The Doctor Weighs In

By Dov Michaeli MD, Ph.D.

I often wondered why it is that the practice of medicine is so error-prone. Hundreds (yes, hundreds) of patients die every year because of errors in administration of medications. Or, how about the cases from hell of the wrong leg amputated, the wrong breast removed, the wrong eye enucleated? Is it even imaginable that a car would be produced that has wheels of different sizes? The cliché that “if we can send a man to the moon, why can’t we … (fill in the blanks)” is actually thought-provoking. Sending a man to the moon entails a vast amount of detail, inordinately complex coordination of interacting systems and sub-systems, and concerns of safety at every step of the way. Yet, several well-known mishaps notwithstanding, NASA’s track record is admirable. Or consider the airline industry; if it had proportionately the same rate of errors as medicine, only intrepid adventurers would dare to fly.

Borrowing from the best

The summer issue of Proto, a magazine published by the Massachusetts General Hospital (www.protomag.com) looks at how the most progressive medical centers and medical groups are turning to industry, the military, airline pilots—anybody or anything that can teach how to run a seamless, error-free operation. Here are a few examples cited in the article.

· New York-Presbyterian Hospital trained more than 200 doctors, nurses and administrators in Motorola’s Six Sigma management system. These “black belts” are constantly on the prowl, looking for ways to improve the way the hospital runs. Estimated savings: $65 million. A friend of mine was recently hospitalized there with an exceedingly complicated condition. I couldn’t help marveling at the competent, efficient and friendly manner with which he was treated, despite the multiple disciplines that were involved in his care.

· Virginia Mason Medical Center in Seattle sent physicians and administrators to Japan to study the fabled Toyota Production System, which was developed after WWII to eliminate mistakes, reduce waste and empower frontline staff to institute improvements. On the assembly line, they learned how to deconstruct a job into specific tasks, reconstruct it so as to maximize efficiency, and then redesign the process so that each step could be reproduced by anybody doing the job. Assembly line medicine, you might aver. There is a lot to be said for assembly lines. I experience the joy of assembly line efficiency every year when I receive my flu shot at Kaiser. You are moved from station to station, each one performing a single task (hand out consent forms and instructions, collect signed forms, administer injection). Hundreds of people a day go through the process—and you are out the door in less than 5 minutes.

· Doug Bonacum joined Kaiser Permanente as VP of safety management, after eight years in the Navy submarine force. At a conference on perinatal safety he was struck by the complaints of nurses that when they thought a labor was not progressing as it should, their concerns were ignored by physicians. Doctors, on the other hand, complained that nurses did not express themselves clearly and quickly. In a submarine clear and concise communication is essential in situations that require quick responses, and the margin for error is quite small. Together with two colleagues, Bonacum developed a communication protocol based on the one used in the Navy. The SBAR system—situation, background, assessment and recommendation—is now used at Kaiser in everything from shift changes for nurses at the hospital, to managing critical events in the ER. The process begins with a summary of the current situation, followed by a succinct background on the patient, a clear assessment of what the staffer thinks is going on, an a recommendation of what should be done.

· The University of California , San Diego Medical Center , is instituting in the OR the seemingly excessive ritual a pilot and co-pilot go through before take-off. The pilot says “flaps” and checks the flaps. The co-pilot checks the flaps and answers “flaps”. Then the pilot rechecks the flaps. And so down the whole checklist. Using this procedure, it would be almost impossible to leave an unaccounted sponge in a patient’s abdomen; too many people have to keep count, and confirm the others’ count. And during an operation anyone has the power, and the responsibility, to halt the procedure if something doesn’t look right.

Physicians hate regimentation. I remember my frustration when in training I was forced to follow protocols of taking history, physical exam, differential diagnosis and detailed report writing, when it was ‘obvious’ that the patient had, say, a simple rash. But it kept me (and the patient) out of trouble.

