Taylorized Medicine: Where Medical Care Meets Maximal Efficiency

Frederick Winslow Taylor

My friend and colleague, Dr. Michael Edmond, published a thoughtful essay in Annals of Internal Medicine titled Taylorized Medicine. The practice of medicine and the education of resident and student doctors have changed.  The pressure of abiding by an 80 hour work week, the need to efficiently admit, treat and discharge patients, has added to the stress of medical training and has chipped away at the collegiality, banter and humor of working within a medical team.  Inpatient medical care resembles a mechanized process of maximal efficiency, much like the field of scientific and industrial management pioneered by Frederick Winslow Taylor.

Effective July 2011, the ACGME will limit intern shifts to 16 hours, night float is limited to 6 consecutive nights and ‘strategic napping’ (yes, that term is actually used) is encouraged for residents taking overnight call. These recommendations are for sake of patient safety. This may be a noble aim, however, a timely a review published in the Annals of Internal Medicine acknowledges that there are significant limitations in the data supporting these measures.

While I believe in patient safety and in reducing work hours for residents, my hope is that the upcoming changes do not inadvertently dehumanize the patient-doctor encounter to that of a mere transaction.  Were that to occur, then joy of medicine would be irrevocably altered.

Curbing the HIV Epidemic:Everything Has Been Said Before But No On Was Listening

Andre Gide- Frenchman of Letters

“Everything has been said before, but since nobody listens we have to keep going back and beginning all over again.”

 Andre Gide, French writer

In 2009 The American College of Physicians published a guidance statement on routine screening for HIV in primary care settings.

This week, a paper in Annals of Internal Medicine, reported on the cost-effectiveness and outcomes of expanded HIV screening and antiretroviral treatment in the USA. The authors conclude that expanding HIV screening and treatment simultaneously offers the greatest health benefit and is cost-effective. However, even with expansion of HIV screening and treatment programs, these efforts will not significantly reduce the U.S. HIV epidemic without reductions in risk behavior.

So we are back to what has been stated over and over again: risk reduction behavior is critical to curb the HIV epidemic. This includes needle exchange programs for drug users, increased access to drug rehabilitation, and comprehensive sexual education that includes promotion of condoms for all sexual orientations. 

It’s a Cold, Get Over it

Sneezing is an excellent way to spread contagion!

Tis the season for viral upper respiratory infections! These are known better as the common cold.

The Annals of Internal Medicine just reported a randomized trial of Echinacea for the treatment of the common cold.  Despite a quality study design, illness duration and severity were not statistically significant with echinacea compared with placebo. One caveat: the study may have not have been adequately powered to detect a small difference between placebo vs. echinacea.

The bottom line: based on this study, the results do not suggest that echinacea can substantively change the course of the common cold.

Once again, with respect to the common cold, we are left to our own devices, as pharmaceutical interventions are of little to no benefit.

If you have a cold: rest, try some chicken noodle soup (also not supported by scientific data) and, most importantly, stay home, so as not infect the rest of us!

Cultural (In)Competency in Medicine

Now, more than ever, medical students are taught to approach medical care through the lens of cultural competency and sensitivity. A nice perspective, written in Academic Medicine, can be found here. For me, cultural competency in medicine is treating patients with respect, dignity and in a fashion that is consistent with their personal, ethnic, and religious beliefs.

Once again, it appears that end of life doctor-patient discussions may be distorted by right wing reactionaries, with emotional sound bites likening end of life care to ‘death panels’ and government rationed health care.  As recently reported, under new Medicare regulations, the government will reimburse physicians for office visits in which the focus is not a physical exam or EKG. Rather, the focus is on discussing options for end-of-life care, including advance directives to forgo aggressive life-sustaining treatment.

Providing end of life care, with treatments and measures specified and limited by the patient, in accordance with his/her wishes and beliefs, is culturally sensitive and competent.

Those who argue against doctor-patient discourse on end of life decision making, are, in fact,  insensitive and culturally incompetent. 

