Friday, January 28, 2011

Scientific Management, Systems Thinking and Evidence-based Practice

It is Friday evening. I am studying for a first set of questions in the course I am taking at Georgia Health Sciences University. The material involves an overview of the challenges of healthcare management and healthcare policy in the United States. At the moment I am wondering if evidence-based management (and evidence based clinical practices) are only new labels for the old scientific management. When Frederick Taylor calculated the optimal size of a shovel for a particular purpose was he not collecting evidence to be used in practice? And in a way were not his instructions to "Schmidt" (so as to get him to handle 47 tons of pig iron per day) somewhat analogous to telling instructing a manager or a physician in the one best way to do something, as derived from evidence? Is it a surprise that physicians resist systems by which they are evaluated upon compliance with procedures, especially when there are conflicts between the interests of particular patients and the financial interests of organizations?

http://www3.niu.edu/~td0raf1/labor/Story%20of%20Schmidt.htm

Evidence-based clinical practices are based upon observations of outcomes in large populations of patients. But physicians face their patients one by one. It is the particular patient that a physician is trying to understand so as to diagnosis and treat correctly. Under DRG's (diagnostic related groups), for example, the patient becomes a diagnosis. The correct evidence-based process is based not on the patient as a person but on a diagnosis. Many patients have multiple chronic conditions. If we go to evidence-based practice are we assuming that physicians lack the ability to use his or her systems thinking skills (informed by the evidence of personal experiences) to assess the needs of this patient. Does process ultimately replace cognition? Is the use of professional discretion something to be driven out of clinical processes as is variance in industrial processes?

I value evidence, process, efficiency and economy. But I hope that we are not driving good physicians out of the profession by constraints that may in a way reduce the profession to something of an industrial profession in which obedience is more highly valued than personal insights. Physicians rightly value professional discretion and autonomy. If we come to no longer trust physicians as human beings with advanced knowledge and cognitive skills, can we substitute a trust in evidence-based processes?

Monday, January 17, 2011

Summary of New Health Reform Law

Readers hoping to gain a better understanding of the new health reform law will be interested in this summary made available by The Henry J. Kaiser Family Foundation.

http://www.kff.org/healthreform/upload/8061.pdf

Sunday, January 16, 2011

Reflecting on An Information Technology Implementation Challenge

This is an initial reflection upon an assigned reading by Ann Scheck McAlearney in our textbook Health Services Management, Cases, Readings and Commentary (9th) by Kovner, McAlearney and Neuhauser. The title of the case is, "An Information Implementation Challenge." The focal character is Dr. Dan Johnson who has been appointed CEO of a hospital system. Johnson favors the adoption of new information systems including a computerized provider order entry (CPOE) system and or a more comprehensive electronic health record (EHR) system. The hospital system presently runs on paper-based systems and those systems are working. Dr. Johnson, a physician, is getting push-back from physicians and the supervisor of the medical records department. He has done his homework and can cite evidence that automated systems are better once through the period of deployment and transition. The case sets up a discussion of the challenges of transformational leadership. Those who are resisting a change have also collected "data" indicating that early adoption is problematic. Dr. Johnson favors early adoption and is planning his next steps carefully. He wants this to happen sooner rather than later. He realizes that if he pushes too hard he risks alienating good people whose work the success of the hospital system depends upon. He is inviting people to become part of a working group, but the key players he needs on board have strong reservations.

What is at stake is the future of the hospital system and the future of Dr. Johnson's career as an administrator. While some younger employees and physicians appear open to use of electronic devices the culture of the organization is not aligned with Dr. Johnson's plans. I see problems with all the "obvious" solutions. A likely future scenario is that he pushes forward quickly, the plan fails, the hospital system falters, and Dr. Johnson is forced to leave. The incremental approach (what Charles Lindblom termed, "muddling through") is not likely to be acceptable to Dr. Johnson. Sometimes you can't get from "here" to, "there" incrementally, and moving slowly becomes an excuse for not moving. Johnson should look for allies in other high places in the organization but he may not find any. It would be better if the energy for this initiative had emerged from within the organization and he had been "recruited" by others to become a sponsor. So far, his attempts to reason with people appear to not be successful. He is apparently not working from an external mandate that requires this change at this time. He is likely to call a meeting and find himself the lone voice in support of this idea.

