Category Archives: Outcomes

Pro Publica and Rating Surgeons: Garbage IN equals Garbage OUT.

Recently, the independent investigative journalism research group known as Pro Publica has received a great deal of attention for a newly published project for rating surgeons. This particular project has been met with a great deal of scrutiny by the medical community and has stirred significant debate since it was released in early July 2015. While providing patients with an objective metric by which they can evaluate physicians before deciding where and when to receive care is a lofty goal, Pro Publica’s attempt has fallen significantly short—and if anything—has created more confusion and frustration among both doctors and patients.  Several of my colleagues have written blogs and commented publicly about this rating system–Here is my take.

Helping the public make informed decisions about healthcare is an essential part of the process of improving the quality of care throughout the US—However, any information provided to the public must be easily digestible, RELIABLE and ACCURATE and supported by solid, well-conducted research. The methodology by which any data is assembled and any particular meaningful conclusions are reached is critical in determining whether or not the conclusions are of ANY use to the intended audience.

What Exactly is Pro Publica?

According to their website, Pro Publica is an “an independent, non-profit newsroom that produces investigative journalism in the public interest”. It is labeled as a non-profit organization and is funded by philanthropic donations as well as advertising dollars. The organization is staffed by nearly 45 investigative journalists and is located in Manhattan. Their mission statement is published as follows:

“To expose abuses of power and betrayals of the public trust by government, business, and other institutions, using the moral force of investigative journalism to spur reform through the sustained spotlighting of wrongdoing.”

What exactly was the Surgeon Rating project?

In the surgeon rating project, Pro Publica sought to produce a mechanism by which healthcare consumers could examine outcomes data prior to choosing a medical professional. In the project, journalists collected data from Medicare billing databases—these data were limited to a few selected low risk procedures and only included patients admitted to hospitals for these procedures. The analysis did not consider outpatient surgical center locations, nor did it evaluate data from patients admitted from the Emergency Department.   Doctors in particular specialties such as orthopedics, neurosurgery, general surgery and urology from all over the US were rated based on two outcomes—death and readmission—and all data was mined from a Medicare billing database. The journalists clearly state their methodology on their website. They examined records from in patient hospital stays from 2009-13 and looked at complications from what they defined as low risk surgeries. While Pro Publica does insist that they consulted with “experts” in each area evaluated, they do not mention if they had any guidance from statisticians, and other experts in the design of medical research investigations.

In their project, Pro Publica journalists collected information from nearly 3600 hospitals involving almost 17,000 surgeons. The outcomes of almost 64,000 Medicare patients were evaluated. A searchable “surgeon scorecard” was created online and has been available to the public since early July.

What DOES make a good surgeon?

The most important quality of a successful surgeon is judgement. Ironically, many outcomes are determined by the surgeon before operating—choosing an appropriate surgical candidate is often the most difficult decision a surgeon will make. This database does not take any of the pre surgery decision making into consideration. A good surgeon certainly has inherent physical talent and dexterity—most great surgeons have exceptional skill with a scalpel. In addition, patient volume is a huge determinant in surgical outcome. A surgeon with a large volume practice is much more adept at performing a routine procedure and is also much more skilled at handling intra operative surprises. Moreover, surgeons who have been well trained and well educated at academic institutions during their residencies and fellowships are more likely to practice evidence-based medicine and adhere to “best practices” and clinical guidelines.

Why is the Pro Publica project fundamentally flawed?

The project, while well intended, is of no practical use. The methodology is flawed at the beginning. Mining Medicare databases assumes that the data entered is in fact accurate. There are coding errors and data entry errors that occur every single day in hospitals and at CMS. The project does not take into consideration surgeons who accept patients that others would turn away—due to high risk, etc. In addition, the data analysis only takes into consideration inpatient procedures. Many of these low risk procedures are also performed in outpatient surgical centers—including these numbers would certainly bolster a surgeon’s “scorecard”. The research presented by Pro Publica was NOT peer reviewed. Any reputable medical journal requires that all investigations are reviewed by a minimum of two or three independent and anonymous EXPERTS in the discipline of interest. These experts are charged with evaluating not only the quality of the research and its findings but also the methods that were utilized in the study. Other than mentioning a group of physician experts that were consulted to identify complications, there is no mention of a peer review process and no mention of a methodology review.

Epilogue: Pending Impact of the Pro Publica Surgeon rating project?

