What I've Learned As A Hospital Medical Director

“39 yo female presented in cardiac arrest after being found down with needle in her arm. Multiple epinephrine and Narcan given prior to arrival with no ROSC. Resuscitation continued briefly with PEA on monitor and patient was pronounced dead.” Every week, we review all deaths in the hospital. One of our quality nurses summarizes each case in a couple of sentences. Every 2-3 weeks, there is one similar to this one from last week. The perpetrators: heroin and fentanyl.

We often consider heroin abuse as a problem of modern times. But opioid use has been with us for at least 5,000 years and heroin abuse has been a plague on humanity for more than 100 years. It all started with the ancient Sumerians. They migrated from what is now Iran to settle between the Tigris and Euphrates rivers around 5,000 BC. They had one key advantage over all of the other tribes in the area, in that they learned irrigation techniques to keep their crops from dying during periods of drought. They flourished and by 3,000 BC, they had invented writing and from their writing, we can learn about what crops they grew. For example, we know that they grew barley and about 40% of it went to the brewing of beer. They also grew poppies that they called the “plant of joy”.

By 500 BC, the secret of opium poppy cultivation spread to the Akkadians, the Assyrians, the Egyptians, and then the Greeks. Two thousand years later in 1,500 AD, Europeans had figured out that you can get a stronger effect of opium by smoking it rather than by drinking it and from this was born the opium dens. With fast and sturdy sailing ships, the Europeans were eager trade with China for spice, porcelain, and silk. But Europe needed something to take to China in return and that something was opium.

In 1720, the British East India Company shipped 15 metric tons of opium to China and by 1840, that had increased to 2,555 metric tons. In 1804, morphine was first extracted from opium and it rapidly gained commercial success as an analgesic. In 1874, a chemist in London was experimenting with morphine by mixing it with various acids and he created diacetylmorphine. His work was forgotten and then in 1897, Felix Hoffman, working for the Bayer chemical company accidentally synthesized diacetylmorphine when he was trying to produce codeine. Scientists at Bayer had just invented another drug that they called aspirin and the head of Bayer decided to move forward with diacetylmorphine first because it was felt to have more commercial potential than aspirin. They called their new product heroin and said that it was 10 times more effective then codeine as a cough medicine and more effective than morphine as a pain reliever. They also pushed it as a treatment for asthma, bronchitis, and tuberculosis. In its first year, Bayer produced 1 ton of heroin. It was initially claimed to be completely non-addictive but soon there were heroin addicts world-wide and by 1913, Bayer decided to stop producing the drug.

Today, 80% of the world’s heroin comes from poppies grown in Afghanistan. Here in the United States, most heroin comes from Mexico and Colombia. Mexican heroin production has significantly increased over the past decade, rising from 26 tons in 2013 to an estimated 70 tons in 2015. The reason for the increase is the economics of capitalism in its purest form. First, Drug cartels previously were primarily in the business of cocaine and marijuana importation but with the increase of legalized marijuana production in the United States for recreational and medicinal purposes, the demand for illegal Mexican marijuana fell significantly. Second, coincident with this was the burgeoning appetite of Americans for opioid prescription pain pills resulting in a rather dramatic increase in the American demand for opioids. With a recent nation-wide crackdown on excessive opioid prescriptions, the supply of pills dried up. The reduction in the demand for Mexican marijuana and the increase in demand for opioids resulted in a ramped up production in Mexican heroin as business shifted from cannabinoids to opioids. It is simple supply and demand – the heart of capitalism.

A big part of the cost of heroin is the transportation costs – getting it across the U.S. border. As with any transportation cost, if you can decrease the size of your product, you can reduce your cost to get it to the market. Enter fentanyl. In medicine, we’ve used it as an intravenous anesthetic for many years. It is 50-100 times more potent than heroin. Therefore, by adding fentanyl to heroin, you can dramatically decrease the size and weight of the opioid, thus significantly decreasing transportation costs. So now, we have heroin that is often more than just heroin and will additionally contain fentanyl and its many derivatives, such as carfentanil (which is 100 times more potent than fentanyl)

The net effect of this is that we now have heroin available on the street that is more potent and cheaper than ever before. A single dose of heroin costs about $10-$15 dollars. In comparison, to buy a 40 mg oxycontin tablet on the street will cost about $25-$40. So, heroin is now usually cheaper than prescription pain pills when purchased illegally. As “pill mills” declined, street sales of heroin exploded.

In 2014, 1 out of every 300 Americans used heroin and more than 10,000 Americans died from heroin overdose. And the number keep going up. In 2015, 1,424 Ohioans died from a heroin overdose, an increase from 1,196 in 2014. Fentanyl overdose deaths in Ohio increased from 503 in 2014 to 1,155 in 2015. Last year, Franklin County (Columbus, OH) had 279 drug overdose deaths. Heroin and fentanyl have emerged as the top overdose killers in our state. At the same time, deaths from prescription opioids has fallen.

The Sumerians didn’t die of overdoses from sipping tea made from poppies 5,000 years ago. The Europeans didn’t die from overdoses from smoking opium 300 years ago. And people didn’t die from drinking Felix Hoffman’s newly invented heroin 100 years ago. But today, we have cheap and incredibly powerful heroin and fentanyl derivatives that make it all too easy to overdose and die, for as little as $15 or $20. So, for the near future, a chief complaint of “Found down with needle in her arm” will continue to be a common first line in the emergency room chart and a common epitaph on our nation’s gravestones. Opioid deaths come down to the principles of Economics 101.

