Terry Loftus MD Weblog

There was a recent post on the Medscape discussion forum which referred to an article on the use of mnemonics in psychiatry.  The title of the article is: Mnemonics in a nutshell: 32 aids to psychiatric diagnosis.  Many of these memory aids are simple acronyms such as the CAGE assessment which is used to quickly determine a person’s risk for alcohol abuse.  Of note, among the 32 aids listed is the number of discrete units used for each mnemonic.  CAGE is one of the simplest with 4 discrete units and under delirium diagnosis is “Deliriogenic Medications” which has 15.  For those fans of Miller’s Magical Number Seven this may seem excessive.  In 1956 George Miller, a cognitive psychologist from Princeton, published a paper in which he demonstrated the capacity of our working memory was about seven, plus or minus, two elements (for English speaking people).  It is interesting to note that the number 7 is frequently referenced in our language to describe a list of various elements such as: 7 days in the week, 7 numbers in a phone number, 7 deadly sins,  7 hills of Rome and , of course the 7 wonders of the world. As it turns out the average number of discrete units for all 32 aids is 7.5 and the most frequently occurring value (mode) is, no surprise, 7.  The range is 4-15 which appears to deviate from Miller’s claim of 7 plus or minus 2.  Since we are referring to a memory aid, the aids with a low number of elements are not critical.  Of the 32 aids only four of them appear to violate the upper part of the range.  Fortunately  a simple mnemonic trick is used to facilitate these memory aids.  Each of these is broken up into smaller discrete units much the way we break up phone numbers.  The 15 element “Deliriogenic Medications” is given the mnemonic “ACUTE-CHANGE-IN-MS”.  Even “WWHHHHIMPS”, which lists the life threatening causes of delirium can be seen as “WW-HHHH-IMPS”. With the massive growth in information in healthcare it seems like we are rapidly approaching the point where mnemonics will no longer be adequate to support human memory.  It has served as a useful bridge but the information age is becoming more and more dependent on information technology as the primary memory aid.  Miller’s Magical Number Seven will not go away though, it will become more important in how information technology presents information to us.  This is the realm of information management.  For healthcare to progress we are going to need to become much better at how we manage information.  It is going to take more than mnemonics to overcome our memory capacity limitations, not to mention the other limiting features of bounded rationality.  The information age will allow us to move beyond satisfactory solutions and endeavor toward optimal solutions.  This assumes, of course, we learn how to manage this vast amount of information in a way that compliments our natural capacity to understand and use it.

Blame, when appropriately dispensed, assigns responsibility for a past occurrence.  The event that occurred is typically one which resulted in a negative outcome.  As in, “Hey, it’s all your fault.  You screwed up.”  The paradox is, there is an interesting opportunity which becomes available when blame is not appropriately assigned.  As in, “Hey it’s your fault.  You screwed up but… (wink-wink everyone knows you really were not the one who screwed up.)”  The general rule is, none of us wants to accept blame, especially when we were not the responsible party.  There is an exception to this rule and that is when everyone knows you really were not the person responsible for the bad outcome.  This is sometimes referred to as, “taking one for the team.”  By accepting blame, you now become the responsible person (and better team player).  The opportunity granted to you for accepting blame is that you can now fix the problem caused by the person who was previously responsible.  If you fail, then it really is your responsibility.  If you succeed you have now earned the right to the new position of responsibility.  Since you were not responsible in the past, you were not in a position of authority to affect the outcome. By accepting blame, under certain circumstances, you can advance to a new position of responsibility.  This assumes, of course, you learned from your predecessor’s’s mistakes and can affect a good outcome. It’s a risky tactic but one that comes with rewards if performed effectively.  The key is to recognize and guarantee the quid pro quo.  In exchange for accepting blame, you will be given the opportunity to correct the problem.  Therein lies the paradox.  Given the choice between blaming the person truly responsible, who has proven they don’t know how to fix the problem, and “blaming” the person who is not responsible, who can fix the problem, blame sometimes tends to find the problem-solver. This is more common when responsibility is distributed to many individuals, and difficult to assign, or when saving face for the responsible person is warranted, for whatever reason.  It’s an odd thing to say but sometimes “blame” is another way of saying opportunity.