One of those ‘simple’ rashes turned out to be an unusual presentation of malignancy. I gained an enormous respect for protocols, as well as some sorely needed humility.

Dov Michaeli MD, PhD. Is currently in the Biotech industry, involved in drug development.

Living with diabetes can be tough. There is so much stuff to learn and so many things to do. It can be hard to keep track of everything. And, it can seem overwhelming, particularly around the time you are first diagnosed.

That’s why I am recommending if you have diabetes or if you know someone who has diabetes, get your hands on a great little book, "Know your Numbers, Outlive your Diabetes.” It is written by Richard Jackson, MD, a doc at the world famous Joslin Diabetes Center and Amy Tenderich, a professional journalist who also happens to have diabetes (check out her website: www.DiabetesMine.com).

Five Numbers to Know

This book points out that there are five essential tests everyone with diabetes should have:

• Hemoglobin A1c (often just called A1c). This is a measure of the average blood glucose levels over the previous two to three months
• Blood pressure
• A full lipid profile – not just a total cholesterol, but a full panel that determines LDL, HDL (often called good cholesterol), and triglycerides (blood fats that go up after we eat)
• Microalbumin: a test of whether diabetes has cause kidney damage
• A Retinal Eye Exam to asses whether there is any evidence of eye damage

The authors explain what these tests mean and how often you should get them. What I particularly like is that they stress that you need to be the owner of these numbers:

“These numbers belong to you, and knowing them is your right, as well as critical to your health – just like the numbers in your bank account.”

They even give you advice on how to get your hands on these numbers:

“It is your right to request them, so don’t feel intimidated about speaking up….A call to the office should suffice…” but they recommend, “make the call at a time when you have some other paperwork to do, and use a speakerphone so that you don’t get too frustrated trying to get through or waiting on the line.”  It seems like they may have had some first hand experience calling doctors' offices.

Don’t feel like you have to do everything at once

There is a chart in the book that the authors titled “Your Diabetes Health Account.” Using it, you can compare your numbers to the certain targets in order to determine how well you are doing. For example, if all of your numbers are at optimal targets, you can see that you have five “bags of money” in your diabetes account. These are your health assets. If your tests are past due or way out of whack, then you have health debts which should be paid off as soon as you can. By taking a close look at your diabetes health account, you can pinpoint your focus of what you need to do to get your health account back in balance.

They counsel, “Rather than depressing you, knowing your priorities should boost your confidence; you have learned exactly which health factors are most important for you right now and which may not need attention on an everyday basis."

Take Action

Once you learned your numbers and assessed your diabetes health account, it is time to take action. The book provides strategies for how to improve every one of the five essential factors. The tips provided are practical, but detailed enough to help even a novice diabetes-self-manager get started.

The first part of the book lays out the strategies for improvement and the second part dives deeper into the diabetes toolkit they are helping your prepare. Advice on diet and exercise are clear and easy to follow. For example, one strategy for portion control, an important element of a weight loss diet, is to share a meal. Pretty simple, huh? Or you can divide your food before you start to eat and have it put into a “doggie bag” before it automatically goes into your mouth to end up around your middle. Avoid buffets. We all know we eat too much at buffets…it is simply too easy to pile it on the plate.

Other good information

There are chapters on diabetes drugs and diabetes devices as well as information about low and high blood sugar. The chapters are well laid out with important information placed in boxes.

Sprinkled through the book are stories of real people living with diabetes, like Loretta, a kindly grandmother with type 2 diabetes who lost weight and brought her hemoglobin A1c into control or Marci, a “high-powered New York City account executive" who enlisted her husband to help her deal with “diabetes frustration.”

Empowerment

Yeah, I know, some of you hate the “empowerment” word. But that is what this book sets out to do. It arms you with information. It helps you understand your particular needs and challenges. And it provides guidance on how to go, one step at a time, from where you are now to where you want to be in terms of diabetes health.

