Category Archives: Healthcare

Changing Clinical Practice Doesn’t Have to Take So Long

Guest post by Seshadri Mudumbai, MD, MS.  Dr. Mudumbai is an Assistant Professor of Anesthesiology, Perioperative and Pain Medicine at Stanford University School of Medicine. He is also a health services researcher and physician anesthesiologist at the Veterans Affairs Palo Alto Health Care System.

time-for-changeChanging physician behavior is rarely easy, and studies show that it can take an average of 17 years before research evidence becomes widely adopted in clinical practice. One study published in JAMA has identified 7 categories of change barriers:

  1. Lack of awareness (don’t know guidelines exist)
  2. Lack of familiarity (know guidelines exist but don’t know the details)
  3. Lack of agreement (don’t agree with recommendations)
  4. Lack of self-efficacy (don’t think they can do it)
  5. Lack of outcome expectancy (don’t think it will work)
  6. Inertia (don’t want to change)
  7. External barriers (want to change but blocked by system factors)

Why Change?

According to the Institute of Medicine’s Crossing the Quality Chasm: a New Health System for the 21st Century:  “Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place.”  Our group has focused our efforts on implementing updated evidence-based medicine initiatives for surgical patients with a special emphasis on the total knee replacement population.  Knee replacement is already one of the most common types of surgery in the United States (over 700,000 procedures per year).  Given an aging population, the volume of knee replacement surgeries is expected to increase to over 3 million by the year 2030.

We now have sufficient evidence to support “neuraxial anesthesia” (such as a spinal or epidural) as the preferred intraoperative anesthetic technique for knee replacement patients.  With neuraxial anesthesia, an injection in the back temporarily numbs the legs and allows for painless surgery of the knee.  Several studies have now shown better outcomes and fewer complications after knee replacement surgery with neuraxial anesthesia when compared with general anesthesia.  Despite these known benefits, a large study evaluating data from approximately 200,000 knee replacement patients across the United States reveals that use of neuraxial anesthesia occurs in less than 30% of cases.  At our facility prior to changing our practice, we noted a 13% rate of neuraxial anesthesia utilization.  In the face of growing evidence, we chose to change our practice, and the results of these efforts are reported in our recently published article.

How Did We Start?

An important tool used to coordinate the perioperative care of knee replacement patients has long been the clinical pathway.  A clinical pathway is a detailed care plan for the period before, during, and after surgery that covers multiple disciplines:  surgery, anesthesiology and pain management, nursing, physical and occupational therapy, and sometimes more.   The concept of the clinical pathway should be dynamic and not static.  This requires a process to ensure clinical pathways are periodically updated and someone to take a leadership role in managing the process.

At our institution, we established a coordinated care model known as the Perioperative Surgical Home (PSH).  The PSH provides the overall structure and coordination for perioperative care, and multiple clinical pathways exist within this structure.  With a PSH, physician anesthesiologists are charged with providing leadership and oversight of specific clinical pathways, collecting and reviewing data, engaging frontline healthcare staff and managers across disciplines, and suggesting changes or updates to clinical pathways as new evidence emerges.

Within our PSH model, we invested in a 5 month process to change our preferred anesthetic technique from general anesthesia to neuraxial anesthesia within the clinical pathway for knee replacement patients.  This process involved many steps and followed the Consolidated Framework for Implementation Research:

  1. Literature review and interdepartmental presentation
  2. Development of a work document
  3. Training of staff
  4. Prospective collection of data with feedback to staff.

After one year, the overall percentage of knee replacement patients receiving neuraxial anesthesia increased to 63% from 13%, and a statistically-significant increase in neuraxial anesthesia use took place within one month of the updated clinical pathway rollout.

How Do We Keep It Going?

Neuraxial anesthesia continues to be the predominant anesthetic technique that our knee replacement patients receive today.  We attribute the ongoing success of this change to multidisciplinary collaboration, physician leadership in the form of a departmental champion, peer support and feedback, frequent open communication, and engagement and support from facility leadership.  The results of our study and experience show that a PSH may help facilitate changes in clinical practice quicker than other less-coordinated models of care.  As PSH models continue to be developed, further evidence to support the impact of clinical practice changes on patient-oriented outcomes related to quality and safety and healthcare economics is needed.

For patient education materials regarding anesthetic options for knee replacement surgery, please visit My Knee Guide.

 

 

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Reality and the Ivory Tower

At our conferences and workshops focused on regional anesthesiology and acute pain medicine, we present and discuss the latest and greatest advances in nerve block techniques for patients having surgery.  As physicians and scientists, we are very familiar with the evidence supporting the use of nerve blocks for postoperative pain management.  We know they are extremely effective in preventing and treating pain, decreasing the need for opioid medications, and even avoiding the common side effects of general anesthesia such as nausea and vomiting and confusion.

ASRA 2015

We believe in them.  

We are passionate about them.  

We want all patients to have access to them.

Within the meeting sessions and sometimes in the common spaces outside the lecture halls, regional anesthesiologists often vigorously debate various things like:  the best sites and techniques for nerve block injections, needle and catheter equipment, ultrasound transducers and machines, and local anesthetic selection and use of adjuvants among other things.  

