Instead of White Coat Ceremony....How About a White Coat Funeral?

With the help of my sister and best friend, Emily, I can confidently walk out of my house knowing that I will not look like a fashion disaster. Shopping with them has helped me learn that while some fashion trends don't make sense (sunglasses with slits), a lot of fashion does make logical and practical sense. There are silhouettes and fabrics for specific seasons and occasions (wool when it's cold or skirts in the spring). So even in the name of fashion, it's about time doctors align fashion with practicality!

Yesterday, the AMA agreed to recommend that hospitals ban the white coat. As the WSJ Health Blog reports, "the risk of cuffs spreading infection between hospital patients isn’t worth the symbolism of the white coat."

Hospital-acquired infections is a serious and unfortunate problem within our health care system. According to the CDC, in 2002, 100,000 US patients died from infections acquired in hospitals. This makes hospital-acquired infections a leading cause of death in the US (click here to see a great Scrubs TV show episode illustration of how easy it is to spread harmful bacteria in a hospital). While there is no conclusive study that links white coat cuffs to infections, there are studies that have demonstrated that white coat cuffs do carry bacteria like MRSA and C. difficile.

In Shannon's visit to Scotland a few months ago, she noticed that no one wore a white coat or a tie. Most importantly, everyone rolled up their sleeves when seeing patients to abide by a new uniform dress code.

Ironically, I have just ordered my white coat in preparation for my White Coat Ceremony in just a few months. The first thing I'm going to do with my coat is to shorten the sleeves. The AMA has only passed a recommendation to abandon the white coat and says that it will be contacting the AHA to help implement this recommendation.



Here's where I think the IHI Open School could get involved. For every White Coat Ceremony that is going to occur this fall, why don't we advocate for a new extra step to the ritual. All incoming medical students should cut off the long sleeves of their white coat together. The purpose of the White Coat Ceremony, as started by the Arnold P. Gold Foundation, is to promote humanism in medicine. Why not take that extra pledge to our future patients by ensuring their safety?

What are your thoughts on the idea? For those of you in other health professions, do your professional uniforms need a fashion update too? Post a comment here!

A Hospital-Based Chapter: Curriculum, Research, and Reasons to Exist

In my second posting about my experiences as Aultman Hospital’s Institute for Healthcare Improvement (IHI) Open School Chapter Leader, I will describe the responses that the IHI Open School received from my medical school and hospital administrators and faculty. Each entity seemed to be drawn toward different aspects of the Open School. I believe such responses can serve as reference points as to how the Open School and individual Chapters can improve and evolve over time.

As I stated in my first posting, Aultman Hospital is a hospital-based Chapter of the IHI Open School. The hospital, itself, is a training ground for students in various health professions – including the students of my medical school whose main campus is about 35 minutes away. Those students at the medical school’s main campus are mainly first and second-year medical and pharmacy students who have yet to start their formal clinical training.

The response on campus was positive – if not slightly hesitant. The apparent hesitation as well as the overall positive reaction both appeared to stem from the same theme: quality improvement (QI) and patient safety (PS) in the curriculum. At our kick-off event, the topic of QI in medical education was touched upon by our speaker. Immediately, questions and comments arose from the audience, which was made up of both faculty and students. The discussion revolved around a point that was made by one of the clinical faculty members: to insert a topic into the curriculum, many times, can only result at the expense of another. If this is true, how does one justify the teaching of a topic that will not be directly tested on student exams?

There are no easy answers to this question. But, after the kick-off event, I wanted to look for clues.

I set up a meeting with my school’s Director of Career Development and Advising. I was interested to hear what the actual buzz was in terms of the Open School as well as the possibility of injecting IHI’s ideals into the medical school curriculum. I was surprised to hear of the faculty’s strong interest in the direct teaching of topics such as QI and PS. I gave my opinions on how such a thing could be implemented, and the meeting ended with both parties taking a “we shall see”-approach.

