Happy Doctor's Day

National Doctor’s Day is celebrated every year on March 30th.  The first Doctor’s Day was observed more than 90 years ago, on March 30, 1933 by the Alliance to the Barrow County Medical Society in Winder, Georgia (a small town located just east of Atlanta).  Members of the Alliance selected the date to honor all physicians on the anniversary of Dr. Crawford W. Long’s first administration of anesthesia in 1842 (Dr. Long used ether during surgery to remove a tumor from the neck of James Venable).  The first Doctor’s Day was observed by sending cards to all the physicians and their spouses, and a red carnation flower was placed on the graves of deceased doctors.  Through a series of resolutions in the years that followed, Doctor’s Day was widely celebrated throughout the southern United States, with sponsorship by the Southern Medical Association.  Eventually, a resolution was adopted and approved by both the U.S. House of Representatives and the U.S. Senate on October 30, 1990 and signed by President George H.W. Bush, designating March 30 as “National Doctor’s Day."  The red carnation remains as the symbol of Doctor’s Day.

I have never been more proud to be a member of this great profession.  We've all had a difficult past few years with everything that has been going on in our world.  Regardless, physicians have been at the forefront leading societal change during one of the most difficult periods in our history.  Importantly, our influence is due in large measure to the trust and respect that society has for our profession.  Physicians are still one of the most trusted of all professions.  As a matter of fact, we are second only to nurses, who have ranked as the most trusted of all professions for twenty years in a row.

I can honestly say that if I had the chance to do it all over again, I would still choose medicine as my life's work.  Medicine has been my passion and my calling.  Being a physician has made me a better person, and I am incredibly proud to be a member of this esteemed profession.

To all Doctor's - thank you for what you do, each and every day!

"When you invent the ship, you also invent the shipwreck"

The French philosopher Paul Virilio said, "When you invent the ship, you also invent the shipwreck; when you invent the plane you also invent the plane crash; and when you invent electricity, you invent electrocution.  Every technology carries its own negativity, which is invented at the same time as technical progress."  I've been thinking a lot about this quote for the past day or two.  If you haven't heard, RaDonda Vaught, a nurse at Vanderbilt University Medical Center was just convicted of gross neglect and negligent homicide for commiting an error.  

I believe that this verdict will have profound implications on American health care.  I know there are individuals (mostly outside of the health care industry) who would argue that justice has been done, but this verdict and those responsible for it just made our health care system less safe.  It is a well-established fact that reporting mistakes and errors is absolutely critical to learning, improving, and creating safer conditions.  Both the commercial aviation and NASA have drastically improved safety by instituting blame-free reporting of mistakes and errors.  

Near-misses are events in which harm is averted, due to either just plain old luck or active intervention.  They are virtually indistinguishable from adverse events, with the sole exception of the outcome (harm).  As such, they represent golden opportunities to address underlying defects and gaps in critical safety processes.  Experts estimate that near-misses are up to 300 times more common than adverse events in health care, and most adverse events are preceded by a near-miss event.  Unfortunately, near-misses are underreported in health care due to the fear of litigation and/or punishment.  The case of RaDonda Vaught will lead to an even greater reluctance to report mistakes and errors.

W. Edwards Deming, one of the original founders of the quality improvement movement once said, "Eighty-five perscent of the reasons for failure are deficiencies in the systems and process rather than the employee.  The role of management is to change the process rather than badgering individuals to do better."  Deming would be aghast at the recent verdict in the RaDonda Vaught case.  Janie Harvey Garner, the founder of a nursing advocacy group on Facebook called "Show Me Your Stethoscope" said, "Health care just changed forever.  You can no longer trust people to tell the truth because they will be incriminating themselves."

Back to the quote by Paul Virilio.  "When you invent the ship, you also invent the shipwreck."  We have a major problem in health care today - we created a system where people are afraid to come forward and admit when they make a mistake.  The verdict this past week has only made that worse.

