Monday, November 16, 2015

Teaching Doctors the Art of Negotiation - The New York Times

Doctors negotiate every day, almost constantly — sometimes dramatically, often imperceptibly. They hold family meetings to resolve sensitive end-of-life issues. They address barriers to medication adherence. They encourage patients to receive uncomfortable screenings like colonoscopies and mammograms. They refuse treatments that are requested but not medically indicated. Yet they receive almost no formal instruction in how to do so.
Dealing with medical colleagues creates an additional layer of negotiating complexity—especially in busy academic centers with competing demands on specialists’ time. Medicine is increasingly a team sport. In 1970, only about 2.5 full-time clinical staff cared for the average hospital patient; today, that number is greater than 15.
Doctors consult other doctors many times a day to discuss potential treatment options and decide on the best course of action. They work closely with residents, students, nurses, physician assistants, care coordinators and others to implement those plans. At each interaction, opportunities for collegiality and efficiency — or rancor and resentment — abound. That can mean the difference between a timely or delayed blood draw, accepting or refusing a consult, or getting those biopsy results today versus tomorrow.
Recognizing the importance of negotiation, medical schools are starting to invest in communication training for students — and it seems to be paying off. Research suggests communication training can improve patient adherence, diagnostic accuracy and chronic disease management. But good communication, by itself, is only part of the solution. We need to teach doctors how to negotiate.
Negotiation, in this context, is not about winning or losing, or haggling over price or scare resources. It’s about exploring underlying interests and positions to bring parties together in a constructive way. It’s about creative, innovative thinking to create lasting value and forge strong professional relationships. It’s about investigating what is behind positions that may seem irrational at first to understand the problem behind the problem.
The medical profession is no longer one in which doctors dictate a given treatment course to patients, who are then expected to follow it. Rather, clinicians and patients deliberate about treatment options, weigh costs and benefits together, and determine the best course of action. This approach requires eliciting patient concerns and addressing underlying fears to arrive at the most effective strategy for maximizing health and well-being. As diseases like H.I.V. and some cancers that were once uniformly fatal become chronic conditions, and a greater diversity of treatment options becomes available, the ability to negotiate long-term care plans will only grow in importance.
Physicians are also increasingly assuming leadership roles. They are expected to negotiate with a vast array of third parties, including health plans, governments and pharmaceutical companies. Health care changes double down on this expectation. The Affordable Care Act creates incentives for doctors and hospitals to band together to create networks known as Accountable Care Organizations — provider groups responsible for caring for an assigned patient population. Under new Medicare rules, providers can be paid less if they have low patient satisfaction scores or excessive readmissions. As quality metrics and cost-effectiveness play a larger role in reimbursement, physicians will need to negotiate with governments and insurers to establish fair and reasonable performance measures.
Each medical encounter, then, becomes a multiparty mini-treaty signed by doctor, patient and family members — and sometimes, consulting physicians, ancillary staff, insurers, hospitals and governments. Law, business and public policy schools all offer classes in negotiation, recognizing the interdisciplinary and interdependent nature of their professions. Isn’t it time medical schools did, too?
Remember, almost everything is negotiable.

Dhruv Khullar is a dual degree candidate at the Yale School of Medicine and Harvard Kennedy School, where he is a fellow at the Center for Public Leadership. Follow him on Twitter:@DhruvKhullar.

Teaching Doctors the Art of Negotiation - The New York Times

Landlocked Islanders | Hakai Magazine

Landlocked Islanders

Can Marshall Islanders whose lives are tied to the sea maintain their culture in Oklahoma?
Published November 16, 2015
The amount of water is incomprehensible. We’ve been flying for hours, and just when we’re about as far from a landmass as you can possibly get—a spot where the curving, wave-flecked Pacific Ocean stretches thousands of kilometers in every direction—an island slides into view. It’s no more than a snippet of sand and palm trees, a snake winding through the blue plain of the Pacific. Fanning out around it are 1,200 similar islands, some inhabited, others not, arranged into a constellation of 29 atolls like stars in a universe of ocean. For every square kilometer of land in the Republic of the Marshall Islands, there are 10,732 square kilometers of ocean.

