Stan's Story Redux

“You’ve already heard most of this story, Jaded Julie, but not the ending. In January of 2007 I visited Stan (not his real name), a very close friend from my college days. When Mrs. Curmudgeon and I entered their house, Stan recognized me and said, ‘hello,’ but I couldn’t understand much else that he said.”

“I remember our posting the original Stan’s Story on October 30, 2008. I guess more has happened in Stan’s life since then. In any case, because of its lessons on patient safety, the story merits retelling. Please repeat the original Stan’s Story and bring us up to date on what occurred after it was posted.”

“Shortly after his retirement, Stan, who lived very far away from here, suffered a stroke. While he was recovering in the hospital, he sustained a tragic fall that injured his brain much more than the stroke had. After the fall, Stan, always a gentle giant, could not speak a coherent sentence. Although he was cared for by his devoted wife, this was not the way Stan planned to spend his ‘golden years.’

Here are some of the details as provided by Stan’s wife: Stan experienced a severe stroke early one evening a few years ago, and his wife rushed him to the hospital a few minutes away. She anticipated that Stan would be treated with thrombolytics within the ‘golden three hours.’ (However, I never did learn whether the stroke was ischemic or hemorrhagic.) Stan was first seen by a physician in the ED two hours after they had arrived; he apparently did nothing. At 2:00 a.m., a cardiologist appeared, and he pronounced that it was ‘too late’ for treatment with t-PA (or whatever). So Stan was admitted to the ICU.

While in the ICU, Stan fell and crushed the bones around one of his eyes. The eyeball was out of the socket, and 15 stitches were required to close the cut. After performing the necessary repairs, the physician checked the sight in Stan’s eye by holding up three fingers and asking Stan to count them. At that point, Stan was in no condition to count anything.

When Stan’s wife left the hospital the night of his fall, the rails of the bed were up and an alarm was in place. Stan’s condition would have prevented his lowering the rail by himself, and the alarm should have alerted the nurse had he done so. Yet the nurse in the ICU said that the rail was down when Stan fell (of course it was, but who lowered it?). Stan was her only patient. And so the risk management and legal issues began. Ultimately, Stan and his wife had to accept what they considered a very inadequate settlement from the hospital.

The final outcome as of January 2007 was as I described at the beginning of our conversation. Stan’s wife became his constant caregiver. Stan recognized me but not the names or anything about many of our close college friends. He could say ‘hello’ and ‘good-by,’ but his long sentences were quite incomprehensible. We planned to see Stan and his wife whenever we visited the far-away city where they lived, but reminiscing about our college days would have been pretty difficult.”

“Curmudge, that is so sad. And it appears to have been preventable. So what occurred in Stan’s life between your last visit and now?”

“It was not good. Stan experienced a botched removal of a kidney stone that resulted in a nosocomial infection that kept him hospitalized for a month. Then on December 18, 2008 Stan died of an apparent heart attack.”

“The latter years of Stan’s life appear to have been a tragedy of errors. I guess that explains why you became a patient safety zealot.”

“Julie, everyone should be a patient safety zealot, but it’s inevitable when tragedy strikes close to home.”

Affinity’s Kaizen Curmudgeon

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.    

Fifty More Curmudgeons

“Golly, Curmudge! Isn’t one Curmudgeon enough?”

“I hope there’s only one Kaizen Curmudgeon, because that’s my nom de plume. The world may be filled with curmudgeons (lower case ‘c’) or nasty old men. But, Jaded Julie, what I was referring to were the fifty more Kaizen Curmudgeon postings since October 29, 2009, when we celebrated the first hundred.”

“So we’ve had 150 postings on 150 ideas of things to write about. It’s too bad that most of the ideas weren’t very good.”

“Many thanks for your vote of confidence, Julie. Please remember that you were co-author. So what can we do for our readers to celebrate this sort-of anniversary?”

“It’s really hard to find a specific posting unless you know when it was posted. So why don’t we add to this note the Table of Contents for our most recent 50 postings? Then the reader can scan down the list, find a title of interest, and then click on its Date Posted to be linked to the posting.”

“Setting up all those links will be a lot of work, Julie. I trust that you will do that for me.”

“Of course, Curmudge. (I’d do most anything for the old codger.)”

Kaizen Curmudgeon Blog Title--Date Posted

101 Curmudgeons--10/29/09
Change Your Primary Care Mindset—the Physician 2--11/05/09
Change Your Primary Care Mindset—the Rest of the Team--11/12/09
The Medical Home Team Comes Together--11/19/09
It Takes More Than a Team--12/04/09
“I’m from Corporate, and I’m here to help you.”--12/10/09
Holiday Greetings from Curmudge and Jaded Julie--12/17/09
Volunteering: the Seniors’ Raison D’être--1/07/10
Curmudgeon’s Wastebasket--1/13/10
Father Clark’s Sequence--1/22/10
“Welcome to my (our) world.”--1/28/10
The First Step in New Health Care Construction: the Voice of the Patient--2/04/10
From Customer Ideas to Project Choices--2/11/10
Heart, Lung & Vascular Center: From Current State to Future State--2/18/10
Lean Lessons from Long Ago--2/25/10
Packrattery, Chaos and their Countermeasure, 5S--3/04/10
Kanban--3/11/10
What do you say after, “Lean is based on the Toyota Production System”?--3/18/10
A Culture of Elegance--3/25/10
Mistakes--4/01/10
Mistakes 2--4/08/10
Operas and Hospitals--4/15/10
Assisting Clinical Excellence (ACE) Awards--4/22/10
Hey patients, checklists are okay.--4/29/10
The Sensei is Concerned--5/06/10
Twice Blessed--5/13/10
Teamwork—It’s the People--5/20/10
Happy Third Birthday--5/28/10
The Guys in the Yellow Shirts--6/10/10
Judgment--6/18/10
AIDET Redux--7/01/10
Docs on a Treadmill--7/15/10
Mistakes 3--7/22/10
Amazing Devices--8/05/10
Amazing Devices 2--8/12/10
The World Health Congress--8/19/10
Medical Home Workflows--8/26/10
Amazing Devices 3--9/02/10
Amazing Devices 4--9/09/10
Evidence-Based Medicine—The Patient’s Perspective--9/23/10
Evidence-Based Medicine—The Patient’s Perspective 2--9/30/10
Evidence-Based Medicine—The Patient’s Perspective 3--10/14/10
Evidence-Based Medicine—The Patient’s Perspective 4--10/14/10
Evidence-Based Medicine—The Patient’s Perspective 5--10/21/10
The Robot--11/03/10
Superbugs--11/04/10
The Old Scout’s Funeral--11/18/10
The Evolution of Lean Education at Affinity--11/26/10
Why Lean?--12/02/10
The Evolution of Lean Education at Affinity 2--12/09/10

Affinity’s Kaizen Curmudgeon

Holiday Greetings from Curmudge and Jaded Julie

“Get with it, Curmudge. The holiday season is upon us.”

“I know, I know, Jaded Julie. It’s a joyous time for most folks, but for blog writers, it’s a real challenge to say something new and profound every year. Over the past three years we’ve written about political correctness, family gatherings, and macro and micro happiness and unhappiness.”

