Powerfully built and with the face of a boxer, he cast a bone-chilling shadow wherever he went in the hospital.
At least that is what my medical school classmates and I thought whenever we passed by a certain resident, or doctor-in-training, just a few years older than we were.
With the wisdom of hindsight, I now see that the young man was a brilliant and promising young doctor who took his patients' conditions to heart but who also possessed a temper so explosive that medical students dreaded working with him. He had called various classmates "stupid" and "useless" and could erupt with little warning in the middle of hospital halls. Like frightened little mice, we endured the treatment as an inevitable part of medical training, fearful that doing otherwise could result in a career-destroying evaluation or grade.
But one day, one of our classmates, having already been on the receiving end of several of this doctor's tirades, shouted back. She questioned one of his conclusions in front of the rest of the medical team, insisted on getting an explanation, then screamed back when he started yelling at her.
The entire episode unnerved us all; and over the next few weeks, we marveled at her courage and fretted over her potentially ruined career prospects. But there was one aspect of the event that disturbed us even more. One classmate who had witnessed the "screaming match" described how our fellow medical student had raised her voice and positioned her body as she threatened the doctor. "It was weird," he recounted. "It was like watching her turn into him."
For 30 years, medical educators have known that becoming a doctor requires more than an endless array of standardized exams, long hours on the wards and years spent in training. For many medical students, verbal and physical harassment and intimidation are part of the exhausting process, too.
It was a pediatrician, a pioneer in work with abused children, who first noted the problem. And early studies found that abuse of medical studentswas most pronounced in the third year of medical school, when students began working one on one or in small teams with senior physicians and residents in the hospital. The first surveys found that as many as 85 percent of students felt they had been abused during their third year. They described mistreatment that ranged from being yelled at and told they were "worthless" or "the stupidest medical student," to being threatened with bad grades or a ruined career and even getting hit, pushed or made the target of a thrown medical tool.
Nonetheless, many of these researchers believed that such mistreatment could be eliminated, or at least significantly mitigated, if each medical school acknowledged the behavior, then created institutional anti-harassment policies, grievance committees and educational, training and counseling programs to break the abuse cycle.
One medical school became a leader in adopting such changes. Starting in 1995, educators at the David Geffen School of Medicine at the University of California, Los Angeles, began instituting a series of schoolwide reforms. They adopted policies to reduce abuse and promote prevention; established a Gender and Power Abuse Committee, mandated lectures, workshops and training sessions for students, residents and faculty members; and created an office to accept confidential reports, investigate and then address allegations of mistreatment.
To gauge the effectiveness of these initiatives, the school also began asking all students at the end of their third year to complete a five-question survey on whether they felt they had been mistreated over the course of the year.
The school has just published the sobering results of the surveys over the last 13 years. While there appears to have been a slight drop in the numbers of students who report experiencing mistreatment, more than half of all medical students still said that they had been intimidated or physically or verbally harassed.
Students described being yelled at, pushed and threatened. One student recounted being slapped on the hand by a more senior doctor who said, "If teaching doesn't help you learn, then pain will." Some students wrote about racial insults, with senior staff members making noises to mimic a foreign language; others reported being grabbed, asked out on a date or passed over because of their sex.
"We were really crushed when we saw the results," said Joyce M. Fried, lead author of the paper and assistant dean and chairwoman of the Gender and Power Abuse Committee at the medical school. "We were disappointed that it was so difficult to change."
U.C.L.A.'s experience is not isolated. In fact, national medical education surveys that include questions about mistreatment indicate that the environment at that school is about average. And the striking similarity of experiences across a generation of students suggests problems not just with one institution, but with the culture of medical training itself. "This is a national problem," Ms. Fried said. "Our faculty and doctors-in-training come from all over, including schools where some of them might have been mistreated."
While their findings are disheartening, Ms. Fried and her colleagues continue to believe that medical student mistreatment can be significantly reduced — but only if all medical schools come together to work on the issue. "We're talking about the really hard task of changing a culture, and that has to be done on a national level," Ms. Fried said. Such an effort would include shared training programs, common policies regarding mistreatment and greater transparency about the mistreatment that currently exists in medical schools.
"There are a lot of really good people and role models out there," Ms. Fried said. "But the culture for all these years has been to just take the mistreatment and not say anything."