Shortly after this meeting, I was informed by multiple third year medical students as well as the Chair of the Department of Family Medicine that IHI’s online questions were used as part of the school’s M3 clinical site orientation (what my medical school calls “Intersession”). Though the Chair was extremely happy with the questions, themselves, he found that students were not as interested in doing the questions as he would have liked.

Nevertheless, as a Chapter Leader, I was sold on the idea that it was possible to include various lessons about QI and PS in an already established curriculum without sacrificing other lessons. The hope is that disseminating such information so early in the curriculum creates a stronger foundation upon which the student can build his or her tools as a physician. Also, such topics may even strike a chord of emotional importance to a few students as they did me. Further, I believe these events show the evolution of a campus from one that was once “IHI-less” to one that is working (even, at times, seemingly fighting the students, themselves) to include the ideals of QI and PS in the curriculum.

While the school seemed to be interested in curricular matters, the hospital at which my Chapter is based seemed to be more interested in matters of research and inclusion. The whole point (and rightly so) of a hospital-based chapter (as opposed to one that is campus-based) was to stress the universal importance of PS and QI. As I mentioned in my last posting, a number of nursing students seemed to have latched onto these ideals, and it remains to be seen how easily such ideals will be able to be stressed to other health care disciplines. As for communicating our message to medical students at Aultman Hospital, I found great partnerships with the hospital’s residency directors. In fact, one went out of his way to personally invite his students to our hospital kick-off event. I was also impressed with Aultman Hospital’s interest in the vast amount of possibilities that a group of students such as the Open School Chapter can offer in terms of conducting research. The broad topics of QI and PS allow for a vast amount of research options as well as a way to research ways to improve in-hospital methodology directly.

After setting the goal of developing a research project with my Open School Chapter, the hospital went out of its way to help our Chapter create, develop, fine-tune, and submit our research request and protocol to the human research review board. My Chapter Advisors did their best to read literature and brainstorm along with our Open School Chapter to develop the best research project. Yet, they allowed us the freedom to find our own way in terms of developing the project, itself. The research project was recently passed by the hospital’s HRRB, and it will begin at the end of the month of June.

Thankfully, I encountered very little in terms of negative reaction towards the IHI and the Open School. Many were excited to help bring the ideals of the IHI to the students on campus and at the hospital, and the lessons I took away from these experiences are important ones that I would like to pass on. To be honest, such lessons may be old-hat to the driven students who are no doubt reading this post. Yet, they are worth repeating because, in the midst of our busy lives as students, it is always nice for a Chapter Leader to have a starting point.

1. Do not be afraid to talk with administrators 1-on-1. My school is constantly fine-tuning its curriculum in order to continually improve its students’ knowledge-base. Yet, evaluations and focus groups aside, you and the administrator may surprise one another by merely sitting down in a quiet room for a candid discussion in regards to your passions.

2. This stuff is new – so make it familiar. Going over the possibilities of IHI’s curriculum with a school administrator was easy only after I sat down to reflect as to where such information would naturally fit into what has already been established. Sessions prior to clinical courses, times normally set aside for small group discussion, and lectures dealing with ethical considerations were areas in the curriculum where the IHI’s curriculum can be included without necessarily excluding other material.

3. Open School = inquiring minds who WANT to know – and have some time to find it out. Many physicians with whom I spoke about possible research topics seemed to be bursting with research questions that they had always harbored. Unfortunately, they never had the time or the man-power to investigate. Your Open School Chapter has that time and that man-power. The only rule: decide on a research question as a group. While discussing possible research topics (no matter how I felt, personally) I always inquired as to how each individual member felt about each particular topic. If even one person was not on board, I discarded the topic. My reason? The Open School is made up of unpaid students who all have other responsibilities and stressors other than the Open School. Therefore, I wanted to choose a research topic that would sustain the interest of the entire group for the duration of the project.

4. Act fast. I set up my meetings with administrators and students very shortly after our IHI Open School events. Even though they were engaged at our events, I wanted to be able to speak to them personally while they were still interested. Again, people have other things going on in their lives, so make sure to speak to them personally while their interest has been peaked.