“How about something about Lean? It’s hard to relate Lean to the holidays, but you should be safe from criticism.”

“I’ve got it, Julie. W. Edwards Deming’s Eighth Point, ‘Drive out fear.’ I could preach a sermon on that, and I’m the world’s least likely person to be a member of the clergy.”

“Go to it, Curmudge. I’ll be right here wave’n my arms and shout’n ‘Amen’ or ‘Hallelujah’ periodically (oops, that’s not politically correct).”

“To begin with, the intensity of fear is a continuum. In addition, fear can be only an occasional raising of the hairs on the back of your neck to a continuous gnawing in one’s innards.”

“I believe the fear that Dr. Deming had in mind was a low-level, obsessive feeling of insecurity within an organization. But I don’t see what that has to do with holidays. Perhaps if you provided some more examples…”

“A very low-intensity fear might be a teenager concerned about acceptance by her peers. At the highest end of the scale would be a soldier on a mission in Afghanistan fearful that his next step will be on an IED that could blow him to bits. Also at the high end would be an Afghan woman’s continuous fear that she could be beaten or her nose cut off by her husband (see page 39 in the December 2010 National Geographic). Here is an example that is downscale a bit: A senior citizen concerned that her next illness will be ‘the big one’ that will be debilitating or terminal.”

“I think I have the picture, Curmudge, and it’s not a pretty one. How can these people drive out their fear, and what does it have to do with the holidays?”

“In some cases the fear will be permanent, like the Afghan woman’s having to live with her fear, mutilation, and humiliation. However, she might be able to hold out some hope for her daughter. The soldier’s fears will be temporarily allayed when he is back at the forward operating base (if it is not mortared) eating a big holiday meal in the mess tent or opening a package from home. The senior citizen’s worries about her health will be momentarily forgotten with the first hug from her grandchild. And the teenage girl’s concerns about her social life will be swept away by an invitation to a holiday party.”

“I’ve got it, Curmudge. Holidays are for driving out our fears. Occasionally the respite is permanent, most often it is temporary, and sometimes it is just not in the cards. But with the help of our friends and families during the holiday season, we’ll give it our best shot.”

“Merry Christmas, Jaded Julie.”

“Happy Holidays, Curmudge.”

Affinity’s Kaizen Curmudgeon

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.   

The Evolution of Lean Education at Affinity 2

“Curmudge, you promised to start today’s discussion with one of your illogical-and-funky-but-true tales from long ago.”

“Albert Einstein would occasionally visit Professor Hubert Alyea’s lectures on physical chemistry at Princeton University. When the professor made a particularly important point in his lecture, he would look to the back of the room and see Einstein’s white head nodding in approval. Alyea’s tacit and illogical conclusion was that if Einstein understood, everyone in the class would understand.”

“I’ll admit that your story is nonsensical, but does it have a parallel in our teaching of Lean?”

“Sure, Jaded Julie. If you can design a course that is viewed as worthwhile by a physician, it will be worthwhile for everyone.”

“Well Curmudge, it took you a long time to point out that several physicians have attended our one-day Lean Overview class, and they haven’t gotten up and walked out. For docs to view something as valuable, it must help their patients, their practice, or their personal life. Lean should do all three. Our congrats to the course designers and presenters.”

“Julie, in my professorial days I taught for just 50 minutes several times per week. Standing before a class for almost eight hours would require exceptional concentration and physical stamina. Our Lean presenters have to make that sacrifice in order to cover the Lean essentials in a one-day time period acceptable to physicians and others who require a basic knowledge of Lean.”

“From my experience I know that nurses follow the physicians’ lead. That’s why physicians—especially those in a position to influence others—must learn the Lean basics. One cannot do anything of real significance in a hospital or clinic without the understanding and support of the physicians. So Curmudge, just what is in this one-day blockbuster Lean Overview course?”

“Everything…sort of. The principles and most of the tools of Lean; they are familiar to most of us and don’t need to be recited here. However, it’s important to note that it would be futile to attempt to cover every detail of Lean manufacturing discussed in The Toyota Way and The Toyota Way Fieldbook.”

“I agree. It would be sort of like insisting that one study the Bible in the original Hebrew and Greek.”

“In addition to the Lean manufacturing classics, there are several books available now that are devoted exclusively to Lean in health care. These would be efficient resources for the course presenter and appropriate for the students’ further reading.”

“Okay, Curmudge, some examples please.”

“One might use Graban’s Lean Hospitals as a how-to-do-it fieldbook. For case studies on ‘how we did it,’ read Grunden’s The Pittsburgh Way, Toussaint’s On the Mend, and Kenney’s Transforming Health Care (about Virginia Mason Medical Center—just published). Of course, one could remain a strict purest and stick to the classics on manufacturing, but that’s a route I haven’t followed. When I was a student I might have used ‘Cliff’s Notes,’ but they hadn’t been invented yet.”

“Thanks for being a paragon of virtue, Old Guy. So in addition to appropriate resources, are there other features of the Lean Overview course that are worthy of mention?”

“The handout booklet of PowerPoints has space beside each slide for the student to take notes. When the presenter makes a point that’s not on the slide, the student should feel compelled to write it down. That keeps the brain engaged in moving one’s fingers and hopefully paying attention in class. Another valuable feature of the course is the showing of the video, Hospitals Healing Themselves. That should convince the students that Lean in health care is for real. And finally, the students put to use what they have learned in a simulated process that they perform, study, and improve. Recall the quotation from Benjamin Franklin, ‘Tell me and I forget. Teach me and I remember. Involve me and I learn.’”

“If you haven’t already forgotten them, do you have any final thoughts?”

“Lean education at Affinity is a good example of kaizen—continuous improvement. The courses are continuously being revised and improved. Stay tuned for updates.”

Affinity’s Kaizen Curmudgeon

Why Lean?

“Hey Curmudge, last week we had the cart before the horse. We talked about Lean training before we explained why it is Lean, and not something else, that we are teaching.”

“Good catch, Julie. We older folks who wish we could live life backward sometimes get things out of order. Let’s go back one step and explain why we are doing what we are doing.”

“I understand that you have some stories from long ago—back when you were middle-aged—that illustrate the need for more efficient processes in health care.”

“There was a story about Pope John XXIII. In an audience with the Pope, a visitor asked the Holy Father, ‘How many people work in the Vatican?’ He answered, ‘Oh, about half of them.’ When I was living in the Northwest, I went to the local hospital for some outpatient testing. There were employees all over the place standing around and chatting. I thought, ‘This must be the Vatican. Which way to the Sistine Chapel?’”

“You concluded that health care back then was not very efficient and needed help?”

“That’s it, Julie. Fast forward to six years ago. My last paying job had ended, and like the city’s other derelicts I spent a lot of time in the public library. I found books on Six Sigma, Gemba Kaizen, Total Improvement Management, and other systems for process improvement. In my last employment I had worked with ISO 9001 and had learned about the Baldrige Award. All of the programs had some common elements, but ISO and Baldrige were very heavy on documentation. Six Sigma was felt to require a lot of training before any payoffs could be achieved.”

“So Curmudge, of the documents you could find, you favored Gemba Kaizen.”

