Overstating certainty

How do we know what we know? It is a simple question but not so simple to answer. Sometimes there are things that we know which require no proof. I love my wife and I know this. I am not required to prove this (except perhaps to my wife at times such as our anniversary). Whether I can prove this or not does not really affect other people.

Other beliefs have consequences which impact on one or many other people. In the world of health care, what we know dictates what we do and how we advise our patients. When someone presents with chest pain, shortness of breath, diaphoresis, tachycarida, and classic ST changes on EKG, we know they are at risk of cardiac arrest based upon hundred's of thousands of observations. Specific interventions have been tested in controlled fashions and although there are still gray areas in terms of optimum interventions, there are reasonably solid numbers in terms of risk associated with specific scenarios.

It is unfortunate that in many if not most of healthcare we see certainty where it does not exist and nowhere is this more disturbing than where health care and law intersect. There is a recent story about Dr. Marta Cohen, a pathologist in England who has taken on the study of the neuropathological findings in shaken baby syndrome. From the New Scientist:

A triad of markers

The three markers for a shaken baby diagnosis are retinal haemorrhages in both eyes; subdural haemorrhages between the fibrous dura layer that protects the brain and the brain surface beneath; and swelling of the brain. Subdural haemorrhages are said to arise from ripping and shearing of so-called bridging veins. New lines of evidence challenge this hypothesis with the discovery that subdural bleeds are much more common in babies than generally appreciated, and for a host of innocent reasons (see "Anatomy of a murder?").

Last year, Cohen and co-researcher Irene Scheimberg of Barts and the London NHS Trust examined post-mortem tissue from fetuses and newborns and found subdural haemorrhages in 16 of the 25 fetuses and 20 of the 30 newborns. They also found haemorrhages within the dural layer itself, suggesting that the bleeding started here (Pediatric and Developmental Pathology, DOI: 10.2350/08/08/0509.1). The research is just the latest of many reports to show that subdural bleeds can occur without shaking (see "Anatomy of a murder?").

http://www.newscientist.com/article/mg20727713.600-doctor-gagged-for-doubting-shaken-baby-syndrome.html?full=true

It seems that by calling into question the dogma accepted as fact by an army of expert witnesses who have testified in trials over many years, Dr. Cohen has raised the ire of those who have a vested interest in maintaining the aura of certainty. The General Medical Council has placed restrictions on her medical license which bar her from further testimony as an expert witness. It appears that she was consistently spoiling the party by showing up to testify in trials and unlike her adversaries claiming the that the triad of findings were specific, she had actual data to support the opposite contention.

I have seen this before. Twenty five years ago the presence of genital or peri-anal warts in an infant was declared proof positive of child abuse. However, after putting countless parents through the ringer, we discovered that..oh never mind, such warts can be transmitted through many other means. Furthermore, the actual numbers which are relevant are poorly defined. Are half of the cases of genital or peri-anal warts in children due to sexual abuse? 25%? 10%? 1%? Who knows and who knows how to know?  How many people were jailed or placed upon the sex offender list based upon the testimony of experts whose hypotheses were essentially untestable.

I have done a modest amount of expert witness work and reviewed a number of depositions. I am surprised by the culture of certainty which prevails. It is scary how many people who are certain they know, don't know that they don't know. Furthermore, they have no concept of what they need to do in order to know how they know. The casualties are people like Dr. Cohen who has the audacity to take on a contrary opinion based upon actually testing the evidence and the tools used to make these assessments of certainty. She had her license restricted based upon the fact she failed to agree with a consensus. Sounds like Galileo. Oh yes the sun does revolve around the earth.

Our koala health care economy

Koalas are interesting animals. They have adapted to survive in a very narrow ecological niche, consuming only eucalyptus leaves. This food source is a poor nutritional source, low in protein and energy and rich in toxins. Over time reliance on this solitary, non-optimal low energy food has resulted in a shrinking brain which has lost almost half of its former size. The koala is the product of compromise.

I see elements of the koala in health care financing at multiple levels. Within an academic medical center we have multiple missions including research, teaching and training, and patient care. Like all activities, these require an energy source, that being primarily human creativity and money. Track the funds that flow into an institution like my own and you find that the vast majority comes from a single source, the federal government. This cash flow comes in many forms including federal grants from the NIH, NSF, or the Veteran's Administration, direct payments from Medicare or Medicaid (indirectly through states), GME payments to support resident education, and federal grants and loan guarantees to support the education of a host of health care professionals. Federal monies are the eucalyptus leaves of the health care economy.

