly half of adult Americans smoked; today, the rate is down to one in five.

If the surgeon general's report changed America, it also had a profound effect on public health. Gone were the days when it focused on environmental factors in health. Inspired by the success in the war on smoking, public health now focuses on bettering people and the choices they make. Today, public health is as much concerned with safe sex as it is with safe food.

But there is a problem with this approach: it applies a 1960s solution to 21st-century problems. The surgeon general's report was issued at a time profoundly different from today - before the Internet and mass health literacy. Indeed, the war on smoking itself has fallen on hard times, with smoking rates remaining relatively stable over the past decade despite a record amount spent by governments on education.

How Are We to Address the Obesity Epidemic?

In many ways, the solutions outlined in the papers by Seeman and Hobbs simply wish to continue on as public health has for the past four decades, seeking to inform and push people toward better choices. Professor Hobbs, as an example, writes, "As a business owner, for example, I may prefer not to reveal the high level of artery-clogging saturated fat or trans fat in the cookies I market. However, government regulations - the rules - may require me to list on the package label the nutritional content of my product." Later, she argues for some type of government leadership in this field, and I assume that she applauds the efforts of cities like New York to make caloric counts mandatory on some restaurant menus. It's hard to argue against such transparency measures. It's also hard to feel that this is particularly useful. In this day and age, does anyone really consider cookies - heavy with trans fats or otherwise - to be healthy? Speaking of New York, do people really walk into a McDonald's with a milkshake on their mind but not understand that this is a high-calorie snack? Hobbs bemoans the "underfunded educational campaigns" of the Bush Administration, but has it ever been easier for people to get informed about good eating habits?

Seeman, too, finds much comfort in education and transparency. He envisions teenagers mentoring children on how to be physically active. Again, it's hard to argue against such a measure. But is childhood obesity really stemming from children who don't know how to run around? Will such programs teach children how to play tag or monkey-in-the-middle?

Hobbs and Seeman do of course advocate many other ideas. That said, these ideas seem antiquated. Both Hobbs and Seeman think that it's the government's role to make exercise more available; they have fashioned themselves as modern-day Dr. Bakers, except that they want to regulate sidewalks and parks (Hobbs) or grant tax-subsidized gym memberships (Seeman) instead of building milk stations.

The approaches of Hobbs and Seeman differ - between the stick and the carrot - but the goal is the same: to get America off its couch and out of the house. But what to make of the West Virginia experience? The state is one large rolling park. Surely the problem there is not a dearth of green space but people's lack of motivation to use it. In fact, American's have never had more disposable income or leisure time, making it easier than ever to buy a skipping rope from the local Wal-Mart and then use it.

How are we to deal with the obesity crisis? First, we can all agree that government policy shouldn't directly foster bad habits. Hobbs is right when she points out that some cheap food, particularly corn syrup-based food, is a consequence of agricultural subsidies. FDR's New Deal may or may not have lifted America out of the Great Depression, but the ongoing subsidies of corn aren't helpful.

Second, we can consider the various indirect subsidies of poor health decisions. Many Americans receive their health coverage from Medicaid (the poor) or Medicare (the elderly). Should taxpayers foot the bill for morbidly obese Americans without any restrictions? Non-government healthcare, whose underpinning is the US Tax Code, also indirectly subsidizes the unhealthy with the health dollars of the healthy - the three-pack-a-day smoker two cubicles down from the fit gentleman pays basically the same monthly premiums. Is that right?

Ultimately, though, I wonder about the limits of government policy. FDR's corn subsidies existed for decades before America grew fat. For all the indirect subsidization of healthcare, being medically ill seems a more overwhelming deterrent than a good deal on an insurance premium.

The recent obesity trend seems to be more about cultural acceptance than government policy. Lawsuits argue that the obese are discriminated against; overweight actors win prized roles and then proclaim their win for the overweight; prominent citizens discuss their inability to lose weight. Even our language has changed - we talk about the "obese" and not the "fat." What then should our politicians do? Legislation will take us only so far. For other major cultural trends - from the decline in divorce to the drop in drinking and driving rates - it has largely been about people speaking up and leading by example.

Maybe our politicians can toughen up their language and speak more like this: "We talk about people being 'at risk of obesity' instead of talking about people who eat too much and take too little exercise. We talk about people being at risk of poverty, or social exclusion: it's as if these things - obesity, alcohol abuse, drug addiction - are purely external events like a plague or bad weather. Of course, circumstances - where you are born, your neighbourhood, your school and the choices your parents make - have a huge impact. But social problems are often the consequence of the choices people make." The speaker isn't from West Virginia but from Britain: David Cameron, the leader of the opposition. But his fundamental idea, that one's life is his or her responsibility, is distinctly American.

About the Author
David Gratzer, MD
Senior Fellow, Manhattan Institute

One of a series of related papers in the journal Healthcare Papers.

References
Cameron, D. Speech in Glasgow. Retrieved July 7, 2008. < http://www.telegraph.co.uk/news/newstopics/ politics/conservative/2263705/David-Cameron-attacks- UK-moral-neutrality---full-text.html > .

Surgeon General's Advisory Committee on Smoking and Health. 1964. Smoking and Health. Report of the Advisory Committee to the Surgeon General of the Public Health Service. Washington, DC: US Department of Health, Education, and Welfare.

Wydner, E.L. and E.A. Graham. 1950. "Tobacco Smoking as a Possible Etiologic Factor in Bronchiogenic Carcinoma; A Study of 684 Proved Cases." JAMA: Journal of the American Medical Association 143(4):329-26.

Hammond, E.C. and D. Horn. 1958. "Smoking and Death Rates - Report on Forty-Four Months of Follow-up of 187,783 Men." JAMA: Journal of the American Medical Association 166(11): 1294-1308.

Workplace Rudeness: A New Pandemic?

noreply@blogger.com (Longwoods) — Tue, 07 Apr 2009 19:04:00 +0000

Neil Seeman

Smartphone addiction (Blackberry or iPhone) during meetings, showing up late for meetings, and a lack of "Thank-yous" are infecting the workplace. Healthcare is no exception.

What can be done to reverse the trend? Equally important, is workplace rudeness a public health issue?

There are few legitimate excuses for everyday rudeness. Let's forget about our intensely busy selves; the tough economy; or demanding clients or colleagues. We all know that the busiest people, under the most stressful of circumstances, can be the most polite and responsive in the simplest of ways.

Low-tech approaches could help turn the tide. First, my brother, a globe-trotting entrepreneur, has a tag line on his e-mails saying: "Apologies for the curtness of this e-mail; I'm typing with my thumbs." Second, some industry associations now instruct members to respond to correspondence within 24 hours. This is eminently feasible - if you check e-mail even once a day (a policy I recommend for efficiency), and, if busy, say you'll reply at a later date. Last, be tactful if using an out-of-office message. I've seen someone flare in their out-of-office subject line: "VACATION" - nothing more.

I asked a former hospital CEO how to get around the problem of email jail and general time crunch, and he advised, "Hire an EA." "What's that?" I asked (seriously). (It's an Executive Assistant). But there may be a simpler, less expensive and more personal solution.

I think the social remedy to workplace rudeness is, paradoxically, to be more blunt.

Be blunt about being late for a meeting
Tai Huynh, a colleague of mine, tells me: "I personally dislike people arriving late to meetings. I think it's rude, disrespectful to colleagues (especially if the late person is the organizer) and eats into valuable meeting time. For me, the rudeness clock starts ticking at about the 5 minute mark. At about 10 minutes, the disrespect factor kicks in and by about the 15 minute mark, I wonder why the person bothers showing up."
I figure that toting up the costs to the health system of people being late for meetings - i.e., assessing the waste by reference to the total annual salary of attendees who agreed to come but were late - could save the system significant sums if we are transparent about these costs.
Be blunt about meeting unnecessarily
According to Glenn Parker and Robert Hoffman, authors of Meeting Excellence, knowing the expense of meetings may be an impetus to make meetings more productive. I believe this could be especially powerful in the culture of health policy, where, to quote one globally renowned physician-researcher, the running ethos is to "to meet to plan to partner." Better to make a decision to partner - or not - at the first meeting, and to start the partnership project (i.e., writing things down) at the first meeting. If you exceed two cancellation notices prior to landing at the first meeting, you know it's not worth it.
Messrs. Parker and Hoffman point to a survey conducted at the Milwaukee Area Technical College that recorded the time that members of the college's 130-person management council spent in meetings. The evaluators used salary as the basis to calculate how much this time was worth. Meetings reportedly cost the college more than $3 million US per year.
I know managers who charge people money who are late for meetings. I personally don't like this approach. I have young children: I know just enough about psychology to suspect negative incentives generally don't work in this context. People just end up grousing at the boss. Besides, often times the reason for being late for the meeting is because you've had back-to-back meetings all day and the first one started late. After all the meetings conclude, I've been told by some very senior people in healthcare that the day's real work happens "off line" - whatever that means.
Be blunt about the use of smart-phones while meeting with someone
Personal digital assistants are another curse. So-called "intraviduals" (a term invented by author Dalton Conley in Everywhere, USA) are neither here nor there when tied to their Blackberry. A friend of mine, economist Patrick Luciani, calls this the "excuse-me-your-Highness-I-have-to-take-this-call" syndrome; even when speaking to the Queen, the other call is always more important.
I had the pleasure of speaking recently with a wise man who told me that, not long ago, it was the height of rudeness to take another call while speaking to another. Nowadays, it's the new normal.
"Of all of the standard irritants, uncontrolled BB use is the largest," writes Borys Chabursky. He tells me of an incident where two individuals came in to interview him for a project. "They asked a question and I would start answering and as I did, they would start checking their emails on their BBs. When I suddenly stopped speaking, they, without looking up said, 'it's ok, we're listening, just keep going.' I couldn't believe it and just stopped the interview."
We need leaders in healthcare to rebel against the culture of passive-aggressive behaviour, Blackberry addiction and meeting creep. Several years ago, University of Michigan-Ann Arbor psychologist Lilia Cortina found that 71% of workers had been mocked, taunted, ignored, or otherwise treated uncivilly by their coworkers and bosses. Last summer, researchers at West Chester University in Pennsylvania found that 75 percent of workers are treated rudely by bosses or colleagues at least once a year. I could not find any comparable Canadian data. If you know of comparable data in healthcare, please share.
Give incentives for good communication manners
When we talk about "a healthy workplace" in hospitals or care facilities, we often refer to policies and protocols that enforce existing health and safety legislation. Innovative initiatives like the Healthy Healthcare Leadership Charter, created by the Quality Worklife-Quality Healthcare Collaborative (QWQHC), are making important strides forward to cultivate healthier healthcare workplaces.
Imagine if basic civility were the touchstone for a healthy workplace. That might go a long way to saving money, stopping burn-out, and promoting happiness at work - and at home.
Say "Thank You" more often
I invite you to express your gratitude and send a "thank you" note to someone who is making a difference to help put a stop to the incivility disorder in the workplace. Thank you for reading this.