“Right. Kaizen was used not only at Toyota but throughout Japan’s manufacturing sector. It might have been properly called, ‘The Japanese Production System.’ The focus of Kaizen was process-oriented management, as contrasted against results-oriented management used in the West. As Masaaki Imai (1) stated, ‘Many Japanese management practices (Kaizen) succeed because they are good management practices.’”

“Then, somewhat later, you learned about Lean.”

“It appears that Kaizen came to the U.S. and for most users acquired a new name, Lean manufacturing. An English word (Lean) that is often misinterpreted is better than a phrase in Japanese (Gemba Kaizen) that happens to be trademarked. It is also more palatable to Americans to speak of the Toyota Production System than the Japanese Production System. The two systems are essentially identical—same tools and same management principles.”

“Okay Curmudge, back to my original question. Why are we adopting Lean as our culture at Affinity?”

“What really matters is what one does and not what name one gives to the program. (Whenever I write that I am reminded of the line in ‘My Fair Lady’ that says the exact opposite, ‘The French don’t care what they do, really, as long as they pronounce it correctly.’) We could just as easily call Lean the ‘Affinity Performance Excellence System.’ One reason for keeping the term, Lean, is that it identifies, in general, what we are doing to all who are also striving for performance excellence.”

“So much for terminology. What I am really asking is why Lean—irrespective of its name—was selected by Affinity management to be the cultural target for Affinity Health System?”

“Our top management appreciated the value of continuous improvement, a hallmark of Lean. Our immediate boss learned about Lean in his graduate studies. Lean has been used with success in many health care locations. And Lean’s successes at Affinity are validating their choice on a daily basis.”

“Curmudge, you once told me that culture is the summation of everyone’s perception of ‘the way we do things around here.’ And that’s why Lean education is essential for as many people as possible in the organization.”

“You’re exactly right, Jaded Julie. You must have been reading my mind. I’ve always wondered how you do that.”

Affinity’s Kaizen Curmudgeon

(1) Imai, Masaaki. Kaizen (McGraw-Hill, 1986)

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.  

The Evolution of Lean Education at Affinity

“Most people speak of Lean training, Curmudge, but we have education in our title. Is there a real difference between the terms, or are you just being curmudgeonly in your old age?”

“Me? Curmudgeonly? I’ve read that education is for people and training is for dogs. We do have some poodles as hospital volunteers to cheer up our patients, but none has signed up for a Lean course.”

“So other than the hominid vs. canine situation, what are the differences between education and training?”

“In my opinion, Jaded Julie, education tries to answer the questions, who, what, where, and especially why, and training teaches us how. Although a dog sometimes cocks his head in presumed wonderment, I’ve never heard one ask ‘why?’ Lean learning contains both education and training. Education involves leaning the Lean culture and principles, and training teaches us how to apply the Lean tools.”

“Despite your semantic nit-picking, Curmudge, training is used more than education in health care; so let’s consider training to include ’why’ as well as ‘how.’ I trust your ossified brain can handle that.”

“No problem, so let’s get on with our topic. Attendees at the initial Lean instruction at Affinity, the Lean Health Care Tool Kit, came from two populations: (1) top management, directors, and some managers, and (2) Lean facilitators-in-training recently selected to staff the incipient Kaizen Promotion Office (KPO). Those in the management group had been told that Lean represented Affinity’s future, and they attended the initial training to prepare them for service in Affinity’s guiding coalition for change. Two weeks of comprehensive Lean training might have been excessive for this group, but it was essential that they receive training at the outset of Affinity’s Lean journey.”

“In contrast with the management folks, the first crop of Lean facilitators needed the comprehensive training to prepare them to spread Lean to the far corners of Affinity. They would require a command of Lean principles and culture, Lean tools and examples of their use, and—as you would say, Curmudge—the whole geschäft. Like you once advised, ‘they should always know more than they teach.’”

“This training ran for two weeks, contained a lot of PowerPoints, and had an open-book exam at the end of each topic. Presenters were from WCM (World Class Manufacturing) and were affiliated with the Milwaukee School of Engineering. Participants received several books (Liker, Dennis, Kotter, Rubrich & Watson) that are now considered Lean classics. Those two weeks were undoubtedly a busy period for course participants. For the KPO people, a one-week course on being a facilitator was presented later.”

“That sounds pretty intense, Curmudge, but the KPO staff taking the course knew that their future at Affinity depended on their ability to apply what they learned. Everyone appreciates that a mid-career course correction can’t be taken lightly. Learning is not very easy when one has to sit and watch PowerPoints fly by, but they did it.”

“For the record, Julie, the two-week course ran through 2007 and attracted 151 participants. For any adult learner, the gain from a course must be worth the time required. Two weeks is a pretty big time demand for busy people, so the KPO decided to shorten the course to one week for 2008. Participation by mid-level management is key to a Lean transformation, and the KPO felt that a one-week course would be attractive to managers and provide them with an adequate introduction to Lean.”

“How did the one-week course differ from the two-week course?”

“Topics were not covered as extensively, and there were no exams. The PowerPoints were from WCM, but the course presenters were from our Kaizen Promotion Office. The shorter duration of this course and the lack of out-of-class assignments made it easier for the middle-management participants to keep their fingers on the pulse of work in their regular jobs. In 2008 and 2009 the one-week course had 58 participants.”

“And then in 2010 the one-week course was subdivided into three one-day classes. These include one on Lean principles (Lean Overview), and two on tools (A3 Problem Solving and 5S and Kanban). I presume we’ll discuss the rationale behind these changes, Old Guy?”

“We will, but not today. It’s time for lunch followed by my afternoon nap.”

Affinity’s Kaizen Curmudgeon


Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link. 

The Old Scout's Funeral

“A few weeks ago I attended the funeral of a former assistant scoutmaster of the troop to which our sons belonged. It seemed as if about half of the attendees were either former scouts or parents of scouts.”

“I assume, Curmudge, that you were there to show your respect for the deceased.”

“If it were only respect for the deceased, Jaded Julie, we should have visited him while he was alive. It was more than that. I believe it was respect for what he stood for and for what Scouting—with the involvement of all of us—had done for our sons many years ago.”

“That sounds pretty important; and since we are talking about it here, it must have something to do with Lean.”

“Although Scouting and Lean occur at different points in a person’s life, i.e., they are not contemporaneous, they are quite complementary. Here are some Lean (and Scouting) examples: Respect for people (Do a good turn daily. Help other people at all times. A Scout is trustworthy.). Continuous improvement (advancement from Tenderfoot to Eagle Scout). Leadership (Patrol Leader, Senior Patrol Leader, and leading a team in the scout’s Eagle project).”

“Let’s talk about that ‘not contemporaneous’ thing, Curmudge. A lot of time can pass between Scouting in adolescence and when an adult assumes a leadership role in industry, the military, or a hospital. What keeps the lessons of Scouting from being lost in the interim?”

“They need to become hardwired, Julie. That comes from repetition, dedication, and advancement, and that’s why Eagle Scouts are valued in any organization. I know of a young man who enlisted in the Marines and because of his Eagle rank was promoted almost immediately.”

“Scouting sounds like a unique opportunity for boys, Curmudge, but these days being unique is not always considered a virtue.”