"Fewer jobs, more machines"

If you are about my age, give or take a few years, you likely have watched an episode or two of the Hanna-Barbera television show, The Jetsons.  If The Flintsones and Fred Flintstone were about the past, the Jetsons and George Jetson were all about the future.  I remember watching an episode where the youngest member of the Jetson family, Elroy, was sick.  His doctor saw him virtually through a space age cartoon version of telemedicine (see my previous post, "What can health care learn from Uber?" for more) - except I'm not sure why the doctor needed to wear a mask in this case:

Amazing how so much has changed!  Several months ago, in the middle of the COVID-19 pandemic, I read an article in Time magazine by Alana Semuels entitled, "Fewer Jobs, More Machines".  The article focused on how automation is making certain jobs obsolete, citing the statistic that nearly 400,000 jobs have been lost to automation from 1990 to 2007.  Here's more evidence - the most valuable company in America in 1964 was the American Telegraph and Telephone Company (now known as AT&T), with 758,611 employees.  At the time that Semuels wrote her article, the most valuable company in America was Apple, Inc with just under 137,000 employees.  That's quite a difference!  And the difference is due to the changing and evolving technology landscape.

With these statistics in mind, it's easy to suggest that the major impact of automation on the labor market will be through job destruction.  However, the World Economic Forum argued that by 2025, technology will create 12 million more jobs than it destroys.  Ashley Nunes recently argued in the Harvard Business Review, automation doesn't just create or destroy jobs, it transforms them.  Regardless of whether the principle effect of automation will be creating versus destroying jobs, there is no question that technology will have a dramatic impact on how we work in the future.

It's tempting for those of us in health care to say that our jobs cannot be automated.  The patient-doctor relationship is sacrosanct and is critically dependent on a human-to-human connection.  The art of medicine requires human touch on the most personal of levels.  Or so we thought.  COVID-19 has changed how we practice medicine, and these changes are likely permanent.  Just think about it - the vignette I mentioned above about Elroy Jetson has more or less come true!  Shortly after the World Health Organization officially declared the start of the pandemic, most businesses (outside of health care) went virtual.  Elective surgical cases were canceled, and most doctor's visits also went virtual!  My own institution significantly ramped up the number of our telemedicine visits, which were more or less nonexistent before the pandemic.

Let's talk about artificial intelligence.  There are clinical studies showing that computer programs do better at diagnosing certain clinical diseases compared to humans (see for example the following reviews on the use of artificial intelligence in dermatology and medical imaging).  Will machines ever replace doctors and nurses?  I don't know the answer to that exactly, but I can say that it's almost certain we will be using some sort of artificial intelligence in our daily work.  It's exciting and scary at the same time.

It's also easy to say that the current generation of patients will drive the implementation of digital health options (telemedicine, remote monitoring, online scheduling - the list goes on).  We live in a world where consumers demand constant (24/7) access to information.  They also want easy access to care.  Ignoring the changing health technology landscape is simply not an option for leaders in health care.

I'm certainly not an expert in this area.  As most of the members on my team know, I am challenged by technology!  Things seem to break a lot when I use them!  Health care leaders really have two options - either become an expert in digital health technology or surround themselves with experts.  Thankfully, I've surrounded myself with a number of experts in the digital health domain.  And I am lucky to have two children who work in this field!  

I think that, rather than being afraid of how automation and technology will impact the health care workforce, we should embrace it.  It's really an exciting time to be in health care.  Digital health will improve the care that we provide to our patients, and for that reason alone, we should not be afraid of what the future may hold.  

London Hackney

My wife and I love the CBC television reality show, The Amazing Race.  We routinely binge watch some of the seasons we've missed (actually, we haven't missed too many).  During Season 31, the contestants who made it to the 11th leg of the race in London, England experienced the "Detour" ("a choice between two tasks, each with its pros and cons"), "Know or Row."  In "Know" contestants had to ride in one of the famous London black taxicabs ("hackneys") and memorize fifteen streets and seven landmarks that their taxi driver pointed out to them during the ride. At the end of the ride, contestants had to correctly recite their route to another cab driver in order to receive their next clue.  It sounded very hard (the other option "Row" was more physical in nature).

Apparently, the test that prospective London cab drivers have to pass to obtain a license is one of the most difficult tests in the world!  Basically, the cab drivers have to memorize a detailed map of the city of London and pass a series of progressively more difficult oral examinations before they are allowed to drive a taxi cab.  The entire process can take up to four years, and in many cases prospective cab drivers spend even longer.  Some experts have quipped that it might be easier to pass a test to become a lawyer or physician!  