 Ultimately time will tell. This database unfairly evaluates surgeons. While not all physicians are created equal, the methodology involved in arriving at the Pro Publica ratings has produced unreliable and inaccurate data. I fear that rating projects of this sort—that are not based on good, sound science—will result in many physicians refusing to treat sicker, higher risk patients. Ironically, it is the BEST surgeons that must take on the toughest cases. I, along with many of my colleagues, applaud any effort that can potentially empower patients to make informed decisions about their healthcare. However, I cannot endorse faulty science. If you put garbage data into a statistical program, you simply get well analyzed garbage out. As British economist Ronald Coase once said….”If you torture the data long enough, it will confess to anything…”

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Reflecting on Medicine in 2014: Sailing Rough Seas and Finding Uncharted Waters Ahead

As we close out on a tumultuous 2014 in healthcare, many physicians are looking forward to a better and more stable 2015. For most of us, 2014 has been marked by significant change. Many healthcare providers have seen their jobs and their patient care roles transform completely. Physician autonomy has diminished and regulation and mandated electronic paperwork has more than doubled. Many physicians find that they are spending far less time caring for patients and a greater proportion of their available clinical time is now being spent interfacing with a computer—both at work and at home on personal time.

During the last year, we have all been affected by the rollout of the Affordable Care Act (ACA), changes in reimbursement, as well as the implementation of a new billing and coding system (ICD-10). For many of us, it also marked a year of transition to system wide electronic medical record systems such as Epic and the growing pains associated with such a major upheaval in the way in which medicine is practiced.   Many practices have continued the trend of “integration” with larger healthcare systems in order to remain financially viable. The American College of Cardiology estimates that by the end of 2014, nearly 60% of all physician members have integrated with hospital systems and this number is expected to rise even further in 2015—ultimately defining the death of private practice as we know it.

Why have these changes occurred?

Ultimately, I believe that the changes to the way in which healthcare is delivered has come about due to 3 distinct reasons:

 1. Declining Reimbursement

Currently reimbursement continues to fall. Multiple government budgetary “fixes” have led to much uncertainty and instability in medical practices (much like seen in any small business with financial and market instability). In addition, the implementation of the ACA has resulted in the expansion of the Medicaid population in the US—now nearly 1 in 5 Americans is covered under a Medicaid plan. Traditionally, Medicaid plans reimburse at levels 45% less than Medicare (which is already much lower than private insurance payments). While the Obama administration did provide a payment incentive for physicians to accept Medicaid, this incentive expires this week. Many practices are becoming financially non viable as overhead costs are risking to more than 60%. As for the ACA, many exchanges have set prices and negotiated contracts with hospital systems—leaving many practices out of network. Both patients and doctors suffer—longtime relationships are severed due to lack of access to particular physicians.

2. Increasing Administrative/Regulatory Demands

With the implementation of the ICD-10 coding system, now physicians are confronted with more than 85, 000 codes (previously the number of codes was approximately 15,000). In addition, “meaningful use” mandates for payment have resulted in increasing documentation requirements and even more electronic paperwork. In addition, the implementation of new billing and coding systems has required increasing staff (more overhead) as well as intensive physician training. Sadly, the new coding system that has been mandated by the Federal government includes thousands of absurdities such as a code for an “Orca bite” as well as a code for an “injury suffered while water skiing with skis on fire”.

3. Electronic Medical Record Mandates

Federal requirements for the implementation of Electronic Medical Records and electronic prescribing have resulted in several negative impacts on practices. While in theory, the idea of a universal medical record that is portable and accessible to all providers is a noble goal, the current reality in of EMR in the US is troubling. There are several different EMR systems and none of them are standardized—none of them allow for cross talk and communication. Many small practices cannot afford the up front expenditures associated with the purchase and implementation of the EMR (often in the hundreds of thousands of dollars).   In addition, the EMR has slowed productivity for many providers and resulted in more work that must be taken home to complete—not a good thing for physician morale. Finally, and most importantly, the EMR often serves to separate doctor and patient and hinders the development of a doctor-patient relationship. Rather than focusing on the patient and having a conversation during an office visit, many physicians are glued to a computer screen during the encounter.

So, What is next in 2015?

