Hurricane

 

What follows is a very long caveat, followed by very short message; it seems to me the caveat is actually more important.

Two weeks ago, I talked about where we were. As difficult as things are now, some things are better than in April (e.g. patients seem to be somewhat younger and less critically ill, we have some emerging treatments). There is a little glimmer of hope.

Last week, I talked about where we are: the fact that our only real weapons against the viral invader are scrupulous attention to physical distancing, masking and staying away from others if you develop symptoms. Please re-read that message and broadly share with others. I still see the occasional mask-less person in the hallway and hear of someone who “didn’t feel well” for a few days at work, and turned out to test positive. I think these exceptions are few, but we need to all push for universal compliance. Mask, distance, don’t come to work sick.

As we are now in an environment where the community presence of the disease is on the rise, the natural question for this week is, “Where are we going?” What’s next?

The most honest answer – and the one that makes this whole situation so difficult – is no one knows.

It is about 6:30 Wednesday morning, and pouring down rain. I look at my weather app and see a large cloud settled over Houston. I am very confident it will be raining in half an hour. It is less clear what will happen this afternoon. I would like to spend some time outdoors on Saturday, and don’t have a clue as to whether it will rain or not.

To me, that is what the COVID-19 pandemic feels like. We can only see what is just around the corner. Everything else is opaque. Will it spontaneously fade like SARS? Become an endemic pathogen, waxing and waning for months or years to come? Mount a major recurrence during flu season? Will a safe and effective vaccine be available this year? Next?

No one knows. Dr. Fauci doesn’t know, nor do the politicians, nor do the media pundits. We have guesses – often well-educated ones – but still guesses.

We use the hurricane analogy a lot, but increasingly it is a poor fit to this situation. In Houston, we are really good at hurricane response. We know when one has the potential to hit. We have context and experience from prior storms to know how bad it might be. It makes landfall, does its damage and passes. Houston can then do what it does best – pick itself up and recover.

This is not a hurricane, though I struggle to find an accurate comparison. Comparisons all seem either trite or overblown. It is like an innocent civilian population caught between warring powers. It is like dealing with the complex physical, emotional and cognitive needs of an aging relative with dementia. It is like losing a job in a down economy and struggling to care for your family. You know it will end, but you do not know when. Part of you knows you have the resilience to get through it, and that you will find strength in a difficult situation. However, in the moment, the uncertainty is the hardest part.

So, with that caveat (nobody knows), here is my view of what to expect in the next couple of weeks:

• The viral numbers in Houston (total new cases, TMC hospital admissions, ICU census) will continue to rise.
• TMC hospitals capacity will begin to be stressed, and hospitals will activate plans for sustainable surge capacity. This will involve adjusting staffing patterns for physicians, nurses and other providers and opening additional ICU beds. The hospitals can function at this level for an extended period of time. As viral numbers continue to climb, there will be increasing planning around emergency surge capacity. It is hoped the more disruptive emergency changes in the delivery system will not be needed, and even in worse case projections right now are at least three weeks off.
• We will all know someone who develops the COVID-19 illness – a family member, friends, neighbors, co-workers. It is inevitable as the virus spreads in the community. Most of the disease in our Baylor community will be imported from the outside. Our internal testing and contact tracing processes will effectively limit the spread of the virus at work.
• The increased viral numbers and associated media focus will get the attention of the citizens of Houston and surrounding communities. For those who have not taken this seriously up to now, we will see virus avoidance behaviors start to improve. More masks, less congregation in crowded bars and beaches. The July 4th holiday weekend will still present challenges, but will be materially better managed by the public at large than Memorial Day.
• State and local officials have already started to stake out a more aggressive posture on virus control. In Harris County, masking is now required in all businesses. Officials will continue to explore effective means of limiting viral spread (through education, regulation and enforcement), while attempting to avoid the economic impact of a broader business “lockdown.”
• Improvements in masking and heightened public awareness will slow the viral spread to a degree. The success of these efforts is a major variable in predicting our peak. My current guess is that our peak will occur in late July. Remember the caveat – I don’t know if it will rain on Saturday.

My most important prediction: Our Baylor community will be stressed by the disease burden in our community, but will continue to work together effectively to meet our organizational mission. We will continue in challenging circumstances to take care of a population that needs quality healthcare more than ever, pursue new discoveries and educate future providers and scientists. Most importantly, we will keep each other safe. Thank you all.

