22 November 2011

The Physics of Angry Birds

The Physics of Angry Birds | Wired Science | Wired.com:

Yes, OF COURSE somebody has taken the time to figure it out.

Turns out the slingshot is 4.9 meters tall (yikes!) and the red bird is about 70 cm tall. Yowza. The launch velocity is a constant 22m/s.

God, I love the internet.

21 November 2011

YAQRIAS (Yet Another Quality Reporting Initiative Acronym Set)

Okay, I am officially overwhelmed. I am about as well plugged in to the bureaucracy of medicine as any nonprofessional administrator can be. I am familiar with the joint commission audits, with the physician quality reporting program, with CMS core measures, with hospital compare, with HCAHPS, with meaningful use, with the hospital inpatient quality reporting program, with leapfrog and a variety of other patient safety and quality initiatives. Yet it seems that every time I turn around there is a new set of quality metrics being developed and implemented. I can't keep track of them anymore. It turns out, unsurprisingly, that our hospital is preparing for a new set of measures which will be tracked as of January 1, in addition to the measures that I was only vaguely aware of which they had already been tracking for the last 2 years.

This is, of course, the Hospital Outpatient Quality Reporting Program. You all knew about that one, right? Cause I didn't. So what this is, apparently, is yet another quality data reporting program. In these programs, the healthcare provider, in this case a hospital, is required to report their performance on certain quality performance metrics. If they comply with the reporting requirement, they receive the full payment update for their Medicare outpatient services, and if they do not report the measures, then they are penalized 2% of their Medicare outpatient dollars, a figure which can run into many millions of dollars for the typical hospital system.

It's important to understand, that at least at this time, hospitals are not being paid for how well they are performing these measures, simply for reporting them. It is not unreasonable to presume, based on experience with previous quality reporting initiatives, that ultimately payment will be linked with performance rather than just for reporting.

So what are the reported quality metrics which are relevant to emergency department care?
The existing metrics are:

  • Acute MI: median time to thrombolysis
  • Acute MI: thrombolysis within 30 min.
  • Acute MI: median time to transfer for PCI
  • Acute MI: aspirin on arrival
  • Acute MI: median time to ECG
  • Nontraumatic headache: Use of CT scan (medicare patients only)
New metrics being reported and tracked as of January 2012:
  • Troponin results within 60 min. for chest pain or MI patient.
  • CT head interpretation for acute stroke within 45 min. of arrival
  • Left without being seen rate
  • Door to Doctor time
  • Median time from arrival to departure for discharged patients.
  • Discharge instructions
  • Time from arrival to pain medication for long bone fractures 
I have to say, somewhat reluctantly, compared to previous attempts to develop quality metrics for the emergency department, these are not terrible. I remember when we had a hard time in which we had to have given antibiotics to patients with pneumonia, which turned out to be not supported by evidence and drove overuse of antibiotics in the emergency department for patients who wound up not actually needing them. I knew one emergency department, not mentioning any names, where it became protocol to give an oral dose of antibiotics to anyone at triage who complained of a cough. These new metrics seem to focus more on ED throughput and efficiency, which is certainly a major factor given the ED overcrowding epidemic. And I don't think anybody would argue that getting a troponin back on a chest pain patient in less than 60 min. is an unreasonable expectation in this day and age.

The discharge instruction metric is interesting in and of itself. This is simply a prescriptive requirement that discharge instructions, which are curiously renamed "Transition records," contain the following data elements: major procedures and tests performed during ED visit; principal diagnosis at discharge; patient instructions; plan for follow-up care; list of new medications and changes to continued medications. Again, this does not strike me as unreasonable, and seems crafted  in such a manner to compel EMR vendors to modify their standard discharge instructions to contain these fields by default.

