Putting It into a Way Patients Can Understand

The dance performances that I look forward to every year are performances for the Harvard China Care kids at their weekly "Dumplings" activity Saturdays and their annual Children's Day Carnival. The kids are just too cute!

In an hour's time, I have to get the kids, ranging in age from 3-8 years old, excited about cultural dance and teach them a short routine. The excitement part is easy. Rhythmic music, extravagant costumes, flashy props, and the mere fact that I'm someone new is usually enough to generate excitement. Teaching is where I have to get creative.

Forget about formal dance terms. Plie, chasse, fifth position, and even the concept of beats often don't make sense to these kids. What do I do? I translate these dance terms into words and concepts they can understand. I tell them to not just stand on their toes to releve with their hands above their heads, but to reach for the stars. Instead of telling them to maintain a happy expression during the fast moving section, I tell the kids to remember to smile at their mommys and daddys who will be watching them.

I also constantly fish for feedback. I tell the kids to "Follow me!" or "Show me!" If there are any kids left standing still with a confused look on their face, I repeat the movements and try different analogies. For example, instead of smiling at their parents, I tell them to look for the funniest person in the audience. After the short lesson, we give a quick performance for the parents and China Care mentors. Performing, teaching, and then watching the kids dance is such a rewarding experience! It even beats dancing for audiences of over 1000 people!

Pauline Chen of The New York Times, recently wrote two pieces that I feel should be read together. The first piece is about connectedness as a measure of the strength of the doctor-patient relationship (click here to read!). In the piece, Chen refers to The Annals of Internal Medicine study led by researchers at Massachusetts General Hospital, which found that 60% of patients had a "connected" relationship with their doctor, 1 in 3 patients were "connected" to a practice of doctors, and 5% of patients were not "connected" at all. The study suggests that patients who are "connected" with their doctors receive better care.

The second piece is about health literacy and the large percentage of people who do not follow a doctor's advice simply because they do not understand it (click here to read!). Chen reports that nearly half of all Americans have difficulties obtaining, understanding, and acting upon information important to their health. The story Chen recounts of a former patient called Jack illustrates the great tragedy that a lack of understanding can lead to.

The messages of these two pieces intuitively make sense. As Chen says, for patients that she has known for a long time, she knows about their family and work and the patients know about her family and work. This allows for doctors to establish what Chen calls a clinical baseline. Providers then are quickly able to sense whenever the patients veer from that baseline.

It's quality interactions that help achieve this sense of connectedness between patients and their providers. In Chen's article, Dr. Steven Atlas talks about how care should be patient-centered. To illustrate this, Dr. Atlas suggests different models of care including patient interactions via e-mail, instant messaging, and phone calls all in addition to regular visits-- adapting the care model to the patient rather than trying to fit the patient to the provider.

While I believe exploring different models of care to adapt the care model to the patient is an important component of making care patient-centered, patient-centered care also puts a lot of the responsibility of care on the patients' shoulders. Shared decision making is what many call it. But, how do patients make good decisions if they lack understanding? How do patients and doctors achieve "connectedness" without understanding?



These questions become extremely important when treating underserved populations. How do you establish connectedness or impart the importance or urgency of medical advice if the patient doesn't speak English, works several jobs, does not have a reliable source of transportation, and only seeks medical attention when absolutely necessary? How are providers supposed to deliver the best possible care to these underserved populations? Simply waiting for these patients to come knocking or waiting for them to ask questions is not delivering patient-centered care and not delivering the best care possible to these populations. Providers need to mold care to the lifestyle of the patients and in a way these patients can understand.

As an Asian American, the difficulties minorities face in receiving the best care is a reality that I see often. Just a few months ago, a very close family friend was admitted to the hospital with an abdominal aortic aneurysm. My family friend, whom I'll call Auntie Ling, is an immigrant from Taiwan. She has been living in the United States for over twenty years. In that time, Auntie Ling has developed a strong support network of friends from the local Chinese school and local Chinese church. We are her extended family.

When we went to visit her in the hospital, Auntie Ling explained to us her various treatment options. She could either wait out the aneurysm and take blood pressure lowering medications or she could undergo surgery. Auntie Ling's husband then interjected that he did not want her to have surgery because there was only a 7% survival rate in the surgery. While we were visiting, the doctor came in for a short check-up and we were told to leave. We did not have the opportunity to discuss her condition with the doctor. Auntie Ling and her husband can both speak English more or less fluently, but did they both really understand what was going on?