About the Author
Neil Seeman, a Longwoods essayist, is Director and Primary Investigator of the Health Strategy Innovation Cell, based at Massey College at the University of Toronto.

AMA, BMJ, and the Innovator’s Transparency Rule

noreply@blogger.com (Longwoods) — Mon, 30 Mar 2009 16:21:00 +0000

By Neil Seeman

As of the time of writing, we do not know all of the facts in the current controversy surrounding the Journal of the American Medical Association (JAMA). Reportedly, JAMA editors threatened a researcher, Jonathan Leo, who had criticized the author of a 2008 JAMA research paper. Dr. Leo’s rebuke appeared in an online letter in the British Medical Journal (BMJ).

The American Medical Association has asked an oversight committee to investigate the events. Dr. Leo, a neuro-anatomy professor at Lincoln Memorial University, alleges that senior JAMA editors threatened him and his dean following his publication of the BMJ letter. Dr. Leo’s BMJ letter criticized how results were reported in the 2008 JAMA study that looked at the use of Lexapro, an anti-depressant medication, in stroke victims. Dr. Leo claimed that JAMA did not appropriately disclose the author of the JAMA study’s financial relationship with Forest Laboratories Inc., the maker of Lexapro. Forest disclosed that it had indeed paid the author for speeches, but maintained that his Lexapro research was independent.

According to Dr. Leo, based in Harrogate, Tennessee, JAMA editors insisted that Leo retract the BMJ letter. Further, in an explosive allegation, he reportedly claims JAMA’s executive deputy editor, Phil Fontanarosa, told him, “You are banned from JAMA for life. You will be sorry.” Dr. Fontanarosa has disputed this version of events. Ray Stowers, the dean of Dr. Leo’s faculty, claims JAMA editor-in-chief Catherine DeAngelis told Stowers during a telephone conversation that she would “ruin the reputation of our medical school” unless Stowers forced Leo to retract the BMJ letter and stop speaking to the media. Dr. DeAngelis has denied this.

Further, in an online editorial on the JAMA Web site, Drs. DeAngelis and Fontanarosa accused Dr. Leo of a “serious ethical breach of confidentiality” by wading into alleged problems with the JAMA study whilst the medical journal was investigating the controversy. The JAMA editors said that, in future, anyone complaining of an author failing to report a conflict of interest would “be specifically informed that he/she should not reveal this information to third parties or the media while an investigation is under way.” Here is Dr. Leo's response to the JAMA editorial.

Is the JAMA policy even possible to enforce? Does it serve the interests of innovation and the scientific process? Leaving aside the potential worries about free expression (both for the critic making the allegation, and for the journal publishing it), keep in mind that in the age of health 2.0, most critics of scientific research are not academics. They are patients and their families. In the days since this story emerged, my quick search on Google and online health blogs suggests that at least several dozen bloggers have echoed Dr. Leo’s concerns about conflict-of-interest in the original JAMA article. It can get tricky to try to discipline every research critic on the Web.

The time when editors knew best is passé. Whether or not the army of reader/critics on the Web is right or wrong, they cannot, and will not, be silenced. Transparency governs.

Ignore criticism at your peril

The JAMA controversy reminds me of another industry that failed to heed the transparency rule. When I worked in the newspaper business in the pre-Internet era, we had space for roughly 10 letters, yet 10-15 times that number flowed in by fax or letter every day.

Today, print newspapers are suffering heavy revenue declines (and in some cities, have disappeared altogether) because of not taking criticism and openness seriously. The venerable Rocky Mountain News is defunct. The Tribune Co., owner of the Los Angeles Times and the Chicago Tribune, has filed for bankruptcy. The Seattle Post-Intelligencer is now online only. And just two weeks ago, the San Diego Union-Tribune was sold to a private-equity firm.

Notably, mainstream newspapers such as the Wall Street Journal that were among the first to embrace aggressive reader criticism via blogs, early amid the ascendance of the Internet, are the only ones today that enjoy sustained readership and continued influence. For anyone in the information business, the new mantra is no longer “content is king”. It’s “transparency rules.”

The demise of mainstream newspapers should be a lesson to the titans of research and innovation. Heed the transparency rule: embrace openness or wither on the knowledge vine.

-----------------------------

Neil Seeman, a Longwoods essayist, is Director and Primary Investigator of the Health Strategy Innovation Cell, based at the University of Toronto’s Massey College. He is also an adjunct professor of health services management at Ryerson University and writes the “Second Opinion” health innovation column for the National Post. neil.seeman@utoronto.ca

Privacy has lost its “cool factor”…

noreply@blogger.com (Longwoods) — Tue, 24 Mar 2009 15:40:00 +0000

Neil Seeman

According to the Talmud, there are two times you’re allowed to boast: when courting a potential spouse, or when looking for a job. In the current recession, many people are searching for a job, and so put their best résumé forward for everyone to see. Scanning the world of healthcare résumés posted freely on social networks such as Linkedin reveals a trend: privacy is out, “publicness” is hot.

As of the time of writing, Linkedin – the leading business professionals’ network online – included the résumés of 653 people working in the “hospital and healthcare sector” who described themselves as privacy professionals. More than twice as many (1,559) described themselves as patient advocates. The largest professionals’ discussion forum dealing with privacy had 867 members; the largest “health 2.0” discussion forum (of which there are many) had 4,888.

A limitation on my analysis: by definition, the very people who use Linkedin to look for employment or to connect with other professionals in their field – 35 million registered users and growing – are people who believe in what author Jeff Jarvis calls “publicness”.

Web 2.0 means social collaboration on the Web. Most “health 2.0” enthusiasts embrace “publicness.” “Publicness” is the new ethic of transparency in all things. Social networking sites such as Facebook, Linkedin, Twitter and MySpace trade off people’s growing willingness to disclose details about their personal lives, accomplishments…and their failures. Twitter, the fastest-growing Web phenomenon, is completely open source. Every entry is searchable on Google.

Contrary to popular myth, the ethic of publicness is much less about vanity than about a fundamental belief that “letting it all hang out” is a value system to be admired. This is part generational (so-called “Generation G”) and partly a function of our loss of faith in Wall Street and its culture of opaqueness. Even Swiss bankers are embracing publicness. Healthcare is not far behind. As the Wall Street Journal’s L. Gordon Crovitz has written, “a right to privacy seems to be transforming into a duty to disclose. We can know more, so we expect to know more.”

…it’s about control

Health 2.0 websites such as patientslikeme – which boasts a heavy contingent of Canadian users – allow members to share treatment and symptom information in real-time in order to monitor and to learn from real-world outcomes. As of March 2009, there were reportedly more than 11,000 users with multiple sclerosis, 8,000 with mood disorders, 3,500 with amyotrophic lateral sclerosis, 3,000 with Parkinson’s disease, and 2,000 users of the site with HIV.

As Jarvis writes in What Would Google Do?, “Privacy is not the issue. Control is. We need control of our personal information, whether it is made public and to whom, and how it is used.” Patients who “let it all hang out” on patientslikeme – name, age, location, symptoms – care more about controlling how their information gets used than about whether fellow sufferers can access it.

The same is true for job-seekers. In the old world, the perfect candidate for the CEO’s office – or for the entry-level position – was someone with an unblemished past. Today, the perfect candidate is someone who has disclosed his or her past missteps online. The superstar healthcare employees of today still boast about their accomplishments, but also about how they have learned from failure and humility.

Neil Seeman is Director and Primary Investigator of the Health Strategy Innovation Cell, based at Massey College at the University of Toronto.

DSM-Twitter: Are We Happy Or Sad Right Now?

noreply@blogger.com (Longwoods) — Mon, 16 Mar 2009 16:46:00 +0000

Neil Seeman and Carlos Rizo

Sadness is a global phenomenon. It is also challenging to measure in a timely manner. Imagine if we could measure it in real-time and reach out to those in need with more immediacy. We think we can.

