richard[WINTERS]md

Me. The Doctor.

The patient comes to see me, the doctor.
Right?

The patient doesn't come to see the assistant.
Or the nurse.
Or the CMO. CNO. CEO.

They come to see me, the doctor.
Right?

Wrong.

The patient seeks care.
To feel better. To get that part working again.
To know what is going to happen.

I, the doctor, can examine.
I, the doctor, can diagnose.
I, the doctor, can write an order.

But then what?

Nothing.

If I am alone.

…

The assistant welcomes and readies.
The nurse monitors vital information. Medicates.
Advocates and listens.

The CEO. CNO. CMO.
They see the system. They see the limits.
They grow the opportunity.

I am not alone.

Without others. My order. A silenced suggestion.
My exam. A momentary thought.
My diagnosis. Only that.

…

I can see patient after patient.
Look down and look forward.
As if I am alone.
As if the hospital is built around me, the doctor.

Or I can look left. Look right. Diagonally.
And see what I am a part of.
I see an office, a hospital, a system built around the patient.

And I can make it better.

Me. The doctor.

Weird Dream

I had a weird dream.

I was getting bills. Unexpected bills. For things I didn’t remember purchasing. 

One day a bill from LG Display for $90. Then a few days later from some engineer in Shenzen, China for $50. Then $179 from Apple. Then ST Microelectronics and Wintek and TriQuint.

Bill after bill. $1300 worth.

I called Apple.

The phone rep said, “You purchased an iPhone 4 on June 25. We have adopted the US healthcare model of billing. You will be billed separately for each part and by each individual involved in the manufacturing of your new iPhone.”

Genius.

People seem convinced that bundled payment will be the wave of the future. Why would a patient or an insurance company ever want just one bill for healthcare services?

Rich Doctor, Poor Patient

Robert Kiyosaki’s book Rich Dad, Poor Dad may rival the medical literature as the modern text of choice.

“An asset is something that puts money in your pocket, whether you work or not.”

might translate to:

“A patient is someone that puts money in your pocket, whether you see them or not.”

Patient care can fuel a prime motive of seeking multiple streams of passive income. 

Here are some ways to earn passive income:

The subscription model of infusions.
The doctor gets paid a hefty amount with each monthly treatment.

The device kick-back.
As the indications to use the device increase, so does the salary of the physician.

The procedure upgrade.
Do one vessel, or level, or joint, and get paid one thing. Do a second and get more.

The on-call beeper charge.
On-call pay grows exponentially. The beeper charge can be over a thousand dollars a night. (And a midlevel practitioner will answer the call.)

The expert witness.
The standard of care is whatever the expert witness gets paid to say on that day in court.

The lecture circuit.
Talk about the latest drug and get paid. Talk about penicillin or vitamins, not so much.

The padded hospital stay.
Keeping the patient in the hospital one more day is a lot less work than admitting another patient, and it pays well.

It’s easy to believe in the science behind something that pays you to believe in it. The more money spent. The more money made. 

Current drivers of healthcare promote spending. But do they promote wellness?

As physicians we make a good living. We speak of protecting the sanctity of the patient - physician relationship. We may speak vigorously of the dangers of taxation and malpractice. However, we need to look inward.

We serve the patient. Not vice versa.

The Social Contagion

In my office, there hangs a picture. It states love begets love. It's one of three Hugh MacLeod prints I own.

It is a reminder to me that we define our path. It also reminds me that we define the path of those around us. At various times I might read it to say misery begets misery. Or fear begets fear. Or insecurity begets insecurity.

Behavior is contagious. The love virus. The cooperation virus. The zombie virus.

I hang it over the chair where visitors sit. It reminds me of my approach.

I have a choice.

We Speak in Code

We use the same words. We mean different things.
The same words mean different things.

For example, in the hospital we talk of whether we are "fully staffed", "overstaffed" or "understaffed."

What could they mean when they say "fully staffed"?

• All of the scheduled shifts are assigned.
• Nobody has called in sick.
• We are on budget.
• I like to hear the sound of my own voice.
• We were never in over our heads.
• There is no wait.
• There was the correct number of patients to staff.
• I don't know how to get more staff.
• There is a balance of patient sickness to staff ability.
• Our staffing is comparable to similar hospitals.
• I go home on time and have all of my breaks on time.
• That is one well-equipped wizard.