Medical School in the Caribbean: Students Against the Tide

The American Association of Medical Colleges predicts a significant physician shortage by as many as 90,000 doctors in 2020. To meet this challenge, nationwide, new medical schools have emerged and existing medical schools are expanding class sizes. As the director of 3^rd and 4^th year internal medicine student training at VCU, the educational challenges of increased student numbers are well known to me. Providing more learners with quality training, direct patient care experience and meaningful physician-educator mentorship is not logistically simple.

So it was with interest that I read a recent article about medical schools in New York State fighting the inflow of Caribbean medical students.  The campaign aims to persuade the State Board of Regents to make it very hard for foreign schools to use New York hospitals as extensions of their own campuses.  This is not insignificant as Caribbean medical schools have attracted thousands of Americans over the year. As most Caribbean medical schools lack large teaching hospitals, many students will complete their clinical training in the USA. The argument against Caribbean medical schools is that they are for profit entities, with lower quality students, who compete for clinical training slots by handsomely paying hospitals to take their students (US medical schools pay nothing as hospitals and medical schools are typically ‘partners in prestige’).

Many health care challenges are ahead, including ensuring access to all, containing costs and training more physicians to curb the projected doctor shortage so as to meet the needs of an aging population.

If you are a Caribbean medical student, your career may sail against the changing tide of medical education, at least in New York,

Vaccination: Perspectives from the Haves and Have-Nots

I recently read news report in the British Medical Journal about pneumococcal vaccination of infants in developing countries. Nicaragua will be the first of about 40 developing countries to begin pneumococcal vaccination of all children less than 12 months of age. The vaccine is now made available via a funding mechanism devised by the Global Alliance for Vaccines and Immunization (GAVI Alliance), a public-private partnership set up in 2000 to quicken the introduction of new vaccines into poor countries. This will result in a greater than 90% vaccine price reduction for developing countries. Understandably, there is much excitement as vaccination for S.pneumoniae has significantly decreased morbidity and mortality from pneumonia and meningitis in wealthy nations.

In wealthy countries, conversely, vaccination appears to generate little excitement save for the vocal anti-vaccine movement. This is particularly evident in Western Europe, the USA, Japan and Australia. The skilled use of the media and internet has resulted in immense influence by the anti-vaccine movement. One interesting review proposed the ‘pyramid effect’ as an operative for understanding how societal decisions about vaccine acceptance are made.

• The pyramid base represents the broad impact that vaccination policy can have on a common disease
• The pyramid peak represents harm or risk from vaccination
• The vast majority who benefit from vaccination are passive participants while the minority who experience or perceive harm become passionate and vociferous opponents

Vaccines have become victims of their own success: as widespread vaccination lessens or eliminates the risk of a disease, the public’s perception of the vaccines’ value and impact will paradoxically diminish as the illness is no longer perceived as a threat.

Perhaps one day Nicaragua and similarly impoverished countries will have the luxury of their own anti-vaccine movement.

D.I.Y Science: Geek to Chic?

I have heard of D.I.Y. fashion, websites etc., but D.I.Y science? The epicenter of this nascent movement is in Brooklyn and was recently featured in the NY Times.

Quoting from the article, the goal “… is to promote science as a viable hobby for children and adults. ‘The more people get their hands dirty in a lab, the less likely they’ll be to have knee-jerk reactions to things like stem-cell research and genetically modified organisms’…..”

The movement is a motley group of amateur scientists who, empowered by internet based access to information, are performing research in their D.I.Y Labs. D.I.Y Science may be best represented by DIYbio.

What sort of long term impact this may have is largely unknown. Perhaps it can interest young students to pursue a career in medicine. The AAMC predicts a significant physician shortage in the USA, so any boost in interest is welcomed.

Architecture and Design: Agents of Change

I am going to tread beyond my comfort zone now with a new yet hopefully related topic.

In my public health seminar, the students read Dr. David Hilfiker’s book, Urban Injustice, How Ghettos Happen.  Dr. Hilfiker clearly articulates the complex history of urban poverty and explores the weaknesses and strengths of societal responses to poverty.  As a physician, he focuses on the need for access to healthcare as one of the essential ingredients for breaking the poverty trap.

