Tag Archives: evidence-based medicine

May 8, 2016

Key but hard-to-find esoterica in evidence-based medicine

Mother’s Day Brunch is over, and I am feeling appreciated and loved, though a bit bored and lonely now that the “kids” have left for home.   So I’m catching up on stuff.

I went back to finish reviewing a draft practice guideline via an on-line questionnaire.  The authors wrote that I was selected to participate because of my particular field of expertise.  I started but didn’t finish the questionnaire last month.  When I logged in again today, the software jumped me straight to a question that asked whether I agree with a statement that begins: “There is OCEBM Grade C supporting evidence that ……”

This terminology was only semi-famliar to me, so I Googled OCEBM which wasn’t much help.   I still haven’t found the criteria for Grade C (which implies there exists criteria for Grade A, B, and maybe other grades beyond that too).    More Googling will probably help.  But to be truthful, I decided to give up on this effort.   When the researchers asked me to participate, they didn’t tell me the survey has SIXTY FIVE questions each of which seems to require a whole lotta cognitive work including evaluating a set of brief descriptions of the scientific literature pertaining to the subject of each question.   I am NEITHER an academic type nor a methodologist (a person who critiques the experimental design and analytical methods used in research).

HOWEVER, while Googling around I did find a document  entitled “Understanding GRADE: An Introduction” that MAY BE USEFUL to you.  It was for me.  It succinctly describes  (in LESS than 1,500 words) the steps that developers of systematic reviews and practice guidelines should use to assess and rank the quality and strength of evidence supporting a particular practice or treatment.  This method is widely used in appraising scientific studies.  Worth a read – particularly if you are confused by competing guidelines.

Methodology is KING in evidence based medicine — if the scientific quality of a study sucks, you shouldn’t view the results as reliable/valid/believable — no matter how much you love them.  So if you’re like me and not a methodologist yourself, you need to make sure that the committee that produces an “evidence-based guidelines” has members who really do know that stuff.

In theory, I like the idea of wide participation of experts in development and review of practice guidelines.  But based on my (limited) experience with development of the ACOEM practice guidelines for occupational medicine, the work is so hard, detailed, and time-consuming that it tends to be done by a small group of committed experts who put in a TON of hours, and then send their finished product out for comment.  Part of the reason why I felt so uncomfortable reviewing the practice guideline today is that there was so little background information and context provided to me as a reviewer.  Like:  (a)  what were the 65 questions going to be like; (b) how long would it take me; (c) where are they in the development process, and (d) what use is going to be made of the on-line reviewers’ input?

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November 19, 2015

Early EVENTS influence outcomes: You have power to make good things happen!

Few people realize how important early EVENTS are in determining the eventual outcome of a work disruption due to a health problem, particularly the most common kinds of conditions:   low back pain and other kinds of muscle and joint sprains and strains, depression, and anxiety.

Let’s call this a poor outcome:  a failed medical recovery that results in over-impairment and excessive “disability” accompanied by work absence and loss of employment that could have been avoided.  And let’s call this a good outcome:  the fullest possible medical recovery with the least possible physical or mental impairment and the smallest possible impact on the rhythm of everyday life, including minimal lost work time and continued employment.   Do you agree?

Here’s the exciting “so what” about this news that EVENTS influence outcomes:  all three of the professionals who respond to an individual CAN influence what some of those EVENTS are going to be.  Those three professionals are:  the treating doctor, the workplace supervisor, and the benefit claims handler.  This news means that each of them actually has some POWER to nudge things in a good or bad direction!!

See below for a brief description of why early events are so important, and how the experience of  people destined for lucky or unlucky outcomes differs.  In fact, these ideas are some of the main concepts of the work disability prevention model.  (NOTE:  The scientific articles that support the  evidence-based concepts are briefly noted in parentheses.  Their full literature citations appear in the list of References in our report that recommends the establishment of a nationwide Health & Work Service.)

