A Customer Emotion Dashboard
The job of a CIO is filled with challenges. There's a delicate balance in constant flux among:
*Short term urgencies
*Long term strategies
*Ever changing compliance/regulatory requirements
*Day to day operations
*Budgets
What's the right objective measure of success?
Uptime?
On time, on budget project performance?
Positive feedback from your Governance groups?
All of these can look rosy but customers can still be unhappy. The juggling of IT supply and customer demand means than not all projects can be done. The complexity of IT work means that projects will take longer than customers expect. All communications plans, no matter how comprehensive will still miss some stakeholders. The end result of all of this is customer dissatisfaction.
A CIO can never achieve 100% customer satisfaction. In fact, if only 10% of my customers dislike me on a given day, then I've achieved a stellar approval rating.
By human nature, we want to make everyone happy and avoid conflict. When I lecture about my top 10 leadership principles for surviving as a CIO:
10. Select your change and what not to change
9. Identify those who will lose
8. Acknowledge their loss
7. Over Communicate
6. Be Honest and Consistent
5. Consensus is not essential
4. Embrace conflict
3. Focus on your detractors
2. The last two minutes of the meeting are the most important
1. You cannot please everyone
#1 is that you cannot please everyone. There will never be enough budget, enough staff, or enough governance to ensure everything is perfect.
Normally, the naysaying can be addressed through focused customer service, planning, and conversation.
However, it's getting harder now that the economy is challenging and expectations of technology support are escalating i.e. "I just bought a new smartphone yesterday, how come you do not provide application support for it?'
The level of tension in every sector is increasing. Civility is diminishing.
This means that I must carefully monitor the pulse of all my customers.
I've emailed my staff that at our next leadership meeting, I'd like to develop a new type of scorecard for each major stakeholder group. I will empower my staff to rate the emotional trajectory of each group as red/yellow/green. With such a scorecard, I'll be able to anticipate growing discontent before it escalates and then focus my time and energy on detractors, embracing conflict to proactively change strategy and tactics before it's too late to change.
A customer dashboard based on the trajectory of stakeholder emotion rather than budgets, projects and timelines - I have a feeling that it will be very effective in directing my management focus, especially in trying times.
I'll let you know how it works by the end of 2010.
Monday, October 18, 2010
S Military Pursues Patient Engagement
I had an amazing experience last Thursday. I encountered some of the smartest, fastest-thinking, most motivated healthcare transformation thinkers I've ever seen. The ideas were flying so fast it was like transformation popcorn. And this was in an organization I'd never heard discussed as health leaders: a U.S. Army "Physician Champions" meeting in Boston.
The people I met with have a particularly passionate commitment to effective care: having chosen the military themselves (not the world's best working conditions), they're distinctively committed to their patients. They have a long-running EMR system (electronic medical record), so that any "doc" who encounters a patient can see what previous providers have entered. And because of frontline military circumstances (at the front, a medic is the one you call "doc"), the records are used by all tiers of providers. In these conditions the value of accurate information is acutely apparent - as are the challenges of system usability and workflow.
The event leaders who invited me to speak were as passionate about patient engagement as anyone I've met anywhere. I spoke about participatory medicine, and heard discussions of real-world workflow issues and best practices for working with the system to get the job done. It was concrete and practical.
I had a strong sense that U.S. hospitals will have lots of meetings like this in the next few years as they implement EMRs.
I wondered why in all our civilian discussions of EMR I haven't heard of this group of change leaders. Sure, I've heard about the DOD's long-standing use of their medical record, and I know about the VA's system (which is not the same as DOD's). But I had no idea there was a group aggressively advocating for patient engagement in the military.
And to me that makes a ton of sense, because for the most part, when soldiers leave the service their medical record will no longer be visible to their new providers. They'll need to be engaged in their care.
My gratitude to Dr Bob Walker from the Europe Army Medical Command in Heidelberg and his team for introducing me to this special operation. Great
The people I met with have a particularly passionate commitment to effective care: having chosen the military themselves (not the world's best working conditions), they're distinctively committed to their patients. They have a long-running EMR system (electronic medical record), so that any "doc" who encounters a patient can see what previous providers have entered. And because of frontline military circumstances (at the front, a medic is the one you call "doc"), the records are used by all tiers of providers. In these conditions the value of accurate information is acutely apparent - as are the challenges of system usability and workflow.
The event leaders who invited me to speak were as passionate about patient engagement as anyone I've met anywhere. I spoke about participatory medicine, and heard discussions of real-world workflow issues and best practices for working with the system to get the job done. It was concrete and practical.
I had a strong sense that U.S. hospitals will have lots of meetings like this in the next few years as they implement EMRs.
I wondered why in all our civilian discussions of EMR I haven't heard of this group of change leaders. Sure, I've heard about the DOD's long-standing use of their medical record, and I know about the VA's system (which is not the same as DOD's). But I had no idea there was a group aggressively advocating for patient engagement in the military.
And to me that makes a ton of sense, because for the most part, when soldiers leave the service their medical record will no longer be visible to their new providers. They'll need to be engaged in their care.
My gratitude to Dr Bob Walker from the Europe Army Medical Command in Heidelberg and his team for introducing me to this special operation. Great
No country for old men
I'm probably going out my realm of expertise here, but it's just something I have to try to articulate. The wife and I saw the movie "No Country for Old Men" this past Friday. Now, judging by the nearly unanimous rave reviews the movie has received from expert movie critics, you'd think that this was the second coming of Citizen Kane or the Sistine Chapel or something. Phrases like "work of art", "darkly poetic", "modern masterpiece", "cathartic", and "flawless" can be lifted from literally hundreds of positive reviews. I admit, I was excited to see it. I hadn't read the Cormac McCarthy novel of the same name, but I enjoyed his latest offering (The Road) quite a bit. When it was over, however, I walked out of the theater feeling completely empty, detached from what I had just witnessed. I wasn't moved. I didn't feel anything. Nothing. It was like going out to a highly recommended restaurant and having them serve a plate of thin air. A strange sensation to have after watching, ostensibly, "one of the great American movies of the decade", indeed. And that bothered me. Why was I feeling nothing when the rest of the country was apparently swept up in rapturous delight?