There is no question that the infusion of federal monies changed the health care environment and in the short term were a driver for dynamic change, much of it positive. However, because the growth and expansion based upon federal monies is not sustainable, it has created an economy which is unhealthy in terms of its increasing dependence upon a "food" supply which is both constricting in terms of what it can support and gradually more toxic in terms of poisoning other aspects of general operations.

The koala responded to sole dependence on a poor energy source with scaling back on what required energy, it its case its brain. Successful adaption meant re-allocation of energy to digestion and detoxification. I would suspect that at some point in the past the koala ancestors had a more varied diet but they evolved toward greater and greater reliance on what appeared to be an abundant but poor quality eucalyptus diet.

It now appears that the health care dependence on federal diets is looking more like eucalyptus leaves. While at one point in time this energy source was robust and supported missions with sufficient margins, it is not looking increasingly like a low energy source. Patient care supported by federal monies must be underwritten by subsidies from private insurers. The scramble for federal research dollars is looking more and more like a giant zero sum game with institutions making large bets vying for indirect dollars to offset operating costs. The entirety of graduate medical education is supported by GME dollars or VA monies to support resident salaries in a hospital based format. All of these pools are either shrinking or growing at a pace not capable of supporting these missions as presently configured.

Like eucalyptus leaves, these monies are also increasingly toxic. The regulations which accompany these monies require more and more oversight and reporting. This takes time, money, and people. Perhaps the most pernicious element of this scenario is the fact that the regulations are constructed in such a way that the more federal money you take, the more difficult it becomes to use other financial sources. Furthermore, the regulatory environment is capable of transforming other revenue sources, which may be of higher quality and less toxic,  into eucalyptus like sources.

Ultimately, we need to be able to hedge our bets. Where are the financial resources going to come from to support all of these various important care, teaching, and research missions? I don't know. However, I do know that the more dependent we become on any given source, particular on a single source, the more at risk we become for a really bad outcome. We need to learn to liberalize the diets which feed this machine.

The koala spends its days eating constantly to derive sufficient energy to survive.

Duty hours and what constitutes work

We are moving to dedicated use of an EeMR and electronic notes in a busy outpatient clinic setting. The pace is quick and the patients are very complicated, often on a host of immunosuppressive medications. The workflow is  still very awkward which results in us taking notes in the room and then later completing the actual note. In fact, the ratio of "work" done during the face to face encounter vs. after the patient has departed is one or greater. Appropriate management generally includes subsequent reading, synthesis of all data obtained during the actual visit as well as subsequently, discussion and reflection, and ongoing tweaking of the management plan. The question is, is that activity which happens after the patient leaves and perhaps even at home or somewhere off site actual work which counts toward duty hours?

The ACGME defines duty hours as:

All clinical and academic activities related to the program; i.e., patient care (both inpatient and outpatient), administrative duties relative to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled activities, such as conferences. Duty hours do not include reading and preparation time spent away from the duty site. 

There is a stark contradiction in this definition since it states in the first statement that duty hours are "All" clinical and academic activities related to the program while in the last statement it says it does not include reading and preparation time spent away from the site. This statement is based upon an archaic concept of what constitutes actual work and where it can and should be done. In the present world, "work" may not  necessarily linked to a specific place.

Let me throw out a hypothetical scenario. I have a patient who developed an unusual immunological reaction to an device that was implanted. As part of the resident's role in the care for this patient they took on the responsibility of researching the possible offending substances, contacting the manufacturer's representatives regarding the actual makeup of this and related devices, and the possible approaches to sort out the problem, all directed at solving this patient's problem. This actually takes many hours and of all the activities which will in fact provide value to the patient, these activities are most essential.

They do not appear to qualify as work that applies to duty hours. They involve much reading and preparation and do not happen on site. There are no CPT codes which apply. The patient is not physically present although there might be communications via phone or email. There is no financial value to the health care system in doing these activities despite any value they provide to the patient. There are no additional RVUs which would be credited to that particular physician.  By all objective measures of value, this does not appear to be work in virtually anyone's book.

This is crazy. Not that I want to make duty hour tracking any more difficult but I believe this (and other similar scenarios) underscore a fundamental problem with how we view work and value within the health care system. This is a throwback to the pre-market based systems of work and value which were held hundreds to thousands of years ago. These philosophical systems basically viewed that any activity which did not involve physical labor or producing something tangible did not constitute work. There was great distrust of merchants who were perceived as providing no value since they functioned as middle men, facilitating the distribution of things that other men made. There was little concept of creating value through cognitive work as opposed to producing tangible items or doing physical labor.

In the world at large we have moved beyond this narrow minded concept of work and value, that is except for medicine. We are stuck with the idea that worthwhile work is somehow confined to discrete and definable packets of physical activity. It permeates how we think about what constitutes work by trainees. It thoroughly has corrupted all metrics of physician productivity. RVU's are linked to discrete encounters and fail to account for value created cognitive work outside of specific face to face encounters.