While I have probably painted a bleak picture for Medicine in 2014, it is my hope that we are able to move forward in a more positive way in 2015. I think that there are several very exciting developments that are gaining momentum within medicine and healthcare in general.  Innovation and medical entrepreneurship will be critical in moving healthcare forward in 2015.  Physicians must continue to lobby for the tools and freedoms to provide better patient care experiences for all stakeholders in the healthcare space.

2015 begins with much promise. I am excited to see what we as healthcare professionals will be able to accomplish in the coming year. We must continue to put patients first and strive to provide outstanding care in spite of the obstacles put before us. While 2014 provided challenges, we must rise above the fray and continue to advocate for a better healthcare system in the US today and in the future.

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An Apple A Day—Changing Medicine Through Technology and Engagement

The practice of medicine and healthcare in general has become an electronic and increasingly mobile interaction. Patients are better informed, more engaged, more connected and have a much greater virtual presence. In fact, according to Pew Research data, the fastest growing demographic on Twitter are those who are in the 45-65 age bracket.   Nearly 50% of all seniors engage online on a daily basis through at least one social media platform and many of these interactions and online engagements occur via mobile devices. Almost 75% of all adults go online within hours of attending a visit with their physician in order to gather more information about their particular medical problem. For healthcare providers—and for patients—the internet and mobile technology presents us all with wonderful opportunities to interact, engage, support and ultimately improve outcomes.

New connected devices and medical applications for mobile devices are on growing exponentially.   The world responded favorably to the latest release of the iPhone 6 and the iOS8 operating system recently released by Apple. The new device has many interesting features but one in particular caught my eye early on. Apple has created a standard package for all iOS 8 devices that is called the Health Kit. This particular application allows a user to track calories, steps taken (similar to a pedometer), flights of stairs climbed and other customizable health related data points. These data can be organized into graphs and charts that allow users to track progress and adjust activity levels to achieve particular goals. More impressively, the device will allow other health related applications to organize data in the Health Kit as well. One of the biggest problems with medial applications in the past is that there has never been an easy place to organize, store, collect and view all of the data together. Moreover, this data is not easily shared with healthcare providers. The Health Kit and Apple may revolutionize this entire process of data collection, retrieval and sharing—Apple has partnered with a major electronic medical record service known as EPIC. Work is underway to allow the Health Kit data and applications to easily interact with the EPIC medical record. This would allow for easy downloads of health data during a face-to-face encounter with healthcare providers. Currently, most major hospitals and healthcare systems are moving to the EPIC platform. The data collected and downloaded at one location would subsequently be available to all providers in the system—portability of data allows for better care and less duplication of effort.

Much has been written about patient engagement and improved outcomes in the medical literature. I can think of no better way to improve engagement than through the use of real time health applications –these allow patients to receive real time feedback—both good and bad—and respond quickly in order to improve their overall health status. I think that this type of technology will only continue to grow. Apple plans to release the Apple Watch in early 2015. I expect that this will also be integrated with Health Kit and allow for the measurement of respiratory rate, heart rate, body temperature and other biologic measurements. As these tools continue to develop and applications grow, healthcare providers as well as patients must be receptive to their use. These technologies have the potential to allow clinicians to better assess patients between office visits and provide more directed and timely changes in therapy. Ultimately I believe these technologies will transform healthcare. As we continue to struggle with healthcare cost containment in the era of healthcare reform, the ability to shift care and routine interaction to mobile platforms may very well prove to be a critical piece of the puzzle.

This is an exciting time in medicine as well as in healthcare technology. Moving forward, I look to a day where biologic sensors collect data, relay data to mobile devices and then transmit information seamlessly to healthcare systems. The healthcare providers are alerted to any abnormalities and electronic responses are generated—those patients requiring timely in person visits can be identified and scheduled, while those that can be handled virtually can be managed quickly and effectively as well. Ultimately, our goal is to better manage disease and improve outcomes. I think that technologies such as the Health Kit and the Apple Watch are giant leaps forward and are just the beginning of a new age of virtual healthcare.

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Setting the record straight: New stool DNA test for Colorectal Cancer Screening (A guest Blog by @DrDeborahFisher)

 

A bit about today’s Blog Post…..

Dr Deborah Fisher is a brilliant Gastroenterologist at Duke University Medical Center.  She is also a fantastic wife and mother.  A Twitter fanatic, Dr Fisher has taken to Social Media to promote issues in Gastroenterology.  Today, she writes about a very controversial subject in GI–Does a New stool DNA test Replace Colonoscopy and is the Media Creating Confusion in the Market? 