March 12, 2029 (CBC.ca) - Canada's happiness index has risen to the level of Denmark's for the first time in two decades, capping a five-year run on the back of booming demand for the nation's improvement in mental health. The Canadian happiness index rose as high as $1,000.800 smiley emoticons before dipping to 998.700 smiley emoticons at 4:16 p.m. on the New York exchange. It has soared 62 percent from a record low of 617.667 smiley emoticons in 2002. The Canadian happiness currency last closed above $1M on Nov. 25, 2008, when Stephen Harper was Canada's prime minister. In other news...

Researchers are accustomed to estimating the prevalence of mood disorders through surveys or through analysis of physician billing databases. The data are disquieting. In any given year, surveys suggest about 8% of Canadians will suffer clinical depression at some point in their lives. Other approaches to measuring prevalence rates include reviewing expert opinion and conducting epidemiological surveys.

Dr. Dan Bilsker and colleagues showed in a 2007 paper in the Canadian Journal of Psychiatry that the physician-treated prevalence of depression in British Columbia grew from 7.7% in 1991-1992 to 9.5% in 2000-2001. More than 95% were seen by family physicians, and in the final year, just 7.5% were seen by psychiatrists. In an alarming statistic just published in the same journal, Mel Slomp and colleagues in Alberta, using physician databases, report a 35% treated prevalence rate for mental disorder (mainly anxiety and depression) for adults seen over a three-year time period.

Introducing DSM-Twitter: A real-time happiness measure
There are roughly 8 million Twitter users, according to a February 2009 report by Compete.com. As the online encyclopedia Wikipedia explains, Twitter "enables its users to send and read other users' updates (known as tweets), which are text-based posts of up to 140 characters in length. Updates are displayed on the user's profile page and delivered to other users who have signed up to receive them."

We were curious as to what Twitter would reveal about the mental health of Canadians. The results are fascinating. So-called "tweets" are often accompanied by "emoticons". In Twitter, the emoticon :) or :-) means happy or joyful. The emoticon :( signifies sad. The double string, :) :), means very happy or :( :( means very sad.

Using our real-time analysis, there were 417 tweets - within 15 miles of Toronto - expressing sadness (or what Twitter calls a "negative attitude") during 17 minutes on March 12 (from 1:06pm EST to 1:23pm EST). During the very same time frame, there were 1,500 tweets from Toronto showing happiness or a "positive attitude." This suggests that the ratio of happy comments to sad comments in the Toronto area was 3.6 to 1.

Is DSM-Twitter "scientific"?
The scientific process is in flux - in large part because the dynamic data available on the Web are growing at a stunning pace. Admittedly, our approach is far from perfect. Among other things, expressions of sadness may result from Twitter service outages, downturns in the stock market, bad sports results, frustrating weather conditions, traffic, or even the playful use of the emoticons. Still, social networking and micro-blogging services such as Twitter are entirely public (to which users consent), increasingly rich - and free! - tools of analysis. This, while the old-world scientific method is under renewed attack because of alleged bias, plagiarism and even fraud, inadequate methodology, and the fraternity-esque culture of peer review. We feel that peer review, critique, replication and validation are essential to innovation. However, we do need to quicken the pace of inquiry in order to enrich our understanding of the fast-changing world.

New paths of investigation
In a 12-hour period on March 12, we found 260 Vancouver-area tweets (connecting from many gadgets, including cell phones and Blackberries) which demonstrated joy. Eighty Vancouver-region tweets expressed sadness during this same time.

It may be unsettling to know that we might be sadder than earlier survey findings indicate. Yet, at the same time, it is exciting that we may have a way of capturing mood trends in real time. With Twitter, we may even have a new device to help reach out directly to the people who are suffering right now. One tweet at a time. :)

About the Author
Neil Seeman is Director and Primary Investigator of the Health Strategy Innovation Cell, based at Massey College, University of Toronto. He is "the Thank you Twitterer" at twitter.com/neilseeman and writes on health innovation for Longwoods and the National Post. Carlos Rizo is the Innovation Cell's Chief Imagineer. He has a Twitter grade of 98/100 (twitter.com/carlosrizo).

Correspondence: neil.seeman@utoronto.ca

A Westjet Health Care System?

noreply@blogger.com (Longwoods) — Tue, 10 Mar 2009 16:06:00 +0000

Steven Lewis

I fly a lot - too much actually; I am chagrined by my carbon footprint. Most of my flights are on Air Canada (AC), indisputably an international class, full-service airline. You can go pretty much anywhere in the world on AC or its Star Alliance partners. You can pick your fare, frills, seat, and class. I've been an Elite AC member for about 15 years, so I get to wait for my flights in swanky lounges with free food, booze, newspapers, magazines, and business centres. I get free flights from the Aeroplan miles I accumulate and an annual stack of upgrade certificates. I get a special number to call if I need to change a reservation or seek help. Cool, eh?

But I fly Westjet (WJ) whenever I can, and would happily abandon AC altogether if WJ decided to go after the Saskatoon-to-wherever (especially Toronto) business traveler markets. Why? What would lead me to turn my back on the airline that gives me all this stuff, and what accounts for the almost giddy affection for the one that doesn't? Here's my hypothesis: it's because Canada's airlines are akin to the health system we have (AC) and the health system we need (WJ). Here's how.

What do I need? Business class to Kuala Lumpur? Single malt scotch in the lounge? Special meal? AC can do it. WJ? No can do. AC is pretty good at tertiary air care; WJ is the primary care airline. Most travel needs are primary: a reasonably priced ticket, leave on time, decent legroom, a modern aircraft. My own travel life is, well, pedestrian: Calgary, Vancouver, Toronto, Ottawa, Winnipeg (quit smirking - I like Winnipeg). WJ gives me a Boeing 737 with good overhead luggage capacity and a quiet ride - every time, all the time. AC gives me cramped Bombardiers that force passengers to compete for comically little carry-on baggage room. Advantage: WJ for the basic journeys; AC for the continental transplant operation.

What happens when there's a problem? Planes break down and weather mocks schedules. The test of an airline is not when things are ticky-boo; it's when misery descends. AC appears to believe that keeping the passengers in the dark about why the flight is delayed is reassuring, and that parcelling out the delays in two hour increments is comforting. "The 2 o'clock flight that was to leave at 4 is now departing at 6. We can't tell you which gate." WJ makes it a point to tell you what's happening. Call AC with a problem and you almost feel the blame-the-passenger vibes as the agent leafs through the policy manual to confirm your non-entitlements. WJ seems to want to help. AC has done some nice things for me, but WJ has performed truly heroic feasts of creative problem-solving and in one case was generous beyond the call of duty. Advantage: WJ on both comportment and delivery.

Surprise, it's a service industry. Aviation is incredibly safe. Planes of equal size are pretty much interchangeable. The highway up there is the same for everyone and an airport is an airport. WJ offers no business class, no hot meals, no fancy lounges, no air miles of its own. It pursues advantage by other means: the attitude of its people and their capacity to solve problems. Their entire ethos is built around the customer. I used to think the "AC attitude" was the inevitable result of an aging workforce fatigued by the wear and tear of a zillion flights and alienated by repeated labour strife and restructuring. Likewise I was sure that the happy-faced, fun-loving, energetic WJ honeymoon would end.

Well, WJ is a decade old and still no sign of passive aggression; not all their employees are fresh-faced kids. AC actually tries, but there is too much ennui and complexity . Their own agents can't figure out their absurd aeroplan mileage redemption rules and its website produces some legendarily idiotic itineraries. Small wonder they can't reliably produce quality service in the crunch. Pleasantness and can-do are hard-wired into WJ's DNA: I once bought a ticket from a WJ baggage service agent. WJ gives you more while giving you less. It has chosen the right quality indicators. Advantage: WJ.

Simple, reliable, effective, pleasant: whether from an airline or from health care, that's what we need most of the time. And where simple won't cut it, more than ever we need reliable, effective, and pleasant. AC is besotted with complexity and covets the overseas, long-haul market segment. You can tell it doesn't really care about most domestic routes outside the big cities. Though they try their best, it's clear the employees have no great love for the corporation they work for.

AC is to air travel what our acute care-obsessed, high-tech-envy health care system is to health. It's great that we can find the cystic fibrosis gene and separate Siamese twins but not so good that chronic disease management is a national catastrophe. The vast majority of people don't need glitzy miracles; we need sound, evidence-based, timely, respectful, and well-communicated primary health care from a team dedicated to getting it right.

In the end it's about culture, that maddeningly elusive notion that signals what an organization or system is about. The truly successful put the customers first and pay attention to the workforce and the workplace. They get the fundamentals right and understand where their bread is buttered. WJ has mastered primary air care; it makes money where AC bleeds red ink. Health care, take a lesson.

Our Health Policy Contranyms

noreply@blogger.com (Longwoods) — Wed, 04 Mar 2009 17:13:00 +0000

by Neil Seeman

Smiles, says the old joke, is the longest word in the English language, since there is a mile between the two s's. Whoever thought this up missed the health policy literature - with its long, deliberately obtuse abstractions.

I have worked as a lawyer (where "submit" means "say") and in the large corporate sector (where a "resource" is a "person"). But in health policy we see the increasing use of contranyms, words that contain opposing meanings. A non-health care example of a contranym is "to buckle," which can mean "to fasten" or "to wobble and break." Contranyms can result from what grammarians call polysemy, where one word morphs into different, and ultimately opposing, meanings.