(Note:  Between June 2020 through November 2021, I wrote weekly COVID-19 pandemic updates seen through the lens of a health sciences university.  My intent was to provide reliable information, acknowledge legitimate concerns, console, and encourage.  Each posting reflects issues our community was experiencing at that moment in time.  I have reproduced selected examples on this site).

Control

 

Today I want to talk about control – specifically, frustration over those things we cannot control, and the importance of recognizing and maximizing those things we can.

For a phenomenon that has been with us for a relatively short period of time, it may seem strange to speak in terms of “epochs,” but it does feel like we have lived through some very distinct phases in this pandemic. April was categorized by a long list of unknowns, rapid community viral spread and an overall mood of fear and anxiety.

May seemed different. We regained a little more of a sense of routine. The virus, though not in retreat, seemed to have reached a point of community equilibrium. We breathed a small but tentative sigh of relief, and even had some optimism that we could simultaneously re-engage our regional economy and hold the infectious invader at the gate.

By June, we started to see the impact of the loosening of distancing in the community. If you have followed the recent numbers, community cases are sharply increasing, and hospital capacity is feeling the strain. Political polarization has accelerated and become personalized – “you can’t make me wear a mask” vs “I am offended by your reckless behavior.” Some of April’s anxiety has returned, but this time tinged with fatigue. When will this all end?

One of the hardest parts of dealing with the impact of the pandemic is that so much is out of our control. City, county and state officials will make decisions regarding how our community will respond. Leadership of Baylor and other TMC facilities are engaged on a daily basis in encouraging appropriate action. We can recommend, promote, cajole, provide data, and we have substantial influence. But at the end of the day, these decisions are out of our control.

The reality of the situation is obvious, but bears stating. We will be working and living our lives outside of work in the midst of a significant – and at this point, growing – viral presence in our community. Given this reality, let’s focus on those things we can control:

• Mask/maintain distancing/don’t come to work sick. This is our armor, unequivocally the best things we can do to keep the virus out of our Baylor work environment.
• Adopt a “universal precautions” mindset. In the hospital environment, providers are at risk for exposure to blood-borne pathogens (e.g. HIV, Hepatitis B & C). As a consequence, if a provider is at risk of coming into contact with any bodily fluid, it is universally assumed that the patient has a blood-borne disease, and appropriate protocols followed. We need to adopt this same mind-set around COVID-19. You should assume everyone with whom you come into contact is infected and actively shedding virus – even if you know they had a negative test yesterday. If you mask and maintain distancing, you are relatively safe.
• Hold each other accountable. Masking is required at Baylor. To keep our environment as safe as possible, we need to point out to each other when we are falling short. If I am not wearing a mask, or if I am not maintaining appropriate physical distancing, I want you to point this out to me. This needs to be not in the spirit of “tattling,” but as a collective act of compassion to our work community.
• Carry your armor outside of Baylor. Most of our time is not spent at work. I strongly encourage you to maintain scrupulous attention to masking and distancing outside of work. Frankly, your risk of exposure from a store clerk, waiter or the person on the next treadmill is probably greater than anything you will encounter at work. Wearing your armor and maintaining universal precautions outside of the walls of Baylor helps to protect you and your family. It also provides positive role models in our community. We will win converts not by preaching or scaring people into compliance, but by serving as an example.

A word of warning. We will see more infections of members of the Baylor community. This is not a failure, but an expected consequence of living in the middle of a pandemic. Baylor leadership and the ICC will also continue to do whatever is necessary to keep our community as safe possible. We have a rational approach to workplace testing (symptomatic employees and learners, surveillance testing of high exposure areas, random voluntary sentinel testing, internal contact tracing).

I have asked our Testing Advisory Committee to reconvene to review our internal testing guidelines in light of the increase in community spread. We are refreshing our surge planning efforts from earlier in the outbreak. We have passed all our internal social distancing audits with flying colors, and are making good progress in an a appropriately paced recovery across all mission areas.

We seem to say this a lot – this is far from over. I share in your concern, anxiety and fatigue in dealing with the situation thrust upon us. However, I remain extremely confident that our community will work together to see us through this ongoing crisis.

Stay safe.

(Note:  Between June 2020 through November 2021, I wrote weekly COVID-19 pandemic updates seen through the lens of a health sciences university.  My intent was to provide reliable information, acknowledge legitimate concerns, console, and encourage.  Each posting reflects issues our community was experiencing at that moment in time.  I have reproduced selected examples on this site).