Setting the record straight: New stool DNA test for Colorectal Cancer Screening (A guest Blog by @DrDeborahFisher) 

An occupational hazard of being married to a rising media star is that when I expressed my concern and exasperation at the misinformation being circulated about a newly FDA-approved colorectal cancer screening test, his response was “write a guest blog for my blog page”. Another occupational hazard is having the local NBC-affiliate news truck parked in front of our house at 9:30 on a random summer evening. But that is for another blog.

For full disclosure, I am a gastroenterologist and much of my research and clinical focus is colorectal cancer screening. Some of my previous comments on the new stool DNA test, Cologuard, have already been published in the New York Times as well as in a previous issue of @MedPageToday. However, I have recently noticed a number of misleading articles in various newspapers across the country and wanted to address these, likely common, misconceptions about the new test.

First, I want to openly acknowledge the positives about Cologuard. The study in the New England Journal of Medicine examining its ability to find a colon or rectal cancer as a one-time test (compared to colonoscopy as the gold standard) was large, well-designed and well-executed. It showed that as a one-time test Cologuard was 92% sensitive for cancer. It also showed that the false positive rate was about 13%.

The problem has arisen in how the study results are being spun in the media. Here are a couple emerging myths to debunk:

  • Cologuard is for patients who absolutely positively want to avoid colonoscopy.

                                                     FALSE

While colonoscopy is the most common test used in the US to screen for colorectal cancer , it is not the only test. It is not even the “best” test. It is the most accurate test for finding cancers and polyps but that is not the same as the “best” because there are clear downsides including cost, risk of complications, access. A screening strategy of using a non-invasive test first can greatly decrease the need for colonoscopy but does not eliminate colonoscopy because Positive Screening Tests Should Be Followed By a COLONOSCOPY. Therefore, a positive stool DNA test needs to be evaluated with colonoscopy or the point and potential value of screening is lost.

The fecal immunochemical test, aka FIT, is also a non-invasive colorectal cancer screening test. It has been around for decades, and in its current form is a widely available test that is included in all the US colorectal cancer screening guidelines

In fact, I will argue that it is a better test for your patient who is not completely against screening but would prefer to avoid colonoscopy if possible because 1) its false positive rate is 5% vs. 13% for Cologuard. Therefore it carries a lower risk of leading to an unnecessary colonoscopy 2) it is currently covered by all insurance carriers

  • Cologuard will increase colorectal cancer screening rates in the US population

                                                       FALSE

Or perhaps a more accurate response might be “We have no idea” since it is a new test and the only people who have used it were in a research study.

On the other hand, we have compelling data that FIT increases screening rates compared to the older guaiac-based fecal tests and among patients who were previously unscreened.

 

  • Cologuard is the best non-invasive test for colorectal cancer screening

                                                       FALSE

And a bit of a trick question because we really do not have a Best Test at this point. Nonetheless, Exact Science is clearly going after the screening market leftover after colonoscopy takes its lion’s share. In addition to my general case for no “best” test, I would argue that Cologuard has not accumulated enough data to knock FIT off its best non-invasive test perch.

Yes, Cologuard had a higher rate of diagnosing cancer in one-time testing compared to a single FIT product in a single study, but

1) Screening is not a one-time test. FIT is meant to be repeated annually (or biennially in most screening programs outside the US). We have no idea if after 2 or 3 rounds of FIT the higher sensitivity (detecting cancer among individuals with cancer) of Cologuard will remain.

2) The interval of annual FIT testing has a wealth of data support vs. no data whatsoever supporting ANY testing interval for stool DNA tests (currently CMS is considering a 3 year interval

3) In a healthy population, it is important to consider harms and the higher rate of false positives leading to colonoscopy could translate into an increased rate of adverse events.

4) FIT is $25 vs. $600 for Cologuard

 

Now, some might say, “hey colonoscopy is the most expensive, risky option out there”. To which I say touché. Perhaps unfortunately, no headlines are claiming any test is better than colonoscopy. That might be another blog. Poor Dr Campbell is creating a social media monster.

Deborah Fisher, MD, MHS

Associate Professor of Medicine

Duke University Department of Medicine

Division of Gastroenterology

@DrDeborahFisher

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Turf Battles and Collateral Damage: Are We Really Putting the Patient First?