"It wasn't right back then, and it shouldn't be tolerated anymore," she added.
http://well.blogs.nytimes.com/2012/08/09/the-bullying-culture-of-medical-school/?hpw
Friday, August 10, 2012
Soaring Ointment Prices Are a Dermatologic Mystery - NYTimes.com
They are the staples of most dermatology practices: generic creams and ointments that treat everything from skin rashes to athlete's foot to scabies. Many doctors prescribe the drugs without a second thought. But increasingly, some dermatologists say, patients are complaining about a recent, mysterious and rapid rise in price.
Take betamethasone dipropionate, a cream used to relieve itchy skin. In 2008, a tube cost $18.17. The medicine now costs $71.28, according to Red Book, which tracks wholesale drug prices. Permethrin cream, which kills scabies mites, cost $29.25 in 2008 but has jumped to $71.08 today.
The hefty price increases have stumped doctors and their patients. "It seems to me that something is going on, but I don't have quantitative details," said Dr. Steven R. Feldman, a professor of dermatology at Wake Forest Baptist Medical Center in Winston-Salem, N.C. "I wouldn't have thought that these old-timey, generic drugs would be very costly."
The added revenue from the higher prices has improved the bottom lines of the handful of companies that make such drugs, and has even figured into a contested buyout of one of the companies by an India-based drug maker, Sun Pharmaceuticals.
The phenomenon offers a window into the murky and often illogical world of drug pricing, where prices are not always driven by the usual rules of supply and demand. "In most markets, basic economics would say the lower the price, the higher the volume," said Les Funtleyder, the health care fund manager for Poliwogg, a private equity and hedge fund. "But health care isn't one of those standard markets."
Other than pharmacy benefit managers, which manage prescription drug plans, few other players in the health care market make decisions based on cost, said Mr. Funtleyder. When doctors write a prescription, they often fail to consider the price of the drug. And since many patients have prescription drug coverage, they also often ignore the cost. The situation can create a lucrative opening for some companies, especially in a low-profile corner of the industry like dermatology, where price increases might not attract broader notice.
"You might have a lot of itchy people, but people can go around and manage O.K." Mr. Funtleyder said. "A rash is not a public health emergency."
Even so, some doctors said the prices were unacceptable. "Patients complain about it at every office visit," said Dr. Mark G. Lebwohl, chairman of the National Psoriasis Foundation's medical board and of dermatology at Mount Sinai Medical Center in Manhattan. "I think it's outrageous that the cost of a generic cream — or any cream — exceeds the cost of a doctor's office visit."
Most generic creams and ointments in the United States are made by three companies: Perrigo, Taro and Fougera, which was recently acquired by Sandoz, the generics division of Novartis. It is a specialized business, requiring both the right equipment and expertise. Before getting clearance to make a drug, the companies must demonstrate to the Food and Drug Administration that their creams are absorbed through the skin in the same quantities as the brand-name drugs, a more difficult task than proving that a generic pill is equivalent.
"It's much more time-consuming and expensive to get these drugs approved," said Brian Sheehy, managing partner of IsZo Capital, a minority shareholder in Taro, who said that increased scrutiny of manufacturing practices by the F.D.A. had raised costs and forced some companies to stop making certain drugs. So even if prices increase, "it's still not worth anyone's time to supply the market."
In all, the prices of more than a dozen generic dermatology drugs have increased significantly since 2010, according to the distributor Cardinal Health, which tracks price fluctuations in generic drugs. Express Scripts, the pharmacy benefit manager, found that total spending on dermatology drugs increased 18.2 percent in the first five months of 2012 over last year, driven mainly by the rising cost of individual prescriptions.
Jim Grossman, a public relations executive in Manhattan, said he was surprised when Target recently asked him to pay about $24 for the nystatin and triamcinolone antifungal cream, made by Taro, that he has used on and off for years. The drug had been on Target's list of generics that the store sells for $4.
"I can understand why the price might go up, but not go up six times all at once," said Mr. Grossman. He added that Target allowed him to pay the $4 price when he complained.
James Kedrowski, the interim chief executive of Taro, said the company did its best to offer fair prices to customers. But, he said, pricing structures for many of its products had gotten so low that other drug makers "were dropping out because they couldn't make any money at it."
That's not to say the companies aren't reaping the benefits of the price increases. In a May earnings call, Perrigo's chairman and chief executive, Joseph C. Papa, told investors that a "favorable pricing environment" in the company's prescription drug business was one of the reasons prescription net sales increased last quarter by 84 percent. On Monday, Taro reported that net income for the previous quarter had increased to $62.9 million from $35.7 million last year, a 76 percent increase.
