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What’s happening in burn care?

From a recent interview that I did with Chris Porter, of OnSurg.

(I’m a huge fan of his OpReport videos- check more than mine out!)

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Reading round-up, May edition

What’s caught my eye in the literature recently?

This multi-dimensional frailty score is a nice new addition to the body of literature on frailty as a predictor of operative mortality.  I, of course, have been carping that I still want a frailty score for the acutely injured patient, particularly the injured burn patient.  I probably just need to turn that into another project on the project board, don’t I?

Inevitably I can find an education article to recommend.  The output from a national invitational conference gives us some meaningful ideas on how to address challenges in transitioning from residency to independent practice.  A great companion piece to read with it is a survey about readiness to practice.  Clearly lots of concerns persist from many about how we best bring our residents forward from training to being our partners.

Because I have one PRP trial running and another starting soon, I was delighted to see someone else state they think that this is an area for broader investigation in burns.

Not surprisingly, Medicaid expansion is accompanied by increased use of specialty surgery services.  I’m aware of several related manuscripts coming to publication in the next couple of months re: the Massachusetts experience with universal coverage and other Medicaid expansion projects.  It’s important background for understanding the true impact of the ACA.

Last but not least, one more education piece, discussing how medical students define mistreatment.  While I don’t support the concept of a hostile learning environment, I’m not certain that defining it as mistreatment is appropriate either.  This is a genuine challenge as an educator and clerkship director.

For fun reading?  I’m in the last 100 pages of Haldor Laxness’ Independent People.  Earlier in the book I was ambivalent.  I’ll now move to a full recommend, both for the beauty of the descriptions and for the characters.  Bjartur is both pitiful and comical in his inflexibility, and while it costs him dearly at a personal level, the tale that unfolds is magical.

 

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Profit motives and healthcare delivery

This morning I had the opportunity to spend time with a group of 2nd year medical students facilitating a patient/ family case for their Life Cycle Unit.  In this particular case, the students had just under two hours to work their way through how to provide healthcare to a young (well, younger than 40) man with a chronic health issue.  The intent of the case, as I understood it, was to get the students to consider healthcare options available to those who are economically marginalized through job loss; the case took some twists and turns from unemployment to underemployment to the patient’s family losing their home.  At each step of the way, the students were to consider what options were open to the patient to get his medications and follow-up care that he needed.  While I was impressed at how quickly they managed to access resources- one of them going so far as to make a quick phone call to get more information on a program- I was more impressed at their ability to cast this man’s ability in the broader context of how we deliver healthcare in the U.S.  The truth is that he was designed to fall into one of our “gaps” where healthcare coverage is expensive to obtain, and the students truly understood the implications of that.  They also expressed frustration that we live in a country where someone’s family can be working hard and doing the right thing, yet healthcare is still a commodity for them.  The students really left their politics at the door and discussed these things from the perspective of people who are responsible for the care of other people- and trying to puzzle their way through how to do the “right” thing for this man when faced with a series of challenging circumstances.

I had the opportunity earlier this year to hear Thomas Lee, the CMO of Press Ganey, address the issue of the future of healthcare; he’s someone who has some important ideas, though they are also ideas that would require a fundamental change in how the healthcare system in the U.S. is aligned.  In October, 2013, Dr. Lee and Michael Porter published “The Strategy that will Fix Health Care” in the Harvard Business Review.  If you haven’t had the chance to read it, it’s worth the time and effort to get a copy of the article.  To give you the short version, their fundamental premise is that healthcare delivery is threatened by rising costs and uneven (at best) quality of care.  They acknowledge that while efforts have been made to fix the things that are broken, none of these incremental efforts have met with much success.  Their core strategy?  Maximizing value for patients- delivering the highest quality care at the lowest cost.  They believe we need to put in place a “value agenda” in order to save healthcare from itself.

The move towards value in care is already happening.  At my own institution, it’s under the aegis of “Value Driven Outcomes” (VDOs) as a system priority.  However, for the value agenda to really work, it seems to me (and my students) that two fundamental things have to happen:

  1. Everyone involved in the delivery of care (not just clinicians, but facilities, drug and device companies, etc.) has to have the same motive- to provide best care to the patient.
  2. In order for 1 to really happen, the profit motive needs to be either removed or contained.  Certainly the caps on drug prices in the EU represent a first move in this direction- one that isn’t capitalistic by any means, but the only clear way forward to focus fully on patients as the raison d’être for the healthcare system in the first place.

With that likely controversial statement, I’ll close- and, of course, ask for thoughts, particularly if you can see a way to maintain any significant profit motive with the primacy of the value agenda for our patients.