Last week, Medpage Today reporter Sarah Wickline Wallan tackled a very controversial issue in medical practice.  In her piece, Ms Wallan explores the ongoing battle between Dermatologists and AHPs (Allied Health Professionals) over the performance of dermatologic procedures.  As independent NPs and PAs begin to bill for more and more procedures (thus potentially talking revenue away from board certified Dermatologists) specialists are beginning to argue that the AHPs are practicing beyond their scope of practice. According to the Journal of the American Medical Association, nearly 5 million dermatological procedures were performed by NPs and PAs last year–this has Dermatologists seeking practice limits–ostensibly to protect “bread and butter” revenue streams from biopsies, skin tag removals and other common office based interventions.

In response to this controversy and the article, I was asked to provide commentary for Med Page Today’s Friday Feedback.  Each week, the editors at MPT discuss a controversial topic and have physicians from all over the country share their feelings on the issue in order to provide readers with a mulit-specialty perspective.  This “Friday Feedback” feature is typically released on the web near the end of the day on Fridays and often spurs a great deal of social media activity and discussion.  Based on reaction to Ms Wallan’s article our topic this past Friday was “Specialty Turf Battles”.  Each respondent was asked to provide commentary on the growing angst between Dermatologists and Allied Health Professionals.    As I began to reflect on the issue itself and its potential impacts on all aspects of medicine, I felt that a complete blog would be a more complete forum to discuss my thoughts.

First of all I want to say that AHPs are essential to providing care in the era of the Affordable Care Act.  NPs and PAs are able to help meet the needs of underserved areas and do a remarkable job complementing the care of the physicians with which they work.  With the rapidly expanded pool of newly insured, as well as the increase in administrative tasks (electronic documentation) assigned to physicians, AHPs must help fill in the gaps and ensure that all patients have access to care.  In my practice we are fortunate to have many well qualified AHPs that assist us in the care of our patients both in the hospital as well as in the office.

We must remember, however, that physicians and AHPs have very different training.  Each professional posses a unique set of skills and each skill set can complement the others.  Many of us in specialty areas spend nearly a decade in post MD training programs and learn how to care for patients through rigorous round the clock shifts during our Residency and Fellowship years.  In addition, we spend countless hours performing specialized procedures over this time and are closely supervised by senior staff.  Most AHPs, in contrast, do not spend time in lengthy residencies and often have limited exposure to specialized procedures.  Turf battles have existed for decades and are certainly not limited to Dermatology–nor or they limited to MDs vs AHPs.  In cardiology in the late 1990s, for instance, we struggled with turf battles with Radiology over the performance of Peripheral Vascular Interventions.  In many areas, these battles resulted in limited availability of specialized staff to patients and a lack of integrated care.  Ultimately, the patients were the ones who suffered.

Fortunately, in the UNC Healthcare system where I work (as well as others across the country) we have taken a very different approach.  After observing inefficiencies and redundancy in the system, several years ago our leadership (under the direction of Dr Cam Patterson) decided to make a change.  The UNC Heart and Vascular Center was created–Vascular surgeons, Cardiologists, Interventional Radiologists, and Cardiothoracic surgeons–all working under one cooperative umbrella.  Patients are now discussed and treated with a multidisciplinary approach–Electrophysiologists and Cardiothoracic surgeons perform hybrid Atrial Fibrillation ablation procedures, Vascular surgeons and Interventional Cardiologists discuss the best way to approach a patient with carotid disease–all working together to produce the BEST outcome for each individual patient.  We have seen patient satisfaction scores improve and we have noted that access to multiple specialty consultations has become much easier to achieve in a timely fashion.  Most importantly, communication among different specialties has significantly improved.

Unfortunately, with the advent of the ACA and decreasing reimbursement I suspect that turf battles will continue.  Financial pressures have become overwhelming for many practices and the days of the Private Practice are limited–more and more groups will continue to “integrate” with large hospital systems in the coming years.  Specialists such as Dermatologists and others will continue to (rightly so) protect procedures that provide a revenue stream in order to remain financially viable.  However, I believe that our time will be better spent by working together to improve efficiency of care, quality of care and integration of care.  NPs and PAs are going to be a critical component to health care delivery as we continue to adapt to the new (and ever changing) ACA mandates.  We must put patients FIRST–turf battles and squabbles amongst healthcare providers will only limit our ability to provide outstanding, efficient care.  Let’s put the most qualified person in the procedure room–and make sure that ultimately patients get exactly what they need.