While casually perusing Dwell magazine the other day, I came across a novel perspective on curbing urban blight. The article was about a young couple who focus their talent in design and architecture to affect sustainable social change in diverse and economically troubled areas. The result is the Detroit based Power House Project, which purchased a foreclosed home in a rough and tumble area of Detroit for $1900. The home serves now as the demonstration center and network for sustainable design and urban renovation, running through solar power and wind energy. It is a partnership of creative professionals, artists, architects, laborers, and social geographers interested in this neighborhood as an experiment in sustainable design, social change and urban rejuvenation. The project has now expanded to include 10 homes in the neighborhood.

This movement will likely not impact traditional health measures. However, thinking outside of the (public health) box, it may foster a greater sense of personal and community satisfaction in economically challenged neighborhoods, a precursor to healthy living.

Well done.

Military Recruitment in High Schools: A Public Health Controversy

Each spring I teach a seminar for the VCU Master in Public Health program title Contemporary Issues and Controversies in Public Health.  We cover issues such as obesity, poverty and health, gun control, down low behavior, and overtreatment in medicine. I recently came across a new (to me) public health controversy: military recruitment of high school students and its public health implications.

In a paper published in the American Journal of Public Health, the authors raise a seemingly valid concern about the effects of military recruitment in high schools. They chronicle the efforts to limit military recruitment of students by a PTA organization in Seattle, highlighting the aggressive measures used by recruiters, likened to predatory grooming, to gain access to students in high schools. Recruitment efforts are particularly aggressive in rural and low income urban areas. The authors cite several potential public health impacts such as studies demonstrating  the highest rates of all mental health disorders, including alcohol abuse, anxiety syndromes, depression, and posttraumatic stress disorder among the youngest cohort of military recruits, those aged 17-24 years. Youngest military recruits also have the highest rates of suicide and self inflicted injuries.

The Bush Administration’s No Child Left Behind Act, Section 9528,requires public schools to give military recruiters access to students at school and access to student’s contact information.

I remember recruiters in my high school in the mid-late 1980s. My Dad, a pediatrician, would half-jokingly provide me some wise advice when learning of their presence - "don't sign anything."

L.O.T

Labyrinth of Terror

What do you get when a world renowned epidemiologist and infectious diseases physician turns his efforts to writing fiction rather than science? The result is a unique combination of infection control, infectious diseases and bioterrorism played out in an international arena. No one other than our very own Dr. Richard Wenzel could weave the intricacies and challenges of infection prevention in a gripping and clever plot with engaging and creative characters.

The pages will turn themselves.

Who said that epidemiologists are boring?

Drs. Wenzel and Stevens at today's booksigning

Losing Touch, Sort of

Last week I promised to discuss glove use in clinical care.  So here it is.

There has been growing concern that donning gloves for patient care has led to a literal and figurative loss of touch between doctor and patient. In many ways, the gloved hands represent an artificial barrier to the healing touch. This was nicely explored by Dr. Pauline Chen in the following article. My quote in this article would suggest that glove use is a modern reality with little chance of reversal, especially given today’s emphasis on universal precautions and on controlling drug resistant bacteria.

Consider, however, the alternative. There are many advocates of aggressive screening of patients with implementation of contact isolation (precautions). I refer the reader to a spirited back and forth commentary on the expansion of contact precautions in the HAI Controversies blog. There is a growing body of literature highlighting the adverse effects of contact isolation in the hospital. For a nice review, click here. In brief, patients in contact isolation are visited less frequently by HCWs, have vital signs taken less often, have increased adverse events and experience symptoms of depression and dissatisfaction.

We favor the least restrictive approach. We aggressively promote broad based infection prevention efforts without hospital wide active detection and isolation. Hand hygiene and adherence to infection prevention best practice has allowed us to control drug resistant pathogens effectively in our ICUs. We published a manuscript documenting that universal gloving (without contact precautions) in a surgical ICU is as effective as the standard of care with contact precautions. This approach was well received by our HCWs, suggesting that it is sustainable.

So, gloving may result in a latex barrier, however, it is less restrictive and likely less damaging to the doctor-patient relationship than the barrier of isolation.

Healthcare Workers: Protect Yourselves!

Leading the Pack: VCU Internal Medicine Nurses Do it Safely!