5. Have a reason for your Chapter to exist. In other words, set a goal for your Chapter. On a number of occasions, I was asked to not merely restate the overarching goal of the IHI or the Open School but to instead explain why it is important for my particular Chapter to exist in a particular place (“Why at Aultman?” or “Why start this student group on campus?”). Truthfully, students create “student interest groups” all the time. Differentiate your Chapter from these groups by using the tools on the IHI Open School website and the goals that you and your Chapter decide upon.

6. Smoothly and competently transition leadership. I have since graduated from medical school and will begin life as a resident in July. The transition from me to our new Chapter Leader was an easy one, because I did not accomplish any of what has been described above alone. I started my Chapter of the Open School knowing that I did not want to put my time into something that would dissolve shortly after my departure. More likely than not – if you are reading this – your Chapter of the Open School would not exist if it were not for your hard work. Therefore, why hand it over to someone who is only casually interested in the topic? Transfer leadership to a person (or a group of people) you trust and who will work to build upon what you have worked so hard to achieve. For me, that person is Holly Dyer. She has attended almost every IHI Open School meeting with me, has dealt with my crazy M4 schedule, and, most importantly, cares about this stuff as much as I do.

In my opinion, the IHI Open School’s broad range of possible topics and methodologies for individual Chapters to cover is a double-edged sword. Research, online cases, clinical case discussion, on-call conferences are just a few of the possible topics to cover at Chapter meetings. This aspect is wonderful in terms of catering to the different interests of individual members. Yet, I believe so many options can sometimes make it difficult for new Chapters to find their footing, their niche, and, really, their reason to exist. My Chapter has elicited positive reactions from both campus-based and hospital-based administrators. Our Chapter’s existence has opened up new discussions about matters of curriculum as well as avenues of research. Nevertheless, such things would not have been possible without our Chapter’s work to narrow its focus, set its goals early, and be proactive.

I am interested to know how other Hospital-Based Chapters are faring. Has anyone encountered any negative reactions towards their Chapters? Are any Chapters having trouble finding members or establishing/accomplishing goals?

Obama's AMA Speech and Media Response

Regular New York Times contributor and Costs of Care team member Ariana Green recently summarized the media response to President Obama's AMA speech on the Costs of Care blog:

In the wake of President Obama’s speech in front of the American Medical Association, various interesting conversations about health care costs have occurred in national media. The New York Times ran an editorial on what could be done so that doctors no longer feel they need to order potentially unnecessary tests to protect themselves against malpractice suits. The Times also ran a story scrutinizing the health care “rationing” rhetoric.

On NPR, health care was the topic of the day following Obama’s address. It’s worth listening to On Point’s show where professors and journalists field questions about the feasibility of reform. Also interesting is Talk of the Nation’s examination of whether doctors are the "problem" in terms of driving high cost care .

Lastly, here is a reported piece on a model, low-cost county.

What Causes a Plane to Crash?

With the crash of Air France flight 447 still fresh in many of our minds, I thought it was a coincidence that an entire chapter of Malcolm Gladwell's Outliers: The Story of Success (an audiobook I'm currently listening to) would be devoted to discuss plane crashes.

The chapter investigates the causes behind the Avianca flight 52 crash and here are some interesting points that were discussed:

Plane crashes are more likely to be a result of an accumulation of minor malfunctions and extenuating circumstances. Characteristics of a typical crash include:

• Poor weather (causing a little more stress than usual)
  
• Planes are behind schedule (causing pilots to be rushed)
  
• The pilot has been awake for over 12 hours (meaning the pilot is tired)
  
• In 44% of crashes the two pilots have never flown together before (communication difficulties)

Crashes are usually not a result of problems in knowledge or flying skills. The kinds of errors that do lead to crashes are almost invariably errors of teamwork and communication. Is this beginning to sound familiar to anyone? The health care lights were definitely flashing in my mind!

What led to the Avianca crash was a series of crucial misunderstandings. Communication between the flight crew and air traffic control and communication between the captain and first officer was not clear and effective. In the chapter, Gladwell highlights excerpts of the black box transcripts. The conversations that took place just minutes before the crash are disturbingly calm and ambiguous. There was no sense of urgency or emergency, until it was too late. There were several apparent examples of mitigated speech, communicating in deference to higher authorities.