Hospital administrators view things differently. One of the primary reasons any firm in any industry (health care included) brings an individual who provides a service or produces a product in as an employee is to reduce transaction costs. Firms exist because transactions that occur within them are more efficient than if those same transactions occur outside of the firm.  Once the marginal cost of a physician’s services consistently exceeds the marginal benefit the physician provides to a hospital it is in the hospital’s best economic interest to employ the physician in order to control the costs or improve the benefit. For example, as physician reimbursements decrease and their costs increase they must seek alternative revenue streams or practice efficiencies in order to maintain the same income. With the paltry 1.1% raise coming from Medicare and the July 07-08 inflation rate at 5.6% it is not difficult to understand why this is happening. As physicians struggle to keep up it seems it is inevitable they will lean on hospitals to either boost revenue (stipend for call, reimbursement for uninsured patient care) or cut costs (EMR support, medical office space). These are transaction costs administrators are willing to support in order to keep the hospital doors open. When it is less costly to employ a physician than pay these costs hospitals must as a practical matter move toward employing physicians. It’s an expensive choice but when the alternative is more costly it becomes the best alternative to a negotiated agreement (BATNA).  In order for physicians to remain independent they must be able to generate revenue and decrease costs in a manner that does not make them dependent on the hospital. I don’t claim to know where this will lead to in the coming years but I think as long as physicians squeeze more of their revenue stream out of the hospitals they will ultimately increase the probability they will become employees of the hospital.

It’s been a busy couple of months between returning to school and starting a new job so I thought I would share a recent assignment I wrote for school.  It’s based on my understanding of a Harvard Business Review article (HBR 9-808-072) titled, Transforming Arizona’s Health Care System: Developing and Implementing the Health-e Connection Roadmap.

In his recent bestseller, The Age of Turbulence, Alan Greenspan recounted an article written by Paul David, a professor of economic history at Stanford, who explained why it took nearly four decades for the electrical motor to displace the steam engine as the primary source of power in America.  When Thomas Edison first demonstrated the superiority of electrical power in 1882 nearly everyone could appreciate its merits.  It was also assumed that it would be just a few years until electrically powered motors would be everywhere and still it would be decades before it happened.  As Professor David explains the reason it took so long is because the process was capital intensive and required a restructuring of the existing cultural, social, architectural and technological infrastructure supporting the status quo, the steam engine.  The same could be said of the use of computers in the evolution of electronic data exchange in our healthcare system. 

            Everyone can see that computers should be able to improve the delivery and efficiency of healthcare.  Just like electrical power it is obvious that computers will displace the status quo, the paper chart, but it has not happened as yet on the grand scale and many are getting restless.  Governor Napolitano’s Executive Order 2005-25 was an attempt to jump-start the process by bringing the state of Arizona’s healthcare stakeholders together to create a roadmap to “achieve statewide electronic health data exchange between various entities in the health care delivery system”.  The driving force behind this is the increasing awareness of the problems that exist in our healthcare system and the recognition of the role information technology can play in the solutions to those problems.

            Since the Institute of Medicine’s 1999 report, To err is human: Building a safer health system, there has been a growing urgency to fix the long standing problems in healthcare.  It is now estimated that there are thousands of injuries and deaths due to avoidable medical errors.  In addition, millions of dollars are wasted every year as a result of redundant tests, missing information and lost productivity.  It has been shown that the use of computers and information technology can not only reduce medical errors but also lead to a significant cost savings over time.  The Governor’s roadmap (Arizona Health-e Connection) was intended to provide a path to improving the delivery of healthcare through the collaborative use of information technology and act to build momentum toward achieving these goals.  So if the merits of this roadmap are so obvious what is holding back the universal acceptance and rapid rollout of this project?