Auntie Ling was discharged from the hospital on meds after a few days, but by the end of the week, she was back in the hospital because her pain and nausea had worsened. By the next week, she was transferred to another hospital for surgery. Her sudden decision to have surgery baffled me. My mom later explained to me that one of Auntie Ling’s friends from church had asked for clarification on the risks of surgery and found that Auntie Ling and her husband had misunderstood the survival rate. The surgery had not a 7% survival rate, but a 7% failure rate. That's a completely different message!

What kind of improvements could we have made to avoid this confusion? Auntie Ling and her husband demonstrated the ability to speak English, but this misunderstanding still occurred. Several national campaigns including Speak Up and Health People 2010 address health literacy and several reports including the 2007 National Healthcare Disparities Report and the National Quality Report recognize that significant gaps in care to underserved populations still exist.



On an individual level, all patients need to feel empowered to raise questions and providers should constantly check back for understanding. Recommendations and advice need to be framed in a way patients can understand. The National Healthcare Disparities Report and the National Quality Report recommend increased efforts of cultural competency training. Actions related to cultural competency are calling for language interpreters and using any means possible to communicate including pictures and diagrams while maintaining a respect for each patient's beliefs and culture. Families should also be involved in understanding when appropriate. Rather than "Do you understand?", perhaps "Can you please explain back to me what I have just said, so that I know you understand?" is more helpful.

What efforts can be made on a macro level to improve the connectedness between doctors and patients and improve the health literacy of all?

When it's health that is at stake, taking the extra time to ensure understanding by putting information into a way that patients can understand seems like a wise investment. When a patient returns with improved health because he/she was able to obtain, understand, and act upon good health advice, I'm sure that is just as, if not more rewarding, than teaching kids how to dance!

International Forum on Quality and Safety in Healthcare - Berlin

From the 17th to the 20th of March, nearly a 100 students and teachers/mentors from 9 different countries participated in the BMJ & IHI International Forum on Quality and Safety in Healthcare. Being a part of this group of enthusiastic group, truly made the Forum an unforgettable and inspirational experience for me, and it gives an extra boost when it come to spreading the word about the importance of quality and safety in health care to your peers back home.

The Forum had nearly 2000 participants from 65 different countries alltogether, all meeting up to share their experiences from and to learn about initiatives to improve the safety and care for patients worldwide. The spirit of the Forum is very idealistic, these people gather with a common objective, to take an active part in changing health care systems, to insure that every single patients recieve the best possible care.

Dr. Don Berwick adressed the issue of Patient and Family Centered Care in his Keynote on the 18th of March, sharing his vision about a health care system that rather would look upon patients as individuals, with different needs, rather than an unpersonal mass. This represents a different way of thinking, which in my view is what the improvement-movement is all about. To redefine the way we provide healthcare, and actually acknowledge that one might need to think outside the box to do it. This is something that struck me and many of my peers during the four hectical days in Berlin. Working on improvement and safety isn't necessarily very difficult, but it requires that you get a different perspective on the job you are doing. One of my favourite quotations from last year, which I heard again in Berlin is "We all have two jobs, one is to do the job we're trained to do, the second one is to constantly improve the job we're doing."

The improvement work that is going on in developing countries also impressed me. IHI, USAID among others, are running projects in collaboration with local authorities in several low-income countries. To see what they have accomplished, e.g. with the distribution of HAART-medication, and on maternal health should be a big inspiration for all of us, I know it is for me. It also shows one of the big strengths of the methodology of quality improvement and safety, it is universal and applicable to most health care systems.

Being given the possibility to take part of this more or less idealistic movement is an opportunity I wish all health care professional students would get. This sounds like utopia, but it is actually possible, through the IHI Open School. That however requires advocates, both students and teachers, that share their experiences and get the message across to their peers. That is something all the students and their teachers agreed upon on the very last day; we're stronger together, and we can contribute to make a change for the better.

Our first meeting

Hi there. This is my first stab at blogging. I wanted to tell you about our first meeting of the IHI Open School at Beverly Hospital. We have a non-traditional chapter in that our chapter is sponsored by a hospital, and has three nursing schools associated with it. We have only been organizing since the Congress in January, and I am very excited about the membership so far, and even more, how we can lay the foundation for this chapter for the fall. During our first meeting, we got to know each other and where everyone is in their nursing programs. We viewed a few videos that are available on You Tube, and then started a discussion about some of the things in healthcare that we have seen that need to be fixed. Many of us shared not only experiences that we had as clinicians, but many shared experiences from the perspective of being patients and family members of patients. It was amazing to me the insight that everyone had not only into the things that didn't work well, but the systems that needed to be improved. I am looking foward very much to getting to know everyone better, and for ideas surrounding improvement projects that will be meaningful to those involved!!!