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Trying to stem the tide?

I suppose this is at least in part a monster of my own making.

Generally I like email as a form of communication.  I like the asynchronous nature and that I can control when I respond to whom.  I like that I can (generally) be the one to prioritize the urgency of something that is sent.  I mostly love not having to talk on the phone unless it’s a planned conversation (yes, I really don’t like the phone as a mode of communication unless it’s really urgent or we planned to talk).  Some of this may be reflective of a couple of features of introversion:  wanting my space to be just that, and wanting time to process information carefully before responding to it.

This morning, however, my email inbox pushed me up to the brink- and almost over it.  50 emails before 10 am.  Let me reiterate.  Fifty.  Before 10 am.  A handful were necessary, yes, but many from abuse of the “reply all” function in a number of conversations (no, we don’t all need to know that the meeting  scheduled based upon a Doodle poll at a specific date and time isn’t good for you).  Some were a series of rapid-fire questions that if the authors of said questions had thought before they sent could have been consolidated into one or two emails instead of 10.  Quite a few were simply because the EBRS list-serv was busy with discussion of the April article today, though again- why can’t these be sent as a digest format at the end of the day?

Needless to say, I was frustrated.  I dug into resources I have saved every time I have begun to suspect that I’m not managing my email “right.”  The recent set of tips I saw in the HBR struck me as…well, utterly unhelpful, to be honest.  Fortunately, a follow-up HBR blogpost (written my someone who a couple of years ago had a near-decompensation like mine today and blogged about it) gave me some better ideas.  I’ve installed SaneBox as of 1130 this morning, I’m training it, and I promise to let you all know if it is actually effective in making the deluge more manageable.  (Note:  If you have SaneBox experience/ tips, please share!)

So, yes, email.  It’s necessary.  It is my preferred mode of communication.  We all, myself included, need to be thoughtful about how we manage it.  I’m thinking more from a framework of, “Is this message completely necessary?” than I have before, and I could get used to this!

 

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Disruptive surgeon behavior, effects and coping mechanisms

I’m currently reveling in the amazing event that is Surgical Education Week, and I promise a blog post generated from my experiences here sometime next week.

In the meantime, here’s a link to what I talked about today- the effects of disruptive surgeon behavior, and how those exposed to it cope.  This merely skims the surface of the work that Will and I have done in this area, and I hope it will give you some food for thought. Of course, the question that underlies all of this work is what do we do about it. My response? Team training, conflict styles education, and zero-tolerance policies. Quite frankly, it’s beyond time for a culture change.

Effects of Disruptive Surgeons- ASE 2014 from amaliacochran
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I’m not overly-busy, I’m just programmed for a 30-hour day!

I haven’t done a confessional in a while, so here we go with one:

I’m tired today.  In fact, not just tired.  Exhausted.

The proximate cause is the fact that I was up until midnight last night finishing some manuscript revisions that were due…uh…today.  (Note:  I am not usually a procrastinator.  This issue is what brings us to today’s blog title.)  Could I have finished them before midnight?  Probably, but it would have meant not spending some focused time with some students yesterday, time that they deserved, and it would have meant skipping my workout.  Could I have made more progress over the weekend?  Again, yes, but the haircut, pedicure, long dog walks, and church were all good for my soul.  If I’ve learned one thing over the years, it’s that I am more productive by allowing myself some rests while I’m running, so to speak.  Over the weekend I also had student activities to prepare for this week- again something that got put off not because I procrastinated deliberately, but because my plate overfloweth.

If I pull my schedule since the first of the year, it’s been a wild ride.  Lots of clinical time, lots of travel (meeting season, I’m almost done with you!), lots of student obligations, lots of research productivity.  In a simplified world, I would simply decide to give up one of the things that’s keeping life so full to the point of being crazy-busy.  But that’s a simplified, reductionistic view of my life and the things that I do.  Could I give something up, or do a less-good job at some of these things?  Yes, I could.

Is that going to happen?  Highly unlikely.  The truth is that while the last 3 months and 8 days have resulted in my current state of exhaustion, they’ve been a pretty terrific quarter year.  The truth is that if I take a step back and contemplate giving up something that I’m doing right now, I don’t know what it would be.  It’s all incredibly different, and maybe that’s why I love moving from researcher self to ICU doctor self to leader self to educator self to burn surgeon self.  It keeps me challenged, maybe a bit off balance at times, but always striving to stay on top of my game.  I feel privileged to get the opportunity to do so many things that I am truly passionate about, to be able to do them well, and to live to tell the tale.

