What Academic Medical Centers Can Learn From Lippi

Fra Filippo Lippi - Madonna with the Child and two Angels

What does this 15^th century Renaissance painting have to do with a 21^st century academic medical center?  Painted by Fra. Lippi (a monk of some questionable repute) in about 1465, I selected this image as an analogy for our two broad challenges in building a successful academic medical enterprise in the rapidly changing healthcare environment.

The first challenge is the need to innovate.  At first blush, Lippi’s Madonna With Child and Two Angels may not scream innovation.  However, in its time it included a number of groundbreaking techniques.  For a moment, focus on the landscape in the background of the painting.   The use of realistic perspective was an innovation of the period, and separated it from flat two-dimensionality of medieval art.  Note also the painted frame surrounding the scene; the placement of the characters in front of the frame brings them into the world of the viewer.  Coupled with the cherub in the lower right – who makes direct eye contact with the viewer, and looks like he knows a secret he wishes to share – the effect is to draw you into the painting.  This is a degree of interactivity that would have been startling at the time; something akin to watching a 3D movie when all you have known is black-and-white television.

The need for innovation in today’s academic medical center is driven by the pace of economic, demographic and scientific change.  This topic could consume (and probably deserves) many pages of discussion.  However, at least some of the challenge is represented in the Institute of Medicine’s call to create the Learning Health System (LHS) of the future from the Academic Medical Center (AMC) of the past.  A Learning Health System uses data to drive continual improvement in the care of patients.   All three words – Learning Health System – have meaning.

Academic could be interpreted by some as detached and separate from the care delivery system.  Note, that one secondary definition of the word “academic” is “theoretical, speculative; having no practical or useful significance.” Learning implies a continuous and ongoing feedback loop.  The process of discovery and acquisition of new knowledge, while still invaluable in their own right, must be actively applied to improve care.  Care that is suboptimal or inconsistent across populations must be a major catalyst for the process of discovery.

Medical strongly suggests we are focused on the diagnosis and treatment of disease –still a priority in the new world order.  However, the concept of health broadens the mission.  Not only will our emerging LHS develop startling new treatments, we will also take responsibility for maximizing the health of populations.  Prevention of disease and improvement of environmental and behavioral determinants of health will become much more critical components of an institution’s academic portfolio.

Center strongly invokes a specific place (perhaps an ivory tower).  The concept of system conveys a heightened priority on connectivity.  In the traditional model, the care delivery system is where learners go to practice when they finish training.   In the emerging model, learners and the educational process will be integrated into the delivery system.  In the Academic Medical Center, research produces knowledge that is pushed out to providers of care.  Frequently, it takes many years for this knowledge to be integrated into practice for the benefit of patients.  In the Learning Health System, the acquisition of new knowledge remains critical.  However, in addition, the science of care delivery – the implementation of new knowledge – takes on added importance.  The care delivery system becomes an important laboratory.

The second challenge represented by Lippi’s painting is the changing nature of the “halo effect” in academics.  The Madonna’s halo is faint and ethereal.  It does not jump off the canvas at the viewer, and could even be missed by the casual observer.  This reflects the diminishing value the patina of academia has for health care systems.  Over the past half a century, in a system relatively flush with revenue, a hospital could reasonably be expected to contribute resources to education and research almost purely for the associated reputational benefit.  In the emerging health care economy, hospital margins are small against historical standards, and economic success is driven by managing cost and improving outcomes.  The economic value of reputation is waning.

The challenge for the LHS of the future will be to repaint Lippi’s halo with heavy, bold, thick brushstrokes.  Successful Learning Health Systems must foster partnerships with successful care delivery systems (like Catholic Health Initiatives).  Ideal partnerships will be mutually symbiotic:  the care delivery system will provide new academic opportunities for educators and researchers.   In return, the engine of academia must drive concrete strategic advantage back to the health system partner.  I will develop this concept more fully in a future posting.

Lippi’s Madonna and Child frames the questions we all need to be asking of ourselves.  How does my work help the Baylor College of Medicine drive the culture of innovation necessary to be the national model of a Learning Health System?  How do our great strengths in education and research drive measurable strategic benefit to our health system affiliates and partners?  Finding the right answers to these questions will drive our success for decades to come.