Julie Holden, Beverly Hospital Chapter Leader

The Sorting Hat?

For about 24,000 fourth year medical school students, today is an important day. Today is Match Day, the day where fourth year medical students find out where and in what specialty they will be doing their residency training. I am not yet in medical school, but I couldn't help but feel anxious and excited for all those fourth year students across the country. Let's just say today was not one of my most productive days at the office.

What's Match Day like? Most medical school students will be at least 25 years old on Match Day and in an innocuous looking white envelope will be a decision--a decision on where you will spend the next two to seven years of your training and how you will be spending that time. Several medical schools host ceremonies for this important day that allow all fourth year students to open their envelopes together with family and friends. A colleague of mine traveled to be with her boyfriend on this important day. So, while this may just be any ordinary Thursday to you, Match Day is kind of a big deal in the world of medicine.

The number one question on my mind is not the results of Match Day, but what the experience of Match Day must feel like. I don't have too many experiences to draw upon, but I do have some guesses.

Perhaps, Match Day is like waiting to receive college or medical school admissions letters. Thinking back to the spring semester of my senior year of high school, that wasn't all that bad. Life went on as usual, classes, band rehearsal, homework, International Culture Club after school activities, etc.--except for those two weeks just around Spring Break. Those two weeks were extremely stressful. At the time, I had to share a computer with my sister and I distinctly remember hogging time in front of it, compulsively checking my e-mail. But, those two weeks passed by fast.

Medical school admissions was an entirely different story. All of those feelings of anxiety, excitement, worry, frustration, anger, happiness, and surprise were dragged out over a course of months! You can submit your application as early as mid-June and depending on how quickly schools get back to you, the process could be drawn out all the way up until your first day of class as a medical school student. That's nearly a year of stress! Match Day is just one day, so it's got to feel better than waiting for medical school admissions letters, right?

There is one important distinction between Match Day and college and medical school admissions. In that white envelope is just one specialty and one location. There is no room for personal choice. To avoid any misconceptions, fourth year medical school students do have the opportunity to turn in a rank list, but after that list is handed in, all control is forfeited to a computer algorithm.

Youtube video showing Harvard Housing Day celebrations. Though here, mistaken for anti-war protests

Coincidentally, today is also an important day for about 1600 Harvard freshmen. Today, is Housing Day! This morning, each Harvard freshman was given a white envelope and in it contained the name of the upperclassmen house they would spend the next three years of their undergraduate careers. Now, though not as life-altering as Match Day, Housing Day does have several parallels to Match Day. About two weeks before Housing Day, each Harvard freshman must turn in a list of up to eight fellow freshmen that they would like to "block" with. To "block" with someone means that you and your "blockmates" would be guaranteed to be placed in the same house. In addition to a "blocking group," a maximum of three "blocking groups" can "link" with each other to ensure that these groups would be placed in neighboring houses. But, outside of these decisions, a fancy computer decides where you will be spending the next three years of college. Some students will run around to all of the houses the night before Housing Day "praying" to the Housing gods for a favorable placement, but realistically, a computer determines your fate.

The Sorting Hat Song from Harry Potter

Oh, you may not think I'm pretty,
But don't judge on what you see,
I'll eat myself if you can find
A smarter hat than me.
You can keep your bowlers black,
Your top hats sleek and tall,
For I'm the Hogwarts Sorting Hat
And I can top them all.
There's nothing hidden in your head
The Sorting Hat can't see,
So try me on and I will tell you
Where you ought to be.
You might belong in Gryffindor,
Where dwell the brave at heart,
Their daring, nerve and chivalry
Set Gryffindors apart;
You might belong in Hufflepuff,
Where they are just and loyal,
Those patient Hufflepuffs are true
And unafraid of toil;
Or yet in wise old Ravenclaw,
If you've a steady mind,
Where those of wit and learning,
Will always find their kind;
Or perhaps in Slytherin
You'll make your real friends,
Those cunning folk use any means
To achieve their ends.
So put me on! Don't be afraid!
And don't get in a flap!
You're in safe hands (though I have none)
For I'm a Thinking Cap!