Consider three leading contranyms in the health policy context. One meaning is the word as originally conceived in the dictionary; the other, opposite meaning, is how it has come to be applied in health policy discussions. In each case, there may be an unstated, but rational, method to this linguistic madness.

1. "Stakeholder" is generally used in the health policy lexicon to mean: "a person or organization with a legitimate interest in a given situation, action or enterprise." Since this definition of "stakeholder" is opposite to the original meaning of the word, "stakeholder" - "a person holding the stakes for others," i.e., a lackey - the word has become a contranym.

If we think about it, all Canadians should be "stakeholders" - equal, and equally legitimate - in all matters of health policy (in fact, our Canada Health Act mandates as much). We use the word "stakeholder" to limit, pragmatically, the numbers of individuals whose views we consider when planning policy: in so doing, do non-stakeholders (i.e., "fringe" players) thereby become lackeys?

2. Next time you're at a policy conference, count how many times you hear the word iterative. (Prior to this essay, there were over 100 separate references to the word in Longwoods publications). Its use seems to be growing. "Iterative development" - or common variants, "the next iteration," or "iterative process" - contain a contradiction. "Iterative" means recurring or repetitive, and, yet, "development" or "process" signify advancement. When we use any such phrases, we are unconsciously hedging our bets, insinuating that the "next iteration of the strategy" may veer sideways or even reverse course.

3. To "invest" in an initiative, as understood in the private sector, is to expect a financial return, or profit. And yet, in health policy, there are finite government resources. Policy choices require trade-offs, and a failure to consider trade-offs leads us into the trap of the open-ended fallacy, or what economists consider the failure to think clearly about a policy's knock-on effects. And so, every time you hear the word "invest," consider whether the "investment" is being used in its purist sense (to realistically expect a return) or whether the "investment" will necessarily cleave (itself a contranym) realizable gains from another policy.

To be sure, the US context offers more colourful context for oxymorons, notably "managed care." There may be something uniquely Canadian about the health policy contranym: a deliberate obfuscation of what we aim to say. We care about all stakeholders, but sometimes some stakeholders may be more important to us than others; policy forges ahead in iterative stages, since, perhaps, we are too risk averse to embrace the frontier of innovation; and we may talk a good game about investment, but we may be leery of appearing to endorse the language of profit.

This sort of linguistic muddle is a matter of custom. Is the "custom" a byproduct of "conventional behaviour" or "deliberate design"? That's a conundrum.

About the Author
Neil Seeman is Director and Primary Investigator of the Health Strategy Innovation Cell, based at Massey College, University of Toronto.

Green Healthcare: You Are What You Serve: Healthy and Environmentally Friendly Food Service

noreply@blogger.com (Longwoods) — Tue, 03 Feb 2009 02:44:00 +0000

by Trevor Hancock

The quality of hospital food has long been the butt of comedians' jokes. More recently, hospitals have also been criticized for serving fast food. One recent U.S. survey, for example, found that 38% of top U.S. hospitals - six of the 16 "Honor Roll" hospitals listed by US News & World Report's 2001 ranking of "America's Best Hospitals" - have fast-food franchises on site. Gottlieb and Shaffer found that more than 25% of 47 U.S. children's hospitals had fast-food franchises within them .

Meanwhile, a 1997 report from Toronto's Food Policy Council entitled "If the Health Care System Believed You Are What You Eat," suggested that we need to transform hospital food service systems into facilities providing healthy food choices and local food.

In response to these criticisms, as well as out of a genuine concern for the welfare of their patients, a growing number of hospitals have started to focus more on the healthfulness of the food they serve. For example, Planetree hospitals, which are committed to creating healing environments for their patients and healthy workplaces for their staff pay particular attention not only to the quality of the food they serve but the nurturing role of food "as a source of pleasure, comfort and familiarity" during a stressful period of hospitalization. Many Planetree hospitals, for example, have small kitchens on each floor where family members can cook favourite foods for their loved ones and nutritionists can demonstrate healthy food preparation, while volunteers fill the halls with the smell of fresh baked goods every morning.

In the U.K., two Scottish hospitals recently won the Healthy Choices Award from Scotland's Health Education Board, while in Wales a hospital in Powys, working with the Soil Association, now provides organic milk for its patients in spite of the difficulties imposed by World Trade Organization regulations that prevent organizations from specifying local produce. This latter example begins to show the links between healthy food and food that is produced in an environmentally sustainable manner - and the challenges involved in being environmentally and socially responsible!

Given the growing concern with the potential health impacts of pesticide residues, particularly for children, and the fact that as a result of eco-toxicity and the contamination of food chains, we get 75 to 90% of our daily dose of persistent organic pollutants such as dioxins from food, serving organic food as much as possible makes sense. Of course, there are many important environmental benefits from producing food organically.

Perhaps the most advanced example of organic food service in hospitals is found in Vienna, where currently about 20% of the food served in the hospitals is organic. There, studies have shown that a move from 0 to 30% organic food results in a 17% increase in the cost of food, which only translates into a 0.1% increase in the overall costs of care; a move to 50% organic food results in a 30% increase, or less than 0.2 % of overall costs of care. In addition, there are significant energy benefits for society as a whole from not having to practice energy-intensive agriculture or move food over long distances (Klausbruckner 2001).

Environmentally-friendly food service not only includes serving organically grown food whenever possible, it also means paying attention to the environmental impact of food preparation and service, and the disposal of food wastes. The U.S. Environmental Protection Association has produced a guide to operating a green cafeteria. Among the key points are the following:

* using permanent china and stainless steel service-ware to minimize generation of waste;
* offering monetary discounts for those who bring their own re-usable coffee mugs;
* using starch-based cafeteria-ware, which has several beneficial environmental characteristics: it is compostable, biodegradable, and uses less energy to produce than paper or polystyrene containers;
* using 100% recycled unbleached napkins, which are compostable;
* recycling plastic and glass bottles and aluminum cans.

Such an approach is compatible with modern hospital operations, as can be seen in the case of the Itasca Medical Center in Grand Rapids, MI. This 108-bed community hospital switched from single-use to re-useable salad plates and dessert bowls for a net savings of $3,500 per year (Canadian Centre for Pollution Prevention 1996).

Food waste forms a significant proportion of a hospital's waste stream, as shown by a 1990 environmental audit of the Ottawa General Hospital, which found that it formed 17% by weight of hospital waste (Canadian Centre for Pollution Prevention 1996). Guidance on management of food wastes can be found at the website of the California Integrated Waste Management Board, which suggests the following order for food scraps management: (1) prevent food waste, (2) feed people, (3) convert to animal feed and/or rendering, and (4) compost.

Food scrap management can even be turned into organic produce at little or no cost to a hospital, as illustrated by The Medical Center Hospital of Vermont. This hospital prepares 3,000 meals a day. And every day, it trucks hundreds of kilograms of kitchen waste (not food from anyone's plates) to a compost site managed by a non-profit group dedicated to organic food production (thus avoiding landfill charges). The 80 tonnes of food wastes that the hospital sent to compost in 1993 was transformed into 40 tonnes of compost and in return the hospital received 10 tonnes of fresh organic produce at a wholesale price of $6,000 (Raver 1994).

Finally, a comprehensive approach to sustainable food services in hospitals is provided by the U.K. government's Sustainable Development Commission which has recently produced a comprehensive report on sustainable food procurement for the NHS. The interim report proposes that "in the NHS, procurement policies should promote health. Trusts should be required to procure food in a way that impacts positively on long-term health outcomes"
.
About the Author

Dr. Trevor Hancock is Hospital Quarterly's Environmental Editor. He is Chair of the Board of the Canadian Association of Physicians for the Environment and a founder of the Canadian Coalition for Green Health Care. He can be reached at greendoc@telus.net.

Physicians, Thou Shalt Ration: The Necessary Role of Bedside Rationing in Controlling Healthcare Costs

noreply@blogger.com (Longwoods) — Fri, 16 Jan 2009 17:20:00 +0000

Peter A. Ubel MD
HealthcarePapers
Vol. 2 No. 2 2001 | Physician Rationing

Abstract:
Physicians are often asked to be "gatekeepers," determining their patients' access to medical therapies and technologies. At the same time, most physicians have been taught that they should act as patient advocates, pursuing patients' best interests regardless of cost. This paper reviews moral arguments ethicists have made for and against "bedside rationing." It argues that healthcare rationing is appropriate in order to help control healthcare costs, and that rationing decisions made at the bedside by physicians must be part of the rationing system. A system that attempts to control costs by mandating an elaborate set of rules would be burdensome, and many physicians would find ways around the rules anyway.

Physicians are deeply conflicted about their roles in cost-containment. Some of the conflict has to do with discomfort over the concept of "rationing," but they are also in conflict about much deeper issues. The author argues that patients can do with less than the "best" treatment and physicians must come to terms with this. Finally, healthcare systems need to signal physicians that it is acceptable for them to offer "less" to their patients in order to serve the greater good.

Ms. Johnson comes to her physician with symptoms of gastric reflux (GERD). Her doctor gives her a prescription for cimetidine, even though he knows omeprazole would be better at relieving her symptoms. He thinks the cost of this other medication is too high for it to be the initial treatment.

In an old Mel Brooks movie,Moses is seen coming down from the mountains with three stone tablets. He announces to his people in a stentorian thunder: "I come down with a copy of God's Fifteen . . ."- he fumbles one of the tablets, and it falls to the ground - ". . . er,Ten Commandments for how to live a good life."