Perrigo and Sandoz declined to comment on pricing strategies. In a statement, however, Sandoz said "we believe that complex, difficult-to-make dermatology generics continue to offer great value to U.S. patients and payers."
Whether the price increases will last is a matter of debate. Mr. Kedrowski said that in some cases prices were starting to drop again as competitors who had stopped making certain drugs saw opportunity and returned to the market. Until recently, Taro was the only producer of nystatin, he said, but now the company has four competitors. The price of the cream used by Mr. Grossman, a combination of nystatin and triamcinolone, remains elevated.
"We basically believe the market will resolve itself," Mr. Kedrowski said. One analyst echoed his sentiments, saying there were signs some drug prices had already begun to drop, even if it wasn't reflected in available drug pricing data, which is notoriously vague.
But not everyone agrees. The question of whether prices will stay high has become a flash point in a dispute between Sun Pharmaceuticals, which owns two-thirds of Taro, and minority shareholders who have argued that the shares are worth more than Sun is offering. In July, a special committee of the board rejected a buyout bid by Sun, describing the offer as inadequate.
Mr. Sheehy of IsZo Capital has opposed the buyout, arguing that the higher prices are here to stay. "It's a strange situation because all of these products individually are tiny, but collectively, they're significant," he said.
PeerJ - Your Peers, Your Science. Academic Publishing is Evolving
PeerJ is an Open Access, peer-reviewed, scholarly journal. Initially, it will be publishing Research Articles in the Biological and Medical Sciences. It will aim for rapid decision making and will publish articles as soon as they are ready.
Taking its inspiration from PLoS ONE, PeerJ will select articles based only on a determination of scientific and methodological soundness, not on subjective determinations of 'impact,' 'novelty' or 'interest.' It will apply the highest standards to everything it does - specifically, the publication will place an emphasis on research integrity; high ethical standards; constructive peer-review; exemplary production quality; and leading edge online functionality.
http://peerj.com/
Taking its inspiration from PLoS ONE, PeerJ will select articles based only on a determination of scientific and methodological soundness, not on subjective determinations of 'impact,' 'novelty' or 'interest.' It will apply the highest standards to everything it does - specifically, the publication will place an emphasis on research integrity; high ethical standards; constructive peer-review; exemplary production quality; and leading edge online functionality.
http://peerj.com/
eLife - the funder-researcher collaboration and forthcoming journal for the best in life science and biomedicine
eLife is a unique collaboration between funders and practitioners of research to communicate influential discoveries in the life and biomedical sciences in the most effective way.
We are a joint initiative of the Howard Hughes Medical Institute, the Max Planck Society, and the Wellcome Trust. Along with a growing number of public and private research funders worldwide, these three organisations recognise that the communication of research results is as fundamental a component of the research process as the experiments themselves. Disseminating new findings as widely and effectively as possible maximises the value of research investments. The first step in the initiative is to establish a new, top-tier open-access journal covering basic biological research through to applied, translational and clinical studies.
The eLife journal will be a platform for extending the reach and influence of new discoveries and to showcase new approaches to the presentation, use, and assessment of research.
http://www.elifesciences.org/
We are a joint initiative of the Howard Hughes Medical Institute, the Max Planck Society, and the Wellcome Trust. Along with a growing number of public and private research funders worldwide, these three organisations recognise that the communication of research results is as fundamental a component of the research process as the experiments themselves. Disseminating new findings as widely and effectively as possible maximises the value of research investments. The first step in the initiative is to establish a new, top-tier open-access journal covering basic biological research through to applied, translational and clinical studies.
The eLife journal will be a platform for extending the reach and influence of new discoveries and to showcase new approaches to the presentation, use, and assessment of research.
http://www.elifesciences.org/
Tuesday, August 7, 2012
For better cures, let’s do science differently - The Globe and Mail
Most everyone believes medical research is necessary. The problem is that it takes too long for research to be translated into meaningful outcomes for patients and new enterprises for the economy.
Worse still, the time from discovery to treatment will only slow as worldwide economic problems bring major cuts to government and private-sector research.
To understand what's at stake, consider a health problem that is as insidious as it is devastating to Canadian families: dementia.
According to a study published by the Alzheimer Society of Canada, the prevalence of Alzheimer's disease and related dementias will grow from the current 500,000 Canadians to more than 1.1 million within a generation. This explosive growth will drive the total economic burden associated with the disease from $15-billion to more than $153-billion.