January 3, 2017

Tenure [ten-yer] noun:  Guaranteed permanent employment, especially as a teacher or lecturer, after a probationary period.

In academic medicine, the ultimate professional achievement is tenure. But what, exactly, is tenure? Historically, it meant that if you proved yourself, you got tenured and you were given academic freedom to do whatever research you wanted and the freedom to express your own opinions as an educator. And then, you would be protected from being fired.

The history of tenure in the United States.

In the 1800’s, professors served at the discretion of university’s boards of trustees who hired and fired them. But by the turn of the century, there was concern that this system led to influential donors dictating what professors could and could not research and teach. In 1915, the American Association of University Professors (AAUP) created a declaration of principles for academic freedom and tenure:

• Trustees raise faculty salaries, but not bind faculty with restrictions.
• Only committees of other faculty members can judge a member of the faculty.
• Faculty appointments be made by other faculty and chairpersons, with three elements:
  1. Clear employment contracts
  2. Formal academic tenure, and
  3. Clearly stated grounds for dismissal.

In 1940, the AAUP recommended that the probationary period before granting tenure should be 7 years. But the AAUP’s declarations did not provide academic freedom protection. In the McCarthy era, professors suspected of being communists could be fired and in the 1960’s, twenty states passed laws that professors who voiced anti-war sentiments could be fired from public colleges. Legal cases in the 1970’s helped to create protection from dismissal of tenured professors leading to the system that we have today, where tenured faculty are insulated (although not completely immune) from job termination and censorship.

Tenure track versus clinical track.

The problem with this is that it has created a caste system in academic medicine where physicians are either in the “tenure track” or the “clinical track”. If you are in the tenure track, you are promoted from “Assistant Professor” to “Associate Professor” and ultimately to “Professor”. When you are promoted to Associate Professor, you become “tenured”. However, if you are in the clinical track, you are promoted from “Assistant Professor, Clinical” to “Associate Professor, Clinical” and ultimately to “Professor, Clinical”. The clinical track faculty do not have the same rights as the tenure track faculty. You cannot be tenured in the clinical track and your contract is year-to-year rather than an indefinite duration.

Each department has a promotions and tenure committee that then reports to the college promotion and tenure committee that then reports to the university board of trustees. At each level, a faculty member who is up for promotion is voted on whether or not to be promoted.

But there is a problem with two academic tracks.

At the promotion and tenure committee levels, committee members who are in the tenure track vote on whether or not to promote both tenure track candidates and clinical track candidates. However, committee members who are in the clinical track can only vote on clinical track candidates. Inherent in this system is the assumption that tenure track faculty can judge the qualifications of clinical track faculty but clinical track faculty are incapable of judging whether tenure track faculty are qualified.

As a result, the criteria for promotion in the clinical track ends up looking a lot like the criteria for promotion in the tenure track. Being the best diagnostician or surgeon in the university does not get you promoted. Similarly, being the best teacher in the university won’t get you promoted. Even in the clinical track, you have to write articles about diagnoses and surgeries or write articles about teaching to get promoted. The clinical track in academic medicine has become in essence, the junior varsity track with the tenure track becoming the varsity track.

Last year, my son was doing campus visits as a high school senior when deciding where to go for college. At one university, which by all of the college ranking lists was among the top universities in the country for chemistry, the upper classmen that we met with told him that he should take his freshman chemistry courses at the 2-year community college on the other side of town and then transfer the credit because the professors that taught freshman chemistry were not as good of educators and were largely unavailable since their primary focus was their research rather than teaching undergraduates.

Our academic promotion values are out of synch with the needs of academic medicine.

The only way to get grants and write manuscripts is to have time during the week to do it. This has resulted in the concept of “protected time”, that is, time that you are not required to be seeing patients. The more protected time you are able to negotiate in your employment contract, the better your chances of being promoted, either in the tenure track or in the clinical track. One of the problems is that someone else has to pay for the cost of your salary during that protected time and that someone is often the physicians seeing patients full-time.

But to survive in the future, academic medical centers will not maintain financial viability purely by populating themselves with as many famous physicians as possible. Academic medical centers are increasingly in a vicious competition with private hospital systems for their very survival. If the academic medical center is not seeing enough patients, then it doesn’t have enough clinical income. And if it doesn’t have enough clinical income, it goes broke. So we are now in the difficult position of rewarding our academic physicians to to see fewer patients while we need our academic physicians to see more patients to stay in business. Our need priorities and our reward priorities are out of alignment.

So what do we do with tenure?