So, there you go. If you have diabetes, if someone you care about has diabetes, or if you are a health professional working with people with diabetes, then buy (and read) this book. You will be glad you did.

Pat Salber, MD

I am in Houston. This is not to point a finger at Houston, but merely to point out how our environment is anti-fit and pro-fat. Be prepared. This is a rant, but I will be brief.

I am staying at a very nice Hyatt Hotel. I am on the second floor. I can’t find the stairs to walk up and down between the ground level and my room. Why? Because there aren’t any...at least that is what the woman at the reception desk tells me. She says, “There aren’t any stairs for guests, but the elevators are safe in the case of an emergency.” She looked astonished when I explain that my question is a health question, not a safety question. Apparently, she hasn’t had a lot of guests asking how they can walk up and down the stairs to get from point A to point B.

While I am on the topic of using stairs, instead of the elevator, to go up or down one floor, let me tell you that my current workplace has secure access to the staircase (a safety issue). I finally figured out that my security badge will allow me to get back into the offices if I use the steps (although it took a while, asking a number of different people to determine that). So, today, I took the stairs. They are bare concrete, stained with something brown. They are ugly, in fact, a little creepy. The unspoken message is, only use these stairs if you really, really have to escape from the building in case of emergency.

After work tonight, I parked my car at the hotel and walked to The Galleria -- one of the best shopping centers in the world. But crossing the main street from the hotel to the mall was, frankly. scary. It took forever for the light to signal that a pedestrian could cross. Cars going straight, turning right, turning left, and going fast to wherever they were going. Clearly, pedestrians crossing the street are not a priority in this neighborhood, and, in fact, this action may be hazardous to the health of the brave walker who tries to get to the Galleria on foot.

I wonder why this is the case, but then I noticed that no one else is walking. Ah, now I get it, if there are no pedestrians, why bother to time the signals to help walkers get across the street safely? The unspoken message is that I should have driven the two blocks to the mall, paid to park, and then driven two blocks back to the hotel. This is what the “environment” supports.

Hey folks, why do we have to go to a gym to walk on a treadmill or use a stairmaster in order to move our body parts? Why can’t we get some exercise during our day-to-day activities at work and after work?

I suggest you pay attention to the details of your everyday environment. Is your community designed to make it easy and pleasant to walk or ride you bike from one place to another? Or is it designed to get you and keep you in your cars? Does your workplace encourage body movement and healthy eating or does it have built in barriers to physical activity and healthy eating.

For those of you who have to fly on planes a lot for work (does anyone really do it for pleasure anymore?), ask yourself, what do the airlines want you to do on those 3, 4 or 5 hour flights. Do their procedures keep you trapped in your tiny rented space for hours on end, or do they make it easy to stand up and walk in the aisles?

If this type of stuff bothers you and if you would like to see real health care reform, then I suggest you become a LHE (a local health environmentalist). Let’s not quibble about the name -- if environmentalist sounds too liberal or green for your tastes, then suggest another name, but not another approach. Remember that obesity and physical unfitness are politically agnostic. Liberals get fat, libertarians get fat, and conservatives get fat. Red or blue, Republican or Democrat, we all can benefit from an environmental focus on fitness.

If you want to live in a healthy community, live in a healthy home space and work in a physical environment that promotes your health, then get out of your car and onto your feet and agitate, really agitate, for structural changes in your environment that support fitness.

Pat Salber, MD, MBA

If you are like many Americans, you spend more of your “awake” time at work than you do at home. At home, I can control my environment. I don’t keep calorie dense foods in the house. I read food labels and use a food scale to help me determine portion sizes. I have a personal trainer who comes to my house five days a week – rain or shine, whether I am in the mood or not. And, I have my husband – a guy who is religious about good nutrition and physical fitness – to serve as my live-in health coach.