I think Johnson has to assess the situation and consider that this fight may not worth the effort. Dr. Bernadine Healy, former president of the Red Cross, took on the culture of that organization trying to make needed changes and wound up sacrificing her career. If Johnson is indeed a lone voice in the culture of this hospital system he may be best for him to find another professional opportunity now. When reason is pitted against fear reason is likely to lose. The people who resist change are not bad, selfish or dumb. They prefer the known to the unknown. We all have a natural attachment to known ways of doing things, even if we realize that the status quo is not ideal. Concerns about job loss or spending less time in direct patient care are realistic concerns. Automation involves process reengineering which often results in reducing the number of employees and modifying the responsibilities of those who remain. Physicians rightfully value their autonomy and resist changes that may force them to explain some of the decisions they make regarding their patients. Transformation is costly and requires faith that the gain will ultimately be worth the pain.

It appears from the case study that Johnson has the ability to listen. It is necessary to listen in order to gain empathy for others. The key is to create an alignment of interests if possible. I am not recommending a political approach such as Nancy Pelosi collecting Congressional votes for healthcare reform one deal at a time. But I question that Johnson can win this one based on evidence-based management alone. He must address peoploe's fears, including possible job loss and possible reductions in professional autonomy. The external environment of healthcare organizations is changing rapidly. Organizations must adapt. By adapting they have some ability to affect environmental changes. A failure to adapt is risky. I am remembering the movie, "Other People's Money." Clinging to a dying organization is futile. As a physician Johnson had to make difficult decisions involving the best interests of patients. Now as an administrator he must make difficult decisions involving the best interests of a hospital system. He has to assess what is possible and what may not be possible. He has to assess how important the future of this particular hospital system is to him. It is not selfish to walk away from one situation to join another organization more ready to accept one's heart-felt beliefs. I believe Johnson needs some internal allies to be able to make this change.

There is an episode of the original Star Trek series in which Captain Kirk materializes in some strange parallel universe by a malfunction of the transporter. Spock and other team members in that other universe are evil deriveratives of the characters we know. Spock of the other university figures out what has happened and arranges for Kirk and others to return to the right universe. The following dialog is part of this episode named, "Mirror, Mirror."

KIRK: You're a man of integrity in both universes, Mister Spock.
SPOCK: You must return to your universe. I must have my captain back. I shall operate the transporter. You have two minutes and ten seconds.
KIRK: In that time I have something to say. How long before the Halkan prediction of galactic revolt is realised?
SPOCK: Approximately two hundred and forty years.
KIRK: The inevitable outcome?
SPOCK: The Empire shall be overthrown, of course.
KIRK: The illogic of waste, Mister Spock. The waste of lives, potential, resources, time. I submit to you that your Empire is illogical because it cannot endure. I submit that you are illogical to be a willing part of it.
SPOCK: You have one minute and twenty three seconds.
KIRK: If change is inevitable, predictable, beneficial, doesn't logic demand that you be a part of it?
SPOCK: One man cannot summon the future.
KIRK: But one man can change the present. Be the captain of this Enterprise, Mister Spock. Find a logical reason for sparing the Halkans and make it stick. Push till it gives. You can defend yourself better than any man in the fleet.
SCOTT: Captain, get in the chamber!
KIRK: What about it, Spock?
SPOCK: A man must also have the power.
KIRK: In my cabin is a device that will make you invincible.
SPOCK: Indeed?
KIRK: What will it be? Past or future? Tyranny or freedom? It's up to you.
SPOCK: It is time.
KIRK: In every revolution, there's one man with a vision.
SPOCK: Captain Kirk, I shall consider it.
(He beams them away.)

http://www.chakoteya.net/StarTrek/39.htm

Cultures change slowly, but they can change. One voice can possibly initiate a change if joined by other voices. In the case study, Johnson may find a way to change the culture of the organization he leads. Johnson has power but his power is derived from the support of those he leads. He appears to have the sensitivities needed to understand the situation in a systematic way. Logic may gain its end and his vision may be realized.