For every square kilometer of land in the Marshall Islands, there are 10,732 square kilometers of ocean. The islands are mostly ring-shaped, inviting a unique system of direction: lagoon-side and ocean-side. Photo by Greg Vaughn/VWPics/Newscom
By the year 2100, it’s conceivable that climate change will force the entire population of the Marshall Islands to US shores. Already, more than 25,000 Marshallese—over a third of the population—have left the islands, many in the last 15 years. Among them was Sarah Joseph, now 22 and a resident of Enid, Oklahoma.
Through all of this, Marshallese culture adapted and survived. But today, it’s facing the one battle that might be impossible to win. Climate experts predict that because of rising sea levels caused by greenhouse gas emissions, the Marshall Islands could be uninhabitable by the end of this century.
As the ocean seeps into homes and buckles roads, it’s shifting from a source of inspiration to one of fear. 
Infant mortality is high, and celebrating the first year of life is an event which is special to Marshall Islanders

Unlike many Marshallese-Americans of her generation, though, Marla will later be able to say that once, she knew the ocean. She sat on her mother’s lap at the edge of the lagoon and felt the tropical water tickle her legs. She took her first steps in her paternal grandparents’ gecko-green house that rises from the sea on a piece of land sprouted from oil drums and old tires. She looked into the eyes of the sea turtle that the men speared for her first birthday feast. And, the night before her first birthday, just before midnight, she watched quietly, her brown eyes wide, as a chorus of women and children streamed into the house strumming ukuleles and singing, welcoming her to the world. To her home.
Paradise lost

Landlocked Islanders | Hakai Magazine

Monday, August 17, 2015

The Loss of your Identity

Everyone is fearful of their online identity being stolen and hi-jacked, however what does one do when you lose your identity ?  Where does it go?

It happened to me about 8 years ago for the first time. I was not aware of what was happening, and attributed it to other factors.

I was operating at a new facility with equipment I had not used previously. Although the equipment was the same brand (a high quality preferred operating microscope) and the most commonly used for microsurgery, including neurosurgery, hand surgery, and eye surgery.

There were five cataract surgeries scheduled. The first two did not go well. After removing the cloudy lens using an ultrasound probe I attempted to place an intraocular lens into the space where the normal crystalline lens is located. It usually is placed in a space approximately 8 mm in diameter and less than 3mm in depth. It requires very fine depth perception akin to what fighter pilots must have to fly jets, and extremely fine motor control of one's hands  I cancelled my last three cases asking the operating room director to have the microscope checked.  

We all live in couldn't be that it was my "fault"  I had been operating since 1976 for over thirty years. I considered myself a better than average eye surgeon.  I was always an early adopter of new technology, and had good results, as evidenced by the numerous physicians who chose me to perform their cataract surgery. I had  been a humble surgeon, not seeking attention although on several occasions was interviewed by a national feature program on NBC news.  I never advertised, and after the program the demand for my services increased greatly. I remained current with new skill sets, travelling to take training courses.

The power of the media is enormous. I was a  embarrassed when my colleagues mentioned it and brought attention to my television interview.  I immediately regretted my acquiescence to being photographed and having a surgery broadcast (with patient permission and all personal identification of the patient masked for the broadcast).

I could feel the blood rushing to my head as I felt embarrassment at my sudden notoriety. Somehow or other I felt I had crossed an ethical line. I came from a generation where this type of activity was somewhat unethical and some surgeons have been warned or even had their membership in professional organizations suspended or removed.

I had agreed to the broadcast not for self-aggrandizement but as an educational message to patients how outpatient surgery which took less than an hour allowed a patient to go home immediately following surgery. Prior to this patients would remain in hospital or the outpatient surgery center for less than 2-3 hours, only long enough for the anesthesia to wear off.

Several other developments had occurred to allow this.  A technique allowing a 3 mm incision to replace a 10 mm incision to remove the cataract with a relatively new ultrasound probe that dissolved the cataract to be dissolved with ultrasound. Also the development of safe intraocular lenses and fine nylon sutures about the width of a spider's fine web which restored normal vision and immediately allowed normal functioning eye sight without glasses or contact lenses.