Was it a bad movie? No. It was actually entertaining and extremely well made. The acting was top notch. Javier Bardem just nails the role of the remorseless sociopath. Nails it. But when the credits rolled, I stood up and left without a pause. Within 2 minutes my wife and I moved on to other conversational topics. Isn't a "work of art", a "masterpiece" supposed to ingrain itself into your psyche just a wee bit longer? What was my problem? I liked the movie; don't get me wrong. The scene where Bardem makes a poor gas station clerk call heads or tails to determine whether or not he lives is a masterful combination of humor and horror. I just don't get why critics are falling over themselves with praise and adoration, as if the Coen brothers have contributed to the aggrandizement of the collective human mind.
For one thing, I think there's an important distinction between "technical excellence" and "art". No Country for Old Men is certainly flawless in its construction. The scenes are taut and steely. The dialogue crackles. The characters are developed with a minimum of exposition. The cinematography is occasionally breathtaking. No denying the superiority of the film in these regards. But is it art? Did it force me to look deep within, to acknowledge a truth that perhaps I hadn't realized? Was there a hidden human beauty, carefully delineated, that became steadily more manifest as the film reached its conclusion? What edifying idea was transmitted?
The film is about a bizarrely hilarious psychopath, Anton Chigurh, who spends the bulk of his time on screen mercilessly gunning down innocents with a compressed air gun, usually used to subdue cattle prior to slaughter. Chigurh's inexorable, inevitable killing rampage is conducted on a barren, craggy south Texas landscape almost completely devoid of anything soft or gentle. Tommy Lee Jones as the aged lawman with lines in his face like a dry, cracked riverbed, can only follow the carnage, always showing up a little late, helpless to stop it. Josh Brolin is the everyman, suddenly thrust into the crosshairs, who decides to challenge the ineluctability of his own death, unable to overcome the temptation of easy money. In the end, evil triumphs. The last twenty minutes elapse quickly in retrospect. The violence, so meticulously portrayed in all its gory detail in the frst half of the film, is elided at the end, the Coen brothers leaving to our imagination the senseless concluding butchery. I suppose that was nice of them.
We like our violence in America, I get that. We also love our psychopaths. But just because talented filmmakers are able to package that recipe into a well-made movie, that doesn't necessarily mean that ripples have been made in the river of historical aesthetics. Maybe I'm a little biased, given what I do for a living, but I see plenty of suffering and needless pain almost every day. It's very clear that the 45 year old woman with stage IV breast cancer didn't do anything to deserve her plight. Or the guy who comes in with perforated diverticulitis. Or the elderly lady with a massive myocardial infarction. I don't need to watch a goofy looking sadist leave a trail of horror for two hours to illustrate the vicissitudes and randomness of the human condition. Most of the beauty of art isn't in the actual work itself, but rather in the discussion and soul searching and enlightenment that the work of art triggers in each individual and the subsequent sharing of such insight. It's sad commentary that in this modern age, it takes someone like an Anton Chigurh to rouse us from our cruise control ennui and complacency. It shouldn't have to be like that. Suffering is all around us. In our neighborhoods, within the walls of our own homes. Even when we look in the mirror. No Country for Old Men is merely well made escapist fare with cool characters (a la Pulp Fiction)that satisfies our national fetish for violence. That isn't art. So let's all get down from our cultural purveyor thrones (I mean you Roger Ebert, AO Scott, Peter Travers, etc), wipe the blood from our lips, and save the awards for something a little more ennobling.
Was it a bad movie? No. It was actually entertaining and extremely well made. The acting was top notch. Javier Bardem just nails the role of the remorseless sociopath. Nails it. But when the credits rolled, I stood up and left without a pause. Within 2 minutes my wife and I moved on to other conversational topics. Isn't a "work of art", a "masterpiece" supposed to ingrain itself into your psyche just a wee bit longer? What was my problem? I liked the movie; don't get me wrong. The scene where Bardem makes a poor gas station clerk call heads or tails to determine whether or not he lives is a masterful combination of humor and horror. I just don't get why critics are falling over themselves with praise and adoration, as if the Coen brothers have contributed to the aggrandizement of the collective human mind.
For one thing, I think there's an important distinction between "technical excellence" and "art". No Country for Old Men is certainly flawless in its construction. The scenes are taut and steely. The dialogue crackles. The characters are developed with a minimum of exposition. The cinematography is occasionally breathtaking. No denying the superiority of the film in these regards. But is it art? Did it force me to look deep within, to acknowledge a truth that perhaps I hadn't realized? Was there a hidden human beauty, carefully delineated, that became steadily more manifest as the film reached its conclusion? What edifying idea was transmitted?
The film is about a bizarrely hilarious psychopath, Anton Chigurh, who spends the bulk of his time on screen mercilessly gunning down innocents with a compressed air gun, usually used to subdue cattle prior to slaughter. Chigurh's inexorable, inevitable killing rampage is conducted on a barren, craggy south Texas landscape almost completely devoid of anything soft or gentle. Tommy Lee Jones as the aged lawman with lines in his face like a dry, cracked riverbed, can only follow the carnage, always showing up a little late, helpless to stop it. Josh Brolin is the everyman, suddenly thrust into the crosshairs, who decides to challenge the ineluctability of his own death, unable to overcome the temptation of easy money. In the end, evil triumphs. The last twenty minutes elapse quickly in retrospect. The violence, so meticulously portrayed in all its gory detail in the frst half of the film, is elided at the end, the Coen brothers leaving to our imagination the senseless concluding butchery. I suppose that was nice of them.
We like our violence in America, I get that. We also love our psychopaths. But just because talented filmmakers are able to package that recipe into a well-made movie, that doesn't necessarily mean that ripples have been made in the river of historical aesthetics. Maybe I'm a little biased, given what I do for a living, but I see plenty of suffering and needless pain almost every day. It's very clear that the 45 year old woman with stage IV breast cancer didn't do anything to deserve her plight. Or the guy who comes in with perforated diverticulitis. Or the elderly lady with a massive myocardial infarction. I don't need to watch a goofy looking sadist leave a trail of horror for two hours to illustrate the vicissitudes and randomness of the human condition. Most of the beauty of art isn't in the actual work itself, but rather in the discussion and soul searching and enlightenment that the work of art triggers in each individual and the subsequent sharing of such insight. It's sad commentary that in this modern age, it takes someone like an Anton Chigurh to rouse us from our cruise control ennui and complacency. It shouldn't have to be like that. Suffering is all around us. In our neighborhoods, within the walls of our own homes. Even when we look in the mirror. No Country for Old Men is merely well made escapist fare with cool characters (a la Pulp Fiction)that satisfies our national fetish for violence. That isn't art. So let's all get down from our cultural purveyor thrones (I mean you Roger Ebert, AO Scott, Peter Travers, etc), wipe the blood from our lips, and save the awards for something a little more ennobling.