            It may be, as Professor David explained regarding the electrical motor, that we are undertaking a restructuring of the legacy systems that have maintained the status quo and that replacing them involves disrupting the established cultural, social, architectural and technological infrastructure we currently depend on to deliver our healthcare.  It’s not as easy as unplugging the old system and replacing it with a new system.  The new system must be built upon, co-exist, and ultimately replace the old system.  Fortunately the Arizona Health-e Connection Committee anticipated some problems with implementation and attempted to avert them by building a coalition based on broad representation of healthcare stakeholders.  Despite broad representation and the obvious merits of the project roadblocks remain and some may simply take more than a roadmap to overcome.

            Arizona has some unique challenges to overcome.  One issue that must be addressed is that at least a quarter of the state’s population is rural and spread out over a wide geographical area.  At the time of the committee meetings only 13.5% of physician practices used electronic health records (EHR).  With many of these practices classified as small or medium in size and located in areas that exist outside of the main information technology networks it is difficult to bring everyone on board and deliver the same standard of care to all state and Native American populations.  Electronic health record technology also has significant start-up costs which are considered prohibitive in an environment of declining reimbursement and rising costs.  Physicians are skeptical about the immediate return on investment of high cost technology and like everyone else who has seen the price of computers, plasma screen TV’s and cell phones plummet are willing to take a “wait and see” approach.  While waiting may lead to continued errors and cost issues for the system as a whole it may also lead to lower IT costs for an individual practice and the likelihood of a markedly superior EHR when it becomes more affordable.  This is not to say physician practices are the only stumbling block.

            The massive build-up of information technology hardware and software is the result of numerous innovators and firms with a vested interest in the proprietary rights of their intellectual property.  This has resulted in a wide range of vendors, products and services as well as a healthy dose of competition to facilitate the innovative process.  Each hospital and healthcare system has, to varying degrees, invested in these various products and services.  In an effort to seek a competitive advantage for both the vendors and healthcare systems many of these innovations were not necessarily designed to enhance interoperability with one’s competition.  For example, if you are in the business of selling electricity and lamps it makes sense in the early phase of a product or service life cycle to sell only lamps that can plug into your power grid.  As the electrical companies focused on delivering power and got out of the lamp business the new focus became interoperability, which means getting a common standard for electrical outlets so everyone can plug into the power grid.  This may be analogous to what we are experiencing in our healthcare system.  Without standardization within the electronic data exchange networks it will be impossible for everyone to focus on innovating more improved and less costly plug-in products and services. 

            The Arizona Health-e Connection should focus on network standardization and interoperability.  The early days of electrical power dragged on while standards were being established but once they were the realization of the true merits of Edison’s vision materialized.  Once standardization and interoperability are established it will also be critical for stakeholders to agree on what information can be shared and with whom it can be shared.  Any risk of creating a network which provides asymmetric information to privileged entities will sabotage efforts at collaboration.  In addition, once standardization and interoperability are established this will articulate a clear message to the market.  The health information technology industry will be able to focus more capital on innovations that specifically are designed to reduce errors, redundancy, misinformation and costs in healthcare.  Instead of each healthcare system differentiating them-selves by owning a unique EHR that lacks network interoperability they can now focus their attention on systems that utilize network information for improving care.  The real goal after all is to improve patient care and decrease the cost of delivering that care through enhanced integration of the statewide health information system.  Standardization and interoperability eventually worked for delivering electrical power.  Let’s hope it doesn’t take as long to do the same for delivering better healthcare. 

It was one of the big healthcare stories in today’s New York Times.  It started out by saying:

      ”A growing chorus of discontent suggests that the once-revered doctor-patient relationship is on the rocks.  The relationship is the cornerstone of the medical system — nobody can be helped if doctors and patients aren’t getting along. But increasingly, research and anecdotal reports suggest that many patients don’t trust doctors.”