This has been cross-posted from the Baylor College of Medicine blog Momentum

Data is the New Oil

I recently was given the opportunity to represent Baylor College of Medicine at the Association American of Medical Colleges (AAMC) as part of a year-long conversation on becoming a “Learning Health System”.

At the inaugural event, I heard from others around the country examples of substantive efforts to harness the power of academic medical centers to improve the care delivery system and the health of populations.

There is no one definition of a LHS – in a subsequent post I will discuss my understanding of the concept, and what it could mean to Baylor and our affiliates.

In this post, I want to focus on a single phrase, which resonated with me. It resonated because it is pithy and succinct. It resonated because it encapsulates succinctly much of what it is to be a Learning Health System.

Perhaps it also resonated because, after more than a year at Baylor, I consider myself a fully acculturated Texan. It is such a simple phrase, I am sure most of you have heard it before, but I had not:

Data is the new oil.

In Texas, oil is literally under our feet. We cannot see it, but it is everywhere. Like oil, data is all around us: In our electronic health record; in our billing and insurance systems; in hospital quality measures; in our patients’ genetic material; in disconnected and disparate tissue biobanks. We cannot see it, but it is all around us in quantities that boggle the mind.

Like oil, it is worthless where it is—it must be extracted. We must drill for oil, we must mine for data. It is necessary to pull data together into systems that can make connections and recognize patterns.

Oil comes out of the ground dirty—full of impurities and contaminants. It must be refined and processed. The impurities must be removed, and desired compounds isolated. Raw data is similarly dirty. It is filled with errors and noise. It needs to be filtered and cleansed to be useful.

The resulting petroleum product—gasoline, heating oil—then needs to transported to the end-user. Investment is needed in trucks, rail, pipelines and tankers to get it to the consumer.

Likewise, data is of limited utility if it remains locked in servers, or in the hands of a data sensei. Systems need to be developed to get actionable data in the hands of providers, teachers and researchers where it can make a difference.

For example, assume based on data (patient demographics, physiologic parameters, social factors, genetic factors) we could predict with reasonable certainty the likelihood a patient would be readmitted. Would an attending physician and case manager alter their discharge and follow up plans for a patient with a known 75 percent chance of readmission?

Finally, before the analogy becomes overly tortured, the oil buried under our feet is entirely worthless. It is only after it is extracted, purified, refined and delivered to the consumer that it has value, and its value is substantial—influencing the rise and fall of nations. The data in my computer is worthless. Our data—extracted, purified and accessible—also has incredible value, upon which health systems may rise and fall.

Baylor will continue a discussion of what it means to us to be a Learning Health System. Our definition will and should be unique to our organization. However, it will certainly demand the effective and efficient use of data.

Note: Based on extensive research (i.e. a Google search) the phrase “data is the new oil” is attributed to Clive Humby in 2006.

This has been cross-posted from the Baylor College of Medicine blog Momentum

Monday Morning: Little Things

Learned helplessness — I have heard this term used for years, but never knew (or forgot) its experimental roots.  Here is an experiment that I am confident no institutional animal protection committee would approve today:

In the 1960’s, Martin Seligman, a psychologist, performed a series of experiments on dogs to evaluate the behavioral effects of chronic, unavoidable aversive stimuli (The Gale Encyclopedia of Psychology, Second Edition).  In the original experiment, dogs were confined in a small box, with no exit.  A buzzer sounded, followed shortly thereafter by the administration of a painful electrical shock through the floor of the box.  Over time, the dogs, who could not avoid the shocks, learned when the buzzer sounded there was little they could do but cower in a corner of the device and whimper pitifully.

Once trained the painful stimulus could not be avoided, the investigators then opened an escape hatch in one of the walls.  Any dog who had not been through the initial training would immediately escape through the opening.  The trained dogs, however, would still cower and whimper — having learned that escape was impossible, they were unable to help themselves.

Thus, the concept of learned helplessness was born:

An apathetic attitude stemming from the conviction that

one’s actions do not have the power to affect one’s situation.

In humans, the construct is useful in understanding some forms of depression and anxiety.  The phenomenon has further been characterized by “3 P’s”.  Permanence — my life situation is bad, and will remain bad forever.  Pervasiveness — because this aspect of my life is bad, the rest of my life is bad as well. Personalization — the bad things that are happening to me are directed specifically at me.