So what is my take away from these new metrics and this program in general? Simply put, I think we are seeing the maturation of ED quality measurement and the nationalization of the concept of the emergency department dashboard. I also think that this is a continuation of the long planned trend of cost-cutting masquerading as quality management. Those hospitals that at this time are not reporting their data are already losing reimbursement from Medicare, which represents an overall savings to the program. By the time that all hospitals are on board and fully reporting the data, I anticipate that as we have seen on the inpatient side of things, payment will be linked to performance. In that setting, reimbursement will likely be withheld from those hospitals which are performing below the median or some other arbitrary percentile threshold. This moving target guarantees that at least half (or more) of the hospitals in the program will have a reduction in their reimbursement, even though they might be achieving a fairly high level of quality.

While I understand the overall crisis in healthcare costs in this country, and I understand the need to cut costs, and I also understand the need to improve standardization and quality of care, I do not like the fact that cost-cutting has essentially been piggybacked onto quality measurement. However, this appears to be an inexorable force that we are all just going to have to live with.

So, there you have it: enjoy! Another year, another set of quality metrics to measure and manage to.

20 November 2011

This seems about right

 Though my personal graph would have the crossover point way earlier.

via SMBC

18 November 2011

Frozen in Time

We respond to certain "Code Blue" situations in our hospital. In the ED, of course, and in the outpatient areas and radiology, and if needed as back-up in the inpatient units. The hospital issues one of those overhead calls when there is a code blue -- a cardiac arrest or other collapse, person down, injury, etc, but we also carry a pager in the ER in case we don't hear the overhead call. The pager also signifies which doc is designated to respond to such a call, since we often have 8 docs working at once. It's a little ritual we have at change of shift, passing off the pager and the spectralink phone, like the passing of the torch to the oncoming doc.

So of course I took the pager home the other day and had to make an extra trip to the hospital to return it. Ugh.

As I was driving back in, I took a moment to really look at the thing, and it struck me that this pager is the exact same model I used in medical school and residency, way back in the mid nineties. The exact same one.

How bizarre is that, when you think about it? This device ought to be a relic in a museum of outmoded technology. This device was in use before the iPad and iPhone, before smartphones at all, before digital cell phones. When this device was first put to market, the internet barely existed, if it did at all, computers all had CRT monitors and the fastest computers out there was running a 200mHz Pentium Pro.

Yet it remains in widespread use, having never been updated, improved or (as far as I can tell) altered in any way whatsoever. Where else will you ever find a piece of technology still in use unchanged for a decade and a half? What industry is so ossified and hidebound that it would fail to adapt to the rapid improvements in communication technology?

Only in health care, my friends, only in health care.

13 November 2011

Way Cool

Bach's 1st suite of cello, visualized

(Apologies -- Blogger ate the link)

11 November 2011

10 November 2011

Work-life balance for physcians

Doctors are, famously, workaholics. That's just the way it's been forever, at least as far back as my memory goes.You work crazy hours in residency, you graduate and work like a dog to establish your practice or to become a partner in your practice, and then you live out your career working long hours because there just aren't enough hours in the day to do everything that needs to be done. I remember, growing up in the '80s, that my friends whose parents were doctors were latchkey kids whose dad (usually the dad, then) was never at home when we were hanging out in the rec room playing Atari.

Yeah, Atari. Look it up, kids.

Not much had changed by the time I went to medical school. There was recognition of the fact that burnout was an issue -- that divorces, alcohol abuse and suicides were more common among physicians than in other professions. The unspoken implication was that being a doctor was difficult and stressful, which increased the risk of these consequences of an over-burdened professional life. These stresses were accepted as part of the turf, as a necessary part of "being a doctor." It wasn't optional, and indeed, most physician teachers that addressed the matter chose to sublimate it into a mark of nobility. Being a physician was a calling and a duty, and a physician must gladly subordinate his or her own happiness and well-being to the service of their flock.

But things have changed, or at least a slow shift is in progress. It was probably ongoing when I was in training, though I was pretty oblivious at the time. I see it more and more clearly as time goes on.Young physicians have different priorities now, and they are making career decisions based on a more self-centered set of values.

For example, a study in Amednews, cited by @Skepticscalpel, revealed that graduating residents place "free time" and "lifestyle" as their top priorities in choosing a position, above even financial considerations. Young doctors are opting for large multispecialty practices and for hospital employment in droves -- stable and predictable practice environments -- and the practice model of small group or independent practitioners withers on the vine. At the same time, driven by slightly different motives, residency hours are being restricted.

