The 10 foot rule

There's nothing quite like a "rags to riches" story to foster the belief that the so-called "American Dream" is alive and well.  And there is perhaps no better "rags to riches" story than that of Sam Walton, the American businessman who founded both Walmart and Sam's Club and who was at one time the richest individual in America.  Both Walton and his stores started from humble beginnings, and the store chain would eventually become one of the largest corporations (by revenue) and largest employers in the world.  Not too bad!

Walton used to talk about something that he called the "Ten Foot Rule".  He described the rule by saying, "I want you to promise that whenever you come within 10 feet of a customer, you will look him in the eye, greet him and ask him if you can help him."  Walton's rule has since been adopted by a number of organizations in the hospitality and service industry.

The Walt Disney Company has taken the "Ten Foot Rule" a proverbial step further.  Any time that a Disney "cast member" (the employees at Disney's theme parks are called "cast members") comes near a "guest" (the visitors to Disney's theme parks are called "guests"), cast members are supposed to remember the Seven Service Guidelines:

1. Make eye contact and smile
2. Greet and welcome each and every guest
3. Seek out guest contact
4. Provide immediate service recovery
5. Display appropriate body language at all times
6. Preserve the "magical" guest experience
7. Thank each and every guest.

How hard is it to use the "10 Foot Rule"?  It doesn't seem that difficult, so I decided to give it a try this past week while walking around our hospital.  I made a conscious effort to make eye contact, smile, and say hello to every individual who was within 10 feet of me while I was walking down our main concourse.  Not everyone replied in kind - there were a number of individuals who were looking down at their cell phones.  Some of these individuals looked up at me when I greeted them, while others continued on their way without acknowledging me.  Several other individuals smiled back at me.  It was a very gratifying experience for me.

There are a number of companies who have now adopted something called the "Ten and Five Foot Rule", also known by some companies as the "Zone of Hospitality."  Basically, employees should make eye contact and smile at everyone within 10 feet of them, and they should greet and ask the customer if they need any assistance if they are within 5 feet of them. 

I would take this one step further.  The "Zone of Hospitality" should not just apply to customers, patients, visitors, or guests.  We should apply the "Ten and Five Foot Rule" to fellow employees!  Imagine what effect it would have on the overall culture of an organization, if everyone was friendly and smiled at each other!  Rather than looking down at our cell phones, we should be greeting each other, smiling at each other, and saying "Good morning" or "How are you today?" 

It's important to recognize that the "Ten Foot Rule" takes a conscious and deliberate effort.  It's very easy to fall back into our own "personal space" and avoid making eye contact with people who pass us by.  But imagine how much better it would be if we put forth the effort.  What a wonderful and magical experience that would be...

The history of standardization - 200 BC to 1945

I came across an interesting article the other day, "Standardized care vs. Personalization: Can They Coexist?"  The first sentence of the article is somewhat prophetic, "Mention the word 'standardization' to a group of healthcare professionals, and you may start a debate."  We hear a lot about standardization in healthcare today, and it's not always a very popular concept for physicians in particular.  Mention the word "standardization" on the hospital wards to a group of physicians and you may get the response, "That's cookbook medicine!"  I'm not sure what "cookbook medicine" refers to (actually, I do), but I suspect that it's not meant to be a positive affirmation of standardization.

Standardization is actually a really good method of improving the delivery of healthcare.  There are multiple examples of how standardization can simplify care, decrease expenses, and improve outcomes.  For example, in my own specialty (pediatric critical care medicine), children with new-onset diabetes mellitus often present with a serious complication of their illness, called diabetic ketoacidosis.  Our hospital - really, every hospital that I have ever worked in - has had a standardized protocol for managing children with diabetic ketoacidosis for many years.  Why?  These protocols simplify care, in terms of making sure that everyone - physicians, nurses, and even the patients and their families - are on the same page on how these patients will be managed and what to expect next.  These protocols shorten the length of stay in the PICU and prevent unexpected and untoward complications.