But, at heart, I am weak. I love, love, love to eat, eat, eat. I eat when I am stressed out and I eat when I am relaxed. Eating right does not come naturally to me. I have to work at it. I do like to exercise, but when I get busy, it is usually the first thing to fall off of my “to do” list.

Sometimes, I spend long periods of time working out of my home. During those times, I am physically fit. Sometimes, I travel to work long hours in remote workplaces. What I have learned is this type of work-life makes me fat. Let me give you some recent examples:

• I travel to a different time zone to work on a fascinating and challenging assignment. The flight is delayed. I am hungry. I am in the Continental Airlines lounge. They have cheese and crackers. So, I eat cheese -- lots of it. Why, because it is there.
• My flight is delayed. I arrive at the hotel after 11 pm and, guess what, I am hungry again. There is nothing to eat at 11 pm except what is in the mini-bar. Hmmm. What’s there? A container of cashews and a container of peanuts. I choose the cashews. It is only after I have shoveled many dozens of the tasty nuts into my mouth that I read the label: 90 calories per portion - a portion is 5 (that’s right 5) cashews. OMG
• I give myself permission not to work out on the first travel day, after all I can only get 7 hours of sleep and I need eight hours minimum to feel even remotely human.
• I have 30 minutes to get ready in the morning. I ordered oatmeal – pretty healthy? But it came with (and I ate) milk and brown sugar.
• Now, I am at the office. It is 11 am. It is too early for lunch, but I am hungry. So, I go to the vending machine. Here are my choices:
• The top two rows are various types of potato and corn chips
• The next couple of rows are cookies and sweet rolls.
• At the bottom are some corn nuts (I love corn nuts), and some candy bars.

Really?

• Ok, I am good. I didn’t get anything from the vending machine…do I get any points for that? Probably not because the company has arranged a “potato bar” for lunch. The potato was, no question, the biggest Idaho potato I have ever seen in my life—this was a potato on steroids or maybe it was genetically engineered to be humongous. I bet it weighed 2 pounds. The toppings were all in trays. They included huge mounds of butter and sour cream (not low cal, low fat). There were also containers of (the most delicious) shredded beef, Tex-Mex beans, and shredded cheese. And, just in case you couldn’t ingest enough carbs via the potatoes and toppings, there was also a bowl of potato chips and dip. Now, I must admit there was a bowl of raw veggies. It was sitting on a counter behind the table with the potato bar.
• I would like to use the stairs to go to meetings on different floors, but there is a sign by the staircase warning that you can’t exit the stairwell once you have entered it except on level one….some sort of security thing (definitely not a health thing).  Maybe there is a way around this, but I am too busy to find out.
• It’s close to 7 pm when I leave work. I am tired and I am hungry. I call room service. Do I need to tell you the rest of the story?

Sound familiar?  If so, I am not surprised.  The typical American workplace is not designed to keep us healthy. Our workplaces and our work habits are making us fat:

• We work obscenely long hours
• We have long commutes
• We are surrounded in the workplace by high energy density foods
• We have no time to exercise – before, during or after work
• Doesn’t matter because we are too tired to exercise anyway
• We have workplaces that are designed to help us avoid any type of physical activity (except for our typing fingers – mine, by the way, are quite thin)
• When we fly across time zones for work, we have an excuse to eat more and exercise less – we are tired and the airlines treat us like cattle – which, by the way, also eat too much and exercise too little.

There are better scenarios our there. In a post to follow, I will explore the concept of a workplace that is healthy by design. This is a workplace where it is easier to walk up the stairs than take the elevator.  There are apples and carrots in the vending machine instead of candy bars and potato chips.  In this type of workplace, "work-life balance" is an expectation, not a slogan.

Lest you think it is too expensive or too inefficient for American companies to have a healthy work place, let me remind you that those of us susceptible to developing diabetes, heart disease and other related conditions when we get fat and out of shape will cost you a ton of money.  We are a part of the reason why your health insurance costs are so high. And you know what that does to the bottom line.

