Bertrand Russell on the scientific method

"Aristotle maintained that women have fewer teeth than men; although he was twice married, it never occurred to him to verify this statement by examining his wives' mouths"

Dr Yoda & the Pirates of the Caribbean

Rather than review some health related news stories, I thought Dr ZDogg would do a better job.
Have a great weekend.

Angry Bird Medicine

A wonderful title to a great blog entry on the BMJ blogs site. Talking about reducing medicine to an App that can be downloaded to ones phone. He has a fantastic quote, “6 years of medical school and 10 years of training can now be put onto an App and sold for a few dollars – where did I go wrong?”

I dont think a 99 cent app on your phone is going to take the place of a doctor just yet, but the natural progression is that knowledge becomes a commodity, it moves down the value chain, and it no longer becomes cost effective for a particular expert to broker that knowledge. So for example, there is no reason why someone with hypertension cant be monitored at home, blood pressure readings relayed by phone to a central station and feedback given around diet, medications etc, all without the person ever leaving home.

Disruptive Innovation & healthcare education

One of the great difficulties in bringing safety and quality to the fore in healthcare is that although it impacts everyone, no specialty sees it as their responsibility to take the lead, itself a damning sign of the inability of the profession to see the critical merits of teamwork and systems thinking. The IHI set up its Open School some years ago in an attempt to bring this knowledge directly to healthcare students. My impression is that it is certainly proving successful, but it is the nature of such developments to take many years to fully bear fruit. But bear fruit it will. The message is too compelling and students will naturally ask why they are not being exposed to this area by their own teachers. It's all part of a bottom up approach to change. As an example, I suggest you check out this video, part of the course materials for the Open School.

Learned Helplessness

It has struck me repeatedly that there is a huge degree of learned helplessness in the public sector around the world. I am unsre why this should be the case. Does it reflect a risk averse culture? An overly bureaucratic one in which every action must be backed by a memo? Who knows? The great pity is that one of the great motivating forces for skilled professionals is to have pride and autonomy on their work. See the video, (thanks John F) for a great example of the phenomenon.

Public Reporting of Surgical Outcomes

In this weeks Lancet, a discussion around public reporting of surgical outcomes. Specific mention is made of the Society for Cardiothoracic Surgery in Great Britain and Ireland. Since 2005, the society has made outcome data freely available to the public; this has been associated with a 50% reduction in risk adjusted mortality, i.e. half as many people have died as would have been expected to die.

In terms of cost savings, the program costs £1.5 million annually, but is estimated to save £5 million per year in reduced length of stay costs.

While clinicians may be resistant to public reporting of data, it is inevitable. My opinion is that it is better to be proactive, seek to develop such databases and ensure the data represents as accurately as possible the reality, i.e. risk adjusted. 

See also this post from Paul Levy.

Trends in youth mortality around the world

Published in The Lancet today, an analysis of WHO data looking at mortality trends in children and young adults around the world over the last 50 years. There have been dramatic improvements in mortality reduction around the world, as much as a 93% reduction in children aged 1-4. The smallest reduction occurred in young men, aged 15-24. More focus should be directed on reducing mortality in this group. However, this is a very encouraging and optimistic paper, showing that greta work can be achieved.

Statistics for dummies.

For anyone who love data, check this out. Rosling is magnificent and can summarise in 4 minutes of pictures what may are unable to do in a book. Wealth increases health.
Also see his website. www.gapminder.org

Reduced work hours for doctors

In both Europe and the US, there has been a push to reduce the hours worked by doctors. This has been based on the belief that tired doctors make more mistakes. An article in this weeks BMJ points out that to date there is no evidence that these measures have brought about an improvement in safety. Why should this be? There are many possible explanations, but in my view, these reductions in working hours have been implemented without taking a fundamental look at how doctors work. in other words, a dramatic change in work hours should have been accompanied by a radical restructuring of shifts, handovers, continuity and so on. It is likely that this has not occured. The other problem is that junior doctors work hour and patterns evolved to match those of senior physicians. The work patterns of these senior doctors also needs to be considered and modified.

Thank you for the music

Falls are an major problem for the elderly. An interesting piece in this weeks Archives of Internal Medicine reports that using music to in effect co-ordinate walking substantially reduces the risk of falls in a community based elderly population.