"Fully staffed" may mean all, none, or some of the above. It depends on your point of view. The specific meanings of your words depend on your life experience.

We speak in code. Our words translate our point of view. Our words are shortcut interpretations of our life experiences. "Fully staffed" is code.

Decipher the code in conversations to get to productive outcomes. Clarify the words and their specific meanings.

• In what way are we "fully staffed"?
• How specifically are we not "fully staffed?"
• When are we "fully staffed?"
• What does it mean to you to be "fully staffed?"

Then have a more cogent discussion.

Skipped a beat.

The handle bar of the snowmobile fractured his ribs.
Nice guy. Mid-60s. Talkative and generous in his remarks.

It occurred yesterday. He thought it would heal by itself.
Didn't want to bother us. But now he was a little breathless.

His lung was punctured. His skin was full of air. It crackled and popped as I rubbed the betadine on his chest in preparation for the procedure.

I numbed his skin and ribs.
I pushed the 6-inch metal trocar into his chest.

He started to die.

"I don't feel so good," he said.
His heart beat began to slur. Slower and slower.
His skin drenched in sweat in an instant.
Flat line.

What have I done?
Did I puncture his heart?

He was lifeless.

I sucked the air out of his chest.
We gave him atropine.
We pushed fluids.

And he began to talk. He was embarassed.
He apologized for passing out.

We started to breath again.

----

My wife lies on the bed.

My unborn daughter is breech.
She is pointing the wrong way.
The obstetricians. Our friends. Will try to turn her.

We watch her tiny heart with ultrasound.
They apply slow, firm pressure.
Slow pressure to my wife's uterus.
To my daughter's body.

"I don't feel so good," my wife said.
The tiny heart began to slur.
The instant of the moment became eternity.

She began to die.

What have we done?

We paused.
Fluids. Oxygen.
My wife lay on her side.

The tiny heart began to beat again.

---

We carry with us an index of moments.
Visceral moments. Pauses in time.

We wonder.

What have we done?

Fewer Steps

One of our scribes wore a pedometer.
She walked over 6 miles each shift.

Six miles of chasing the doctor.
Six miles of chasing the chart, the order, the nurse, the patient.

We focus on process improvement.
Reduce the number of steps.

It doesn't make sense to have the same physician take care of patients in beds 1 and 43.

You can't see bed 43 from bed 1.
There is a different nurse.
A different tech.
A different secretary.
It's a long walk. Many steps.

It's like having a barista work the same shift at 2 different Starbucks. Just across the street from each other.

"Did you hear that order for the half double decaffeinated half-caf, with a twist of lemon?"
Nope.

"Did you know they couldn't get a line or draw bloods on that patient in 43?"
Nope.

They tried to call you, but you were doing a procedure in 1. Then they did a procedure in 42. Now it's an hour later. Nothing's done.

You can't see through walls. You can't answer every phone call. You can't eyeball the treatment result of the patient in room 1 from room 43. You can't.

One of our physicians said, "I like the walk from 1 to 43. That's how I get my exercise." That's an exercise in futility.

We aim to have the nurse, the tech, the physician, the chart and the patient walk the fewest steps for each patient visit. We want each care team to control one space.

See more patients. In less time. With fewer steps.

How many Starbucks do your baristas cover in one shift?

Administration By Email

We're no longer a group of 8 sitting around a table hashing things out. We're a partnership of 19. It's hard getting the group together in one place to talk about department and partnership issues.

How do we keep everyone up to speed?
How do we make informed decisions?

We're using a lot of email. It's an excellent way to update and get things done. But it has its problems.

Writing in the past.
There's always one person who's three days behind in the discussion. They reply on a busy email thread and everyone thinks "Dude, that was 3 days ago! Keep up."

They skipped previous emails and jumped to the present. It's not that the points made by the late responders are superfluous. Their comments may be key. But the discussion starts over again. Again.

Tangents.
In the beginning it was an email discussion of consultant coverage. Then it it transitioned to personal anecdotes about specific consultants. Then a joke. Now, it's a discussion about investing in real estate.

Tangents can be easy to redirect in a meeting. They are difficult to control in an asynchronous email conversation.

Spam.
There's a fine line between spamming and informing.