I certainly feel for Seligman’s dogs.  But I also feel for another group that has a tendency towards learned helplessness — doctors, nurses, allied health professionals and others who work in the US healthcare system.

Pick up a newspaper, read a professional journal, attend a medical conference, watch any commentary from broadcast media (regardless of the political slant) and you will hear about a broken system in need of fundamental change.  In my Seligman’s dog analogy, there are myriad electrical shocks: pressure to see more patients while providing more personalized care; incorporating a not-ready-for-prime-time, work-flow-disrupting electronic health record into daily practice, while increasing efficiency and productivity; discharging patients more quickly, while decreasing readmission rates.  The list goes on. (See prior postings: Cloud of Healthcare Anxiety Part I and Part II)

Like Seligman’s  dogs, the means of avoiding the shock seems to be out of our control.  There are proposed solutions, but few an individual can implement.  The individual doctor, nurse or therapist cannot start an Accountable Care Organization.  They cannot build a vertically integrated regional care delivery system.  They cannot develop data aggregation and analytics capacity to manage populations.  They cannot assemble a large physician network.  As a consequence, a growing body of literature suggests health care professionals are increasingly burned out and dissatisfied.

Obviously, no one has an easy solution to this dynamic.  Eventually, the system will stabilize.  The privilege working as a medical professional — of impacting the lives of others in a deep and meaningful way — will outweigh the stress created in an environment of change.

In the meantime, it is our responsibility to look for our own way out of our box.  I propose we as individuals need to focus on little things we can do to improve our situation that are within our control today.  Small actions to take care of ourselves. Activities to help prepare us personally for the future.  Small interventions to help build a functional organizational culture.  If on Monday morning, a small number of people in your organization committed to doing some positive and achievable thing, and followed through, you could start to replace helplessness with optimism.  Intermittently, in future posts, I will suggest some "little things".  In the meantime, I invite others to help answer the question (please leave comments):  to prepare for a fulfilling future career in healthcare, what little thing can I start to do on Monday?

On-line educational content: harder than it looks

Quite some time ago, I wrote a blog post reviewing Salman Khan's "One World Schoolhouse". That book introduced me to the concept of the flipped classroom, in which the teacher provides educational content in an asynchronous format (usually on-line), with the expectation the learner will access the material on his own schedule at his own pace.  The in-class time with the teacher is then reserved for working through problems, clarifying concepts and developing a deeper understanding of the material.

Recently, I posted a link describing a mnemonic device to assist in learning brainstem neuroanatomy. Inspired by Khan (and the proliferation of educational content on YouTube) I have been experimenting with on-line lecture formats, and subsequently reworked my brainstem material into video format. In other words, you've read the book, now see the movie.

The first video (about 7 minutes) reviews the anatomical location of the major cranial nerve nuclei:

The second is shorter (just over 3 minutes) and covers the major longitudinal tracts of the brainstem:

Lesson learned:  It is hard to produce high quality on-line content.  A degree of technical expertise is required.  The ability to stand in front of a large audience and be relatively engaging does not automatically transfer to the on-line virtual lecture hall.

The production value of these is fairly meager, and the narrator a tad monotone.  Hopefully the information comes across.

(Note:  If you are actually interested in the content, the videos are easier to watch on YouTube.  Click on the following links to go directly to the site: Brainstem Part I, Brainstem Part II)

Medical Education: Toy Airplane or Stone Flywheel?

Jack Nicklaus, during his first full year as a professional golfer, defeated the heavily favored Arnold Palmer to win the 1962 US Open, launching one of the greatest careers in professional sports.  Would it surprise you to learn that following this achievement, Nicklaus was quoted as saying, “I have golf all figured out now.  Now that I have mastered the game, I should be competitive for the next several decades”?  It should surprise you, because it is not true.  On the contrary, Nicklaus returned to his long-time teacher Jack Grout at the beginning of each golf season to revisit his fundamentals.  It may be apocryphal, but it is widely repeated that Nicklaus would approach Grout every year and reintroduce himself — “I’m Jack Nicklaus, and I want to learn how to play golf”.

This commitment to life-long learning, and humility to acknowledge room for personal improvement, was obviously part of the key to his success.  This commitment is important even in a game which has not fundamentally changed since the rules were established 250 years ago.