“The Venturing program of the Boy Scouts includes young women aged 13-21. Many cultural mores similar to those of Scouting are taught in other organizations ranging from Girl Scouts to kindergarten to Sunday school. Even in service clubs for adults, like Rotary International. It certainly appears, however, that Scouting is more fun. Here’s an interesting observation: ‘Scouting's genuinely egalitarian goals and instincts are more important now than they've ever been. It's one of the only things that kids do that's genuinely cooperative, not competitive.’ (1)”

“It would appear that former Scouts and members of many other groups will have a head start in learning Lean.”

“You’re right, Julie. They already have a humanizing background and should readily understand Lean principles and culture. Next they’ll need to hone their leadership skills and learn to use Lean tools and procedures. Ultimately, these people would be ‘early adopters’ and perhaps members of the organization’s guiding coalition. If you found these people in a Lean Overview class you were teaching, you’d feel glad all over.”

“I certaily would. But what if people had become corrupted by working in a command-and-control, dog-eat-dog environment?”

“They would need to start Lean training at square one. If they couldn’t adapt to a Lean culture, it might be better if they ‘got off the bus.’”

“Although over 30 years have passed, Curmudge, you seem to be as enthusiastic about Scouting as you are about Lean. What did you do in Scouting that was so great?”

“Camping with the troop in the north woods and running the Pestigo River rapids in open canoes. Developing the required coordination between father (paddling in the stern) and son (paddling in the bow) builds a bond that lasts a lifetime.”

Affinity’s Kaizen Curmudgeon

(1) Applebome, Peter (2003). Scout's Honor: A Father's Unlikely Foray Into the Woods. http://en.wikipedia.org/wiki/Boy_Scouts_of_America

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link. 

Superbugs

“Jaded Julie, a couple of weeks ago Mrs. Curmudgeon had some minor surgery, and I was really concerned.”

“Why should you be concerned, Curmudge? It was performed by an experienced surgeon, in a hospital that you respect, and the three little incisions were less than an inch long.”

“Perhaps I’m just an old worry-wart, but I was concerned that my wife might contract a nosocomial infection. I read a lot about infections a couple of years ago, and we talked about them on January 29 and February 5, 2009. It’s still a hot topic in the literature, and I read some newer stuff last month. When it comes to nosocomial infections, one may be either concerned or clueless; there’s no middle ground.”

“Despite your advanced age, Curmudge, you are rarely clueless. That makes me concerned as well. So what did you read that put the pepper in your Metamucil?”

“Dr. David Shlaes, MD, PhD has spent his career in the development of antibiotics, and he recently published a book, Antibiotics-the Perfect Storm. The book’s price as around $150, so I’ve had to be satisfied with reading his blog by the same name.”

“So what is the good doctor’s thesis, Curmudge? It must be mighty serious if he calls it a perfect storm.”

“Despite the appearance of new drug-resistant bacteria almost every day, the major pharmaceutical companies in the U.S. are abandoning the development of new antibiotics. If this continues, we’ll soon be as defenseless against these new ‘superbugs’ as we were against their predecessors 100 years ago.”

“I now appreciate your concern. But why are the drug companies getting away from antibiotics?”

“It’s a matter of economics, Julie. When a new drug is developed for a chronic illness, a patient might take it (buy it) for the rest of his life. Contrast that against a new antibiotic; the patient will take it for perhaps two weeks or until the infection is cured. With the latter scenario it’s very hard for the company to sell enough of the drug at a reasonable price to recoup its multi-million dollar development cost.”

“As I understand it, Curmudge, clinical trials are an essential and expensive part of new drug development. We talked about trials just a few weeks ago, on September 30. They are required to prove the drug’s safety and effectiveness.”

“The drug people call that efficacy, Julie. Recruiting participants for the traditional clinical trial of an antibiotic is especially difficult. People with a potentially deadly infection would be reluctant to join a trial in which they had only a 50% probability of receiving the medication. Those in the control group might die before the trial’s conclusion.”

“So what’s the answer? Or to use a term you brought from industry, what’s the path forward?”

“Approaches to this problem involve definitions of safety and efficacy, trial design, ethics, and controversy. Any one of these puts their discussion beyond the scope of this blog. I invite you to read Dr. Shlaes’ blog, or if your rich uncle just died, his book. If you need some grisly statistics to catalyze your concern, consider these from the Centers for Disease Control: ‘As many as 90,000 people die in the nation’s hospitals every year from bacterial infections. About 70,000 of these deaths are from drug-resistant bacteria—well above the 58,000 U.S. soldiers who died during the Vietnam War era.’”

“Okay, Curmudge, you’ve really got my attention.”

“Here’s another statistic that I’ve been thinking about in recent weeks: ‘Of all the complications that occur in the 30 days after surgery, such as infection and blood clots, almost half will surface after the patient leaves the hospital.’(1) That’s why I scrubbed my hands thoroughly before I changed the dressings on Mrs. Curmudgeon’s incisions.”

Affinity’s Kaizen Curmudgeon

(1) Landro, L. Patient, Heal Thyself. Wall Street Journal, October 26, 2010.

The Robot

“Wow, Jaded Julie! That da Vinci robot is the greatest thing to hit the OR since anesthesia.”

“No way, Curmudge, am I going to let a robot operate on me. It might run amok and start ripping out my innards.”

“This isn’t ‘Star Wars,’ Julie; this is the ultimate in modern surgery. The robot simply mimics the movements of the surgeon’s hands and fingers. In a demonstration, I sat at the console and remotely maneuvered pumpkin seeds around inside a jack-o-lantern. Except for the fact that I don’t know anything about anatomy, even I could be a surgeon.”

“I shudder at the thought. As I understand it, the robot is an enhancement to laparoscopic surgery, which I already considered a great innovation. However, I’ve been both amazed and somewhat apprehensive at major surgery performed through three little incisions.”

“Before we reassure and further astonish you, let’s set the stage. The patient has at least three small incisions, one for the camera and two for the robotic probes. The surgeon sits at the console, puts his hands on the controls, and views the inside of the patient (‘the field’) through a binocular scope. What the surgeon sees is also projected on a monitor above the patient so the nurse can follow the action and anticipate the surgeon’s need for different probes.”

“Hey, Curmudge, this is getting interesting. I can appreciate why you got a kick out of ‘operating’ on a pumpkin.”

“There are two features of the robotic probes that provide the da Vinci’s great advance over conventional laparoscopy. At the end of the probe is a ‘wrist’ that can rotate and allow the probe to reach areas that are inaccessible to a conventional probe. The other enhancement is the da Vinci’s ability to shrink the surgeon’s motions by a factor of 5, i.e., when the surgeon moves 1 cm, the probe moves 2 mm. This permits delicate work that would be impossible with a conventional laparoscopic probe or extremely difficult with gloved fingers in open surgery.”

“I’m sold, Curmudge. Buy me one for Christmas with your Social Security check, or more realistically, donate your check to the hospital foundation. But seriously, what kinds of operations can be performed with the robot?”

“Most things that are currently done with conventional laparoscopy: hysterectomies, radical prostatectomies, cholecystectomies, nephrectomies, and several others. I suspect that all of these can be done better and safer with the da Vinci robot. And following surgery, the patient has less pain and can go home sooner.”

