Random Thoughts from a Restless Mind

You’ve heard this before: the more solutions you have for a single problem, the less likely it is that the true solution has been discovered. Once a real, conclusive solution is discovered it is accepted and implemented by essentially everyone who is presented with that particular problem. This process occurs unfettered in an open market or open system, and the cost of a particular solution depends on a combination of need for the solution and the economic incentives that exist to solve the problem.

Unfortunately, in healthcare in the U.S. this “rule” is not always the case.

Here’s a story about a solution that is NOT being used to the extent it should because private surgery centers are punished financially if they do the right thing. This example is truly a case of perverse economic incentives violating what we think of as a law of nature, that the discovery of a solution for a vexing problem will be adopted by all who suffer the problem if it is shown to be superior to all other solutions. Let’s look at the “Floppy Iris Syndrome” (AFIS) in cataract surgery.

The iris is the colored part of your eye, and the pupil is simply an opening in the iris, much like the shutter of a camera. The pupil is dilated prior to cataract surgery so that the cataract, a clouding of the lens that sits in back of the iris, can be reached and removed. Six or Seven years ago cataract surgeons began to be ambushed by pupils which spontaneously constricted or shrunk like a pursestring closing, or by an iris that started to billow like a parachute placed over a fan. Dubbed the “Floppy Iris Syndrome”, it turned out that it was caused by exposure to a certain class of medicines used for the seemingly unassociated problem of urinary retention in men with enlarged prostate glands; it has since been found to be caused by an increasing number of other medicines. It was a disaster. The complication rate for surgeries with AFIS was 10X or greater than those with a normal iris and pupil.

The search for the cause was important because cataract surgeons could now be forewarned that they might encounter AFIS during surgery if their patient had ever been on one of the medicine culprits. Once the cause and the extent of the problem were known the race was on to find a solution. Unfortunately, all of the intra-operative tactics we’d used in the past to handle small pupils were largely ineffective against AFIS. In fact, some of the standard ways to address a small pupil actually made the surgery MORE difficult because of the floppy, flaccid iris. Every week brought one or two new ideas to add to the dozens already on the table, proving the rule that many solutions means that no true answer has been found.

Enter Dr. Maluygen and his marvelous eponymous ring. The Maluygen Ring essentially solved the entire problem by simultaneously expanding the pupil and stabilizing the iris, and it was both vastly superior to all other solutions available and technically within the capabilities of pretty much every cataract surgeon. Bingo. QED. Kudos, heartfelt thanks, and a bit of profit to Dr. Maluygen and the company that marketed his Ring, right?

Not so fast there, Cowboy. Every week we STILL see articles on how to deal with AFIS in surgery despite the fact that not a single surgeon has stated, on or off the record, that there is anything that is as good as the Maluygen Ring. Here is where the perversity begins. It turns out that only hospital owned surgery centers can bill insurances for additional or special items used during surgery, and the $125 that the Maluygen Ring costs is extra and therefore not reimbursed. The majority of cataract surgeries in the U.S. are performed in private surgery centers, mostly owned by surgeons who operate in them. To begin with, private surgery centers are paid roughly 60% of what hospital-owned surgery centers are paid. $125 represents in most cases 50% or more of the gross profit (before interest, taxes, depreciation, etc)  generated in a case.

That’s right, there is a 50% financial penalty for using the best and safest method to avoid a preventable complication.

It’s no wonder that the owners of surgery centers continue to look for an alternative solution to the problems cause by AFIS. In a misguided attempt to save money, Medicare has led the charge to pay independent surgery centers less than hospital owned centers, and along the way has stripped the independent centers of the ability to pass on the cost of items that represent the “best practices” for certain situations. Rather than use the acknowledged superior solution (the Maluygen Ring) we continue to see inferior techniques utilized despite the fact that they often prolong the surgical case and fail to completely solve the problem. All because policies are created by non-clinical personnel who are only  empowered to save money.

We should be mindful of these perverse economic incentives as our American system of curing disease undergoes an historic upheaval. Do we really want doctors and others considering the economics of utilizing true, proven best practices? Do we really want non-clinicians creating policy that turns medical decisions into economic ones?