The guidebook issued to prospective cab drivers by the London Taxi and Private Hire (LTPH), which oversees the test, summarizes the requirements as follows:

To achieve the required standard to be licensed as an “All London” taxi driver you will need a thorough knowledge, primarily, of the area within a six-mile radius of Charing Cross. You will need to know: all the streets; housing estates; parks and open spaces; government offices and departments; financial and commercial centres; diplomatic premises; town halls; registry offices; hospitals; places of worship; sports stadiums and leisure centres; airline offices; stations; hotels; clubs; theatres; cinemas; museums; art galleries; schools; colleges and universities; police stations and headquarters buildings; civil, criminal and coroner’s courts; prisons; and places of interest to tourists. In fact, anywhere a taxi passenger might ask to be taken.

Notably, the six-mile radius of Charing Cross "only" contains 25,000 streets, and cab drivers have to know which ones are one-way and which ones are not.  They also have to know what's the best way to get on or off a particular street, in addition to everything on these streets.  One cab driver reported that he was asked to locate a rather obscure statue of two mice eating a piece of cheese - the statue was only 1 foot tall!

For more than a century, the test has been known as "The Knowledge of London" or simply, "The Knowledge."  The Season 31 Amazing Race Detour "Know" gave contestants and television viewers just a glimpse of the test.  "The Knowledge" is testament to the incredible capacity of the human brain to acquire and store a vast amount of information.  Here is where things get really cool!  Apparently, the volume of the hippocampus (a structure located deep within the brain's temporal lobe that plays a major role in learning and memory) relative to the body size of small mammals (mice, rats, and birds have been studied in particular) varies based on the demands placed on spatial memory (even from year to year).  So, for example, during seasons when animals need to remember how to go back to the place that they stored food, the volume of the hippocampus will increase (the volume of the brain meets the demands placed on it).

The natural question is (1) whether the hippocampus of individuals who pass "The Knowlege" is larger than those who haven't passed it and (2) whether the hippocampus increases in size as individuals study and prepare to pass "The Knowledge."  Cognitive neuroscientist Eleanor Maquire and her team have published a number of studies using advanced magnetic resonance imaging (MRI) and positron emission topography (PET) techniques to answer these questions.  These studies can be summarized by the following key points:

1. The right hippocampus of the brain is most active (shown with PET) during spatial memory tasks (London taxi cab drivers asked to recall famous London landmarks and/or street directions).

2. Structural MRI shows that the posterior hippocampus is larger in volume in London taxi cab drivers compared to control subjects (moreover, the gray matter volume of the posterior hippocampus correlates directly with the number of years spent as a taxi cab driver).

3. Structural MRI shows that the posterior hippocampus is larger in volume in London taxi cab drivers compared to London bus drivers.

4. The gray matter volume of the posterior hippocampus increases over time as London taxi cab drivers study for "The Knowledge" from start to finish.

Collectively, these studies illustrate the remarkable ability of the brain to adapt to the demands of its environment over time (called plasticity in the neuroscience literature).  What's the take-home message here, you ask?  First, no matter what age we are, our brains can continue to develop with practice and experience.  Second, if we want to get better at something - even learning how to navigate the city streets of London, but more relevant, perhaps leading others - we have to practice!

"Before I make a mistake..."

Legendary Dutch football player and manager Johan Cruyff is widely regarded as one of the greatest football players in the history of the sport, having won the Ballon d'Or (a player of the year award which current football stars Lionel Messi and Cristiano Ronaldo have won seven times and five times, respectively) three times in the 1970's.  After retiring as a player, he became one of the greatest managers of all time, leading the professional clubs, Ajax (1985-1988), Barcelona (1988-1996), and Catalonia (2009-2013).  Cruyff has had a major influence on the sport and has been a strong proponent of a style of play known as "total football" (for all of you Ted Lasso fans out there, the formation known as the "False 9" mentioned in the second season of the show is a major tactic in this style).

Cruyff is also known for often stating the obvious in a rather humorous and lighthearted way (similar to the legendary New York Yankees player Yogi Berra).  For example, Cruyff once said, "You have got to shoot, otherwise you can't score."  He also said, "To win you have to score one more goal than your opponent."  And here is one of my favorites, "I'm not religious.  In Spain, all 22 players make the sign of the cross before they enter the pitch.  If it works all matches must therefore end in a draw."

More germane to what I most frequently write about it here in this blog, Cruyff once said, "Before I make a mistake, I don't make that mistake."  Again, on the surface it seems that Cruyff is stating the obvious.  If you unpack the quote a little more though, it actually is quite a profound statement.  How can someone not make a mistake before they actually make it?  It's easier than it sounds, and it comes down to two safety concepts borrowed from other so-called High Reliability Organizations - the time-out and the huddle.  

