A new way to get spammed

Just what we needed, getting advertisements as text messages on our cell phones.  It's one thing for the cell company to try to sell you an enhanced service plan or something like that.  It's another to try to sell you a music album.

At least they don't charge you extra to be bothered.

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A fraud, but not a villain. What about us?

Bruce Ramshaw, a surgeon from Daytona, FL, has spent a lot of his career exploring the ramifications of complexity science.  In this article in General Surgery News, he offers some observations worthy of attention.

He starts with a story:

In September 2010, a 44-year-old academic superstar was named dean of the Tilburg School of Social and Behavioral Sciences faculty at Tilburg University in Tilburg, the Netherlands. Just one year earlier, this acclaimed social psychology researcher, Diederik Stapel, received the Career Trajectory Award from the Society of Experimental Social Psychology. Stapel moved to Tilburg University in 2006 and started TiBER, the Tilburg Institute for Behavioral Economics Research. By the pinnacle of his career, Stapel had authored and co-authored dozens of papers, some published in the most prominent journals, such as Science. The problem was that Diederik Stapel was a fraud. For more than a decade, Stapel made up data for his studies, regularly hoodwinking his co-authors, colleagues and students alike. Why would a recognized brilliant student and young researcher do this? He was clearly beyond capable of producing valuable scientific research. Why would he risk so much when he had the ability to do the work honestly?

The New York Times gave the answer:

In his early years of research—when he supposedly collected real experimental data—Stapel wrote papers laying out complicated and messy relationships between multiple variables. He soon realized that journal editors preferred simplicity. “They are actually telling you: ‘Leave out this stuff. Make it simpler.’” So, Stapel decided it would be better for his career to make the results of his studies simple to understand. He chose to make things up because that is what the editors, and presumably the journal readers, wanted to read. 

Bruce brings the lesson closer to home:

Although blatant fraud, as in the case of Diederik Stapel, does exist, it is not very common. A much more common problem in medical research is that the simplistic conclusions of published studies do not completely make sense when tested in the real world of patient care. Our traditional clinical research methods seek to prove or disprove a hypothesis to produce generalizable medical knowledge: that is, scientific medical truths that will apply to most (or to average) patients. Complexity science shows how incomplete this kind of thinking is when applied to the real (complex) world of patient care. Patients bring variability into the process and local variables make processes different in different clinical settings, even when the same disease is being treated with the same test or treatment.

We are a major part of the problem when we do not understand the complexity of the tests and treatments we prescribe and recommend. We need to evolve beyond our simplistic understanding of the results and application of medical research and apply a much more complete understanding of our world.

For essentially every test and treatment we have in health care, there are basically three subpopulations of patients who undergo a test or receive a treatment. First, there is a group that benefits from the test or treatment, but there is also a group that does not benefit (this is waste in our system), and finally, there is a group of people who are harmed by the test or treatment (directly or indirectly). Until now, our simplistic thinking has allowed us to rationalize that the waste and harm was just a necessary evil to help those patients who benefit from a test or treatment. Who could argue that a few unnecessary mammograms are justified to save a woman’s life? But complexity science argues, and the data from the use of vaccines and more than 30 years of screening mammography have shown, that it is not so simple and we are perpetrating a degree of waste and harm in patient care that is not sustainable and not ethical.

He concludes:

Diederik Stapel was a fraud, but he is not a villain. The villain in our world is not a person or an organization. The villain is our lack of understanding of complexity. Stapel’s desire to seek success by accommodating the desire to read simple results of complex biologic processes is the fault of no one individual but the fault of all of us who participate in the application of biological sciences.  

When we gain a more complete understanding of health care and our world, we will not only not allow simple-minded efforts like that of Diederik Stapel to achieve undeserved rewards, but we will also begin to address the waste and harm that is caused every day in our system that results from a much too simplistic understanding of how we care for patients and how we try to improve patient outcomes.

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Saskatchewan leaders take sides on Lean

I want to make clear that I am not taking sides in the internal political debates of another country, but I think it is instructive for all to watch a current scuffle in Saskatchewan.

Several years ago, the provincial government began an effort to adopt the Lean process improvement philosophy in the health care facilities across the province.  This was to require a large investment of time, money, and other resources.  Those of us in the health care world who have participated in Lean roll-outs--and have seen the value that it offers in increasing efficiency and quality--were impressed by the vision and commitment of the government.  We knew, as did they, that this kind of cultural transformation would take years, and we admired a government that had a long-term view of the return on the taxpayers' investment.

Over the months, consultants have been brought in to conduct training and offer support, and staff members in the various institutions have become more and more familiar with the philosophy and with the techniques and approaches used to create true front-line driven process improvement.

But the size of the investment has now raised concerns.  This article in the StarPhoenix summarizes the dueling points of view:

Under fire from the Opposition, Premier Brad Wall defended the provincial government's spending on the "lean" health quality management system.
 
"The overall amount is a significant investment and when we made the decision in cabinet, we're a government that looks at these things from the perspective of thrift and value and it was a long discussion."

The premier said the province is recouping its investment.

"We sought the very best and made the difficult decision to do this because of the dividends. What we're able to show is that between the savings just on the design of the children's hospital, on the design of the new Moose Jaw hospital, on the blood management system, we've recovered the entire costs of the four-year program, never mind all of the efficiencies that we have found," Wall said.