Besides, I keep hearing a piece of (bad) advice I was given during my second year out of training.  I was told it simply wasn’t realistic for me to have any sort of personal life and to maintain my vision of dividing my career fairly equally between clinician/ educator/ investigator/ leader.

Sometimes it’s exhausting, but it can be done.  And this week, even in my fog, I’m feeling pretty good about it.

(And here’s a nice piece describing how to overachieve and not go insane…I don’t agree with it all, but I do agree with most.)

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April reading round-up

What’s caught my eye in the literature lately?  A few things.

  • The POISE-2 trial’s aspirin data, showing that perioperative aspirin in non-cardiac surgery patients increases the risk of perioperative bleeding but doesn’t impact the risk of MI or cardiac death in that same time period.
  • A decrease in complications in Florida that is driven by a NSQIP-based quality improvement process.
  • The evidence-based modern management of diverticular disease.  As someone without a general surgery practice, this review provided a nice way to keep me current on an important disease in general surgical practice.
  • PPIs may not be the Holy Grail of GI prophylaxis in the ICU.  Provocative data, to be sure, and the authors’ call for a prospective multicenter trial is appropriate.
  • Does Gabapentin help with the management of post burn pain?  Apparently not, at least for non-neuropathic pain.  To be answered:  The role of Gabapentin in burn itch.
  • Sarah Smailes’ group in the UK continues to generate terrific work on the role of tracheostomy in burn patients, this time comparing perch trach and surgical trach complications and dysphagia.
  • And, last but not least, my work with a wonderful group of surgeons on the use of Twitter at academic surgical meetings.  Our publication stands in interesting contradistinction to the conversation I had with 20 4th year medical students on Friday in which I discovered that zero of them are on Twitter.  Many of them said, “We don’t understand the point of Twitter.” Here’s hoping that giving them some professional justification can change their hearts and minds.

 

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This is the place

I have quite a few friends and colleagues who are headed to Salt Lake City for SAGES this week, and I’ve had several ask me for tips on places to go, things to do, etc.  While I’m lots of help for grown-up things to do, I’ll confess to having crowdsourced for kid-friendly activities for anyone who is bringing their children.

Awesome things to do with your kids or if you want to play hooky and do something fun:

Natural History Museum of Utah– In truth, it’s awesome for the young-at-heart as well, and the current chocolate exhibit is fascinating.  I have a membership there because I love it so much.  Note:  This was overwhelmingly the #1 answer for a must-visit place.

Discovery Gateway– Lots of awesome interactive things going on here!

Living Planet Aquarium– Brand new, and it looks like something for me to check out on a rainy day when I don’t mind going to the South end of the SL Valley.

Clark Planetarium– Also has an IMAX theater.

Tracy Aviary– Note: If it’s a beautiful day the Aviary sits within Liberty Park, which is a great place for a walk and has nice playgrounds too.

And, if you don’t mind a bit of a drive (30-45 minutes from downtown SLC, dependent upon traffic), Thanksgiving Point has gardens, dinosaurs, and a petting zoo.

In and around Downtown SLC:

Temple Square is beautiful this time of year with tulips, daffodils, etc.

City Creek Center has some shopping (if you’re from a true shopping mecca, it’s not that impressive) but also has lots of restaurants, any of which are kid-friendly.  Same for the Gateway.  As one friend noted, most restaurants in SLC tend to be family friendly.

My personal food favorites:

Fresco Italian Cafe at 15th and 15th.  The fact that it is next door to a wonderful small independent bookstore (The Kings English) is simply a bonus.

Pago, which does lots of local sourcing and even has their own Pago Farms, and its sister restaurant Finca.

Mazza Middle Eastern Cuisine is one of my go-to places, also a bit less fancy than above recommendations.

Cucina Deli, which started dinner service about this time last year.  This is my neighborhood go-to restaurant for eat-in or takeout.  You can’t miss here, and Dean (the owner) is always a delight- please tell him I sent you if you go there.  Note:  dinner specials are posted daily on their Facebook page.

For casual Italian and some delicious pizza options, Vinto.  Also, excellent gelatos!

Eva.  Try the brussels sprouts- you won’t be sorry.

No SLC food list is complete without including the Red Iguana.  Traditional Mexican food, amazing moles, legendary Tacos Don Ramon.

Activities:

From downtown, heading up Memory Grove to City Creek is a beautiful run or walk.

The Bonneville Shoreline Trail traces along the hills at the level of the historical Lake Bonneville shoreline.  Again, a beautiful place to walk or run.  I won’t rub in the fact that it is directly “out back” from University Hospital.