Sick
Physicians have a different conception of what the word "sick" means. It's different than the meaning an eight year old boy gives it when he tells his mommy he feels "sick". Different than what a college kid means when he relates how "sick" he got after shot-gunning six beers. For a physician, deeming someone "sick" is a declaration of war, of sorts. It means the patient isn't doing well. It means death lurks around the corner. Usually the patient is in an ICU, hooked up to a ventilator, on multiple antibiotics, vasopressors, swollen and distorted, fluids seeping out the vascular system. I was closing the fascia on a guy yesterday who had perforated his cecum. This guy's going to be sick, I kept thinking. Sick patients keep you on edge. There's no relaxing. You can't miss anything. The degree of vigilance has to be ramped up ten fold. They give me an ulcer sometimes. So how do you know if someone's really "sick"? What are the best indicators? How can you predict the ones who are likely to struggle? Here's a top five list of clinical indicators that a lot of docs use:
5. White blood cell count: I'm not a fan of this one. Sure, leukocytosis is usually associated with severe infection/inflammation but I've seen planty of patients on death's door with normal WBC counts.
4. Lactate levels: When tissues aren't being perfused, the cells undergo anaerobic metabolism. Thus, lactate will be elevated. I don't use this one very often. It always takes the lab too long to run it and lactatemia doesn't usually manifest until the patient is already starting to decompensate. So it just confirms what you already know.
3. Heartrate: An old school surgeon from my Chicago residency used to call us in the middle of the night for updates on his post op whipples. I'd ramble off streams of data; urine output, CVP, blood pressure, etc. Stop, he'd say. What's the pulse? That's all he wanted to know. Tachycardia is the first response mechanism to stress. All tachycardia ought to be investigated. Post op tachycardia should make you very very nervous. Find out why it's so fast.
2. Bandemia: I like this one. Bands are immature WBC. In the face of severe infection/iinflammation, the bone marrow will mount a massive leukocytosis. Initially, this won't show up on the CBC. Always look at the differential. Bandemia and left shifts are early indicators of something drasticly wrong.
1. Base Deficit: This is my favorite. Cells that aren't getting enough oxygen will undergo anaerobic metabolism. Lactic acid then builds up in the blood stream, lowering the pH. The body has an amazing buffering capacity, but when it gets overloaded, the pH will drop anyway. Base defict is a way of measuring one's relative buffering capacity. A high base deficit is suggestive of a body being overrun by a catastrophic event.
1a. Gestalt: How does the patient look? If they look like shit, trust your hunch. It's like that Malcolm Gladwell book Blink; sometimes your intial, subconscious perception is right on. Be very afraid of patients with a sense of impending doom, telling you they feel like they're about to die. They probably are.
On a brighter note, Happy Thanksgiving.
5. White blood cell count: I'm not a fan of this one. Sure, leukocytosis is usually associated with severe infection/inflammation but I've seen planty of patients on death's door with normal WBC counts.
4. Lactate levels: When tissues aren't being perfused, the cells undergo anaerobic metabolism. Thus, lactate will be elevated. I don't use this one very often. It always takes the lab too long to run it and lactatemia doesn't usually manifest until the patient is already starting to decompensate. So it just confirms what you already know.
3. Heartrate: An old school surgeon from my Chicago residency used to call us in the middle of the night for updates on his post op whipples. I'd ramble off streams of data; urine output, CVP, blood pressure, etc. Stop, he'd say. What's the pulse? That's all he wanted to know. Tachycardia is the first response mechanism to stress. All tachycardia ought to be investigated. Post op tachycardia should make you very very nervous. Find out why it's so fast.
2. Bandemia: I like this one. Bands are immature WBC. In the face of severe infection/iinflammation, the bone marrow will mount a massive leukocytosis. Initially, this won't show up on the CBC. Always look at the differential. Bandemia and left shifts are early indicators of something drasticly wrong.
1. Base Deficit: This is my favorite. Cells that aren't getting enough oxygen will undergo anaerobic metabolism. Lactic acid then builds up in the blood stream, lowering the pH. The body has an amazing buffering capacity, but when it gets overloaded, the pH will drop anyway. Base defict is a way of measuring one's relative buffering capacity. A high base deficit is suggestive of a body being overrun by a catastrophic event.
1a. Gestalt: How does the patient look? If they look like shit, trust your hunch. It's like that Malcolm Gladwell book Blink; sometimes your intial, subconscious perception is right on. Be very afraid of patients with a sense of impending doom, telling you they feel like they're about to die. They probably are.
On a brighter note, Happy Thanksgiving.
Rushing
There's this old guy with dementia/chf etc who came in with SOB and a dislodged gastrostomy tube. He isn't one of those quiet/gorked-out type of demented guys either. You walk in his room and he starts rambling incessantly. "Doctor, let me ask you a question..." and then he trails off, mumbles or else "Doctor, dont leave, I have to know something...." whenever I try to leave, but he never completes a thought. He never actually asks me anything. It's annoying I'll admit. I don't usually spend a lot of time in his room. I just want to get in, get out, make sure the new tube is working properly and sign off the case as soon as I can. Well the last day I went in and his wife was there. She's this small, frail, soft-voiced old lady who sat quietly in the corner in the shadows when I was examining him. I didn't notice her at first. As I pulled up his covers and made to leave, he started his usual demented rambling. "Doctor I have to ask you.." And his little wife shot up out of the chair in a flash and was holding his hand saying Joe, Joe what is it you want to ask the doctor and his eyes looked scared and she said Im here Joe Im here Joe just tell me what you want to ask the doctor. And then he went silent. He just stared at her. He looked terrified and lost. And then she started crying I know Joe it's ok it's ok Joe and kept holding his hand and she looked at me and I felt like the biggest asshole for wanting to rush through things and sign off the case. I'm sorry I said, hoping she would understand everything I meant by that and I stood there and rubbed his damn shoulder or something like that for a while and then I left...