For knee replacement patients in particular, we want to provide the best form of pain management while maximizing their postoperative function.  Since 2011, dozens of research articles have studied the more distal adductor canal block for pain management in patients who undergo knee replacement as a replacement for the long-standing incumbent, the femoral nerve block.  In reality, these sites of nerve block placement are mere centimeters apart and represent different sites of injection along the same set of nerves.  Anesthesiologists and surgeons continue to debate this issue in person, in social media, and in publications.

It’s time for a reality check.

I had the opportunity to do a big data study with my friend and colleague, Dr. Stavros Memtsoudis.  In this study of over 191,000 knee replacement patients who had surgery across over 400 hospitals in the United States, only 12.1% of all patients had a peripheral nerve block of any kind!  Over 76% of patients had general anesthesia alone with no other regional analgesic technique. 

A more recent study published this month in the Journal of Arthroplasty evaluated over 219,000 patients who underwent knee replacement, and only 27.3% of patients received a peripheral nerve block.  The database used for this study was NACOR, operated by the Anesthesia Quality Institute and the American Society of Anesthesiologists.  This was brought to my attention through a Tweet sent by My Knee Guide (@mykneeguide).

Screenshot_20160817-203011

Where is the disconnect?  The efficacy of peripheral nerve blocks for pain control in patients having knee arthroplasty was first published more than 25 years ago.  It is easy to assume that such well-established evidence is being applied daily in clinical practice for the hundreds of thousands of patients who receive this surgery every year, but it’s not.  Today, there is more awareness than ever about the risks of opioids, and nerve blocks offer proven opioid-sparing pain relief.  Perhaps this is just another example of the gap separating the “ivory tower” of academics and real life.

In a previous post, I wrote about the obstacles to changing clinical practice, and there are many:

  1. Lack of awareness (don’t know guidelines exist)
  2. Lack of familiarity (know guidelines exist but don’t know the details)
  3. Lack of agreement (don’t agree with recommendations)
  4. Lack of self-efficacy (don’t think they can do it)
  5. Lack of outcome expectancy (don’t think it will work)
  6. Inertia (don’t want to change)
  7. External barriers (want to change but blocked by system factors)

Maybe it’s time to focus less on debating minor differences in the ways we do blocks and focus more on figuring out how to make sure more patients actually get them.  

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Physician-Led Anesthesia is Safe Anesthesia

Anesthesia1Many people, even those who work in the operating room every day, take safe anesthesia care for granted.  There has been growing pressure recently to abandon the team model and remove physician anesthesiologists’ supervision of nurse anesthetists with the latest threat coming from within Veterans Affairs (VA) healthcare.  For our Veterans, our heroes and arguably some of the most medically complex patients, having both physician anesthesiologists and nurse anesthetists working together as a team makes sense.

Having a team with members who train differently and have different perspectives can only benefit the patient; physician anesthesiologists draw on their medical training while nurse anesthetists bring valuable nursing experience.  Providing anesthesia is often compared to flying a passenger airplane, and the care team model is like having both a pilot and a co-pilot.  Has flying become so safe that we no longer need the pilot?  Seconds count in flight, and they count in the operating room when a patient’s life is on the line.  If approved, the proposed change in the VA nursing handbook will abolish this team model without giving Veterans a choice and will require VA hospitals to assign Veterans having surgery either a nurse anesthetist OR a physician anesthesiologist but not offer both.  If they were given the choice, however, I think our Veterans would choose “AND” instead of “OR.”  We all should.  In case a crisis happens during surgery, every patient should have access to a physician anesthesiologist.

Not too long ago operating room personnel had to worry about explosive anesthetic gases, and patients faced the risk of developing organ failure after every time they had anesthesia in addition to the usual perils of having surgery.  This changed when anesthesiology became a medical specialty and profession for physicians.

How is anesthesiology different than anesthesiaAnesthesia, a word with Greek origin, means “without sensation.”  Often referred to as “going to sleep,” general anesthesia is more like a complex drug-induced coma that can still carry serious risk, and a person’s physical and emotional reactions to anesthetic agents are not always predictable.

Anesthesiology is a science like biology or physiology and a specialty field of medicine like cardiology or radiology.  Modern anesthesiologists are physicians, scientists, educators, and patient safety advocates.  The heart of anesthesiology continues to be the patient experience.  As physician anesthesiologists, we specialize in relieving anxiety, preventing and treating pain, preventing and managing complications related to surgery, and improving the outcomes for patients who undergo invasive procedures.  The average physician anesthesiologist spends nearly a decade in postgraduate education after college and logs 16,000 hours of clinical training to learn to apply the best available evidence in clinical practice.  Academic physicians and scientists focused on anesthesiology are responsible for the discovery of the newer and safer anesthetic and analgesic agents we use every day.

Anesthesia administration by non-physicians such as nurse anesthetists and certified anesthesiologist assistants is supported by the American Society of Anesthesiologists within the physician-led anesthesia care team model.  A similar model is used in the intensive care unit with physician intensivists supervising teams that include acute care nurse practitioners.  To preserve safe, high-quality physician-led anesthesia care for our nation’s Veterans, please support the team model and #SafeVACare by speaking up on http://www.safevacare.org by July 25th.  It only takes a minute to post a comment, but the consequences of not saying something may be serious and long-lasting.