Outside of my specialty, there are standardized protocols for treating patients with cancer that have been around for years.  These protocols have facilitated progress in understanding on how best to treat patients with certain types of cancer.  If everyone with a certain type of cancer is being treated the same way, physicians from multiple different centers can collect data and determine if the protocols have the desired effect.  Treat everyone differently from center to center and it becomes difficult to compare outcomes (no single center would likely have enough patients to measure the impact of treatment).

I am amazed at how long standardization has truly been around.  It's actually not a new concept at all.  For example, there was a fire in the city of Baltimore in 1904 ("Great Baltimore Fire").  The city of Baltimore burned for over 2 days, and over 1,200 firefighters were required to bring the fire under control.  Fire departments from Baltimore, Washington, D.C., and even Philadelphia and New York City came to help put out the fire.  Why did it take two days to control the fire with so many different fire departments and so many firefighters working together?  As it turns out, there were no standards back in those days, so all the different water hoses didn't fit to the local fire hydrants. 

Did you know that more than 200 billion screws are used every year in the United States alone?  Imagine, if you will, if all of the screws that were manufactured by different companies were different.  The earliest screws were handmade, and no two screws were the same.  Can you imagine if you had to replace a screw today and couldn't find one to match?  That was actually the case until around 1920, when the National Screw Thread Commission provided recommendations to standardize how screws were manufactured (see "History of Standardization of Screw Threads").

Finally, consider why you stop at a red traffic light?  Was there ever a time when "red" meant "go" and "green" meant "stop"?  It turns out the answer to this question is "yes"!  Traffic lights in the city of New York weren't standardized until the 1920's (see "A History of New York Traffic Lights").  At one time, the different colors in traffic lights meant different things depending upon where you lived.  Imagine someone from Boston coming to New York and trying to drive when "Red means stop" in Boston and "Red means go" in New York!

It turns out that standardization can be a very good thing.  Standardization makes us more efficient, and standardization is actually safer in almost every case.  We are somewhat behind the times in healthcare.  I know there will inevitably be someone out there that will point out that "Patients aren't fire hydrants" or "Patient care is not like traffic safety."  I would argue otherwise.  Standardization is not only a good idea, it can coexist with personalization of care.  More on that later.

It's all about the chocolate

The start of another school year is fast approaching!  Teachers and students alike are groaning a little bit, but I suspect there is at least some excitement for the start of a new year too.  Parents have mixed feelings about the start of the school year too.  Some parents are glad to get the kids out of the house and back to the regular school routine.  On the other hand, for a lot of middle school parents, the start of another year of school means that the annual science fair is just around the corner!  Science fair projects can certainly be fun, but they can also be stressful to students, parents, and of course, teachers!


Our kids were required to participate in science fair in both 7th and 8th grade.  It was always a lot of work for our family, but we tried to make the projects fun.  We had some really good projects that involved reading and recall ("Do sight readers or phonics readers have better short-term memory?"), alertness and test-taking performance ("Does eating a peppermint right before a math test improve performance?"), and growing plants in space ("What is the effect of centrifugal force on plant growth?").  One of our daughters tested the immediate effects of chocolate on blood pressure.  As it turns out, eating a sugar-free chocolate candy results in an average reduction in systolic blood pressure by 10 mm Hg! 


So, speaking of chocolate...I recently came across an interesting study that looked like it should have been a science fair project!  The study was referenced in a book I am reading right now about customer service at Disney ("The Experience: The 5 Principles of Disney Service and Relationship Excellence").  The authors, Bruce Loeffler and Brian Church, mentioned a company called Intentional Chocolate that is using a technique that they call "embedding good intentions" with their product.  If you look on the company's website, they state that their core mission is to do no harm and benefit others.  They go on to state that their strategic advantage is an innovative technology that embeds the intentions of advanced meditators into chocolate and bridges the gaps between spirituality and science.  In other words, one of their expert "meditators" places good thoughts and vibes into each and every piece of chocolate that the company makes and sells.


