porter-photo

“I’m your friend,” Harvard Business School Professor Michael Porter, MBA, PhD, told a sometimes skeptical audience during his keynote address at the ASA’s annual meeting, ANESTHESIOLOGY 2016. “I’m trying to help you see a better way forward, and avoid the bad outcomes that may happen if we don’t transform healthcare.”

Porter is a well-known economist, an expert on business strategy, and the author of the book Redefining Health Care: Creating Value-Based Competition on Results. In his speech to the ASA, he argued the case for redefining health care by making “value for the patient” the unifying purpose, and he urged anesthesiologists to forget pay for volume.

“How should anesthesiologists engage in bundled payments?” Porter asked. “Jump on them!”

Explaining that he has spent the past 15 years immersed in studying health care delivery, Porter said that he looks on health care as one of the world’s “most fundamental and intractable problems.” He asked listeners to think again about anesthesiology practice, and its role and responsibilities in the future of health care.

“We’ve got to get over some history here,” Porter said, and abandon a strategy which up to now has been chiefly defensive. “Our most important role is to be part of the care team for a condition.” He believes that the medical condition is the proper unit of value creation and value measurement in health care delivery.

“If we’re not improving value, we’re failing. It doesn’t matter how smart or well-trained we are, or how hard we’re working,” he said. “Value is created in caring for a patient’s medical condition over the full care cycle. It’s the set of outcomes that matter for the condition, divided by the total costs of delivering these outcomes over the full cycle of care.”

Stop protecting our traditional roles”

“You can’t think about anesthesiology as a discrete service,” Porter said. “We can’t think of ourselves as specialists. We’ve got to stop protecting our traditional roles and get ahead of this.” Porter advised anesthesiologists to think about expanding our role in value creation outside the traditional operating room, including pain management outside of surgery, and hospice/palliative care.

Paralleling the often-quoted and widely disliked language of the Institute of Medicine’s 2010 report, “The Future of Nursing”, Porter advised the audience to “use physicians and skilled staff at the top of their licenses.” That statement prompted ASA President-elect Jeff Plagenhoef, MD, to comment later, “I heard that line from the Institute of Medicine, and I thought ‘But he was doing so well!’”

Porter advised anesthesiologists to change our frame of reference. “We can’t think about our specific silo. Value is created around conditions, not around specialties or procedures or locations. Departments, service lines – none of these make sense for value.” His belief is that the structure of healthcare systems must evolve toward integrated practice units and high-volume centers of excellence organized around specific conditions – “the right care in the right location.”

“You guys have been a specialty silo, and you’ve got to change,” Porter declared. “In too many health systems I’ve been involved with, the anesthesiologists didn’t want to play. They wanted to keep their departments separate from the institutes of the centers.” This is an unwise strategy, he said. “The future is going to be what you’re avoiding.”

Today’s poor measurement of cost and quality

Efforts to reduce cost don’t work, Porter said, because we haven’t accurately measured it. “Medicine has been a fact-free zone,” he said. “Cost must be measured by patient and condition, with costs aggregated over the full cycle of care. This requires mapping the care process. We need to look at actual expense, not the sum of charges billing or collected.”

Porter believes that incremental solutions for improving a specific piece of the healthcare system have limited impact. “Incremental improvement doesn’t change the trajectory of the system. We can’t continue laying more requirements on the fundamental structure,” he said.

Porter’s key points about quality and outcome measurement are already familiar to ASA and CSA members who have taken part in Perioperative Surgical Home initiatives. Much of quality measurement today is flawed because it focuses on processes and indicators rather than on outcomes.

“We’re going to be measuring a lot of stuff, but not the stuff we’re measuring now. Forgive me, but a lot of that really is not important,” he said.

Porter recommends using three major categories of outcome measurement after illness or operation:

The health status achieved or retained;

The process of recovery, defined as the time to recovery and return to normal function, and the barriers to recovery including pain, complications, and adverse effects;

The sustainability of health, including recurrences, long-term consequences of treatment, and long-term clinical and functional status.