How to wash your hands properly in hospital

Great video from NEJM, free to view. Obligatory for all healthcare staff, (and also patients, families, kids so they can be sure their carers are doing it the right way.)

Immunisation

I was going to do a piece on immunization. These guys do a far better job than I ever could. Check out zdoggmd.com

How not to deal with the media

St Stephens Green, Dublin

Overdiagnosis

A fantastic piece in the Archives of Internal Medicine, about incidental findings (incidentalomas) picked up while testing for something else. This opens up a whole Pandoras box. A great line about a New York Times columnist who believed he had survived a brush with death following the finding of one such incidentaloma. No, the authors say, he survived a brush with overdiagnosis.
This is very important. The fundamental issue is that each patient will feel they have been saved and each becomes an advocate for more and more testing. However, there is no evidence that many of these findings, even if malignant, will ever pose a threat to health. The authors provide some practical suggestions as to how best to approach these matters.

Clinically Integrated Systems

Following on from my thoughts about disruptive innovation, what structures in the UK and Irish setting might prove disruptive? Starting from the assumption, which may be mistaken, that some disruptors will be players in the current system, what could one possible future look like?
I believe the likeliest candidates are current general practice and primary care structures. They have the benefit of decent infrastructure, a critical mass of clinical, (not just medical) staff, and a population base that is large and varied enough to allow sub-specialistation. What are the missing ingredients?

1. Seamless integration between priamry care and hospitals; to deliver this, I believe there needs to be consultant presence in the primary care teams. Consultants would work between hospital and primary care, with benefits to staff and patients, (improved access to specialist opinion, greater communication between professionals, enhanced learning opportunities for all)
2. A payment system that rewards health, and is not just based on following processes, (e.g. check blood pressure every visit). What would this look like? Look at it from the patient perspective. What he/she wants is health, as few visits as possible, as little interruption to daily life, mot missing school or work. Can this be done. I believe it can, but it will require a fundamental shift in the way health, (as opposed to healthcare) is delivered.
3. A recognition that an unplanned hospital admission represents a failure of care for the team providing care
4. Quality and outcome metrics allied with an IT system sensitive enough to provide real time data

There is an interesting paper just published on the BMJ site by Chris Ham discussing this. They report the experience of Torbay, summarised below:

• Reduced use of hospital beds (daily average number of occupied beds fell from 750 in 1998-9 to 502 in 2009-10)
• Low use of emergency bed days among people aged ≥65 (1920/1000 population compared with regional average of 2698/1000 population in 2009-10)
• Minimal delayed transfers of care

"hospital providers could also take the initiative in moving in this direction, especially in areas where general practitioners are relatively weak and specialists strong. London is a case in point, not least because it has several academic health sciences centres that present the potential to extend high quality care from hospitals into the community. In this context, integration might build on the strengths of academic health sciences centres by allocating them a capitated budget in conjunction with general practitioners and community health service providers. Patients would be able to choose between integrated systems based on academic health sciences centres and could also access care outside these systems in order to create an incentive for providers to deliver responsive care of high quality."

Are guidelines tainted?

One of the truisms of healthcare is that we should adhere to guidelines in so far as possible, to reduce variation, to improve outcomes and to minimize waste. Guidelines are developed by eminent professionals in a field; it is assumed that they are guided only by the evidence. However, many of these guidelines are sponsored by pharma companies.
A study just published in the Archives of Internal Medicine examined conflicts of interest amongst panel members charged with developing almost 20 cardiology guidelines. They find that 56% of panel members have a declared conflict of interest, e.g. owning stock in a company whose product is recommended, and 81% of panel leaders have a COI. That is not to say that these were unduly influenced by these conflicts, but some wonder whether like Caesars' wife, all should be above suspicion.
One suggestion is to prohibit all guideline developers to have a COI; my own view on this is that it may just exclude those who have the most to offer.

How the iPhone is going to save the world. Seriously!