This is pure speculation, but I would guess that somewhere on that broken tablet was a commandment that read: "Physician, thou shalt not ration!" I base my speculation on the tone many people take when debating the appropriateness of bedside rationing by physicians. Opponents of bedside rationing argue vehemently that physicians should never ration from their patients. For example, in a New England Journal of Medicine editorial, Howard Hiatt (1975) wrote: "A physician must do all that is permitted on behalf of his patient." In a similar vein, Dr. Norm Levinsky, chair of medicine at Boston University, has written that: "Physicians are required to do everything they believe may benefit each patient without regard to cost" (Levinsky 1984). Hiatt and Levinsky's statements are consistent with the traditional moral view that physicians should advocate for their patients without regard to costs. This view is treated almost as a theological truth in the United States. But I am a heretic. I think that it is sometimes appropriate for physicians to ration healthcare from their patients in order to help control healthcare costs. In this article, I briefly describe the "theology" of bedside rationing - why so many people think bedside rationing is immoral. I also discuss why I am a heretic. I think any method of controlling healthcare costs is doomed to fail, unless it is joined by some relaxation of physicians' advocacy duties. Finally, I discuss linguistic confusion about bedside rationing.Many people debate the appropriateness of bedside rationing without ever defining what they mean; this leads to disagreements about the morality of bedside rationing among people whose moral values are actually the same.

Theology 101: the Immorality of Bedside Rationing
Opponents of bedside rationing contend that it violates physicians' moral duties to advocate for patients' interests. In addition, they believe that bedside rationing would erode trust between patients and their physicians. Moreover, they hold that bedside rationing creates savings that do not necessarily go toward improving patient care for other patients. I elaborate on each of these objections below.

It has been long argued that physicians have a "fiduciary duty" to advocate for patients' interests (Morreim 1989). A fiduciary is someone who acts on behalf of those who otherwise may not be able to pursue their interests (Hall 1997). Physicians are seen as fiduciaries for patients because they have more knowledge than patients do. Patients may not know what is in their best interests or may not be able to pursue their best interests without a physician's help. Physicians also have fiduciary duties because patients are often dependent on them. Patients are emotionally dependent on physicians because their illnesses make them vulnerable; in addition, patients are legally dependent on physicians, who have been given powers to order medications and perform procedures that other people can not do. Finally, physicians' fiduciary duties arise because healthcare issues are often high stakes. These high stakes distinguish the doctor-patient relationship from otherwise parallel relationships, such as between an auto mechanic and a client. An auto mechanic has more knowledge about cars than a typical person and may have tools to repair a car that the average person could not afford. Although auto mechanics have moral duties, such as to be honest with their clients, their duties are not fiduciary, because the stakes are not high.

People often feel strongly about physicians' advocacy duties towards patients because they recognize that patients need to trust their physicians in order to receive good care (Goold 1998). Many aspects of healthcare depend on trusting interactions between patients and their providers. Patients who do not trust their healthcare provider may not tell the provider about the symptoms they are experiencing, or may not tell about high-risk behaviour they are engaging in. If worried that physicians were rationing healthcare from them, patients might lose trust in their physicians. Consequently, the quality of healthcare that physicians can provide to their patients would erode.

Some opposition to bedside rationing arises because of concern about who would really benefit if physicians rationed healthcare from their patients (Asch et al.; in submission). In the case presented in the introduction, a physician prescribed a less expensive medicine to a patient with reflux in order to save money. But whose money was being saved? If the patient would not have incurred most or all of the increase in costs of the more expensive medicine, then who benefits from this rationing decision? Many people think the money will simply go to a greedy insurance company or to the CEO of a managed-care company. These people contend that there is no moral justification for withholding the best care from patients, given that the money saved by bedside rationing will not necessarily benefit patients.

For these and other reasons, the traditional moral view is that physicians need to do what is in patients' best interests regardless of cost. But, as I stated above, I do not hold that view. Below I will describe why I oppose the traditional view of physicians' moral duties. First, however, I need to define what I mean by "bedside rationing."

Defining My Terms
Bedside rationing is a subset of healthcare rationing; in other words, it is one of many ways to ration healthcare. For the purposes of this article, I hold that healthcare rationing occurs whenever the healthcare system, or "society," allows patients to receive less than the most beneficial healthcare service. If a patient receives treatment A because of resource constraints, when a more expensive treatment, B, would have been better, then treatment B has been rationed from the patient. This rationing could have occurred because of bedside rationing - a clinician might have decided to prescribe A rather than B; or it could have occurred through market forces - the patient could have been asked to pay for either A or B and, thus, chose A; or it could have occurred through any number of other mechanisms.

The definition I have proposed for healthcare rationing is consistent with how most health economists define the term. I have defended this definition elsewhere (Ubel and Goold 1998). Nevertheless, there is no single "best" way to define a complex term like healthcare rationing, nor is it crucial for me to convince you that the definition I propose is the best. Instead, I put forward this definition as a way to clarify the term as I discuss why I believe bedside rationing is morally acceptable.

Before discussing why I believe bedside rationing is an acceptable method of rationing healthcare, I need to note a fact that is perhaps obvious. If healthcare rationing is unacceptable, then bedside rationing is unacceptable. In other words, those who argue that healthcare should not be rationed not only disapprove of bedside rationing but also would disapprove of any other method of rationing healthcare. I will not argue against this view here. Others have argued convincingly, I believe, that there is a need to ration healthcare (Hall 1997; Callahan 1990; Eddy 1994). The proliferation of new technologies being offered to patients with a wide range of illnesses has made it impossible to offer every patient the best possible healthcare services in existence. Each day, new medications become available that, if they were free, would probably be offered to hundreds of thousands of patients. These medications are so expensive, however, we often hesitate to provide them to everyone that would benefit. Cholesterol medications, for example, are slowly diffusing towards a broader group of patients, but if they were as free as water, many people at relatively low risk of coronary heart disease might start taking them. To make this discussion manageable, then, I will ask readers to assume that some amount of healthcare rationing is necessary to help control healthcare costs. The question for this article then is whether any amount of this rationing ought to be done at the bedside by clinicians. In other words, is bedside rationing a legitimate form of healthcare rationing?

Not surprisingly, it is helpful to begin with a definition of bedside rationing. Susan Goold and I have argued that three conditions are necessary for a clinical action to qualify as bedside rationing: (1) the patient must be given less than the best available healthcare, (2) the best healthcare must be withheld in order to save societal resources, and (3) the physician (or clinician) must have control over the healthcare decision (Ubel and Goold 1998). For example, in the reflux case described in the introduction, the physician prescribed the less expensive reflux medicine in order to save society money. Hence, the case was an example of bedside rationing. A subtle change in the case, however, would change this classification. If the patient was responsible for the difference in cost of these two medicines, the decision would not necessarily qualify as bedside rationing, because the physician could potentially be ordering the less expensive medicine to save money for the patient. (In such a situation, the physician ought to talk with patients about how they want to spend their money.) Another change in the case would also eliminate it as an example of bedside rationing. If the patient's health plan required physicians to prescribe less expensive reflux medicines before prescribing expensive ones, the doctor's prescription would not be at her discretion and the health plan would be rationing the expensive medicine from the patient, not the physician.

To better understand what I mean by bedside rationing, it is helpful to think of alternative ways to ration healthcare. Healthcare can be rationed by ability or willingness to pay. Healthcare can also be rationed by formulary committees who decide that expensive reflux medicines are no longer available to all patients. A health plan may decide not to offer lung reduction surgery to its patients, and a government insurer may decide to limit PET scanners for its citizens. These are examples of administrative level healthcare rationing, but not examples of bedside rationing.

Can the Cost of Reflux Treatments Be Contained without Bedside Rationing?
Imagine a healthcare system that is trying to reduce the use of expensive proton pump inhibitors (PPIs), such as omeprazole, in patients with reflux disease. Imagine at the same time that all the physicians in this healthcare plan have vowed never to ration at the bedside. How would this healthcare system go about reducing the use of PPIs?

To begin with, if this healthcare plan did nothing to control PPI use and physicians were committed to providing the best possible care to their patients without regard to cost, then physicians would almost never prescribe the less expensive reflux medicines. PPIs are simply better reflux medicines than the less expensive H2 blockers. Some people might reject the idea that offering less expensive reflux medicines to patients is an example of rationing (Asch and Ubel 1997). They might argue that many patients do just as well with H2 blockers as with PPIs. For these patients, then, no benefit has been withheld if they receive H2 blockers first; if no benefit has been withheld, then no bedside rationing has occurred. This reasoning is faulty, however, because it utilizes an after-thefact evaluation to judge a prior-to-thefact decision. Prior to prescribing a reflux medicine, physicians do not know whether H2 blockers or PPIs will work better for a particular patient. However, patients' chances of successful reflux treatment will be significantly greater with PPIs. Indeed, if money were no object, there would be no reason (in most patients) to prescribe an H2 blocker instead of a PPI.

Because PPIs are superior to H2 blockers but more expensive, the healthcare plan has to find a way to keep physicians from prescribing them if it wants to save money on reflux medications. One way to do so would be to require that all patients undergo a trial of H2 blockers before receiving PPIs. How would such a requirement work? First, the health plan would need a system for documenting whether patients had already been on H2 blockers, so that they could receive PPIs after the H2 blockers failed. The system would also need to track whether patients had received H2 blockers from other healthcare plans prior to transferring to their new plan. In addition, it would need to develop a system whereby physicians could appeal and prescribe PPIs for patients who had taken H2 blockers on the outside or who had some "contraindication" (some medical reason they could not take H2 blockers). Preparing for such exceptions and appeals costs money. The health plan would need to spend money to develop information systems that could monitor the program. This in itself has resource implications and would have to be weighed against the amount of money that would be saved by reducing PPI prescriptions.