Incontrovertible data does not always lead to the expected outcome. Take for example the much-trumpeted call for “evidence-based medicine”, choosing courses of action or care patterns that have been shown to be beneficial with regards to outcomes, reduced complications, or reduced cost when no benefit has been proven. The recent movement in which several national physician organizations have been asked to identify procedures or tests that should be eliminated for lack of proven efficacy is a presumed “no-brainer” way to reduce the cost of healthcare. In my eyecare world routine pre-admission testing for cataract surgery has been singled out as unnecessary, a waste of time and money for almost everyone involved. A New England Journal of Medicine article from 1990 is cited which unequivocally  shows no benefit to the patient or the cataract surgeon. The data comes from the NEJM. From 1990. This is only a tiny bit removed in both historical context and gravitas from a couple of stones and a guy named Moses. Why are we even talking about this in 2013? Why isn’t this already a done deal?

Ah…there it is…”a waste of time and money for ALMOST everyone involved.” Some very powerful someone has an economic incentive that does not rest on either an outcome or on safety. Someone is getting paid for all of those EKG’s and blood tests for pre-admission testing prior to cataract surgery (I am a cataract surgeon; it isn’t us),  and they have found a way to interpret various and sundry Medicare and OR accreditation documents in such a way that pre-op testing is mandatory. This blatantly ignores the evidence because the evidence ignores the economic incentives: a hospital is getting paid for pre-admission testing. All those patients are being robbed of their time, and every one of them who has an “abnormal” test result is then directed down the rabbit hole to chase a “cause”.

I know, I know…you’re shocked. SHOCKED! As bad as that example may be, and as perverse as it is that the champions of evidence-based medicine ignore the evidence when money is on the line, a story of a hospital doing something extra to get paid more is kinda boring; it just seems to happen all the time. In the private world of free-standing surgery centers that are not associated with a hospital pretty much everyone gets the joke about pre-admission testing and would do pretty much anything to be able to quit. You see, the private surgery centers don’t get paid the same way and pretty much lose money on pre-op testing. If they could get away with it they would all drop pre-admission testing for cataract surgery. The barrier is the economic incentive for the hospitals that own surgery centers and their influence on how regulations are interpreted.

In the face of data that provides a pathway to cost savings in healthcare, evidence-based medicine will only be utilized if the incentives are such that the invested players stand to gain, or if lights bright enough and cries loud enough arise to point out the perversity of the economics at hand.

Transparency is the new buzzword in medicine. Systems should be transparent with regard to prices, if not costs. Doctors and other providers of healthcare services should publish their costs and fees, too. Various ratings and measurements have been developed in an attempt to measure that nebulous and elusive entity “Quality”. Calls have been made for transparency here as well; hospitals, doctors, and others are browbeaten to release any and all manner of quality measurements so that we might create something one could call an “informed patient”.

The first, and therefore most important challenge in the quest to measure quality is to agree on a definition of just what quality is. Like all rational discussions the first order of business is to agree on terms and the terms of engagement.

Let’s take the question of evaluating the quality of an individual surgeon. What are the salient metrics? Are we concerned with only outcomes? You know, success rates, complication rates, stuff like that. Is there more to the measurement? Should we be concerned with EFFICIENCY, the ability to obtain high quality outcomes in a more timely manner? How about VALUE, the soft and difficult to measure combination of quality and COST? In this day and age of “economic credentialing” in which doctors, hospitals, and other providers are held responsible for the cost of care, not only on an individual basis but also a societal one, it seems as if value is an inescapable aspect of quality, at least in the eyes of our government and the people who actually pay for healthcare.

Quality measures will be different for surgeons of different stripes; we will want to evaluate different complications and their rate of occurrence for an ophthalmologist versus, say, a cardiothoracic surgeon. Even similar adverse events like infection rates will have a different meaning across specialties. One classic example of a surgical complication is post-op infections. From my limited reading about heart and chest surgery it appears that the post-op infection rate is around 1-2%. This would be scandalous in eye surgery where the post-op infection rate is 100X lower, closer to .01-.02%. Stuff like this should be fairly easy to uncover, or at least you’d like to think so. It turns out that even this metric is rather hard to come by since multiple doctors will participate in the treatment of post-op infections, and literally no one offers up these stats uncompelled. Similar issues apply to specialty-specific complications (vitreous loss, graft leak) for similar reasons.