Right there in the opening sentence, written between the lines, is the crux of the problem.  The author like so many of us put the “doctor” first in the “doctor-patient relationship”.  It’s a subtle but important distinction.  It is essential that the public and those of us in the medical profession learn to appreciate this distinction.  If there were no patients there would be no need for physicians.  Ergo it is the patient that comes first in this relationship.  The patient’s healthcare needs are what created the physician’s healthcare solutions.  Like I said it is a subtle distinction to reverse the order but it says so much about how we view the world of healthcare services.

While I am on this topic you may have noticed a couple of other related observations.  One is that I specifically did not refer to the “patient-doctor relationship”.  In the United States the conventional use of “doctor‘  refers to a medical doctor.  This is not always the case and “physician” or “medical doctor” is the more appropriate term.  Another point is that recently the “patient-physician relationship” is quickly being replaced by the “patient-provider relationship”.  I’ve discussed some of the reasons for this in a previous blog.  Suffice it to say I believe it is because the “cornerstone of the medical system” is changing.  I suspect this is really the reason the trust is breaking down.  The real question is if patients don’t trust doctors who will they come to trust?

The knowledge worker is an expression first described by Peter Drucker in 1959.  Over the last fifty years the knowledge worker has become the most essential and fastest growing member of the workforce.  It can be argued the knowledge worker has always been the most essential member of any workforce but in the information age they have taken on new value due to their vast numbers.  What is interesting is not only the growth in numbers of knowledge workers but also the cost of maintaining this booming generation.

Each age places an extraordinary amount of value on that which most contributes to output.  When we were primarily an agricultural economy value was placed on the land and the means to grow, harvest and bring to market the crops it could produce.  During the industrial age a factory’s plant, property and equipment were the primary assets of value.  In both ages the owners of the land or factory invested a relatively large amount of resources to insure the most efficient use of the assets that were the drivers of production and the creators of wealth.

The times are changing and it is the knowledge worker that has become the primary asset that creates future wealth.  Due to the growth of this member of the workforce is it any wonder that the value we place on health and education has increased?  Education is the way we maintain and upgrade the intellectual capital of the knowledge worker.  Healthcare is not only a way to repair and heal the knowledge worker during the down-time of injury and illness it is a way to maintain the long-term operational effectiveness and efficiency of this valuable workforce.  When we look back on the rapidly rising cost of our healthcare system we may find that one of the primary reasons for doing so was to preserve and protect the knowledge worker and the value they bring to our society and our economy.

With all of the emphasis on reading, writing and arithmetic in our educational system it leaves little time for courses that could also be beneficial to our society.  They would fit under the broad heading of “Life 101″.  These would be a series of courses that teach all that stuff that can make everyday life run much smoother.  For example, how about a short course on “Elevator Etiquette”.  We can start the course by having everyone memorize ten simple rules. 

Rule #1: Pressing the up or down button multiple times does not make the elevator move any faster.  The corollary to this rule is that pressing the button harder (or punching/kicking it) also does not make the elevator move any faster.

Rule #2: While waiting for the elevator do not stand in front of the door.  You can’t get in until the current occupants of the elevator make room for you and they can’t do that unless you get your big butt out of the way and make room for them to exit.

Rule #3: Do not, repeat do not let children under the age of ten press the floor button.  It’s like eating potato chips; they will not be satisfied with just one.  They just can’t resist the urge to press every floor button.

Rule #4: The “close door” button: A) is broken and will never be repaired. B) was never hooked up and was only installed to make you feel like you are doing something by pressing it repeatedly. C) has a delay built into it and the doors will close when the time delay has elapsed. D) once worked but was disconnected because of too many complaints about people closing the doors too quickly. E) All of the above.  (Correct answer “E”)

Rule #5: Under no circumstances is anyone allowed to pass gas.  This is especially true for those who are about to disembark.  That’s just rude.

Rule #6: Unless you have a health problem or are moving things (furniture, packages, baby carriage, etc.) the rule for using the stairs is “one up, two down”.

Rule #7: The elderly, disabled, people carrying stuff (babies, packages, food) and those with nothing better to do move slower and must be allowed adequate time to board the elevator.  (Yea I know it seems to take forever but just remember, some day it may be you who needs that time.)