When a working person’s life is disrupted by a new or changed illness or injury, the first few days and weeks after onset are an especially critical period.  The likelihood of a good long-term outcome is being influenced, either favorably or unfavorably, by some simple things that either do or do not happen during that interval (Bowling 2000; Cornelius et al. 2011; Franklin et al. 2013; Loisel and Anema 2013; Nicholas et al. 2011; Shaw et al. 2013; Waddell and  Burton  2004; Waddell,  Burton,  and  Main  2001).  It  is  the  optimal  window  of  opportunity  to improve outcomes by simultaneously attending to the worker’s basic needs and concerns (Shaw et al. 2013)  as  well  as  by coordinating  the  medical,  functional  restoration,  and  occupational  aspects  of  the situation in a coordinated fashion (Wickizer et al. 2011).

The  way  the  episode  unfolds  over  time  in  all  dimensions — biological,  psychological,  social,  and economic — can have a big impact on the outcome. Events that occur can either mitigate or aggravate existing  risk  factors  in  the  situation,  leading  to  better  or  worse  outcomes.  There  are  usually  many opportunities to actively influence the course of events immediately after onset of a health problem (and  many  fewer  opportunities  later  on),  but  today  there  are  few  resources  devoted  to  finding  and exercising these opportunities.  Most of the current attempts to steer situations to a better outcome are made long after the best opportunities have passed by.

The best opportunity for basic intervention appears to last about 12 weeks or three months (DeWitt 1995; Franklin et al. 2013; Hashemi et al. 1997; Johnson and Fry 2002; Loisel and Anema 2013; Turner et  al.  2008)  although  some  data  shows  it  ending  by  6  months  (Rumack  1987;  Waddell  and  Burton 2004). A modest set of simple services —that embody an immediate, systematic, pro-active, integrated, and multidimensional approach — can mitigate the potentially destructive impact of common injuries, illnesses, and chronic conditions on quality of life among the working population (Burton et al. 2013; Hill et al. 2010; Iles, Wyatt, and Pransky 2012; Kendall et al. 2009; Lagerveld et al. 2012; Loisel and Anema  2013;  McLaren,  Reville,  and  Seabury  2010;  Mitchell  2012;  Nicholas  et  al.  2011;  Shaw  et  al. 2013; Sullivan et al. 2005; Turner et al. 2008; Waddell and Burton 2004; Wickizer et al. 2011).

This new approach will allow people to avoid the kind of adverse secondary consequences of medical conditions that they too often experience today (Institute of Medicine 2001; Dartmouth 2008; Franklin and  Mueller  2015).  Those  consequences  are  not  usually  obvious  until  months  or  years  later,  after unfortunate things have happened. The unlucky ones have received sub-optimal health care, been left with undertreated or iatrogenic impairment, become dependent on opioids, found themselves socially isolated, lost their jobs, withdrawn from the workforce, lost economic independence, and ended up on long-term disability benefits programs or SSDI in order to survive (Darlow 2011; Franklin et al. 2008; Franklin et al. 2014; Franklin and Mueller 2015; Habeck, Hunt, and VanTol 1998; Nguyen et al.)

CLARIFYING KEY TERMS

Figuring out where the opportunity to improve outcomes actually lies will be easier if we first clarify some terms that are often used carelessly or that mean different things to various audiences.

Work Disability vs. Disability
In the world of employment and commercial insurance, the word  “disability” is carelessly used.  In this world, the correct term is often “work disability” –which means absence from or lack of work attributed to a health condition.

According to the ADA, disabilities are impairments affecting major life functions (such as work).  Having a disability need not result in work disability.  This is a core concept embodied in the Americans with Disabilities Act. Similarly, having symptoms or a diagnosis need not (and usually does not) result in work disability.

Medical Recovery vs. Functional Restoration
Medical recovery refers to the resolution (disappearance or remission) of the underlying pathological process. Functional restoration refers to reestablishing the usual rhythm of participation in everyday life including the ability to go about one’s regular daily business: performing necessary tasks and enjoyable activities at home and work, and participating fully in society. Functional restoration often accompanies medical recovery, but not always.  Even when medical recovery is not possible, restoration of function often is.   In some cases, it may require separate and specific professional attention.  Functional restoration may include rehabilitation (broadly defined), the successful use of assistive technology, adaptive equipment, and/or reasonable accommodation in the workplace.