Time-outs have become the standard before and after every surgical or bedside procedure performed in the hospital.  While pre-procedural time-outs were originally designed to confirm the right patient, the right procedure, and the right surgical site, they have evolved far beyond their original intended use.  Time-outs make sure that all members of the surgical care team know each other by name and by role.  During the time-out, the plan for the procedure is clearly communicated to all of the members of the team, and any concerns that are raised get addressed before proceeding further.  When performed well, the team develops a shared understanding (known in the safety world as a "shared mental model") of the plan.  

Time-outs were initially performed at the beginning of the procedure, but now they are performed at each critical stage of the procedure, as well as at the end as a final debrief.  The Joint Commission has identified some of the most common errors when performing time-outs:

1. Time-outs occurring before all staff members are ready or before prep and drape occurs

2. Performing time-outs without full participation of the staff

3. Lack of senior leadership engagement in the time-out

4. Staff feeling passive or unable to speak up (an issue of psychological safety)

5. Distractions or rushed time-outs

When done well, time-outs reflect a patient-centered safety culture and create an environment of trust and psychological safety, so that team members feel empowered to report patient safety concerns without fear of reprisal.  Huddles are related to the time-out, though they are generally a little longer in duration than the time-out and generally occur at the beginning of a hospital shift or clinic.  The overall goal of the huddle is to review the scheduled events of the day and highlight any areas of potential concern.  Huddles are used in a number of industries outside health care (see my previous post "The morning huddle").

Huddles can be structured in a number of different ways, and some hospitals (notably The Cleveland Clinic and Intermountain Healthcare) have adopted the concept of tiered huddles, which generall start at the unit (microsystem) level, eventually rolling up through the meso- and macro-system levels.  For example, here is what tiered huddles look like at our children's hospital (more or less - I've simplified the structure slightly):

Tier One: Unit-based Huddle (team members working on an inpatient unit huddle at the start of a nursing shift )

Tier Two: Inpatient Huddle (representatives from each inpatient unit huddle together shortly after the unit-based huddles end)

Tier Three: System-wide Huddle (representatives from the inpatient, ambulatory, peri-operative, and emergency department huddle together, along with key stakeholders from security, safety, information technology, etc huddle together at 9:45 AM every morning)

Huddles generally work best when they occur in person, however hospitals have experimented with virtual and hybrid models as well.

So you see, Cruyff's statement wasn't really that far off base.  With time-outs and huddles, we can stop mistakes before they occur.  Recognizing that we can't prevent every mistake from occurring, time-outs and huddles can mitigate the impact of these mistakes and stop them from compounding and causing harm.

The Law of Continuous Improvement

Have you seen the following figure circulating around social media?

I will admit that I am not mathematically gifted.  Luckily, our children inherited their mother's mathematical abilities and not mine!  Regardless, even I can appreciate the poetic beauty here.  The figure is a great illustration (in mathematical terms) of the so-called Law of Continuous Improvement.  In this case, small, incremental improvement over time results in significant improvement of a process, as opposed to the "breakthrough" improvement that occurs all at once.  

W. Edwards Deming, an American industrial engineer and statistician who is one of the founding fathers of the modern quality improvement movement, preferred the term "continual improvement" as it was broader and more general in scope.  "Continual improvement" includes both "discontinuous improvement" and "continuous improvement."  The philosophy here is that while continuous improvement is preferable, any improvement is good.  I prefer to use the term "continuous improvement" as it aligns with other concepts, such as kaizen (the Japanese word meaning literally "change for the better" but generally referring to "continuous improvement"), operational excellence, and the High Reliability Organization principle of "Sensitivity to Operations".  

Continuous improvement is a scientific management philosophy embedded in quality improvement methodologies, such as Lean, Six Sigma, Zero Defects, Total Quality Leadership (TQL) / Total Quality Management (TQM), and the Model for Improvement.  Operational excellence has developed from concepts originally described by quality control engineers, management gurus, and scientists such as Walter Shewhart, Joseph Juran, Frederick Winslow Taylor, Taiichi Ohno, and the aforementioned W. Edwards Deming. 