“For a surgeon, training in any new technique has to be a serious undertaking. That is undoubtedly true with learning to use the robot.”

“Julie, I believe they start by observing, and then they practice on pigs. Initial surgery on human patients is closely observed by experienced surgeons. That’s facilitated by the monitor above the patient that we described earlier.”

“Considering your enthusiasm, Curmudge, I assume that you will volunteer for robotic surgery as soon as possible.”

“My last major surgery was 51 years ago, Julie. I’m quite willing to wait another 51 years for the next.”

Affinity’s Kaizen Curmudgeon

Evidence-Based Medicine--The Patient's Perspective 5

“As you forecast, Curmudge, another week has passed and I am very much affected by my affliction. I don’t understand it. My physician diagnosed my illness and prescribed what she felt was the best evidence-based treatment. Quite honestly, she gave it her best shot.”

“Jaded Julie, it appears to be time for a second opinion. Consider your situation: (1) Your disease is serious and even life-threatening. (2) Your treatment doesn’t seem to be working or leaves you feeling worse than your disease. (3) Your diagnosis was difficult, performed by just one person, or was somewhat uncertain. Any one of these would lead us to consider a second opinion.”

“But won’t my physician be offended when I propose getting a second opinion?”

“If her primary goal is your good health and if she recognizes that no one can know everything, she will support your decision. That’s why there are specialists, subspecialists, and world-renown academic medical centers. If you look hard enough, you have a good chance of finding someone who can make a conclusive diagnosis and has successfully treated people with your disease. As we discussed back on June 18, 2009, errors in diagnosis do occur. When your disease is life-threatening, you want it to be diagnosed and treated by those who know it best. Remember, it’s your life.”

“Okay, Curmudge, I’m convinced. So please step down from your soapbox and tell me how to proceed.”

“Recall, Julie, that the objective of this series of postings was to teach you how to become a more informed and effective member of your health care team. So if you feel the need for a second opinion, begin by discussing it with your physician. Ask for her thoughts and guidance. Ask, ‘If you were in my situation, where would you go and whom would you see?’ Her answer might be someone across the street or across the country. She (or someone in the office) will tell you how to make the appointment and get your records sent to the appropriate destination.”

“A few weeks ago you quoted Meg Gaines as saying that one should ‘become an active patient ready to make your own way through your disease.’ What do I do if I feel that my physician’s suggestion for a second opinion is a bit conservative and I want to arrange the second opinion on my own?”

“Don’t go away, Julie, it’s possible. Let’s assume that you want your case reviewed by the specialists in an academic medical center and are uncertain where to go. Here’s one approach: Start with the U.S. News Best Hospitals rankings. Then select the specialty that fits your problem (you might not know the exact diagnosis, but you certainly know whether it’s Gynecology or Ophthalmology). A list of the best hospitals, in order, for that specialty will appear. Then follow your mouse for more detailed information.”

“I’ve found one whose reputation appears to be world class in my specialty. What do I do next?”

“The hospital’s Web site should tell you how to proceed. Oh, and by the way, you should probably check with your health insurance to learn if your second opinion will be covered. At some point you will need to authorize your physician’s sending your medical records—including labs, radiology, and pathology—to the second-opinion hospital.”

“This sounds like a big undertaking, Curmudge, especially if the medical center is a thousand miles away.”

“Some hospitals will evaluate your case on the basis of your records alone without your going there personally. The Cleveland Clinic (MyConsult) and Johns Hopkins (Remote Second Opinions) do this. Most commonly, their reports go to your personal physician. Partners Online Specialty Consultants is a physician-to-physician online second-opinion service provided by physicians affiliated with Harvard Medical School. The appropriateness of these programs may depend on the nature of your illness.”

“You wrote on May 13, Curmudge, about how we in the Fox Valley are blessed with quality medical care. In addition, there are two academic medical centers within the state and the Mayo Clinic only two hundred miles away. No wonder so many people around here simply die of old age.”

Affinity’s Kaizen Curmudgeon

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link. 

Evidence-Based Medicine--The Patient's Perspective 4

“I’ve forgotten, Jaded Julie, where our story ended last week.”

“I’m not surprised, Curmudge. You tend to forget everything except when it’s time to take a nap. As a patient with a life-threatening disease, I had learned how to learn about my disease by studying review articles, journal articles, and clinical trial results. I had become the local expert on me. So what’s next?”

“In a discussion with your physician you agreed on an evidence-based treatment plan. After following the plan for a couple of months, you were astonished to realize that your condition had not improved. In fact, you even felt worse.”

“What? Not improved! The treatment was evidence based. Clinical trial results indicated that I should have improved. What’s wrong? Did science fail me?”

“No, Julie, science is alive and well. Your problem might be that you are unique and not average. I wrote about this four years ago when I had a different name, Quality Curmudgeon, and you were not yet a member of the team. Readers of Kaizen Curmudgeon probably never saw my original note, so perhaps we should reprint part of the original posting.”

“Do it, Curmudge. By the time I have read it I might not feel cheated by evidence-based medicine.”

The Evidence Behind Evidence-Based Treatments

“Evidence based” is one of today’s health care buzzwords. If a clinician is faced with a patient whose disease may be mitigated by a medication shown to be effective in a large clinical trial, i.e., “evidence based,” he/she can confidently prescribe it and go on to the next patient. This sounds great, but there is more than meets the eye.

Let’s begin with the basics. Assume a pharmaceutical manufacturer’s preliminary studies have, in general, suggested that Compound A at a determined dosage is safe and effective against disease X. The final test is a clinical study in which large numbers of patients with disease X are recruited and divided randomly into two groups. One group is treated with Compound A; the other group is treated with a competing medication or a placebo. At the conclusion of the test, results from both groups are averaged. If the average outcome from the Compound A group is more favorable, the study is written up, peer reviewed and published. Treatment of disease X with Compound A becomes evidence based, and a new “blockbuster” drug is born.

So what’s the problem? The study has shown that the average outcome from a population of hundreds of patients was positive; but it has not answered the clinician’s most important question, “Will it help my patient?” The test population contained some patients with severe symptoms and some with mild symptoms, some with a host of other ailments and some who were otherwise healthy, and some young and some old. Many individual patients were helped by Compound A, but other individuals may have experienced no effect or might even have been harmed. These individual results were obscured by the magnitude of the test population, which on the average demonstrated a favorable outcome.

“I’m sure it won’t make you feel any better, Julie, but if you had been a participant in the trial of this treatment, you would have been part of the population that the treatment didn’t help.”

“Understanding the reason doesn’t make me feel any happier, Curmudge. So what do I do next?”

“I’m afraid that you are going to have to stay sick for another week, Jaded Julie. Then we’ll talk about a possible path forward.”

Affinity’s Kaizen Curmudgeon

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link. 

Evidence-Based Medicine--The Patient's Perspective 3

“Here we are again, Curmudge, back in Kaizen Curmudgeon. A week ago we thought our third discussion of evidence-based medicine would be too technical for this blog and would have to go in Curmudgeon’s Wastebasket.”

“Well, Jaded Julie, I asked Mrs. Curmudgeon to review this. If she can understand it, anyone…”

“Stop right there! One more word and you might not get supper tonight. So back to our topic, how I can learn more about my disease, become a more knowledgeable patient, and achieve a better outcome. I guess you’ve been reading the scientific literature for a long time, Curmudge.”