1. Promote academic physicians for excellence in teaching. This seems so intuitive, so why don’t we do it? As an analogy, if you were hiring a contractor to remodel your kitchen, would you want the contractor who has the reputation as the best remodeler in the community or the contractor who writes a lot of articles in The Journal of Home Remodeling but had all negative reviews on Angie’s List? If our business is teaching medical students, why wouldn’t we value the best teachers?
2. Promote academic physicians for excellence in clinical care. One of the best clinicians I have ever known spent 33 years as an Assistant Professor before retiring (as an Assistant Professor). He was known at Ohio State as “the doctor’s doctor” because all of the doctors who knew him wanted him as their doctor. If our business is taking care of patients, why wouldn’t we value the doctors who do the best job taking care of patients?
3. Eliminate the caste system of tenure versus clinical tracks for promotion. Promotion and tenure committees should either be comprised of both tenure track and clinical track faculty who all vote on all candidates who are up for promotion or we need to have two entirely separate promotion systems: one comprised only of tenure track faculty who vote on exclusively tenure track promotion candidates and one comprised only of clinical track faculty who vote exclusively on clinical track promotion candidates.
4. Eliminate the word “Professor” for academic physicians who are not in a tenure track. In some health systems, the physicians have other titles that better reflect their commitment and achievement in patient care. So maybe we’d be better off using consultant: “Assistant Consultant”, Associate Consultant”, and “Senior Consultant”. Or maybe clinician: “Associate Clinician”, “Senior Clinician”, and “Master Clinician”.

What did I do?

In 1997, I became tenured when I was promoted from Assistant Professor to Associate Professor in the tenure track. However, rather than feeling like I had academic freedom to do what I was passionate about, I felt constrained because in this track, I would not be able to do what I really enjoyed: teaching medicine, taking care of patients, and taking on administrative leadership roles in the hospital. Instead, the tenure track had me locked into a future of submitting research grants and writing journal articles. Don’t get me wrong, these are noble and valued activities and I had a lot of passion for them. Its just that I had even more passion about teaching and patient care. So in 2002, I resigned my tenure which meant that I actually had to resign from my job at Ohio State, and then was immediately re-hired as a “Professor – Clinical”, no tenure. And now, I have the best job in the medical center.

The whole idea of tenure was to protect university faculty from being fired because of their opinions and to give them the freedom to study the things that they were passionate about. But the unintended consequence of tenure is that in today’s academic medicine environment, the tenure process discriminates against those academic physicians whose passions are teaching and clinical care.

December 31, 2016

We do monthly audits of how compliant our hospital personnel are with hand hygiene. Last month, our hospital hit 97% and the month before, 98%.  The policy is that everyone (doctors, nurses, physical therapists, housekeeping, etc.) has to sanitize their hands when entering a patient room and again when exiting a patient room. No exceptions. Our audits are done by incognito auditors who walk around the hospital watching to see if anyone goes in or out of a room without sanitizing their hands.

In addition to our own internal compliance audits, the Ohio Hospital Association sends “secret shoppers”, who are nursing students, out to Ohio hospitals to do additional audits of hand hygiene compliance. This year, hospitals in Ohio are at 84% compliance which doesn’t sound all that great until you compare it to the national average of 68%.

Until about 15 years ago, hand hygiene meant using soap and water. This was a problem for people like me – in a 19-bed ICU, I would wash my hands more than 100 times a day. Consequently, especially in the winter, my hands were constantly chapped, cracked, and bleeding. Not only was this a deterrent to regular hand washing, but it was disturbing to patients to be examined by a physician with crusty, bleeding hands. Now, we use alcohol hand sanitizer that is mounted on the wall outside every patient room and this is far less damaging to the skin of the hands which helps promote compliance.

Hand washing in medicine seems like such a no-brainer. But it wasn’t always that way.

The history of hand washing dates to 1847 in Austria. At that time, Louis Pasteur was still working on his thesis in chemistry and had not yet discovered bacteria. There was a Hungarian physician named Ignaz Philipp Semmelweis who was working in the maternity Department of the Vienna Lying-in Hospital. Semmelweis observed that the number of cases of peripartum fever and the mortality rate was higher in one hospital ward than another. When he looked closer, he determined that the key difference was that the ward with the high death rate was staffed by medical students whereas the ward with the lower death rate was staffed by midwife students. It turned out that the medical students were coming directly from lessons in the autopsy room to the delivery room, whereas the midwife students did not attend autopsy lessons. This same year, his close friend, Jakob Kolletschka died after being accidentally poked by a medical student’s scapal while performing an autopsy. Kolletschka’s autopsy showed the same findings as the woman who were dying of post-partum fever in the maternity ward.

Semmelweis then found that the number of cases of fever could be reduced if medical students washed their hands before contact with pregnant women. He proposed some type of “cadaveric material” brought from the autopsy room caused the fevers and deaths. When he lectured about his discovery, he met with considerable hostility by his peers, so much so that he was ostracized by the Viennese medical community and his ability to practice obstetrics was severely restricted. He spent the next 14 years developing his theory about hand washing and ultimately wrote a book in 1861. Unfortunately, his book received very poor reviews by a medical community that was strongly opposed to his theory and he suffered a nervous breakdown resulting in him being committed to an insane asylum where he soon died after being beaten by attendants.

We’ve really come a long way and now no one is going to commit you to an insane asylum for washing your hands before taking care of patients. But the story of Dr. Semmelweis does illustrate just how hard it can be to change practitioners beliefs about measures to improve quality of care.