Reflecting on Evidence-based Management

This is an initial reflection upon an assigned reading by Kovner and Rundall in our textbook Health Services Management, Cases, Readings and Commentary (9th) by Kovner, McAlearney and Neuhauser. The essence of the reading is that healthcare managers should make decisions based upon evidence just as physicians should practice evidence-based medicine. Basically this means there should be close ties between scholarly research and managerial practices. My approach to this is shaped by my experiences as a academic person who teaches public administration.

If there is a disjoin between scholarly research and managerial practice the easy explanation is to fault practitioners for not reading academic journals. It is not that simple. Even in public administration (PA), which is an applied field of study and practice, there is a substantial divide between scholarship and practice. The best practitioners were often not outstanding students. Successful PA scholars are not necessarily able to make a transition to successful practice. Success in scholarship requires a deep, narrow focus. Success as a practitioner requires a wide variety of interests and abilities. Scholarly journals are much more geared toward the needs of academic persons than practitioners. Even in PA, an article seldom includes an "executive summary," to clearly identify the relevance of findings to practice. Getting a paper published in a scholarly journal often requires the use of advance mathematics in the data analysis. Few practitioners have either the need or the interest to work through the mathematics. The bottom line is that practitioners are more likely to learn through informal communities of practice than by reading articles written by academics as required to advance their academic careers. Peer-review does not usually include practitioners as reviewers and what is required by peer-review to get work accepted for publication is sometimes not as rational and scientific as the public may assume. Assuming that what I have observed in PA applies to healthcare management the status quo does not favor greater use of evidence based management practices. As indicated by Kovner and Rundall, healthcare managers claim to practice evidenced-based decision making but do not cite scholarly research as the evidence they draw upon.

If a disjoin exists between research and managerial practices I believe the scholars must accept at least part of the responsibility for closing the divide. Academic cultures are probably among the most durable of all organizational cultures. It is unlikely that in the near future tenured or tenure-track faculty members will be rewarded for their abilities to span related areas of knowledge or to contribute to successful practice. If this is correct, this is sad. There is a degree of distain for academic "ivory towers" among some practitioners. And there is a degree to which some scholars look down upon successful practitioners. It is cause for concern when former students who did not display advanced cognitive skills as students sometimes move quickly into high-paying positions with major responsibilities. While evidenced-based management practices are surely important they are probably not highly correlated with successful careers as practitioners. "Success" of course can be defined in different ways, but that is probably more evident to scholars than practitioners. If the major institutions of society were ever managed by persons with the most advanced cognitive abilities it appears that those entering the systems now may be less well prepared to practice evidence-based management. If there is a gap between research and practice it is the responsibility of all concerned to try to address that divide.

Saturday, January 15, 2011

Addressing the Challenges of Multiple Chronic Diseases

This is a reflection on the article, "The Growing Burden of Chronic Disease in America" by Gerard Anderson and Jane Horvath, Public Health Reports, May-June 2004, Volune 119. The essence of the article is that a growing percentage of Americans have multiple chronic diseases; that the costs of treating people with multiple chronic diseases is high; that people with multiple chronic diseases usually see multiple physicians; and that physicians are not very successful in coordinating their efforts with one another to address the needs of specific patients. The theme here is complexity.

The human mind/body is a complex system. Physicians always take into account the complexity of multiple body systems when addressing a single medical need. But when the same body has multiple needs the complexity of interactions among the conditions drives up the complexity of trying to help the patient. And then when multiple physicians become involved (and multiple medications are prescribed by various physicians) the entire situation is likely to get out of hand. The patient is the center of the system of care but is unlikely to have the knowledge necessary to try to orchestrate the entire effort.

W. Ross Ashby introduced his Law of Requisite Variety in about 1958. The law states that if a system is to be stable the number of states of its control mechanism must be greater than or equal to the number of states in the system being controlled.

http://en.wikipedia.org/wiki/Law_of_Requisite_Variety#The_Law_of_Requisite_Variety

In the case of a patient with multiple chronic conditions, it follows from Ashby's Law of Requisite Variety that the coordinated medical care delivery system (the "control mechanism") must be at least as complex as the human body as a macro system (system of systems). Well, we are going to lose that one!

