Innovator's Prescription

Thanks to one of my mentors, I have been tasked to read The Innovator's Prescription by Christensen, Grossman and Hwang, and assigned to speak with one of the authors.  This book has a fantastic vision of where health care needs to move in order to improve by uncomingling business models and service lines that have nothing to do with one another.  As a caveat, I am only 5 chapters in.  I will get more out as I read more. 

Blood Culture effect

Stepped out of M&M (Morbidity and Mortality Conference) for a second to get this one out...
I am sure there is a better name for this in the quality/process improvement literature, but there is a strange phenomenon in medicine where we react all aggresively to the notification that blood cultures have turned positive.
To give you a little background- blood is taken from ill patients in whom we suspect infection, and grown on culture media (think buffet for bacteria).  In the next 12-36 hours, bacterial colonies will grow (if present in the blood) and become large enough for us to see, identify and test.  By the way folks, that's why blood cultures take so long to come back relative to other tests, the things have to grow.
Anyway, it is common practice to receive a call from the Micro lab that your patient's cultures are positive for something.  Upon getting this news, the typical thing to do is have a small moment of panic, then go check on the patient.  Now, think this one through.  The blood was taken 2 days ago.  They have been fine/stable/sick the entire time.  But now that we have received the information, we are all of a sudden worried.
I am unsure why this phenomenon exists, but it seems that alarm bells bother us because they are sometimes all we have to know that a system is malfunctioning---even though it has been doing so for the last two days!  Illogical, yes, but I also wonder how responsibility/liability comes in, because positive blood cultures tend to become a hot potato.

Back to M&M...

Water

Not to start too many thoughts with... "I Can't believe it is 2010 and..." but I have to say, what a surreal weekend in the Boston area, with the basic concern of clean water taking up so much of our time.  Saturday morning, after a busy night shift, I spent a good 3 hours in the process of boiling, cooling, and filtering water, while attempt to locate bottled water in my neighborhood.  Feels strange in 2010.

The Joys of Working Nights

I love working nights, because it allows my brain to wander and in its fatigued state, think things like-- "Maybe it is so humid in Boston because everyone is boiling water."

Back to days, reality and accountability.... sigh

Obsolescence

I had the pleasure of reading this article right at the end of last year, and it is one that I continually bring and up and send on to folks.  10 obsolete technologies to kill in 2010 by Mike Elgan : orignially appearing in Computerworld (somehow Google brings up the Macworld version first. This article touches on once useful technologies that have outlasted their usefulness and have better, cheaper alternatives.  Nowhere are these thoughts more prevalent than in Medicine.  I recall early 2010, late at night working in the Emergency room, having to fax a signed document to a clinic to receive one piece of information about a patient that they had forgotten. 
Fax.... in 2010!  We are past the foreboding dates of two Arthur C. Clarke novels and still have to put up with faxing!

Along the same lines, I read this intersting historical fact today in Meet Marty Cooper - the inventor of the mobile phone at BBC News: "Handheld phones were originally produced to help doctors and hospital staff improve their communications.  Amazing, given that we are just about the only profession that still uses beepers! At some institutions, on weekend coverage, physicians have to carry multiple pagers, until recently necessitating a "pager bucket" to carry them.  

It is curious that our industry needs massive government spending to "incentivize" electronic medical technology.  What is it about health care that causes it to defy useful technology so? 







 

Negotiation, MD

Earlier this week, I had the pleasure of attending Paul Levy's seminar on negotiation. http://runningahospital.blogspot.com/2010/04/how-much-would-you-bid-for-10-bill.html

It was a great seminar, and covered many of the fundamentals of the art and science of negotiation in a 3 hour period. What I found most interesting, is how innately uncomfortable many physicians are with negotiation, especially with monetary negotiation. I have often thought about this problem as it applies to physicians as a group, as our negotiation skills lag far behind, especially given our training on rigorous analysis, decision making, and interpersonal skills.

Having grown up in a household whose sport was negotiation, I feel I can shed a little light on this issue that has often puzzled me about my colleagues. I can come up with at least three reasons why physicians fail at negotiation:

1. We never hear "No."

As physicians, we are not used to being told No. A real No, the kind that sticks. Sure patients, nurses and colleagues will often say no, but it is usually transient and we can move them to yes very quickly by leveraging our knowledge and positional power. We never have to develop the more subtle mechanisms for reaching agreement, because these tools work so well. In the negotiating world outside of medicine, we often have neither, and yet try in vain to invoke our favorite tools.

2. Physicians are risk averse.

By the nature of our profession, we endeavor to prevent the worst from happening, and it is always on our minds. We see risk as something to be minimized, and when we do balance risk and benefit, it is always on behalf of our patients, rarely for ourselves. We never feel the primary burden of our decisions, only the secondary consequences of a bad decision. If you want to beat a physician in a negotiation, instill him or her with the fear of loss.

3. Our training teaches us to be suspicious of money and tolerant of abuse.
We are the "good people," sacrificing our time, energy and potential earnings to help those around us. In order to rationalize how we earn so little for so much work in our training days, we develop a culture that places money in a strange place; a necessary evil but not for us. Therefore, the people that want money must also be evil, and we are willing to give it up in a negotiation, to rise above. Additionally, we learn from early in medical school that those above us in the hierarchy may act inappropriately, but it is in the best interest of our patients that we accept this abuse. While this phenomenon has improved over the years as professionalism standards grow in import, we still tolerate abuse from colleagues, other non-physician staff and patients themselves all so that we may benefit our patients. Appeasement does not work as a negotiating strategy.

So what do we do about all this? How can physicians improve?

1. Read about negotiation-- it is a skill and an extremely important one, study it
2. Attend workshops, seminars, etc.-- Negotiation is a performance sport, you must have practice time in order to succeed.
3. Develop negotiating mentors-- find someone that helps you think through problems critically, and with negotiating experience.  My father often fills this role for me.
4. Negotiate-- As Jeff Wiese always taught us at Tulane, Playing time makes all of the difference.

Some recommended reading:
Roger Dawson- most of books are great
Getting to Yes by Fisher, Ury and Patton
Bargaining for Advantage by G. Richard Shell