“Reading a lot and writing a bit for about 50 years, Jaded Julie. But clinical research is different from the industrial type, and the layperson needs some guidance in order to learn from it. When we last talked about this, you were playing the role of a patient with a disease who had learned how to use the major secondary sources of information such as Cochrane Reviews, emedicine, and clinicaltrials.gov. Today we are going deeper into the subject. Oh, and one thing further. If anything in your reading leads you to suspect your diagnosis, share it with your physician. There’s not much value in a patient’s studying a disease that she doesn’t have.”

“So here I am, a patient with the full text of what looks like a valuable article in hand or on my monitor. How do I proceed?”

“The sections of articles in most disciplines follow a similar order dictated by the journal: Abstract, Introduction, Experimental Methods, Results and Discussion or Outcomes, Conclusions, and Literature Cited. What you should learn in each section is described in Gaeta and Nagurney’s Evaluating the Literature. Your first objective is to decide if the article is really pertinent to your interest; that should be evident in the Abstract.”

“But, Curmudge, what if the Abstract is a bunch of medical gobbledygook?”

“It shouldn’t be if the article is truly pertinent. Your previous reading of reviews and other secondary sources should have taught you a lot of essential terms. The Introduction will describe what is unknown about the topic and how the proposed research will fill in some of the gaps in our knowledge. From the Methods section you will learn which of the several types of experimental design was used. Common designs include retrospective (looking backward at patient records) and prospective (following subjects forward in time and collecting data as they are generated).”

“My guess is that the design will tell me a lot about the validity of the results.”

“It should, Julie. Let’s assume that you are looking at a prospective study of a treatment that might cure your disease. The findings should be more meaningful if the treatment groups were randomized with everyone equal at the baseline, double-blind with neither patients nor physicians knowing who received the treatment or a placebo, and accounting for all patients.”

“I’m still with your train of thought, Curmudge. The next stop should be Outcomes. All aboard!”

“Look at the figures and tables of results. You might not know all of the words, but an upward or downward trend means something happened; and it’s often a good something. In my earlier life I was sometimes able to interpret figures even if the captions were in a foreign language.”

“So then, how will I know that the study’s findings were not just by chance and that the treatment might really do me some good?”

“Julie, authors usually use statistics to characterize their results. The so-called p-value provides a useful guide for the reader. The smaller the p-value, the more significant the difference between results from the treated group and the control group. Look for p-values less than 0.05, or even better, less than 0.01.”

“Curmudge, you can’t imagine how delighted I am that you didn’t go any further into statistics.”

“Various organizations have adopted formal guidelines for evaluating the literature, including the evidence grading system from the Institute for Clinical Systems Improvement and the Infectious Disease Society of America—US Public Health Service Grading System for ranking recommendations for clinical guidelines. The latter system uses letter grades (A-E) for strength of recommendation and Roman numerals (I-III) for quality of evidence. You may have encountered these grades in your reading of review articles. In general, if you are interested in a specific intervention, look for prospective, randomized, controlled clinical trials.”

“You have made my brain very crowded, Curmudge, but I believe I can proceed with a little more confidence. Do you have any final words of wisdom?”

“Never final, Julie, but I do have two additional comments and one caveat. First, if you see an abstract to a promising article but can’t obtain the full text, see your medical librarian (Margo Lambert at St. Elizabeth Hospital or Michele Matucheski at Mercy Medical Center). Second, many widely used treatments have never been subjected to a controlled clinical trial and are not, strictly speaking, evidence based. They have been used successfully over time and represent the consensus standard of care; one might consider them to be ‘grandfathered.’ The caveat is that there seems to be nothing in the clinical trial literature about the eventual cost of a particular treatment or medication. So don’t allow your hopes to get too high. What does one do after learning that he can gain an extra four months of life at a cost of $93,000 per year?”

“Wow! That’s a problem in medical ethics that neither of us would touch with a ten-foot pole.”

Affinity’s Kaizen Curmudgeon

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.

Evidence-Based Medicine--The Patient's Perspective 2

“Tell me again, Curmudge, why I should become an expert in the diagnosis and treatment of a disease that I presumably have. I’ve heard that a little knowledge is dangerous.”

“Jaded Julie, a little knowledge isn’t dangerous if you discuss it with your physician. Furthermore, it rarely stays little, especially if you have a life-or-death driving force to learn more. There may be a time when your physician will present you with a choice between two apparently equal therapies; you’ll feel better choosing based on understanding instead of just flipping a coin. There might also be instances when treatment decisions involve a trade-off between potential benefits and risks; you’d certainly want to be an informed participant in that discussion.”

“Have there been cases where the patient’s study of diagnosis and treatment made a difference?”

“Read Chapter 5 of Dr. Groopman’s book, Julie (1). A mother’s knowledge—and especially her persistence—saved her daughter’s life. And if you don’t have access to the book, read about Meg Gaines’s experience with ovarian cancer.”

“But, Curmudge, Ms. Gaines’s life was saved by a new procedure performed far from home that wasn’t evidence based.”

“True. But she wouldn’t even have known about the procedure had she not studied her disease and learned of the best medical centers at the forefront of clinical research on ovarian cancer. After her experience she founded the Center for Patient Partnerships in Madison (2). She advises patients to ‘act as if your life depends on it, because it does,’ and to become an active patient ready to make your own way through your disease and its treatment.”

“Okay, Professor, I’m convinced. Teach me more about how to become my own best caregiver.”

“As I promised last week, we’re going to be looking into more technical literature. A Cochrane Review is a scientific investigation into the literature on evidenced-based health care, including randomized controlled trials and sometimes non-randomized observational studies. Individuals without a subscription click on Browse Free Summaries at the bottom of the page and then enter the disease of interest under Search Abstracts and Summaries.”

“Without your instructions, Curmudge, I would have had to follow my nose through these documents like you did.”

“It’s called trial-and-error, Julie, but it’s amazing what one can learn. You next select a title that interests you from those listed under your disease, and out pops a two-page summary. It contains a one-paragraph Summary of the disease, results of completed clinical trials of proposed treatments, and trials that are ongoing. The Main Results section is more technical listing numbers of patients, details of the trials, and some statistics on the results. Findings are summarized in the Authors’ Conclusions. Also given are the dates that the review was published online and when it was last assessed as up to date.”

“Okay, Curmudge, I think my brain is getting better at handling technical information. How can I find a discussion of my disease that is truly comprehensive?”

“Go to http://emedicine.medscape.com/. A page will appear inviting you to Browse by Specialty (within the main categories of Medicine, Surgery, and Pediatrics). Then search under disease categories such as these under Medicine: Emergency Medicine, Hematology, Pulmonology, etc. You should find a very detailed review of your disease, including results of clinical trials. The language will be technical, but the gist of the findings should be evident to the layperson. If I had to select the site that would yield the most information from just three mouse clicks, this would be it.”

“You have been mentioning clinical trials, Curmudge. If I wanted to participate in one, how would I learn more?”

