Why Some People Should Never Have a Pet

A dear friend and IT nerd who has bailed my ass out 101 times put this post up on FB. This just speaks to why idiots should not have dogs EVER. 

So my wife says as she walked the dogs last nite she saw some guy hitting his pit bull dog with the leather part of the leash. She yelled at him to stop and besides the usual profanities of ‘mind your own business’ he said he was punishing the dog for eating garbage. She said the dog just stood there and took the punishment, poor thing. As she moved on, he started following her and even said “I’m

not even hitting hard!” and this time DEMONSTRATED on the dog again, while it was just standing there doing nothing. THIS PIECE OF SHIT doesn’t even get what “REINFORCEMENT” means… now this dog sees “High Energy/Stress” + “Just Standing Around Next To Master” = “Wack on the head with leather belt.” Yah, the poor dog might not be a *bit* more on edge the next time these ingredients mix together. Tell me these pit bull owners aren’t just damn asking for it when their dogs go off the deep end? OMG what a scumbag.

Are We Not Men? We Are Devo! Or Customer Driven Healthcare not Product Driven

NEJM August 29, 2012 published a perspective by Asch and Voipp titled: What Business Are we In? The Emergence of Health as the Business of Health. They present a cogent argument that healthcare today is similar to Eastman Kodak who after 131 years in business filed for Chapter 11 protection in the US. Kodak had an opportunity to create digital images and meet what customers wanted. Well they didn’t. Our healthcare system is in the similar throws of failing to read the handwriting on the wall. Are elements of our healthcare system behaving similar to Kodak, ignoring consumer wants and needs?

Our healthcare system largely focuses on producing healthcare, not health. Consumers want health and healthcare is a means to that end. It is the system we have in place, it is the fact of life and death in the US. Our system is designed around writing prescriptions, performing surgeries, and imaging. The authors rightly state this is how we get the health we want, through this system. They also go on to present the fact that our current system looks at health and disease as if it were entirely biologic and not in reality driven by social determinants, economics, personal behavior, social disparities, environmental influences, geography, etc.

Add to that the simple fact we are now in an age of outcomes. Never before have we had the ability to identify, measure, and report outcomes from entire systems and populations down to a single physician. We know what is working for whom and are making healthcare decisions based on that knowledge.

Finally the authors point to the fact our healthcare system is now testing costs and non-payment for preventable readmission or payment for bundled care. Outcomes and payments will be linked going forward.

In summary the authors state that unlike Kodak who were clueless about what their customer wanted successful physicians, hospitals, and provider systems will ‘shift their activities from delivering health services within their walls toward a broader range of approaches that deliver health’ They will in effect answer this question, ‘What do we need to do to move from a product-oriented industry to a customer-oriented one?’

Currently healthcare is about selling a product based on a response to a need, an illness an accident. It is a reactive model built less on customer’s needs and more on a situation. The system orders more tests, lowers costs, and drives utilization. It is like a broker churning your account. This strategy is inherently going to fail because of the changes listed above. The system is not looking at what customers want and where the puck is going to be but what is an immediate point of purchase behavior. The system is built on more use greater the revenue and ultimately profit.

The authors speak to the need for organizations and providers to look at wellness programs and other offerings that move the hospital away from being a provider of products to meeting customer needs.

In my opinion there are two additional factors that point to a direction that becomes a solution to the need to become customer oriented. We know the numbers. A larger portion of the adult population uses the Internet to search for health topics. To solve a health problem a greater number of patients and people are searching, chatting, joining, sharing, etc. online health questions, knowledge, information, etc. They are integrating this new knowledge into their healthcare corpus compendium. Some may be using it with their HCP but it is more likely their efforts are thwarted or fall on deaf ear. But they remain steadfast in their access of healthcare knowledge, data, and information.

Healthcare can get into a simple customer oriented business: information and knowledge transfer. Each hospital, each physicians office, each clinical department, etc. can become resources for knowledge, information, and data. Each and every one of these parts within healthcare can become a resource that customers (aka patients) can turn to, rely on, and trust.