“We want patients to tell us how they’re doing,” Porter said. “Outcomes are always multi-dimensional, and should include what matters most to patients, not just to clinicians. We need a standard set of outcomes for each condition that everyone is using.”

Our professional societies, including the ASA, Porter believes, should lead the emphasis on conditions as the foundation for transforming healthcare, and should help with insight and research. They should also promote bundled payment “as a way to preserve our incomes and to get credit for what we do,” he said. “We’ve got to get on the bus for bundles!”

“I don’t want to be overly simplistic,” Porter said, “but we can’t defend the roles we’ve had in the past. It’s not good for patients, not good for the system, and not good for us.”

1 COMMENT

Richard Ogden

I have spent the best part of 26-years working in the operating theatres in the UK, alongside some magnificent anaesthetists; and I must say this article is rather a sad one. The Anaesthetist, from a rather prejudiced point of view, is by far more important than the surgeon: if not because they facilitate safe operating conditions for the surgeon, then because they are the patients brain (Dr A Vohra Cons Anaesthetist) whilst under anaesthesia. Moreover, the Anaesthetist has the ability to provide considerable skill and ...Read More

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bob-dylan

Classic rock music lovers who think they don’t like poetry, and literary purists who think they don’t like popular music, may have been equally baffled to hear that Bob Dylan is a winner of the Nobel Prize in Literature. As an unrepentant English major, I’m delighted.

I can’t remember a time when Dylan’s music wasn’t a part of my growing up, from the rebelliousness of the anti-Vietnam era to the bittersweet maturity of “Tangled Up in Blue“, my all-time favorite.

When you think about it, any time you listen to a song — a current popular hit, a 1950’s oldie, or a centuries-old ballad like “Greensleeves” —  you’re listening to poetry, only with a tune. In ancient times, before most could read or write, people turned stories into poetry and sang them because rhyme and melody made the stories easier to remember and retell. Much of rap music is poetry (often crude, but still poetry) with complex use of rhyme and assonance, and the musical element reduced to a backdrop of pounding rhythm.

Poetry set to music can convey any and all human emotion. Love, of course. Jealousy — absolutely. Just pick a musical genre, and there’s a hit song about jealousy. In pop music, Taylor Swift’s “Blank Space” lets her revel in her psycho side. In country music, Carrie Underwood graphically explains in “Before He Cheats” what can happen when a woman wants revenge on her faithless lover, and takes it out on his car. And the still-creepy “Every Breath You Take“, the 1983 classic rock hit by The Police, blurs the fine line between devotion and obsession.

Then there’s the universal human experience of grief. There was a time when every parent expected to lose a child, or more than one, because children often died from pestilence and poor sanitation. When my daughter Alexandra died unexpectedly at the age of five months, I couldn’t decide which was worse — thinking that I wouldn’t survive, or being horribly afraid that I would.

During the years of savage grief that followed, I often thought about a poem I had read first when I was in college. It wasn’t exactly comforting, because nothing truly eases the pain of losing a child except the merciful passage of time. But Ben Jonson’s simple words, written in 1598 after the death of his first daughter, proved that others had lived through the same experience. This is the poem, which Alex’s father read at her funeral:

Here lies, to each her parents’ ruth,
Mary, the daughter of their youth;
Yet all heaven’s gifts being heaven’s due,
It makes the father less to rue.
At six months’ end she parted hence
With safety of her innocence;
Whose soul heaven’s queen, whose name she bears,
In comfort of her mother’s tears,
Hath placed amongst her virgin-train:
Where, while that severed doth remain,
This grave partakes the fleshly birth;
Which cover lightly, gentle earth!