“I’ve found a couple of routes to the same end point, Julie. Start with http://gateway.nlm.nih.gov/. At the home page, NLM Gateway, fill in the box with your request for ‘clinical trials on (your disease)’ and click on Search. Then under Consumer Health Resources click on ClinicalTrials.gov. That will yield a listing of trials that pertain to your disease. This will show for each entry the title, condition (disease), URL, and status (Terminated, Active, Recruiting, Completed). Click on the URL for details, including Purpose, Study Design, Criteria for Inclusion or Exclusion, Locations, and person to contact.”

“What about the second route?”

“That one starts at http://clinicaltrials.gov/. Follow your talented mouse to the same details as above. If you see a trial that is recruiting and interests you, discuss it with your physician. Remember, however, that a trial is just what the name implies. You might be in the population that receives a placebo, or the treatment under study might turn out to be ineffective.”

“I suspect, Curmudge, that our discussion of this topic might turn out to be endless and increasingly technical. This might be a good time to pick up our pieces of new knowledge and go home.”

“You’re right, Jaded Julie, but I hope we can talk more about this next week. Meanwhile, happy googling.”

Affinity’s Kaizen Curmudgeon

(1) Groopman, Jerome. How Doctors Think. (Mariner Books, 2008)
(2) Center for Patient Partnerships: Comforting the afflicted.
http://www.patientpartnerships.org/

Evidence-Based Medicine--The Patient's Perspective

“Jaded Julie, how would you feel if you were diagnosed with a serious illness?”

“I’d feel very much alone, Curmudge. Your family and friends can give you food, shelter and care, and they can even assume your debts. But no matter how much people love you, no one can be sick for you.”

“So what would you do?”

“I would have a choice. If I chose to be a totally passive patient, I could take the prescribed medicine, suffer its side effects, and hope and pray for the best. The other option—and that’s what I would select—is to become an expert on my disease and an active participant in my health care team. That way I could take full advantage of personalized care and maybe even help to cure my illness. Hey, the game of life vs. death is one that you can only lose once.”

“Sounds like a plan, Julie. How would you proceed?”

“Well, if I lived near a hospital with a library, like St. E’s or Mercy Medical Center, I’d seek the librarian’s help in learning all I could about my situation. But tell me, Curmudge, what should I do if a city is not nearby or if I were reluctant to share the details of my health with a librarian?”

”In the privacy of your home office, you or a relative or friend should use your computer to google your disease. That will open up a world of medical knowledge.”

“But I don’t want the world. I just want some stuff that I can comprehend.”

“There’s something for everyone out there, Julie, including a lot of sources that one can understand without an MD degree. Your Google search will provide a list of titles followed by a couple of lines describing the contents followed by the URL. Note, however, that the pages of your Google search results will show so-called Sponsored Links; some of these may contain testimonials and ads for non-FDA-approved treatments. Below are a few URLs that should be helpful; they will usually provide an overview of symptoms, diagnosis, and treatment in everyday language.
Mayo Clinic (www.mayoclinic.com)
MedLine Plus (www.nlm.nih.gov/medlineplus)
Merck Manuals (www.merck.com)
Wikipedia (en.wikipedia.org).”

“This sounds pretty useful, Curmudge, but where does evidence-based medicine enter the picture? It’s in our title, but you haven’t mentioned it once.”

“The sites mentioned above contain review articles written, for the most part, in everyday language. Procedures for diagnosis and treatment are evidence based as understood at the time of writing. To learn about new knowledge developed since then we’ll have to look into other—and often more technical—resources. We’ll also have to come back for more discussion next week.”

“So that I don’t go away empty-handed, can you give me a definition of evidence-based medicine?"

“Of course, Julie. Evidence-based medicine is the generally accepted best procedure for the diagnosis or treatment of a specific illness or condition. ‘It requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report (1).’”

“Thanks bunches, Curmudge. It will take me all week to figure out what you just said. But I do understand that I would want to receive the best care available. Presumably that will be evidence based unless my physician and I agree on a good reason to do otherwise.”

Affinity’s Kaizen Curmudgeon

(1) Agrawal, P. and Brown, C. A. An evidence-based approach to acetaminophen overdose. EBMedicine.net, September 2010.

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.

Amazing Devices 4

“I’ve seen it, Curmudge. I’ve seen how your reading and writing about amazing devices has awakened the long-dormant scientist in you.”

"You’re right, Jaded Julie. As they say, ‘If you don’t use it, you lose it,’ and I’ve lost it. A whole new world of communication technology has passed me by. Those devices in Dr. Topol’s video that we saw last week went by pretty fast, so I decided to mosey through the literature and learn more about them. Before our readers have these things strapped onto their chest or put in their shoe, they are likely to encounter them in their doctor’s office; so let’s focus on that venue.“

“Can we begin with the humble stethoscope that we mentioned on August 5? I’ve continued to be amazed that it has remained virtually unchanged for almost 200 years.”

“Most of those you see around necks or in pockets are the old kind, but with the advent of the electronic stethoscope (Littmann 3200), the changes are dramatic. It looks similar to the classic design, except on the back of the chestpiece there is a handle and LCD display through which the features of the device are controlled. Variable sound amplification can adjust for the clinician’s hearing acuity or the patient’s obesity. Onboard recording can be played back through the eartubes.”

“Even with your hearing problem, Curmudge, you could use one of these.”

“Sure, although it would require medical education for me to understand what I was listening to. But Julie, there’s a lot more to these things than amplification. Bluetooth technology can be used to wirelessly transfer sounds to your computer for further analysis. This requires a USB wireless adapter inserted into the PC on which proprietary software has been installed. The software allows one to visualize what has been heard in a wave file format, save it in the patient’s record, or send it via the Internet across the world for further consultation.”

“Gosh Curmudge, with that perhaps I could be a cardiologist in my spare time.”

“That would indeed be a stretch, Julie. Let’s start our next topic with a trivia quiz. What is an ER doc’s first question to himself when he sees a patient with no visible trauma?”

“I’ve got it, Curmudge. He looks at the patient and asks, ‘What’s going on in there?’ Then he attempts to find out with history and physical, lab tests, and an armamentarium (see, I remember the word) of increasingly complex tests and procedures.”

“Great answer! However, one powerful procedure is noninvasive and fairly easy to perform, but it requires a trained eye to interpret. It is ultrasound, and it’s what we’re going to talk about next.”

“Hey, Curmudge, one of those tests was done on me several years ago in the ultrasound lab. I looked at the readout, and I appeared to be a confusing mass of angry storm clouds inside.”

“As I said, Julie, a trained eye is needed. A notable innovation is that now we have handheld ultrasound units that can be carried in one’s pocket (1). When not being used on a patient, the scanner (viewer) and probe sit on a docking station connected with a USB cable to a PC. Handheld ultrasound is being promoted for use by cardiologists, obstetricians, primary care physicians, in the ER, and probably everywhere a physician is asking himself, ’What’s going on in there?’ They might become as ubiquitous as the stethoscope.”

“(Ubiquitous? I’ll know what he means when I see them everywhere.) Okay, Wizened Wizard, give me an idea of some of the things that can be diagnosed by ultrasound.”