But the system would have to be even more complex than I have indicated, or it would create some clinical problems. For example, PPIs are important medicines for treating patients who have non-reflux related stomach problems caused by the bacterium H. pylori. Would physicians be able to prescribe PPIs for such patients? In addition, should the system be prepared to allow exceptions for patients who come in with "severe reflux symptoms"? If so, how should we define severe reflux disease? Once these exceptions are made, how would they be monitored?

I am trying to show, through examples, that rule-based rationing is problematic because the rules can very quickly become unmanageable. Perhaps just as important, rule-based rationing systems are susceptible to physician "gaming"- physicians interpret rules in ways that benefit their patients (Morreim 1991). A notable example of gaming is occurring in the state of Oregon, which, since the mid-1990s, has been trying to reduce its Medicaid expenditures through an explicit rationing plan. Medicaid is a U.S. healthcare program for poor people and is paid for by a combination of federal and state monies. Oregon was having a hard time keeping its Medicaid expenses in line while trying to maintain coverage for all the poor people who needed healthcare. One solution, as formulated by then legislator (and now governor) John Kitzhaber, was for Oregon to specify which healthcare services it would offer to Medicaid patients and which ones it would not. The state hoped to save money by withholding Medicaid services that were deemed less important than other services (Garland 1992). The savings garnered by not paying for such services could then be used to offer Medicaid to more patients.

Despite good intentions, the Oregon Medicaid rationing plan has not saved a dime, because physicians have found ways to get around the rules (Kilborn 1999). For example, if patients have multiple diagnoses below the funding line, physicians will get reimbursed for their treatment. Consequently, when patients come in with "below-the-line diagnoses," physicians almost always find several other "below-the-line" diagnoses in order to get reimbursement for their treatments. Through this and other loopholes, physicians have found ways to make sure patients get the treatments that are best for them. Indeed, physicians are notoriously good at gaming healthcare systems to get benefits for their patients. Thus, to the extent that healthcare plans try to tie physicians' hands to control healthcare costs, physicians wriggle free of the ropes.

What about a Simpler Type of Rule to Control Spending?
So far, I have discussed several rule-based methods of reducing PPI prescriptions. I have argued that these rules need to become more elaborate in order to control healthcare costs, but they can still often be overcome by physician gaming. How about a simpler rule: require gastroenterologist approval of every PPI prescription. Would this simpler rule control costs? Such a rule would have several advantages over more complex rules. It would allow for clinical judgments to be made about which patients really needed PPIs. No committee would need to create an official definition of "severe reflux disease." Instead, clinicians talking to each other on the phone could decide whether a patient really needed a PPI prescription. Such a rule allows for clinical judgments based on the specifics of individual patients. This contrasts with previous rules, which were meant to be applied to all patients.

Despite its advantages, this type of rule has pitfalls too. Most important, it could potentially overwhelm gastroenterologists with pages and phone calls about PPI prescriptions. At one institution where I worked, this plan was rapidly defeated when gastroenterologists told primary-care physicians to write down that they had GI approval any time they wanted to prescribe a PPI. The gastroenterologists were so fed up with receiving phone calls about PPI prescriptions that they found a way to defeat the system.

Let us shift our attention away from reflux disease for a bit and consider a common diagnostic test that has significant expense - CT scans.Who should be able to order a CT? Should all primary-care physicians be able to do so without prior approval? What about primary-care nurse practitioners? At one institution where I worked, nurse practitioners could order CT scans (and MRI scans, for that matter, a significantly more expensive test) without discussing this with a radiologist or primary-care physician. I saw patients who presented with new onset shoulder pain who were referred for MRIs by clinicians without anybody asking a radiologist if that test was indicated. In my clinical judgement, this is a wasteful practice. But how do we keep it from happening?

Healthcare systems could require that all CT scans and MRI scans be approved by radiologists. As with the gastroenterology example described above, however, such a policy would potentially overwhelm radiologists with such requests. Moreover, in many cases, primary-care practitioners have every reason to know that a scan is indicated.

Although it makes some sense to require clinicians to speak with radiologists before ordering extremely expensive radiology tests, I have concerns about a system that requires such conversations. First, such a system ignores many less expensive tests that, nevertheless, are ordered frequently enough that they cost healthcare systems a lot of money. Think of all the plain film x-rays that are ordered for low-back pain and for routine screening of lung fields that have almost no clinical value. Second, such a system imposes burdens on radiologists and other physicians who must now find time in their busy days to speak with each other, even in circumstances where the correct radiology test to order is obvious. This not only takes up these clinicians' time, but also ultimately costs healthcare systems money, because radiologists and other physicians are highly paid professionals. Third, the systems create a layer of bureaucracy in order to document that conversations have occurred between radiologists and other clinicians. Bureaucracies create hassles. Just as important bureaucracies cost money.

Instead of Bureaucratic Rules or Time-Consuming Approval Requirements, Why Not Give Physicians Feedback about Their Utilization?
There are alternatives to forcing clinicians to call each other on the phone to get approval for every lab test, radiology test, and expensive medication they want to order. One alternative is to give clinicians feedback, every few months or so, about how much they utilize expensive diagnostic tests in comparison to their peers. Research has shown that such feedback reduces physicians' utilization (Berwick and Coltin 1986; Schectman et al. 1991). Physicians hate feeling like they are outliers; they do not want to rely on expensive tests more than other physicians do.

Such feedback systems deserve a role in helping control healthcare costs. They do not require burdensome rules, but they do not avoid bedside rationing. If physicians are only interested in patients' best interests, they will completely ignore how their utilization patterns compare to other physicians. In fact, in a world without bedside rationing, they will continue to order what they think is best for their patients. Those who order fewer CTs and MRIs may have reason to wonder if they are ordering too few tests.

What about Avoiding Bureaucratic Rules by Implementing Capitation or Other Financial Incentives?
Asking physicians to bear some financial risk for the tests and medicine they order for their patients has also been shown to control healthcare costs. Under such "capitated" healthcare systems, physicians are given a certain amount of money to take care of their patients (Hillman 1990). Some percent of the money they spend caring for their patients is then taken from their salary. This encourages physicians to order fewer tests and referrals.

Many people have raised moral objections to capitation-reimbursed systems. I do not plan to discuss these arguments here. Instead, I want to make a simple point: capitation systems only control healthcare costs by encouraging bedside rationing. If patients' best interests were all that mattered, most clinical decisions would be unaffected by capitation: clinicians would still do what is best for their patients, regardless of costs.

What about Rationing with Practice Guidelines?
Some colleagues of mine in Michigan recently published an article on the cost effectiveness of performing routine retinal screening exams for diabetic patients (Vijan et al. 2000). The standard of care, up to now, has been to make sure that all diabetic patients have ophthalmology examinations each year to screen them for diabetic eye disease. My colleagues argued that annual screening is unaffordable for patients with mild diabetes; such a screening rarely prevents blindness, compared to screening every two to three years.

If physicians only worried about patients' best interests, they would ignore my colleagues' work, because annual screening would still prevent more cases of blindness than less frequent screening. However, it is likely that in the near future, leading diabetes organizations will change their recommendations on how to screen patients with mild diabetes and recommend screening every other year in low-risk patients. These guidelines will probably have a significant influence on physicians' referral practices.

If physicians begin to follow diabetes society "guidelines" for how often to screen people for retinal disease, they will be engaging in bedside rationing. However, I expect that many physicians will not realize that they are rationing at the bedside when they follow these guidelines (Asch and Ubel 1997). I happen to think these guidelines are signals from society about how much money they want physicians spending to prevent rare illnesses. The decision is, however, still ultimately up to individual clinicians. Such guidelines will have no effect on clinical practice unless physicians are willing to ration at the bedside.

How Do I Justify My Heretical Support of Bedside Rationing?
As hinted above, I have a major concern with healthcare systems that ration without any reliance on bedside rationing: these rationing systems will be burdensome. I scratched the surface in discussing how a healthcare system might try to reduce the use of PPIs. I did not even begin discussing the similarly burdensome rationing mechanisms the system would need to control the use of expensive hypertension medicines, reduce subspecialty referrals, decrease the use of marginally beneficial lab tests, reduce the length of outpatient visits, or reduce the frequency with which physicians order follow-up appointments. A system that controls healthcare costs by creating elaborate rules around all these varied types of clinical decisions would be a bureaucratic nightmare and a clinical disaster.

Those who want to control healthcare costs must decide how they will trade off between blunt, obtrusive rules that completely delineate physicians' behaviours and some amount of bedside rationing that encourages physicians to reduce their use of marginally beneficial healthcare services (Welch 1991).

When I say I am in favour of bedside rationing, I mean the following: at times physicians need to relax their advocacy duties and give their patients less than the best possible healthcare services in order to save money for society. The entire rationing burden should not fall on physicians' hands. There is an appropriate role for administrative rationing mechanisms. In fact, many of the "burdensome rationing rules" I discuss above would be made much less burdensome if we could rely on physicians to occasionally ration at the bedside. For example, a healthcare system could ask physicians to prescribe H2 blockers whenever possible before prescribing PPIs. Such a guideline, handed down by a healthcare system or by a respected medical society, would help physicians remember that H2 blockers are still good medicines for many patients and that society needs to control healthcare costs by reducing the use of expensive PPIs. At the same time, this guideline would allow physicians to use their judgment about when to make exceptions to the guideline.