Right away the difficulty of measuring quality is obvious: even the simple quality measures appear to be something other than simple to discover right now.

Outcome measures are even trickier. Since I know eye surgery best let me stay in that arena and use cataract surgery as my example. For our discussion let’s assume that we have magically been granted unfettered access to every eye surgeon’s charts (and that they are all legible, and that they all contain the same basic information). It should be a rather simple proposition to draft meaningful criteria–let’s say “how well do the patients see after cataract surgery.?”  Would that it were so. The answer to that very simple question–how well do you see after surgery–depends on several variables, and further varies if you ask the question slightly differently. How much improvement did the patient achieve compared with pre-op? How fast did the improvement come? How well does the patient see without eyeglasses?  Is the patient more or less dependent on eyeglasses following surgery? What level of vision constitutes a success? Does the surgeon get the same results with complex cases?

I imagine these issues are not specific to ophthalmology. I can see the same types of questions and complexities in orthopedic surgery, for example. Think about hip replacement–along with cataract surgery and cardiac bypass surgery, hip replacement is arguably one of the most significant medical developments when we think about the quality of life enjoyed by an older person. What defines success in hip replacement? How long do you allow for success to occur for it to be deemed one for the  “win” column? Do we give bonus points for speed in the OR, both from a patient’s standpoint and an economic one? How about a surgeon’s ability to achieve the same level of success in a thin 70 year old tennis player and an obese, cart-riding smoker?

Seriously, if docs can’t come to an agreement about what constitutes “quality”, how can we in good faith measure it? Furthermore, if we WON’T define it we have no one but ourselves to blame when some nameless, faceless 30 year old sociology major in D.C. does it for us.

Nobody asked me (again), but as long as I’m here let me offer up a 3-part proposal to measure and promote quality using surgeons as a theoretical template. Let’s start with a thought exercise borrowed from CrossFit. Fitness training using the CrossFit methodology involves high intensity exercise while trying to maintain near-perfect movement and form. One is shown three targets from a shooting range. The first has random bullet holes all around the bullseye, the second has every shot dead-on perfect, and the third has 95% of the shots within the center bullseye and 5% on-target but not perfect. Which one represents the most desirable CrossFit training strategy?

In CrossFit the answer is “C”, 95% accuracy with the misses still close because this represents the optimal combination of form (accuracy) and intensity (speed). Is this directly applicable to surgery? Well, that depends on how far outside the bullseye the misses land, doesn’t it? And in surgery I think we also need a more accurate measurement of intensity; we need a clock. Speed matters, from both a medical standpoint and a financial one. The shorter a surgery lasts while still hitting the target, the less physically and mentally taxing it is for the patient, and the fewer costly resources (OR time, staff time, doctor time, supplies, etc.)  you are consuming during surgery. All things being equal, the surgeon who achieves the desired outcome faster without increasing her complication rate is the better surgeon.

Put surgeons on the clock.

A successful outcome must be explicitly defined for each common surgical procedure. Pre-operative factors that reduce the likelihood of success should certainly be taken into account (e.g. a morbidly obese cart-riding smoker and hip replacement), but care needs to be taken so that a measurement can’t be gamed (two guttata do not constitute a corneal dystrophy and increased likelihood of swelling) in order to work with a lower standard. Surgical societies should show some spine and make a call, define what constitutes a high-quality outcome, regardless of the howling that will emanate from the mediocre and the incompetent. It’s gonna happen anyway, and physicians making the call would be orders of magnitude better than MBA’s and philosophy majors.