Egocentricity can be a dangerous personality defect for a surgeon. Denial also can be treacherous to a patient.  Self analysis and critique are essential. The first question that should run through a surgeon's mind must be 'did I do something wrong ?'   Surgeons  must be forward thinking and predict what may go wrong to produce a less than perfect result. I taught this to all my surgical residents as they began their careers.

Even after I was informed there was no problem with the operating microscope I pursued the thought that it was an isolated event. I chalked it up to a bad day. In the past I had cancelled surgeries if I did not feel up to snuff, with a cold or some other malady that might effect my performance. (prim um non nocere--first do no harm).

Losing one's primary identity is a serious event in a surgeon's life.  Most physicians primary worth is to help patients. The feeling is enormous and probably related to endorphin release, not unlike an addictive behavior or pleasurable activity such as jogging or other sports events. It often leads to depression and anxiety. Some physicians turn to substance abuse to compensate.

In my case it led to depression, even requiring treatment. If severe enough it may even be due to underlying emotional disturbance deriving from underlying psychiatric disease, such as bipolar disorder. However t hat is another subject.

Eventually my deterioration became self-evident and my cases were reviewed as my complication rate increased. Vitreous (the gel inside the eye behind the   lens should not be disturbed during cataract removal. The incidence of this increased to 50% of my cases. Still I lived in denial rationalizing this occurrences, as acceptable since I had dealt with this event in the prescribed manner....vitrectomy..a procedure. in  which the vitreous is meticulously removed with a special cutting device. All of the cases did well although their recovery was delayed. I felt pretty good being able to handle that complication. But why was  that occurring in the first place? (still in denial)

I had a series of cardiac events, one serious enough to require a four vessel cardiac surgery bypass. In the back of my mind I wondered if the surgeries and/or anesthesia had effected my fine motor coordination. I noted a slight intention tremor when picking up a glass of water....was that a tremor?? Nah...not me, I am fine.

Eventually I realized how fatigued i had become, missing  educational meetings, and in a  hurry to get through my operations. Besides fine motor skills and vision, patience is a necessity for any kind of surgery. Complications or difficulty during a case were never a problem for me to deal with. Now they became more than annoying.

My first cardiac event occurred when I was only 47 years old. My father and mother's family had a history of heart disease and my cholesterol levels were elevated requiring statin drugs which corrected it to normal levels. (but not me ?!)  Only fools tread where no men go)  I had evolved into my worst fear.

After all Dick Cheney continued to be vice-president as his heart condition deteriorated far beyond mine. Arnold Schwarzenegger continued as governor of California after his cardiac surgery. I prided myself how I had glided through angioplasties and open heart surgery...My foolish mantra was, " I am like the Timex watch, I take a licking and keep on ticking"  No one mentioned if it still kept correct time.

I was great at offering advice to others, but not myself. Eventually one night i awoke at midnight unable to move my right arm. I had a stroke.  Things became crystal clear to me .  I was aging. Today I am fortunate that my arm (brain) rewired and the paralysis is completely gone.  I have some balance problems and fall wit hout warning when I suddenly turn. I  fell down a flight of stairs twice rolling like a basketball and bouncing several times. I could not get up for about ten minutes.

I completely retired at age 67, my last year of practice was medical ophthalmology.  I still had a fantasy of operating...I was (and my patients even more fortunate that I was denied operating privileges) Thanks to my colleagues.  It relieved me of making my own decision.....a foolish thought. Age and wisdom are two separate qualities and not related,

I hope that this article helps young surgeons to look forward and plan retirement voluntarily rather than being passive as I had been.

I leave this message to my young colleagues as a final passing shot...Enjoy it as much as possible, it will eventually leave. And remember you are not just a surgeon, but a father, a husband, and very educated. Your intellectual skills are transferable.  Plan early to have a hobby or a second career.  Mine is health reform and health information technology, hoping to improve patient care.

Tuesday, August 4, 2015

When Surgeons listen to their Preferred Music, their Stitches are better and Faster -- ScienceDaily

Mozart, Beethoven, Country or Rap ?