My hospital email account is filled with "Adopt An Angel", "Boiler-Room Network Upgrade", and cafeteria menu emails. The H1N1 virus has transformed into an email virus. I get nascent and forwarded emails about H1N1 from the CDC, Public Health, EMS, ACEP, and Hospital Infection Control. Mixed into this institutional spam are hospital, medical staff and department policies needing review.

There is an art to deciding what to forward and what to withhold. Is this actionable information or is it spam?

Big or small.
Write one long email with lots of little points and risk not having it read. Separate a large email into multiple smaller emails and risk not having them read.

Time.
It takes time to write a well-thought email. It takes little time to write a reflexive email. If the goal is to develop and reflect upon ideas, email is a challenging medium.

Typing-challenged.
Some individuals don't like to type. Others are Luddites. While some ROFL and LOL. Others don't. Email discussions alienate some individuals.

Discoverable.
Will I be reading this email in a court of law? Will I be reading it in the local newspaper? A verbal discussion is transient. An email is forever. A forwardable forever.

Impasse.
A Harvard Business Review article cited that face-to-face negotiations more commonly result in mutually beneficial agreements, while phone negotiations result in asymmetric agreements where one party dominates. The most common result of email negotiation is impasse (>50% vs face-to-face 19%).

Positional Bargaining.
The authors of the same article found that individuals in email discussions tend to focus more on what they may be giving up, rather than what may be the best group solution. They may focus on positions, rather than interests. This "haggling", used car salesman type of bargaining is at odds with the "openness" and give-and-take of face-to-face communications.

 
The flexibility, speed, and availability of email cannot be denied. However, it is important to think about whether it is the appropriate medium for the message.

Is there a middle ground?

We could use a password-protected moderated blog to have more substantive and on-point discussions. Tangential messages could be moderated down or serve as new threads in other focused discussions. The blog would still alienate the Luddites, may be discoverable, and may sit unused.

So how about multiuser video conferencing?

Would CMS Allow Concierge Emergency Departments?

I recently wrote about Concierge Emergency Departments. There are challenges to such a model.

Scalpel, who blogged about free-standing EDs in Texas last year, commented:

"The concept won't work unless Medicare and Medicaid are excluded because you can't balance bill."

Can we separate care from amenities? We can't balance bill on care, but can we charge for amenities? Patients visiting the ED can purchase food from the cafeteria. They can also purchase bottled water from a vending machine in our lobby. I don't believe this violates any CMS billing standards. Even though, some patients have coins for the vending machine and others do not. Do regulations prohibit charging for a private fancy chair versus a standard waiting room chair?

Those waiting in a non-private area need to receive the same level of care. Comfort scores and pain scores could be difficult to separate. How would we audit and defend the differences?

Peter from Medical Pistache commented:

"An individual may need to visit the ER once every 5 years perhaps. Few would be willing to pay a yearly subscription for services unlikely to be needed every year."

A subscription model is one model. Segmentation of services by price and per visit would provide more service options. You can get first class, business, or coach seats on a flight. Different prices and levels of service, yet all include a chair in the sky that transports you from point A to point B.

Emergency departments generate 119.2 million visits per year. That is 227 visits per minute. An extra $1 here, or $10, or $100 there could add up to significant revenue for hospitals. Service profit could be applied to help pay for the care of all patients.

Thanks to KevinMD and GruntDoc (two of my daily reads) for their referrals.

The Fainting Physician

I never thought I could be a doctor. I used to faint at the sight of anything medical.

I was 13 years old. Our class was attending a birds and the bees talk. I sat with 50 other kids on the steps of a mini-amphitheater. The teacher pointed to the large plastic uterus. Tunnel-vision, weak all over... My teenage survival instincts told me to pretend to sleep on the steps. The other pre-syncopal teens with heads bowed evidently had a similar inner voice.

As an orderly in a local hospital I watched a well-intentioned nurse insert a urinary catheter. The world became a tunnel, I soaked with sweat and the chair on wheels ran away as I grappled to sit. Suddenly I was the focus of attention. Where was I?

We dissected a placenta in medical school. I hobbled in my black-out fog to the more private bathroom.

As a resident emergency physician I was peeling fruit and accidentally created a 3 mm cut in the web space of my left hand. I gently explored my dinky incision. I awoke on the kitchen floor. Then I ate the apple.