While at first blush it might appear to be a trivial point to focus upon. However, this conceptual problem has resulted in real world consequences where what is valued financially in the work of health care is not necessarily what benefits patients. It results in a huge hole in the valuation of a particular set of activities which appear to be essential for the functioning of an integrated health care industry. What we need are the middle men of medicine, those who may not actually do things directly to patients but provide value by coordinating the activities of others. Just because Aristotle did not see the value of such activities it does not seem we should continue holding these views.  The legacy of this misunderstanding goes back centuries and is still accepted without much thought as to its origins.

Wikileaks, Military reports, and office notes

There was an interesting Op-Ed piece in the WSJ on the military reports leaked to the public through Wikileaks by Noah Shachtman. He describes the difference between what was recorded in these reports and what actually happened.

The vast difference between what actually happened at the Moba Khan compound in Helmand province and what the report says happened there should give caution to those who think they can discover the capital-T truth about the Afghanistan conflict through the Wikileaks war logs.

It should also give pause to those officers in military headquarters who rely on these updates. The military has a problem in how it talks to itself. These reports—ultra-compressed and focused solely on the bombs-and-bullets part of the war—are a symptom of that shaky reporting system.

He went on to say:

That's not to say Echo company hid the truth. It's that these reports from a harried commander at the farthest edge of the war zone are by nature clipped, compressed, clunky and incomplete. But they also made their way up the chain of command. At the Marines' provincial headquarters at Camp Leatherneck, this was one of the primary methods by which officers were kept apprised of Echo company's actions: number of rockets fired, number of enemies killed, number of bombs dropped. Next report.

In a counterinsurgency, such metrics often matter least. A counterinsurgency is a contest for the loyalties of the people. Munitions expenditures and body counts are, at most, tangentially relevant. More important is insurgent motivation, the mood of the local shopkeeper, and the local farmer's ability to bring his crops to market.

 I was struck by the how this sounded like the documentation we use in medicine. Not that anyone is shooting at us but like the soldiers, our primary job is not documentation and the documentation we do is under harried conditions. We record objective information which tends to be both objective and recordable, although often irrelevant to actual good medical decision making. It increasingly is serving as the basis for metrics to assess quality and safety, and decisions regarding allocation of scarce resources. Where the military fails to capture information crucial to the local shopkeeper or farmer, in medicine we tend to overlook information which is important to our patients.

While the military does a stellar job at assembling data to target its enemies and rearm its troops, it still has problems processing this other kind of information, which is the most crucial to the war effort. Even the top U.S. intelligence officer there thinks so. "Having focused the overwhelming majority of its collection efforts and analytical brainpower on insurgent groups," wrote Maj. Gen Michael Flynn in a report earlier this year, "the vast intelligence apparatus is unable to answer fundamental questions about the environment in which U.S. and allied forces operate and the people they seek to persuade."

Any time a signal gets compressed, information is lost. Think about the difference in sound quality between a live rock show and an MP3. Think about a news report of a political rally, and the feeling of actually being there.

In health care, what information we record tends to be similarly compressed and what is documented is primarily what is needed to justify the bill and stay out of legal trouble. We have serious troubles using medical records to talk to ourselves. Medical records are generally next to useless as communication tools and the electronic medical record is not improving this aspect of communication.  It is the body counts all over again.
 (see http://georgiacontrarian.blogspot.com/2009/07/legacy-of-robert-mcnamara.html)

At least we have transparency

http://www.youtube.com/watch?v=ACbwND52rrw&feature=player_embedded

Barriers to multidisciplinary clinics and care

There is a developing consensus that the products available in the current health care market are woefully inadequate when it comes to delivering integrated care. There are no shortage of policy wonks who weigh in in the subject and substantial revenues are slated to be deployed in the health care reform act for demonstration projects attempting to develop new products.

I do not think I am in a position to predict what will come as a product of all these effort, whether it will be better than what we have, or even whether we will be able to measure anything meaningful that will tell us unambiguously that it is better or worse. I know we will get spin and lots of it. I do have the benefit of being able to look back at the past and see what I think are the biggest mistakes in terms of creation of the wrong incentives.

Let me set the stage by asking a very basic question. Why such a focus on multidisciplinary endeavors? What is missing presently that will improve if we use a multidisciplinary approach? What is a multidisciplinary approach? I would argue that we have such a multidisciplinary approach now. Most patients I see with one or more chronic problems have many physicians caring for them. It is simply not a thoughtful and coordinated multidisciplinary approach.  What we are missing is thinking, reflection, and the communication required for optimal problem solving.

