Heads Down, Thumbs Up

Acute ischemic stroke patients may benefit by simply lowering the head of their bed. An inverse relationship was demonstrated between bed angle and residual blood flow to ischemic brain tissue. Similarly, Jugular Venous Distension becomes clearer when a patient is reclined. Therefore, this finding is not totally surprising. What is compelling is that the improvement is distinct and occurs even across small gradients: 15 degrees is preferred to 30 degrees even if not as ideal as a patient laying flat.

Clinically implementing the finding still requires a bit of common sense judgement. Patients with dysphagia are at an increased risk of choking which is greater when they lay flat. Because the same patient who has suffered a midbrain stroke is often dysarthric, they are at risk to silently aspirate. A real risk of choking must be weighed against the perfusion benefit described in the study. Occupational therapy can help in the management of these stroke patients.

While the hospital bed controls which set head angle are simple, keeping a patient's head down can be more complex. Patient compliance is required. Those short of breath when laying down (orthopnea from Congestive Heart Failure), and those prone to choking (dysphagic after a midbrain stroke) desire to sit up. Many stroke patients spend the first hours after the diagnosis of stroke in the ER. Therefore, the ER staff must also understand the importance of heads down just as well as the specialized staff of a dedicated stroke team. Even once admitted to a stroke unit, visitors may raise a patient's head earlier than is desired. Technicians who perform cardiac echos may raise the bed or ask the patient to prop themselves up, into positions which obtain a better ultrasound image. A well-meaning family member will often raise the head of a patient's bed, allowing the patient to more easily see and interact with family, at the expense of critical perfusion.

The heads down study has encouraged neurologists to emphasize a seemingly small detail to physicians and practitioners outside their specialty. It can be found by referencing: Neurology. 2005 Apr 26;64(8):1354-7.Heads down: flat positioning improves blood flow velocity in acute ischemic stroke. Wojner-Alexander AW, Garami Z, Chernyshev OY, Alexandrov AV.

"Ischemic stroke is a potentially reversible process that is dependent on restoration of arterial blood flow within a window of cellular viability that varies according to the severity and duration of the flow deficit. Measures that promote blood flow during the acute phase of ischemic stroke may directly impact the subsequent development of brain infarction and associated clinical deficit. One such measure may be flat head-of-the-bed (HOB) positioning to promote a gravity-induced increase in arterial flow to ischemic brain tissue; however, patients with stroke and other neurologic diagnoses are routinely positioned using 30° HOB elevation by paramedics and emergency room personnel."

Source: Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX 77030, USA

Photo by Flickr user: chimothy27

Fishbone Diagram: Promotion Category

Product Place and time Price Promotion Process People Productivity Purpose

There are many strategies for well run promotions. The AMA employs a promotional strategy to gain members by allowing medical students to join at greatly reduced rates. The AMA follows a strategy that uses elements of discounts, limited time offers, and versioning.

Hopefully, for the individual medical student, the discounted rate is a limited time offer and they are eventually eligible for the more expensive physician rate. The experiences available as a Student differ slightly from those enjoyed by a Physician. The distinction between these two versions is most evident during the National Meeting when two separate House of Delegates are maintained in a fashion similar to a House of Lords (Physicians) and House of Commons (Student section).

Versions work best when different tiers more closely approximate the individual needs of users. For example, only the most gunner Medical Student would think that they benefit professionally from spending time in the Physician House of Delegates. While the pomp and circumstance of that venue is an enriching experience, the small talk with physicians that ensues is unlikely to make a lasting impression. Working with peers has more peripheral benefits. The versions employed by the AMA appropriately assign members to work with their colleagues and are priced accordingly.

Simplifying the Square

A goal of 2directions is to help physicians win the corner office at the hospital and to begin making business decisions in the best interest of the Patient-Physician relationship.