Perhaps a little less productivity, a little less stress, and a little more work-related body movement might be cheaper in the long run. Think about it.

Pat Salber, MD, MBA

I’m writing this post at 37,000 feet. I am in United Airlines Flight 95, Seat 20A, an aisle seat in the back of the plane. I hate aisles. I hate the back of the plane. I hate United Airlines. I am not in a good mood.

Seat 20 A. This is My Space for the next 6 hours. It is the “space” I purchased from United Airlines (UAL) to transport my body from glorious New York City via Newark back to my home near San Francisco. My Space is about 16 inches wide, armrest-to-armrest. My knees are touching the seat in front of me even though I am only 5 feet 3-1/5 inches tall. The back of my forward neighbor’s seat touches my forehead if I lean forward a bit. So, I have cranked my seat “all the way back.” Now, my seat bumps my backward neighbor when he leans forward. We are a cozy bunch, but I am not in a good mood.

I have two sleeping bodies between me and the aisle, although both are pretty reasonably sized, thank heavens. I think it means I can escape My Space if I really have. But I have to time it just right. The seat belt sign is on until the beverage service starts. There’s no getting up until they are finished. It is almost impossible to wriggle out of My Space if my tray has a half-full drink, so I am careful to drink my beverage all the way down before attempting to move. Oh, no!  They just turned the seat belt sign on. Trapped, again! I am really not in a good mood.

I decide to vent. I am a blogger. Blog and vent. Vent and blog. That will make me feel better. But, I can’t fully open up my teeny, weeny Sony Vaio computer in My Space. So I suck in my tummy and pull the computer onto my lap. I will write and vent and vent and write.

“United Airlines, I hate you! And, you hate me.” Your space, that you rented to me for 6 hours for My Space, makes me sick. You make me sick. Did I mention that I am in a very bad mood?

Ok, here we go, let me count the ways you, UAL, make me sick:

1. On the way to the airport, on the New Jersey railroad, I called you to see if I could get on an earlier flight. After ten frustrating minutes of talking to the Electronic Voice Guy, he finally apologizes for not understanding the difference between the words “yes” and “no.” Yessssssss. And, noooooo. He transfers me to a busy signal and there is no way to back out of it. I have to hang up. Oh, no. Blood pressure rising…deep breath…just dial again…and try a new tact. This time, I refuse to answer Electronic Voice Guy’s questions. It works. EVG transfers me to a real human being in India. But, she has trouble with my accent. “Salber, what is your last name?” What Flight? Number 95, cancelled, no other flights.” What? What! What!!!

2. I am at the airport. What are my options? Hmmmm. Flight 95 is not, never was, and will not be cancelled. Was the telephonic notification of cancellation just a little United Airlines humor? “What if we tell her that her flight is cancelled? What do you think she will do? Hahahahahahaha.”

3. Once at the UAL ticket kiosk, I try to get an upgrade, although I know that, on a bad weather day—or any other day --  it is foolish to even imagine you can snag an upgrade. The computer plays with me though. It accepts my offer of 15,000 frequent flier miles in exchange for the tantalizing thought of a First Class Space. When I check it out with the real life person in the UAL lounge, she laughs out loud, “no way, no way, no way are YOU (you lousy United flier without any Premier status) going to get an upgrade.”

4. The computer at the kiosk also offered me the opportunity to buy 5 more inches of Space at $10 an inch, but only for a middle seat. Now, I admit it.   I am cheap.  But this is not about the money. It is the principle of the thing. I am going to pay to switch to a middle seat? No way. I would rather suffer in the back, in an aisle, in My 20A Space.

5. Time to board. I am in boarding group #2. Do not, do not dare get in line if you are not boarding group #1. But, I worry, if I am not at the front of boarding area #2, I will have to check my carry-on bag. Please, god of the airlines, don’t let this happen to me.