I believe there is another approach. It is root cause analysis. What becomes manifest in a patient as multiple chronic conditions may be the product of a few root causes. Stephen Wolfram has demonstrated that recursion among a very few simple rules can produce very complex fractal patterns. A chronic condition (or a combination of them) may possibly be interpreted as complex fractal patterns derived from a relatively few root causes.

http://en.wikipedia.org/wiki/Cellular_automaton

While reflecting on the article by Anderson and Horvath I am wondering if it may be possible to make clincal applications of root cause analysis in the treatment of patients with multiple chronic conditions. As it is, these authors are advocating addressing complexity with complexity, as per the insights of Ashby. Medical conditions are products of causal trees. If physicians aim too high on the causal trees they are likely to produce cascading complexities. It is the difference between the perspectives of physics and the other sciences. While others see complexity, physicists search for the simpicity from which complexity springs. If it is possible to aim closer to the roots of causal trees it may be more feasible to address the needs of patients with multiple chronic conditions more effectively.

Friday, January 14, 2011

The Roles and Responsibilities of Managers

Our reading assignments this week in the class at Georgia Health Sciences University regard the role of managers in healthcare organizations, including aspects of control, design, professional integration, adaptation and accountability. One of the points made by the authors of our textbook (Kovner, McAlearney and Neuhauser) is that the measurement of aspects of processes and outcomes is important in assessing quality of care provided. I have no doubt that Lean Six Sigma, the Toyota Way, balanced scorecard and other similar management tools are valuable. But there is also a lot to be said for just good old common sense. I wonder if managers don't sometimes become so detached from what is really happening in the organization that they miss the obvious. Bureaucratic and highly regulated organizations can create people so fixated on rules and procedures that they can miss what is obvious and common sense.

I am remembering the statement of "Dr. Leonard McCoy" in Star Trek IV: The Voyage Home as the crew is pondering what their next ship will be. "The bureaucratic mentality is the only constant in the universe. We'll get a freighter." My point is that the foundation of good management is good sense. If someone steps forward and identifies a problem or an opportunity there are probably many others who share the observation and for whatever reason have not expressed the obvious. In my opinion, good managers do not thrive on rules. Over time, they shape the culture of an organization in such a way that that common sense and shared values reduce the dependence on rules.

There is a Taco Bell store in Albany that I like. The people are friendly and the food is good. But there is one light fixture that customers are always bumping into. Its placement is a design flaw. It is suspended at a height of less than six feet. It is in the exact location that people walk to get to a table and then to place used cups and papers in the waste can. Many people bump into it. It is so obvious that it needs to be either raised or removed! There is no need for a customer satisfaction survey asking whether you enjoyed bumping your head into a light fixture today. I have asked managers at the Taco Bell store at least five times to either raise or remove the light. I have sent e-mail to "Taco Central" with the same plea. Nothing happens. Either the local managers don't care or they are powerless to take such a radical initiative as to raise a lighting fixture.

I bet there are plenty of situations like that in hospitals that managers miss because they are watching the numbers rather than looking up and seeing the obvious.

iPhone ECG Application



My guess is that apps will also be written for purposes of verifying medical compliance. For example, Medicare does not want to continue to pay for CPAP devices that are not being used by patients. An application could be created that would interface with the SD card in the machine to verify that the patient has actually used the machine at least four hours a night.

Thursday, January 13, 2011

Making Sense of Hospital Charges Data

This blog post is related to a reading assignment in a course I am taking online taught at Medical College of Georgia -- soon to become Georgia Health Sciences University. The article which was published in The New York Times is titled, "In Health Care, Cost Isn't Proof of High Quality." This article by Reed Abelson observed that there is substantial variation in the costs of various medical services among institutions and that higher costs do not necessarily correlate with better outcomes or higher quality of care. The data was derived from reports submitted by hospitals in Pennsylvania.

http://www.nytimes.com/2007/06/14/health/14insure.html

http://www.phc4.org/reports/hpr/09/

Abelson's point appears to be that payers are questioning why they are apparently sometimes paying providers relatively larger amounts of money for medical services that do not appear to be producing better outcomes overall. The data is reported by procedure/treatment, by hospital.