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Data is (Em)Power(ment) for Patients: Using Fit Bit to Impact Disease Management

For scientists and researchers who are developing new treatments for disease, Data is power.  For patients, Data can mean empowerment.  Devices that track health indicators are readily available.  These devices can track heart rate, blood pressure, blood sugar and even respiratory rate and body temperature.

This week in the Wall Street Journal, the medical applications of the Fit Bit device are explored.  The Fit Bit is a basic pedometer that tracks movement, steps taken, calories consumed and (in certain models) sleep habits.  This device is commercially available for around 100 dollars and was initially embraced by serious athletes in order to improve performance.  Now, according to researchers, these devices may be able to impact health outcomes–both inside and outside of the hospital or healthcare setting.  These impacts may forever change how physicians and healthcare systems think about managing chronic disease.

As I have mentioned in previous blogs, I firmly believe that smartphone applications for medicine are going to be a part of mainstream medical practice in the coming years.  Providers will prescribe apps just as they do pharmaceuticals.  In the case of the Fit Bit device and others like it, data obtained from physiologic monitoring can be used to assess physical fitness and progress towards obtaining specific health goals.  In several recent studies, researchers at Massachusetts General Hospital in Boston, have found that the Fit Bit users who have diabetes are more likely to have better control of their blood sugars and achieve weight loss related goals better than those who do not use the device.  Many patients with type 2 diabetes can better control their blood sugars through reduction in BMI (body mass index) and the data provided from the Fit Bit device seems to have a positive correlation with weight loss in this particular patient sample.  In the hospital setting, researchers at the Mayo clinic found that in post-operative cardiac surgery patients, the Fit Bit was able to identify patients that needed more physical therapy intervention–by tracking movement in the early post-operative days.  It is likely that by identifying and intervening early in patients who are not progressing after surgery we will be able to prevent many common complications such as deep vein thrombosis (DVT), pneumonia and other morbidities associated with lack of activity after surgery.

At this point, the FDA has no immediate plan for regulation as long as they are not specifically created to treat a particular medical condition or disease process–however, I do expect regulators to act on all types of biomedical data collection devices within the next 5 years.  According to the WSJ, the health monitoring device industry is projected to exceed 5 billion dollars in 2016–largely due to our focus on patient engagement and prevention.  Concerns have been raised as to the security of data and as to the reliability of the data generated by these devices.  As with most new medical innovations, there is still much work to be done.  We must create secure servers where patient’s data can be safely deposited (and HIPAA compliant) and easily accessed by their healthcare providers in order to provide necessary changes to care.  In addition, the patient must be able to access their own data in order to assess progress, adjust goals and optimize their lifestyle changes in order to produce better health outcomes.  Additional concerns have been raised around the legal implications of a large repository of medical and physiologic data—are physicians responsible for every reading and every piece of data in the repository?  Will there be frivolous lawsuits initiated by ambulance chasers (or Fit BIt chasers) in the future?

I contend that more data is better.  Data provides me with the power to make better decisions for my patients.  Data provides my patients with real, meaningful feedback.  When we are sick, we often feel as though we have lost the ability to determine our own destiny and lose any semblance of control.  Data allows patients with chronic illness to actually regain some sense of control—and achieve ownership of their disease with the power to invoke change.

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“Thinking” About How We Lead: How We Make Better Decisions and Produce Better Outcomes

As physicians we are trained to assimilate data, analyze and interpret findings, and make the correct decision–every single time.  Often these tasks must be performed very quickly and in emergency settings.  For those who perform invasive procedures, decisions are often made “on the fly” and can have significant consequences.  In addition to our clinical duties, physicians are now thrust into executive roles as well.  Managing practices, budgets, government mandates and regulations have now become part of everyday clinical life for many practitioners.  The concept of the physician executive is now commonplace—and for many doctors and practices– a key to survival in an unstable and volatile healthcare market.  Improving skills in both decision making and communication can be critical to success in the new world of healthcare.  Learning to LEAD is critical to providing outstanding care for our patients every single day.

This week in the Wall Street Journal, author Andrew Blackman explores the inner workings of a business executive’s brain–exactly how the brain functions when making effective decisions in the world of business.  Researchers evaluated how executives make decisions under a variety of circumstances–they localized the biologic processes that occur in the brain via advanced neurologic imaging techniques.  From a biological standpoint, this research provides great insight into how successful decision makers formulate plans and solve problems.  In addition, the research provides insight into how leaders can make more effective decisions when under duress.  Using complex imaging to map the electrical connections in the brain when decisions are made, researchers are able to better quantify–biologically–what makes some leaders better than others.