The company actually tested their process in a double-blind, placebo-controlled, randomized study with 62 participants (see "Effects of intentionally enhanced chocolate on mood").  Study participants were assigned to one of four groups and recorded their subjective mood every day for a week.  On days three, four, and five of the study, participants ate a piece of chocolate at two times during the day (the time was prescribed by the study protocol).  Subjects in three of the four assigned groups ate chocolate that was intentionally treated by three different techniques (basically different "experienced meditators" as used by the company, "Intentional Chocolate" - in one of the three groups, the meditators were Buddhist monks), while the subjects in the fourth group served as control and ate just regular chocolate.  By the third day of eating the chocolate, mood had significantly improved in the three "intention conditions" compared to the placebo.  Subjects reported decreased fatigue and increased vigor.  The investigators concluded that "the mood-elevating properties of chocolate can be enhanced with intention."


I know what you are thinking - it sounds kind of kooky.  I thought the same thing when I first read the passage in the book describing this company and this study.  I think it is pretty well accepted by traditional science that mind-behavior techniques such as prayer, meditation, yoga, etc can improve both emotional and physical wellbeing.  All good, but even more interesting is that there is a growing body of literature that links these kinds of techniques with better emotional and physical wellbeing in others.  In other words, you can certainly improve your own wellbeing through meditation and spiritual prayer, but these studies are showing you can use these techniques to help improve the emotional wellbeing of bystanders (check out a similar study using tea enhanced with "good intentions" here)!


I am not sure I am ready to purchase stock in "Intentional Chocolate" just yet.  However, there is certainly a lot about the mind-body connection that we do not fully understand.  I think it would be naïve to discount some of these studies, and I am definitely interested in learning more.  It is, after all, all about the chocolate.

"Five Days at Memorial"

It's time for another book review.  Hurricane Katrina, a Category 5 hurricane (the highest category on the Saffir-Simpson scale, with sustained winds documented over 157 mph) that made landfall on the Gulf Coast of Florida and Louisiana in August, 2005 was one of the most destructive hurricanes in the history of the United States.  According to the U.S. National Weather Service, Hurricane Katrina was the fourth strongest Atlantic hurricane to make landfall in the contiguous United States (preceded by the 1935 Labor Day hurricane, Hurricane Camille in 1969, and Hurricane Michael in 2018).  It was also the deadliest hurricane in the United States, causing at least 1,836 deaths and over $125 billion (in 2005 USD) worth of damage.  A lot of the damage (in fact, the majority of it) caused by Hurricane Katrina came after the initial landfall.  There were over 50 levee breaches around the city of New Orleans, and eventually 80% of the city and surrounding parishes flooded. 


The local, state, and federal governments' response to this natural disaster have received a lot of criticism and led to the highly publicized resignations of the Federal Emergency Management Agency (FEMA) director, Michael D. Brown and the New Orleans Police Department Superintendent, Eddie Compass.  New Orleans Mayor Ray Nagin, Louisiana Governor Kathleen Blanco, and President George W. Bush were also highly criticized.  Conversely, the United States Coast Guard, the National Hurricane Center, and National Weather Service were commended for their response.  Russel Honoré, now a retired Lt. General in the U.S. Army served as commander of Joint Task Force Katrina and was highly commended for his leadership during the relief efforts following Hurricane Katrina. 


Unfortunately, the government was not alone in being criticized for their response.  The book, Five Days at Memorial by Sheri Fink (who won the 2009 Pulitzer Prize for Investigative Reporting) tells the story of what happened at the New Orlean's Memorial Medical Center (now Ochsner Baptist Medical Center) over the course of five days (August 28, 2005 to September 1, 2005) following Hurricane Katrina's landfall.  Basically, the hospital flooded and its generators failed.  Thousands of hospital employees, patients, and in some cases, family members (of both staff and patients) were trapped inside the building waiting to be evacuated by either boat or helicopter. 