This post has also been featured on KevinMD.com.

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Pain Medicine, Perioperative Surgical Home, and the Patient Experience

VAPAHealthcare around the world is changing. In the United States, healthcare reform has been focused on achieving the “triple aim” as described by Berwick (1). This triple aim encompasses 3 goals: improving the patient experience, reducing costs of care, and improving population health. The Perioperative Surgical Home (PSH) is a conceptual model introduced by the American Society of Anesthesiologists (ASA) in the past 5 years that may serve as an integrator to help hospitals achieve the triple aim (2). PSH is defined as “a patient-centered, physician anesthesiologist-led, multidisciplinary team-based practice model that coordinates surgical patient care throughout the continuum from the decision to pursue surgery through convalescence” (3). In reality, a PSH can take many forms, and the concept is analogous to the “Perioperative Medicine: the Pathway to Better Surgical Care” initiative by the Royal College of Anaesthetists in the United Kingdom. To date, there have been few published descriptions of actual PSH programs.

Role of Pain Medicine in the PSH

Pain medicine is woven throughout the three main elements of the PSH: preoperative preparation, intraoperative care, and postoperative recovery and rehabilitation (4). Preoperatively, anesthesiologists and pain medicine specialists have an opportunity to influence patient care by identifying patients who are considered high risk for surgery and tailor an individualized preoperative preparation plan for them. For example, the patient with chronic pain treated with long-acting opioids may benefit from optimizing the preoperative analgesic medication regimen, even tapering the opioid dose, or prescribing cognitive, behavioral, or physical therapy prior to elective major surgery like lower extremity joint replacement. During the intraoperative period, anesthetic protocols provide consistent care for surgical patients, and implementing clinical pathways that include regional anesthesia techniques have been shown to decrease perioperative opioid use and improve outcomes. For patients who have surgery, pain has a profound influence on the hospital experience. In the United States, the patient experience of care is one of three domains that influence hospital incentive payment amounts from the Center for Medicare and Medicaid Services. Patient experience is assessed using a survey, and 7 of 32 questions directly or indirectly relate to pain management (5). After the immediate postoperative period, integrated pain management can help patients achieve physical therapy goals and facilitate the transition to after-hospital rehabilitation. For challenging patients with chronic pain, this process may require careful coordination between the in-hospital anesthesiologist, outpatient pain clinic physician, and primary care physician (4).

Thinking Beyond Pain

The practice of anesthesiology in the United States is evolving, and there is a greater emphasis on demonstrating value. Anesthesiologists have historically been successful in establishing perioperative clinical pathways that improve acute pain management especially in orthopedic surgery, and setting up regional anesthesia and acute pain medicine programs has played a key role (6). However, competing priorities require revision of clinical pathways from time to time. For example, concerns regarding quadriceps muscle weakness with femoral nerve blocks (7) and the potential for falls (8) have led to innovations in selective nerve block techniques for knee replacement patients (9) and greater achievements in functional rehabilitation (10). By establishing a PSH model, anesthesiologists have greater opportunity but also greater responsibility for reducing perioperative complications that may or may not typically be considered within the realm of anesthesiology (11).

Future Directions

physical_med_rehab_indexTo date, anesthetic interventions focused on targeting acute pain have not demonstrated long-term functional benefits (12,13). Perhaps implementation of a PSH with better care coordination that includes individualized preoperative preparation and follow-up after surgery during rehabilitation will have greater potential for positive long-term outcomes. In addition to improvements in functional outcomes, a PSH may be able to provide patients a smoother transition from hospital to home in terms of pain management and decrease the incidence of chronic pain after common elective procedures like joint replacement (14). Finally, more health economic research is needed to prove the financial benefits of a PSH in terms of cost savings for hospitals.

In summary, the PSH is a model that can be applied many ways to provide coordinated care of the surgical patient from the decision to proceed with surgery through convalescence. Pain medicine plays an integral role in any PSH implementation. However, to be effective, anesthesiologists as leaders of the PSH need to target improvement strategies beyond pain outcomes and the immediate postoperative period.

