Aug 8, 2009

The Journey Ahead...

This time last year, I had just stepped off a plane returning to the US from Taiwan. And without an extra second to breathe, I moved straight to Boston to start working at the Institute for Healthcare Improvement (IHI). In the same whirlwind fashion that I started at IHI, it is now time for me to embark on my next journey: medical school.

Leaving is never easy. As I scroll through my iTunes library for musical inspiration, songs like NSYNC's "Tearin' Up My Heart", Ray Charles' "Georgia On My Mind", and The Sound of Music's "So Long, Farewell" pop out to describe how I feel. But, since I've never been a big fan of good-bye's, instead, I think the song "I've Had The Time of My Life" by Bill Medley and Jennifer Warnes popularized by the movie Dirty Dancing best encapsulates how I feel about my amazing year at IHI. So, Youtube the song and listen as you read! (Apologies to those who don't appreciate my cheesy-ness!)

Now I've had the time of my life
No I never felt like this before
Yes I swear it's the truth
and I owe it all to you

Taking a leap of faith, I deferred from med school to work at IHI without fully understanding what IHI did on a daily basis, its role in the quality movement, or its impact on the world of health care. Fortunately, after a year, I now know the answers to those questions.

IHI's work aims to improve health care by applying operations management skills and tools to improve the efficiency, reliability, and effectiveness of health care delivery--viewing health care as a system. At the heart of all of this work is a strong commitment to make health care more patient-centered-- promoting patient safety and allowing the needs of the patient to drive the redesign of how health care professionals deliver care and how patients interact with the health care system. Most importantly, IHI aims to spread these changes and ideas to all. These activities include bundles to reduce hospital infections, lean and waste reduction skills, measuring and evaluating progress and improvement, learning how to work in teams across disciplines, and so much more. The content of IHI's work is truly impactful and fascinating, but is just one component of my amazing year.

Far more inspiring is the culture that IHI promotes locally within the office that not just propels us in our work, but also motivates all those in health care to continuously improve. IHI is an organization that "practices what it preaches". The culture in the IHI offices allows each individual to maximize his/her potential and relish in the energy and dynamism that teamwork provides. No one worries alone and like family, there is always at least one IHIer there to help when you need it. We work hard and we celebrate our successes. Best of all, every single person in the office is passionate about health care and their work. The enthusiasm is palpable and definitely flows freely around the boundariless office. If you ever need to feel inspired, take a walk around the office and you will be shocked with all that can be accomplished is a short amount of time. Remember that Surgical Safety Checklist Sprint? We asked hospitals to test the checklist in just 90 days! (Click here to see the map). I learned so much in my one year at IHI and feel so much pride to be a part of the IHI family. I didn't know what to expect when I started, and was given the world. Thank you to everyone at IHI for making my year memorable and life-changing!

My last few weeks at IHI were tough. All I could think about was inserting myself back into the broken health care system and how I could continue to cultivate those IHI values and skills while working hard to become a doctor. Would it be impossible for me to find opportunities to work with other health professions students? Would people find my IHI advocacy annoying? How will I find students interested in quality improvement? Do I even remember how to study? Was this going to be a really painful journey? While it has been extremely comforting to hear that the IHI doors will always be open for me, I knew I had jump out of the nest and test out my new wings.

Even though the incorporation of quality improvement and patient safety into health professions curricula has been slow moving, I have been very pleasantly surprised several times during my orientation week at the University of Michigan med school. My White Coat Ceremony did not emphasize the prestige of the medical profession, but rather the sacred gift we will now have to be a part of the lives of our patients. The Dean's address was focused on teamwork being integral to practicing medicine in the 21st century. We all spent time in the forests engaging in team building physical exercises that tested our ability to communicate effectively, pay attention to detail, and place our trust in each other. We've also already had two patient presentations where care that transcended across specialties and physical buildings was quintessential to positive patient experiences.