Clearly something must be done to stem this rising tide. But what? How do we address our country's astonishing need for improved diagnoses, treatments and cures for dementia given the snail-like pace with which current research practices deliver benefits to patients and spawn new companies and, with them, new jobs.
The answer is by doing science differently.
A unique model to do just this is at the heart of the Canadian Consortium on Neurodegeneration in Aging, whose creation was announced recently in Vancouver by the Canadian Institutes of Health Research.
Like other emerging approaches, including the Ontario Brain Institute's Integrated Discovery System, the consortium's model emphasizes the support of platforms (e.g., imaging, genetics) used by researchers from different institutions. The end result: co-ordinated efforts, more patients in studies and novel investigations both within and across diseases.
Of course, the applicability of these models isn't limited to dementia research. Indeed, we believe that their application could transform how new diagnostics, treatments and even cures are discovered and delivered to the huge number of Canadians who are touched by brain disorders, ranging from autism to depression to schizophrenia.
There are four common elements to these emerging models for discovery.
First, they assume that the millions of Canadians who are affected by disease should play a meaningful role in shaping the development of their treatments. Disease associations, spurred on by patients and their families, must have the opportunity to engage researchers and clinicians at all points along the reseach-and-development pathway – not just as end users but as "discovery developers."
The second element is to accept that all research, whether "basic" or "applied," is part of a single continuum, with some research questions closer to impact than others. For example, without the basic and seemingly useless research on the electromagnetic properties of blood carried out by Linus Pauling and Charles Coryell in 1936, the whole field of magnetic resonance imaging would simply not exist.
Third, breakthroughs will come sooner when clinicians and researchers from many disciplines, disease foci, research platforms and institutions all start working together. The fact is much of science today is siloed. Genetic and behavioural researchers don't talk enough; depression researchers typically don't work with Alzheimer's researchers – even though these disorders have much in common.
Fourth, scientists and industry need to work together more effectively. Virtually everyone agrees that Canadians are brilliant researchers, but we punch far below our weight when it comes to moving our knowledge to practical value. Data needs to be collaboratively shared. Industry needs to be at the table early in the process in order to effectively guide research discovery, health outcomes and commercial impact.
Ultimately, it is not so much that we need to ask new questions about dementia and other disorders of the brain; it is that we need to answer the questions in a more collaborative and multidisciplinary way.
The bigger question isn't "Can we afford to spend money on research?" It's "How can we invest in better ways of doing science?"
Donald Stuss is president and scientific director of the Ontario Brain Institute, a province of Ontario initiative.
Monday, August 6, 2012
Can Hospital Chains Improve the Medical Industry? - Atul Gawande - The New Yorker
It was Saturday night, and I was at the local Cheesecake Factory with my two teen-age daughters and three of their friends. You may know the chain: a hundred and sixty restaurants with a catalogue-like menu that, when I did a count, listed three hundred and eight dinner items (including the forty-nine on the "Skinnylicious" menu), plus a hundred and twenty-four choices of beverage. It's a linen-napkin-and-tablecloth sort of place, but with something for everyone. There's wine and wasabi-crusted ahi tuna, but there's also buffalo wings and Bud Light. The kids ordered mostly comfort food—pot stickers, mini crab cakes, teriyaki chicken, Hawaiian pizza, pasta carbonara. I got a beet salad with goat cheese, white-bean hummus and warm flatbread, and the miso salmon.
The place is huge, but it's invariably packed, and you can see why. The typical entrée is under fifteen dollars. The décor is fancy, in an accessible, Disney-cruise-ship sort of way: faux Egyptian columns, earth-tone murals, vaulted ceilings. The waiters are efficient and friendly. They wear all white (crisp white oxford shirt, pants, apron, sneakers) and try to make you feel as if it were a special night out. As for the food—can I say this without losing forever my chance of getting a reservation at Per Se?—it was delicious.
The chain serves more than eighty million people per year. I pictured semi-frozen bags of beet salad shipped from Mexico, buckets of precooked pasta and production-line hummus, fish from a box. And yet nothing smacked of mass production. My beets were crisp and fresh, the hummus creamy, the salmon like butter in my mouth. No doubt everything we ordered was sweeter, fattier, and bigger than it had to be. But the Cheesecake Factory knows its customers. The whole table was happy (with the possible exception of Ethan, aged sixteen, who picked the onions out of his Hawaiian pizza).
