Category Archives: Healthcare Information and Trends

Do Buildings Matter?

Dr. Phil Kibort and Children's of Minnesota

In mid-October 2010, I had the wonderful privilege and pride-inducing opportunity to give tours of our marvelous new hospital campus in Minneapolis (I look forward to doing this next year in St. Paul) to leaders from 25 other children’s hospitals, as well as the CMOs and VPMAs of local hospitals and corporations. I continue to do so with many private practice groups.

It was gratifying for someone like me who has worked on both Children’s hospital campuses since 1976, and seen the phenomenal transformation of the buildings and facilities to 21st century levels.

We now have state-of-the-art, 400-plus square-foot private patient rooms, operating rooms that look like they may even be 22nd century, a spacious emergency department designed with patient flow in mind, a cardiovascular unit with operating rooms and intensive care and med/surg beds on the same floor so a patient never has to leave that floor before going home, as well as a beautiful family resource center, sibling playroom, in-hospital Ronald McDonald House, and an Arts and Healing environment second to none.

I also know that our local friends and competitors have beautiful new facilities as well. So the thought crossed my mind; do buildings matter?

My sense is that while nice to have and important from a family standpoint, it will not be buildings only that give one institution an edge over another.
It is the same factors that have always led clinicians to send patients to Children’s Hospitals and Clinics of Minnesota, or others. It is the basic fundamentals of what I consider to be the three A’s:

  • Availability
  • Affability
  • Ability

    Which system will be most responsive and available to referring physicians? Which system will make it easier to have access into it? Which system’s clinicians and advanced practice nurses will be most affable? Who will thank their referring physicians the most? Who will do it with a positive attitude? Who will do it with a “can do” attitude more than the others, and also important, who can do it with the greatest ability; abilities proven with outcomes. Referring physicians will continue to make decisions based upon these factors.

    There is also a value equation. Which organization gives the best quality (both clinical and functional) with the best service at the most reasonable cost, showing that they are the best steward of resources? Which organization will make it the easiest for the outside world to utilize? That’s who will continue to thrive.

    I believe Children’s will remain a dominant player in the market based upon these factors. We will continue to be the hospital where attending level staff are in-house 24/7, whether it is intensivists, neonatologists, ED physicians, or hospitalists, here to teach residents, but not depend on residents to care for patients. We will be the institution whose values of true family-centered care matches those of pediatricians and family practitioners in the communities we serve.

    Each morning I look upon our beautiful new facility and take great joy in how open and beautiful our new facilities are, and I remind myself of the lessons our parents taught us – it is not what is on the outside that counts, it’s what is on the inside that makes a difference.

    It is my desire and hope that the clinicians in the community, the metro area, and the state, know that the place to send their children when they need it is Children’s Hospitals and Clinics of Minnesota. Not because of what’s on the outside, but rather what’s on our inside.

    Phil Kibort, MD, is Children’s vice president of medical affairs and chief medical officer. Read his bio here.

  • Societal Perceptions of Physicians

    Knights, Knaves, or Pawns?
    Sachin H. Jain, MD, MBA; Christine K. Cassel, MD

    Dr. Phil Kibort

    I recently read this article in the Journal of the American Medical Association (JAMA) and it was quite disturbing for me. According to the authors, a British economist named Julian LeGrand suggested after World War II that public policy is grounded on the concept of humans being either knights, knaves or pawns.

    Human beings motivated by virtue are knights, those who have rigid self-interest are knaves, and those that are passive victims of their circumstances, pawns.

    These authors take this concept and apply it to today’s American healthcare system. The question is which one are you? According to these authors, physicians are either in practice for the betterment of society (knights) their own selfish gain (knaves), or they are automatons whose actions are defined more by external rules and regulations (pawns).

    If physicians were all knights and well intentioned, the healthcare system would place the stewardship of it firmly in their hands. They would be trusted to use and deploy resources wisely, minimize waste, and look beyond their narrow, individual, and specialty interest to protect the system as a whole. Individual physician decision-making and autonomy would be given the highest priority. They would constantly study to improve themselves, they would do clinical research to advance science, and they would do their jobs as professionals.