Rule #8: Regarding speaking on cell phones in public places, don’t say anything you wouldn’t want printed in tomorrow’s paper (or blog).  And BTW, “CAN YOU HEAR ME KNOW!”, speaking louder does not improve your cell phone reception.

Rule #9: As a general rule the personal body space  distance in social situations is about 18 inches (OK, OK it varies by culture but for most people in the US it’s still about 18 inches.).  The personal body space distance in intimate situations is less than 18 inches.  Just because we break from convention to allow more people to fit in the elevator doesn’t mean we’ve become more intimate.

Rule #10: Eighty-five percent of buildings with at least 13 floors do not have a named ”13th floor“.  It’s considered unlucky or superstitious to have one.  That’s just the way it is so the next time you are on an elevator and some smart-ass gets on and asks you to press floor thirteen just tell him to press it himself if he is feeling lucky.  (BTW for all of you who live or work on the 14th floor in building that don’t have a “13th floor” it is really the 13th floor.  Sorry to ruin your day.)

Well that is it for today.  If you can think of any more add them to the list.  Who knows, someday we may have an ”Elevator Etiquette” course manual.

This is a continuation of my previous post on this subject.  I am at the halfway point in pursuit of an MBA degree and have found myself reflecting on this question once again.  The first time I did this was before I applied to the Executive MBA program at ASU.  This time it is after a year of study and a great deal of “If I knew then what I know now would I still make the same decision” thinking.  The short answer is yes but I’ve made some observations over the last year that may be of interest to any physician considering the same decision.  (For the initial three observations click on the previous post link above.)

4) Nobody will value your investment in an MBA degree more than you.  This may seem obvious but it is an extremely important point.  When you invest time during the course of your studies this time commitment will mean someone else will be responsible for covering your practice in your absence.  The people who cover you may be your business partners, employees of the hospital or colleagues who you have asked to assist you while you are away.  At first it will be easy for them to cover but if they are doing it out of the goodness of their heart that arrangement will grow thin over time.  At some point in time it will become obvious to them that if they do not feel like they are benefiting from the arrangement the deal will go bad.  While you are away studying they are covering you and despite all their initial support for your endeavors they will come to regret it.  The looser your coverage arrangements the quicker the deal will derail.  If there is some value they will get in return for your endeavors the greater the likelihood they will support you.  If they perceive no value in return, while covering for you, the greater the likelihood they will sabotage your efforts.  That is painfully obvious to me now but I was completely unaware of this a year ago.

5) An MBA degree, or any other investment in human capital for that matter, expands and alters your view of the world.  What you do with that new view is up to you so ultimately the answer to the question of whether it is worth it to pursue such a degree will always be in the hands of its possessor.  An MBA degree provides a view of the world in which you live and work that is different than the one you previously held.  It also provides specific tools you can use to re-evaluate how you approach your work.  It’s similar to what I experienced the first time I used the Internet.  I thought “That is really cool”.  Little did I know at the time how indispensable it would become in my life.  Anytime we can view the world differently and that knowledge can add a significant benefit to our lives it is worth it.

6) The immediate non-financial return on investment (ROI) from an Executive MBA program is the contact and connections you make with your classmates.  They come from a wide variety of industries and cultures but in many ways they are like minds.  They have the same love of learning and need for intellectual stimulation as you do.  They wish to acquire a new skill set and view of the world which will further open their field of opportunities.  Regarding the long-term ROI I liked the response Hugh O’Neill, the Associate Dean of the Executive MBA program at UNC, gave.  MBA programs attract “climbers”, “shifters” and “launchers”.  The climbers are already established in a company and wish to move up the corporate ladder.  The shifters are those who wish to change their career or move to a different type of job in the same industry in which they currently practice.  The launchers are the entrepreneurs who wish to start their own business.  Each of these types of people wishes to enhance the quality of their life and for that reason alone, for them, the pursuit of an MBA is worth it.  Follow this link if you want to see the relationship between an MBA and the financial ROI regarding salary.  As a general rule it increases but physicians should note well it can also decrease if they are in the shifter category.