References

  1. Berwick DM, Nolan TW, Whittington J: The triple aim: care, health, and cost. Health Aff (Millwood) 2008; 27: 759-69
  2. Vetter TR, Boudreaux AM, Jones KA, Hunter JM, Jr., Pittet JF: The perioperative surgical home: how anesthesiology can collaboratively achieve and leverage the triple aim in health care. Anesth Analg 2014; 118: 1131-6
  3. Mariano ER, Walters TL, Kim TE, Kain ZN: Why the perioperative surgical home makes sense for veterans affairs health care. Anesth Analg 2015; 120: 1163-6
  4. Walters TL, Mariano ER, Clark JD: Perioperative Surgical Home and the Integral Role of Pain Medicine. Pain Med 2015; 16: 1666-72
  5. Mariano ER, Miller B, Salinas FV: The expanding role of multimodal analgesia in acute perioperative pain management. Adv Anesth 2013; 31: 119-136
  6. Mariano ER: Making it work: setting up a regional anesthesia program that provides value. Anesthesiol Clin 2008; 26: 681-92, vi
  7. Charous MT, Madison SJ, Suresh PJ, Sandhu NS, Loland VJ, Mariano ER, Donohue MC, Dutton PH, Ferguson EJ, Ilfeld BM: Continuous femoral nerve blocks: varying local anesthetic delivery method (bolus versus basal) to minimize quadriceps motor block while maintaining sensory block. Anesthesiology 2011; 115: 774-81
  8. Feibel RJ, Dervin GF, Kim PR, Beaule PE: Major complications associated with femoral nerve catheters for knee arthroplasty: a word of caution. J Arthroplasty 2009; 24: 132-7
  9. Lund J, Jenstrup MT, Jaeger P, Sorensen AM, Dahl JB: Continuous adductor-canal-blockade for adjuvant post-operative analgesia after major knee surgery: preliminary results. Acta Anaesthesiol Scand 2011; 55: 14-9
  10. Mudumbai SC, Kim TE, Howard SK, Workman JJ, Giori N, Woolson S, Ganaway T, King R, Mariano ER: Continuous adductor canal blocks are superior to continuous femoral nerve blocks in promoting early ambulation after TKA. Clin Orthop Relat Res 2014; 472: 1377-83
  11. Kim TE, Mariano ER: Developing a Multidisciplinary Fall Reduction Program for Lower-Extremity Joint Arthroplasty Patients. Anesthesiol Clin 2014; 32: 853-864
  12. Ilfeld BM, Ball ST, Gearen PF, Mariano ER, Le LT, Vandenborne K, Duncan PW, Sessler DI, Enneking FK, Shuster JJ, Maldonado RC, Meyer RS: Health-related quality of life after hip arthroplasty with and without an extended-duration continuous posterior lumbar plexus nerve block: a prospective, 1-year follow-up of a randomized, triple-masked, placebo-controlled study. Anesth Analg 2009; 109: 586-91
  13. Ilfeld BM, Shuster JJ, Theriaque DW, Mariano ER, Girard PJ, Loland VJ, Meyer S, Donovan JF, Pugh GA, Le LT, Sessler DI, Ball ST: Long-term pain, stiffness, and functional disability after total knee arthroplasty with and without an extended ambulatory continuous femoral nerve block: a prospective, 1-year follow-up of a multicenter, randomized, triple-masked, placebo-controlled trial. Reg Anesth Pain Med 2011; 36: 116-20
  14. Lavand’homme PM, Grosu I, France MN, Thienpont E: Pain trajectories identify patients at risk of persistent pain after knee arthroplasty: an observational study. Clin Orthop Relat Res 2014; 472: 1409-15

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To the Next Generation of Physician Leaders

I was recently invited to visit an academic anesthesiology department to speak to the residents about becoming a leader (see SlideShare). In addition to recognizing the honor and privilege of addressing this important topic with the next generation of physician anesthesiologists, I had two other initial thoughts: 1) I must be getting old; and 2) This isn’t going to be easy.

Balloon FiestaI came up with a short list of lessons that I’ve learned over the years. While some examples I included are anesthesiology-specific, the lessons themselves are not. Please feel free to edit, adapt, and add to this list; then disseminate it to the future physician leaders who will one day take our places.

  1. First and foremost, be a good doctor. Always remember that we as physicians take an oath. In the modern version of the Hippocratic Oath commonly recited at medical school graduations today, we say, “May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.” As a physician anesthesiologist, we care for the most vulnerable of patients—those who under anesthesia cannot care for themselves. Examples of anesthesiologists who do not honor their calling exist in the news and even scientific journals, but we cannot follow this path. 

     

  2. Define your identity. We live in the era of the “provider,” and this sometimes causes role confusion from the perspective of our patients. Team PhotoWe also don’t tend to do ourselves any favors. How many times have you heard someone say, “Hi I’m [first name only] with anesthesia”? According to the American Society of Anesthesiologists newsletter, approximately 60% of the public may not know that physician anesthesiologists go to medical school. While every member of the anesthesia care team plays a crucial role, the next level of non-physician provider in this model has one-tenth the amount of clinical training when compared to a physician anesthesiologist at graduation. I’ve written before about what I love about being an anesthesiologist, and being the physician whom patients trust to keep them safe during surgery is a privilege which comes with a great deal of responsibility.
  3. Consider the “big picture.” The health care enterprise is constantly evolving. Today, the emphasis is on value and not volume. Value takes into account quality and cost with the highest quality care at the lowest cost being the ultimate goal. The private practice model of anesthesiology has changed dramatically in the last few years with the growth of “mega-groups” created by vertical and horizontal integration of smaller practices and sometimes purchased by private investors. In this environment, physician anesthesiologists and anesthesiology groups will have to consider ways they can add value, improve the patient experience, and reduce costs of care in order to stay relevant and competitive.
  4. Promote positive change. Observe, ask questions, hypothesize solutions, collect data, evaluate results, draw conclusions, and form new hypotheses—these are all elements of the scientific method and clinical medicine. These steps are also common to process improvement, making physicians perfectly capable of system redesign. The key is establishing your team’s mission and vision, strategic planning and goal-setting, and regularly evaluating progress. Books have been written on these subjects, so I can’t do these topics justice here. In my opinion, physicians offer an important and necessary perspective that cannot be lost as healthcare becomes more and more business-like.
  5. Be open to opportunities. Thomas Edison said, “Opportunity is missed by most people because it is dressed in overalls and looks like work.” I have written previously about the merits of saying yes. As a resident or new staff physician, it often seems impossible to get involved. However, most hospital committee meetings are open to guests. Consider going to one that covers a topic of interest and volunteer for a task if the opportunity presents itself. In addition, many professional societies invite members to self-nominate for committees or submit proposals for educational activities at their annual meetings.
  6. IMG_7673Thank your team. Taking the first steps on the path to leadership is not going to be easy. There will be many obstacles, not the least of which is time management. A high-functioning healthcare team of diverse backgrounds, skills, and abilities will accomplish much more than what an individual can do alone. Celebrate team wins. Respect each team member’s opinion even when it differs from yours.