Baudrillard and the Hyperrealism of the Parathyroidectomy
This is going to be a bizarre post; I'm just warning you.
I've been reading from Jean Baudrillard recently. Baudrillard is a post modernist French thinker/philosopher who writes about the preponderance of images, signs and representations in our technologically-driven, post modern lives. A lot of what he writes is almost deliberately obscure and esoteric. You find yourself re-reading entire chapters two or three times because nothing makes sense and you get pissed off thinking hey I'm not a moron, I have advanced degreees why is this guy being so intentionally obtuse? I sort of hate Baudrillard, actually, for that reason. But he does have some interesting takes on the nature of reality that are rather illuminating.
Baudrillard comments on the deluge of signs and images that are pounded into our collective consciousness in modern America. We are overwhelmed by ubiquitous advertising, television, celebrity culture, media supersaturation of "important events", mass information, instant communication via the internet and Blackberry and Twitter, the constant forward march of technologic innovation. What happens after a while is that the the signs and images start to become more important than the actual events/objects that they represent. It achieves a reality of its own, which he dubs "hyperreality". After a while, the images and signs become so disconnected from the objects they represent, that the objects themselves start to disappear, leaving us with this unsubstantiated, hollowed-out simulation of post modern America. The hyperreal as depicted on "reality" television becomes more "real" than the lives we actually lead, becomes a model to pattern ourselves after. The manipulative images of advertising alters our perception of what is important, of what has value. Henceforth, commodities become not just objects of desire, but function to define who we are, our social status, our relative value in American society. The SUV isn't necessarily a utilitarian, modern transport device; rather it is now a status symbol, a sign of the successful, modern, happy, American upper middle class family. The function (mode of transport) of the object (vehicle) now assumes a secondary role, while the sign/image of the object takes on the primary role in shaping the identity of the subject who acquires said object. We have a strange reversal of the subject/object dichotomy where the the object now dominates the subject, reducing the subject to something more thing-like, rather than an autonomous subjective being. (Baudrillard calls this reification).
So what does all this nonsense have to do with hyperparathyroidism? You'll have to bear with me.
I was reading an article in the March 2009 American Journal of Surgery called "Surgery Improves the Quality of Life in Patients with 'Mild' Hyperparathyroidism". Hyperparathyroidism is defined as an abnormal elevation of one's parathyroid hormone level (PTH) in the setting of hypercalcemia. There are four parathyroid glands, intimately associated with the thyroid gland in the neck. They function to maintain calcium homeostasis in the body. If calcium levels get too low, PTH is released to help bring calcium concentrations back to normal. When calcium levels correct, the PTH is down-regulated. It's an simple, elegant design. In hyperparathyroidism, the negative feedback loop goes haywire (most often secondary to a single adenomatous parathyroid gland) and PTH production occurs independent of body calcium levels. The body then starts breaking down bone in order to liberate more calcium to keep up with the demand from abnormally high PTH. The resultant hypercalcemia leads to a wide range of symptoms. Classically, primary hyperparathyroidism manifests as "stones, bones, abdominl groans, and psychic overtones", i.e. kidney stones, bone pain/fractures, peptic ulcer disease, and depression. The treatment is to identify the source of the autonomous PTH production (usually a single adenomatous parathyroid gland) and remove it. We surgeons love these kinds of diseases; cut to cure.
As usually happens, however, in this new era of extreme subspecialization within the field of general surgery, once a disease is named, an entire brigade of academic surgeons gravitate toward said disease and crank out paper after paper on the intricacies of it, its biochemical basis, surgical approaches and of course papers that boast of superior results when compared to surgeries performed at "low volume" hospitals, with the overall purpose of defining it (hyperparathyroidism) as a separate entity from the discipline of mere "general surgery". Hence, the birth of the "Endocrine Surgeon".
Give them credit though. Parathyroid surgery used to routinely involve a large Colombian necktie incision, similar to the incision of a thyroidectomy. It was also routine to explore all four parathyroid glands, because you could never be sure you were dealing with a single adenomatous gland versus two adenomas versus four gland hyperplasia unless you eyeballed them all yourself. Obviously, the more you dig you around, the more risk of injury to important structures (i.e. the recurrent laryngeal nerves, the thyroid gland itself, the carotid sheath) and the more risk of post-operative complications such as recurrent nerve palsy, neck hematoma, respiratory compromise, and hypocalcemia, not to mention the unseemly cosmesis of a large neck incision. So for many years, parathyroid surgery was done strictly on patients who manifested classic signs of the disease. The surgical treatment was effective, but fraught with too many potential adverse side effects to justify it otherwise.
But things changed. Nowadays, we are able to pre-operatively determine where the offending adenomatous gland is with a high degree of certainty using a combination of ultrasonography and something called a sestamibi scan. This allows the operating surgeon to minimize the incision and avoid unnecessary dissection in potentially dangerous tissue planes. Furthermore, the development of intra-operative parathyroid hormone monitoring has allowed us to determine cure before we even leave the OR. A drop of PTH levels of over 50% from pre-op levels gives a surgeon the confidence to close up shop, leaving the patient with a tiny, cosmetically appealing incsion. Some surgeons are also approaching the adenomatous parathyroid bugger endoscopically via tiny incisions in the axilla, eliminating the need for any visible neck scars.
These are all exciting new developments. Parathyroid surgery has now become more precise, sleeker, faster, more definitive, more cosmetically appealing; in a word, elegant. It's almost a shame that primary hyperparathyroidism is such a relatively rare disease (incidence about 1 in a 1000). And based on some of the recent surgical literature, one gets the sense that endocrine surgeons are also a little frustrated that it doesn't occur more often. I mean, these are terrific new surgical innovations. Wouldn't it be a lot cooler if hyperparathyroidism occured more often?
With the ubiquity of screening blood draws in American medicine, we are identifying patients with hypercalcemia whom we would have missed twenty years ago. A PTH level that is inappropriately elevated in such a setting will instigate a referral to an endocrine surgeon. But many of these patients have never had kidney stones, they don't have peptic ulcer disease, and they don't recall any specific bone or joint complaints. So what do you do?