From classical to rock, music can be heard in operating rooms across the world. Although previous studies have shown that listening to music during operations can lower the stress levels of surgeons, there is limited information on the effects of music on technical performance while completing a surgical task, such as closing incisions. Stitching prowess and speed is especially important for plastic surgeons.
Fifteen plastic surgery residents were asked to close incisions with layered stitches on pigs' feet obtained at a local food market -- pigs' feet are widely accepted as similar to human skin.
The residents were not informed of the purpose of the study. They were asked to do their best and to notify the researchers when they completed a closure. The day after the first incision closing exercise, the residents were asked to do another repair using identical technique with the music either being turned on or off, in opposition to the first closure. They were not told that the researchers were comparing times or that the results would be graded until the study was completed.
"We recognized that our subjects could potentially improve on the second repair simply as the result of repetition," said author Dr. Shelby Lies, the UTMB chief plastic surgery resident. "This effect was reduced by randomly assigning the residents to music first or no music first groups."
The average repair completion time for all residents was 7 percent shorter when their preferred music was playing. This effect was magnified as the experience of the surgeon grew. Playing their preferred music led to a 10 percent reduction of repair time for senior residents as compared to an 8 percent time reduction seen in the junior residents.
The quality of the work was judged by plastic surgeons who did not know whose work they were analyzing or other conditions of the study. The judges' ratings confirmed an overall improvement in repair quality while music was played, regardless of whether the resident did the repair with their music first or second.  The residents were 'blinded' by not knowing why music was introduced to the surgery lab.
The report did not specify what music genre  was played.

Alessia Pedoto, MD in a report of music as a possible hazard in the operating room.  Noise levels were measured in the operating rooms. The noise levels approached 100 decibels. O.R. personel reported the cacaphony of sounds. 

Current research demonstrates that OR decibel levels
of constant or intermittent noise exceed the National
Institute of Occupational Safety and Health (NIOSH)
limits for damaging noise at baseline without the additive
noise of music.   Furthermore, a 2013 study noted that
OR performance outcomes have been previously linked
to changes in mental loading such as task complexity and
workload at baseline noise levels without additive noise
effects such as music.

The UTMB study was performed in a surgical laboratory on animal pigs feet, (not a normal operating environment). This study may have no valid information regarding stiching times with music in the background.

  1. Shelby R. Lies, Andrew Y. Zhang. Prospective Randomized Study of the Effect of Music on the Efficiency of Surgical ClosuresAesthetic Surgery Journal, 2015; sju161 DOI: 10.1093/asj/sju161

When surgeons listen to their preferred music, their stitches are better and faster -- ScienceDaily

Sunday, August 2, 2015

The Google + Haters

Those reports of Google +s death are premature.  It is still a very active social media presence despite the dooms day emanations from the disenfranchised social media FBers, Tweeps and others.

It should never have been promoted as an alternative or competitor with Facebook. It is common knowledge the first developer of technology, be it software or hardware dominates the space.

Yes Facebook is a giant in the social media niche, far surpassing G + and all  others for that matter. The leadership at Google is not afraid to fail. Google is not to be judge for it's failures. It remains at the forefront of search, so much so that the EU is now considering an anti-trust action again Larry Paige's offspring.  Some well known executives have left, but probably not from dissatisfaction with Google.

In most industries executives have short lives, take Hewlitt-Packard, IBM, Microsoft, Apple and many not IT industries.  The head of  Proctor and Gamble defected and went to work with the Veterans Administration. This hardly seems like a promotion leaving a very successful and stable consumer driven company that has been in existence for decades, constantly growing both in volume and in stock market capitalization.

Facebook has been in existence far longer than Google +.It is a bit like buying new software, the new one may be better but it is hard to transition to a new work flow.

I was never  a user of Facebook before Google +.  I still use both.  Users of Faceook are faced with a conundrum..Do they build a new social media network ?  Do they learn a new system ?  Many are dissatisfied with Microsoft upgrades. Simple is good. Unless there is a marked advantage to using new software users hesitate to do so.