Anticipatory  programs  that  ensure  the  right  things  happen  from  the  start  and  include  early identification of those needing extra support are the simplest and most effective way to prevent later adverse secondary consequences of these conditions. A professional needs to provide the following services throughout the immediate response period (which typically ends with stable RTW or 12 weeks post onset).  These services are not generally available today, especially to lower-wage workers and those who work for small firms:

  • oversee and champion the affected individual’s stay-at-work and return-to-work (SAW/RTW) process until it is successful.
  • conduct a quick initial assessment and planning session that considers the individual’s entire situation, screens for known risks for poor outcomes, helps the individual and/or employer make a  SAW/RTW plan and  support them  in  carrying  it  out;
  • drive towards the best outcome by:
    — expediting and coordinating external medical,  rehabilitative  and  other  kinds  of helping services, including referrals for specialized services as needed to address remediable obstacles in a variety of life domains;
    — facilitating communications among all involved parties, ensuring they get the information they need so everyone has a shared picture of the situation and the goal;
    — taking a problem-solving approach with affected individuals, treating physicians, employers, and payers.

If RTW has not occurred by the time the 12 week period has ended, that should trigger a hand-off  to another professional with broader expertise for a deeper assessment which is likely to reveal the need for a different strategy, revised goals, a new approach, or the involvement of other disciplines.

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October 26, 2015

Medical “red herrings” lead to over-treatment & leave patients suffering

When I give a presentation, my goal is to give a gift to the listeners — some new information, perspective, or insight they might not have had before.  I spend time beforehand, imagining how they see the topic now, what they might be thinking, and how I should structure my talk to take them from “here” to “there.”

It’s very gratifying when they send signals that they “got it.”   The funnest [sic] part about public speaking is seeing people’s eyes light up or heads nod as I speak, or having them come up all excited to talk to me afterwards, or when they send an email — or when they write about what they heard.  It’s particularly graifying when the article a reporter writes matches up with what I hoped they would notice.  All those things were true last week when Keith Rosenblum (a senior risk consultant from Lockton), Dr. David Ross (a neurologist and developer of the NP3 diagnostic testing method) and I gave a presentation at the SIIA (Self-Insurance Institute of America) conference last week.  Our audience was a small group of professionals who work for companies (employers) that are self-insured for workers’ compensation.  Our topic was “How Medical Red Herrings Drive Poor Outcomes and Big Losses— and What You Can Do to Stop Them” .

And in particular, here’s a shout-out to reporter Robert Teachout (wow, a rhyme!) for really GETTING what we were trying to get across in our session.   Robert’s article appeared last Friday in HR Compliance Expert.

Dr. Ross taught the audience about the latest definition from pain experts on the essential nature of pain:  it is an EXPERIENCE put together by the brain after it analyzes and interprets many things.  Pain is NOT a sensation in the body.  He also described why and how “objective findings” on MRI often lead doctors to over-diagnose structural spine problems and provide over-aggressive treatments — because the actual source of the pain lies in soft tissues or the brain itself.

My job in the session was to point out this obvious but often overlooked fact:  doing surgery on the wrong problem is not going to make the patient’s pain and distress go away.  And I introduced the audience to the idea that there are other very common causes of prolonged back pain, distress and disability (summarized as biopsychosocioeconomic (BPSE – bipsee) factors) that may mimic or worsen noxious sensations coming from the spine.  Screening for and dealing with easy-to-treat BPSE factors BEFORE resorting to aggressive testing and treatment makes more sense than waiting until AFTER you’ve subjected the patient to those potentially harmful things.  That’s because MRIs, opioids, injections, and surgeries increase the patient’s certainty that their problem is in their spine while at the same time failing to relieve their pain AND causing side-effects and additional problems.    Keith recommended that employers / claim organizations start screening for the presence of a variety of BPSE factors — and get them addressed — BEFORE aggressive, potentially destructive and definitely expensive treatment even begins.  Screening methods can include simple things like questionnaires, or fancy things like the NP3 testing methods.

