Cast & Curious

Tag: Medicine

  • Personalising Quality of Care in Healthcare Professional’s Practice

    “What doesn’t get measured doesn’t get done.”-William Thomson

    John is a 55 year old software engineer at a large firm in Manila. For four consecutive days now, he had episodes of vague “chest heaviness” coupled with some difficulty breathing. Privately insured, he asked for a day off to seek their company physician’s consult. He drove an hour to the clinic, waited for another two hours in the waiting room before being seen by the company physician lasting for 15 minutes. He was given a list of diagnostics and was referred to a cardiologist. The process of seeing a cardiologist is almost the same, only this time, much longer.

    “Travel time was two hours because of traffic, waiting time doubled to four hours, diagnostics to 2 days yet being seen by a doctor lasted only for 8 minutes” said John.  “I’m nervous. I’m not sure if its about my chest tightness or the whole rigodon of trying to determine what cause it. All I’m told it was a Non Specific T wave changes. I don’t even know what that means but it took me two weeks to finish the whole check up thing!”

    Manang Tina is a 35 year old vegetable vendor. She temporarily stopped selling vegetables because her 7 year old daughter had a throat pain, difficultly eating food and fever for 3 days already. She asked her daughter’s teacher if she can be excused for a day. “I had to bring my daughter to the rural health unit” she said. At the RHU they had to wait for almost 4 hours before being seen by the doctor. Her daughter was seen and examined for 10 minutes. “She needs a CBC, a chest x-ray and urinalysis Manang Tina” said the doctor. “Have this done and come back here once the results are out. In the meantime, your daughter may take paracetamol and gargle with this liquid 3x a day” followed the doctor. The diagnostics took a week to finish, the fever and pain now gone and my daughter able to eat painlessly now. In fact she is already back in school. What shall I do with this lab results?” ask Manang Tina.

    In this digital age, did Mr. John or Manang Tina’s daughter, received quality health care?

    Quality of health care, defined
    Agency for Healthcare Research and Quality of the US Health and Human Resources Department cite The Institute of Medicine’s definition of health care quality as “the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” I has six domains- effectiveness, efficiency, equity, patient centeredness, safety and timelines but has concomittant consumer perspectives of staying healthy, getting better, living with illness, and coping with end of life.

    Complex, Divisive Issue
    Quality of care is a complex, multi dimensional topic that most healthcare professionals avoid discussing. True enough, learning quality health systems and models could take some 4 or  5 years of formal study and a lifetime of iteration and improvements. Simplifying quality of care seems to be an impossible task for every health stakeholder. Everyone have the answer to quality issues yet our health system is going everywhere but forward.

    “I leave that to experts” said Dr. D a busy private heart specialist. Dr. D is referring to quality assurance professionals, compliance personnel and regulatory agencies “to do their thing while we, healthcare professionals do what we’re good at- taking care of our patients.” We’re too busy to debate on such topic.” Dr. D explained.

    But if a healthcare professional, a primary mover and health stakeholder doesn’t have a good grasp of what quality care is, how does one know he’s providing one?

    “Look, I have a full, standing only waiting room at my clinic. If that’s not a measure of how patients see the quality of my care, I don’t know what is.” Said Dr. S a family physician.

    Making quality care, personal
    But how do we know we are giving the best of care to our patients? If you are a patient, how do you know you’re receiving quality medical care? What are our personal “yardstick” for “quality of care”? In the digital age where technological innovation has disrupted some areas of medicine- form intuition to precision diagnostics, did quality of care improved? How does this affect the present “business model” of physician’s practice? Of nursing care practice?

    These are just some of the questions a healthcare professional, student or even patients must confront head on to improve health care. While healthcare professionals need help from external personnel for regulatory compliance and quality assurance, quality of care should be “personal” to every health stakeholder. In this technological age where innovations have the potential to improve some aspects of our health system, every health stakeholder has the responsibility of knowing what quality of health care is.

    This is the topic of our #HealthXPh chat this Saturday 9PM Manila time. I’m inviting every health stakeholder out there- patients, healthcare students, healthcare professionals etc, join in your personal views on quality care in this interesting chat. In your personal practice ( if an MD, Nurse, allied professional), plan (if you are a student), experience (if you are a patient),

    • T1. What is your personal idea of quality health care and how do you measure it?
      T2. Name one innovative step you implemented to improve quality of care in your practice.
      T3. Name one technological innovation that should improve quality of healthcare in 3-5 years. Explain

    References:

    William Thomson (June 26, 1824–December 17, 1907), 1st Baron Kelvin, often referred to simply as Lord Kelvin, was an Irish mathematical physicist. https://en.wikiquote.org/wiki/William_Thomson

    Understanding Quality Measurement. Content last reviewed July 2018. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/chtoolbx/understand/index.html

    Christensen, Clayton M., Jerome H. Grossman M.D., and Jason Hwang M.D. The Innovator’s Prescription: A Disruptive Solution for Health Care. McGraw-Hill, 2009.

