Category Archives: communication

Atul Gawande on healthcare: 15 Cooks in the Kitchen and Nary a System in Sight

Maine’s Quality Counts! just had their annual conference. The statewide aggregator for health improvement, blessed with great leadership, partnership and a following, did a fantastic job getting 1,100 people there and bringing in phenom speakers.

A conference highlight was Atul Gawande @AtulGWande. Dr. Gwande, renowned in healthcare and quality circles, a surgeon at Brigham and Women’s Hospital, writer for The New Yorker magazine and best-selling author of 3 books (Better; The Checklist Manifesto; and Being Mortal: Medicine and What Matters in the End).

You can watch his full Quality Counts! presentation on YouTube:

Gawande talked about how healthcare has become so sophisticated, with 4000+ procedures and 6000 medications (is that all?), has tremendous science, with a capability to provide care to almost every person in every town. Yet we continue to drive up costs and resource use. He said that in 1970, for patients with pneumonia and heart attacks, it took 2.3 FTE of care. Now for the same patients, we need 15 FTE. 15 people who all know the plan. We’ve become specialists – but silo’d, and separated from communities. Most importantly, we don’t really have a system. We have to put health and healthcare together.

We have extraordinary technology. We are the best trained, over-educated, but with no sense of how it comes together.

Gawande spoke about how we’ve become obsessed with having the best components in healthcare. But patients may not necessarily care about living longer. How do we find out what people really want? Their goals? Priorities? Then he said an amazing thing: ASK THEM.

To do this, we as health professionals need to stop talking. We have to stop being “explainaholics“.

Some of his comments had inherent tensions. Data, measurement, quality, checklists. Then, he mentioned rigid rules for older folks in nursing homes. Rules for eating. Rules for movement. Rules for behavior. He noted what people want is to optimize their autonomy, as long as they can. Being able to eat a cookie (or have a refrigerator to open when they want) can be a simple solution with key rewards. Tangible and intangible, if you ask me.

Can we measure and focus on data, at the same time also really care? I think we have some ways to go. To measure what people value, rather than to value what we measure

Gawande had some great things to say about Maine, where we have some great improvement efforts and tremendous collaboration.

I look forward to curling up and reading Being Mortal, which I picked up at the conference. I don’t mind, though, that he slipped out of the Civic Center before he signed my copy. It was a treat to have him in Maine. To Lisa Letourneau, Director of Quality Counts: strong work, girl! 😉

Read – Jackie Farwell’s post, What Atul Gawande, medicine’s rock star, thinks about Maine health care

We Must Have Patients and Caregivers Shaping Medical Curriculum

Many years ago, I sat through 2 years of lectures in medical school. Then, 2 years in the hospital. Then residency and clinics, hospital wards and more wards. How patients were viewed was always the same. They were there to answer questions, put up with exams, a lot of testing and feeling poorly. Writing of notes was endless, as were lists of possible diagnoses, test ordering and treatments.

At no time, and in no venue, did anyone consider patient as teacher. It was never conveyed that ‘patients were the experts of their issues’.

Such a lost opportunity. Maybe, just maybe, healthcare is waking up.

Pt Educ Counsel
A wonderful paper in
Patient Education and Counseling, What parents want from emails with their pediatrician: Implications for teaching communication skills is well worth a careful read. I believe it’s an important step and signal for the future. It’s a great example of Participatory Design, having patients and caregivers contribute to improvement of the health care system.
Schiller et al.

Researchers and educators in Ann Arbor, led by author Jocelyn Schiller, asked parents to read and review secure email messages between parents and medical students during their pediatrics clinical rotation.

Pediatrics faculty created ‘simulated messages’, or hypothetical messages from parents of pediatric patients. The medical students were asked to reply to the secure emails. Parents were then asked to read and comment on the messages. Finally, the parents comments were compared to the assessments done by the Pediatrics faculty.

The results were not surprising, but have significant implications for teaching medical students (or any health professional trainee) about communication. Parents were pleased when students provided information in a clear manner, with specifics on what to expect or ‘next steps’. Parents, however, gave lower scores than faculty for students’ ability to show empathy or show respect. The authors state,

…there may be subtleties in expressing empathy and respect that are acceptable to faculty and medical students, but that communicate negative connotations to patients and parents. These differences may be exacerbated in written communication.

The researchers remark that patients and caregivers are an important stakeholder in curricular reform, offering a different perspective from health professionals that enhances communication skills education.

The paper is a key contribution to Participatory Medicine. Patient advocates and participatory clinicians see this as necessary direction — getting patient voice into medical training. This needs to go even further than what this study accomplished; parents and patients directly involved in educational sessions, not just giving feedback on paper. After reading this work, the services of patient advocates just got better defined.

Patient portals, Blue Button & OpenNotes are the next generation of quality.

It’s been awhile since my last blog post. Summer does that. Particularly if there’s a winning combination of sun, beach, family, fresh corn (I heart Cape Cod). You get my drift. The right factors combine, giving you a great experience.

The same thing goes for digital tools. We intuitively know what’s needed. Easy login. Nice interface. Valuable functionality. Bringing the right information at your fingertips when you need it.

Making an application easy to use and beneficial doesn’t sound so hard, right? Yet why does it take so long for health care to figure this out?

I was asked to give a webinar on the topic of Patient Portals for Maine’s HealthInfoNet last week. I focused on the combination of features that bring the most value – in other words, what people need (based on what they use) and how positive change can happen – based on evidence and experience. We have a rapidly expanding literature about this information, and this data needs bright lights shining on it, firing it up.

I did a back of the envelope summary of some evidence. Not a systematic or exhaustive synthesis, but my cumulative view of a continuously expanding bibliography of relevant papers and presentations.

Co-presenters included Steve Bien, a physician at Wilson Stream Family Practice, the first independent practice to use Maine’s health information exchange. As an early adopter, Steve touted the use of secure email, remarking that online communication not only meets patient needs but reduces workload and offers efficiency. Nice to hear that from a small practice.

Adding the patient voice to the panel was Ann Sullivan, advocate and HealthInfoNet Board member. She provided insightful, day-to-day experience of how eHealth tools add value by fitting into the patient workflow (life!) through convenience, access and helping with self-care.

Thanks to Gemma Cannon, Service Coordinator for Maine’s Regional Extension Center, for convening the group to focus on patient meaningful use!

Slides from the @hinfonet webinar are available from HealthInfoNet and on slideshare.