Deniers exist in every corner of medicine and science. In 1492, people were convinced that Christopher Columbus was going to sail off the end of the world, because, of course, the world was flat and only an imbecile would thing that it was round. In the 16th century, Copernicus’s theory of heliocentrism of the universe was derided as “absurd” and the Pope banned publication of his books. In the 17th century, when Galileo championed heliocentrism, he was placed on house arrest. In 1925, substitute teacher John Scopes made the mistake of teaching human evolution in a public school and he was famously found guilty and fined. In my own lifetime, in the town of Lancaster,  just south of Columbus, all of the children get cavities; that is because the town’s leaders were convinced that fluoridation of the water did not protect against dental caries and moreover, it would cause cancer – so 1969, they banned fluoridation of city water; in 2004, they voted to continue the ban.

In my first month of medical school, a professor told me that 50% of everything I was about to learn was false. In hindsight, most of what I learned still holds true (the aortic valve still has 3 leaflets and there are still 5 toes on people’s feet) but there was a lot of dogma of 1980 that turned out to be totally wrong: to prevent SIDS, babies should sleep on their stomach; beta blockers are contraindicated after a myocardial infarction; amyl nitrate causes AIDS, etc.

We now look back on the hand-washing deniers of 1847, who emphatically stated that Semmelweis’s recommendations were ludicrous, as being ignorant deniers of what seems to us to be the obvious. But it does make me wonder, how many of the things that I currently think are ludicrous will in the future turn out to be correct after all? When you are a human, you have to work hard to keep from being a denier, it seems to be in our nature.

December 27, 2016

I got on the Social Security Administration’s Life Expectancy Calculator and found out that I’m probably going to live until 83.1 years. That means that October 2041 is going to be a bad month for me. Two weeks ago, the Center for Disease Control reported that for the first time since 1993, the U.S. life expectancy decreased by 0.1 years to 78.8 years.

Since the report came out, there has been a lot of speculation about the causes: increased opioid abuse-related deaths, the effect of obesity, etc. But if you look at the data, the death rate is up for heart disease, respiratory disease, accidents, stroke, Alzheimer’s disease, diabetes, kidney disease, and suicide.

Americans already live shorter lives than inhabitants of other economically developed countries. The OECD (Organisation for Economic Cooperation and Development) reports on the life expectancy in 43 countries – the U.S. ranks 26th, just above Chile, the Czech Republic, and Turkey. But will the reduction in American life expectancy save Medicare?

This year, the Medicare Board of Trustees determined that the Medicare Hospital Insurance Trust Fund was going to run out of money in 2028 and after that time, federal Medicare tax revenues will only be able to cover 87% of Medicare costs. The reason is that there is a bolus of baby boomers retiring and going on Medicare, plus people were living longer (at least up until this year).

One of the problems is that when Medicare was created in 1965, it set the retirement age that Americans become eligible for Medicare as 65 years old. At that time, the life expectancy from birth was 66.8 years for men and 73.7 years for women. Now, men live 9.5 years longer and women live 7.5 years longer. But the Medicare eligibility age has not changed and has remained 65. If you just take those people who actually make it to age 65, then in 1965, the average American would live 14.8 years on Medicare and now they live 19.4 years on Medicare. That is an increase of 4.6 years since the inception of Medicare, a 31% increase in the demands on Medicare.

So to make Medicare hold out, there are only a few options:

1. Increase the Medicare tax
2. Increase the Medicare eligibility age
3. Reduce Medicare benefits
4. Reduce Medicare costs
5. Reduce the life expectancy

If this year’s reduction in American life expectancy continues as a trend in the future, then it would take 46 years to reduce life expectancy back to 1965 levels and Medicare will run out of money in 12 years. So living shorter lives probably isn’t going to work.

We could reduce Medicare benefits and require seniors to pay more out of pocket for their health care but given the increasingly large voting block of people over 65, I doubt that any congressman supporting this measure will stay in congress very long.

Reducing Medicare costs by reducing health care costs sounds great in theory but given our lack of success in the past 30 years, I don’t think we can count on costs coming down in the near future.

So, that pretty much leaves increasing the Medicare eligibility age or increasing the Medicare payroll tax (currently at 2.9% of wages).

My preference would be to tie the Medicare eligibility age to the U.S. life expectancy so that the projected average number of years an American would have Medicare coverage would be something around 18 years. With current life expectancy, that would mean increasing the Medicare eligibility age from 65 to about age 67. The bad news would be that you’ll have to retire 2 years later than your grandfather did but the good news is that you are going to live 4.6 years longer than he did. By increasing the eligibility age from 65 to 67, there will be two additional years that Americans pay Medicare payroll taxes and two fewer years that they are consuming the Medicare Trust Fund.

On the surface, this sounds like making Americans work more years. However, according to the U.S. Census, in 1965. about 50% of American adults completed high school; in 2015, 88% of adults completed high school. In 1965, about 10% of American adults completed college; in 2015, 34% of adults completed college. Therefore, Americans are completing their education and entering the workforce at an older age than they did in 1965 so by extending the Medicare eligibility age by 2 years to age 67, we wouldn’t be asking the average American to work more years than their grandparents did, we’d really be asking them to work the same number of years as their grandparents did.

So, the bottom line is that Americans don’t live as long as residents of other countries and we’re not living as long as we used to. However, our declining life expectancy alone will not save Medicare. We’ll have to take other measures.