Well in 1990, the NIH published a consensus paper that determined the indications for parathyroidectomy in patients who were either mildly symptomatic or asymptomatic. Many have found these indications to be far too restrictive. And by "many", I mean endocrine surgeons. The surgical community has consequently responded to this consensus paper with a series of counter-papers arguing for the utility of parathyroidectomy in these minimally symptomatic patients. This article in the March AJS is yet another salvo from the front line of the endocrine surgery battalion.
The common denominator in these pro-surgery papers is an intense focus on that fourth realm of symptomatology, i.e. "psychic overtones". What they aim to prove is that a patient's "quality of life" is significantly ameliorated by successful parathyroidectomy. Generally this has been done via the comparison of answers to pre- and post-operative questionaires which address one's subjective appraisal of such nebulous categories as "energy levels" and "happiness" and "fatigue". How else are you going to do it? It's not like "happiness" can be measured in the same way your calcium level can be (and if it could, I'd be sending off assays of my daughter's every other week). So the data they use is not exactly hard data; it's subjective and contingent on a lot of factors outside of whether or not your left parathyroid gland is incrementally larger than the others.
For example, in the cited article in AJS, 151 patients were evaluated. 133 of the patients had "classic" disease (NIH criteria or stones/bones/groans) while only 18 were patients with mild or asymptomatic disease. Something called the SF-36 Health Survey was administered to all 151 patients. The SF-36 is "a standardized instrument used to assess general health and wellness". (Just reading that, I'm already on the verge of speed dialling George Orwell.) Using the data from the survey, 8 scales of "well-being" are fashioned: Physical Functioning, Role-Physical, Bodily Pain, General Health, Vitality, Social Functioning, Role-Emotional, and Mental Health (yes, they are all ominously capitalized). Moreover, a combination of all 8 scales yields 2 additional derivative scales (Physical Component Summary and Mental Component Summary). Scores are then tallied and compared pre-parathyroidectomy versus post. What they found is that patients with mild/asymptomatic disease had improvement in all 10 scales, while those with classic hyperparathyroidism had improvement in 9/10 scales. Ergo: patients with asymptomatic disease derive a greater efficacy from parathyroidectomy than those with stones/bones/groans. Or something to that effect.
Now let's just take a step back for a moment. Is measurement of Vitality standard operating procedure when you go for your yearly check-up? No? You mean your internist doesn't check your blood pressure, order an EKG, send off blood work for cholesterol, hemoglobin, and Vitality? I mean, Vitality? I feel like I've become embroiled in some bizarre surgical game of Dungeons and Dragons. Shouldn't we also measure Wisdom and Dexterity levels?
What we have is a very Baudrillardian situation where the object is now defining the subject. The surgical procedure, heretofore a response to the ravages of a disease, is now redefining the very disease that it purportedly hopes to assuage. The excellence and refinement of the procedure itself mandates a re-appraisal of where we draw the line between where the actual disease begins and ends. It's a classic reversal of the subject/object dichotomy and I think this sets a dangerous precedent. As medical innovation continues unabated, we will inevitably see more refinement (at great cost) of other procedures/operations, innovations that reduce complications, improve cosmetic results, and augment patient satisfaction, and there will undoubtedly be a corresponding demand to do these procedures more often, given the expense invested in research and development. Even now, for example, we take out way more gallbladders than we ever used to, simply because laparoscopy makes it worthwhile to do so. But at least biliary colic is a definable, reproducible disease. The current push for incisionless abdominal surgery (pull your gallbag out through your vagina!) is more concerning. Will we see papers advocating the removal of asymptomatic gallbladders with stones, based on questionaires and surveys?
Anyway, I have to go. I have a battle lined up with an Orc this evening; if I win, I earn 50 Vitality points.
I've been reading from Jean Baudrillard recently. Baudrillard is a post modernist French thinker/philosopher who writes about the preponderance of images, signs and representations in our technologically-driven, post modern lives. A lot of what he writes is almost deliberately obscure and esoteric. You find yourself re-reading entire chapters two or three times because nothing makes sense and you get pissed off thinking hey I'm not a moron, I have advanced degreees why is this guy being so intentionally obtuse? I sort of hate Baudrillard, actually, for that reason. But he does have some interesting takes on the nature of reality that are rather illuminating.
Baudrillard comments on the deluge of signs and images that are pounded into our collective consciousness in modern America. We are overwhelmed by ubiquitous advertising, television, celebrity culture, media supersaturation of "important events", mass information, instant communication via the internet and Blackberry and Twitter, the constant forward march of technologic innovation. What happens after a while is that the the signs and images start to become more important than the actual events/objects that they represent. It achieves a reality of its own, which he dubs "hyperreality". After a while, the images and signs become so disconnected from the objects they represent, that the objects themselves start to disappear, leaving us with this unsubstantiated, hollowed-out simulation of post modern America. The hyperreal as depicted on "reality" television becomes more "real" than the lives we actually lead, becomes a model to pattern ourselves after. The manipulative images of advertising alters our perception of what is important, of what has value. Henceforth, commodities become not just objects of desire, but function to define who we are, our social status, our relative value in American society. The SUV isn't necessarily a utilitarian, modern transport device; rather it is now a status symbol, a sign of the successful, modern, happy, American upper middle class family. The function (mode of transport) of the object (vehicle) now assumes a secondary role, while the sign/image of the object takes on the primary role in shaping the identity of the subject who acquires said object. We have a strange reversal of the subject/object dichotomy where the the object now dominates the subject, reducing the subject to something more thing-like, rather than an autonomous subjective being. (Baudrillard calls this reification).
So what does all this nonsense have to do with hyperparathyroidism? You'll have to bear with me.
I was reading an article in the March 2009 American Journal of Surgery called "Surgery Improves the Quality of Life in Patients with 'Mild' Hyperparathyroidism". Hyperparathyroidism is defined as an abnormal elevation of one's parathyroid hormone level (PTH) in the setting of hypercalcemia. There are four parathyroid glands, intimately associated with the thyroid gland in the neck. They function to maintain calcium homeostasis in the body. If calcium levels get too low, PTH is released to help bring calcium concentrations back to normal. When calcium levels correct, the PTH is down-regulated. It's an simple, elegant design. In hyperparathyroidism, the negative feedback loop goes haywire (most often secondary to a single adenomatous parathyroid gland) and PTH production occurs independent of body calcium levels. The body then starts breaking down bone in order to liberate more calcium to keep up with the demand from abnormally high PTH. The resultant hypercalcemia leads to a wide range of symptoms. Classically, primary hyperparathyroidism manifests as "stones, bones, abdominl groans, and psychic overtones", i.e. kidney stones, bone pain/fractures, peptic ulcer disease, and depression. The treatment is to identify the source of the autonomous PTH production (usually a single adenomatous parathyroid gland) and remove it. We surgeons love these kinds of diseases; cut to cure.