The measures of quality of care include mortality rating, length of stay, and readmission ratings -both for any reason and for reason of complication or infection. Average charge per case (for each selected medical procedure/ treatment) is shown for each surveyed hospital. The data reflects risk adjustment factors for all of the variables. The data is for fiscal year 2009.

So, what are people to make of this? In many instances the number of cases of a particular treatment in FFY 2009 in a given hospital is very few. Averages based upon a very few cases can be dramatically skewed by one or two exceptional cases. The data is reported in a way that is a bit confusing because unexpected high rates of short average lengths of stay are appear with the same large dark circle that otherwise is used to represent high mortality rates and high readmission ratings. It is hard to interpret the data by just looking at the representation of it, which resembles the way years/models of automobiles are rated in Consumer Reports publications. It does not appear to me that high mortality rates tend to be associated with either higher or lower costs per case. Nor does it appear that average length of stay correlates with average charge. It does not appear that the number of cases treated in FFY 2009 is correlated with any of the other data. It would take a substantial amount of quantitative analysis to test hypotheses for each procedure and treatment. It would be helpful if the data that has been published was aggregated by hospital rather than only by procedure/treatment.

My guess is that detailed quantitative data analysis would not produce any clear explanation of why some hospitals charge substantially more (on average) than others for the same procedures/treatments. I think a qualitative approach to data analysis might produce more insights. I suggest identifying the hospitals that tend to produce higher charges across most categories of procedures/treatments and then ask insiders what other attributes those hospitals share. They might be hospitals that provide high levels of charitable services and need to shift the cost burden onto patients with insurance or other sources of revenue. They might be hospitals that offer up-scale accommodations. They might tend to be for-profit hospitals, or hospitals deeply in debt. Given the list of the "high chargers," I bet one or more explanatory themes would quickly become apparent.

Tuesday, January 11, 2011

Anticipating "Black Swan" events

Nassim Nicholas Taleb's best-selling book, The Black Swan: The Impact of the High Improbable(now in its second edition) regards the anticipation of low-probability, high consequence possible events. Managers generally focus their attention on the crisis of the day and on likely near-future scenarios. There are so many low-probability possible scenarios that it may not be a productive investment of time and attention to give them much thought. It is difficult to plan for a radical change in circumstances. And an executive or manager is not likely to be faulted for failing to anticipate an event that was very improbable before its occurrence.

But medical insights are evolving rapidly. For example, the discovery of a cure for aging, resulting in radical life extension, would certainly have huge consequences to medical institutions and societies at large. It would probably result in a large increase in numbers of people with chronic medical conditions and would surely lead to substantial population growth, further taxing the limited resources of the earth. It could happen. Many unlikely things of high potential consequence are possible. Some of the work being done in theoretical physics would surely have dramatic consequences if radical new ideas could be implemented.

Monday, January 10, 2011

Healing the Body Politic

As I write this Gabrielle Giffords is in an ICU unit and expected to survive. Americans and others are praying for her recovery and remain mindful of those others who were shot recently. Physicians and other medical providers and administrators who helped save Representative Giffords life are to be commended. This includes the legislative intern with some medical training who was with her at the time of the shooting. With others, I am trying to derive meaning from what is happening in our nation and around the increasingly interconnected world.

Medicine is the art and science of healing. Distress is fractal and exists at the scales of individual and society. Our "body politic" needs healing. I find it odd that some now reason that it is the specific motivations of the shooting suspect that will determine whether or not the shooting was related to political issues, including healthcare reform. Words and images have consequences. The scope of our inquiry and concern is not the thought patterns of one apparently disturbed young mind -- that of the suspect in this case. The person is probably mentally ill and his motivations do not define the larger reality. As Representative Giffords said prior to the shooting, words and metaphors have consequences. This is about a fractured body politic. While we cannot expect neurosurgeons to heal our nation we can perhaps learn from medicine by seeing healing in a larger context.

Sunday, January 9, 2011

Representative Giffords' MSNBC Interview following Healthcare Vote

The Power of Memes

Many Americans and others around the world are trying to make sense of the killing of six people and wounding of twelve people in Arizona yesterday. We continue to think about and pray for all the victims and their families, including Representative Gabrielle Giffords. The tie to this blog, of course, is the fact that her support for passage of the recent health care reform legislation may be related to recent events. I have been thinking about why health care reform is such a sensitive issue and has such power to shape political and social divides in our nation.