The book is divided into two parts - the first part, "Deadly Choices" tells about how the hospital's medical staff prioritized the ambulatory patients for evacuation first, keeping the most critically ill patients or those with active "Do Not Resuscitate" orders last on the evacuation list.  In most cases of triage, the most critically ill patients are attended to first and the ambulatory patients ("walking wounded") are treated last.  The evacuation of patients did not start until day number 3 (again, recall that the initial response to this disaster was entirely inadequate and poorly organized) - there were actually fights over whose jurisdiction the hospital fell under for evacuation!  Evacuation was proceeding so slowly, that at some point between day 3 and day 5, hospital medical staff made the decision to hasten the deaths of some of the patients who they felt would not survive, administering lethal injections of morphine (essentially, active euthanasia). 


The second part of the book - "Reckoning" - discusses the ramifications of the decisions that were made in the heat of the moment.  Three hospital employees - one physician and two ICU nurses were charged with second-degree murder.  The charges against the two ICU nurses were eventually dropped, and a grand jury chose not to indict the physician nearly 2 years later.


It's hard for us to say if we would have acted differently.  Fink does a very good job discussing the ethics of these kinds of decisions, and I won't go into any further specifics on these discussions.  The take-home message, for me (notwithstanding these ethical decisions, which I also found very interesting and thought-provoking), was that hospitals absolutely need to be better prepared for any and all contingencies with which they may be faced in the future.  During any mass casualty or natural disaster, individuals and groups will fall back to their training.  If they haven't been trained to deal with the kinds of issues that arise in these events, then they will be forced to "make it up" and improvise.  If there was any failure at Memorial Medical Center, it was on the part of the hospital administration.  There should have been a set of policies and procedures to follow, specifically addressing what to do in an emergency (specifically addressing the what, when, who, and how of an evacuation).  There's an old saying that I remember from my military days, "The more we sweat in training, the less they bleed in war" - it's actually true.  Hospitals should run evacuation drills and train their staffs so that they won't be left "making things up."  Would that have changed what happened during those "Five Days at Memorial"?  I don't know, but I suspect that it would have made a difference.

Two are better than one

There's an old saying that "Two are better than one."  Did you know that the saying actually comes from the Bible (see Ecclesiastes 4:9-12)?  I actually didn't - here's the passage:


Two are better than one,
because they have a good return for their labor:
If either of them falls down,
one can help the other up.

Anyway, last time (see "It pays to be nice...") I talked a little about a legal doctrine known as the Captain of the ship doctrine.  Basically, this doctrine held that during a surgical procedure, the surgeon of record was liable for all actions conducted in the course of the operation.  In other words, the surgeon was legally accountable for the actions of the nursing staff and anesthesiologist.  The doctrine first became a legal statute in the case of McConnel v. Williams in 1949, when the Supreme Court of Pennsylvania ruled that, "It can readily be understood that in the course of an operation in the operating room of a hospital, and until the surgeon leaves that room at the conclusion of the operation...he is in the same complete charge of those who are present and assisting him as in the captain of a ship over all on board."  The doctrine was frequently used in the 1950's, but has finally started to fall out of favor (see "Captain of the ship doctrine continues to take on water").  The phrase, unfortunately, is still used today.


Okay.  Why shouldn't the surgeon be liable for the actions of others in the operating room?  I made a point last time that medicine has become a team science.  Our patients have become so complex that the responsibility for any one patient's care shouldn't fall upon one individual's shoulders.  We have made substantial progress in improving safety by taking the individual out of the equation and focusing on system-level issues.  Similarly, we have made substantial improvements in outcomes when we focus on training teams to provide care at the bedside, not just one physician or one nurse.  We work better as a team, and our patients are better for it.


As it turns out, there is solid evidence to back up that "two heads are better than one."  We do work better as a team, and our patients are better for it.  And now there's proof.  Check out a recent study called "Comparative accuracy of diagnosis by collective intelligence of multiple physicians vs individual physicians."  It's a great study that shows that teams of physicians make more accurate diagnoses compared to individual physicians.  Over 2,000 physicians worked on more than 1,500 individual medical cases.  Physicians worked alone or in groups of 2-9 individuals.  The diagnostic accuracy for individual physicians was 62.5% - in other words, physicians made the right diagnosis in slightly over half of the cases.  The diagnostic accuracy significantly improved as the number of physicians working together increased.  The best performance occurred with groups of 9 physicians working together, at which point diagnostic accuracy had improved to 86%. 