From Mugglenet.com

Or perhaps Match Day is similar to the Harry Potter Sorting Hat experience. Individual wizards and witches have no control over the Sorting Hat. You put on the Hat and in a few seconds he announces to all of Hogwarts your House. And in the Harry Potter world, a House is not just where you will be living for the next seven years, but shapes your training and career as a future wizard or witch. So, as we gather from Harry Potter's own experience under the Sorting Hat, this process is also kind of a big deal.

Well, because I still have a few years before my own Match Day, the best I can do is imagine what Match Day is like or try to experience Match Day vicariously through others. Congratulations to all fourth year medical school students and congratulations to all Harvard freshmen (especially those placed in Pforzheimer House!)! I'm sure just making it through this day is enough cause to celebrate!

Check Out The New York Times Pauline Chen's reflections on Match Day and an introduction to a book titled Match Day by Brian Eule.

Combining Design and Medicine: Diabetes Design Contest!

Living with and managing a chronic disease is not easy. Yet, as we all age and live longer, chronic diseases will become a fact of life. As future health care providers, we need to think in terms of the patient. What can we do to make the lives of our patients, who carry with them these chronic diseases, better? Check out this contest!



Hosted by DiabetesMine, a blog by Amy Tenderich with all sorts of resources to help those living with Diabetes, and sponsored by the California Healthcare Foundation, the DiabetesMine Design Contest is looking for innovative design products to improve the life of those with diabetes. Individuals and groups are both encouraged to join! The Grand Prize is $10,000! Click here to find out more details, read the press release, watch the youtube videos of last year's entries, and learn more about DiabetesMine.

Contest Found on Paul Levy's Blog: Running A Hospital

AMSA: One of Many "Powers"

Quality improvement of health care requires the help and participation of all of the players in the health care system: patients, nurses, physicians, administrators, insurers, government, employers, etc. This joint effort reminds me of the classic TV cartoon, Captain Planet. In order to save the environment, Wind, Water, Earth, Fire, and Heart needed to be combined in order for Captain Planet to appear and save the world! Similarly, to save the world from escalating health care costs and improve the health and wellness of all, we need to combine our powers and cooperate!

On Wednesday, Shannon and I had the wonderful opportunity to meet the future of one of these powers in the movement to improve health care at the 59th Annual American Medical Students Association (AMSA) Convention’s Preconvention Symposium on Patient Safety and Medical Quality. We were joined by about 40 other MD/DO students for an interactive day and complete immersion into patient safety and medical quality.

The day kicked off with a keynote presentation by former AMSA National President, Dr. Helen Burstin, now at the National Quality Forum. Dr. Burstin provided everyone with a high-level overview of what medical quality means, specifically focusing on the six aims outlined in the Institute of Medicine’s (IOM) charter document on quality, “Crossing the Quality Chasm.” These aims include: safety, timeliness, efficiency, patient-centeredness, effectiveness, and equity. Dr. Burstin also stressed the need for cooperation among all players of the system and introduced the National Priorities Partnership that brings together 28 of these players to the table to discuss and set goals for health reform. Click here to see a list of the diverse partners.

Dr. Don Berwick, then took the stage and gave a keynote presentation that delved deeper into what patient safety means and how students can act and make an impact on the field. Through descriptions of IHI’s 100,000 Lives Campaign and 5 Million Lives Campaign, Dr. Berwick illustrated various bundles to improve the safety and effectiveness of care, such as a bundle to prevent central line infections.



After the two keynotes, Pre-Convention leader, Wes Fischer, led the students in a emergency situation simulation. Students role played and learned firsthand the many nuances of effective teamwork and communication in a chaotic situation. Great job to all of the volunteers!



During lunch, Dr. Berwick led the students in the Red Bead Game demonstration. This teaching tool developed by W. Edwards Deming illustrates the methods of improvement. It sounds like a very dull demonstration, but I’ve watched the demonstration at least 5 times and still really enjoy it and learn something new from it every time! Click here to learn more about the game.



After lunch were three very interesting break-out workshops. In these workshops, we learned and practiced skills in effective communication between physicians and patients (SBIRT: Screening, Brief Intervention, and Referral to Treatment) and effective communication in teams (iSBAR: Introduction, Situation, Background, Assessment, and Recommendation). We also participated in a reflective session led by Dr. Paul Uhlig of the University of Kansas on why we were all interested in patient safety and quality improvement and learned of ways Dr. Uhlig had implemented interprofessional rounds and meetings to transform the culture of medicine in his health system.