Knowledge is power and that is not limited to who has the knowledge but, where that knowledge resides, how it is transferred, what its context, and how the receiver of that knowledge uses it and where. This model becomes the single most important connection driving exchange of knowledge and changing the dynamic from providing a product to providing a service based not on need but a relationship.

PS: A great analysis of content and publishing to support this idea from Digital Tonto. 

What If We Gave Ribbons for EOL and HPM?

Wednesday night during the hospice and palliative medicine (#hpm) chat there was a great deal of discussion on how to improve the HPM message to achieve wider acceptance. The question was; why aren’t more people supporting/using/talking HPM? It was a veritable Mumbi traffic jam of brain cells crashing into one another and tweeting ideas. There were the headlines, tag lines, messages, data, and a slew of tactical other recommendations. Some were good, some were not, overall the earnestness of those wanting to fix this demonstrated how critical it is that we once and for all get a handle on HPM and bring its benefits to more.

The literature is filled with references, data, studies, support, and more for the value of HPM. There is no shortage of organizations and groups promoting and advocating for HPM. We know the data. But we also know the other data, neither HCPs nor patients want to talk about it or learn it. Once they do understand it they are more likely to discuss it.

We have Death Cafe’s  and Death with Dignity The CAPC is an amazing resource for HCPs. With all this and more in place and the brave new digital world we live it should be a slam-dunk to change how we view, use, and accept HPM. The reality, it’s moving at a glacial pace. What can be done to change that?

It’s time to role out P&G, MickeyD’s, Big Pharma, etc. marketing departments and attack this problem as if we are selling soap on a rope. I will lean heavily on Greg Satell at Digitaltonto. His keen marketing and digital insight will help guide this discussion.

Last October Greg posted ‘The Post-Promotional Paradigm‘ which looked at how consumers and brands interact in the digital era. He presents three pillars of the brand (HPM for this discussion) awareness, advocacy, and sales.

Yes I said sales meaning physicians speaking about HPM and patients understanding it and adopting it. Have we been converting awareness to uptake? How efficiently are we converting awareness to use to avocation? I am not sure I’ve seen the data that shows growth in both understanding and use of HPM between both HPC and patients. We need to measure change to know if what we are doing is working and how to adjust it.  

Awareness is clearly critical for HPM. To create awareness you can spend money or you can be clever. People are aware but the accuracy of that awareness is sorely lacking and misguided. Greg states rightly so that consumers are likely to buy your brand if they are familiar with it. With HPM they need to be comfortable with it but most patients are aware of the wrong message. You need to convert misinformation to good information and that effort is harder than simply raising awareness. You need to replace misinformation with accurate information.

Advocacy is not simply someone speaking well about HPM. It is a complex interrelated process. We have advocacy galore with all the chats etc. but it is our echo chamber. Advocacy as Greg sees it is part of awareness. Those who come to understand and accept HPM need to advocate for it and means a sea change in peoples attitudes. It means they must accept it for themselves and then speak up for it, which currently has a degree of discomfort.

Greg further presents a framework that fits with HPM. It is seed, convert, and share. Seeding is the action of non-paid media. We seed messages on FB, G+, Twitter, Blogs, etc. It and of itself is only part of the an overall strategy it needs the addition of paid media to succeed. For our discussion of HPM paid media can be as minor as local hospices placing small space ads.

Share is where brands or those of us advocating HPM share our messages with others who advocate similar messages or messages within the same ballpark. I would agree with Greg here sharing as we currently do it does not have the consistency of message we had all hoped for. It is not reaching who we need to reach. We talk to ourselves and share with those who already have similar views. That may be changing.

Greg ends his article by addressing the fact consumers (i.e. learners) haven’t changed how they talk to each other. We are assuming that we should stop promoting in favor of conversations. We assume the Internet and social media will help change awareness and understanding of HPM. In reality we need to build a more traditional approach to promoting and marketing the benefits of HPM.