December 24, 2016

On Monday, I got a text message from our hospital’s Chief of General Surgery at 6:40 AM that the operating rooms were in excess of 100° F. When the air temperature in the OR is too high, it is not only uncomfortable for the surgeons and OR staff who are all wearing surgical gowns, it is unsafe for the patients because of the risk of infection. When temperatures are too high, microorganisms grow. When the humidity is too high, condensation can develop on the ceilings and equipment resulting in non-sterile indoor “rain” on patients or instruments. If either the temperature or the humidity is too high, then the surgeons start sweating which is not only a distraction but no one wants drops of sweat falling into a patient’s open incision. Too cold is also bad, hypothermic patients are more likely to get wound infections. Because both too hot and too cold is dangerous, the CDC adopts the American Institute of Architects parameters for operating room ventilation:

Temperature: 68-73° F

Humidity: 30-60%

Air changes: 15 total air changes per hour and minimum 3 air changes of outdoor air per hour

Keeping a relatively narrow temperature and humidity range turns out to be more difficult than it might seem because of the relationship between temperature and humidity. For example, if a room is 68° F with 60% relative humidity (within parameter range) and you drop the temperature to 64° F, the relative humidity will rise to 68% (out of parameter range).

Operating rooms have visual alerts in a central location when the OR air temperature or humidity is out of the parameter range but these alerts are on monitors and if no one happens to be looking at the monitors, then the alerts go unnoticed.

When a hospital goes through a JCAHO (Joint Commission) site survey, the surveyors will make a bee-line for refrigerators and freezers to be sure that there are temperature logs being kept and alarms when there is a loss of power or refrigeration. However, no one ever thinks to have logs or alarms for the air temperature in an operating room.

So, on Monday morning, we moved as many procedures from the overheated primary OR area to an unaffected secondary OR area. However, when temperatures get to 110° F, many disposable supplies can be damaged and have to be thrown out and sterilized instrument sets need to be re-processed. Therefore, a number of surgeries had to be canceled at the last minute. Fortunately, although there was inconvenience, no patients were placed in jeopardy.

The best way to avoid excessive heat in the OR is to have multiple, redundant alerts. So, make sure that you have both audible alerts as well as visual alerts on the temperature monitors.  Also, arrange that the alerts trigger auto-pages to hospital administrative staff when OR temperature or humidity parameters are out of range.

I must have missed the class on HVAC systems in medical school.

December 21, 2016

Every day, I get an email with all of the statistics from the previous day’s emergency department activity. The one statistic that can drive me crazy is the emergency department diversion hours. These occur when the ER goes on “divert” status which means that emergency squads are told to bypass our emergency department and take patients to some other hospital’s emergency department. We never close the emergency department and patients can still walk-in to the ER normally.

There are several reasons that the ER can go on divert:

1. The ER itself is overwhelmed (for example, multiple critically ill patients arrive at the same time)
2. We don’t have any empty beds on the nursing units to admit patients to from the ER
3. We don’t have any ICU beds to admit patients to from the ER
4. We don’t have enough inpatient nurses to take care of more admissions

Diversion is bad news for several reasons. First, and most importantly, it means that our hospital does not have the resources to care for the patients in our community at that particular time. A patient who lives 5 blocks away should not have to be taken to another hospital 15 miles away where their family and friends cannot easily visit. Second, it disrupts continuity of care. Patients who always get their care in one hospital and whose physicians practice at that hospital are best served by being taken care of by the doctors who know them the best. Third, it is bad business. Hospital admissions are the fuel that keeps the hospital running and patients arriving by squad are far more likely to be admitted to the hospital than those who walk in through the front door who are more likely to be treated and released.

Last year, our ER diversion hours reached record highs. Rather than being a rarity as it had been for more than a decade, it was becoming a regular occurrence, at least once a week. Our initial solution was to open up 4 new ER beds and 5 new inpatient beds to avoid the “no room at the inn” phenomenon. That helped but didn’t solve the entire problem entirely. So next, we asked the 5 whys.

The 5 whys was a concept developed by the founder of the Toyota Corporation, Sakichi Toyoda. His idea was that if you identify a problem, then you keep asking why it occurred through 5 layers of inquiry in order to get to the root of the problem and solve it. So, for example, you identify a problem that your medical students are passing out when holding retractors during pancreatic surgeries.

1. Why are the medical students passing out? Because they are hypoglycemic.
2. Why are they hypoglycemic? Because pancreas surgeries go on for 5 hours and the medical students haven’t had anything to eat.
3. Why don’t they get something to eat before the start of surgeries? Because they are pre-rounding on their patients until 8:00 AM and all of the donuts in the physician lounge are gone by 7:00 AM.
4. Why are all of the donuts gone by 7:00 AM? Because the donut company only brings 3 boxes of donuts even though the administrator in charge of donuts always orders 8 boxes of donuts.
5. Why do they only bring 3 boxes rather than 8 boxes of donuts? Because the donut administrator always fills the donut order out in blue ink and faxes the order to the donut company and since the blue ink doesn’t fax well, the “8’s” look like “3’s”.

So, what is the solution to the syncopal medical students? Buy the donut administrator a pen with black ink.