In addition, even when surgery IS needed, it makes sense to screen for complicating BPSE issues and address them BEFORE surgery as well as during recuperation — because having clear indications for surgery and being a good surgical candidate doesn’t mean a person is free of the kind of BPSE issues that reduce the likelihood of a good recovery.

I sent Robert, the reporter, a compliment via email that read:  “Robert, you did a remarkable job of capturing the salient facts, important implications, and key take home messages from our session.”  I hope you will read his article — and that you’ll send him a note if you found it informative or helpful

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October 22, 2015

Star rankings for doctors who deliver better outcomes in workers’ comp

I was in the audience for a presentation on “outcomes based networks” in workers’ compensation while at the SIIA conference this week (Self-Insurance Institute of America) in Washington DC.   The two presenters were from Sedgwick (which I believe is now by far the largest workers’ comp claims administrator [claims payer] in the country — servicing mostly self-insured employers) and from Multi-Plan (a huge PPO).

The bottom line is that Sedgwick is now putting INDIVIDUAL treating physicians into ranks, from 5 stars (most preferred) all the way down to 1 star (least preferred) .  HOWEVER, many physicians cannot be ranked because the “n” (number of cases for which the payers have data) is too small to analyze with any statistical confidence at all.  The star ratings are NOT generally shared with the physicians — but I bet doctors who know the rankings exist can ask pointed questions about where they stand.

The two speakers have been deeply involved in developing the data sets and metrics to assess physician performance.  They have also been responsible for packaging that information so people who need to know where to send patients can quickly find the best available nearby doctors.  (I am an informed listener on this topic, having developed a physician “report card” myself with less sophisticated data tools in the late 1990’s.)

The presentations were fascinating, both because of what the speakers DID say, as well as what they DIDN’T say.  The four most important things they DID say (if I heard correctly) were that:
•    Sedgwick’s clients, claims adjusters, and case managers who are making referrals / recommending physicians to care for work-related injuries now have access to a user-friendly website that automatically lists doctors within certain geographies IN ORDER OF STAR RANKING (though the ranking itself is not displayed).  Reality check:  Some locations simply don’t HAVE any super-top-ranked providers.
•    Employers who are able to get most or all of their employees to 4 or 5 star doctors have DRAMATICALLY BETTER RESULTS in terms of medical/functional outcomes, disability duration and cost, including higher patient satisfaction/lower litigation rates.   These employers are seeing roughly 15-20% improvement in the parameters of interest.  I heard later that these are mostly California results.
•    The highly ranked doctors are happy to get the referrals and have NOT been asking to be compensated better when it has been confirmed that they are the best.  The highly ranked doctors also tend to be the ones who do a lot of work comp — so they are attuned to the critical issues that need to be managed.  Personally, I think those who DO deliver the best results SHOULD thrive and prosper as a result — not just get more patient volume.  MANY doctors already feel maxed out!
•    A nice endorsement for occupational medicine specialists in general.  The speakers consider “occ docs” as “primary treating” providers (along with urgent care, internists and family practitioners) rather than as specialists (e.g. orthopedists, pain management).  In general, occ docs rank high.  The speakers said it was because of our specialty’s philosophy of care that puts high priority on employing evidence-based techniques for medical treatment and preventing needless work disability in order to optimize patient outcomes and control total episode costs. They said it’s not a sure shot — there are SOME duds in our specialty — but both speakers agreed that as a rule, occ med physicians are among the best.  (They only mentioned occ med because I specifically asked the question –and that was because I suspected what the answer would be –and wanted the audience to hear it!)