I wondered how they pulled it off. I asked one of the Cheesecake Factory line cooks how much of the food was premade. He told me that everything's pretty much made from scratch—except the cheesecake, which actually is from a cheesecake factory, in Calabasas, California.
I'd come from the hospital that day. In medicine, too, we are trying to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality. Unlike the Cheesecake Factory, we haven't figured out how. Our costs are soaring, the service is typically mediocre, and the quality is unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of two or three, even within the same hospital.
It's easy to mock places like the Cheesecake Factory—restaurants that have brought chain production to complicated sit-down meals. But the "casual dining sector," as it is known, plays a central role in the ecosystem of eating, providing three-course, fork-and-knife restaurant meals that most people across the country couldn't previously find or afford. The ideas start out in élite, upscale restaurants in major cities. You could think of them as research restaurants, akin to research hospitals. Some of their enthusiasms—miso salmon, Chianti-braised short ribs, flourless chocolate espresso cake—spread to other high-end restaurants. Then the casual-dining chains reëngineer them for affordable delivery to millions. Does health care need something like this?
Big chains thrive because they provide goods and services of greater variety, better quality, and lower cost than would otherwise be available. Size is the key. It gives them buying power, lets them centralize common functions, and allows them to adopt and diffuse innovations faster than they could if they were a bunch of small, independent operations. Such advantages have made Walmart the most successful retailer on earth. Pizza Hut alone runs one in eight pizza restaurants in the country. The Cheesecake Factory's major competitor, Darden, owns Olive Garden, LongHorn Steakhouse, Red Lobster, and the Capital Grille; it has more than two thousand restaurants across the country and employs more than a hundred and eighty thousand people. We can bristle at the idea of chains and mass production, with their homogeneity, predictability, and constant genuflection to the value-for-money god. Then you spend a bad night in a "quaint" "one of a kind" bed-and-breakfast that turns out to have a manic, halitoxic innkeeper who can't keep the hot water running, and it's right back to the Hyatt.
Medicine, though, had held out against the trend. Physicians were always predominantly self-employed, working alone or in small private-practice groups. American hospitals tended to be community-based. But that's changing. Hospitals and clinics have been forming into large conglomerates. And physicians—facing escalating demands to lower costs, adopt expensive information technology, and account for performance—have been flocking to join them. According to the Bureau of Labor Statistics, only a quarter of doctors are self-employed—an extraordinary turnabout from a decade ago, when a majority were independent. They've decided to become employees, and health systems have become chains.
I'm no exception. I am an employee of an academic, nonprofit health system called Partners HealthCare, which owns the Brigham and Women's Hospital and the Massachusetts General Hospital, along with seven other hospitals, and is affiliated with dozens of clinics around eastern Massachusetts. Partners has sixty thousand employees, including six thousand doctors. Our competitors include CareGroup, a system of five regional hospitals, and a new for-profit chain called the Steward Health Care System.
Steward was launched in late 2010, when Cerberus—the multibillion-dollar private-investment firm—bought a group of six failing Catholic hospitals in the Boston area for nine hundred million dollars. Many people were shocked that the Catholic Church would allow a corporate takeover of its charity hospitals. But the hospitals, some of which were more than a century old, had been losing money and patients, and Cerberus is one of those firms which specialize in turning around distressed businesses.
Cerberus has owned controlling stakes in Chrysler and GMAC Financing and currently has stakes in Albertsons grocery stories, one of Austria's largest retail bank chains, and the Freedom Group, which it built into one of the biggest gun-and-ammunition manufacturers in the world. When it looked at the Catholic hospitals, it saw another opportunity to create profit through size and efficiency. In the past year, Steward bought four more Massachusetts hospitals and made an offer to buy six financially troubled hospitals in south Florida. It's trying to create what some have called the Southwest Airlines of health care—a network of high-quality hospitals that would appeal to a more cost-conscious public.
Steward's aggressive growth has made local doctors like me nervous. But many health systems, for-profit and not-for-profit, share its goal: large-scale, production-line medicine. The way medical care is organized is changing—because the way we pay for it is changing.
Historically, doctors have been paid for services, not results. In the eighteenth century B.C., Hammurabi's code instructed that a surgeon be paid ten shekels of silver every time he performed a procedure for a patrician—opening an abscess or treating a cataract with his bronze lancet. It also instructed that if the patient should die or lose an eye, the surgeon's hands be cut off. Apparently, the Mesopotamian surgeons' lobby got this results clause dropped. Since then, we've generally been paid for what we do, whatever happens. The consequence is the system we have, with plenty of individual transactions—procedures, tests, specialist consultations—and uncertain attention to how the patient ultimately fares.