This has provoked a chorus of curmudgeonly disapproval from many, especially from within the surgical specialties. Skeptical Scalpel himself mused:

Does all this bother anyone else? I wonder what people expected? Did they not know that being a doctor involves commitment and self-sacrifice?
One commenter was rather more direct:
Being a doctor is not a job like being a banker or contractor. It is a life. The decision to become a doctor should carry as much weight as the decision to enter the priesthood. Medicine is not a dilettante's profession. Make the commitment or get out.
Which, I think, aptly summarizes the position of the "old guard," the guys who paid their dues and expect the next generation to do the same. But we (and I still include myself in this group) who are younger don't agree, at least not entirely. It seems like the demands of this profession are, in part, not intrinsic to the job but rather culturally and institutionally generated -- and thus, subject to change. Why should I spend my entire career working 60 hours a week? Is that necessary to maintain my skills? Is is worth the cost to my family and my personal life? Is it more important to me that I be a "good doctor" than it is that I be a good father and a good husband? I don't think so, and in fact, personally, I identify myself more as a father than a doctor.

Note that I am referring to a career, not to training, where there is some argument in favor of intense experience. That is a different topic.

So I am entirely in favor of the movement towards more humane and livable practice environments for physicians. And I do not think this movement is going to reverse itself, but rather, will become the new standard going forward. The phenomenon of cohort replacement, or "the replacement of old guards of organizational members and leaders with newer cohorts who have different beliefs, opinions, and values," will likely slowly but inexorably change the culture of medicine towards one in which the accepted, default position is that physicians have robust extra-professional lives.

John Mandrola, an electrophysiologist, is cautiously supportive of this transition, but poses the unsettled question of whether this is good or bad for patients.

To some degree, it's a clear win for patients. A well-rested surgeon performs better. An ER doc who is suffering from burnout is not the one you want treating your child. An internist who retires at age 50 because the office life is too demanding represents "brain drain" as the most experienced and valuable docs flee the workforce.

The surgical and procedural-based specialists seem to have the most resistance to this change, and they do have some valid points. There is a correlation between how many times you do a procedure and how well you do it.  You can learn to do a lap chole in residency, but you may not be really good at them until you have done a few hundred in the first few years of your practice. Further, surgeons have a different relationship with their patients, usually shorter duration but much more intense. This makes it harder to place boundaries on intrusion of their practice into their personal lives.

However, these hurdles are logistical barriers which can be overcome, at least in part. The use of trained and experienced physician extenders can greatly streamline the non-operative elements of care and allow the surgeon to focus his or her time where it carries the most value: in the OR and at the bedside.

The greater question of whether this is good for patients relates to the the looming physician shortage. If physicians, as a group, are cutting back on their time at work, this will require a larger workforce to deliver the same amount of care. There are some efficiencies that can be gained, especially through the use of PAs and NPs, which may mitigate the matter. However, it's hard to escape the conclusion that the trend towards a firmer life-work boundary for doctors will exacerbate the physician shortage.

I don't think that's an argument against greater work-life balance in medicine. That's still good policy. The consequences need to be acknowledged and addressed, and it's worrisome because little is being done to address the physician shortage in the first place. But it doesn't change the fact that the ability of doctors to have stable and fulfilling extraprofessional lives is good for both doctors and the patients we serve.

And in any case, the argument of whether this is a good thing or a bad thing is about as important as a debate over the tides. It's happening, as the result of thousands of individual docs all making the same personal choices, and it's very unlikely to change. So we had best recognize it and make plans to deal with it.

08 November 2011

It's all a matter of perspective

There's technically no difference between "I almost sent home that baby with bacterial meningitis" and "I made a tricky diagnosis of a life-threatening case of bacterial meningitis." The facts of the case are the same. One statement expresses justifiable pride in a job well done. The other emphasizes how close you can come to utter disaster without ever knowing it.

Apropos of nothing, I think I'll buy a lottery ticket today.