A good leader should earn the trust of his or her team every day.

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Changing Clinical Practice Shouldn’t Take So Long

An interesting article I read recently confirmed previous studies’ estimation that it takes an average of 17 years before research evidence becomes widely adopted in clinical practice (1)–17 years!

In this article, Morris and colleagues differentiate “translational research” into two types: Type 1 (T1) which refers to experimental testing of basic science research findings in human subjects; and Type 2 (T2) which is the process of taking the results of clinical research and changing clinical practice based on them.

translating research to practice


In 2001, the Institute of Medicine released “Crossing the Quality Chasm: a New Health System for the 21st Century.” One of the ten rules for redesigning the system refers to evidence-based clinical decision-making. The report brief explicitly states: “Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place.”

Changing physicians’ behavior is rarely easy (although occasionally it can be), and many smart people have tried to study what works and what doesn’t. One study published in JAMA that focused on physician adherence to practice guidelines identified 7 categories of change barriers (2):

  1. Lack of awareness (don’t know guidelines exist)
  2. Lack of familiarity (know guidelines exist but don’t know the details)
  3. Lack of agreement (don’t agree with recommendations)
  4. Lack of self-efficacy (don’t think they can do it)
  5. Lack of outcome expectancy (don’t think it will work)
  6. Inertia (don’t want to change)
  7. External barriers (want to change but blocked by system factors)

Outside of medicine, many industries have explored the reasons behind failure of change management or failure of implementation and have made suggestions intended to facilitate change. While these recommendations make sense, they are often easier said than done. In health care, there is a great deal of “dogma-logy” (the non-scientific practice of doing what you’ve been told to do based on no available evidence) that must be overcome. Implementation researchers suggest “incremental, context-sensitive, evidence-based management strategies for change implementation” and the need for local champions within front line staff (e.g., nurses and unit managers) to drive change (3). This is consistent with lean management. This still may not be enough, especially if the proposed change is perceived as being overly complex or just more work (4).

The evolution of modern communication may help overcome some of the perceived barriers (2). Use of social media, Twitter in particular, may be a powerful tool to rapidly disseminate new knowledge. It can be used to share new journal articles as they are published or exciting research results even before they are published. Physicians can follow their professional societies and scientific journals, but also follow thought leaders, business schools, and economic journals that post on organizational culture and change management. In the era of Twitter chats and “live-tweeting” medical conferences, lack of awareness (#1) or familiarity (#2) is no longer an acceptable excuse.

In addition, social media networks may also provide moral support (#4) through global conversations, and colleagues may provide real-life examples of successful implementation strategies (#5) that may help generate enough motivation to drive change (#6). However, sometimes inertia may be easy to overcome. According to Dr. Audrey Shafer, Stanford Professor and physician anesthesiologist, “There should be some acknowledgement of the complexity-to-benefit ratio. If complexity of the change is low, and the benefit high, then I believe the behavioral change is swifter. The prime example in my lifetime is the use of pulse oximetry. It may have been a long time from the concept of pulse oximetry until the first viable commercially available oximeter was available in clinical practice, but after an anesthesiologist used it once, he/she did not want to do another case without one.”

That still leaves lack of agreement (#3) and external barriers (#7). Even if you don’t agree with the scientific evidence, at least be open to observe. I really like the design thinking approach as described by Ideo and others and think it has a place in health care change implementation. You can download the free toolkit for educators here. I tweeted Ideo’s figure of the design process with its 5 phases recently and got a great response.

Tweet design

This approach makes a lot of sense in medicine. It has many similarities to the way we approach patient care: observe a diagnostic dilemma, order tests and interpret them, consider the differential diagnosis, attempt a treatment, and adjust treatment based on the observed outcome.

To overcome external barriers to change in health care, senior leaders must be engaged and actively participate in improvement efforts (5). I strongly encourage physicians to step up and take on some of these leadership roles. Sometimes saying “yes” to something that seems relatively small will lead to bigger opportunities down the road. By becoming leaders, physicians can be the ones to drive the change that they want to see in clinical practice.

