Another Example of Overuse

I have harped on the overuse of medical equipment, procedures and tests as a major cause for the high cost of health care in the U.S. in numerous blog posts. In addition, I have occasionally spoken to the fact that this excessive use is leading to harm in many instances in the patients we treat.

Although we hope that the greater acceptance of evidence-based medical and surgical protocols will start the decline of overuse, we know that this will take significant time and never be totally successful as long as physicians and other providers have full or partial ownership of the imaging technologies. Some providers will unfortunately permit the misalignment of the increased revenue from unnecessary procedures to drive their ordering practices. So what else might help? Of course, a greater involvement of the patient in determining the need for a specific procedure.

I recently saw an AP story carried in both the Wall Street Journal and The Dallas Morning News supporting my position. Speaking to the overuse of radiation in America, the author clearly articulates the negative consequences of too much radiation for any individual over his or her lifetime. Some authorities predict that in the next 10 years, two to 10 percent of cancers in the U.S. will be caused by excessive radiation—a truly sad outcome if any or all of these cases become true.

The author of this article, aware of the misalignment of incentives described above, listed nine questions that Fred Mettler, a radiation-safety expert, suggests every patient asks before getting a scan or other radiologic tests. Because I agree totally with him, I list them here:
• Is it truly needed? How will it change my care?
• Have you or another doctor done this test on me before?
• Are there alternatives like ultrasound or MRI?
• How many scans will be done? Could one or two be enough?
• Will the dose be adjusted for my gender, age and size? Will lead shields be used to keep radiation away from places it can do harm?
• Do you have a financial stake in the machines that will be used?
• Can I have a copy of the image and information on the dose?

It is my hope that through the combination of the use of evidence-based medical practices, the education of the public through similar articles, and the patient/family questions like those listed above, the overuse of medical and surgical treatments will be eliminated, thereby achieving our goal—high quality, low cost health and wellness care for all!

Now it’s Recalls!

In last week’s blog post, I talked about my growing impatience with public apologies, connecting the dots to the importance of effective, honest, and transparent communication for excellence in leadership, including those of us on leadership teams in the health care industry!

Unfortunately, this week I have reached the same level of impatience with recalls, which are escalating in car companies as well as in the pharmaceutical industry and with other health care vendors.

We all know that as a whole, health care delivery sites in the U.S. and globally have not yet reached the highest quality and, therefore, zero occurrences of bad outcomes driven by strict adherence to safety guidelines. However, if the magnitude of violations of safety standards causing massive recalls in the industries listed above was occurring in U.S. hospitals, many would need to be closed.

In addition, if you would peruse the quality review processes in the car industry, I seriously question whether some members of their leadership teams are spending sufficient time debriefing and establishing a clear list of both lessons learned and what must be done to prevent the same bad outcomes from repeating themselves. How much into their quality improvement initiatives and how quickly are they being transparent and honest with their consumers?

What does all of this mean for us reaching for the best health and wellness practices for those we serve? I can think of at least seven implications:

1. Any recall/bad outcome is one TOO many!
2. We are taking care of human beings, not cars, and the sanctity of the trust our patients put in us cannot be violated.
3. Significant resources in ensuring our processes and procedures are correct must be placed up front rather than retrospectively!
4.Regardless of our prior success, we never can become complacent.
5.We must be as transparent as quickly as possible when we know we have made an error.
6.We must debrief on all misses and near-misses and make sure we have maximized our learnings.
7.We must turn our learnings into implemented corrective action plans to prevent the negative results from occurring again.

So the next time we hear about another recall, I would ask us to pause and make sure we review the seven implications for us outlined above. CHRISTUS Health is constantly striving for excellence because it is what we are called to do and what our patients deserve.

Sick of Apologies!

Are there others out there who are sick of hearing apologies? It seems recently that almost every day, some government or public leader, present or past, is apologizing for remarks he or she made. In addition, company CEOs are having to apologize for both their unfavorable actions’ outcomes as well as explanations they are giving initially to us—the consumers—to support these actions.

Has everyone forgotten the old adage, “Think before you speak?” We know one of the critical competencies for successful leadership is strong communication skills, both verbal and written.

Trusting relationships among leadership teams are dependent on consistent, open, honest, and transparent communication. Credibility of leaders depend on clearly-communicated rationale for the decisions, strategies, and vision the organization is taking.

We all know that to be successful in a leadership team, whether at the system, hospital, department, service line, project or task force level, one must embrace the following guidelines:
1. Articulate your position clearly, with consistency.
2. Be open to listening to other positions if they likewise are clearly communicated.
3. Be prepared to maintain your position or have it changed based on the communication of others in the meeting.
4. Be willing to support the consensus of the group, once it is reached, even if it is not your original position.

Clearly, we have somewhat of a void in strong and successful leadership in parts of our federal, state and local governments as well as in some for-profit and not-for-profit industries. Perhaps one of the drivers of this void is that too many leaders are speaking before they think it out. Excellent, successful outcomes will not be led by people who have to apologize for their verbal and written communications and their actions. To avoid such detrimental events, one must thoughtfully reflect on what comes out of their mouths.

In the end, we all know there is no substitute for intelligence that supports excellent communication skills. I would ask us to all ponder if leadership in all aspects of the public and private sectors would not be more successful if many leaders talked less and thought more!

There is a lot of gray in medicine

A significant saving in health care costs in the U.S. has been produced due to the increased incentives tied to the use of evidence based medicine-driven protocols. An article I read recently entitled “Rational Arguments – Evidence is Only one Part of the Story,” clearly highlights the challenges that evidence-based medicine and their outcomes will face.

For me, it was again a reminder that although we would like medicine to be black and white for both providers and patients, that in reality it clearly exists in a grey zone. It also is a stark reminder that technology-driven diagnostic tests are rarely a completely, 100 percent accurate diagnosis for a patient’s symptoms, and the final treatment plan must be devised by coupling the diagnostic study with the physical examination. Therefore, arriving at the best treatment plan—somewhere between the totally subjective and objective—must be done in the gray zone.

What does this mean? Should we walk away from the research studies that are described in the article? Should we forgo seeking the best clinical trials to guide us to the best treatment plan or drug? Because a large percentage of patients will not follow proposed treatment plans which they know will improve the quality of their life, should we decide that the effort of seeking the evidence is not worth it?

We all know the answers. We must continue to get providers to follow well-proven practices so that more consistency and predictability in the appropriate mix of studies, supplies and treatment plans will occur. This approach will result in a reduction of overuse, underuse and misuse of health care resources, which ultimately will lead to a higher quality, lower cost health and wellness outcome.

Secondly, we must continue to educate the patients with data on what would be in their best interest to keep them as healthy as possible and symptom-free. Recognizing that achieving 100 percent compliance is an issue, and will never be reached, we still need to always do what is right, and recognize that improving the health of a large population will always be done one patient at a time.

Clearly the article is correct—evidence is only part of the story. Pneumonia can mimic gall bladder diseases. “Heart symptoms” can be attributed to gastrointestinal disease, and a migraine can masquerade as a temporary stroke. This gray zone will always exist in medicine, but by collecting more and more evidence and sharing this information with both providers and patients, I firmly believe that the gray zone will be significantly narrowed, and higher quality/low cost health and wellness care will be the result!