Okay I’ve given you marketing 101 according to Digital Tonto. This is as helpful as tossing URLs on Tweets. Here is how I would apply Greg’s views to HPM. And one caveat this is marketing and communications, there is not one yellow brick road but a super highway to sell HPM.

Humans are little tiny hope machines. They exist for hope, for belief in the future and life. That is at the core of why HPM is not selling like the strawberry pancakes at IHOP. Hope trumps EOL. We have an infinite loop of ribbons and survivor stories. People are donating to find cures and data shows improved survival rates. Our war against cancer is working. People are no longer shunning the word cancer. HPM and EOL pales next to this. Both have huge benefits. I won’t go into that since I’ve posted it before here and other place. HereHere

Most people consider HPM as the Darth Vader of medicine. It needs to become Luke Skywalker. So we have to change perception, gain awareness of a new HPM, position it as a benefit to patients, family, and HCP. We need to create awareness, advocates, and measure change. We need a SM message consistent with a paid message. This is a tall order for groups that are budgeted poorly, if at all.

The steps I would take would be: shock/awe, convert awareness, educate, create knowledge base, reinforce understanding, and measure uptake. I will speak to the first two and perhaps address the others later.

Shock/awe is my way of saying we need to dramatically move HPM EOL out of the musty dank dark trunk in the attic. It needs to burst into the sunlight. So to that end I propose we create a ribbon for HPM or EOL a black ribbon with a smile face. How dramatic would that be? The uproar in the media, the net, and among groups who have ribbons galore would create a natural platform to speak from and if enough media runs with this awareness of HPM would grow. Yes it could backfire and just reinforce the HPM EOL bad press or no press. But as Neil Young says, “It’s better to burn out than fade away” I double dog dare any group out there to have a HPM EOL fun run with ribbons. Money donated goes to supporting palliative care and education. Make your local media sit up and take notice. I’m a bit glib here and I recognize messaging of this is critical but the concept is big and bold. I’m open to other ideas within this context.

Following shock/awe is converting that awareness into useful knowledge by consumers. Once you create the drama you need to provide knowledge base for people. Here is where you apply traditional marketing with digital. Continue the discussion.

So do we politely talk and advocate for HPM and EOL? Or do we step up and tackle it head on with aggressive and smart marketing? HPM and EOL is not something you are left with it is a decision, a choice as critical and evidence based as any treatment option with well defined outcomes for everyone.

What To Do With 5000 Hours

July 5 NEJM published an article titled ‘Automated Hovering in Health Care- Watching Over the 5000 Hours’. 

The primary premise presented is that the US is ‘a reactive, visit-based model’ where patients are seen when they become ill, are hospitalized, and as outpatients. Besides being expensive and not driving proactive improvements in health it fails to address the 5000 hours per year that all of us spend outside of those healthcare encounters. It is during those 5000 hours where we engage in healthy or not behavior.

The importance of those 5000 hours is being addressed with various initiatives focused on employers and employee wellness programs, medication adherence, transitional care, and identifying the highest needs patients. These programs engage personal hovering, which make them expensive and difficult to scale up. A multi-center telemonitoring trial with heart failure patients showed no effect on outcomes of rehospitalization and death.

The authors presented three developments where automated hovering offered promise. The first is payments for outcomes as well as non-reimbursement for preventable readmissions. The second is the application of behavioral economics and the human desire to want better health and know what needs to be done to achieve it by applying motivation and financial incentives. And finally new technologies such as cell phones, wireless, and the Internet offer new ways to hover during those 5000 hours at a lower cost.

A study using a home-based pill dispenser connected to a lottery system offering a chance to win prize money reduced the rate of incorrect doses from 22% to about 3% in patients taking warfarin. Another study randomly assigned difficult to control patients with diabetes to receive standard care or mentorship from another patient who was successful in managing their glucose levels. After 6 months glycated hemoglobin levels were greater than a full percentage point lower then those in the control group.