A meme is an idea that seems to have a will to proliferate itself and to survive. We do not often think of ideas as having a will. But it can be insightful to consider them that way. Successful religions can be thought of as systems of memes that have evolved over time and that are especially good at reproduction and defense. For example, "go forth and multiply" is a meme and an important part of a meme system because a person's children are likely to carry the same memes as the parents.

Political ideologies are also meme systems. The virtue of gun ownership, for example, has apparently become a political meme important enough to be a criterion for the selection of president of the Republican National Committee. To the encouragement of the audience the candidates for the position recently either lamented their having an inadequate few guns or boasted of the number and fire-power of their personal collections of guns. The "gun ownership" meme is apparently thriving in at least one sector of American political ideology.

I am reaching here to try to understand why health care reform is such a hot-button issue in America today. Obviously, it is important because we realize the importance of medical care in our lives and we fear for the loss of access to costly resources. But, there is more to it than that. I believe that health care debates are intense in a democratic society because they involve the clashing of powerful meme systems.

This is like chemistry. I remember from childhood experiments that the mixing of the content of two containers can have very dramatic results. Memes and systms of memes have powerful survival instincts and when threatened defend themselves at all costs. I don't know exactly what the "powers and principalities" phrase in the Bible refers to, but memes, while hosted in "flesh and blood" are more than flesh or blood. It is the idea that you can kill a person but you cannot kill an idea. Responsible people who would become our leaders need to be very careful in the use of words and images. It is not just because there are some mentally unstable people out there. It is because memes can be like dangerous biological viruses. Substantial numbers of people cannot deal with complex reasoning and take what may be intended figuratively as literal.

The Internet is the ultimate meme machine. It puts democracy on steroids, for better or for worse. The "market place of ideas" argument is that in a free-for-all among all kinds of ideas the reasonable, rational ones will win. Not necessarily. The memes and meme systems most carefully designed for replication and survival will win. From the perspective of a meme, we are only hosts. Meme systems are complex and adaptive and exist in a common ecology of thought-space. I am concerned by what is happening in the thought-spaces of humanity and I see evidences of "bad chemistry" in many events including the shootings in Arizona yesterday. Public policies are shaped by competions among ideas and the formulation of public policies exert pressures upon highly defensive meme systems. Our leaders (and all of us) need to be careful in our use of words and images.

Friday, January 7, 2011

Democracy as faith

I see the next few years as a critical passage for America's experiment with democracy. The Republican Party is being pulled further toward absolutist perspectives by Tea Party members. The election of a President Sarah Palin in 2012 is a real possibility. Her "death squads" references (as related to healthcare policy) hit a chord among many people.
Around the world we see examples of people in Western Democracies assuming a childish perspective that government can and will make life easy. Reality is not simple and political leaders have limited abilities to, "make it better," like mommy kissing a hurt. At some point, fiscal conservatism is going to run headlong into social conservatism. Medical realities demand difficult choices. It is not possible to maximize quality, accessibility and affordability all together. I am concerned that the nature of political discourse in the United States in the near future is going to strain the fabric of democracy.

Thursday, January 6, 2011

Death of Birds not a Laughing Matter

I think the treatment of the death of birds falling recently from the sky in Arkansas on David Letterman's show is stooping to a form of sick humor not worthy of a professional person or a responsible television network. The preliminary explanations of the event are pretty lame. "Oh, they died of trauma or were startled by a loud noise." Well yes, falling out of the sky onto the earth is likely to produce evidence of trauma. Something caused them to fall and the event is dramatic evidence that we really should figure out and face up to the cause of the event. My guess is that an unusual burst of microwave radiation may be the explanation. Whatever the cause it can't be good for other life forms including humans. Let's figure out what really happened.

Monday, January 3, 2011

Doctors begin to embrace the Web

This news story appearing on the Kaiser Health News site makes the case that it is convenient for patients to be able to view their physicians' schedules and make appointments online.

http://www.kaiserhealthnews.org/Stories/2011/January/03/zocdoc.aspx?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+khn+%28All+Kaiser+Health+News%29&utm_content=Google+Feedfetcher

Physicians can make this service available to patients through a vender called ZocDoc at a cost of about $250 per month. Nearly 85 percent of appointments made on ZocDoc are made by new patients. The service provides patient reviews of physicians on their site.