Unlike golf, medical knowledge changes rapidly.  In 1950, the doubling time for medical knowledge was 50 years.  When a doctor entered practice, he (in that era, usually “he”) could be fairly comfortable the knowledge and skills acquired were durable.  By 2020, medical knowledge doubling time is projected to be 73 days.  Medical knowledge should now come stamped with a “best if used by” date — it is a perishable commodity.

This dramatic change in the shelf life of knowledge demands a new educational paradigm.  By way of analogy, we need to transition from a balsa wood airplane, to a stone flywheel.

Remember the rubber band-powered, red-propellered balsa wood airplanes many of us had as kids?  You would wind the propeller and watch the rubber band start to twist, storing potential energy.  Wound a little bit tighter, the band would start to double back on itself.  Fully wound, with the flaps adjusted appropriately, launched at the correct angle, it would fly clear across the front yard.  That is much how the traditional model of medical education functions.  Bright young people enter medical school, to have their brains filled with knowledge.  Their red propeller is turned, their rubber band is wound.  On to residency, to acquire an even more specialized knowledge base and skill set.  Wind the rubber band some more, and it starts to double back on itself.  Complete the required training, take the required certification exam, and the rubber band is fully wound.  The cognitive balsa plane is now ready to be launched, hopefully with sufficient knowledge stored to carry a physician through a career spanning multiple decades. 

A better modern analogy is to think of medical education as a massive stone flywheel— heavy, with substantial inertia when stopped. It can take many full grown men, literally shoulder to the grindstone, to start it turning slowly.  Students enter medical school with their flywheels at almost a full stop.  It takes a lot of energy, and a lot of pushing to get the wheel turning. Then something magical happens.  Inertia is gradually replaced by momentum.  As the wheel begins to turn, it becomes easier to push and to get it to turn faster. It spins more rapidly as you complete medical school.  On to residency, where it gains even more momentum.

Finally, off to practice, with a fully and rapidly spinning cognitive wheel, that must continue to spin for decades.  Fortunately, it does not take much to keep it going.  A gentle tap or nudge, regularly and consistently applied will keep it spinning.  However, if the gentle taps are neglected or postponed the wheel will start to slow — even come again to a full stop — and require excessive energy to get it restarted.

The flywheel represents the concept of life-long learning.  Life-long learning is not a program, but a core personal commitment.  It is not Continuing Medical Education (CME) or Maintenance of Certification (MOC).  If I jog three times a week, it does not make me an athlete.  To become an athlete requires more than commitment to intermittent exercise.  It requires a thoughtful and directed training regimen, good coaching, a healthy diet, adequate rest, etc.  Completing a required number of hours of CME does not, in and of itself, keep the flywheel turning.  It requires a professional commitment to continually question your practice, measure and improve quality and learn from patients and other members of the health care team.  It is not a program, but a component of professionalism.  This is perhaps the greatest fundamental challenge of medical education today — to create self-directed and motivated life-long learners.  In other words, to trade in our cognitive balsa planes for flywheels.

Learning Brainstem Anatomy: A Mnemonic Device

For those of you with an interest in neuroanatomy, the attached article presents three simple rules to remember the location of all the cranial nerve nuclei and major tracts.

Access is free, but time-limited (12.11.2014). Anyone who clicks on the following link will be directed to the complete article on ScienceDirect, free of charge. No sign up or registration is needed - just click and read!

Link: Learning Brainstem Anatomy: A Mnemonic Device (free full text)


If the link is expired, here is the reference:

McDeavitt JT, King K, McDeavitt KR: Learning Brainstem Anatomy: A Simple Mnemonic Device”. PM&R 6: pp. 963-966, 2014

Book Review...The End of Absence: Reclaiming What We've Lost in a World of Constant Connection

When I was 16 years old, I have a vivid memory of a thunderstorm.  It was probably a Saturday or Sunday afternoon.  The storm clouds started to roll in, and the thunder rumbled in the distance.  I was outside, climbed on top of an old school bus and lied on my back.  From that vantage point, all I could see was the gathering and darkening storm clouds framed by the leaves of old tulip poplar trees.  I remember the leaves revealing their lighter side in the wind, and the tactile sensation as the thunder crept progressively closer, until the rumble became more of a visceral sensation than a sound.