Both Shannon and I learned so much and were extremely grateful to meet so many wonderful students. Hearing everyone’s enthusiasm and eagerness to learn more was very refreshing. Thank you to all of the students we had the fortune of meeting and all of the AMSA leaders for having us! I feel reenergized in my work and hope to have the opportunity to meet students representing the other “powers” soon. I sense that we will be able to soon unleash a “Captain Medical Quality” on the world! I can just hear it…. “By your powers combined, I am Captain Medical Quality!”

What can we learn from TV?

Last month, our poll asked you to pick the show you thought most accurately portrayed working in health care - E.R. won, followed by M.A.S.H. and Scrubs. House and Grey’s Anatomy get honorable mentions. I don’t usually watch much T.V., but when I do, Iend up watching one of the many shows related to health care. It gets worse – I find myself relating most of what I see to the work that we do. You can't help but notice the many examples of quality and patient safety issues that come up. Here are a few...

I couldn’t sleep the other night, stumbled into my living room during the wee hours, and flipped on the TV. I landed on TV Land and watched an episode of M.A.S.H. By the way, M.A.S.H. = Mobile Army Surgical Hospital.

Teamwork and communication. Alan Alda’s character (Hawkeye) works with a visiting surgeon. You know they’re off to a great start when the surgeon picks on the way Hawkeye washes his hands. They butt heads and can’t agree on what should be done to the patient. The medic assistant finally tells them to stop bickering and save the patient. Then, the camp is hit. Both surgeons fall; one breaks his right arm, the other his left wrist. Can you guess what happens next? They suture the patient together - one working with his left hand, the other with his right. In a very utopian fashion, they defer to one another regarding what’s best for the patient and agree on everything; smiles and all! Perhaps this it wasn't entirely realistic, but it reminds us how important teamwork and communication are, especially during stressful situations.

Surgical Safety. If you caught last night’s E.R. episode, the surgeon enters the O.R. in a rush, ready to jump in, but Eriq La Salle's character (Benton) stops the team from proceeding. They perform a time-out and use a surgical checklist. The surgeon again tries to hurry the team, but Benton tells everyone to "slow down, this will only take a minute." Aside from the checklist, you'll notice Benton also reminds the surgeon the use of antibiotics 6o minutes prior to incision cuts the risks of infection by half. I might have to start watching E.R... (Fran Griffin, thank you for sharing this clip today.)

Blame. I caught part of Grey's Anatomy last night. It looks as though Patrick Dempsey’s character (Derek aka McDreamy) is blamed for "messing up" a surgery on the last episode, resulting in the patient's death. The patient's husband sues McDreamy. After giving his deposition, we find Derek sitting in front of a stack of files. The files represent patients who died while under his care; he realizes he has lost more patients than he has saved. Derek goes into a deep depression and refuses to perform any surgeries, despite being one of few neurosurgeons in the hospital. Blame doesn't do anyone any good.

Hand Hygiene & Infection Control. There’s an old episode of Scrubs that shows the importance of hand hygiene and infection control. In the opening sequence, a bird flies around the waiting room. When asked why the bird hasn’t been removed, the janitor tells him the patients like it! Then, a bit of foreshadowing occurs. Dr. Kelso says,

“Do you know the number one cause of death in a hospital? Infection! And do you know how quickly infection can spread in a hospital...infection can start with a simple sneeze, and then a handshake, perhaps an accidental collision, and a simple touch on the shoulder...and just like that, you have a patient in trouble.”

Later, a character named Cabbage picks up a piece of trash before entering a patient’s room. When he touches the trash, his hands glow. Then, he shakes the patient’s hand, she turns green, (spoiler alert) and dies in the next episode due to an infection. The glow is a great visual of how quickly and easily infection can spread. [While I’m unable to pinpoint infections as the leading cause of death in U.S. hospitals, I can confirm hospital-acquired bloodstream infections are a leading cause of death in the U.S. and medical errors are the 8th leading cause of death in the U.S.] (Thank you, Dr. Rainu Kaushal, for sharing this with me last year.)

Where can I watch these episodes?
1. M.A.S.H.: “Lend a Hand”
2. E.R.:


3. Grey's Anatomy: “I Will Follow You Into the Dark”

4. Scrubs: Intro: "My Cabbage

and End: "My Cabbage"

Questions:
1. What examples of quality and safety have you seen when watching these types of TV shows?
2. What examples do students see in TV shows in other countries?
3. What do you think the effect these have on the audience when they see, for example, poor teamwork or errors?