There seems to be endless construction where I work. It is not uncommon for me to pass a construction site at the hospital and note that all workers are seemingly compliant with the use of personal protective equipment; gloves, goggles, hard hats and steel toed boots.

I am still bewildered why healthcare workers are so nonchalant in the use of protective measures, unnecessarily exposing themselves to potentially infectious agents through splashes in the eyes and mouth or through percutaneous injuries with sharp devices. This happens daily.

There is a growing body of literature detailing that personal protective measures result in a safer care. Use of goggle, gowns and gloves will limit the exposure to infectious agents. In the OR, protective eyewear, double gloving, use of hands free zones and blunt tip suture needles, as championed by the American College of Surgeons, will greatly enhance safety.

Sadly, there is a body of literature reporting that healthcare workers are uniformly poor in donning protective equipment at the point of care. Barriers include access to protective equipment, education and perception of risk. In some analyses, it seems that healthcare worker autonomy trumps safety. This is neatly explored in Dr. Atul Gawande’s book, the Checklist Manifesto. The translation of evidence into clinical practice is known as implementation science. For a relevant publication on implementing a safety culture change, I refer you to this article in the British Medical Journal.

Ironically, the same healthcare workers who refuse to wear protective equipment in the hospital will subsequently minimize risk on their drive home by wearing a seatbelt.

HCWs: Please practice safety at all times as you are invaluable to all of us.

Techno MDs: Leaders and Laggards

Although technology in medicine by no means equates to salvation, medical informatics can certainly make the transfer and sharing of patient information much easier in a complicated system. You would think that busy physicians would welcome medical information systems that would facilitate the transfer and hand off of patient histories, diagnostic tests and treatments between both providers and health care systems. Not true. 

I still get many referrals from community physicians and local hospitals with indecipherable chicken scratch for progress notes. I still must request faxes with labs and diagnostic test results.  Perhaps one day medical information systems will allow the secure electronic transfer of patient records between health care systems and providers. Based on recent publications, this will likely not occur soon.

Dr. Mike Edmond’s collaborative medical blog hyperlinks to an article by Megan Mcardle titled “Paging the Luddite”. Among other things, the article highlights how physicians have been slow to adopt medical informatics, partly because of cost and partly because of fear of oversight and loss of autonomy.

The WSJ recently reported the results of a CDC survey on the use of electronic medical records. The results are somewhat disappointing as only half of physicians reported using an electronic medical record, at least in some fashion.

We still have a long way to go.

My message to the other half: you are holding us back.

Feedback? No, Feedforward.

Today I read an interesting paper in Medical Education titled Feedback, the various tasks of the doctor, and the feedforward alternative.

The authors comprehensively review the unintentional damage that feedback may cause to both motivation and performance. In a nice review of the literature and in a meta-analysis, the evidence suggests that traditional feedback can have complex, and at times negative results, thereby impairing performance. At play here is a self-regulatory theory with two distinct foci: prevention-a state of mind characterized by vigilance and concern with punishment, and, promotion -a state of mind characterized by eagerness and concern with rewards.

In essence, the evaluator must understand the self-regulatory focus of the learner so as to best understand the impact of feedback.  The authors argue that positive feedback motivates more than negative feedback under a promotion focus and that this effect reverses under a prevention focus.  

Are you still with me?

Next, they propose the Feedforward interview technique. If done properly, this indeed is an exploratory, self reflective, interview between student and teacher. The authors cite limited data in support of the new technique.

The components are:

• Introduction: set a positive tone
• Story: the learner must recall a life or work story that led to personal fulfillment
• Peak: the learner must recall the peak moment and psychological reaction
• The conditions: the learner must explore what allowed for the story/peak experience
• The feedforward question: To what extent/degree does the current work and educational experience bring the learner closer/take away from the condition of happiness and fulfillment?

The feedforward approach may be too Ivory Tower, even for the Ivory Tower. Here is why this may not play out in reality:

• Many medical schools educate 150+ students per year in clinical clerkships. Most struggle to simply get physicians to complete a written student evaluation.
• Feedforward student interviews would be time consuming. Without a structural change that actually provides protected time for teaching and formal feedback sessions, this will fall by the wayside.
• Extensive training of both evaluator and learner will be required to implement the feedforward interview.
• The feedforward evaluator must understand the self-regulatory focus (promotion vs prevention) of the learner whereas in the traditional model, feedback is dependent upon the observational skills of the mentor. I suspect that the former is less natural than the latter for most physician educators.