The authors conclude by identifying targets fro automated hovering. Those include conditions whose management is dependent on individual patient’s behavior, medication adherence in hearth failure patients, management of diet, exercise or weight. Key to this success is how to make hovering heard over the din of social media, TV, and those things competing for out attention.

The ground work has been laid: behavioral economists, clinicians, educators, and patient groups will be gathered and studies initiated. These are complex studies. Any outcomes from these studies may not be anything that can be easily executed at the bedside or following an office visit.  There may be one or two small things the HCP and the patient can do while waiting for these studies to be completed and initiatives to become part of our healthcare landscape.

Perhaps the HCP and the patient can establish something like shared decision making but in the realm of shared knowledge exchange where both the HCP and the patient agree to exchange information about health related topics specific to the patient. These can be as simple as short text messages regarding glucose monitoring or exercise or articles on a topic specific to the patient. This can all be established prior to the office visit via a tablet and confirmed during the visit. The principle is that at the visit the patient is more aware and interested in health and healthcare: leverage it. No point in loosing an opportunity to establish a conduit for communications, a way for both parties to open up those 5000 hours to each other in simple non annoying nanny state fashion. You can’t change behavior without having both parties sharing the need and desire to listen and learn. Engagement is a small simple step in communications between patient and HCP that begins perhaps a long term relationship.

July 18, 2011

On  July 14, 2011 the oncologist and the team spoke with us to introduce the concept of palliation. It was a hard and difficult conversation to hear and with 20/20 hindsight it was the moment that Donna began to give up.

They recommended home hospice. So that weekend I pulled it together and ordered the bed, etc. I guess after the weekend and taking one look at how emotionally fucked I was they recommended Donna be moved to Karpus 4 the in unit hospice. For the next month the bed remained in the apartment reminding me of what was not happening. What was lost. What will be forever. She will not be back. Of course I can always go to her.

If I’m Not A Survivor Am I a Loser?

Based on an article in the NYT ‘Life, Interrupted: Am I a Cancer Survivor?‘  I posted the a Tweet and received the following responses which is spurring this post. 

These response made me stop to consider who are the losers and winners in terminal and serious illness? 

In the NYTime article Suleika Jaouad asks the following question ‘What does it mean to be a survivor?’ She further states that, and rightly so, the term “survivor” is as ubiquitous as it is hard to define. Cancer, its diagnosis, treatment, and outcome is as complex as Higgs boson. Cancer is not a binary zero or one, on or off, yes or no. It is a gradient of the disease, the patient, the family, the HCP, the insurance plan, and a dozen other variables. To look at someone with cancer as winner or loser I believe harms those with cancer who choose palliation or hospice. The reality is that there may not have been a choice to go into palliative or hospice care but, to position that decision in relation to being a survivor a winner harms the entire spectrum of terminal illness and especially cancer. 

Let me make a point right now. I am not advocating that those diagnosed with cancer don’t fight like hell. They should do anything and everything to not lose that fight. (You can’t help but use that win lose analogy.) At the same time the American Cancer Society states there will be 1,529,560 new cancer cases and 569,490 deaths from cancer in 2010. The ACS further reports Cancer death rates fell 21.0% among men and 12.3% among women during 1991 to 2006. This could not happen if there were not winners and if people were not committed to survive. Those half million Americans who died fought their disease. Are they losers? And as they were losing their fight did they suffer unnecessarily? Did their loved one witness something that will forever remain etched in their memories? Those of us who have benefited from palliative and hospice care I hope feel as I do, even in my loss, my wife’s ultimate loss, there was a small sense of victory, it was dignity for both of us. As I’ve said and still don’t know where I Bogarted it from ‘Hospice saved my life.’

Robert Wood Johnson Foundation had a post ‘The Path to Palliative Care‘ which documents the December 1995 issue of Time magazine publishing the findings of SUPPORT the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. Knowing When to Stop which to quote ‘American physicians often ignored the last wishes of dying patients and caused unnecessary anguish and stress’. The post points to the development of a robust palliative care movement in the US. As I’ve posted here before we have come a long way and many of us have benefited from palliative care and hospice but the data is clear there is more to be done. This movement and those who deliver it know how it makes a huge difference to both patient and family. Would they be investing so much and serving so selfishly if was not a winning proposition? 