The day will probably come when physicians make themselves available to communicate with patients by e-mail in appropriate situations. This is more feasible under some payment plans than others. And then there are the issues of legal liability. I wonder if e-mail communications with patients become part of the patient's record. If yes, and this happens by automation, there may be some risk to patients in terms of making ungrounded information about themselves available to insurers in a way not interpreted by the physician. Patients may speculate about things in an office visit that the physician knows need not (and should not) be entered into the record. If medical services tend to move online those ungrounded speculations by patients may be more likely to become part of a patient's medical record. The value of a person's medical record is a function of professional choices about what is included. If the record becomes bloated with content that should not be included the next step is likely to be automated searching and summary services. Artificial intelligence is not to a place where this prospect is attractive. It seems to me the solution is for e-mail communications between physicians and patients not be entered into medical records automatically.

Sunday, January 2, 2011

USMLE Medical Ethics test preparation guide

Book review: USMLE Medical Ethics test preparation guide by Conrad Risher, M.D. and Caterina Oneto, M.D.


(Image derived from Amazon.com portal.)

This book is intended to help medical students prepare for the to pass the MSLE™ Medical Ethics part of the standardized examinations required as part of their medical educations. It would be unfair to fault this good book for it not being the kind of scholarly work it is not intended to be. It contains insightful explanations of a variety of the ethical and legal situations physicians encounter. The chapters are devoted to the following topics.


  • Patient autonomy
  • Patient competence and the capacity to make decisions
  • Informed consent
  • Confidentiality and medical records
  • End-of-life Issues
  • Reproductive issues
  • Organ and tissue donation
  • Reportable illnesses
  • HIV-related issues
  • Sexually transmitted diseases
  • Malpractice
  • Doctor/patient relationship
  • Doctor and society
  • Doctor/doctor relationship
  • Experimentation


Following the fifteen chapters the book concludes with 100 questions of the type likely to be included on the test. Following the entire set of sample questions are correct answers and meaningful explanations of why the correct answer is the correct answer.

While this book is not intended to include ethical and legal aspects of health care administration I believe it is well worth being read by people preparing to become healthcare administrators. The book is available from a variety of sources.

Note: I derive no revenue from this blog. This is not a commercial post. - bjn

Saturday, January 1, 2011

Time for new physicians to have normal schedules

This news story reports the consequences of surgeons and other physicians working with sleep fatigue.

http://www.cnn.com/2010/HEALTH/12/29/sleepy.surgeons/index.html?iref=allsearch

Maybe there was a time when students completing their medical educations worked long hospital shifts for some reason. Maybe it was some kind of rite of passage. But, in my opinion, all physicians (and other medical professionals) owe it to their patients, their institutions and themselves to work a normal schedule. This is not like students at law schools being required to provide some free legal services prior to graduation.

In my opinion, these are the likely consequences of medical students being required to work excessively long shifts prior to completion of their degrees.

1) Unnecessary risks of medical errors placing patients at medical risks and institutions at financial risks.

2) New physicians becoming alienated from sources of administrative authority, making future collaborations with hospital administrators more difficult.

3) The conclusion from one's required educational experiences that it is okay to work in an impaired condition.

Would we want new pilots preparing to be employed by commercial airlines to be required to fly and land aircrafts full of passengers to demonstrate their ability to function when deprived of needed sleep? It should not be necessary for patients to call their doctor's office asking whether he or she is scheduled to be on call the night before a scheduled surgery. Legislation should not be required to require hospitals to assure that their employees are not sleep deprived. It should not be necessary to train surgeons that they should not be performing surgery when half asleep. There is a statement in the news story attributed to Dr. Charles A. Czeisler saying that, "Asking a surgeon to decide whether they're fit to perform elective surgery after having been up all night would be like asking a bartender asking somebody who's legally drunk whether they can safely drive home." If what this statement suggests is true of even a small minority of physicians it is a shocking reflection on medical professionalism.