REFERENCES:

  1. Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. J R Soc Med. 2011 Dec;104(12):510-20.
  2. Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999 Oct 20;282(15):1458-65.
  3. Rangachari P, Rissing P, Rethemeyer K. Awareness of evidence-based practices alone does not translate to implementation: insights from implementation research. Qual Manag Health Care. 2013 Apr-Jun;22(2):117-25.
  4. Grol R. Successes and failures in the implementation of evidence-based guidelines for clinical practice. Med Care. 2001 Aug;39(8 Suppl 2):II46-54.
  5. Pronovost PJ, Berenholtz SM, Goeschel CA, Needham DM, Sexton JB, Thompson DA, Lubomski LH, Marsteller JA, Makary MA, Hunt E. Creating high reliability in health care organizations. Health Serv Res. 2006 Aug;41(4 Pt 2):1599-617.

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Why Doctors Should Be on Twitter

social-media-healthcareI am a physician, clinical researcher, and educator.

I am also on Twitter and tweet under the handle @EMARIANOMD.

Naturally you may ask:  “How does Twitter fit into a physician’s academic career?”  Some of the benefits that Twitter offers doctors have been described previously by Dr. Brian Secemsky and Dr. Marjorie Stiegler among others.  Here are a few reasons of my own:

  • Global Interaction:  Through Twitter I interact with people from around the world with similar interests.  Participating in Twitter chats like #healthxph or #hcldr can foster innovative ideas that may lead to research questions or other educational opportunities.  For example, by tweeting on #kneereplacement, I was invited by orthopedic surgeon, Dr. Brian Hatten, to revise the anesthesia information page on his site, My Knee Guide, an incredible online portal for people considering or undergoing knee replacement surgery.
  • Search Optimization:  On multiple occasions, I have found research articles that my traditional PubMed searches have missed through the tweets posted by colleagues.  I have even been able to relocate certain articles faster on Twitter than PubMed when I know they have been tweeted.  Researchers can think of hashtags (starting with “#”) essentially like keywords in the academic world.  I periodically check #anesthesia, #meded, #pain, and #kneereplacement for new articles related to my research interests.
  • Lifelong Learning:  When I was in training, I used to peruse the pages of JAMA and New England Journal of Medicine (NEJM) in addition to my own specialty’s journals.  Today, it’s difficult to even keep up with new articles just in my own subspecialty.  Now I follow JAMA and NEJM on Twitter.  By following journals, professional societies, and colleagues with similar interests, I honestly feel that my breadth of knowledge has increased beyond what I would have acquired on my own.
  • Research Promotion:  As a clinical researcher, my hope is that my study results will ultimately affect the care of patients.  Sadly, the majority of traditionally-published scientific articles will not be read by anyone besides the authors and reviewers.  Through Twitter, I can alert my followers when our research group publishes an article.  I also get feedback and “peer review” from colleagues around the world.  After a recent publication that I tweeted, I received comments from anesthesiologists in Canada and Europe within an hour!
  • Enriched Conference Experience:  A growing trend at medical conferences is “live-tweeting” the meeting.  One of my own issues when I attend or present at conferences is that I feel like I miss much of the meeting due to scheduling conflicts.  By living vicariously through my colleagues’ tweets at #ASRASpring15 for example, I can pick up pearls of wisdom from speakers in other sessions even while sitting in a different hall.  I can also “virtually” attend conferences by following tweets under the hashtags of meetings like #PCP15 in the Philippines  in the comfort of my own home.

I often get asked:  “Does anyone really care if I tweet what I eat for breakfast?”  Probably not.  The truth is that you don’t have to tweet anything at all if you don’t want to.   Up to 44% of Twitter accounts have never sent a tweet.   Of course, to be a physician actively engaged on Twitter requires respect for patient privacy and professionalism.  I recommend following Dr. John Mandrola’s 10 rules for doctors on social media.

In an interview during Stanford’s Big Data in Biomedicine Conference (video below), I had a chance to explain why I tweet.  I’ll admit that getting started is intimidating, but I encourage you to try it if you haven’t already.   I promise that you won’t regret it, and chances are that you’ll be very happy you did.  If you’re still too worried to take the leap, I suggest reading these tips from Marie Ennis-O’Connor to boost your confidence.  At least sign up, reserve your handle, and observe.

Observation is still a key part of the scientific method.

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Why the VA Inspires Me to be a Better Leader

VA_eagleInscribed on a plaque just below a statue of an eagle in front of my hospital is a famous quote from President Abraham Lincoln that begins, “To care for him who shall have borne the battle….”

It is the reason why the Veterans Affairs (VA) system exists.  It is the reason why we VA physicians come to work each day.

I am honored to care for our special patient population, and I admit to getting defensive when I hear negative, sensationalistic news about the VA.  In truth, VA physicians have good reasons to take pride in their health care system and should be inspired to take on leadership roles.