6. We are queued up, passengers as sheep, awaiting permission to board. The ground staff announces, we are going to board this plane in 6 minutes, if we don’t board all of you in 6 minutes, booms the male ground staff voice, we could be delayed and there is a storm coming. You know what that means. Say no more. We, sheep, hurry, in place, as fast as we can.

7. On board, the flight attendant repeats over and over, please step into your row and then arrange your luggage in the overhead space. Step into your row, don’t block the aisle, let the other passengers pass. The big guy in the middle of the plane apparently couldn’t hear her, he has stuff to find in his briefcase that he has already placed in the overhead compartment. So I politely say, mimicking the flight attendant, excuse me, could you step into your row so I can pass by? Rummage, rummage, rummage. I wonder what he is looking for. The crowd behind me is getting restless. Please, sir, can you step into your row so we, all of us, can pass by. Maybe, he is deaf. I gently touch his back, no response. Eventually, voila, he finds “it” and praise the lord, sits down in his seat.

8. “Please don’t put your coats in the overhead. This is a full flight, please help out your fellow passengers by putting your small carry-on in the seat below.” Right. Coats, purses, hats and small bags abound, there is no room in the overhead for a wheelie. No help from a flight attendant. I guess we passengers are supposed to duke it out ourselves. Did I tell you I am in a really, really bad mood.

9. The threat again. If you don’t all sit down soon, we may get stuck here. There is a storm coming. If you don’t sit down, we may get stuck in Newark. Oh my god, fear and loathing, stuck in Newark!

10. Now medical people know that sitting without moving for six hours increases the risk of developing blood clots in the veins of the legs. These clots can be dangerous and even fatal if they break off and lodge in the blood vessels that feed your lungs (aka, a pulmonary embolus). Medical experts recommend moving your legs periodically during a long flight to keep your circulation moving. It helps to prevent the clots. It’s even better if you can get up and walk. Forget it. There is not going to be any walking on this flight. I try wiggling my toes instead.

11. I am on a six hour flight at dinner time. You, UAL, said we could buy food on board and I believed you. Ok, so I am gullible. Your idea of dinner is a bag of potato chips, a slice of chicken on a cold dry bun all wrapped elegantly in saran wrap. Not exactly a crowd pleaser, but then, I am not sure that pleasing crowds is on your radar screen.

Between my husband and me, modestly crazy frequent fliers, we have stored up more than a million UAL frequent flier miles. Of course, we can’t really use them anymore, because you (UAL), in your (cunning) wisdom, have restricted the number of seats available for “free” travel to less than zero. We have tried to book award travel a year ahead of time, we have tried to book in the low season, we have tried to travel to some pretty unpopular places, but the answer is always the same…"Sorry, all of our award travel seats are booked (you fools, you)."

UAL, I hate you and you hate me. There is not a doubt about it. 

 One of my most vivid experiences on your sorry airline, back in the days when I traveled on business a lot, was being told that “I was only a low 1K traveller.” Let me translate that UAL-talk for you. "Hey, you, passenger. You have only flown a bit over 100,000 miles this year. Why in the blazes should I care about you? I have real 1K travelers to “attend” to. " That little story  says it all. You have no idea where your bread and butter is coming from …a pretty sad state of affairs for what used to be a GOA (grand old airline).

Hey UAL, I hope we, the flying public, have sent you a strong message all the way to bankruptcy. We have choices. Some airlines care about their customers (Southwest Airlines and Continental come to mind) and their customers care about them (take a SWA flight sometime and check out how happy their flying public is and how well they are treated by SWA staff, even if they are on a super-discounted ticket. These people-friendly airlines care about all of their customers, not just the top 0.01% of their customers. They know that lowly 100,000 mile fliers (and even lowlier (if there is such a word?) 10,000 mile fliers) are a good source of recurring revenue.

I am not sure you really care, UAL, but I hate you (and I know that you hate me).

Signed,

Patricia Salber, MD, MBA, AFC*

*a former customer