    If physicians are knaves as conceived by society; then society would develop policies, management and educational efforts to combat and work against physicians not with them. In this scenario, physicians are interested in themselves and their financial well-being first and their patients second if at all. In this system physicians must be given a reward or incentives to motivate them to do what is right by their patients and any such schemes would have to be carefully monitored for abuse, fraud, and waste. Policies and regulations must guard against their malfeasance. I worry that this is what too many of us have become.

    If society views physicians as pawns, then efforts are applied to building systems that ensure that physicians do what is right for patients because physicians cannot be trusted to do so on their own accord. Left to their own devices, physician behaviors are unpredictable. The pawn physician is merely a function of the environment in which he or she practices. Thus they must be given guidelines to follow and policymakers must decide clinical priorities. The role of health policy and regulation for the pawn physician is to guide his or her every behavior because he or she lacks individual agency and judgment to reliably do what is right.

    What were the implications of LeGrand according to these authors? Unfortunately the quality of care policy discourse often reflects the perspective that physicians are an obstacle, not an enabler to a functioning healthcare system. Rather than being counted on to maintain their knowledge and expertise on their own accord, they are subject to periodic examinations to demonstrate continued proficiencies, are grounded in evidence of unwanted variation in care, clear evidence of waste, and even fraud and decline in knowledge over time. The modern U.S. physician is regarded as either a knave or a pawn and is seldom regarded as a knight any longer. Marcus Welby where are you?

    LeGrand offers an important lesson and warning. It is critically important to understand and get “true motivations” right. Disaster may follow a person largely over knavish quality or if treated as knights, but the same may be true for policies fashioned on the belief that people are knaves if the consequences to suppress their natural altruistic impulses and hence destroyed part of their motivation to provide a quality public service.

    LeGrand further warns that policies that treat people as pawns may lead to demotivated workers… again causing adverse outcomes for the policies concerned, while policies that give too much power…may result in individuals making mistakes that damage their own or others welfare.

    The public would be wise to heed LeGrand’s advice and carefully consider whether its perceptions of physicians match reality. For their part physicians must thoughtfully consider whether and how they contribute to the perceptions that they are knights, knaves or pawns.

    I’d love to hear from any of you about your thoughts on this.

    Phil Kibort, MD, is Children’s vice president of medical affairs and chief medical officer. Read his bio here.

    Reflections on Primary Care Physicians and Healthcare Reform

    Dr. Phil Kibort

    In a recent article in JAMA by Robert H. Brook and Roy T. Young, April 21, 2010, Volume 303(15):1535-1536, the authors write a commentary entitled, “The Primary Care Physician and Healthcare Reform”. With changes coming from healthcare reform leading to more and more people being covered, the need for primary care physicians is actually increasing. Unfortunately the number of primary care physicians is decreasing. There are two main reasons for this:

    1. the scope of practice is being constricted for primary care physicians with their ability to do less and less procedures (think of less OB and procedures) and less and less in hospital care, (think of hospitalists), as well and more importantly
    2. the differential between what they get paid and what specialists get paid. The gap is substantial.

    The median salary in large multi-specialty groups for primary care physicians is around $200,000. The median dermatologist salary is $351,000. Given this type of pay differential and the narrowed scope of practice, why should bright, hard-working, debt-ridden or even altruistic medical students choose primary care versus specialty.

    In 2010 only 54.5% of 4,999 residency spots in internal medicine were filled, 44.8% in family medicine and in pediatrics 70.5%. In comparison at least 90% of physicians in neurosurgery, orthopedic surgery, and dermatology were filled by U.S. medical school graduates. Young clinicians are simply not willing to forfeit lifetime earnings of over $3 million.

    To many of these students the authors state the primary care physician has become like the water boy on a football team, making sure that the really important members of the medical team do their work. Our dilemma is we don’t have great solutions. There could be no change and we could just let the inevitable decrease continue.