Lastly, quality should be measured, publicized and praised, and those surgeons (and other doctors) should be explicitly rewarded with as many cases as they can (or wish to) handle. They should also be paid more. Once we decide what constitutes quality we can measure it and publish the data. People will understand this, just like they understand the data in a box score. Why is it so OK for the baseball player with the highest batting average or lowest ERA to be paid more based on his success, yet somehow the most efficient surgeon who has the best outcomes is labeled a “money grubber” who must somehow be doing something wrong if he is also very busy? We want that high batting average guy at the plate in the 9th inning of a tight ballgame, and we pay him more because of his higher quality outcomes. Why aren’t we doing the same thing with surgeons? The very least we can do is stop accusing surgeons of being successful!

It’s time that we apply basic theories about quality to medicine in general and surgery in particular. Indeed, it should be easier to do it with surgeons. Make a call–define a successful outcome. Pull out a stopwatch. Faster, more efficient surgery is less expensive and generally less taxing physically for patients. Once the data is available be transparent and publish the results. I know what Miguel Cabrera is batting this year; my patients (and potential patients) should know my “batting average” in the OR. While I hold out little hope of being heard on this last point, uncountable articles support the benefit of the carrot at the expense of the stick when it comes to promoting excellence. Higher quality should beget higher pay. At the very least we should stop with the assumption that the busy surgeon is somehow “getting over”, guilty of somehow gaming the system (eg. doing unnecessary surgery) until and unless proven innocent.

She may just be better.

My Dad has been hospitalized for many, many weeks now. My siblings, a couple of the daughters-in-law (including my wife) and I  have taken turns either keeping my Mom company or spelling her and just hanging with my Dad alone. We have tried mightily to keep each other abreast of a day’s events, and we have made yeoman’s efforts to help Mom communicate with all sorts of members of the medical community involved in Dad’s care. Man, has THAT been a challenge. The differences in understanding the lingo of medicine, not to mention the vast gulf between the frame of reference that exists between  “civilians” and medical workers on the front line create communication barriers that can seem impenetrable.

Where does the responsibility lie when we enter into a conversation? Let’s define a conversation as the interaction between two people during which there is a purposeful transfer of some kind of information. Let’s refine that by saying that in this day and age we cannot define a conversation as simply as two people talking with one another. We have email, texts, FB chats and PM’s, Twitter @’s and PM’s, phone calls and Skype, and of course plain old face-2-face talking. Any and all of these have been, or yet might be used when we go forward with Dad.

So where does the responsibility lie to ensure effective transfer of information? Upon whom does it rest to make sure that facts or ideas have been successfully transmitted and received? How about the emotional content, the feelings that ride along with the data? Sometimes the emotional content is really the data that’s intended for transfer and is quite obvious, like the color guard accompanying a General. Oft times, though, the feelings attached to the words are as carefully and craftily hidden as a stowaway on a cruise ship. What exactly does it mean when a nurse greets Mom in the morning with the fact that Dad “struggled” the night before?

Here’s my bid: the responsibility lies on BOTH sides of the conversation. Active listening is key. Engaging in the conversation means engaging the individual on the other side. It starts at the very choice of vehicle: to whom am I sending this message? On the receiving end the vehicle should also be evaluated: who sent this to me? Think about it…the universe of topics you would engage with your 75 yo grandparents via text is awfully darned small, and if you are a grandparent who texts you can’t “receive” disrespect in a message filled with contractions and lingo. By the same token, both sender and receiver must be actively conscious of the frame of reference of any “other” in the conversation.

A Facebook status update is like a billboard, meant to be one-way, neither demanding nor expecting a reply. A conversation, on the other hand, is by definition bi-lateral. It requires active listening and anticipatory listening on the part of both people. It requires a shared understanding of the power as well as the limitation of each method one might choose to utilize. The smaller vehicle (text, Tweet) creates the greater distance and so must transfer the more basic information. More nuance or emotional content requires a different vehicle, at once larger (to include the details) and smaller and more intimate (so that everything can be seen as well as heard). Closer.

In the end we are social creatures, driven always to connect. The rules of communication have not really changed despite our ever-increasing ability to communicate, to connect. The more important the interaction the closer we must be to the other. Communication, no matter what vehicle we choose, requires that we listen better. Listen to what is said to us; listen to what we say; listen, especially, to what the other hears.