Opposition Leader Cam Broten took aim at the government over the issue during question period Thursday in Regina.

"There are good components to 'lean' . . . but this government has taken the 'lean' process and allowed it to become fat, allowed it to become a cash cow for consultants," Broten told reporters.

He said $40 million doesn't represent the total cost of "lean" in the province, since regional health authorities and other ministries also have "lean" contracts.

"I think it's gone overboard," Broten said. "I've looked at some of the Twitter feeds of health administrators who are paid to champion these kinds of things. It sounds like they're in a cult, the way that they pursue this type of language, over the top. We have to allow common sense to have its place."

This is an important debate with ramifications beyond this province.  I know from my visits and conversations elsewhere that people in health care throughout Canada are watching the Saskatchewan experience closely.  I think its fair to say that its success would be a signal throughout the country that it is possible to increase quality and safety and service levels and improve operating efficiency.

So how to resolve the political debate? I'm not taking sides, but it seems to me that this is too important an issue to have a "he-said-she-said" type of debate. Two ideas come to mind to help resolve the issue.  First, the government should be utterly transparent with regard to process improvement successes and failures during the roll-out.  Where successes have occurred, document what was achieved and how the stories of those advances are shared throughout the province and therefore contribute to the spread of good ideas.  Where failures have occurred, explain what has been learned from those experiments.

Second, bring in a (volunteer) group of outside experts to review the steps taken by the government and offer an objective appraisal of the roll-out.  Provide that report to the public and allow the government to explain how it will take those expert opinions into account going forward.

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Seeing America, the old way

Lee Crites has recently begun a nine month journey walking across America.  When his three daughters asked why, he gave ten reasons:

10. I want to go back to San Francisco and I'm tired of driving.
9. I need to lose 20 pounds.
8. There are millions of great people out there and I want to meet some of them where they live.
7. "A virtue to cover a multitude of sins" - Horace Kephart
6. My comfort zone has gotten too comfortable.
5. Walking is good medicine.
4. I have helped a lot of patients relearn how to walk in my physical therapist assisting role. Not all have been successful. I walk for those who cannot.
3. To remind my children that outrageous adventure can happen at any age.
2. I need to face my fears.
1. I want to form my own opinions of what America has become.

You can read his American Discovery Trail Journal here. 

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A plane crash every day

Every day that has passed as they search for the wreckage of the Malaysia Airline plane, another plane has crashed in America.  Well, better put, the equivalent number of people have died every day from preventable harm in America's hospitals.

Which story gets our attention?  Which is the greater public health hazard?

Remember Captain Sullenberger's words as he remarked on the scattered application of systemic approaches to safety in the health care industry: "We have islands of excellence in a sea of systemic failures. We need to teach all practitioners the science of safety."

"I wish we were less patient. We are choosing every day we go to work how many lives should be lost in this country."

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Inspiring

I missed this story a couple of years ago about a boy from Sierra Leone, although it was just recently reposted.  If you haven't seen it, I think you'll be inspired when you watch the video.

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Hypertension guidelines on WIHI

Madge Kaplan writes:

The next WIHI broadcast — How High? How Low? Shared Decision Making Amidst Shifting (Hypertension) Guidelines — will take place on Thursday, March 13, from 2 to 3 PM ET, and I hope you'll tune in. This is a special collaboration with the Journal of the American Medical Association that we're calling JAMA on WIHI: An Online Audio Forum on Quality.

Our guests will include:

• Craig W. Robbins, MD, MPH, Medical Director, Center for Clinical Information Services, Kaiser Permanente Care Management Institute
• Don Goldmann, MD, Chief Medical and Scientific Officer, Institute for Healthcare Improvement
• Peter Basch, MD, FACP, Medical Director, Ambulatory EHR and Health IT Policy, Medstar Health
• Eric Peterson, MD, MPH, Director, Duke Clinical Research Institute; Professor of Medicine, Division of Cardiology, Duke University Medical Center

Hypertension is a hot issue, especially in the US, where an expert committee recently recommended that the available evidence does not support initiating treatment (largely medication) for people 60 years or older until their blood pressure climbs to 150 over 90. The decades-long consensus had been to initiate treatment at 140 over 90, which is still the recommendation for adults younger than 60. The reasons for this change are possibly as complicated as the guideline process itself, but one of the chief concerns of the majority on the Eighth Joint National Committee (“JNC 8”) is the risk associated with aggressive treatment of hypertension in older adults.

So, can we talk about this? We certainly hope so, and we invite you to bring your real-world experience making sense of changing guidelines with your patients managing high blood pressure (and other conditions) to a special WIHI produced in collaboration with JAMA: March 13, 2014: How Low? How High? Shared Decision Making Amidst Shifting (Hypertension) Guidelines. 

Some experts take exception to the committee’s findings and the process itself. Our guests are going to take all that into consideration, but, with your help, we’ll focus primarily on the best ways to approach changing and often-debated guidelines when working with patients to achieve optimal health. (The new guidelines for determining who should be put on statins to lower cholesterol are another case in point.)

We want this discussion to be constructive and forward looking. And for that, we need your interest and participation. Thank you in advance for enrolling in the March 13 WIHI!

I hope you'll join us! You can enroll for the free broadcast here.

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