Feedforward interviewing may simply be too forward thinking in the current structure of medical education.

My apologies for today’s unduly long commentary.

Modern Day Nursing: Beyond Caps, Uniforms and Traditional Roles

During my first month of internship, a co-intern and medical school classmate gave me some sound advice on a weekend when I was assigned to the cardiac ICU: “ingratiate yourself to the nurses, they know cardiac patient care much better than you, and they can make your life much easier in the unit.”  Point well taken.

My perception was that young physicians (young perpetually defined as my age or younger) were respectful of nurses and viewed them as important patient care partners. Gone were the days of nurses as mere patient care subordinates in matching uniforms with caps, carrying out doctors' orders and emptying bed pans.

In a recent column titled Doctor and Patient: Nurses’ Role in the Future of Healthcare, surgeon-columnist Dr. Pauline Chen debunks this notion, highlighting how the medical profession, administrators and third-party payers, either intentionally or not, have relegated nurses to the sidelines of the healthcare policy debate. Nursing is heading in a direction of higher standards in education and patient care with greater visibility as patient advocates. This can only be for the betterment of patients, particularly if embraced by physicians and hospital leaders. One hopes that nurses will play a greater collaborative role in all levels of medical care and follow up, resulting in a true team based approach to patient management. A team based, hospital unit model for safe patient care, with active decision making by nursing, is well described and championed by Dr. Peter Pronovost in his book Smart Hospitals, Safe Patients. This is a must read for all physicians, nurses and patients.

On a different note, I was interviewed, for the same column, different article, about glove use at the bedside and how healthcare providers are literally and figuratively losing touch with patients. 

More on that later.

Book Bound

In this week’s Travel section of the NY Times, there was a featured article on the Mission District of San Francisco, an area replete with independent bookstores, cafes and theaters, a veritable Mecca for bibliophiles of all stripes and colors. At the article’s end, I was ready to pack my bags for a literary destination vacation. One of my favorite activities in Richmond is strolling through Cary Town and the Fan district with my wife and dog, popping into used bookstores such as Chop Suey Books and Black Swan Books.

This article reminded me about a very cool read that I picked up in Argentina last August.  The book, titled Nadie acabará con los libros (No one will finish off books) is a true book lover’s book on books. Written as a series of interviews and discussions between Italian literary great, Umberto Eco and French screenwriter and book collector, Jean-Claude Carriere, the manuscript covers literary history, printing, and bookbinding, with beautifully interposed commentary on culture in general. This is a real gem from two men who revere books for their words and for their visual and tactile beauty. The authors argue that despite the Internet, blogs, and other digital media such as electronic books, there will be a continued need and preference (by some) for words in print.

When the power is out, the Internet is down, the Kindle has lost its charge or when I need to simply endure a nuclear winter, at least I will still have a book or two to keep me occupied! I hope that conventional books do not become such a rarity, confined mostly to niche followers, like vinyl records, which, despite the recent resurgence, are largely for the turntables of music lovers.

Richmond City FC Copa Navidad 2010: No losers, Just Winners

Medicine is my profession and football (soccer) is my passion.  As I am near my expiration date as a competitive footballer, it is with great pleasure and pride that I was still able to mix both today.

Richmond City FC successfully completed its 6^th annual Copa Navidad charity fund raiser event. The Richmond City FC Blues faced the Maroons today for bragging rights.  Despite the match ending in a hard fought draw, the real winner was this year’s charity designee: Richmond’s Fan Free Clinic , which provides medical care and access to Richmond's poor and uninsured. 

Richmond City FC is proud to raise money this Holiday season to support the Clinic and its mission.

Thank you, Fan Free Clinic, for all that you do.

The Richmond City FC Blues

The Richmond City FC Maroons

Richmond City FC in the 2010 Copa Navidad

With Richard Corbett, Development Director of the Fan Free Clinic