The three most important things I DIDN’T hear the speakers say were:
•    How OFTEN the employers/adjusters/case managers are ACTUALLY choosing docs based on rankings.
•    What FRACTION of all doctors in any given geography they actually are ABLE to rank.  (In other words, how many cases have Sedgwick’s employer clients actually been SENDING to each doctor.).  I wouldn’t be at all surprised if it’s less than 25% of the doctors.  I suspect the unranked doctors’ names are NOT presented first.
•    How many cases the doctor has to have treated before ranking them makes sense or is fair. Very few payers are going to have the volume of information available that Sedgwick and Multi-Plan do.  Buyer beware:  TPAs and networks that want to keep up with the Joneses may CLAIM to have ranked providers — but it takes a large number of cases AND considerable statistical sophistication to do this ranking stuff accurately and fairly.   One catastrophic injury could make even a great physician look bad without appropriate adjustment.   The speakers both acknowledged that getting accurate data and analyzing it in a fair manner has been a big challenge, and that their capabilities for doing so have improved rapidly over the last 5 years.

This IS the wave of the future.  Physicians who discover they are low ranked should find out why — and do their level best not to be defensive, but rather learn and improve from the experience.  Buyers of /payers for services absolutely do have the right — if not the duty — to select suppliers based on the best information at hand about who will meet their legitimate needs.   And physicians are suppliers in their eyes.

Sedgwick got started building their Outcomes Based Networks after participating in a Cornerstone Conversation co-hosted by the American College of Occupational & Environmental Medicine (ACOEM) and the International Association of Industrial Accident Boards & Commissions (IAIABC).  This was a four-way conversation among a small group of key stakeholders:  ACOEM leaders, large payers, large employers, and state regulators on what needs to happen in order to improve access to high quality healthcare and improve outcomes for injured workers, and to reduce unnecessary costs for employers and payers.  A joint project undertaken by ACOEM and IAIABC as a result of that meeting was the production of a Guide to High Value Physician Services in Workers’ Compensation.  You may find the observations and suggestions made in this succinct document helpful — whether you are a chooser, a recommender, a payer or a physician-supplier of medical care services.

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October 8, 2015

Dan Siegel says I can use my mind to reshape my brain — or YOURS!

I’m in the middle of taking an on-line course by Daniel Siegel, MD.  I hope you do, too.   It’s called “Practicing Mindsight” — 6 hours consisting of 32 video mini-lectures delivered live to an audience of about 240 mental health professionals, physicians, educators, as well as organizational behavior and social policy wonks.   (I’ve also  heard a great TED talk by this guy).  He’s a famous psychiatrist, trained at Harvard Medical School and UCLA, now clinical professor of psychiatry at UCLA, an award-winning educator – and expert researcher in the emerging field of “interpersonal neurobiology”.

It’s on a website called www.Udemy.com.  I’ve listened to the first 9 mini-lectures so far.  He began by asking how many of the professionals in the audience think the mind is important in everyday affairs — and in their practices/organizations.  All hands went up.  Then he asked how many had any instruction on what the mind is?   Five percent raised their hands.   He says that the proportion has been similar in 85,000 professionals he has asked.   He  says the purpose of the course is:  How to see the mind and make it stronger.    I say the course is focused on STRATEGIES for changing the STRUCTURE of the brain (one’s own and that of one’s patients/clients) by using the mind.   Think of that:  USING the mind as a tool to INTENTIONALLY remodel circuits in the brain.

Here are three big points I have heard in his lectures so far:

(a) Key definition:   The mind is a PROCESS not a thing.  It REGULATES (monitors and directs) the flow of energy and information both within an individual and between people.  (Energy is roughly defined as stuff that makes things happen.  Information is both data and meaning or story.)  As part of his grant-funded work, he had put together a group of 40 researchers in a wide variety of fields who were all (eventually) able to agree on this definition.

(b) “Attention” – which is where the mind focuses, what it is paying attention to  – is what CREATES new neural pathways, and STRENGTHENS either existing or new ones by reinforcing the pathway.  As the saying goes: “neurons that fire together wire together”.  For example, the more we pay attention to our pain (assessing it, worrying about it, “fighting” it), the deeper we are carving that channel.  Common sense, grandmothers, and “New Agers” have been telling us for years to focus on what we DO want instead of what we DON’T want  — and now science is confirming it.