We applied this principle to our emergency squad diversion problem. First, we looked at the what days of the week we were going on divert and found that over the course of a year, diversion hours peaked on Wednesdays, pretty regularly and pretty dramatically on Wednesdays. In contrast, diversion was very rare on Fridays, Saturdays, or Sundays. Next, we looked at when our emergency department admissions peaked and it was on Mondays, again, pretty regularly and dramatically peaked on Mondays. Next we looked at when our elective surgery admissions peaked and it was on Tuesdays, very consistently on Tuesdays.

So the solution wasn’t to bring in extra ER physicians on Wednesdays or open additional inpatient beds on Wednesdays. The solution was to move one of our busiest orthopedic surgeons from operating on Tuesdays to operating on Thursdays. What had been happening was that we would get a bolus of emergency department visits on Mondays followed by a bolus of joint replacement surgery admissions  on Tuesdays and then by Wednesdays, we’d be out of inpatient beds. By Fridays, the Monday and Tuesday admissions would be ready for discharge and then we’d have excess inpatient capacity through the weekend. By moving the orthopedic surgeon to Thursdays, we evened out the admissions over the course of the week and presto, the ER diversion hours plummeted.

The 5 whys can keep you from making stupid decisions. Getting back to our medical students who were passing out in the OR, if we had stopped with the first why, we may have banned medical students from holding retractors. If we had stopped with the second why, we may have told the surgeon that he needs to finish his pancreas surgeries in 4 hours. If we had stopped with the third why, we may have required the medical students to come in an hour earlier to do their rounding. If we had stopped with the fourth why, we may have fired the donut company. It was only after the fifth why that the solution of buying a 99¢ black ballpoint pen to fix the problem became apparent.

December 17, 2016

 

Last week, I attended a breakfast that our medical center put on for physicians ranking in the top 10% nationwide for patient satisfaction. The remarkable thing is that last year, no one invited me to breakfast. Not even close. In fact last year, my patient satisfaction scores were abysmal. Did I change my doctor-patient interactions? No… I’m 58 years old and I don’t change anything very easily. So what happened?

Outpatient satisfaction scores are derived from a series of questions on the CG-CAHPS survey (Clinician and Group – Consumer Assessment of Healthcare Providers and Systems). This is a questionnaire is a cousin of the HCAHPS questionnaire used for hospital satisfaction and it is based on a 1-10 rating scale; only 9’s and 10’s really count so in other words, you have to get an “A+” grade every time. One of the questions is: “In the last 12 months, when this provider ordered a blood test, x-ray, or other test for you, how often did someone from this provider’s office follow up to give you those results?” The questionnaire is sent to patients one week after they are seen in the office.

In our clinic site, we found that we were not always getting results to patients before they got their CG-CAHPS questionnaire. It is pretty easy when patients are computer-savey and sign up for the “MyChart” account on our electronic medical record, because with a mouse click, I can release blood test results to the patient’s account and they get an email telling them that there are test results available so they should log-in and check their MyChart account. There were three problems:

1. A lot of the blood tests that I order have to be sent out to reference labs and they can take 2-3 weeks to come back. These results aren’t available when the patients get their CG-CAHPS questionnaire in the mail 7 days after their office visit and so they haven’t been contacted by anyone in my office with lab results.
2. For some of my patients, our hospital is not in their insurance network so when I order labs, those tests have to be done at another hospital and it can often take many days for me to get results by mail. So, if I see a patient on December 1st and order labs, the patient gets their labs drawn at another hospital on December 5th, and then I get the results in the mail on December 9th, then no one from my office will have called the patient with results on December 7th, when the patient gets the CG-CAHPS survey in the mail because I don’t have the results yet.
3. Because of the nature of my practice, a lot of my patients are taking immunosuppressive medications that requires monitoring lab tests every 1 or 2 months. Because many of my patients are from out of town, they get their labs drawn at their local doctor’s office or lab and then the results are mailed to me for review. The results are then scanned into our electronic medical record system and my office staff call the patient to tell them that the labs are OK. Many of these patients are used to being able to see all of their test results on their MyChart account when those tests are done at our hospital’s lab. However, scanned PDF files (of outside hospital labs) are not visible on MyChart. These patients were frustrated because they expected that the labs drawn at their primarily care physician’s office, often in a different state than Ohio, would show up on their MyChart account just like those labs from our hospital.

So, what was the solution? Well, all we did was to add a phrase onto the patients printed after-visit-summary (AVS). The AVS is a printed document that we give the patients after their office visit that goes over their medications, future appointments, etc. We added to the AVS:

“If you had blood tests today, many of those blood tests can take up to 3 weeks to complete; our office will contact you when those results are available. If you have an OSU MyChart account, we will release results to your account within 24 of when we receive those results; if you do not have an OSU MyChart account, we will mail you the results and it may take several extra days for you to receive them by mail. If you have blood tests done at non-Ohio State laboratories, these results will not be available on your OSU MyChart account and the results of these tests may take an extra 1-2 weeks to get back, depending on the mail.”

With this simple change to the AVS, I went from having 91.4% of patients rate me with either a 9 or 10, to having 98.1% of patients rate me with either a 9 or a 10. Because there is a tremendous amount of grade inflation with the CG-CAHPS survey, the difference between a 91.4% and a 98.1% is the difference between significantly below average and being in the nationwide top 10th percentile.