To weigh interests, business schools teach a simple method: ask two dichotomous questions and plot the answers on a 2 X 2 square. Along one side, are the responses to the effect of the action on customers as either Good or Bad. On the other, the same consideration is made, this time regarding the effect of an action on the business itself. Answering these two questions allows quick analysis of whether a project should be pursued, weighed, or rejected. The resulting grid is reminiscent of the Punnet Square. Homozygous recessive is akin to the elusive win-win, while the Heterozygotes fall in the more common grey areas.

While you wouldn’t always think so, MBAs prefer projects which are good for both the customer and the business. However, the MBA doesn't shy away from actions which are unfavorable to one of the two parties so long as the actions are strategic and maximize the long term value of the firm. Mixed responses to the two questions introduced above lead the MBA to consider options, with an eye for the long run, the MBA attempts to maximize profits without losing its best customers.

"Promotions" are actions which benefit the customer more than any harm done to the business. When judged correctly, promotions have a high transaction value even though they may be unfavorable to the business. Groupon capitalizes on this strategy by helping business to generate awareness and goodwill. The business shares with customers the majority of the value it creates. Actions which benefit the customer but aren't necessarily good for the business accumulate Goodwill. Later, the business will have an opportunity to take actions which favor the business at the expense of the customer.

A recent example of cashing in on Goodwill is Netflix upsetting customers by raising its rates and enacting separate billing for postal delivery of DVDs and streaming video. Undoubtedly analysts demonstrated the move is good for Netflix, despite the fact that customers will be lost. Clearly, those customers who stick it out receive less value now that the same product carries a higher price. In the future, greater customer value may return if many more movies are available to stream. Should that happen, customers who are satisfied by streaming alone might discontinue postal DVD delivery, a choice they would otherwise not give much thought to without separate billing. Since the cost to Netflix is greater to ship a DVD than to stream a movie, Netflix will benefit when consumers change their behavior. By billing separately, Netflix encourages customers to drop DVD delivery so that in the future Netflix might discontinue its postal service with less guilt. Despite the fact that customers don’t benefit by this path, the decision supports Netflix’s long term goal to yet again revolutionize the way we watch movies at home.

Should physicians give in to perverse incentives, they breach their fiduciary duty to patients. Whether motivated by greed or the practice of defensive medicine, these actions increase the cost of care without adding value. On the other hand, an action which is not in the best interest of the physician and benefits the patient should be taken. Indeed, a criteria of a profession is to only take actions which benefit the customer. Currently, many hospitals are run by CEOs who approach decisions as an MBA would. To maintain service, and ensure it stands for future generations, physicians must be mindful of when actions harm the business. On average, most decisions the Physician CEO makes would need to benefit the business. However the MBA's approach could be simplified by omitting any option that is not good for patients:

Price doesn't equal Value (Fishbone Diagram)

Product Place and time Price Promotion Process People Productivity Purpose

When setting prices, a business avoids going too low. Of course, we understand this fails to maximize profit. More importantly, consumer behavior demonstrates that a product which is sold for a lower a price than its competitors, is first considered a value. Eventually, the price difference becomes too great. Then the discount is no longer judged to be a better value, and begins to suggest that the product is inferior. For many consumers, the product which they believe has the most value is the second most expensive. For this reason, a business will develop a luxury version of their product. While it may manage to sell a few of these highest end items, more benefit is derived by the now second most expensive item being perceived as a better value.

The price schedule for the AMA is cheap when compared to other professional organizations such as that for trial lawyers. Could the low cost lead many physicians to question how relatively inexpensive professional organizational fees can return value? What if the annual dues were doubled? Would physicians anticipate more value and respond by joining the AMA?

Zane highlighted that much of the cost of participating in the AMA is incurred by traveling to the national meetings. His recognition again raises the question whether a national organization is needed. Or, perhaps Annual and Interim meetings are not regularly required. More productive work may be invested in local improvement, rather than preparing for the next national meeting. When the total cost of participation is largely related to travel expenses, then the disconnect between price and value widens further.

Reviewing the price we find a lot of wasted value. This concept of waste, arises repeatedly in medicine. In the case of the AMA annual events the waste takes the form of travel. Going to Chicago is a fun time, no doubt. However, many physicians would just assume take a legitimate family vacation. Travel to Chicago for CME and professional development workshops allows value to dribble away as hotel receipts, cab fares, and hasty lunches.