I no longer pass out at the site of anatomy, pathology and procedure. Some switch turned on (or off). Medicine moved from the emotional "passing out" section of my brain…to the logical, analytic "red blood cells have no nuclei and mitochondria is inherited from the mother" part of my brain. I forget that these things used to be gross. I have extended periods of consciousness.

Concierge Emergency Department

Is it possible for there to be a bed for every emergency department patient? Quiet individual rooms. Entertainment kiosks. Private bathrooms. Couches for family and guests. There is demand for this level of service.

The number of patients presenting to emergency departments outnumber the beds available. Nationally, ED visits went up 32% from 1996 to 2006. ED visits in my hospital have gone up 35% since 2001. We can't build 35% bigger EDs. We can't squeeze in 35% more ED beds. We don't have the funds.

We improve processes. We see more patients in less space, in less time, with less people, and they are often satisfied.

Many patients go to the ED and never see an ED bed. They see the physician and nurse in an intake area. Blood is drawn, x-rays are ordered, and medications are given. They sit in results waiting areas for their tests and treatment to be complete. They are discharged home. Only the sickest patients get a bed.

Some patients want more service. Some would be willing to pay for that service. Others see that service as a waste of their money.

This might occur safely if we ensure that:

• The sickest patients get a bed.
• Care is not delayed for anyone.
• Although extra service may be purchased, care is equal.

For a fee, families or individuals could become members of the Concierge Emergency Department. They might want:

• A private room.
• Couches and chairs for family.
• Wireless or wired internet connections.
• Flat screen television with movies and video games.
• Food and drinks.
• The hospital's nursing and ancillary service stars.
• Member events and dinners where they get to meet the board, executives and physicians.
• Answers to outpatient questions and appointments with hospital-based preferred physicians.

Many of the tactics used by concierge primary care physicians, hotels, and frequent flier clubs may be adopted by hospitals and hospital based physicians. The fee could be paid annually or at a higher level at the time of service. A source of cash flow for hospitals.

Is it possible to separate service level from quality of care?

Be Great

My 3 yo daughter tripped in the kitchen.
A quick recovery.
A stumble. Not a fall.
She shouts, "Dad, you made me trip!"

I was in the other room.

Similar statements occur at work. From adults.
From patients. From healthcare workers.
Amplifying as we get busy.

We hold admitted patients in the emergency department. All of our beds are full. The ambulances keep arriving. Paramedics with gurneys full of sick patients form a line that extends down the hall. The waiting room is packed with patients waiting to be seen. Every bed in the hospital is full. The patients are ill. The staff is fatigued.

Enter the language of the victim. The blame.

Why are they doing this to me?
Why can't I do this?
Why don't they do this?
That's what's wrong with this job, with this department, with this individual.

Reimbursement is decreasing. Costs are rising. The economy is contracting at the level of the world, country, state, county and individual. Hospitals are starved for cash flow.  This portends intensification of the above scenario.

More sick patients. Less physical resources. Less payment.

Now is the time to rise above.

How can I add value?
How can we make this work?
What am I grateful for?

It is not the time to blame others.
It is not the time to eat our own.

Look at your values.
What is your mission?
Be great.

Hip Dislocations: The Captain Morgan

Joint reductions are one of my favorite emergency department procedures.

The pathology is obvious to both the patient and the physician.
The treatment is clear. Put the bone back in joint.
The success of the procedure is evident. The joint is back in normal alignment.

Some joint reductions are easier than others.
Fingers are very easy.
Shoulders are not difficult, not easy, but almost always successful.
Hips can be challenging. Sometimes they refuse to get reacquainted with their joint.

Hip reductions are one of those procedures that can injure the physician. One method involves standing on the gurney and yanking the leg. This can result in a tweaked back, a pulled groin muscle, and the occasional somersault off the gurney. Not elegant.

My favorite method is less gorilla, more investment banker circa 2008. You know, leveraged. You can pull with all your might or you can think like a 3000 BC Egyptian building a pyramid.

The technique I use is called the Captain Morgan.

Use brevital (not rum) or another concoction to get the perfect level of sedation.

Adopt the stance of the pirate and use your knee as the fulcrum to lever the hip back into place.