  • Nudges in Health: Physicians as choice architects

    Health choices could apparently be influenced or “nudged”. Consider the following hypothetical scene:

    A patient is seeking surgeon’s advise on a much needed surgical procedure and its risks. He asked two equally competent surgeons the same question.  “What is my risk of dying in this procedure doctor?”

    Here’s what the two surgeons replied:

    Doctor A: “Approximately one in 100 patients die in this procedure”.

    Doctor B: “Approximately 99% of patients live well after this procedure” 

    If you are the patient,  would you undergo the procedure? If so, who would you most likely ask to do the procedure on you? If not, which surgeon dissuaded you the most?

    Hypothetical and simplistic, this happen in many patient- surgeon conversations. In many instances, our answers are quite predictable. I’d probably wouldn’t undergo this procedure if I was listening only to Doctor A. If I chose to undergo the procedure, I’d ask surgeon B to do the procedure on me. That is, even if my risk for the procedure is technically the same between the two surgeons!

    Surprised? Don’t be. There’s nothing wrong with you either. Behavioural studies have suggested that many of our choices and consequent actions, aren’t as rational as we believe it to be. We’re homo sapiens after all.

    Physicians are trained to provide patients and the public with the best possible or optimal health choices.  We’re supposed to be adept at providing patients with evidence based health choices and convey this in a language the public would understand. Doctors are supposed to be experts on health statistics and evidence based researches in their own field. Prompt, timely  and effective communication or feedback is also key for patients to make optimal health choices. But are we really providing patients these two essential choice adjunct for them to make optimal choices?  Even experts in some fields don’t agree with each other’s interpretations of the “best evidence”. Just take for example, immunisation.  More over, we’re not better with communicating or giving feedback to patients as well. Even minute differences in framing responses (such as the scenario above) weighs heavily on patient choice.

    The rapid technological change in internet and communications was thought to democratise and exponentially increase access to health information. More information means better  or more rational health choices. Apparently, that’s not always the case. More than half of current smokers wanted to quit but don’t. Many food and lifestyle related diseases such as obesity, hypertension, diabetes are still on the rise. More choices doesn’t necessarily end up with  a optimal choices either. There’s a plethora of toothpaste choices in the grocery store but these did not significantly decrease the incidence tooth decay in the general population.   A “no-harm-yeah-whatever- choice” isn’t also acceptable. Take the case of some vitamins and herbal medicines. Many of these are harmless to patients but are found out to be totally ineffective for diseases it is advertised for. Vitamins are still one of the most sought after over the counter substance in the Philippines.

    Indeed, many behavioural studies have suggested that humans (physicians and patients included), don’t make optimal, rational choices most of the time. This is particularly true in fields which they lack expertise or effective communication abilities. In the field of medicine and health, healthcare professionals happen to be the the “experts”. Whatever communication abilities we have, patients (and colleagues) often seek our expertise for them to make rational health choices. 

    So how do we help patients make optimal decisions for their health?  In this edition of #HealthXPh tweetchat, we’ll explore how healthcare professionals, policy makers, health professions students, patients and advocates help patients make optimal health choices.  Whether you are a patient or a physician, here are our guide questions.

    • T1. What for you, is the most important factor in making optimal choices health? Why?
    • T2. What  is  least likely to influence your health choices? Why
    • T3. When current evidence is vague or equivocal at best,  what do you advice or who’s advice do you seek? Why?

    Join us this Saturday May 12, 2018 9PM Manila time by tweeting your answers to our guide questions (and chiming in your response to others’ too) with the hashtag “#HealthXPh” between 9-10PM Manila time. Of course, for #HealthXPh your opinion matters. 

    References:

    Kahneman, D. (2013). Thinking, fast and slow. New York: Farrar, Straus and Giroux.

    Thaler, R. H. (2016). Misbehaving: The making of behavioral economics.

    Thaler, R. H., & Sunstein, C. R. (2008). Nudge. New Haven: Yale University Press.

    Nisbett, R. E. (2015). Mindware: Tool for smart thinking.

     

  • For using Facebook and other social media platforms, how much of your personal privacy are you willing to give away?

    It blew right in our face.

    The “Facebook Scandal” (FB data breach with The Cambridge Analytica) shook many industries using  this social media platform to “influence” a particular interest.