Further in the Jaouad NYT article she says a friend Tweeted the following ‘I loath the term. It’s either exclusionary or overly broad. So I don’t define it, I avoid it’ The author ends the article by saying she will continue to figure out what surviving is. And that is a great conundrum to face.

Those who know and have experienced palliative or hospice care know it is a hard choice to make and accept. It is hard to travel that path but compared to the alternative it makes everyone a winner. Perhaps those of us who some feel are losers need to let them know we are not.

July 10, 2011

On July 10, 2011 Donna and I had dinner at the Odeon.

The previous week of was a rough one. For much of the year Donna was fighting with HPO (hypertrophic pulmonary osteoarthopathy) a depilating condition of the joints especially in her knees. We spent months trying to resolve it but the bottom line was we had to achieve tumor regression again. So for June Donna was on her third line of chemo, Gemzar. We had a CT earlier in the week and were scheduled to see the oncologist on Friday July 8. He said the chemo wasn’t working and Donna has pleural effusion that should be treated. He scheduled a pleurodesis for Monday July 11. Told us the last place we wanted to be was in the hospital over the first weekend in July. (New residents, interns, and fellow. Think Homer Simpson with a degree)

Dinner on Sunday was low key. The walk home, only two blocks, was difficult. Each step Donna took was painful and slow. She walked like one of Jerry’s kids on a telethon with braces. Stilted halting steps. Each step counted out to avoid getting to where we were going. I wonder how she remained so dignified.

We finally made it home. I believe ‘True Blood’ was on. We watched it and went to sleep. The next day with Donna in even more pain we headed to Beth Isreal. I had to carry her to a wheel chair. Little did either of us realize Sunday July 10, 2011 dinner at the Odeon was our last meal together. The last time we slept together. The the last time she would be home.

Palliative Care and the Hospice: A Gift for the Living

This is going to be largely an opinion post as a follow-up to the previous one about palliation. Clearly palliation has a place and it works just as hospice and EOL care does. This cannot be disputed. And there are benefits for both patient and caregiver when this care is implemented. 

Yesterday during a group session we were talking about palliation and pain management. We were discussing that at times in either nursing homes, at home, or hospitals patients with terminal illness may not be receiving proper pain management. A person familiar with that commented that there are cases that we’ve all seen, where the patient is in abject agony and they are waiting for their next administration of pain meds, which comes but never gets ahead of the pain. Or the family feels that having the patient overly sedated is not fair to them. And there is always the fact the attending may not be up to speed on pain management etc. These are all problems that can be solved with education learning etc. We have to work toward fixing these issues. 

What struck me was how my experience with Donna and her time in hospice etc. was different from some others that I’ve spoken with. Make no mistake about it hospice is horrific for everyone involved. It is not the Four Seasons but it meets a critical need. It serves a purpose and achieves its goal for the patient and the family/caregiver.

Psychosocial adjustment that raises patient quality of life is also dependent on the relief of burdens and the strengthening of important relationships prior to death (Singer et al. 1999). Patients often have great concern that they are being a burden to their family and their caregivers (Steinhauser ct al. 2000a). Improving communication between patient and family and patient and healthcare professionals could do much to relieve the burden that terminal illness may bring and strengthen the relationships that arc necessary to raise the level of quality of life at the end of life. Raising quality of 11% and quality of death maximizes the patient’s opportunity to experience a good death.” 

Beyond the patient’s care and comfort we must consider those left behind. Those who carry the burden of watching and caring for a loved one during illness and at end of life. The time following a passing is as important as the time spend in health. It should be spent in positive memories during healthier times. Time following a death should be spent sorting out what was and wasn’t in the relationship and how to create a tapestry of that love that will stay with us for our lifetime. 