Health-care reforms—public and private—have sought to reshape that system. This year, my employer's new contracts with Medicare, BlueCross BlueShield, and others link financial reward to clinical performance. The more the hospital exceeds its cost-reduction and quality-improvement targets, the more money it can keep. If it misses the targets, it will lose tens of millions of dollars. This is a radical shift. Until now, hospitals and medical groups have mainly had a landlord-tenant relationship with doctors. They offered us space and facilities, but what we tenants did behind closed doors was our business. Now it's their business, too.
The theory the country is about to test is that chains will make us better and more efficient. The question is how. To most of us who work in health care, throwing a bunch of administrators and accountants into the mix seems unlikely to help. Good medicine can't be reduced to a recipe.
Then again neither can good food: every dish involves attention to detail and individual adjustments that require human judgment. Yet, some chains manage to achieve good, consistent results thousands of times a day across the entire country. I decided to get inside one and find out how they did it.
More ...
http://www.newyorker.com/reporting/2012/08/13/120813fa_fact_gawande?printable=true¤tPage=all
The place is huge, but it's invariably packed, and you can see why. The typical entrée is under fifteen dollars. The décor is fancy, in an accessible, Disney-cruise-ship sort of way: faux Egyptian columns, earth-tone murals, vaulted ceilings. The waiters are efficient and friendly. They wear all white (crisp white oxford shirt, pants, apron, sneakers) and try to make you feel as if it were a special night out. As for the food—can I say this without losing forever my chance of getting a reservation at Per Se?—it was delicious.
The chain serves more than eighty million people per year. I pictured semi-frozen bags of beet salad shipped from Mexico, buckets of precooked pasta and production-line hummus, fish from a box. And yet nothing smacked of mass production. My beets were crisp and fresh, the hummus creamy, the salmon like butter in my mouth. No doubt everything we ordered was sweeter, fattier, and bigger than it had to be. But the Cheesecake Factory knows its customers. The whole table was happy (with the possible exception of Ethan, aged sixteen, who picked the onions out of his Hawaiian pizza).
I wondered how they pulled it off. I asked one of the Cheesecake Factory line cooks how much of the food was premade. He told me that everything's pretty much made from scratch—except the cheesecake, which actually is from a cheesecake factory, in Calabasas, California.
I'd come from the hospital that day. In medicine, too, we are trying to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality. Unlike the Cheesecake Factory, we haven't figured out how. Our costs are soaring, the service is typically mediocre, and the quality is unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of two or three, even within the same hospital.
It's easy to mock places like the Cheesecake Factory—restaurants that have brought chain production to complicated sit-down meals. But the "casual dining sector," as it is known, plays a central role in the ecosystem of eating, providing three-course, fork-and-knife restaurant meals that most people across the country couldn't previously find or afford. The ideas start out in élite, upscale restaurants in major cities. You could think of them as research restaurants, akin to research hospitals. Some of their enthusiasms—miso salmon, Chianti-braised short ribs, flourless chocolate espresso cake—spread to other high-end restaurants. Then the casual-dining chains reëngineer them for affordable delivery to millions. Does health care need something like this?
Big chains thrive because they provide goods and services of greater variety, better quality, and lower cost than would otherwise be available. Size is the key. It gives them buying power, lets them centralize common functions, and allows them to adopt and diffuse innovations faster than they could if they were a bunch of small, independent operations. Such advantages have made Walmart the most successful retailer on earth. Pizza Hut alone runs one in eight pizza restaurants in the country. The Cheesecake Factory's major competitor, Darden, owns Olive Garden, LongHorn Steakhouse, Red Lobster, and the Capital Grille; it has more than two thousand restaurants across the country and employs more than a hundred and eighty thousand people. We can bristle at the idea of chains and mass production, with their homogeneity, predictability, and constant genuflection to the value-for-money god. Then you spend a bad night in a "quaint" "one of a kind" bed-and-breakfast that turns out to have a manic, halitoxic innkeeper who can't keep the hot water running, and it's right back to the Hyatt.