It's probably not realistic to expect nine physicians to work on every single medical case.  Such a scenario would be highly inefficient and could lead to problems with communication, collaboration, and coordination of care at the bedside.  Regardless, as it turns out, two heads are definitely better than one. We should definitely keep that in mind when we think about anachronistic doctrines, such as "the captain of the ship."  The captain should never be alone, and thankfully, in most cases at the bedside today, she or he is not.

It pays to be nice...

I am not a surgeon.  But I know a lot of surgeons.  And I work with a lot of surgeons.  Most of them are really nice individuals.  I would trust my life in their hands.  I have also known some not so nice surgeons.  Unfortunately, surgeons often have a stereotype of being egotistical, impatient, mean, arrogant, abrasive, and difficult (take a look at the article, "The evolving surgeon image").  I have heard stories of surgeons yelling at other physicians and nurses in the operating room.  I have even heard stories of surgeons throwing instruments out of frustration.  The British psychologist and author Kevin Dutton conducted an Internet survey of professions with the highest proportion of psychopaths - surgeons ranked in the top 5 of all professions (see his book, "The Wisdom of Psychopaths: What Saints, Spies, and Serial Killers Can Teach Us About Success").  Some authors have even suggested that it's beneficial for surgeons to act this way, claiming that we don't want our surgeons to be nice, we want them to be good ("Is the quest to build a kinder, gentler surgeon misguided?").

Hollywood has only perpetuated these stereotypes.  For example, William Hurt starred as a surgeon in the 1991 movie, "The Doctor" who undergoes a radical, personal transformation in his attitude and approach to patients when he is diagnosed with cancer.  Alec Baldwin played a cardiac surgeon in the 1993 film, Malice.  At one point, his character denied having a "God complex" by saying, "I am God."  There are a few Hollywood surgeons that have broken the mold (think of the Hawkeye and Pierce in the television series, M*A*S*H or the character played by Michael J. Fox in Doc Hollywood).  Let me be clear though, you don't have to be a surgeon to be a jerk.  I've also hear stories of physicians that aren't surgeons who have yelled and treated others in a disrespectful and unprofessional manner.

Here's my point though.  Regardless of their specialty, all physicians (including surgeons) need to treat everyone with respect.  Physicians can't do everything that is required to take care of the kinds of patients that are commonplace today - those with complex, really serious medical problems.  It truly takes a team of professionals working together and collaboratively to provide safe, effective, high quality care.  Gone are the days when the surgeon in the operating room was the "Captain of the Ship" with ultimate authority and responsibility for everything that happens during surgery (there was once a legal doctrine that held surgeons accountable for what everyone else in the operating room, including another physician, the anesthesiologist - thankfully, this doctrine has fallen out of favor).  Similarly, most patients in the hospital today don't just have one attending physician - they have several physicians involved in their care.  Medicine has become a team sport!

As it turns out, there is some pretty solid evidence to suggest that disruptive behavior (such as throwing instruments, yelling at others, or just plain old being mean) leads to worse care.  A group of investigators recently published the findings from their study which looked at the number of post-operative complications (measured out to 30 days after surgery) in a cohort of more than 13,000 patients who were operating on by just over 200 surgeons.  They also reviewed the number of reports of unprofessional behavior by each surgeon during the preceding 36 months before surgery.  Here's what they found.  Patients whose surgeons had a higher number of reports of unprofessional behavior (by their co-workers) had a much higher likelihood of suffering a complication within 30 days of their surgery.  In fact, the complication rate was almost 15% higher for patients whose surgeon had at least 1 to 3 reports of unprofessional behavior in the preceding 36 months!

These findings are not new, and they are not unique to surgeons.  Studies have consistently shown that disruptive physicians have higher complication rates and worse outcomes compared to their peers.  Here's the bottom line.  It pays to be respectful and collaborative.  It pays to be inclusive.  In my own experience and in my own research, we have found that physicians who ask others for their opinions and share a "mental model" of what they are thinking and considering are more likely to have better outcomes.  In other words, it pays to be nice.