As usually happens, however, in this new era of extreme subspecialization within the field of general surgery, once a disease is named, an entire brigade of academic surgeons gravitate toward said disease and crank out paper after paper on the intricacies of it, its biochemical basis, surgical approaches and of course papers that boast of superior results when compared to surgeries performed at "low volume" hospitals, with the overall purpose of defining it (hyperparathyroidism) as a separate entity from the discipline of mere "general surgery". Hence, the birth of the "Endocrine Surgeon".
Give them credit though. Parathyroid surgery used to routinely involve a large Colombian necktie incision, similar to the incision of a thyroidectomy. It was also routine to explore all four parathyroid glands, because you could never be sure you were dealing with a single adenomatous gland versus two adenomas versus four gland hyperplasia unless you eyeballed them all yourself. Obviously, the more you dig you around, the more risk of injury to important structures (i.e. the recurrent laryngeal nerves, the thyroid gland itself, the carotid sheath) and the more risk of post-operative complications such as recurrent nerve palsy, neck hematoma, respiratory compromise, and hypocalcemia, not to mention the unseemly cosmesis of a large neck incision. So for many years, parathyroid surgery was done strictly on patients who manifested classic signs of the disease. The surgical treatment was effective, but fraught with too many potential adverse side effects to justify it otherwise.
But things changed. Nowadays, we are able to pre-operatively determine where the offending adenomatous gland is with a high degree of certainty using a combination of ultrasonography and something called a sestamibi scan. This allows the operating surgeon to minimize the incision and avoid unnecessary dissection in potentially dangerous tissue planes. Furthermore, the development of intra-operative parathyroid hormone monitoring has allowed us to determine cure before we even leave the OR. A drop of PTH levels of over 50% from pre-op levels gives a surgeon the confidence to close up shop, leaving the patient with a tiny, cosmetically appealing incsion. Some surgeons are also approaching the adenomatous parathyroid bugger endoscopically via tiny incisions in the axilla, eliminating the need for any visible neck scars.
These are all exciting new developments. Parathyroid surgery has now become more precise, sleeker, faster, more definitive, more cosmetically appealing; in a word, elegant. It's almost a shame that primary hyperparathyroidism is such a relatively rare disease (incidence about 1 in a 1000). And based on some of the recent surgical literature, one gets the sense that endocrine surgeons are also a little frustrated that it doesn't occur more often. I mean, these are terrific new surgical innovations. Wouldn't it be a lot cooler if hyperparathyroidism occured more often?
With the ubiquity of screening blood draws in American medicine, we are identifying patients with hypercalcemia whom we would have missed twenty years ago. A PTH level that is inappropriately elevated in such a setting will instigate a referral to an endocrine surgeon. But many of these patients have never had kidney stones, they don't have peptic ulcer disease, and they don't recall any specific bone or joint complaints. So what do you do?
Well in 1990, the NIH published a consensus paper that determined the indications for parathyroidectomy in patients who were either mildly symptomatic or asymptomatic. Many have found these indications to be far too restrictive. And by "many", I mean endocrine surgeons. The surgical community has consequently responded to this consensus paper with a series of counter-papers arguing for the utility of parathyroidectomy in these minimally symptomatic patients. This article in the March AJS is yet another salvo from the front line of the endocrine surgery battalion.
The common denominator in these pro-surgery papers is an intense focus on that fourth realm of symptomatology, i.e. "psychic overtones". What they aim to prove is that a patient's "quality of life" is significantly ameliorated by successful parathyroidectomy. Generally this has been done via the comparison of answers to pre- and post-operative questionaires which address one's subjective appraisal of such nebulous categories as "energy levels" and "happiness" and "fatigue". How else are you going to do it? It's not like "happiness" can be measured in the same way your calcium level can be (and if it could, I'd be sending off assays of my daughter's every other week). So the data they use is not exactly hard data; it's subjective and contingent on a lot of factors outside of whether or not your left parathyroid gland is incrementally larger than the others.
For example, in the cited article in AJS, 151 patients were evaluated. 133 of the patients had "classic" disease (NIH criteria or stones/bones/groans) while only 18 were patients with mild or asymptomatic disease. Something called the SF-36 Health Survey was administered to all 151 patients. The SF-36 is "a standardized instrument used to assess general health and wellness". (Just reading that, I'm already on the verge of speed dialling George Orwell.) Using the data from the survey, 8 scales of "well-being" are fashioned: Physical Functioning, Role-Physical, Bodily Pain, General Health, Vitality, Social Functioning, Role-Emotional, and Mental Health (yes, they are all ominously capitalized). Moreover, a combination of all 8 scales yields 2 additional derivative scales (Physical Component Summary and Mental Component Summary). Scores are then tallied and compared pre-parathyroidectomy versus post. What they found is that patients with mild/asymptomatic disease had improvement in all 10 scales, while those with classic hyperparathyroidism had improvement in 9/10 scales. Ergo: patients with asymptomatic disease derive a greater efficacy from parathyroidectomy than those with stones/bones/groans. Or something to that effect.
Now let's just take a step back for a moment. Is measurement of Vitality standard operating procedure when you go for your yearly check-up? No? You mean your internist doesn't check your blood pressure, order an EKG, send off blood work for cholesterol, hemoglobin, and Vitality? I mean, Vitality? I feel like I've become embroiled in some bizarre surgical game of Dungeons and Dragons. Shouldn't we also measure Wisdom and Dexterity levels?