In 1994, the VA was by far the largest networked health care system in the US.  It consisted of 172 acute care hospitals, 350 hospital-based outpatient clinics, 206 counseling facilities, and 39 residential care facilities, with a budget of over $16 billion annually, and was “highly dysfunctional” according to an article co-authored by Kenneth W. Kizer, MD, MPH, the former Under Secretary of Health under President Clinton who headed the VA health care system from 1995-1999.

A decade later, the VA had turned around dramatically.  When Philip Longman, a writer with a long interest in health policy, looked for potential solutions to the healthcare crisis in the United States, he found his “muse” within the VA—not in the private sector.  He titled his 2007 book about the VA health care system:  Best Care Anywhere: Why VA Health Care is Better Than YoursWhat happened to make the VA go from worst to first?

In the mid-1990s, Dr. Kizer guided the VA to reset its focus on three core missions:

  • Providing medical care to eligible veterans to improve their health and functionality
  • Educating healthcare professionals
  • Conducting research to improve veteran care.

His strategies led to a dramatic transformation that took less than five years.  VA health care showed a statistically-significant improvement in all quality of care indicators after the reengineering when compared to the same indicators before, and these improvements were evident within the first two years.  By 2000, the VA outperformed Medicare hospitals on 12 of 13 quality of care indicators.  A comprehensive study using RAND Quality Assessment Tools showed that VA adherence to recommended processes of care exceeded a comparable national sample.  In terms of surgical care, the VA matched or outperformed non-VA programs in rates of morbidity and mortality.

Integral to this transformation was a remarkable nationwide rollout of an electronic health record in less than three years, with the last facility going live in 1999, long before most health care systems in the United States had even started.  Other notable achievements during this period of reengineering included:

  • 350,000 fewer inpatient admissions (FY 1999 vs. FY 1995) despite a 24% increase in patients treated overall;
  • A decrease in per-patient expenditures by 25%;
  • An increase in proportion of surgeries performed on an ambulatory basis (80% in FY 1999 vs. 35% in FY 1995);
  • A 10% increase in total number of surgeries performed with a decrease in 30-day morbidity and mortality;
  • VA health user satisfaction scores that exceeded the private sector; and
  • Realignment of the VA medical research program with establishment of a new translational research program, the Quality Enhancement Research Initiative (QUERI).

These achievements were not the result of one person’s efforts.  Change implementation required engagement of front line staff, especially the physicians and other health care providers.  Unfortunately last year’s VA waitlist scandal raised serious concerns related to veterans’ access to care, scheduling practices, and the reporting of performance metrics.  In an article published in the New England Journal of Medicine, Dr. Kizer expressed his concerns regarding variability in the quality of care provided within VA in 2014 when compared to other top-tier integrated healthcare systems.  Some VA hospitals performed remarkably well while others did not, and some facilities severely lacked personnel and resources.

Flags FlyingToday, there are approximately 9 million veterans enrolled in VA health care, and the VA needs physicians to step up and be leaders.  Advanced technology (e.g., secure messaging, e-consultation, and clinical video telehealth) already exists within the VA to streamline communication between patients and physicians and can be used to promote patient-centered, personalized health care and improve access.  Some of the highest impact medical research in the world takes place within VA, performed by VA physician scientists, and requires leaders to advocate for continued funding.  The results of these studies and others should form the basis of best clinical practices that VA physician leaders need to disseminate and implement at their respective facilities.  VA physicians have pioneered the field of simulation education, and this represents one tool that may be used to facilitate dissemination.  The VA has arguably the richest and most mature electronic health record in the country, if not the world; yet these data are not easily accessible.  Physicians on the front lines of patient care, those engaged in research, and those in leadership positions need to advocate for resources to develop real-time analytics and harness the power of our patients’ data to guide clinical care decisions and make the health care system adaptable to the changing needs of patients.

Finally, I call on VA physician leaders to be innovators, designing and studying new interdisciplinary coordinated models of care, to improve outcomes and then share these models with each other.  We physicians need to work together as “One VA” to decrease variability within the system and improve quality and value throughout.

This post has also been featured on KevinMD.com

REFERENCES

  1. Kizer KW, Dudley RA: Extreme makeover: Transformation of the veterans health care system. Annu Rev Public Health 2009; 30: 313-39
  2. Jha AK, Perlin JB, Kizer KW, Dudley RA: Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. N Engl J Med 2003; 348: 2218-27
  3. Asch SM, McGlynn EA, Hogan MM, Hayward RA, Shekelle P, Rubenstein L, Keesey J, Adams J, Kerr EA: Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Ann Intern Med 2004; 141: 938-45
  4. Choi JC, Bakaeen FG, Huh J, Dao TK, LeMaire SA, Coselli JS, Chu D: Outcomes of coronary surgery at a Veterans Affairs hospital versus other hospitals. J Surg Res 2009; 156: 150-4
  5. Grover FL, Shroyer AL, Hammermeister K, Edwards FH, Ferguson TB, Jr., Dziuban SW, Jr., Cleveland JC, Jr., Clark RE, McDonald G: A decade’s experience with quality improvement in cardiac surgery using the Veterans Affairs and Society of Thoracic Surgeons national databases. Ann Surg 2001; 234: 464-72
  6. Matula SR, Trivedi AN, Miake-Lye I, Glassman PA, Shekelle P, Asch S: Comparisons of quality of surgical care between the US Department of Veterans Affairs and the private sector. J Am Coll Surg 2010; 211: 823-32
  7. Bakaeen FG, Blaustein A, Kibbe MR: Health care at the VA: recommendations for change. JAMA 2014; 312: 481-2
  8. Kizer KW, Jha AK: Restoring trust in VA health care. N Engl J Med 2014; 371: 295-7

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Tips for Future Physician Leaders

LeadershipCompass3This post has also been featured on KevinMD.com.