The conclusion Gladwell comes to is a result of human factors research. Successful flights often require skills that fall out of the normal piloting skill set to include the ability to communicate and share information in the clearest most transparent way possible.

The lessons of the Avianca crash extend beyond aviation. Good medicine also requires effective communication. Doctors, patients, nurses, pharmacists, residents, and health professions students all could use a good lesson in communication, so that medical errors are caught and resolved, processes improved, and most importantly, lives are saved.

If you haven't read Outliers yet, here's a good health care reason to do so!

Doctors and the Costs of Care

A recent New Yorker article described a small border town in Texas with the most expensive healthcare in the United States. The author, Atul Gawande, investigated what led to such high costs in such an unlikely place. The answer was surprisingly simple: doctors in McAllen, Texas, have the most incentives to order unnecessary tests and treatments for their patients.

Unfortunately, researchers at Dartmouth have demonstrated that the problem in McAllen is pervasive throughout the country--a fact that has not escaped the Obama administration. In fact, Atul Gawande's article has become so influential, that the New York Times recently reported that it is now required reading in the White House.

These developments were followed by a New York Times editorial today that specifically advocates for the type of solution that our organization, Costs of Care, is trying to address.

We believe that cost-sensitive doctors are less likely to inflate medical bills with expensive and unnecessary tests. You can join our community of healthcare providers and patients interested in lowering costs at the point of care by becoming a fan on facebook.

Pay for Performance and A Glass Jar for Marbles

Throughout elementary school, middle school, and high school, the best term that would describe me would be, "teacher's pet." I was not trendy, funny, sporty, or rebellious. I was good at following the rules. And most importantly, I was recognized for following the rules both in a good way (by my teachers) and a bad way (by my classmates). I'm not entirely sure what motivated me to follow the rules, but thinking about my quest for good behavior through a "pay for performance" lens may provide some interesting insights.

"Pay for performance" or P4P is a hotly debated topic in health care. Many who see the perverse misalignment of incentives in the current "fee for service" or FFS payment schemes often suggest P4P as an alternative. P4P, as defined by Dr. Don Berwick, is "a contingent relationship, enforced, and implemented in an organizational hierarchy, in which supervisors judge the merit of the work of those below them in the hierarchy and, based on those judgments, give out variable and contingent financial rewards."

In the second grade, the P4P system looked like this: Each student had a glass jar sitting in the corner of his or her desk. Ms. Gabso always carried with her a handful of marbles. Whenever she saw us behaving well, she would drop a marble in our jars. Good behavior meant not talking when she was talking; sitting quietly with our hands folded at the start of each day and as we waited for dismissal; having all of our books ready whenever we switched between subjects; and raising our hand to speak in class. Once our jar was filled with marbles, we got the chance to open the treasure chest on Ms. Gabso's desk and pick out a trinket to take home with us.

In Ms. Gabso's class merit was good behavior and our rewards were marbles. That sounds simple and fair, right?

Well, not exactly. True to being a "teacher's pet" I probably racked up the greatest number of trips to the treasure chest. But, I don't think I was the best behaved student in class. Even though I was just a second grader, I quickly picked up on my fortunate advantages. Consider the following important factors in being awarded marbles:

1) Location in classroom: Ms. Gabso dropped marbles into our jars as she walked around the classroom. The path she walked most often was between her desk and the front of the classroom. I happened to sit right along this path. That means poor Tommy who sat in the back corner of the classroom would never get marbles unless his extraordinary good behavior caught Ms. Gabso's attention or she happened to walk by that corner of the classroom.

2) Material and appearance of the marbles: The marbles were identical and made of glass. Being slippery, they were not easy to maneuver in Ms. Gabso's hands. This made it difficult for her to accurately control the number of marbles awarded. Sometimes one marble became three marbles because two would slip out. Because all of the marbles looked exactly the same, once you accumulated a good number of marbles, mistakes of awarding too many marbles or too little marbles could not be easily corrected.