The responsibility for a successful communication is shared equally by both or all involved. Despite our newfangled world filled with different ways to communicate the most effective strategy hasn’t changed in a few thousand years:

Listen better.

We’ve lost the ability to be amazed. As a society, as a people, North Americans not only fail to be dazzled by things that are downright amazing, we have actually become quite blase about, well, pretty much everything. That sense of wonder at the new we celebrate in children is leached out of our kids at ever younger ages. Our ability to be awestruck has atrophied, and any sense of awe, wonder, or amazement that we DO experience is so fleeting that it’s almost as if it was never there.

How did this happen?

This idea, this observation has been stewing in my subconscious for a couple of months now. It popped its cork yesterday after a couple of experiences I had starting last week. The first, interestingly, actually involved seeing people who actually WERE amazed. I flew to and from Providence to visit my folks last weekend. On the way out I sat in the last seat in the plane (doorman to the restroom), on the way back in the very first seat (Walmart greeter). On both legs of my trip I was seated next to 45 year old men taking their very first trips on a plane. Imagine! 45, and never on a plane. These guys were simply awestruck at the notion that they were drinking a Coke inside an aluminum tube that was cruising at 35,000 feet. One of them took about a hundred pictures of the clouds out the window. Those guys were amazed! I let myself get swept up in their experience; it really IS cool, and not even just a little bit amazing, that I could get to my folks 750 miles away in less than 90 minutes!

Experience #2 occurred in my office on a one-day post-op day. Medicine in general, and certainly my field of ophthalmology in particular, is a victim of its overwhelming success. Indeed, this is not too different from the airline industry. We deliver the goods time after time, on time, without a hiccup. So frequently, in fact, that in those rare instances where things are rocky, or there is a complication, we view the outcome as only slightly less horrific than an airplane crash. Even a fantastic outcome, one that would have been so unlikely just a few years ago, is now viewed as some kind of a disappointment if it fails to meet the outlandish expectations of an audience that has been numbed by routine success.

Take, for example, cataract surgery. I had a patient with a very large cataract, a very small pupil, and a flaccid iris–a set-up for a very challenging surgery, one that a few years ago had a 10X increase in complication risk. Per our protocols the patient was offered several choices of lens implants, and the expected outcome (visual acuity, need for glasses, etc.) for each of these was discussed and explained multiple times by multiple staff members and doctors, all according to our protocols. Some of these implant choices were entirely covered by insurance, and others included fees for which the patient was responsible. These, too, were covered in detail several times by several staff members. In this particular case there was even a second, extra (no charge) visit to the office specifically to discuss these options and the associated expectations following surgery.

So how’d it turn out? The staff and doctors were turning cartwheels when we discovered that the one-day post-op distance vision was 20/20 without any glasses! Imagine our surprise and chagrin when patient and spouse sad glumly in their chairs at the news, not the least bit excited. In fact, the majority of the visit consisted of patient and spouse grilling doctors and staff about the fact that the patient could no longer see up close without glasses. This despite the many counseling sessions about implant choices and post-op expectations in a patient who could not pass a driver’s test with or without glasses prior to surgery. Not a word about how amazing it was that such a challenging surgery resulted in the ability to now pass a driver’s test without glasses!

You might fairly ask if I was amazed by this? Sadly, no, I was not. It’s not enough for the airline to bring you in on time and safely. Nope, now you had to be flown first class on a free ticket and arrive early to simply be satisfied. To be amazed one would need to have somehow been transported to and from the S.S. Enterprise by Sulu personally.

Manned flight, up and down with nary a hiccup each and every time. Cataract surgery that improves your vision 99.9% of the time with nary a hiccup. Joint replacements that allow you to play tennis. GPS in your car that directs you to within a foot of your destination. Neurosurgery while you are awake. Cell phones, for Heaven’s sake! Sometimes you fly first class or see 20/20 without wearing your glasses! Come on…that’s amazing! Right?