This is a consequence of a payment system which values reflection, judgment, communication, and coordination of care at zero. Health insurers do not want to pay for duplicative services and it makes sense that they not pay for more than one colonscopy or CAT scan. However, this is extended to E&M services which is where the multidisciplinary will thrive or fail. What is the consequence of refusing to pay for more than one service for thinking, reflection, and coordination? When the team cannot be financially rewarded for functioning as a team, the life expectancy of the team is likely to be very short.

The question then becomes, how do create a system which has financial rewards for the very things we say we value? I am not sure how this will be accomplished but I can be pretty sure how it will not be accomplished. It will not be accomplished by continuing to use our present administratively set pricing and service definition structure. It will also not likely be solved using the structure of demonstration projects done within health care entities which are constrained by regulatory straight jackets and have a vested interest in maintaining the status quo. True innovation will disrupt what we have now and will come from entities who have not made huge capital investments in infrastructure best exploited using the old rules. Digital photography did not come from Kodak. Desk top computing did not come from Cray. Innovative small cars did not come from GM.

EHR's, scribes, and the purpose of the record

Ever since I can remember I recall learning that one of the most important skill sets which follows from a good education is the ability to communicate using the written word. In virtually all realms of human endeavors, we place a premium on the ability to write and to write well. Why do we value this skill so highly? There are many different takes on this question but certain themes are consistent across authors. First, most organizations rely on effective written communication to operate. Assuming that coordinated human activity is important to accomplish a particular task or tasks, unambiguous communications (generally written since they are more enduring) are absolutely essential for the functioning of operating units. Writing is also an effective tool for organizing your thoughts when face with a problem which requires analysis. It is particularly important when one is trying to extend and test one's initial gut impressions.

It seems to me that these aspects of writing SHOULD be relevant to the practice of medicine. What we do as individual practitioners should be effectively communicated to other members of a greater team caring for the same patient and the written word is the gold standard for communication. Furthermore, physicians are by definition problem solvers, faced with a steady stream of patients who present with a constellation of signs, symptoms, and other data. The gold standard for reflection and analysis is to collect your thoughts, put them down and paper and organize them into a document that conveys as reasonable hypothesis and plan for analysis and treatment.

However, the written record in medicine has been completely high jacked. The elements which must be included are elements needed to justify billing. Everything else is secondary. Coordination of health care activity..what's that? Organization of thoughts..endangered species. Perhaps the best evidence of how unimportant written communication in the form of office notes have become is the task is increasingly being delegated to scribes. In my community, these are generally individuals with high school educations who operate off macro menus in EHRs. Thus they are essentially working off a medical mad-libs menu piecing together documents that are designed solely to contain verbiage that optimizes billing. Each note looks eerily like the previous one, filled with words but no actual information or analysis.

The origins of the present state are obviously in the past. Historically, physicians in the outpatient world operated by themselves. Their notes served their own purposes and even very brief notes may have been adequate to communicate back to themselves at a later date when the patient returned. Furthermore, medicine was simply less complex. There were fever options and the pace of practice was generally less hectic. Fast forward to the present and the world has changed but how we operate has not. We have tried to apply an old practice model to new circumstances where volume and acuity is increased. However, the model is neither functional nor scalable.

The problem is all about essential tasks and workflow. Part of that workflow is collection of data which includes information collected from patients as history and physical exam. After essential information is collected, it needs to be synthesized, an impression created followed by a plan for further evaluation and treatment. In the current state, all of this is jam packed into a time constrained slot which is the face to face encounter (appointment). It creates time pressures where none is really required. Our payment system has created artificial time constraints which prompted physicians to create useless notes. We have become so focused on the use of the medical record to maintain our revenue stream that we have missed its transition to a state where it actually serves no other useful purpose.

Ultimately, we need to change the workflow to encourage better analysis and communication of that analysis. We need to ask what data do we need to guide patients and their physicians to make the best decisions and how and where to collect this? Technology and scribes are fine for recording data. Premium value for physicians can only be justified by unique skills which require intelligence, drive, and years of training and experience. This generally falls into unique technical skills and problem solving skills. Those focused on the former may not require the same analysis and communication skills and their practices may not require dramatic changes in workflow. Medicine is pretty good in this value added realm. However, for those physicians who operate in the realm of solution shop and chronic care models, we need to change the workflows first to collect data first in a non-time constrained fashion and place highest value on our abilities to define and solve problems and communicate our analysis in precise terms using the written word. This is not something can be delegated to those with nominal training nor is it something that can (or should) be done is those fleeting moments before the next patient get roomed.