(c) Humans are genetically programmed to AUTOMATICALLY create internal experiences and capabilities that mirror or incorporate things they see or feel during interactions with others.  As we watch someone else raise a glass of water to his lips, the cells in our brains that move our own arms light up.  We sense his intention to drink, we may experience thirst, or the sensation of water or of refreshment.  We feel sad when someone cries, and are happy at their joy.  Others’ brains shape what goes on in ours —  what circuits are firing and being reinforced — and vice versa.  Simultaneous mutual (interpersonal) experience is a KEY part of the “social” in our “social species”.

So I got this:  The techniques we use to SHIFT our attention (or another person’s attention) away from bad stuff and towards more productive ways of thinking are actually MODULATING neural circuitry in the brain (which is neuroplasticity in action).  This has now been confirmed by rigorous research on techniques such as mindfulness, CBT, etc.   (I personally remember reading a study which showed that SIMILAR changes in the brain can be observed after either medication OR “talk therapy”.  In that TED talk by Siegel that I watched, he asserts that much of the circuitry in our frontal lobe is created and shaped by everyday INTERPERSONAL INTERACTIONS which DEVELOP it – and of course it is our frontal lobes which make us uniquely human.)

The takeaway for us as physicians in tangible organ-system-focused specialties is there is POWER TO HEAL in our words —  and in the human quality of our interpersonal interactions.  We have an opportunity to INTENTIONALLY HARNESS that power and explicitly add it to our therapeutic armamentarium.

Although the mental health professions already are aware of the power of words and relationships, physicians are on the front-line dealing with patients with PHYSICAL complaints and distress.  We are in the best position to use the power of words and relationships to start relieving those symptoms and easing that distress — even if all we do is alert the patient to the healing power of the mind and persuade them to accept help from a mental health professional.  Apparently, the only specialty these days that requires training in patient communication is family practice.  Thus, this appears to be a neglected skill area in all of the other medical specialties.

Those of us who have accepted the idea that sickness and disability are the COMBINED product of bio-psycho-socio-economic factors, and who are setting out to reduce the disruptive/destructive impact of injury/illness on quality of the patient’s everyday life and future – especially in at risk cases and “heartsink patients” — MUST master this stuff.  We need to practice the SCIENTIFIC ART of empathic therapeutic interaction.  We must learn how to effectively redirect the patient’s attention into more appropriate channels so they develop their own capability to adapt to / cope effectively with their own situations.

The tuition for the Siegel Practicing Mindsight course is usually $137, but if you follow the directions below, you may be able to get a $39 special rate.  It supposedly ends TODAY — although it supposedly ended yesterday, too.  Some people don’t seem to be able to find the $39 offer.  There’s probably a glitch of some kind that is making it show up only when you wend your way through the electrons a particular way.

Here’s how I found it again just now:  I use Firefox.  I entered  “daniel siegel mindsight” in the search box, then I clicked on the link for an Udemy ADVERTISEMENT that appeared in the top left corner of the search results.  The website that appears says the rate is $39 again today (coupon valid until October 8).   But when I went STRAIGHT to the udemy site, the cost is $137.

Go for it — fool around, and then REGISTER!   But bring your brain AND appreciation for quirkiness with you.   This is  fascinating material taught by a deep and independent thinker, serious expert and experienced researcher.  And, Siegel is a character with really colorful personal stories:  so far we’ve heard tales of misfittery in medical school, salmon fishery, dance, nudity in Greece, etc.

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July 20, 2015

My “mini-manifesto” to reduce spine disability

You may be interested in the “mini-manifesto” I delivered this past Saturday 7/18 at the Spine 10×25 Research Summit in Chicago hosted by the North American Spine Foundation.  They have declared a worthy and very ambitious goal:  to reduce spine disability by 10 percent by the year 2025.  Thus the name: Spine 10×25. Pronounce it like you’re buying lumber – “10 by 25”.

(You can see the video and listen to my talk —  or even the ENTIRE 8 hour event because it was live-streamed and recorded.  Click here to do so.  Advance the recording by moving the blue dot along the horizontal line.  My talk starts at 5:31:50 and goes until 5:51:30.)