 

It doesn't work 100% of the time. But nothing does. There are 300 lb athletes where the hip pops in, and there are 90 y old ladies where no procedure short of paralysis and intubation will work.

Greg Hendey, one of my mentors, gives an excellent talk on orthopedic reductions. Here is a direct link to the pdf of his lecture at the American College of Emergency Physician's Scientific Assembly. The line drawing is from that handout.

Who Decides Physician Payments

Medicare pays physicians based on Relative Value Units (RVUs). RVUs are set based on the recommendation of the American Medical Association's RVS Update Committee.

This picture represents the makeup of the specialty societies that sit on that committee.


Not many votes for Primary Care.

Show Me The Policy

It is not uncommon in medicine to be told that you cannot do something because it goes against policy.

"CMS has a policy against that."
"OSHA says we can't do that there."
"DHS says that we have to have this ratio."

These statements are very powerful. They are discussion stoppers. They can be process improvement barriers.

I've found that the best defense to these statements is to ask in an inquisitive and polite manner:

"Can you show me that policy?"

Sometimes they can.

The Science of Waiting: Variability

Why are you waiting?
It might be due to variability.

Assume your physician's walk-in clinic can see 10 patients each hour.

The clinic in this case is the server. It's service rate is 10 patients/hour. You, the patient, are the customer.

What affect does the arrival rate of other patients have on whether you are seen in a timely manner?

During the hour you arrive, 11 other patients also arrive to be seen. Will there be waiting at the end of that hour?


Yes. There will be waiting.
The clinic can only see 10 patients in an hour, not 12.

How about a different scenario? What happens if 7 other patients arrive during the hour you get to the clinic?

That's a total of 8 patients in one hour. Again, the clinic service rate is 10 patients per hour. Will there be waiting?

It depends.

Are the patients arriving at exactly 7.5 minutes apart (60 minutes / 8 patients)?

If so, then there will be no waiting. But how often does that occur? Isn't it more likely that patients arrive at a variable rate?

If patients arrive at a variable rate will any of the patients wait?

Yes.

Think about it.

Can the receptionist process 4 people at once?
Can the nurse care for a batch of people at once?
Can the phlebotomist draw the blood on a batch of many patients at once?
Will rooms be occupied as other patients wait to move to the next step in the process?
Will you wait to get a room?

The most efficient processes can crumble as you increase the number of customers and the variability of arrival rate. Plan for variability.

The Science of Waiting: The Server

A queue is a line.

We are queueing specialists. We create lines and we wait in queue.

We wait for the:

• physician to write the order.
• clerk to enter the order.
• nurse to execute the order.
• patient to be ready to get tested.
• lab to process the order.
• physician to see the result.
• etc.

A whole series of queues. Each one dependent on the previous.
A delay at one step results in waits at later steps. Additive delays.

Every step relies on the server to process the customer.

The server can be a thing (blood analysis machine, bed, CT scanner) or it can be a person (tech, nurse, housekeeping, physician, registration clerk).

The customer can also be a thing (lab sample, dirty bed) or a person (patient, family member, nurse).

Each server can only process a specific number of customers during a specific amount of time. Additional customers wait.

Do we have the right number of servers?
Can we eliminate steps?

Seductive Detail

I've been making a mistake during some of my lectures.

I like to emotionally engage the audience. I like to make them laugh. Sometimes I tell stories as a break between content as a sort of cognitive release. Add a little spice. But am I defeating my ability to educate effectively?

Telling stories as part of a lecture can be a great way to effectively teach. However, I need to choose the stories wisely. Highly detailed tangents, while interesting, may hurt the audience's ability to learn my key points.

Cognitive load theorists believe that the brain has a limited ability to process new information at any point in time. Seductive detail is information that is interesting but not necessarily relevant to the key points. New research supports the idea that seductive detail draws cognitive processing power away from learning the main points. In fact, the more interesting the tangent, the more it impaired a deep understanding of the key points. Our brains can only process so much new material in limited time.

Am I giving too much irrelevant detail?
Does my story distract from the key points?

Simplify the Process

What is the probability of a patient visiting the emergency department not encountering an error of process?

Registration functions perfectly.
Labs are ordered correctly and return on time.
Vital signs, medications, transports, x-rays, exams…all performed without error.

Each step of each of these processes has its possibility of error. Every handoff of a task to another person has it's own risk of mistake.