    An alternative approach is to convince 50% of the students entering U.S. medical schools in 2010 to choose primary care as their professional career path. But, to do this we’ve go to change those other two variables. They need a different set of clinical responsibilities and skills, we should make them leaders in efforts to avoid preventable hospitalizations for patients with chronic diseases, eliminate inappropriate or equivocal surgery, radiological procedures, and help individuals die with the least pain and without expense for vast amounts of money.

    Secondly we’ve got to come up with a way that they get paid more in comparison to specialists. Without these changes there is little hope of producing a healthcare system that provides high quality, affordable care to the U.S. population.

    One thing these authors didn’t discuss is the use of advance practice nurses. Perhaps the future is that primary care physicians who want to stay in the field truly have to create systems where they work with advance practice nurses and becomes a conductor of a symphony of advance practice nurses in primary care.

    I’d love to hear your thoughts on this.

    Phil Kibort, MD, is Children’s vice president of medical affairs and chief medical officer. Read his bio here.

    Pure Goodness

    Dr. Phil Kibort Recently, Children’s held its quarterly Champions for Children’s breakfast. This wonderful event is one of the hospital’s many ways of saying thank you to our employees. Staff throughout the organization nominate other employees for going beyond the call of duty in delivering extraordinary care to children, their families, or one another. What I love about this event is that it is all about “pure goodness.”

    An event like Champions for Children’s reminds me why I came to work in a children’s hospital and why the vast majority of us work here.

    Whether it is stated directly or not, the people who work at Children’s do understand its mission of championing the special healthcare needs of children. These amazing stories convey to us that we come to work to find worth, to give, to be compassionate and to help others. To put a smile on a face, warmth in others’ hearts and the relief of pain and suffering. I am never more proud of the organization than at this breakfast whether it’s the nurses, social workers and chaplains, people in materials management, IT, admitting or other areas — they all are amazing, and committed to our patients and families.

    And so while we must be thankful for our good health, for the jobs we have, and realize that we may go through ups and downs, the number one reason we do what we do is because of the goodness in our hearts.

    Phil Kibort, MD, is Children’s vice president of medical affairs and chief medical officer. Read his bio here.

    Got Interpreters?

    Imagine this:

    You are a refugee in a foreign land where they speak a different language.  Your child is sick and you must seek health care.  Without an interpreter your ability to communicate is minimal or non-existent and you are not quite sure what the doctor is saying.  You are sent to the pharmacy with the prescription, but get lost on the way because you can’t read the hospital signage.  Going home takes forever because you misread the bus schedule.  It takes you many days to schedule your child’s needed surgery because of the language barrier with the appointment desk staff, and also because – as a single parent holding two jobs just to make ends meet – you are incredibly short on free time.  The day before surgery you receive a reminder call and even though you don’t quite understand the caller, you say, “yes, yes, OK” because you are trying to be polite.  The day of surgery arrives and by sheer luck a nursing assistant who speaks your language discovers that your child ate a full breakfast that morning.  The surgery is canceled, you receive several “dirty” looks and are sent home to reschedule.

    This scenario and many similar ones were unfortunately quite common until recently.  It is only in the last 10-15 years that we in health care started using trained interpreters to communicate with patients and families who have limited proficiency in English.  At Children’s, these days may seem now like a distant past, as we have had a tremendous growth in this area.  Manager of our interpreter services Michelle Chillstrom tells me that we currently have 35 staff interpreters.  Our most frequent languages are Spanish, Somali and Hmong, but the list of languages that are routinely interpreted at Children’s is long – 43 in the past year.

    Watch this short video by HRET to get the feel for what a health care encounter might look like at Children’s if we didn’t have interpreters:

    Boris Kalanj is the Director of Health Care Equity and Cultural Competence at Children’s Hospitals and Clinics of Minnesota. Read his bio.

    Why are we calling them “providers”?

    Dr. Phil Kibort Over the last decade the word “provider” has been used more and more when describing physicians and other clinicians. Language is an extremely important catalyst to changing cultures and the utilization of this word “provider” does have significant implications to a not-so-subtle change to our health care culture. Now I understand fully the need to move away from hierarchical thinking and actions in health care, especially in high reliability organizations, but I am also aware that this is having secondary, if not unintended, consequences.