Medicine, though, had held out against the trend. Physicians were always predominantly self-employed, working alone or in small private-practice groups. American hospitals tended to be community-based. But that's changing. Hospitals and clinics have been forming into large conglomerates. And physicians—facing escalating demands to lower costs, adopt expensive information technology, and account for performance—have been flocking to join them. According to the Bureau of Labor Statistics, only a quarter of doctors are self-employed—an extraordinary turnabout from a decade ago, when a majority were independent. They've decided to become employees, and health systems have become chains.
I'm no exception. I am an employee of an academic, nonprofit health system called Partners HealthCare, which owns the Brigham and Women's Hospital and the Massachusetts General Hospital, along with seven other hospitals, and is affiliated with dozens of clinics around eastern Massachusetts. Partners has sixty thousand employees, including six thousand doctors. Our competitors include CareGroup, a system of five regional hospitals, and a new for-profit chain called the Steward Health Care System.
Steward was launched in late 2010, when Cerberus—the multibillion-dollar private-investment firm—bought a group of six failing Catholic hospitals in the Boston area for nine hundred million dollars. Many people were shocked that the Catholic Church would allow a corporate takeover of its charity hospitals. But the hospitals, some of which were more than a century old, had been losing money and patients, and Cerberus is one of those firms which specialize in turning around distressed businesses.
Cerberus has owned controlling stakes in Chrysler and GMAC Financing and currently has stakes in Albertsons grocery stories, one of Austria's largest retail bank chains, and the Freedom Group, which it built into one of the biggest gun-and-ammunition manufacturers in the world. When it looked at the Catholic hospitals, it saw another opportunity to create profit through size and efficiency. In the past year, Steward bought four more Massachusetts hospitals and made an offer to buy six financially troubled hospitals in south Florida. It's trying to create what some have called the Southwest Airlines of health care—a network of high-quality hospitals that would appeal to a more cost-conscious public.
Steward's aggressive growth has made local doctors like me nervous. But many health systems, for-profit and not-for-profit, share its goal: large-scale, production-line medicine. The way medical care is organized is changing—because the way we pay for it is changing.
Historically, doctors have been paid for services, not results. In the eighteenth century B.C., Hammurabi's code instructed that a surgeon be paid ten shekels of silver every time he performed a procedure for a patrician—opening an abscess or treating a cataract with his bronze lancet. It also instructed that if the patient should die or lose an eye, the surgeon's hands be cut off. Apparently, the Mesopotamian surgeons' lobby got this results clause dropped. Since then, we've generally been paid for what we do, whatever happens. The consequence is the system we have, with plenty of individual transactions—procedures, tests, specialist consultations—and uncertain attention to how the patient ultimately fares.
Health-care reforms—public and private—have sought to reshape that system. This year, my employer's new contracts with Medicare, BlueCross BlueShield, and others link financial reward to clinical performance. The more the hospital exceeds its cost-reduction and quality-improvement targets, the more money it can keep. If it misses the targets, it will lose tens of millions of dollars. This is a radical shift. Until now, hospitals and medical groups have mainly had a landlord-tenant relationship with doctors. They offered us space and facilities, but what we tenants did behind closed doors was our business. Now it's their business, too.
The theory the country is about to test is that chains will make us better and more efficient. The question is how. To most of us who work in health care, throwing a bunch of administrators and accountants into the mix seems unlikely to help. Good medicine can't be reduced to a recipe.
Then again neither can good food: every dish involves attention to detail and individual adjustments that require human judgment. Yet, some chains manage to achieve good, consistent results thousands of times a day across the entire country. I decided to get inside one and find out how they did it.
More ...
http://www.newyorker.com/reporting/2012/08/13/120813fa_fact_gawande?printable=true¤tPage=all
Sunday, August 5, 2012
Less Hospital Noise Improves Patient Care - NYTimes.com
Clasping her chest and struggling to breathe, the small, birdlike woman had landed once again in the hospital for complications of kidney failure. It was her third visit in the last year and now, with fluid building up around her heart, she had come back in, but only after her family had pleaded with her for a day to do so.
"Oh, it's not because I don't want to feel better," she fumed as she lay gasping on her hospital bed. "It's because I can't get better here, with all those alarms and people waking me up to give me pills and take my blood pressure and get my blood." She stopped for a moment to catch her breath, then started crying. "I feel like I get sicker in the hospital because I can't get any sleep!"