Several years later, Eric Clapton’s four-year-old son Conor died in a terrible accident, leading Clapton to write the song “Tears in Heaven“. The deceptively simple lyrics pose profound theological questions. Every subsequent tragedy involving the deaths of children — from the 19 who died in the Oklahoma City bombing of the federal building’s daycare center, to the massacre of first-graders in Newtown, and the ongoing carnage in Aleppo — brings back to mind for me Jonson’s poem and Clapton’s music. Across the centuries, they unite parents who have become unwilling members of a club that no one wants to join.

One day at the hospital, I went to the preoperative area to examine my next patient, a middle-aged woman who looked angry and unhappy before I even introduced myself. In anesthesiology, we often encounter patients who are anxious about their upcoming surgery, but this woman’s emotions were different. In the course of doing my preoperative evaluation, I couldn’t figure out what was the problem. Her overall health was good, and the planned surgery wasn’t a major operation.

Finally, I said, “Please forgive me. But it seems as though something is terribly wrong. Is there anything I can do to help?” The patient’s eyes filled with tears, and she said that her son had died a month before. After a long moment, I said, “I lost a daughter too, years ago. The sorrow never goes away. But it does get easier to live with over time.” And with that, she relaxed, and the anger dissipated. The chain of connection continued, from Ben Jonson and Eric Clapton to me, and now to my patient.

Poetry and music tell stories of universal experiences, and unite people who, at least superficially, have little in common. To me, the lyrics of Bob Dylan’s songs are just as truly poetry as are the sonnets of John Donne. Dylan’s scratchy voice has the remarkable ability to tell a story and evoke a mood in a few short lines. His lyrics contain a wealth of  literary allusions, whether or not many listeners notice or care. If the Nobel committee’s award can illuminate the fact that poetry is everywhere, and isn’t inaccessible at all, then the committee members will have done a great service.

4 COMMENTS

Beautiful. When we practice medicine and when we practice life with vulnerability we often find just what we're missing -- inevitable connection.

Rick Novak

Well said. Dylan wrote love songs, angry songs, sad songs, uplifting songs, protest songs, long fable songs, and mystifying songs, . . . like no one before him.

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Pediatric anesthesia

You may have read about the recent tragic deaths of two healthy children – Marvelena Rady, age 3, and Caleb Sears, age 6 – in California dental offices. Unfortunately, they aren’t the first children to die during dental procedures, and unless things change, they probably won’t be the last.

State Senator Jerry Hill has asked the Dental Board of California (DBC) to review California’s present laws and regulations concerning pediatric dental anesthesia, and determine if they’re adequate to assure patient safety. Assemblymember Tony Thurmond has sponsored “Caleb’s Law”, seeking improved informed consent for parents.

On July 28, I had the opportunity to attend a stakeholder’s meeting at the Department of Consumer Affairs in Sacramento, to hear a presentation of the DBC’s report, and to be part of the delegation offering comments on behalf of the California Society of Anesthesiologists (CSA). We hope this is the beginning of some long overdue upgrades to the current regulations.

By long-standing California state law, dentists and oral surgeons are able to provide anesthesia services in their offices even for very young children or children with serious health issues. They may apply for one of four different types of permits for anesthesia:

General anesthesia

Adult oral conscious sedation

Pediatric oral conscious sedation

Parenteral conscious sedation.

But the route of administration – oral or intravenous – isn’t the point, especially for small children, and oral sedation isn’t necessarily safer. Sedation is a continuum, and there is no way of reliably predicting when a patient will fall asleep. Relaxation may turn into deep sedation, and deep sedation into a state of unresponsiveness which is equivalent to general anesthesia. Oral medications have led to deaths in children, sometimes even before the dental procedure has begun or well after it has finished. There’s no logic in California’s lower standards of emergency equipment and monitoring for procedures done under sedation as opposed to under general anesthesia.

Isn’t a little sedation enough?

In an older child or adult, mild sedation and local anesthesia are enough for nearly all dental care. But any parent knows that this won’t work for a young child who can’t hold still. There really isn’t any such thing as “conscious sedation” for a toddler of 2 or 3. Deep sedation or general anesthesia are the only choices for a child who needs extensive dental treatment.