I do not know why I retained this memory, and lost so many others.  I also do not know if this experience was formative in some way.  Did it alter the way I saw and appreciated nature?  Did it awaken some latent creative impulse?  Did it help to form my metaphysical view of the universe?  Honestly, probably not.  But it was significant enough that my brain saw fit to establish synapses to encode this memory, and allow me to retrieve it decades later.  Furthermore, there is one thing of which I am fairly certain.  Were I sixteen years old today, and a similar storm rolled through town, instead of being caught up in the wonder of the moment I would more likely be texting my friends, playing Halo on my X-Box 360 or interacting with a social media site.

This is the fundamental premise of Michael Harris' The End of Absence: Reclaiming What We've Lost in a World of Constant Connections.  That is, we now live in a fundamentally different world of constant electronic connectivity, and like most transformational societal change, the transition brings great benefit, but at some cost.  This book addresses this important issue through a well defined truism, an underdeveloped hypothesis and an interesting observation.

First, the truism.  The rapid integration of information and communication technologies into our lives has occurred at a stunning pace.  The world has changed, and if you had any doubt of this fact, Mr. Harris’ book does an admirable job of chronicling the sweeping nature of the change.  The first few chapters are chock full of great factoids to fuel your cocktail party banter.  In 2012, the world performed one trillion Google searches in 146 languages.  During that same year we sent each other 144 billion emails every day.  It took 38 years for the new technology of radio to garner 50 million adopters.  Television: 13 years.  Twitter: 3 years.  Google + : 88 days.  The ubiquitous onslaught of communication technologies into our daily lives is consuming time that used to be spent doing something else.  In Mr. Harris’ view, that something else is unstructured time, free of distraction.  His case is compelling, and presented in a clear and concise fashion.  Still, what he has done is document a truism, albeit in a compelling and entertaining manner.  I doubt there is any adult in the developed world today who would disagree with his premise.

Second, an underdeveloped hypothesis.  The unstructured time we have lost is important, as we form cognitive associations in our brains during times free of distraction.  Ideas tend to come to us in the shower. There is an element of serendipity to discovery.  The story of Sir Isaac Newton and the apple is not a myth, but is actually fairly well corroborated.  He was sitting in a garden and was struck by a falling apple.  He had the sudden inspiration that all objects fall directly towards the center of the earth.   Had Newton been working on his iPad, Googling current theories of attraction and crowdsourcing his thoughts across his social networks, would he have still made the cognitive leaps to the theory of gravity and differential calculus?  The fact is, we do not know.  Maybe the intuitive creative connection of his brain would have never made the needed association to look at the world differently.  Maybe he would have gotten there more quickly (his theory was not published for another 20 years).   Harris does a good job documenting a list of dangers from our hyper-connected state; however, the book leaves underdeveloped the evidence that the loss of our unstructured time is having actual negative consequences.  We are evolving cognitively into beings that do not remember actual knowledge.  We remember paths to access actual knowledge.  For example, I know I can Google "Prologue Canterbury Tales" and immediately access the text in the original Middle English.  I can also recite the first 10 lines from memory (Whan that Aprille with his shoures soote…) because I was required to memorize the prologue by my 10th grade English teacher.  Was that act of memorization important to my neuro-cognitive development? Was a moment of quiet contemplation of nature on top of a school bus somehow formative?  I think they were somehow important.  Intuitively, I agree with Harris’ premise, and I wanted to be convinced.  However, I am not sure the objective case was adequately made that we have lost something critical in moments of absence.  The transition from a horse-driven to auto-driven economy and culture brought with it bane and boon.  Few of us would choose to go back.

Finally, the interesting observation.  The concept of “digital natives” (those born into the digital technology culture) and “digital immigrants” (older people who have adopted technologies) is well plowed ground.  Harris proposes we have a micro-generation of people born in the in the mid-1980’s.  This is a generation that were children prior to the information revolution, and experienced unstructured and uncluttered time, but were subsequently raised as part of the revolution.  He postulates this is the only group who can really have any sense of loss in this transition.  The “loss of absence” will be imperceptible to those born in the 1990s and beyond.  

Harris clearly believes (and I agree) “…the brightest moments of human discovery are those unplanned and random instants when you thumb through a strange book in a foreign library or talk auto maintenance with a neuroanatomist.  We need our searches to include cross-wiring and dumb accidents, too, not just algorithmic surety”.  In the world of The End of Absence we will need to find a way to manufacture moments of isolation and serendipity.