As I stated above, I really like the mathematical illustration of "continuous improvement" above.  However, as I thought about it in greater detail, I realized that the mathematics behind this explanation is not accurate.  The mathematical equation above suggests that a little extra effort every day produces a much larger gain over the course of a year than the same level of effort applied every day.  I am reminded of the concept of simple interest here.  If we are improving in small, daily (i.e. "continuous") increments, the equation would look more like the equation for compound interest.  In other words, when we build upon our improvement every single day (even by just a tiny bit), we improve our performance by a much greater degree over the course of a year. 

We are essentially trying to calculate the sum of what is known in mathematics as an arithmetic sequence.  The sequence increases by 0.01 every day for 365 consecutive days:

1, 1.01, 1.02, 1.03, ...,

So, the sum of this sequence would be calculated by:

Sum = 1 + 1.01 + 1.02 + 1.03 + ...

In this case, the nth term in the sequence is 365 (if we improve every day for a year).  According to my mathematician wife, the formula for the sum of an arithmetic sequence (which is called an arithmetic series) is:

  

So, in our case, where a1=1, n=365, and d=0.01, the sum is then:

Sn = (365/2) x [(2 x 1.0) + (364)(0.01)] = 1,029.3

Wow! Performance significantly (maybe it's appropriate to say astronomically) improves over the course of a year, just by incrementally improving every day for the entire year!  Talk about the power of continuous improvement!  Incidentally, I butchered the calculation and came up with an even larger number during an initial draft.  Thanks to our math whiz kids who corrected my mistake!

The American author Mark Twain said it best, "Continuous improvement is better than delayed perfection."  Or, if you prefer the American statesman, Ben Franklin, "Without continual growth and progress, such words as improvement, achievement, and success have no meaning."  When you look at the concept of continuous improvement from a mathematical standpoint, both Twain and Franklin are correct!

"The times they are a changin'"

I realize that he may be an acquired taste, but I really enjoy listening to the American singer-songwriter Bob Dylan.  I've blogged about him in the past (see the post about my absolute favorite Dylan song, "The Chimes of Freedom").  Several years ago, I watched him play live at an outdoor music venue in Indianapolis (truthfully, the concert wasn't great - Dylan acted like he didn't want to be there, but the music was good).  He is often regarded as one of the greatest songwriters of all time, and he even won the Nobel Prize in Literature in 2016.  The New York Times reported, "Mr. Dylan is the first musician to win the award, and his selection on Thursday is perhaps the most radical choice in a history stretching back to 1901."  Dylan initially remained silent about the award, and many people believed that he would refuse to accept it.  While he did not attend the ceremony in person, he graciously accepted the award and later published a rather poignant essay in lieu of an acceptance speech.

Another favorite Dylan song of mine is The Times They Are a-Changin', which also is one of his most famous songs.  It is a beautiful song that captures the essence of the social and political upheaval of an entire generation who lived through the 1960's:

As the present now

Will later be past

The order is rapidly fadin'

And the first one now

Will later be last

For the times they are a-changin'

Beautifully poetic!  I'm not the first to say it, but the world is constantly changing.  The ancient Greek philosopher Heraclitus said it better than I ever could, when he said that "No man ever steps in the same river twice, for it's not the same river and he's not the same man."  Change is the only constant in our universe.

Yesterday (March 14th) was the two year anniversary of our pediatric hospital's first patient who tested positive for COVID-19.  Since that time, we have tested over 75,000 patients for COVID-19.  Almost 7,000 of those patients tested positive, and we admitted close to 1,000 of these patients to our children's hospital.  The experience at most of the adult hospitals in our city was quite different, but COVID-19 still had a major impact on us.  I took a moment yesterday to reflect on all that has happened in the last two years.  I have changed.  Our hospital has changed.  Our city has changed.  Our world has changed.

We will never be the same.  And that's okay.  As I thought about it more, our hospital, our city, and our world (and yes, even me) would have been different today compared to two years ago, even if COVID-19 had never happened.  Just like Heraclitus' river, with the water constantly moving downstream, we are all moving through our lives and changing every minute.

The ancient Stoic philosopher, Marcus Aurelius said in his book Meditations, "The universe is transformation; life is opinion."  Stated more simply (and perhaps less elegantly), "The universe is change; our life is what our thoughts make it."  Recognize that everything is changing - and accept that there is nothing we can do to prevent it.  And most importantly, with change comes hope.  "Oh, there been times that I thought I couldn't last for long.  It's been a long long time coming, but I know a change gonna come."