In terms of functionality Facebook responds much faster. Google lags considerably at times. Gmail is even worse. Connecting the two was a poor tactical decision, but it is far from destroying Google +. This is not a deprecation....and perhaps it will function better on the servers as a separate entity.  I am not an expert on  YouTube, but it does not depend upon Google or Google + for it's use. It became 'famous' on it's own strength.  Google did stimulate it's use by connecting the log in to Google +

The 4th of July

So what is it about Google +that seems to turn off social media fans?  It is too complicated for social media users who want to communicate with their friends.  It has a long learning curve, and too many segments, communities, collections, notifications, and more. It is confusing where to find your friends.

Google hangouts was a fresh addition, but it too shot itself in the foot by being release too early. It seemed each week there was a new feature...toolbox, messaging, an inconsisten and poor response or even no response to hangout  invites. The events tab was unusalbe,many events did not even disiplay until they were over. Hangout were a bit too intimate until one had developed friends.  It was a forum for adults, not teenagers.  Google presented new opportunities for professionals such as physicians to broadcast surgery for the operating room.

I will place my bets on Google
But then Again I usually lose my bets

Sunday, April 5, 2015

Hillary Clinton

Need anyone say more?  Once the aggrieved spurned spouse of  Bill Clinton, most felt some sort of sympathy toward her when Monica Lewinsky assumed her wifely duties at 1600 Pennsylvania Avenue.

Hillary however has never been willing to 'get down' on her knees literally or figuratively. She always worked from the rear behind her man.  Perhaps this was another figurative way of saying she has been an ass kisser most of her life, to get where she wanted to be.  

I began to suspect these two Clintons of wanton ways when I read about the mysterious 'suicide death of Vince Foster, white house counsel who had coincidentally been subpoenaed to testify before Congress. shortly after the Whitewatergate became a new buzzword dating from a real estate deal in Arkansas when the two were young pups running Arkansas.  Was the potential witness 'neutralized'

Consider the uncanny resemblance here.  Accidental, or planned conciously or unconsciously as an "Untouchable", Hillary seems to be  among some supporters in the Democratic Party.  No one as yet in the party has come out in public as against her running for   President of the United States.  After all what is to gain at this early date, while other pubicly or surreptitiously prepare for the race.

Many suspect that party faithful have gained their positions fo pseudo-power as her supporters and are in fear of what will happen to their livlihoods, and possibly more by 'outing' Hillary.

Many occurences put the American Public at Defcon 6 by her State Department shenanigans,  in Benghazi In additon to her complete lack of humility over the deaths of four men, and damage to wives and children her answer to the questions was 'Four Americans are dead, what's the difference"  The difference Hillary is that you are an emotionless cold hearted unfeeling fake. The women who believed in her to become the first lady to break the glass ceiling  (with her hard head) have been blindly following and supporting her to have a female in our White House.

Some are so ennured to the Clintons that a supporter financed the Clintons at a time when she admittedly was insolvent.  It was not an inexpensive home in a non-descript neighborhood, rather in Chapaqua, N.Y. a very upscale area of privelege for the 1%.  There went that neighborhood.  The Clintons then attempted to sponsored a wing-ding for non other than Mohamar Qadafi (late) who brought along his one entourage, tent and all. Fitting for him as he was born in a Bedouin tent.  (watch the video below)

Qadafi's Tent Gathering

 Located 13 miles from Chappaqua NY in another tony residential area for the 1%, in Bedford, NY the temporary tent was built on Donald Trump Land (another possible Presidential Candidate). You can be sure the "Donald" leased the land for a substantial amount of money for a one week stand. There must have been some oil in the deal.  Qadafi countered by killing several hundred people in shooting down Pan Am's flight over 

The relatively small berg of Bedford filed a legal  suit and forced the up and coming tent to be torn down.

Never under-estimate Hillary Clinton....she knows something we don't know.....55,000 emails.

Sunday, March 22, 2015

The Medical View from Here

Our Digital Health Space web site is 404. We cannot post to that site, we are hoping it will be fixed soon by a Google Guru.  

For the foreseeable future The View from Here will include Medical News

Breakthrough in Cancer Imaging, and the use of Magnets in Surgery

See the imaging breakthrough hoping to transform cancer treatment
· Find out which favorite snack could save your heart
· Watch how magnets could make surgery easier and recovery faster

All this and more in the latest VUCast, Vanderbilt's online newscast. Watch now.

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