Ask any person who has ever been hospitalized or stayed at the bedside of a loved one, and most will agree that hospitals are busy, noisy places. Patients have criticized the clatter for years, but their complaints have largely been ignored because hospital administrators, doctors, nurses and other staff have believed that a quiet environment is less critical for patient care than the alerts from the multitude of alarms, whistles and buzzers and the information garnered from frequent patient checks.
Over the last few years, however, that attitude has been gradually changing, thanks to a greater focus on patients, as well as new policies linking hospital reimbursement to patient satisfaction.
What patients endure, it turns out, borders occasionally on deafening. A study this year from the University of Chicago found that average noise levels in a hospital room easily exceeded the 30 decibels, slightly louder than a whisper, recommended by the World Health Organization, and peak noise levels sometimes approached the level of a chain saw. Not surprisingly, patients in the loudest rooms suffered most, losing as much as an hour or more of sleep a night compared with those in the quietest rooms. And for every hour of sleep lost, the patients' blood pressure increased by as much as six points.
A study published more recently revealed that not all hospital noises are created equal. Researchers looked at the brain wave and cardiac responses to isolated hospital sounds - an ice machine disgorging its cubes, a laundry cart rolling, an intravenous infusion pump beeping, people discussing "good" and "bad" patient outcomes - and then calculated just how disruptive those sounds were to patients who were asleep. The researchers found that while the responses differed depending on stage of sleep, people were more consistently aroused by the electronic alarms from monitors and infusion devices and the ringing from telephones. Each time they woke, their heart rates jumped.
"There is a threat perceived in those noises," said Orfeu M. Buxton, lead author of the study and an assistant professor in the division of sleep medicine at Harvard Medical School, "and hospitalized patients are probably in a high state of 'threat vigilance.' "
Manufacturers of monitoring and medication infusion devices have not turned a deaf ear to the problem. The industry has begunsponsoring and conducting research on the amount of noise generated by medical devices, and several groups have begun working on creating more patient- and sleep-friendly products. Some companies, for example, have tapped into the increasing use of wireless technology in hospitals, designing monitors, pumps and nursing call systems that do not buzz or beep right at the patient's bedside, but rather channel the alarms only to the doctor or nurse responsible.
While these early wireless efforts are promising, many companies and hospitals remain reluctant to switch over completely to the newer designs, and industry standards for device alarms are changing slowly, if at all. "The holy grail is that a pump would never sound its alarm while near a patient," said Tim Vanderveen, vice president of the Center for Safety and Clinical Excellence at Carefusion, a medical technology company that produces infusion pumps and other health care devices. "But what would happen if a hospital's wireless system went down?"
The most challenging obstacle in the quest for quiet, however, appears to be not the machines but rather the approach to patient care in most American hospitals. Doctors, nurses and other members of the hospital staff often wake patients up in the middle of the night or during afternoon naps to assess a non-urgent blood pressure or temperature, draw blood or administer medications that could safely be delayed by a couple of hours.
"Everyone in the hospital tends to do things at their own convenience instead of working together as a team to figure out what might be best for the patient," said Susan B. Frampton, president of Planetree, a nonprofit organization that works with health care providers and organizations to deliver more patient-centered care. "We forget what it is like to be a patient in this alien environment, at the mercy of people and their machines and agendas."
To change this culture, some health care systems have initiated hospitalwide campaigns, with names like "Shhh" (Silent Hospitals Help Healing), "Hush" (Help Us Support Healing) or simply "Too Loud," that institute mandatory quiet times, designate noise reduction teams to encourage compliance and use sound meters in the shape of traffic lights or human ears that turn green when the noise level is acceptable, yellow when it increases, and red when it goes above the acceptable range.
With the support of Planetree, one hospital system, the Department of Veterans Affairs New Jersey Health Care System, has gone beyond minimizing noise and actively elicits suggestions from patients on how the hospital can help them sleep better. When admitted to the hospital, all patients are asked about their sleep patterns, then given a laminated "sleep menu" card from which they can choose a variety of sleep aids, like light-blocking masks, sound machines, warmed blankets and aromatherapy. The patients' sleep preferences are then posted in their rooms to alert staff members, and a nurse assesses their sleep experience each day.
While it is still too early to know whether any of these initiatives will prove successful, it is now clear that patient complaints about noise and lack of sleep are critical to quality of care. "Sleep is such a powerful source of resilience," Dr. Buxton said. "Its absence results in a degradation of that resilience."
"We need to change how we view noise and sleep," he added. "We need to begin grouping sleep with all the other things we do to make patients better."
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