Take the example of ordering and getting the results of an ankle xray.

Assume that getting an ankle xray takes 20 steps (it likely takes many more).
See the patient…
write the order for the xray on the correct ankle…
put the order in the clerks box…
have the clerk enter it correctly…
etc…

Let's say the accuracy of each of these steps is 98%.

In addition, the process of getting an ankle xray involves 5 different handoffs of information. The clerk, the radiology tech, the nurse, the radiologist, and the emergency physician are all exchanging information.

Let's assume that each of these handoffs has an accuracy rate of 95%.

Rolled throughput yield measures the predicted probability that an ankle xray will be ordered and completed error free.

Calculating the rolled throughput yield shows us that the probability of an error free ankle xray process is:

(0.98)²⁰ x (0.95)⁵ = only 52%

What happens if we reduce steps in the process?

We decrease the process from 20 steps to 8 steps.
Instead of 5 handoffs of information we have 3.

Now the probability of an error free ankle xray process is:

(0.98)⁸ x (0.95)³ = 73%

Every step and every handoff of information decreases the probability of an error free process.

An error the majority of the time does not result in a bad outcome for the patient. (eg "Can you re-fax that order?") However, it increases the time it takes to get through the system. It increases the frustration experienced by all involved.

Simplify the process.

Bacon Bandages

Available at Archie McPhee.
They have steak too.

Pattern of Patient Interactions

The same physician.
The same patient.
The same quality of care.
The same amount of time spent with the patient.
But there is a difference.

Visit 1: The physician spends all of her time seeing the patient at the beginning of the patient's visit.
Visit 2: The physician spends all of her time seeing the patient at the end of the patient's visit.
Visit 3: The physician divides her time seeing the patient into three separate interactions during the patient's visit.

After which visit will the patient be happiest?

Tour de Hospital: Don't show your sweat.

I sometimes sweat at work.

Capped, masked and gowned procedures under hot lights.
A difficult negotiation with a consultant.
Hungry. Must eat.
All certain to make me sweat.

I'm a big cycling fan and an avid cyclist.
July is a great month. The month of the Tour de France.

It's 107F in Fresno and I ride at 2p.
I wear an undershirt and it greatly increases my cooling.
It seems counterintuitive, more clothes in hotter weather.
A good base layer wicks away the sweat and provides a larger surface area to evaporate.

I wear a base layer at work.
I may be sweating, but you wont see it.
No wet shirts.
I stay cool.

I wear the 2007 Craft Pro Cool Base Layer.
There are many good base layers made by other companies.

Smile and Handshake

Every time I walk into a room I make it a point to smile.
A gesture that shows happiness, humility, and a desire to please. I'm here to help.

This can be difficult.
I may have just pronounced a patient dead.
I may have just been insulted.
Perhaps the prior patient pointed out my crooked teeth.

If I'm not ready to smile, I wait.
I meet every patient with a smile...and a handshake.

To each person in the room, "Hi! I'm Dr. Winters."
Shake hands.

If they can't shake hands, I grasp their arm.
If they don't have arms, I grasp their shoulder.
If they don't have shoulders, they are likely very ill.

Patients don't come to the emergency department to be triaged.
They don't come to talk to registration.
They are not here to sit on gurneys in half open nightgowns.
They come to see the doctor.

Here I am.

A Better Patient Introduction

At the beginning of each Fresno State basketball game there is a moment of music. Dry ice blows smoke. House lights dim. Spotlights flash. The resonant voice of the announcer shouts "Yourrrr Fresno State Bulldogsss!!!" and the players burst onto the court. The crowd gets on their feet. Everyone cheers.

Why not bring this to the bedside?

Lights down. Dry ice fog. Loud thumping music. My scribe shouts "Yourrrrr Doctor Winterssss!!!" The curtains part. I chestbutt my scribe and give everyone in the room high fives.

Might be effective. Might be awkward. Might kill grandma.

Sports teams understand that the introduction sets the tone for the whole game. A great introduction announces energy and intent. It brings the home team players and crowd together.

I used to walk into a patient's room and say whatever came to mind. Sometimes this brought the patient and myself together, sometimes it was uncomfortable and ineffective.

I've worked to make my introductions more effective.

It is work to change old inefficient ways. However, it makes work more enjoyable.