The Olympic Legacy Park celebrates the 2002 games- and has some cool activities as well (bobsled, anyone?!?).

If you ask people where to ski (Alpine), you’ll get at least 7 different opinions, probably from fewer than 7 people.  I personally am a fan of Snowbasin, which is a little North of SLC but is an easy drive.  Great mountain for all levels of skiers, and the chili in the lodges is to die for.  Snowbasin is also notable for having won awards for their bathrooms (which are opulent, and I feel guilty wearing ski boots in them) and for having hosted the 2002 Winter Games Downhill and SuperG. In my informal poll of friends with children, Park City got high praise because children under age 7 ski free.  Snowbasin and Park City also both have tubing hills It is also a very friendly mountain good for all levels of skiers.  If you’re a little more hard-core, Alta and Snowbird are as good as it gets- but they are NOT easy mountains.

If you find yourself needing a good yoga practice to recover, my go-to is Centered City Yoga.  They’re in the same neighborhood as both Mazza and Pago, so if you arranged your time correctly you could get in a nice practice and a great meal.

Last but not least, if you’re a live music fan and like Blitzen Trapper, they’re playing at The State Room on Thursday night.  This is a fabulous small venue where the fans tend to take their music seriously.

Enjoy my adopted hometown!

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A week for humility and gratitude

First, an apology that I missed my Thursday scheduled post this week.  I have a long list of reasons why, the most parsimonious of which is that my Dad was leaving for Arizona today and dinner with him took priority over my musings here.

Ordinarily I would have written after he left my house last night but I was exhausted.  It’s been one of  those weeks in our burn unit in which I am reminded of how remarkable our team is.  I was supposed to leave last Sunday night for the American Burn Association meeting in Boston.  Instead, I stayed home because my heart (and my experience) told me that I was needed here.  It has been one of my busiest weeks in a long time, and certainly one of my most operatively challenging.

While I am incredibly tired and very ready to hand the service off to my practice partner who is on her way home, I’m also humbled and grateful.  I am humbled by a team that found a way to meet the needs of our patients, even when it meant giving up days off or being a bit inconvenienced.  I am grateful that I work with a team who “gets” the concept of doing the right thing to deliver the care that our patients need.

While many of them have credited me this week for the professional sacrifice of not going to Boston, I would argue that I don’t deserve to be on the national stage if I’m not delivering the goods at home.  And while I’ve spent my week doing things that I was needed to do, there is absolutely no way I could have done it without this group of people who share my passion for burn care.

To my team:  Thank you.  Thank you for your clinical expertise and for being wonderful people.  You’ve kept me afloat when it hasn’t been easy this week.  Most importantly, you’ve done some good things for some people who really needed it.  Your ability to do both small and great things with great love makes you who you are.  Don’t change.

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Matchmaker, matchmaker, make me a match

It’s that day, if you’re in medical education.

Really, it’s the whole week.  Monday is the “big” hurdle, when those students who have successfully matched into residency can stop worrying if they matched and can move on to worrying about where they matched.  Monday is also the day when students who did not match get very busy for a couple of days as part of the SOAP (Supplemental Offer & Acceptance Program), seeking an unfilled spot that will meet their educational and professional needs.

Admittedly it’s been a few years since my Match Day but I still remember it quite clearly.  There was a huge sense of relief about finally knowing where I would be headed in June; I had known for months that I wasn’t staying in Central Texas, though I had no idea of the long-term implications of matching at Utah for my career.  16 years later, here I am, still in Salt Lake (albeit with that year I went back for fellowship in Texas as part of the equation). Subsequent match days have been filled with excitement from seeing who would be following me in the residency program, then who would be “my” residents once I became faculty.  As I’ve become increasingly involved with the medical students over the last 5 years, it’s become a day of pride and celebration as I see where students whom I have mentored find out what the next chapter in their professional lives will be.

Understanding the match process can be a little complicated.  Essentially, students apply for residency interviews.  After the interview season is complete, the student and the interviewing programs each make a rank list in order of preference.  A computer then runs an exceptionally complicated algorithm (and one that favors the students over the programs, appropriately) and voila- matches are made.  If it tells you anything at all, the economists who designed the Match algorithm won the Nobel Prize in 2012.  Generally speaking, the system works and works well.

So, today.  Match Day 2014.  Approximately 17,500 senior medical students in the U.S. will find out where they’ll be in 3 short months on the next part of their journey as a physician.  To those of you whom I know…and those whom I don’t…wishing you good luck today that you land in a place that will be just right for you.