Small children have small airways. Every parent knows not to give a small child big chunks of hot dog, or toys with small parts, because of the risk of choking. During dental work, a child’s breathing can be blocked by swelling or bleeding. Just a few drops of blood may irritate a child’s vocal cords, causing them to snap shut and preventing air from getting to the lungs. In the time it might take to gather emergency equipment, a child can suffer permanent brain damage or death from lack of oxygen. General anesthesia often is safer, since the airway is protected with a breathing tube from start to finish.

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11 COMMENTS

karen

Dear Dr. Silegy, Apparently the province of Alberta, Canada, disagrees, after a four-year-old ended up with brain damage: http://globalnews.ca/news/3036086/alberta-dental-association-suspends-single-operator-model-for-deep-sedation-anesthesia/ The second anesthetist could be one of your partners, or a dentist with additional training in anesthesia as required by state law. Again, it's all about having a second trained independent anesthesia provider whose only job is to watch the child's airway, vital signs, and breathing. Just as I would want for my own child. Best, Karen Sibert, MD

Dr. Tim Silegy

Dear Karen: As I stated in my earlier comment, there are no facts to support your argument that two provider anesthesia is safer than single in these particular cases. Your allegation of oral surgery assistants administering anesthesia is unsubstantiated and NOT factual. I take exception to your comment that my defense of the single operator/anesthetist model is financially self serving. Itinerant medical and dental anesthesiologists have much more to gain from potential new regulations than I do.

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Kennedy and Frost

Is there a direct connection between communication skills and the art of successful leadership? Most of us would agree that there is. But is there a direct connection between blogging and leadership? That may be more of a reach.

Can the process of writing a blog help to develop communication skills that will prove useful in leadership? In my opinion the answer is yes, but a qualified yes. Writing a blog won’t help anyone become a good writer who never learned to write competently in the first place. Perhaps even more important, writing a blog won’t help anyone become a thought leader who hasn’t developed any original thoughts.

Communicating a vision

To make a real mark in history, a leader has to communicate a vision that people understand. The vision must be powerful enough to motivate them to follow. In decades past, for instance, the men who became President of the United States typically were graduates of liberal arts education, trained in the arts of debate, oratory, and essay composition. They knew how to make their points.

No matter which end of the political spectrum you favor, most of us would agree that Presidents John F. Kennedy and Ronald Reagan were gifted communicators. Though obviously they benefited from the help of speechwriters behind the scenes, both were skillful writers on their own, as proved by their private documents and letters.

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2 COMMENTS

Physician on FIRE

I found this article in the ASA Monitor, which led me here to visit your site and the sites of the other great bloggers you listed for us. Thank you for introducing me to a bevy of talented anesthesiologist writers. I'll be busy reading for some time. Cheers! -Physician on FIRE
Thanks for the shout out!. Haven't written for awhile - you've inspired me to get something out there.

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D-Day beach

When Arnold Schwarzenegger was governor, he decided that you and I don’t need to have physicians in charge of our anesthesia care, and he signed a letter exempting California from that federal requirement. Luckily most California hospitals didn’t agree, and they ignored his decision.

When he needed open-heart surgery to replace a failing heart valve, though, Governor Schwarzenegger saw things differently. He chose Steven Haddy, MD, the chief of cardiovascular anesthesiology at Keck Medicine of USC, to administer his anesthesia.

Now some people in the federal government have decided that veterans in VA hospitals all across the US should not have the same right the governor had—to choose to have a physician in charge of their anesthesia care.

That’s right. The VA Office of Nursing Services has proposed a new policy to expand the role of advanced practice nurses, including nurse anesthetists, in the VA system. This new policy in the Nursing Handbook would make it mandatory for these nurses to practice independently. Physician anesthesiologists wouldn’t be needed at all, according to this proposal, even in the most complicated cases – such as open-heart surgery.