What we have is a very Baudrillardian situation where the object is now defining the subject. The surgical procedure, heretofore a response to the ravages of a disease, is now redefining the very disease that it purportedly hopes to assuage. The excellence and refinement of the procedure itself mandates a re-appraisal of where we draw the line between where the actual disease begins and ends. It's a classic reversal of the subject/object dichotomy and I think this sets a dangerous precedent. As medical innovation continues unabated, we will inevitably see more refinement (at great cost) of other procedures/operations, innovations that reduce complications, improve cosmetic results, and augment patient satisfaction, and there will undoubtedly be a corresponding demand to do these procedures more often, given the expense invested in research and development. Even now, for example, we take out way more gallbladders than we ever used to, simply because laparoscopy makes it worthwhile to do so. But at least biliary colic is a definable, reproducible disease. The current push for incisionless abdominal surgery (pull your gallbag out through your vagina!) is more concerning. Will we see papers advocating the removal of asymptomatic gallbladders with stones, based on questionaires and surveys?
Anyway, I have to go. I have a battle lined up with an Orc this evening; if I win, I earn 50 Vitality points.
The meaning of life
The Happy Hospitalist took aim at my post from last week on the spry 92 year old lady with metastatic breast cancer who needed a Mediport for her adjuvant chemotherapy. As anyone who reads the Happy Ho would expect, he comes down hard on the decision of myself, the patient, and the oncologist to proceed with aggressive chemotherapy on someone obviously in the twilight of life. He writes:
So I have to ask the question. Does this 92 year old have the right to consume the resources used to treat an incurable, fatal and futile disease if it means we wont have the money required to treat another disease that is neither incurable, neither fatal and neither futile?
Unsurprisingly, HHO treats this case as yet another flagrant example of the profligate waste we see in everyday medical practice in America. Health care dollars and resources are a limited commodity (like oil and soybeans?), he avers---we cannot afford to waste them on the extreme elderly.
Now I think his heart is in the right place. Happy isn't a preternaturally evil person. Most of what he writes is at least reasonable. Besides, when you are an anonymous blogger, sometimes you write things you don't necessarily mean, with a stridency that you wouldn't normally use in everyday discourse. Who knows, maybe in real life HHO is a giant softy, one of those docs who brings his patients warm blankets and a cup of hot tea every morning. But on this particular topic, I think he's way off the mark and a little out of his depth.
I'm going to veer of course for bit, if that's OK. Notice first the ponderous, pretentious title of this post--- "the meaning of life". What the hell is that all about? Is this going to be another rant about Baudrillard or Kundera or DFW, you ask? Well, sort of. Just bear with me. Much of what happens to us in life is unimportant and ultimately forgettable. The traffic jam on the way home from work. Saying hi to people you pass in the hall. Pumping gas. Watching television. Reading the sports section. The lost moments of time that slip through our fingers every day. But every once in a while moments arise that demand our attention. These are the moments that either force us to step up and make good on the ideal conception of the sort of person we think we are (adversity, ethical quandaries, etc) or force us to stop and re-evaluate the very foundations of our notion of being. No matter who you are, it's important to accept these challenges when they present themselves; otherwise life is a random, arbitrary mess that ends much too quickly. My 92 year old breast cancer patient was, for me, such a moment. As a physician, and this may come off as a bit arrogant, I think I am thrust into situations that demand this sort of introspection more often than the average Joe. This is both a privilege and a burden.
A physician's raison d'etre is arguably to alleviate suffering, to improve a patient's quality of life, and to, in some cases, work to extend the duration of the life of an ill patient. Life is the common denominator. Our purpose, our meaning is driven by the concept of "life"--- making it better, richer, less intolerable. If we admit this, then we are obligated to define what we mean by "life", because that is the fulcrum upon which we operate. What is life? What is it exactly that we are trying to save, to alleviate, to improve?
Now this is purely my take and I'm just some yahoo like all the rest of you so don't get too upset if you disagree. I see our temporal time on Earth as having two distinct components. On the one hand is our contingent, a priori self that thrusts itself upon us, the part that deprives us of our autonomy. I was born in the late 20th century. I could not choose my parents. My genome is unalterable. I was raised a certain way by my mother. This is our contingent life. It didn't have to be like it is, but it is, and there isn't anything we can do about it. And it doesn't end at birth. The contingencies of life continue until we die. Events occur beyond our control that exert pressures upon our being. Wars. Economic depressions. Pestilence. The tragic untimely death of a loved one. A car that runs a redlight as you drive home from your daughter's wedding. We cannot control them. There is no escape from the weight that they bring to bear. But we are not condemned to let contingency define us. There is another side of Life, the side of free choice and alterability. Jean-Paul Sartre wrote about the being for itself (etre pour soi) that exists fleetingly in the instantaneous moment when we are free to decide, to choose to be, to push back against the weight of our contingencies, to create ourselves, fresh and new. Heidegger's dasein (being in time)is a similar concept. We aren't always doomed to serve out the sentences of our contingencies; every moment in time brings with it an opportunity to change, to rectify, to make better. We don't have to accept defeat. Those moments that interminably rush toward us with each waking second of consciousness afford us the chance to get back up off the canvas. And this is the aspect of Life that I find far more interesting.
Going back to my old lady with breast cancer. Her situation is fraught with contingency. She has incurable cancer. The chemotherapy may do more harm than good. She's old as hell. She's seemingly crushed by the cold hard weight of pure contingency. And she knows it. She knows she is going to die, that the cancer will ultimately vanquish her. But in that dark moment of impending, irrevocable mortality, she exercises her right to push back against death for the sake of her unmarried grandchildren and whatever else--- one more spring bloom, one more Thanksgiving, one last morning snow in December. Who are we to deny her that possibility?
This goes beyond charges of ageism. It's far more important than that. What we're talking about is a woman's dignity and free will. This was an intelligent, lucent, fully informed woman who has decided etre pour soi to mount one last counterattack against the ravages of time and human fallibility. It's as simple as that. To me, the succor of life is in those moments that challenge our preconceptions of who we really are, that force us to re-assess whom we wish to become. The full life, the life bursting at the seams with effervescence, is the one where one continues to make those big decisions as long as one can, independently, without meekly capitulating to the forces of time and contingency. To see it in a 92 year old woman is not grounds for condemnation; it's a reason to celebrate. To want to live so much, to have such appreciation for the rising of another sun, to thirst so much for the chance to make it all last just a little bit longer.... man it's just beautiful. The minute we start to ration care based simply on someone's age or some other convoluted bureaucratic formula, we start to lose something indispensable about what it means to be a human being, let alone for what it means to be a doctor.