I know for me with the positive experience I had with palliation and hospice it still took me months not to have the images in my head of Donna wasting in hospice. But they have been largely replaced by our life together. This begs the question, for those loved ones left behind who may not have benefited from palliative care or hospice, what are their lasting images and impressions? Do they question why they were not offered palliative care or offered it late or choose not to implement it? Do they spend their time post death sorting out what happened in the last few weeks and not what they had during a lifetime? Are those family members and caregivers, who did not benefit from palliation, do they have higher rates of depression? Do they suffer greater incidence of complicated grief when compared to caregivers who were part of a palliative care process?

Palliative care is a gift. It is a gift from the healthcare community and the person who passed away. It is a gift for both the living and the dying.

Fear and Loathing During the Office Visit: An Opportunity

Today the NY Times had a short article in the Well Section “Afraid to Speak Up at the Doctors Office” It was a summary of a longer (behind a paywall–grrrrrr) article in Health Affairs “Authoritarian Physicians And Patients’ Fear Of Being Labeled ‘Difficult’ Among Key Obstacles To Shared Decision Making
Three points struck me as I read the article in the Times and the abstract. First, shared decision making is key in collaborative medicine where the patient participates in their treatment and care as an HCP partner. One of the best examples of how SDM works and what it can do is The Ottawa Decision Support Network. Using SDM to it fullest potential with all the features and benefits is not a simple task for the busy practice. Second, the fact that patients have these questions and concerns and want to engage demonstrates that adult learning is at work. Patients want to find solutions to problems they have. They want to be active learners but are held back by …”patients feel compelled to conform to socially sanctioned roles and defer to physicians during clinical consultations; that physicians can be authoritarian..” And finally there exists a huge opportunity for both HCP and patients to create ‘productive inquiry’ that can improve outcomes and how care delivered and its effect.

From the abstract the authors argue that the HCP may not be aware that patients are holding back or are afraid to engage in learning. This is a perfect opportunity for the HCP to manage patient care from a place of partnership and not top down. I wrote a post  “Changing the Office Visit from a Transaction to a Value Experience“. My failure in that post was to assume the HCP was ready to engage. Based on this study it seems the HCP is clueless to this need and opportunity. Nature hates a vacuum and this one needs to be filled.

From my view I would try to demonstrate that engaging with the patient in productive inquiry has benefits not just of warm fuzzy feelings but of improvements in outcomes. And we all know that outcomes is the new black in healthcare for both institutions and individual practices. The key is to not have the HCP try this with an entire practice but do his own small two arm study. Look at patients sharing a common illness or healthcare need, identify those who are seeking solutions to problems they want to solve, and divide them in half. With one group actively participate in their learning. With the other, treat and manage as usual. In six months do a chart audit to determine their clinical outcomes. But also measure the patients knowledge and understanding of their illness and how they are approaching and self managing. I would present that the clinical outcome should equal the social outcome of the patient as an active participant with the HCP in the management of their health.

NPR and Planet Money: Who Gets a Liver Transplant

NPRs Planet Money has a podcast this week titled ‘How Do You Decide Who Gets Lungs?’ It was an excellent examination of the current system for organ donation and recent changes to that system. An interesting point was made. Pre 2002 liver transplant lists were set by patients in ICU and time in ICU. Those in ICU were at the top and the longer you were in the higher your position on the list. Post 2002 it was changed to a more objective criteria including bilirubin, creatine levels among other clinical data. During the discussion physicians said that once the system changed the number of patients in ICU needing a liver transplant dropped significantly. They admitted that that may indicate gaming of the system. doh? In the new system it is harder to game it since the criteria is clinical and objective. 

Overall this was an excellent podcast on a very critical topic in healthcare. But I feel they missed a point. Transplantation is a huge business for both the institution and the HCP. There is an economic incentive to get the organ in order to do a transplant. I am in no way saying institutions or HCP position economics over patient care. What I am saying is that Planet Money may have missed another point to examine, what are the economics of transplants? But that is not as dramatic as life and death.