Amazing…

Fly an airplane. Take Dad’s car on a date. Finish your residency and perform your core surgery without a professor over your shoulder. The first solo is a milestone event, and many such events become life’s touchstones to which we return time and again. My first solo attempt to log on and clear out my “Basket” on EPIC, the EMR that I am mandated to use in order to continue to operate at a surgery center where I’ve been the primary ophthalmologist for >15 years? Meh, not so much.

At 0 Dark 30 I was doing glaucoma lasers, and I finished well before I was due in the office. Perfect time to log onto a dedicated terminal, take a look at the items demanding my attention, and get on with the real work of eyecare. Full disclosure: I called the IT guy with whom I’d bonded a  couple of weeks ago to see what I should do with the pharmacy boondoggle and received permission to blow off all of those entries. Whew! Home free. I sat down and went through the log-in process, just like my new best friend had shown me. No love. 0 for 15. Unable to log in.

BZZZZTTT. Sorry. Johnny, tell Dr. White about our lovely parting gifts for losing contestants.

Might turn out to be more like expected after all.

As I posted a few weeks ago, in order to continue to use an outpatient surgery center where I have performed surgeries for 15 years or so, I am now required to use the electronic medical record EPIC. My hope had been that I would be able to continue to run “under the radar” by utilizing my pre-–dictated notes and standard orders, signing the papers as I have done lo these many years. Tragically, this was not to be. Having come to this realization about a month ago I reached out to the IT department and asked for training on the system. Being the somewhat self–involved surgeon that I am, I naturally assumed that a single phone call or e-mail would see multiple individuals leaping into action in order to help me so that I might continue to use that surgery center and generate revenue for the hospital. Silly me.

Four weeks, a dozen conversations, several e-mails, and I am assured more than several telephone calls later, I finally received a call from IT and one of the physician–advocates/trainers. I explained that I had a back log of signatures (little did I know!), and that I would be taking ER call soon, and did he perhaps have some time available to show me how to use the EMR? In the first of several remarkably positive little things in this process, Andrew did, indeed, have some time available the very next morning when I, too, could sit with him for a little bit.

Andrew himself was one of those little surprises. And ex–cop who had put himself through nursing school with the intention of using his nursing degree as a springboard to management, he informed me that he was one semester away from an MBA. It was clear he was anticipating a hostile interaction; this had been his typical experience when teaching physicians the system, especially private practice physicians. I liked him instantly, we connected, which probably contributed to the speed with which we flew through phase 1 of my indoctrination.

This can’t be all good, of course, otherwise there would be no reason to do this series! After learning how to get into the system (no, you cannot change your username), we looked at my chart deficiencies, specifically op notes that needed to be signed tracing back to November. I cleaned up all the old stuff, and then we got stuck with all of the charts that were sitting there from last week. Apparently part of the efficiency of the system allows the medical records department to put you on the “bad boy” list as soon as the case is done! We agreed to ignore these deficiencies since these would still be paper charts needing to be signed and moved on to pharmacy orders.

This was rich. I looked at about 200 orders with a “signature required” tag. Things like IV orders, and medicine injected to into the IV. Some were anesthesia orders which have no business on my list, and essentially all of the rest had already been signed. Andrew told me he’d taken a look at my in basket before we met and deleted three or four months of the pharmacy orders. I think the number he used was 800,000 orders! Whoa, maybe this isn’t going to go as well as it looks like it might. There is no connection between the electronically entered pharmacy orders and the signatures on the order sheets! 30 some odd orders per patient, each one individually entered and requiring a signature. I did 22 cases yesterday! Are you kidding me? This is what my colleagues were talking about when they mentioned the four minute per chart rule.

Like I said, though, this was a surprisingly positive interaction. Andrew took a couple of screenshots and said that he was going to sit with the IT magicians and see if we might be able to figure this particular one out. Man, that’s gotta work. I mean, the whole exercise took me about 45 minutes, and I didn’t even learn how to ENTER an order.

I can sign one, though. I’ve got some ER call coming up, and I’ll have to do some–patient consultations as part of my responsibilities. I’d better polish up my “helpless look” and rehearse my supplications. Getting someone to take verbal orders is gonna be the key to salvation.

More to come…