3) Placement of marble jar: Glass jars in a second grade classroom is a recipe for accidents. However, our desks were grouped in clusters of six (a two by two square of desks flanked by one desk on opposite sides of the square). Those of us sitting in the square, had our jars grouped in the center. Again, because the marbles often slipped out of Ms. Gabso's hands, a few marbles to my friend Lauren on my right could also mean one or two marbles into my jar by mistake. This meant that my friends sitting on the ends always seemed to have less marbles than those of us in the center.

4) Good posture: Though she never said so, Ms. Gabso was a fan of good posture. Rather than just having your hands folded on your desk at the beginning and end of each day, if you also sat up straight, you were more likely to get noticed and be awarded with marbles.

5) First impressions: After the first few weeks of school, Ms. Gabso had identified a handful of best behaved students and throughout the year it was these students that continually were rewarded with marbles. Ms. Gabso is human after all. So, only consistent exceptional behavior as demonstrated since the beginning of the school year and dramatic improvements in behavior were noticed. If you fell somewhere in between, you were rewarded less frequently.

These five points mentioned have absolutely nothing to do with good behavior and are arbitrary and uncontrollable characteristics of this P4P system for good behavior. From Tommy in the back corner's point of view, Ms. Gabso's marble system was not fair. More troublesome is the attitude that the class developed: we only had to behave when Ms. Gabso was watching. This change in attitude was reflected in the fact that Ms. Gabso never needed to send any of her students to be disciplined by the assistant principle, but our electives instructors did.

Now, if the students were health care providers, the merit clinical performance, and the reward a financial bonus, what could you get in return? A P4P system that encouraged health care providers to only perform well on what was being measured and only when being evaluated. Does that sound like an improved and reliable system to you?

I will have to admit that my "teacher's pet" feathers have not completely been shed. Since Ms. Gabso was the only teacher to have such a P4P system in place, what continues to motivate me to follow the rules and always be on my best behavior? I think it must be the intrinsic satisfaction I must gain from following the rules and behaving well. For example, I don't need a bouquet of flowers after every dance performance to enjoy dancing and performing.

In health care, there is natural satisfaction gained from relieving pain, answering questions, working in a team, and helping those in need. Personally, I'd want my doctor to give me medical advice and the correct prescriptions not because he'll get an extra bonus at the end of the month, but because of the pride and joy he gains from caring for others.

Now, with that in mind, is P4P really a health reform panacea?

WIHI: The Blogosphere's Hospital CEO

Did y'all get a chance to tune into WIHI's discussion about hospital readmissions or the last broadcast about health IT? If you did, I'm sure you can't wait for the next installment of WIHI.

Join Madge Kaplan this THURSDAY for a discussion with Paul Levy, President and CEO of Beth Israel Deaconess Medical Center. Paul Levy with his blog "Running a Hospital" has become a true pioneer in health care. His blog entries are "must-reads" for any health care leader, administrator, or clinician interested in building cultures of improvement, safety, and transparency. Don't forget to register to listen here.

Just a reminder:
WIHI is an exciting new audio program from IHI. It’s free, it’s timely, it's interactive, and it’s designed to help dedicated legions of health care improvers worldwide keep up with some of the freshest and most robust thinking and strategies for improving patient care.

Each episode is 60 minutes and there's a new broadcast every other week. You can listen to WIHI live— via computer or telephone or both — or you can download an archived audio file for listening later (see the Technology tab for more information). All you need to do is register in advance.

The WIHI broadcasts will be hosted by IHI’s Madge Kaplan, who brings a wealth of experience to WIHI from her years reporting on health care for public radio. IHI’s Director of Communications since 2004, and the regular “voice” of the 100,000 Lives and 5 Million Lives Campaign conference calls, Madge is known for her ability to create a shared space for lively and enriching discussions.

Click here for more details about registering and listening in on WIHI.

Past WIHI broadcasts are archived and available for download here.

If you have been following these WIHI broadcasts, please let us know by leaving a comment!