Less than a year ago I entered the Executive MBA program at Arizona State University to scratch an intellectual itch that I’ve had for the last decade.  Throughout my career as a physician it became increasingly obvious to me that the business of health-care plays a dominant role in what we as physicians can do for our patients.  It permeates everything we do in medicine.  It determines what tests can get ordered, what medicines can be prescribed and what treatments can be provided.  Instead of fighting the beast I decided it was better to learn from it.  It begins with learning the language of business and immersing oneself in the culture.  It is like the Grateful Dead once sang, “What a long strange trip it’s been.”

Since I have another year to go before I complete the program and actually receive an MBA degree it is a bit premature for me to make any grand conclusions to the question I proposed.  What I can do is offer a few observations I’ve made so far.  In future posts I plan to add to the list.

1) Physicians, particularly older docs (myself included) tend to prefer to either work alone or work within a pyramidal type of team structure.  I know that may sound harsh but it’s true for many of us.  In our program we are assigned to groups and much of the work done for class is the result of teamwork.  When I first met with my team I explained to them that they need to understand that as a Trauma Surgeon my idea of teamwork is when they do what I tell them to do.  It was meant as a joke but the one or two nervous laughs it got proved it wasn’t all that funny.  It is easy to forget that there are different types of teams with different approaches to problem solving.  A pyramidal form may work well with a severely injured patient in the trauma room but can be a disaster when leadership must be a shared activity.  I learned a great deal from my team members and classmates this past year and so far that has made it worth it.

2) Physicians tend to be suspicious of physicians who study business.  I was warned about this prior to starting the program but considered it paranoid thinking on the part of the person who said it.  It’s amazing but if a physician develops their human capital through lessons on golf, skiing, painting, gardening, woodworking, wine-tasting, a new language, statistical methods or any other form to improve their mental or physical capacity they are rewarded by their colleagues with smiles and approval.  Mention an MBA degree and all you will see is raised eyebrows.  Since beginning the program I’ve been told that I have “gone over to the dark side”, “taken up with the enemy” and begun to “practice in the dark arts.”  It has been a disappointment to see so many who value education so highly to so easily dismiss the value of a business education.  It reminds me of Plato’s Allegory of the Cave.  Once you leave the cave there may be no turning back.

3) An MBA is to the business world as an MD is to the medical world.  It’s a starting point.  It lays the groundwork for understanding how that world functions.  It is not meant to replace the real world knowledge and experience gained through years of training under the guidance of senior management or attending physicians.  The degree is a way to get your ticket punched and it is the punched ticket which allows you to access the next level where the practical education occurs. 

It is with great dismay we watch one of the Wall Street giants take a tumble today.  In just over a year Bear Stearns Cos. went from a market capitalization valued at $25 billion down to its fire sale value of $1.4 billion.  What is even more disconcerting is that 7000 of its employees will be searching for new jobs according to the WSJ.  Despite the massive loss of financial capital the more pressing concern for these former employees is what to do in the short-term. 

In Charles Wheelan’s book, Naked Economics, he defines human capital as, “…the sum total of skills embodied within an individual: education, intelligence, charisma, creativity, work experience, entrepreneurial vigor, and even the ability to throw a baseball fast.”  Well, there probably will not be any Bear Stearns employees fighting for a position in the baseball draft but this disruption will release an enormous amount of human capital.  There will be tough times for many in the coming months but ultimately this is a group of people who will rally back and use this experience to their benefit as well as ours.  It is the most painful but necessary part of what Joseph Schumpeter described as creative destruction.  Out with the old and in with the new as some would say. 

While we have gotten use to to layoffs and mass reductions in the workforce as a blue collar phenomenon the 21st century has demonstrated a predilection for those of the white collar type.  At the level of the individual there are very few people who ever considered losing their job as a good thing regardless of their job description.  My heart goes out to these fine people.  Some may have been directly involved in the practices that led to the downfall of Bear Stearns but most were not.  All is not lost though as they still possess their most valuable asset: human capital.