An artist with an interest in healthcare recently asked me for my thoughts about the future direction of art (broadly defined) in children's healthcare. It's not an area to which I had given much thought but it caused me to consider the benefits, if any, of art and media in healthcare. Simply put, how best to use that which is the favorite activity of children, playing, to assist them in the treatment of their illness.
Just published in JAMA yesterday is a commentary which outlines some of the potential uses and benefits of video games. Before anyone rubbishes the concept, there are good precedents here. My younger patients undergoing a lung function test in which they must breathe into a machine as fast as possible are encouraged to do so by a screen with a birthday cake and candles; the harder they blow, the more candles are extinguished.
The paper in JAMA describes various tools. Mindless Eating Challenge, a weight loss program, is a game where users support one another by sharing photographs of portion sizes. Lit to Quit allows iPhone users to puff into the phone to simulate the experience of smoking.
While the skeptics may rightly laugh off these efforts, bear in mind these are very early days. Analogous to measuring urine glucose in diabetics in the 1920's. This took 5 minutes using some very sophisticated reagents. Underestimate the power of technology at your peril.
While I am not an expert in this area, it seems to me that the real focus of opportunity lies in the nexus of massive multiplayer on line games (MMOG) and social networking. Christakis has published a number of very significant papers showing the effects of social networks on depression, happiness, weight gain and smoking. Imagine a game, aimed at children with diabetes, where children can interact and earn from one another, in which the game incentivizes the appropriate behaviors, such as diet, exercise, compliance with screening and so on. Crazy? Yes, without a doubt. Crazier than our current system where we believe that seeing a child a few times a year in a busy environment with numerous distractions is going to deliver the best outcomes? You decide.

Art in Children's Hospitals

Fascinating website and project, thanks to Helene Hugel.

Healthcare; time to be disrupted.

A disruptive innovation (the term was first coined by Clay Christensen) is a technology or strategy, which disrupts an existing market by radically lowering price, increasing productivity or by gaining an alternative set of customers. Examples include the transition from sail to steamships, the adoption of personal computers in place of mainframes and so on. Henry Ford put it well; “to build a better motorcar one could either develop a faster and stronger horse or do something completely different.”

The question for healthcare is whether disruptive innovations are required to radically improve value and outcomes? Alternatively can tinkering with the system, (QIPP, ACO, Medical Homes, pay for performance, increase measurement and accountability) drive sufficient performance and improvement. To truly understand the significance of this question, one has to understand both the power of disruptive innovation and the failure of those agencies being disrupted to challenge the disruption.

Disruptive innovations essentially create a market for a product or service that the incumbents fail to recognize. They do so, often by offering a cheaper, slimmed down product; think Ryanair. One may not like them but they not only offer a cheaper reliable service, but developed a market for services that no-one could have imagined, (London Lodz anyone?).

Existing airlines had no incentive to develop such innovations; they were happy with their quasi-monopolies. Ryanair had to develop such markets in order to grow. if existing companies were to chase these market opportunities, they would cut into their existing markets and reduce their profit margins. In a sense they are helpless to do anything, apart from resisting and fighting back, (think lobbyists, negative advertising campaigns)

Jump to healthcare, the structures are identical. Seemingly strong vested interests, institutional, professional, academic, who will do their best to fight any interloper promising a better cheaper service. And they are helped immensely by the emotional arguments that if the service they offer is undercut, people will die.

Are there examples of such disruption in health? They are likely to appear when the current model no longer makes financial sense, or where Western models are not applicable. It is likely that if this economic downturn persists that we will begin to see disruptors emerge in both the West, and emerge from the developing world into the West. For example, “Aravind the world’s biggest eye-hospital chain, performs some 200,000 eye operations a year. It takes the assembly-line principle literally: four operating tables are laid side by side and two doctors operate on adjacent tables. When the first operation is done, the second patient is already in place.” (Economist April 2010)

A paper by Robert Brook of the RAND corporation outlined one vision of potential disruptors. These include:

• Considering the entire cost of care, to include not just the cost to the individual but the energy cost, (carbon cost) 
• Unifying the two great silos of medicine and education so that educators play a central role in improving children’s health and healthcare providers are judged partly on their success at improving educational attainment in their patients 
• A shift to non-physican care, e.g. nurse practitioners 
• Reduce the training required for repetitive technical task; for example why go to medical school, residency and fellowship to train how to remove cataracts. Pretty radical. 
• Routine healthcare delivered 24/7. So no more 9-5 operating rooms or clinics. 
• Outsourcing or off-shoring of many tasks, including diagnostics, elective surgery which is already happening. 

It is likely that the most marked changes are ones we cannot even begin to envisage yet. One thing is certain, we will have to change. Or perish. As Deming said, “We do not have to change, survival is not mandatory”