While I do already have hundreds of pages of reading, assignments to complete, and a quiz next week, I think I'm going to like it here. The University of Michigan also has an IHI Open School Chapter. So, I guess IHI will never be too far away. The journey ahead, I'm sure, will be...amazing.

Healthcare Reform and End-of-Life Costs

When President Obama's chief budget deputy Peter Orzag announced the stimulus bill (American Recovery and Reinvestment Act of 2009), he mentioned that the U.S. spends $700 billion each year on medical tests that don't help patients get healthier.

Policy analysts have long known that much of this seemingly wasteful spending occurs during emotionally challenging moments at the end of life. We often are willing to spend the most on those who are the sickest--even when it is unlikely to make them better. Given the highly sensitive situations involved, most politicians have been reluctant to touch this issue with a ten foot poll.

At least until now.

The recent healthcare bill drafted by the House takes on the costs of end-of-life care heads-on by providing doctors with financial incentives to counsel patients on creating "advanced directives" (commonly known as "Do Not Rescusitate/Do Not Intubate" orders). Since many patients can be sustained indefinitely on ICU life-support, the bill is meant to save money by reducing so-called "futile care".

However, the normally sympathetic editorial staff of the Washington Post has taken issue with this aspect of the bill, on the grounds that it is unethical to put financial rewards and end-of-life counseling in such close proximity.

What do you think? Join the conversation here or on Facebook

Aug 7, 2009

First, "The Cost Conundrum." Now what?

By now, someone has probably urged you to read Atul Gawande's New Yorker article on the overuse of care in McAllen, Texas. It's a jaw-dropping piece, truly astounding for what it reveals about what's driving up U.S. health care costs.

The article got noticed in high places. Peter Orszag, director of the White House Office of Management and Budget, blogged about it and concluded:

[I]n looking at an example like McAllen, Texas – a town where Medicare care costs have risen disproportionately relative to national and local benchmarks, and very quickly – it is hard not to ask what our return is on this high-taxpayer investment. From what we can measure, it’s not better health. It is simply more care.

Upon reading Gawande's article, I remember thinking, "Things must be feeling grim over in McAllen today." I felt a little sorry for them. McAllen happens to be among the most expensive health care markets in the U.S., and it's easy (and of course, instructive) to point the finger at wasteful practices there. But I wondered: do articles like this actually prompt other hospital chiefs to examine their own spending? Or does everyone shake their head at the sad state of affairs in McAllen and then continue doing things exactly the same way they've always been done?

Today I came across a really interesting blog post that (in part) answered this question for me. The post describes a memo that an unnamed hospitalist physician sent his residents, using Dartmouth Atlas data to compare the cost of care at their hospital to that of two others. The comparison, let us say, was not favorable. Here's how the physician ended his memo:

We are at the top 1% in terms of cost intensity and we use a hell of a lot of specialists...

Bottom line: When it is time for hospitals to take a haircut, even taking into account higher spending in our area -- and this is a reality as well -- we are still inefficient by the gobful. Trust me, people that matter are watching and they know we can do a lot better. Something to keep in mind as we think about how to practice sensibly. More does not equal better and it is only a matter of time before we are requested to step up and get out our `A' game. The folks who will be asking, by the way, won't be bringing cookies.

Here's what I take away from all this:

1. That is one awesome teacher. All teachers should be that honest with their students.

2. Local health care spending (whether it's especially high or especially low) is about to come under some serious scrutiny. From people like Peter Orszag, and people like Orszag's boss.

3. The people doing the scrutinizing will be relying in part on the Dartmouth Atlas of Health Care, which '"documents glaring variations in how medical resources are distributed and used in the United States."

Anyone can use the Dartmouth Atlas to look up how their state, town, or hospital is doing when it comes to using care efficiently. Is your hospital a big spender? And if so, who's working on fixing that? Go find out. Because people are going to be asking about it, and they won't be bringing cookies.