The lesson is that patient satisfaction is all about expectations and if we set the expectations, in this case, of when lab tests become available, then we can impact patient satisfaction. My patients didn’t know that when they had an anti-strongyloides antibody, that it takes 3 weeks to get the results back. To the patient, the anti-strongyloides antibody wasn’t any different that a CBC (that results come back in a few hours).

Ultimately, however, medicine is a team effort and even though I’d like to think that my patient satisfaction is high because I’m a good doctor, the reality is that the physician’s patient satisfaction is a reflection of the entire team. So, if you as a physician want to have a high patient satisfaction score, get good nurses, friendly registration staff, responsive housekeeping staff, and plenty of convenient parking at your office. Because the doctor’s patient satisfaction scores really aren’t just about the doctor.

December 11, 2016

If you are addicted to the National Geographic Channel, like I am, then you’ve probably seen videos of Adelie penguins. The males build nests out of stones in frozen Antartica in order to attract female penguins. Instead of going out and collecting their own stones, some criminal male penguins will steal stones from one his neighbor’s nests when his neighbor is out stone-hunting. Hospitals do the same thing – except instead of stones, they steal surgeons.

Surgical admissions to the hospitals are more lucrative than medical admissions. Surgical admissions account for 29% of all hospital admissions but account for 48% of hospital costs. If you are paying out of pocket, the hospital expense of a heart valve surgery is about $117,000 and a hip replacement is $39,000. For most hospitals, surgeries are their lifeblood. And inpatient surgeries are far more valuable than outpatient surgeries. Consequently, hospitals are constantly on the prowl for surgeons, especially those surgeons who do big-ticket surgeries that bring patients into the hospital and who can do a large volume of surgeries with low complication rates.

There are two ways that you can get acquire a high-volume, low-complication surgeon. You can hire him or her straight out of residency and then develop him/her by careful mentoring. Or, you can recruit them from another hospital. Recruiting from an out-of-state hospital is usually seen as fair game. A hospital in Columbus, Ohio doesn’t really compete with a hospital in Tampa, Florida when it comes to doing hip replacement surgeries so leaving a hospital in Columbus for a hospital in Tampa is not seen as taking surgical market share to Tampa.

But recruiting a surgeon from one hospital to a different hospital in the same city is typically seen as playing dirty. First, that surgeon likely has a large referral base of primary care physicians and those physicians will continue to refer their patients to the surgeon regardless of which hospital he/she is operating at. Second, the first hospital has invested several years developing that surgeon to get him or her to a point of efficiency and notoriety.

A great surgeon wasn’t a great surgeon the day he/she finished residency. It takes time after training to become really great. In his book Outliers: The Story of Success, Malcolm Gladwell proposed that to be really great at something, you need to spend 10,000 hours in meaningful practice of it. For example, Bill Gates spent about 10,000 hours programming before he came up with the foundations of Microsoft’s operating system. The Beatles practiced and played concerts together in Germany for 10,000 hours between 1960-1964 before they made music history. A surgeon can’t get 10,000 hours of operating room time during a 5-7 year residency. Most of their operating time during training is spent as an assistant rather than being the primary surgeon and even so, they’d have to spend 40 hours a week operating for 5 years to get to 10,000 operating hours. So it takes some time after residency to make a good surgeon a great surgeon – I think it is typically about 7 years. Those 7 years are kind of like the time the Beatles spent in Germany before they became famous.

Not only does it take time for a surgeon to hit peak surgical skill, but it also takes time for that surgeon to cultivate a referral base and to become efficient. That part typically takes about 5 years. Therefore, the hospital has to subsidize the surgeon for about 5 years during the surgeon’s start-up period. So, a typical start up funding package from the hospital for a newly trained surgeon might be $250,000 for year 1, $150,000 for year 2, $125,000 for year 3, $100,000 for year 4, and $50,000 for year 5. That’s a total of $675,000 that the hospital invested in that surgeon to get them to a level of self-sustaining practice.

Now, if you are a competing hospital in the same city, you can either spend $675,000 cultivating your own surgeon right out of residency or you can spend $675,000 recruiting another hospital’s surgeon who is at the end of their 5-year start up. And if you really want to come out ahead financially, you can give that surgeon an extra $150,000 per year for 4 years (total $600,000) and save yourself $75,000 that you would have spent cultivating a newly trained surgeon.

When leaving Africa in 1943, General George S. Patton famously said “No dumb bastard ever won a war by going out and dying for his country. He won it by making some other dumb bastard die for his country.” Similarly, a hospital wins the surgery volume war not by paying to develop its own surgeons but by making some other hospital pay to develop the surgeon… and then stealing them.

Not all types of surgeons are equal in this regard. For example, a surgeon who is really good at something unique and cutting edge that brings in lots of new lucrative elective surgeries to the hospital, like robotic prostatectomy, makes for great stealing. On the other hand, a general surgeon in a city with 50 general surgeons may not be worth spending as much to steal.

Additionally, optimal efficiency is not just a function of the surgeon but it is the entire operating room team, including the physician assistant, nurses, and operating room technician. It is much harder to steal an entire team from a hospital so there is inevitably some lost efficiency from a newly stolen surgeon.