Instead, physicians could receive more value by attending regular meetings at which local financial consultants educate attendees on choosing a medical equipment loan from options locally available. They would attend such conferences with neighboring physicians and discuss the local problems they face. Rather than mulling over what they'd like to do about those problems, then only delivering their decision as a single vote to a national legislative body, they could take action--locally and immediately. Of course there are national problems physicians face which require a national organization. One such problem is how to best adopt EMRs to achieve the furtively defined, "meaningful use." Perhaps a local forum in which physicians can offer lessons learned from their adoption of EMR would be more beneficial. As more and more small clinics merge to grapple with increasing overhead, the need to know local fellow physicians increases.

Now, we'll put more meat onto our Fishbone Diagram. The new problems identified:



By picking apart price, we have noted additional problems with Place. Creating a fishbone diagram should allow this sort of active brainstorming. We can quickly categorize this newly identified problem under its appropriate Place label as we fill in the Fishbone Diagram.

Political or Practical (Fishbone Diagram)

In his recent post, David shared reactions to the recent AMA Annual Meeting in Chicago. Its dwindling membership has led us to question the direction the organization is heading. While we at Two Directions agree there are numbers in healthcare which should not rise, we look to reduce costs and would prefer to increase participation.

To analyze the problem we’ll use the Fishbone Diagram tool, and hope to accomplish the aim of this blog: to demonstrate how QI tools are used so they can be more widely applied to healthcare. In doing so, we also hope to consider solutions to the AMA’s dwindling membership. Given that several of us writing are members, we hope this process can inform our own engagement with organized medicine.

Fishbone Diagrams are a tool to conduct root cause analysis. Here, we’ll look for the root cause of the problem: why do so many doctors not participate in their main professional organization? To analyze this problem, we will organize our brainstorming into categories. This structured approach to problem solving is a technique for physicians to approach QI. To be not only creative, but effective, brainstorming often needs to follow a method; especially when working with a group. Because the AMA is essentially offering services to members, we will seek root causes by organizing our thoughts into the following service oriented groups.

Product Place and time Price Promotion Process People Productivity Purpose

As a happy coincidence, each group starts with P. A few notes about them:

• The first 4 P’s listed above are the classic 4 P’s of marketing
• While QI analysis usually considers “Process” in the scope of a product delivery or manufacturing, in this post we want to focus on the AMA’s legislative process. In a sense, it is a manufacturing process for crafting its organizational objectives
• Since the AMA acts as an advocacy organization, its Purpose is an important factor in determining its quality

To begin filling out this bare-bones diagram, consider how the AMA’s products alienate or fail to meet the needs of potential physician members. As we begin to fill an empty white board, we'll recognize that the product faults we identify are better categorized into another group, such as Place and Time.

CPT Codes. The use of the Current Procedural Terminonology codes to bill insurers is responsible for a large part of back office overhead. Physicians are often required to use these codes to receive reimbursement. Since the coding system changes often, physicians must hire employees who maintain this specialized skill.

Yet, the process adds no value to the Patient-Physician relationship nor does it improve patient health. Sometimes regarded as a cozy monopoly fostered by the AMA and insurers, CPT codes complicate the relationship between physicians and patients. The complexity of the coding system edifies the overhead expense of a medical coder, and facilitates the insurer practice of holding up or denying legitimate claims. Despite this detriment to physicians and the practice of medicine, CPT licensing generates annual revenue on the magnitude of tens of millions of dollars for the AMA.