No system that relies completely on administrative rationing mechanisms will succeed in reducing healthcare costs. In addition, a system that relies heavily on willingness and ability to pay to ration healthcare is morally questionable (for reasons I will not go into here). Thus, the best way to ration healthcare is to have a mixture of administrative rationing mechanisms and clinicians engaging in bedside rationing, with a touch of willingness to pay on the side.

I recognize that there are moral problems with bedside rationing. The problems cannot be eliminated, but they can be reduced. For example, we need to make sure that physicians ration in ways that do not greatly reduce patient trust. I think this is achievable.We also need to do what we can to make sure that money saved by healthcare rationing (bedside or other) goes towards appropriate ends. The goal of healthcare should not be to maximize profits. We need to find ways to help physicians ration at the bedside so that they will not do it haphazardly or in a discriminatory manner. At the same time, we must judge bedside rationing the same way we judge democracy - by comparing it to the alternatives. In this case, the alternatives include burdensome rationing rules, many of which physicians would bend in their patients' favour, and increased use of out-of-pocket expenses to ration healthcare, which favours wealthy patients over others. Bedside rationing has weaknesses, but I think its weaknesses are worth accepting in order to avoid the weaknesses of alternative ways to ration.

What Do Physicians Think of Bedside Rationing?
I have all too briefly discussed the theology behind opposition to bedside rationing and the heresy of relying on bedside rationing to help us control healthcare costs.What do most physicians think about these issues? Do physicians hold to the good old religion and oppose bedside rationing or are they joining heretics like me in accepting its necessity?

Sorting out physicians' attitudes towards bedside rationing is tricky, in part because of linguistic confusion about what it means to ration at the bedside. When physicians disagree about bedside rationing, they could potentially be having one of two kinds of disagreement: (1) they could be disagreeing about the appropriateness of having physicians do less than the best for their patients, or (2) they could be disagreeing about the meaning of the word rationing. That is, physicians might agree with each other that it is appropriate to withhold PPIs from patients, but disagree about whether this is an example of bedside rationing. As an analogy, consider two people who are looking at an insect. In one case, they agree that the insect is a moth, but disagree about whether it is beautiful or ugly. This is similar to agreeing about what it means to ration at the bedside while disagreeing about whether such rationing is justifiable. In another case, imagine they agree that the insect is beautiful while disagreeing about whether it is a moth or butterfly. This is analogous to agreeing that bedside rationing is acceptable - that doing less than the best for patients is acceptable - while disagreeing about whether this is an example of bedside rationing.

To sort out these two ways of disagreeing about bedside rationing, David Asch and I presented 1,000 general internists in the United States with a vignette in which a hypothetical physician offers a less expensive and less effective colon cancer screening test to a patient in order to save money for society (Ubel 2000).We asked physicians whether the physician who ordered the less expensive colon cancer screening test was acting "appropriately" and whether that physician was performing "healthcare rationing."We found that physicians generally agreed that it was appropriate for the hypothetical physician to offer the less effective test to the patient. In fact, only 20% of physicians felt that ordering the less expensive colon cancer screening test was inappropriate. Physicians were completely divided about whether such a decision was an example of healthcare rationing. Forty percent thought it wasn't, 40% thought it was, and 20% had no idea. This suggests that physicians generally support the idea of making cost-quality trade-offs at the bedside. They are comfortable offering a decent screening test to someone, even though a slightly better and significantly more expensive test is available. They are not sure whether to call such a thing "bedside rationing."

This disagreement among physicians about what qualifies as bedside rationing should not surprise us. As I stated above, there is no single way of defining complex terms such as rationing or bedside rationing. And besides, when we conducted this survey, my elegant definition of bedside rationing had not yet been published! More important, rationing is a loaded term. People may support the concept of rationing without wanting to label it that way. I do not have a problem with that. I personally like to use the term rationing, because I think it forces people to consider the moral implications of their decisions. Other euphemisms might be easier to swallow, but they might make us less likely to notice when we are ingesting rotten food.

Nevertheless, I am happy to define rationing in different ways, if that is what people want to do. Instead, what is more important to me is that physicians recognize that they do not currently pursue patients' best interests without regard to costs. I can find examples for almost any physician I know in which they are forgoing a marginally beneficial test or referral because of its expense. Different physicians have different thresholds, but I would guess even Norm Levinsky does not order a thyroid screening test on every patient he sees every few months. If money were irrelevant, even he would order more thyroid tests. Physicians have not done a good job of recognizing that they are making trade-offs between cost and quality. By failing to recognize these trade-offs, they are probably not doing a very good job of making them. If clinicians recognized the trade-offs they made every day, they could begin to look across their entire practices and see when they were trading off too much quality for not enough cost savings, and when they were not trading off enough.

Conclusion
Heated debates about the morality or immorality of bedside rationing have been missing the point.We are so worried about the loaded term "rationing" or about old-fashioned moral ideals that were developed in a time when healthcare costs were not nearly as high as they are that we are not facing up to the new reality.We need to control healthcare costs, and physicians must play a crucial role in helping society do so.

Society is still coming to grips with resource constraints in medical care, especially in the United States. Not surprisingly, many people are not sure who they think ought to be making rationing decisions. Clinicians are equally confused; they do not want to bear a disproportionate share of decision-making over rationing. On the other hand, most clinicians do not want to practise healthcare amid a sea of burdensome rules that limit their abilities to take care of patients.

Whether or not clinicians call it "rationing," they need to recognize that they have a crucial role in helping to control healthcare costs. The best way to control costs is for clinicians to relax their advocacy duties in conjunction with other rationing mechanisms. Clinicians need to recognize that patients can do with less than the best. Physicians need to come to grips, individually if not as a group, with what services they can withhold from patients. And finally, healthcare systems need to find ways to signal to physicians that it is okay to do less than the best for their patients in order to serve the greater good of the population.

About the Author
Peter A. Ubel, MD
Veterans Affairs Health Services Research and Development
Michigan Program for Improving Healthcare Decisions
Division of General Internal Medicine, University of Michigan

Dr. Ubel is a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar, recipient of a career development award in health services research from the Department of Veterans Affairs, and recipient of a Presidential Early Career Award for Scientists and Engineers (PECASE).

READERS (with personal or institutional subscriptions) can access detailed commentary here.

Commentaries are by:

The Tragedy of the Medicare Commons?
Peter H. Barrett

Rationing Healthcare: The Appeal of Muddling Through Elegantly
David J. Hunter

Cutting Healthcare Costs without Rationing at the Bedside: Preserving the Doctor-Patient Fiduciary Relationship
Saul J.Weiner and Charles L. Rice

Bedside Rationing by Physicians: The Case Against
Arthur Schafer

The Need Is to Prioritize, Not Ration
Val Rachlis

Physicians Must Participate in Establishing Standards of Care
Gregory Powell

Advocacy and Rationing Are Compatible
Claude Gratton and Margaret Keatings

Final Response
The Author Responds: Putting Bedside Rationing Back into Perspective

Acknowledgements
The author acknowledges Julie L. Lucas for her assistance in manuscript preparation. References
Asch, D.A., et al. When Money Is Saved by Reducing Health Care Costs, Where do Physicians Think That Money Goes? (in submission).

Asch, D.A. and P.A. Ubel. 1997. "Rationing by Any Other Name." New England Journal of Medicine 336:1668-71.

Berwick, D.M. and K.L. Coltin. 1986. "Feedback Reduces Test Use in a Health Maintenance Organization." JAMA 255(1): 1450-54.

Callahan, D. 1990. What Kind of Life: The Limits of Medical Progress. New York: Simon and Schuster.

Eddy, D.M. 1994. "Health System Reform:Will Controlling Costs Require Rationing Services?" JAMA 272: 324-28.

Garland, M.J. 1992. "Rationing in Public: Oregon's Priority-Setting Methodology." In Rationing America's Medical Care: The Oregon Plan and Beyond, M.A. Strosberg, et al., eds.Washington DC: Brookings Institution.

Goold, S.D. 1998. "Money and Trust: Physician Incentives and the Doctor-Patient Relationship." Journal of Health, Politics, Policy, and Law 23(4): 687-95.

Hall ,M.A. 1997. Making Medical Spending Decisions: The Law, Ethics, and Economics Of Rationing Mechanisms. New York: Oxford University Press.

Hiatt, H.H. 1975. "Protecting the Medical Commons: Who Is Responsible?" New England Journal of Medicine 293: 235-41.

Hillman, A.L.. 1990. "Health Maintenance Organizations, Financial Incentives, and Physicians' Judgments." Annals of Internal Medicine 112(12): 891-93.

Kilborn, P.T. 1999. "Oregon Falters on a New Path to Health Care." New York Times. p. A1.

Levinsky, N.G. 1984. "The Doctor's Master." New England Journal of Medicine 311(24): 1573-75.

Morreim, E.H. 1989. "Fiscal Scarcity and the Inevitability of Bedside Budget Balancing." Archives of Internal Medicine 149: 1012-15.

Morreim, E.H. 1991. "Gaming the System: Dodging the Rules, Ruling the Dodgers." Archives of Internal Medicine 151: 443-47.

Schectman, J.M., E.G. Elinsky, and L.G. Pawlson. 1991. "Effect of Education and Feedback on Thyroid Function Testing Strategies of Primary Care Clinicians." Archives of Internal Medicine 151: 2163-66.