Hospitals create barriers to other hospitals absconding with their surgeons by implementing “non-compete” clauses in the surgeon’s contract. A typical non-compete clause will say that the surgeon cannot work at a hospital within 10 miles for a year after resigning. There are ways around the non-compete clauses, however. They can be contested in court and the surgeon may or may not win. Or the hospital stealing the surgeon can locate the surgeon in a branch hospital or surgical center just outside of the non-compete radius. This happened to us a couple of years ago when 2 plastic surgeons a few years out of residency were recruited by a competing hospital system in Columbus that then located them at one of their branch hospitals that is 10.5 miles away from the OSU Medical Center, a half mile beyond the non-compete radius.

So in deciding whether to grow your own surgeon or steal someone else’s, it all comes down to financial strategy. Either approach can be cost effective and it is ultimately finances and not morality that guides behavior.

December 6, 2016

Academic medical centers’ reputations are rarely built on the quality of clinical care or the quality of education. Reputations are built on the volume of research grants and publications. The academic medical center becomes famous by doing research about clinical care and publishing about education. Similarly, to be promoted as a faculty member at most colleges of medicine in the U.S., it is not enough to be a great clinician or great teacher, you have to do research and publish about medicine and teaching. In theory, devoting a lot of time to research and publication about clinical care and education will also make the institution a better place to provide clinical care and medical education. But in reality, the best researchers and journal article writers are not necessarily the best clinicians or teachers.

To be successful obtaining and implementing research grants, physicians have to have “protected time”. This is time that they are not assigned clinical duties and can devote to scientific investigation and writing in order to be competitive for research grants. The most prestigious grants for physicians are those from the National Institutes of Health and these grants provide money to conduct research projects and also provide money to pay for the physician’s “protected time”.

But we have a problem in American research. Grants from the National Institutes of Health don’t really cover the physician’s protected time. It all comes down to something called the NIH salary cap. This is the maximum salary that can be paid from an NIH grant. Currently, the salary cap is $185,100. To any normal human being, this seems like a lot of money, a whole lot of money. The problem is, that physicians doing clinical practice usually make more than this. In fact, according to the MGMA salary survey, the average salary for most specialties is higher than $185,100. This means that to be a researcher, you either have to accept a lower salary than a clinician in the same specialty or someone else needs to subsidize your salary.

Lets take an example of a group of physicians who have 50% protected time, meaning that they see patients half of the work week and do research funded by the NIH for the other half of the work week. In the table below, the salary is taken from the MGMA survey. The the cost of 50% protected time is listed as 50% salary. The NIH salary cap is for a 100% full-time researcher is $185,100, so half of that (to cover the 50% protected time) is listed as 50% NIH cap. For most specialties, the NIH salary cap will not fully cover the salary that the physician would receive if her or she was a full-time clinician; this difference is listed in the last column.

From this analysis, you can see that a hospital can afford to have 4 specialties do research without having to subsidize them: infectious disease, general internal medicine, nephrology, and general pediatrics. For any other specialty, the hospital has to come up with additional funds to make up the difference between the NIH salary cap and what that physician could make doing pure clinical practice. Neurosurgeons are the most financially challenging since they have the highest salaries: you can fund 19 endocrinologists to do research for the price of funding one neurosurgeon.

In reality, most researchers accept a lower income than full-time clinicians. Researchers don’t have to round on weekends, don’t get called in at night for emergencies, and don’t have malpractice suits filed against them. But there are limits and even the most scientifically curious physicians will find the allure of an extra $50,000 or $100,000 too much to keep them in research.

As a consequence of this, an academic medical center that wants to get the greatest return on research investment will seek a lot of researchers from endocrinology, physical medicine, infectious disease, and nephrology. Researchers who are neurosurgeons, orthopedic surgeons, and cardiologists are too expensive to have more than a small number of researchers.

One of my colleagues who is a cardiologist on his division’s finance committee once told me that that the worst news he can get is a mass congratulatory email from the division director telling all of the cardiologists that one of their peers just got an NIH grant. The unwritten implication of that grant was that the rest of the cardiologists were going to have to pony up to help subsidize the portion of the grant awardee’s salary not covered by the NIH salary cap. Now days, the clinical physicians usually can’t afford to pay this difference because it means that they have to take a pay cut in order to support their research colleagues. Therefore it comes down to the hospital to provide the salary difference subsidy.

So as a hospital medical director, how should we view this? We only have a limited amount of money to invest in researchers so we have to be prudent in how we spend it and who we spend it on. It is like investing. For high salary specialties, the hospital can only afford a small number of researchers and they have to have a high probability of research success – think of this as buying 1 expensive stock share in Apple. For lower salary specialities, the hospital can afford a larger number of researchers and can afford to take a chance on researchers with a less certain probability of research success – think of this as buying 1 inexpensive stock share in each of 10 start-up companies.

The holy grail of research funding is the endowed chair where the academic medical center can use money from donors to off-set the NIH salary cap difference. This is pretty easy at a well-endowed college of medicine like, for example, Harvard. But it is not so practical at a state-supported college of medicine (like Ohio State) with relatively meager endowment funds. For institutions with less endowments, you have to decide what the right ratio of clinicians:researchers is. That ratio will vary depending on the specialty and the percent protected (research) time that the researchers have. The goal is to have the right balance so that you have enough research to make the institution famous but not so much research that institution goes into debt.

December 3, 2016