Do you know of any other medical group that has drawn a bold line in the sand like that?  I don’t.  It had never occurred to me that a professional society would set out to measurably move the needle.  They just don’t take on that type of project.  Most healthcare professional associations content themselves with pontificating:  being experts and telling other people what to do and how to do it.

My own professional society (ACOEM – the American College of Occupational & Environmental Medicine) has made many significant contributions to society.  In particular, our evidence-based treatment guidelines are very well regarded and in use by several states.   ACOEM has produced many other useful publications that have had a positive impact.  In fact, some of them were developed under my leadership.  But, in the end, they all amount to pontification.

In 2006, I told ACOEM I didn’t want one of those documents to just sit on an electronic shelf. We had developed it in order to introduce the work disability prevention paradigm and shift the way all stakeholders think about work disability.  Entitled “Preventing Needless Work Disability By Helping People Stay Employed“, that report needed to go out into the world.  Thus, the 60 Summits Project was born to carry it into the 50 US states and 10 Canadian provinces of North America.  We created groups of volunteer professionals who planned and held 20 multi-stakeholder summit-type conferences in 12 states and 2 provinces.  We invited the attendees to consider ACOEM’s 16 recommendations for improving the stay-at-work and return-to-work process.  We asked them to decide if they liked each recommendation, and if so, to make a plan for how they were going to carry it out in their own business, community, and jurisdiction. (60 Summits eventually ran out of money and was mothballed.)

Then last month, the boldness of the Spine 10x 25 initiative made me realize that even The 60 Summits Project had a pontification angle to it.  Propagating a new way of thinking and discussing a set of recommendations for change is not the same thing as CARRYING them OUT.  I felt compelled to go and check out these NASF people and participate in their Spine 10×25 Research Summit.

My assigned topic was “Precedents and Prospects for Success” in a 15 minute time slot that got expanded to 20.  It seemed important to speak straight and share my ideas about what needs to be true in order for their goal to be realized.  I offered the audience a (draft) conceptual foundation to use as a context for change, as well a summary-level vision of the way things will look in the future WHEN things have ACTUALLY changed and spine disability is BEING REDUCED by 10%.  View it here. Remember to advance the recording to 5:31:50.

I may expand a bit on some of the main points of that mini-manifesto in later posts.  I developed all of those slides at the conference in order to take into account what the speakers said who had gone before me!  Luckily, I also had some time at lunch.  The tight time limit meant a few big ideas got short shrift.

 

 

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May 31, 2015

Overkill describes the problem PERFECTLY!

Dr. Atul Gawande’s new article called Overkill is a great asset for all of us change agents. The tagline is:  “An avalanche of unnecessary medical care is harming patients physically and financially.  What can we do about it?”   It appeared in the May 4 issue of the New Yorker magazine.  The topic is “no value” healthcare, and he describes both over-diagnosis and over-treatment.  Me and my gang know that those things also create over-impairment and over-disabling — and ruined lives!

Recommendation:  Use this article as a tool to educate yourself – and others!  It is much better than most of the stuff on this general topic in medical journals and august scientific publications  – because he explains things so clearly and in such simple yet vivid language.   There’s a powerful vignette of a guy with two prior spine surgeries whose local doctor recommends a third one – and how the story turns out.    A happy aspect of the Overkill article is that Gawande also describes how the dark forces that are driving these things are being countered by more positive ones.  Things are slowly and spottily changing FOR THE BETTER!

I am ashamed at my petty jealous hatred for this man — because he is handsome, brilliant, insightful, incredibly talented, articulate, frank, and a fabulous writer.    He has been a columnist for the New Yorker since 1998.  Based  on his photograph, he must have been a baby then.   I’ve read several of his articles and books, and recommend them to you.   In particular, if you want to be sickened at how the constant emphasis on money has corrupted the physician culture, read his earlier article entitled The Cost Conundrum – like the White House did.   I’ve just finished his latest book Being Mortal.  It is wonderful — richly informative yet with a very positive tone and personal feeling.    See more about Gawande on the New Yorker’s Contributors webpage or on Gawande’s own website.

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