Advocacy. Many physicians feel the AMA advocates for positions which they don’t agree with. Rather than advocate, the AMA may do better to inform. Individual physicians could then better assess how the actions of Congress fit with their personal views. Rather than pay professional lobbyists millions of dollars, the AMA could further shift its focus towards empowering physician's to use their voice in public forums. Again, the AMA's current approach fails to add value for physicians but does reward the lobbying firms the AMA retains. (Product)

Development.The AMA purports to be a professional organization, but has been overtaken by physicians with a fetish for politics. My own experience at A-11 had few opportunities for professional development. The main event was the legislative process. Medical students were exposed to JAMA, AMPAC, pomp and circumstance, but essentially no guidance on the transition from medical education to medical professionalism. A review of the AMA website points to some professional guidance. However, much of it seems to reinforce other AMA products such as the CPT codes. Google is appreciated by its users because the new technologies it offers are designed with the intention of making Google more useful. The AMA is unappreciated as its products seem to only reinforce its necessity.(Product)

The AMA does provide a generous experience to get involved with politics. Participation would likely bolster professional skills; politics and marketing have much in common. However an intensive course, set in Washington, D.C. is impractical to the demands of medical training and practice. (Place/Time)

Continuing Medical Education is a component of a physician's ongoing training which does have the potential to add value to the Patient-Physician relationship. CME offerings compete in a crowded market. The AMA offers CME credits through JAMA and via its Annual and Interim Meeting. Overall, a physician's specialty is typically more successful at meeting educational needs by offering more relevant CME topics. (Product & Place).

A fishbone diagram could capture and portray this analysis as:

The Many Faces of Organized Medicine

Two weeks ago, the AMA met for its 160th annual meeting in Chicago; this year with 12,000 fewer members than during the 159th annual one year ago. At the meeting, I heard many physicians express a growing concern: the membership of this national professional organization has dwindled recently, and now represents less than 10% of the physician voice in America.

Speculation has suggested two reasons for the loss of membership. First is the controversial position of “support” that the AMA gave two years ago to the PPACA. Second is the inconsistency between AMA policy voted upon by its House of Delegates (HOD) and the actions taken by AMA’s Board of Trustees on the organization’s behalf. Rather than leveraging the election and legislative processes to reign in these problems, 12,000 doctors have chosen not to renew membership in their national professional organization.

What would happen if our national legislators decided not to participate in the democratic process because they disagreed with an election or policy vote? Arguably, it would be quite counter to effective democracy. Having observed the policy creation process in the AMA’s HOD, it is clear that the process makes great efforts to entertain the minority opinion prior to a vote. Perhaps for dissenters, the more effective approach to strengthening representation would be to recruit like-minded physicians to pledge membership and run for elected office, rather than leaving the table all together.

Medical politics, like those of our federal government, continue to grapple with unwavering and polarized points of view. Many AMA southern delegates proclaim freedom from government regulation of any kind, while northern delegates are generally more comfortable complying with some terms of the PPACA in order to achieve greater access to healthcare. During debate on more benign policies, like the one requiring physician excuses from physical education in grade school, southern doctors dogmatically proclaim freedom from exercise mandates, while northern states judged such colleagues as holdouts to fighting our nation’s obesity epidemic.

One of the most contentious votes during the last four national meetings of the AMA has been on the healthcare mandate prescribed by PPACA. Prior to the A-11 meeting, the vote in the HOD has been evenly split 50/50 along state and ideological lines. In this meeting, however, almost 60% of the House passed a resolution with language endorsing current AMA policy D-165.966 (find it on AMA policy finder). This policy will provide state governments the freedom to decide how to best cover the uninsured. A state-by-state implementation is already enacted by PPACA, but will not take effect until 2017. The Wyden-Brown Senate bill, currently under debate, would move this deadline to 2014 if adopted by the US Congress.

There are many medical associations representing specialty medicine, regional interests, and national politics within medicine; but only one association - the AMA - purports to represent ALL physicians. Arguably, based solely on membership numbers, the AMA is already a long way from that claim. What’s undeniable, however, is that for this professional organization to continue, new ways to connect new members are required. What are the best strategies for doing this? And how can the AMA empower physicians such that they feel like their concerns are addressed? Is our nation so polarized and the practice of medicine so regionally variable that no one organization can truly represent all US doctors?

We look forward to exploring these questions more in coming weeks. In the meantime, we look forward to reading your input and ideas.