By shedding light on how our brain functions when making good decisions, we may be able to one day “train” our brains to utilize particular regions during specific tasks.  For now, much of what Mr Blackman reports concerning optimal conditions for making decisions is applicable to physicians and other leaders in medicine in one way or another.

According to the Wall Street Journal, there are several things to consider when making important decisions:

(1)  Deadlines and Time Pressures may Limit Creativity and Innovation

In medicine, every day is a deadline.  Schedules of patients packed into the office or procedure list remain a reality.  Making decisions under pressure is a big part of what physicians do on a daily basis.  However, the recent neuroimaging research indicates that often the deadline pressure may stifle creativity and lead to poor decisions.  Stress induces more activity from the area of the brain associated with “task completion” and less activity in the areas responsible for new and creative idea generation.  According to Harvard researchers, one way to potentially combat this change in thought centers during times of stress may be to train workers and leaders to become more self aware and use “mini meditation” to help the mind wonder.  Although in medicine, we are trained to REACT to acute situations, it may be that while we REACT, we can also work to explore other creative centers of our brains in the process.  By combining both quick REACTION and creative thought, we may not only be able to stabilize a critically ill patient but also provide a unique treatment plan going forward.

(2)  Worry and Uncertainty can lead to bad Predictions and poor decisions

I have been accused of being “Chicken Little” on more than one occasion.   Uncertainty is something that is commonplace in medicine yet it makes most of us uncomfortable.  As physicians we rely on data to make good decisions.  However, uncertainty remains a significant part of what we do in medicine on a daily basis.  We often deal with limited data and must make a decision based on the best available evidence.  Clinical trials bring us some level of certainty  but our patients are biologic organisms, each with potential differing responses to treatments and disease.  According to researchers, the areas in the brain that are activated when you are working on problems that are cause you worry are often associated with anxiety and disgust.  Many poor decisions are made due to the “worst case scenario” line of thought.  While worry and uncertainty can never be completely avoided, psychologists argue that the way to avoid poor decisions during these times, is to learn to accept uncertainty and control the things that you can control.  No decision is ever final–even in medicine there are opportunities to act, refocus and change directions if necessary.

(3)  Good Decision Makers may look past the Facts and Incorporate “Gut Instinct”

Many decisions in medicine are made by considering the best available data and incorporating clinical judgement and instinct in order to make a determination as to the best course of action.  Interestingly, when MRI scans were performed on the brains of very successful business executives who were involved in making difficult decisions, the areas of the brain responsible for emotion and social thinking began to light up more than the purely analytical areas.  Researchers concluded that those leaders who relied not just on facts but on gut instinct and emotion tended to be more successful.  Social thinking–in simple terms–is the ability to look at a problem from numerous angles.  Seeing the potential impact of a potential decision from multiple points of view can provide invaluable insight and may lead to better decisions in the long run.  In medicine, involving other team members–nurses, technicians, and support personnel–in the care and formulation of the patient’s treatment plan may actually help a physician leader to make better decisions.

(4) Effective Leaders must stay positive and Inspire Teams

When leaders begin to inspire teams of people and lead with passion, certain other areas are activated in the brain–particularly those areas associated with positive emotions and social thinking.  Along with involving other team members in the care of the patient, it is essential for an effective leader and decision maker to incorporate “praise, encouragement and rewards” when motivating teams to perform at a high level.  Creating an emotional bond among members of a medical team can be as simple as asking for input from all involved parties and recognizing outstanding contributions to patient care.

The Bottom Line…

Business executives are adept at making determinations that affect millions (if not billions) of dollars and these decisions can move markets.  In medicine, we must make decisions every single day. While some decisions may be trivial, others may permanently impact the lives of our patients and their families.  Moreover, from a business standpoint, the management of a medical practice in today’s market requires impassioned leadership and great skill in order to remain viable. The work that is done with neurologic mapping in decision making may have provide us with guidance in the future as we develop new leaders.  It may be that through practice and coaching, we will one day be able to activate specific areas of the brain when we are working to make tough decisions.  The strategies and skills that we are able to glean from these types of research activity will allow us to be more effective physicians, leaders and executives in the years to come.

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