Ubel, P.A. 2000. Pricing Life: Why It's Time for Health Care Rationing. Cambridge,MA: MIT Press.

Ubel, P.A. and S.D. Goold. 1998. "'Rationing' Health Care: Not All Definitions Are Created Equal." Archives of Internal Medicine 158: 209-14.

Vijan, S., T.P. Hofer, R.A. Hayward. 2000. "Cost- Utility Analysis of Screening Intervals for Diabetic Retinopathy in Patients with Type 2 Diabetes Mellitus." JAMA 283(7): 889-96.

Welch, H.G. 1991. "Should the Health Care Forest Be Selectively Thinned by Physicians or Clear Cut by Payers?" Annals of Internal Medicine 115(3): 223-26.

How Well Protected Are Canadian Research Participants: Who Knows?

noreply@blogger.com (Longwoods) — Tue, 06 Jan 2009 03:57:00 +0000

From Dorothy Pringle, the Editor-in-Chief of the Canadian Journal of Nursing Leadership:

The human research enterprise in Canada is large and growing. It spans a wide range of fields that includes political science, sociology, anthropology, education, social work, nursing, epidemiology and medicine among others. Funding comes from many different sources, including the charitable research foundations such as the Heart & Stroke Foundation and the Canadian Cancer Society, hospital foundations, the three national funding councils - the Canadian Institutes of Health Research (CIHR), the Social Sciences & Humanities Research Council (SSHRC) and the Natural Sciences and Engineering Research Council (NSERC) - and the major provincial funding organizations in Nova Scotia, Quebec, Alberta and British Columbia among many others. Not all research is funded. This is particularly true of the humanities and student research across all disciplines.

In Canada, all research on human subjects must be approved by a research ethics board (REB). The major funding bodies will not release funds until an REB has approved the study. In Canada, the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS) (Medical Research Council of Canada, 1998) dictates research ethics. It was developed over the 1990s by the Tri-Council Working Group under the auspices of the three national funding councils (the Medical Research Council preceded CIHR as the health research council signatory) and was finally adopted in 1998. By December of that year, all institutions that conducted research were expected to be in compliance with its tenets, or be in the process of becoming so. Since that time, many organizations have invested significant dollars in staff and in information technology to enhance their capacity to undertake credible reviews. Research ethics offices in universities and hospitals, in particular, have grown in size and expertise to respond to the increase in studies that have to be reviewed and to demonstrate the increased expectations of accountability.

So, is there a problem, and if there is, what is it? The answer is, we don't know, and the existing system does not make it possible for us to know. The current state of research participant protection in Canada has evolved over time and in response to the numerous policies and expectations set by Canadian and international research funding bodies and other authorities. These policies are not necessarily congruent, and it is virtually impossible to be in compliance with all of them. In fact, the TCPS pertains only to research conducted through funding from the three national research councils, although most organizations stretch that to apply to most of the research coming to their REBs. There are no standards for education in research ethics for investigators, graduate students undertaking research, REB members and chairs, or research participants; for example, some REBs have no members with expertise in law, privacy legislation or qualitative research yet are reviewing proposals that require some or all of these competencies. There are no standards for the operation of research ethics offices in terms of resources, compensation for or acknowledgement of REB members' work, and length of terms for REB members. Proportionate review is still a thorny issue, particularly for researchers in the social sciences and humanities, who believe, with some justification, that the TCPS is biased toward medical or health sciences research. They contend that the level of risk to participants in most of their research studies is much lower than that of medical research in which participants' health and well-being may be jeopardized, and their studies do not require the same scrutiny accorded medical research. The TCPS addresses this and calls for risk to be judged appropriately to the circumstances of the research, but REBs are left to develop their own standards on this issue. Researchers proposing studies that involve collecting data in several (and sometimes dozens) of sites face a requirement for their research proposals to be approved by an REB in each site; this can take months and even years.

On the other hand, while there are gaps in policies, concerns about under- and overzealous application of policies that do exist, and angst about multiple REB approvals, Canada has not seen the major breaches in research ethics that have arisen and cost lives in other jurisdictions. In the United States, some universities have had their entire medical research program shut down and all federal funding withdrawn because of grievous breaches to research ethics. However, there is the shared view that "the governance of research in Canada is fragmented and uneven - many players overseeing many other players through the use of many instruments" (Experts Committee 2008: 23) and, at the same time, no way of knowing how well research participants in Canada are protected.

Various groups have been and currently are trying to address these issues. The Interagency Advisory Panel on Research Ethics (PRE) was created in 2001 by the three federal funding councils to continue to elaborate the TCPS policies. The PRE has been working for several years on revising the TCPS, including the section on proportionate review, and is supposed to release its revisions for consultation before the end of 2008. Unfortunately, work from the PRE has been slow in developing, and the panel must live with the fact that its sponsors are in conflict of interest when it comes to developing policies to cover research that they fund. This requires an arms-length relationship. NCEHR, the National Council on Ethics in Human Research, is a voluntary organization of individuals with an interest in promoting research ethics and protecting research participants. It is funded by CIHR, Health Canada, the PRE and The Royal College of Physicians and Surgeons of Canada (RCPSC). NCEHR, which has been on the scene since 1989, has developed well-regarded educational programs and a site-visit program for organizations to assist in improving their participant protection programs. Additionally, in 2003 NCEHR proposed an accreditation program that it would operate. However, NCEHR has not been able to secure funding for the proposed program, is frequently limited in its reach by lack of funding, and faces the same problem as the PRE in that its funds come in part from the body that funds research, reducing its arms-length status. SSHRC proposed a type of oversight program, called a public assurance system, as a way of dealing with its constituency's problems with the TCPS. This program was never embraced because it was seen as having "no teeth."

In frustration, after a meeting called by NCEHR in June 2005 to review the penultimate draft of its report describing its proposed accreditation program, The Royal College of Physicians and Surgeons convened a meeting to try to deal with the lack of progress in developing an oversight program for research ethics. It invited Health Canada, the three funding councils, the Association of Universities and Colleges of Canada (AUCC) and subsequently eight other organizations including the Association of Faculties of Medicine of Canada to form a "coalition" of sorts, called the Sponsors' Table. The main raison d'être was to establish an expert committee to look into a range of governance models for the oversight of ethics in human research and to explore issues including implementation and funding" (as cited in Moving Ahead, 2008, p. 15) The Experts Committee (of which I was a member) had among its members scientists from the humanities, social and health sciences, including those who investigated research ethics as their area of scholarship, research ethics program administrators and legal experts, and was chaired by the late Arthur Kroeger, a highly respected former federal deputy minister (Experts Committee 2008). The committee's mandate was to provide advice on developing a system for human subject research participant protection in Canada that would address the issues of concern. After nine months of meeting and consulting, the committee prepared a draft report, circulated it for consultation, revised it and submitted the final report, Moving Ahead, to the Sponsors' Table at the end of March. A sad note is that Arthur Kroeger died shortly after the report was completed.

The Expert Committee acknowledged both the strengths and weaknesses in the Canadian system but reached the conclusion that a new, independent organization was required that would take responsibility for the oversight of research ethics programs, including policy development, the establishment of educational standards, and the development and operation of an accreditation program for participant protection programs in Canada. These three functions were seen as interdependent, with one influencing the other. It was proposed that the Canadian Council for the Protection of Human Research Participants be established under the Canadian Corporations Act so that it would be at arm's length from all funding bodies. Because of fiscal realities, it was further proposed that the implementation of the Council be staged, with accreditation coming first, then policy, then education.

The Sponsors' Table has acted on some of these recommendations; it has established working groups on policy, education and accreditation and has secured funding to support them. It has not embraced the recommendation of the independent Council at this time, but neither has it rejected it, noting that a number of operational issues must be resolved first. It is not clear under whose auspices an accreditation program would operate or how the most concerning aspects of conflict of interest related to policy and accreditation would be resolved. In the view of the Experts' Committee, it is appropriate for the Sponsors' Table to further the development of an oversight system but it is inappropriate for it to operate such a system. It does not have broad representation of organizations and it perpetuates the problem of conflict of interest because the funding councils are among its members.

Nursing has not been a major player in this national drama. Nursing organizations are not represented at the Sponsors' Table, whereas organizations representing physicians are, and The Royal College of Physicians and Surgeons has played a leadership role. This is not acceptable. Nurses are now major participants in the research enterprise in this country. Nurse executives are responsible for knowing that the REBs under their auspices are staffed appropriately, have the requisite expertise among the members and are conducting appropriate proportional reviews. Deans and directors of graduate programs need to ensure that their students acquire the knowledge of research ethics that will allow them to conduct ethical studies as students, and as investigators following graduation. Nurse researchers use and are dependent on having robust and highly ethical participant protection programs available to them to review and approve their research proposals. All of us - researchers, nurse clinicians, nurse administrators and nurse citizens - need to have confidence in these same research participant protection programs. We cannot at this time. It is essential that nursing get involved, first by securing representation on the Sponsors' Table. At least one (but it could be more) of the national nursing organizations needs to take the lead on this, with a representative that is knowledgeable about issues related to research participant protection programs. Let's step up to the plate on behalf of all those individuals who contribute to nursing and all other types of research.

About the Author
Dorothy Pringle, OC, PhD, Editor-in-Chief

References
The Experts Committee for Human Participant Protection in Canada. 2008. Moving Ahead: Final Report, Ottawa.

Medical Research Council of Canada. 1998. Tri-Council Policy Statement. Ethical Conduct for Research Involving Humans. Ottawa.