Happy says: "Being 92 and functional is, in my opinion, not a good enough reason to abuse patients in their last few months of life, while we choose to ignore the economic realities all around us."
I feel bad for the guy. He's missing something crucial about being a physician. The "economic realities" of society will plague civilations long after we've all shuffled off this mortal coil. But if we cede the terms of our existence to pure contingency and ignore that powerful force of dasein that lurks deep within us all, then we might as well close up shop now because that's not the sort of world I want my grandchildren to live in.
Anyway, that's what a scrappy 92 year old lady, who will probably be dead this time next year no matter what she does, taught me last week....
So I have to ask the question. Does this 92 year old have the right to consume the resources used to treat an incurable, fatal and futile disease if it means we wont have the money required to treat another disease that is neither incurable, neither fatal and neither futile?
Unsurprisingly, HHO treats this case as yet another flagrant example of the profligate waste we see in everyday medical practice in America. Health care dollars and resources are a limited commodity (like oil and soybeans?), he avers---we cannot afford to waste them on the extreme elderly.
Now I think his heart is in the right place. Happy isn't a preternaturally evil person. Most of what he writes is at least reasonable. Besides, when you are an anonymous blogger, sometimes you write things you don't necessarily mean, with a stridency that you wouldn't normally use in everyday discourse. Who knows, maybe in real life HHO is a giant softy, one of those docs who brings his patients warm blankets and a cup of hot tea every morning. But on this particular topic, I think he's way off the mark and a little out of his depth.
I'm going to veer of course for bit, if that's OK. Notice first the ponderous, pretentious title of this post--- "the meaning of life". What the hell is that all about? Is this going to be another rant about Baudrillard or Kundera or DFW, you ask? Well, sort of. Just bear with me. Much of what happens to us in life is unimportant and ultimately forgettable. The traffic jam on the way home from work. Saying hi to people you pass in the hall. Pumping gas. Watching television. Reading the sports section. The lost moments of time that slip through our fingers every day. But every once in a while moments arise that demand our attention. These are the moments that either force us to step up and make good on the ideal conception of the sort of person we think we are (adversity, ethical quandaries, etc) or force us to stop and re-evaluate the very foundations of our notion of being. No matter who you are, it's important to accept these challenges when they present themselves; otherwise life is a random, arbitrary mess that ends much too quickly. My 92 year old breast cancer patient was, for me, such a moment. As a physician, and this may come off as a bit arrogant, I think I am thrust into situations that demand this sort of introspection more often than the average Joe. This is both a privilege and a burden.
A physician's raison d'etre is arguably to alleviate suffering, to improve a patient's quality of life, and to, in some cases, work to extend the duration of the life of an ill patient. Life is the common denominator. Our purpose, our meaning is driven by the concept of "life"--- making it better, richer, less intolerable. If we admit this, then we are obligated to define what we mean by "life", because that is the fulcrum upon which we operate. What is life? What is it exactly that we are trying to save, to alleviate, to improve?
Now this is purely my take and I'm just some yahoo like all the rest of you so don't get too upset if you disagree. I see our temporal time on Earth as having two distinct components. On the one hand is our contingent, a priori self that thrusts itself upon us, the part that deprives us of our autonomy. I was born in the late 20th century. I could not choose my parents. My genome is unalterable. I was raised a certain way by my mother. This is our contingent life. It didn't have to be like it is, but it is, and there isn't anything we can do about it. And it doesn't end at birth. The contingencies of life continue until we die. Events occur beyond our control that exert pressures upon our being. Wars. Economic depressions. Pestilence. The tragic untimely death of a loved one. A car that runs a redlight as you drive home from your daughter's wedding. We cannot control them. There is no escape from the weight that they bring to bear. But we are not condemned to let contingency define us. There is another side of Life, the side of free choice and alterability. Jean-Paul Sartre wrote about the being for itself (etre pour soi) that exists fleetingly in the instantaneous moment when we are free to decide, to choose to be, to push back against the weight of our contingencies, to create ourselves, fresh and new. Heidegger's dasein (being in time)is a similar concept. We aren't always doomed to serve out the sentences of our contingencies; every moment in time brings with it an opportunity to change, to rectify, to make better. We don't have to accept defeat. Those moments that interminably rush toward us with each waking second of consciousness afford us the chance to get back up off the canvas. And this is the aspect of Life that I find far more interesting.
Going back to my old lady with breast cancer. Her situation is fraught with contingency. She has incurable cancer. The chemotherapy may do more harm than good. She's old as hell. She's seemingly crushed by the cold hard weight of pure contingency. And she knows it. She knows she is going to die, that the cancer will ultimately vanquish her. But in that dark moment of impending, irrevocable mortality, she exercises her right to push back against death for the sake of her unmarried grandchildren and whatever else--- one more spring bloom, one more Thanksgiving, one last morning snow in December. Who are we to deny her that possibility?
This goes beyond charges of ageism. It's far more important than that. What we're talking about is a woman's dignity and free will. This was an intelligent, lucent, fully informed woman who has decided etre pour soi to mount one last counterattack against the ravages of time and human fallibility. It's as simple as that. To me, the succor of life is in those moments that challenge our preconceptions of who we really are, that force us to re-assess whom we wish to become. The full life, the life bursting at the seams with effervescence, is the one where one continues to make those big decisions as long as one can, independently, without meekly capitulating to the forces of time and contingency. To see it in a 92 year old woman is not grounds for condemnation; it's a reason to celebrate. To want to live so much, to have such appreciation for the rising of another sun, to thirst so much for the chance to make it all last just a little bit longer.... man it's just beautiful. The minute we start to ration care based simply on someone's age or some other convoluted bureaucratic formula, we start to lose something indispensable about what it means to be a human being, let alone for what it means to be a doctor.
Happy says: "Being 92 and functional is, in my opinion, not a good enough reason to abuse patients in their last few months of life, while we choose to ignore the economic realities all around us."
I feel bad for the guy. He's missing something crucial about being a physician. The "economic realities" of society will plague civilations long after we've all shuffled off this mortal coil. But if we cede the terms of our existence to pure contingency and ignore that powerful force of dasein that lurks deep within us all, then we might as well close up shop now because that's not the sort of world I want my grandchildren to live in.
Anyway, that's what a scrappy 92 year old lady, who will probably be dead this time next year no matter what she does, taught me last week....
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