    The health care industry over the last decade or so has seen many more non-physicians providing care to patients, whether it’s advanced practice nurses, physician assistants, psychologists, chiropractors, or EMTs. Now some of this is very good because of shortages of doctors, and from pure economics, it also makes sense. Nevertheless, the unintended consequence of this language change is that physicians who take the longest to train and have the strongest background in pathophysiology and treatments are now becoming a commodity.
    A commodity that then begin to think of themselves as employees instead of professionals. When they think like an employee, they begin to act like employees: losing the aspect of professionalism that differentiated them from others.

    Continue reading

    Patient-Centered Care

    Dr. Phil Kibort Last month, my father-in-law fainted in a restaurant, and we thought he might be having a stroke. He required an ambulance drive over to one of the local hospitals. The police were great, the EMT was great, and the fire department was great, as were the admitting people in the emergency department and every one of the people over at the hospital. The amount of workup he received was unbelievable for someone who was probably just fainting.

    He had an emergent CAT scan, an MRI and a chest X-ray. Eventually he stayed overnight to get a echocardiogram plus more lab tests. All in all he was probably somewhat dehydrated that morning, took his antihypertensive pills, dropped his blood pressure, had a drink and pretty much keeled over.

    I’m not here to discuss the amount of resources used, because, of course it was my father-in-law — and it didn’t help that besides me, his other son-in-law was an internist in the same hospital and his three daughters are a psychologist, an epidemiologist and an occupational therapist. Everybody in the ED room was so health-oriented, I think the ED felt they had to do everything possible.

    What I really thought about during this episode was not so much the great care they all gave, but rather the claim that hospitals have that they are patient-centered.  The attending physician, after receiving the handoff from the ED physician via electronic medical record (I was very impressed), came into the room and explained the results of the CT scan. This very bright woman explained to my father-in-law, who is not medically oriented, the findings of the CT scan. She used so many medical terms that I had to ask her to stop and tell her that “he has no clue what you are talking about. Speak in layman’s terms.” Sometimes we get so caught up in trying to tell patients technical things that we forget that unless you speak their language, it is difficult to understand.

    I’ve been reading much lately by Dr. Charles Denham and, of course, Dr. Donald Berwick about being patient centered extremists. They believe that patient and family involvement starts with educating patients and families and ends with listening to them and taking them seriously.  Patient-centered care means that patient and family input is emphatically built into systems of performance improvement and if patients and families are taken seriously as real experts, and are respected for their valuable perspective of how care can be improved, then organizations can improve at improving.

    Denham would say, “leaders drive values, values drive behaviors, and behaviors drive performance.” Engaged leaders need to provide the resources necessary to ensure that the systems are in place.  They need to guarantee that vital patient and family input are built into the practices adopted, leadership resources and systems.

    We as leaders need to constantly remind staff and each other that the people whose lives we are guests in deserve us to speak in languages they understand.  Safe, high-quality health care is neither accidental nor static, according to Denham. Rather, it is the result of deliberate actions by dedicated people, including active listening, planning, implementation, and evaluation by organizational leaders and providers of care within their healthcare enterprise.”

    Denham also says the culture is the collective behaviors of an organization, or what some have described as “what people do when no one else is looking.” It reflects the operational values of the organization, which may not necessarily be those espoused in brochures or walls in the lobby.

    We’re doing better, but we can do much better. The final icing on the cake has to do with us treating patients and families respectfully, using their knowledge, and speaking to them in languages that they can understand.

    Phil Kibort, MD, is Children’s vice president of medical affairs and chief medical officer. Read his bio here.

    You’ve Improved!

    Eating VegetablesThere was a time in my childhood when I had gained a bit of weight. Yesterday, browsing through the faded photographs, I tried to imagine how today’s American pediatricians might respond upon seeing my own heavier image as a child. Most would almost certainly find me overweight, perhaps counsel my parents about exercise and healthier eating. The way it was, my pediatrician back then – in mid-1970s Former Yugoslavia – playfully pinched my cheek and exclaimed, “You’ve improved!” She was not joking. She really meant I looked better, healthier.