“With the handheld ultrasound and electronic stethoscope, a cardiologist might be able to avoid ordering a traditional and expensive echocardiogram. In a primary care physician’s office or an Emergency Department, an abdominal ultrasound might reveal an abdominal aortic aneurysm, gallstones, hydronephrosis, kidney stones… An ultrasound of the leg should be the easiest way to detect a blood clot (deep vein thrombosis). These ailments are not uncommon. Each has afflicted one or another of my acquaintances.”

“That, Curmudge, is because your contemporaries are so old. Aside from that, however, the beauty of these in-the-office diagnostic tools is that they can enhance the physician’s communication with the patient. The hand-held ultrasound can provide visual reinforcement of exam findings in real time. The patient can leave the office or the ED with a diagnosis and plan of care—not a schedule of additional tests. So, senior savant, although it should be obvious, what do you see as the lesson for today?”

“Lesson #1 is obvious, Jaded Julie. Advances in technology continue to make the practice of medicine more efficient and effective. However, unless these devices are used in an efficient environment, their effectiveness will not be fully realized. That’s Lesson #2. Here are some examples: an MRI machine that is used only five days per week, a Da Vinci robot on which few surgeons are trained, the report of a CT scan that is misplaced on its way back to the ordering physician.”

“I think what you are saying is that a hospital or clinic needs to have a Lean culture in order to get the most out of its technology.”

“You’ve got that right, Julie.”

Affinity’s Kaizen Curmudgeon

(1) Another handheld ultrasound system is the ACUSON P10.

Amazing Devices 3

“You know, Curmudge, the curious thing about you old guys is that you are so easily amazed. I think the reason is that nearly all of today’s wonderful devices were invented after you had completed your education.”

“Au contraire, Sleeping Beauty. In our years together haven’t you perceived that my education has never been completed? I suspect that at least 90% of the knowledge I used in my professional life was gained either in kindergarten or after graduate school. Even now, every day is an eye-opening educational experience.”

“Okay, mind-boggled blogger, what was yesterday’s gem of new knowledge?”

“Jaded Julie, it’s right here in this video, The Wireless Future of Medicine by Eric J. Topol (1). Although it runs for 17 minutes, it is well worth the viewing time.”

(17 minutes later) “The video was truly impressive, Curmudge. Will you have some comments about it?”

“Perhaps, but not today. If a busy person has spent the past 17 minutes watching Dr. Topol, he will undoubtedly feel that he has learned enough about amazing devices for the moment.”

Affinity’s Kaizen Curmudgeon

(1) Topol, E.J. The wireless future of medicine (video). http://www.ted.com/talks/eric_topol_the_wireless_future_of_medicine.html

Medical Home Workflows

“Jaded Julie, in a symphony orchestra, how does one make sure that all of the bass fiddles play the same notes?”

“I don’t know much about orchestras, Curmudge, but I suspect that each bass player reads from an identical musical score.”

“Closer to home, Julie, if a sample is sent to the hospital’s lab for a multi-step analysis, should the result depend on who the analyst was?”

“Absolutely not! The lab has a standard process and procedure for every step in the analysis that each analyst must follow. Even a non-clinical old geezer like you should know that.”

“And finally, in a medical home with several patient service representatives, should a patient’s phone call to renew a prescription be handled differently depending on the PSR that she speaks with?”

“Of course not. I get it, Curmudge. In the medical home we have workflows just like an orchestra has scores and the lab has standard methods. It’s like you taught me, ‘You can’t improve a process until you can control it; you can’t control it until you understand it; and you can’t prove you understand it until you document it.’ The workflows get everyone on the same page. You can’t have people running around willy-nilly ‘doing their own thing.’”

“You are mighty quick on the uptake, Julie. Can you think of ways in which Lean is used in developing workflows?”

“You know I can. Where do you think I’ve been for the past three years? To begin with, you assemble a team from gemba who know best the processes and procedures in present use. They use sticky notes that are color-coded to differentiate patient service reps, health care associates, and providers. Then they make a process diagram on the conference room wall for each of the clinic’s main processes. Sometimes ‘just do it’ improvements are introduced as the workflow is being constructed.”

“That’s the idea, Julie. What happens next?”

“Then the workflow is copied from the wall with Visio software for printing, discussion, and further improvements. Later the team looks into the individual sticky-note boxes to identify procedures that need to be documented. It looks to me, Curmudge, as if workflows are standard work for clinic-wide processes and individual procedures.”

“The drivers for this effort are the forthcoming implementation of the electronic health record (EHR) and ultimate recognition by the National Committee for Quality Assurance (NCQA). As we said last week, one must not try to overlay a good technology on a bad process. Workflows represent the medical homes’ development of effective paper-based process and procedure descriptions for incorporation into the EHR.”

“It’s pretty obvious, Curmudge, that one must know where she is ‘at’ before finding her way to someplace better. By the way, do you realize that the next generation might not even know what a paper-based process description is?”

“That’s likely, Julie, but if there still are bass fiddles, I’ll bet that bass players will still be reading Beethoven from paper scores.”

Affinity’s Kaizen Curmudgeon

The World Health Congress

“I’ll bet, Curmudge, that during your professional career you attended a lot of meetings and conferences.”

“I sure did, Jaded Julie. Although I found the short courses associated with the conferences to be most valuable, I also tried to observe some of the local culture when the meeting was held in an exotic location. Let me tell you about what I saw as I walked down Bourbon St. in New Orleans one Halloween night.”

“You may, but not in Kaizen Curmudgeon. I understand that several of our newer colleagues recently attended the World Congress on Excellence in Health Care.”

“They did, and after their return they reported on the high points of the conference. My perception is that they brought home a strengthened conviction that Lean is the right culture for Affinity and that we are progressing well on our Lean journey. In fact, we are among the leaders in Lean health care. When a speaker asked—regarding the focus of his presentation—‘Who is doing this?’, our people could proudly raise their hands to signify, ‘We are.’”

“How about some examples, Old Guy. I presume since this meeting was held in Chicago, their examples will be free of New Orleans-style rowdiness and debauchery.”

“Not a problem, Julie. I believe that the essence of the presentations may be discerned by the following statements and quotations:

‘Philosophy—Patients and families first. Then support our people.’

‘Waste comes cleverly disguised as a lot of work.’

‘Lean is lead from the top down; change from the ground up.’

‘The first day of a kaizen event is usually a food fight, i,e., lots of blaming and finger-pointing.’

‘There is an affinity between Lean and Green.’

‘In their personal behavior, employees must distinguish between being on-stage (in view of patients and visitors) and off-stage (out of view).’

‘Lean is a part of the strategic plan (sounds like hoshin-kanri).’

‘Report-outs must be attended by everyone.’

‘The Joint Commission (TJC) is working to improve their consistency of standards interpretation (anyone who has been audited by anyone should appreciate that).’

‘The middle manager is no longer a problem solver but a facilitator of problem solving.’

‘Overlaying a new technology on a bad process is like shrink-wrapping a cactus.’”

“I think I understand, Curmudge. These statements are all familiar or obvious to us. They represent problems that we have solved, or are working on, or that we are aware of and need to work on. To someone totally new to Lean, they might be confusing. To an experienced ‘Leaner,’ they are an inspiration. Come to think of it, that’s what a conference is supposed to be—an inspiration.”

Affinity’s Kaizen Curmudgeon

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.