Our health care system needs more physician leaders. Physician-led accountable care organizations have been shown to improve the quality of patient care while reducing overall costs. Physicians, by their nature, tend to be goal-oriented, have the ability to gather and assimilate evidence, and make difficult decisions, but these traits do not always translate naturally into leadership skills. We are trained to make a diagnosis and map out a treatment plan in medical school and residency, but the typical curriculum does not include developing staff, leading teams, or strategic planning. One option to learn these skills is to get an MBA. However, going back to school is not an option for everyone (like me—at least not yet), and it may not be necessary. Besides first being a good doctor, here are a few tips that may help open up leadership opportunities:

1. Be open to possibilities. Sometimes an opportunity doesn’t always look like one. In other words, plans don’t always work out the way you think they will.

2. Say “yes” to things that sound like more work. Pick up that extra call or volunteer for that hospital committee. Saying “yes” can introduce you to many new people and experiences. If you say “yes” then follow through. New colleagues who see you as a finisher often go back to you again and introduce you to others.

3. Let people look after you. This may not be “mentorship” in the traditional sense. A friend of a friend or someone’s spouse you meet at a department function may introduce you to people with similar interests in clinical care, quality improvement, or research.

4. Give credit to others. “Taking credit” is not about featuring an individual or the leader—it should be about the group. You can’t implement change without a team, and as a leader you have to make sure the group gets the recognition it deserves.

5. Given the opportunity, lead and not just manage. “Leadership” and “management” are often used interchangeably (unfortunately), and managerial duties often come with any leadership position, but they are not the same. People want to follow a leader, not a manager.

In healthcare, a leader should set a good example of professionalism in clinical care, communications, and administrative work. A leader creates a shared vision for the group with a clear direction and celebration of the group’s accomplishments. A leader first invests in his or her staff members to develop them individually so their greater potential can benefit the group. A leader is inspired by his or her staff and is constantly listening and learning.

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Personalized Medicine: What it Means to be a Physician Anesthesiologist

This post has also been featured on KevinMD.com.

I wear a lot of hats in my job. Though I’m a physician who specializes in the practice of anesthesiology, I don’t spend all day every day at the head of an operating room table.

Team Photo 2Many days I spend in an administrative leadership role or conducting research studies. These functions support the best interests of my patients as well as the science and practice of anesthesiology. On my “clinical” days that I spend in hands-on patient care, I provide anesthesia for patients who undergo surgery and other invasive procedures. I also treat acute pain as a consultant. Some of my colleagues in anesthesiology specialize in chronic pain or critical care medicine.

As a medical student, I had a hard time at first understanding what the physician anesthesiologist does. I saw monitors, complicated equipment, and technical procedures that involved a lot of needles. Thankfully, I worked with resident and attending anesthesiologists who inspired me to pursue this specialty.

Anesthesiology is a unique field within medicine. It is at the same time incredibly cerebral and extremely physical. For example, the physician anesthesiologist must be ready to diagnose heart or lung problems that may complicate the patient’s surgery, and decide which medications are appropriate.

BefoAnesthesiologist-4re administering a medication, it’s not enough just to understand the complex pharmacologic effects of the drug and determine the right dose. The anesthesiologist also has to know how to dilute and prepare the drug, the appropriate route for the medication, which other medications are and are not compatible, and how to program the infusion device. In addition, an anesthesiologist has to be technically skilled at finding veins—sometimes in the hand or arm, sometimes leading centrally to the heart—in order to give the medication in the first place.

I am always aware of the trust that patients and their families give me, a total stranger, and I work hard to earn that trust throughout the perioperative period. The job of the physician anesthesiologist is deeply personal. In the operating room, I care for the most vulnerable of patients—those who, while under anesthesia, cannot care for themselves.

– I constantly listen to the sounds of their hearts.
– I breathe for them when they are unable.
– I keep them warm in the cold operating room.
– I provide the fluids that their bodies need.
– I pad their arms and legs and other pressure points.
– I watch the operation step by step, anticipating and responding.
– I learn from their bodies’ response to anesthesia to give the right amount.
– I prevent and relieve their pain.
– I protect them from dangers of which they are unaware.

I have heard people, my colleagues included, compare physician anesthesiologists to pilots. No one claps when the plane lands, just as no one expects any less than a perfect uncomplicated anesthetic every time. We physician anesthesiologists draw great personal satisfaction from doing what we do, and from providing a unique type of personalized medicine. Our patients and their families depend on us to be at our best, always.

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