    I reveal this personal story to point out how our values about body image, including obesity, are socially defined. Throughout much of human history, and certainly still in many cultures and countries of the world today, being “over”weight is actually preferred to being skinny. Many people don’t view extra weight as a health concern – just the opposite! For example, in a place where hunger has been omnipresent in the recent past, a larger body may still be viewed as a sign of good health, good fortune, strength and attractiveness.

    When it comes to body size, large or small, poverty has always been a defining factor. Historically, having a lower income often meant you suffered food deprivation and malnourishment. If you were poor throughout much of human history, chances are you were engaged in hard physical labor, all the while experiencing a shortage of food.

    In recent times, a counterintuitive reversal of that historical pattern has occurred, particularly in societies such as ours where food has become plentiful and cheap. The “new” pattern is that poverty actually leads to obesity. Studies show that the likelihood of being overweight in the poorest 25% of the population is twice that of people in the wealthiest 25% of the population. Children living in poverty have limited access to healthy foods and greater exposure to high-calorie and fatty “junk” food. Supermarkets are scarce in poor areas and the gap is usually filled with fast food restaurants and convenience stores.

    If I were poor, I might also have a harder time being physically active. I might not have discretionary income to join a health club. My neighborhood may not be safe or otherwise conducive to exercise, or I may have to hold two or even three low-wage jobs to support my family, leaving me with little or no leisure time. My child’s school may lack the necessary facilities and have fewer organized sports. Neighborhood safety issues might prevent students from walking or biking to school.

    In sum, there are many social and economic conditions that play a defining role in children’s health, including childhood obesity.

    Trying to change the behavior and choices at the level of an individual child and family is certainly necessary. However, solutions to such intractable socioeconomic problems as overweight in children must go beyond that. They must include interventions at the level of these same social and economic conditions that are the root causes of poor health.

    Children’s healthcare organizations such as Children’s Hospitals and Clinics of Minnesota are uniquely positioned as leaders of multilevel changes necessary to achieve health in children. Our substantial clinical expertise is at its highest impact when it’s leveraged through community partnerships and positive influence on policy and systems change.

    A creative recent example of community partnership that comes to mind is a small urban garden program that Children’s TAMS ran last summer.  Six young people worked with a Latino Health Educator to plan, plant, tend, harvest, cook and enjoy the fresh food that they grew themselves in a community garden plot in our neighborhood.  It engaged these youth in healthy physical activity and community connectedness, while teaching them life-long skills that promote healthy behavior.   The program was based on the innovative local Youth Farm and Market Project.

    Boris Kalanj is the Director of Health Care Equity and Cultural Competence at Children’s Hospitals and Clinics of Minnesota. Read his bio.

    Are you sick? You should be.

    Stethoscope Did you ever notice that if you watch commercials, 50% of them seem to be oriented to some medical problem? Heck, if you watch the nightly news, 90% of the commercials have to do with some medical problem. Whether your leg is restless, you have ED, ADD, OCD, constipation, diarrhea, severe menstrual cramps, headaches, backaches, bloating, allergies, acid reflux, asthma, emphysema, or you need a wheelchair, you can’t get by without some drug.

    I’m beginning to believe that to be normal you have to have an illness. In fact, I doubt there is anybody out there right now who doesn’t have something that they would consider a chronic problem. Now I’m not saying this to be cynical about the people with “real organic illnesses” and many of these other things are symptomatic and real, but at some point we have to ask ourselves, is there any symptom we have that we don’t think about as being a disease? What does it say about our society? What does it say about what we teach our children?

    Perhaps this is another reason why health care costs continue to rise when everybody says they need to feel great and perfect at all times. Just my thoughts for the week and now I need to get my knee looked at by my orthopedist.

    Phil Kibort, MD, is Children’s vice president of medical affairs and chief medical officer. Read his bio here.