Electronic Apostasy: Why I Have Re-embraced the Paper Book

As I write this, I am on an airplane at 30,000 feet, and it strikes me as an ideal time to confess a digital heresy: I have entirely abandoned electronic books.

When the first e-readers burst onto the scene, I was an early adopter; initially on a single function reader, later on a tablet.  The appeal of the technology was immediately obvious.  My entire library was at my fingertips.  I could carry hundreds of books with me everywhere (even at 30,000 feet).  It was quick and easy – virtually instantaneous – to buy a book on line.  Clearly, this was a life-enhancing technological innovation.

After several years, you can now place me firmly in the anti-e-reader camp.  Here are my top nine reasons I have sworn off e-books:

1. I miss the tactile experience.  This is probably the most obvious reason on everyone’s list of a certain generation.  Anyone who was raised (and likely, developed neurologically) reading physical books, probably misses the sensation of turning pages – the weight of the paper, the new-book and old-book aroma, the palpable crack of the spine upon completing the ritual of properly opening a new book for the first time. That ritual, incidentally, came to me courtesy of my outstanding third grade English teacher, Mrs. Walton.  I never think of Mrs. Walton when I fire up my iPad.
2. Thickness of the remaining pages is part of the experience.  E-readers all have some sort of “percent completion” feature to let you know how much of the book you have plowed through.  I need the feel of the remaining pages.  Beyond the purely tactile experience, a thick book, with lots of unread pages, motivates me (“you have a lot to read…better get to it”).  For a cliffhanger, it gives me a sense of how much time the author has to wrap things up. It helps to manage my expectations.
3. My nightstand is a major motivator.  I always have a half-dozen or so books on my nightstand in various stages of completion.  They are a constant reminder of commitments I have made, but have not yet met.  My “stack” in my e-reader probably has dozens of waiting commitments.  I have no memory of many of the books I downloaded on a whim.  I never look at my queue.  My lost books float in cyberspace, like a sailor cast adrift on a life raft hoping to be discovered.
4. The thrill is the hunt.  I love to go to the bookstore, wander around and stumble upon an unexpected treasure.  As I carry my latest acquisition around the store, I have a sense of anticipatory excitement I never experience with an electronic download.
5. Written margin notes help me learn.  As I read, I make occasional notes in the margin.  Frequently, particularly when reading non-fiction, I will flip back to my earlier notes.  Years later, when I pick up a book I previously enjoyed, I review my old notes to jog my memory of the book.  Electronic highlighting does not have the same impact.
6. I like maps.  When I read history, I love books with maps.  I like to dog-ear the pages with interesting maps, and flip back frequently as I am reading.  The ability to casually flip back to a certain page does not work well with an e-reader.
7. I enjoy looking at my bookshelf.  At home, my desk is surrounded by bookshelves.  I enjoy glancing at the spines, reminded of great books I have read.  I feel pangs of guilt for the few volumes I was never able to make it through (but will someday).  I am surrounded by friends.  I never spontaneously flip through my electronic queue, nor does it evoke any real affection.
8. My memory is flawed.  When I read a physical book, every time I pick it up, I see the title…the author’s name…the cover art.  Subsequently, I remember the details, in part due to repetition. When I read an electronic book, I am frequently in the position of enthusiastically attempting to recommend it to a friend, while struggling to remember the author’s name, and sometimes even the title.
9. I am distractible.   Reading is sometimes an effortless pleasure.  Reading is sometimes a painful slog.  Part of the benefit that comes from reading a great book is the investment you have to make of yourself in the experience.  I love to read John le Carré. The early chapters of his books are always challenging.  He drops you into the middle of a confusing story, with incomplete information. The motivation of his characters and the complexity of their situations are revealed very slowly.  It requires patience and commitment.  If the first few chapters of The Spy Who Came In From the Cold had to compete with my email, text messages, Facebook, Instagram, LinkedIn, Solitaire, Pandora, etc., I might not have ever made it through one of my favorite books.

For these reasons, and others, I am declaring my liberation from e-books.  Now, back to my reading, as soon as I finish labeling the Kodachromes in my photo albums.

Accountable Care Organizations, Explained (link to Kaiser Health News article)

Nice, brief review of Accountable Care Organizations, From Kaiser Health News:

Accountable Care Organizations, Explained

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?