If this misguided policy goes into effect, the standard of care in VA hospitals will be very different from the standard of care other patients can expect. In all 100 of the top hospitals ranked by US News & World Report, physician anesthesiologists lead anesthesia care, most often in a team model with residents and/or nurses.

The new policy isn’t a done deal yet. The proposal is open for comment in the Federal Register until July 25. Already thousands of veterans, their families, and many other concerned citizens have visited the website www.safeVAcare.org and submitted strongly worded comments in opposition. I urge you to join them.

Physician-led care teams have an outstanding record of safety, and they have served veterans proudly in VA hospitals for many years. Many university medical centers have affiliations with their local VA hospitals, where their faculty physicians deliver clinical care and conduct research. UCLA, for example, sends anesthesiologists to the VA hospital in Los Angeles, so that our veterans get the same high-quality care as wealthy patients from the enclaves of Brentwood.

Many of our veterans aren’t in good health. They suffer from a host of service-related injuries, and they have high rates of chronic medical disease. Some have been among the most challenging patients I’ve ever anesthetized. Their care required all the knowledge I was able to gain in four years of medical school, four years of residency training in anesthesiology, and countless hours of continuing medical education.

No VA shortage of anesthesia care

It’s clear, of course, why the VA is proposing the change in the Nursing Handbook. The reason is the scandal over long waiting times for primary care. Proponents argue that giving nurses independent practice will expand access to care for veterans.

But there’s no shortage of physician anesthesiologists or nurse anesthetists within the VA system. The shortages exist in primary care. A solution that might help solve the primary care problem shouldn’t be extended to the complex, high-tech, operating room setting, where a bad decision may mean the difference between life and death.

The VA’s own internal assessment has identified shortages in 12 medical specialties, but anesthesiology isn’t one of them. The VA’s own quality research questioned whether a nurse-only model of care would really be safe for complex surgeries, but this question was ignored. The proposed rule in the Federal Register lists as a contact “Dr. Penny Kaye Jensen”, who in fact is not a physician but an advanced practice nurse who chooses not to list her nursing degrees after her name. The lack of transparency in the proposal process is disturbing.

In 46 states and the District of Columbia, state law requires physician supervision, collaboration, direction, consultation, agreement, accountability, or direction of anesthesia care. The proposed change to the VA Nursing Handbook would apply nationally and would override all those state laws, which were put in place to protect patients.

In Congress, many senators and representatives on both sides of the aisle recognize the need to continue physician-led anesthesia care for veterans. Representatives Julia Brownley of California’s 26th District and Dan Benishek, MD, of Michigan’s 1st District are strong advocates for veterans’ health. They have co-authored a letter (signed by many in Congress) to VA Secretary Robert McDonald, urging him not to allow the destruction of the physician-led care team model as it currently exists within the VA system.

Governor Schwarzenegger’s heart surgery is a matter of public record. He has spoken about it openly on television, and he graciously invited the whole operating room team to his next movie premiere. I was lucky enough to go to the premiere too, because his anesthesiologist, Dr. Haddy, happens to be my husband.

But I didn’t set out to write this column on behalf of my husband. I’m writing on behalf of my father, who is now 93, landed on the beach at Normandy on D-Day, and miraculously survived the rest of the war as a sniper. And I’m writing on behalf of all the men and women who have served our country, and who deserve the best possible anesthesia care from physicians and nurses who want to work together to take care of them. If we don’t defeat the proposed change in the VA Nursing Handbook, they all lose.

3 COMMENTS

Rick Novak MD

Terrific column, Karen. I loved the twist about Arnold's anesthesiologist being your husband. I agree wholeheartedly. And my 95-year-old father, like yours a WWII veteran, would agree as well.

Andrew Kadar, MD

Another timely message from Dr. Sibert. I hope that many readers will support her call for helping to maintain physician directed anesthesia in the VA.

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