    “We exploited Facebook to harvest millions of people’s profiles. And built models to exploit what we knew about them and target their inner demons…” Christopher Wylie, the whistleblower who worked with a Cambridge University academic to obtain these data using third party app, told the Observer.

    Mark Zuckerberg & Co built Facebook to fill its users’ need for socialising, online. We all knew however, that Facebook was also created to harvest data in the first place. This is in the fine print of FB’s terms of use you’ve agreed to, when you started using Facebook.   Although the company publicly admitted using data for their own regulated and targeted advertising algorithm alone,  it may have “unknowingly” provided  “limited data” to third party companies thru the various apps. Zuckerberg apologised for the “break of trust” given to them by their users because of this. What those “third party entities” do ( or did) with these data remains a mystery to the public.

    Remember how Target “snooped” on its customers and figured out a teen girls is pregnant before her father found out? By harvesting its customers’ shopping habits and using  predictive analysis, it was able to predict the most likely “next buys” of its customers and “structured” their stores to capture that buying intention. This pregnancy prediction model predicted with 87% accuracy that a lady would soon be delivering a baby if it buys vitamins, supplements, diapers or a blue rug!  We can only hypothesise about the staggering scenarios of “what ifs” if these breached data reached a not so well intentioned party. Elections, politics or buying habits are but to name three.

    In healthcare, privacy breaches are not only considered scandalous. It is  “deadly” as well for it may cost lives.

    To be fair to Facebook, healthcare (willingly or unwillingly) benefitted from some of the platforms “allure”. The relatively inexpensive, easy, accessible and wider user base are very good reasons for educating the masses about health  issues. It is also a very good alternative to ( or in fact dismantling) more traditional, expensive media platforms for getting across messages to a wide range of users.  There are probably thousands if not millions of patient support groups in FB.  Advocacy campaigns aimed at improving healthcare abound in this platform. There are also healthcare professionals who use FB as a listening and or speaking platforms for many well intentioned campaigns. In short, the healthcare industry through its stakeholders, are also benefitting from FB’s social media clout while knowingly giving away part of its privacy. Here’s where the conundrum begin and why this breach opened a  pandora’s box in healthcare.

    Imagine, if user profiles and data went into the hands of not so well intentioned healthcare industry player. What if this data is used “shape”, influence or manipulate minds to buy a particular product? Or tinkered, to accept or debunk certain healthcare issue without the benefit of validated research and recommended protocols by the medical community? What if the data are “manipulated’ to “influence” the medical community itself? This may or may not happen and regulations are something we- the healthcare stakeholders,  have to really look at in so many different ways.

    While social media regulation is still being debated, most rely on “self regulation” on what, when or how they do things on Facebook, to prevent data from falling into the “wrong hands”. Self regulation on social media  is though balancing act itself and remains a huge challenge to many of its users. #HealthXPh believe that educating the masses about health uses of these social media platforms’ plays a key role in this balancing act. This is what #HealthXPh is discussing (on Tweetchat) this Saturday March 24, 2018 9:00PM Manila Time .

    As a patient, healthcare professional, student, policy maker, or advocate, how much of your personal privacy are you willing to “give away” for using Facebook?

    • T1. Why would you or would you not deactivate your Facebook account?
      T2. For using FB, what kind “data” are you willing to give away and why?
      T3. What are your parameters for absolutely stopping Facebook use?

    We are inviting you to a lively discussion thru a twitter chat , this coming Saturday March 24, 2018 9:00PM Manila time. Join discussion!

  • Helping Givers Thrive in the Healthcare Environment

    Mrs. H is a 54 year old single parent of four and a volunteer rural health worker in a community. She logs in before seven at the baranggay health station, checks her tasks for the day, then proceed checking the families she has worked with the past days.  Her daily routine consist of home visits, doing health teaching and family counselling until five in the afternoon. Then Mrs H goes back to the health station to do a quick summing up meeting with fellow volunteers  and get home before 7 PM. Mrs. H has been doing this for 20 +  years, surviving on community donations to run the rural health unit. “I am happy for the opportunity to help my community.” she said. As the community health indicators- maternal and infant mortality rates and malnutrition improved, the ranks of community health workers like Mrs. H dwindled. At the age of 65, Mrs. H had hypertension, type II diabetes, survived two cancer surgeries and had a string of hospital admissions from countless systemic and infectious diseases. After surviving each of these personal struggles, her lament is still ” I wish I could get out of this sickbed and do more!”

    There’s a self assessment tool by Adam Grant to help identify if you are a giver or taker. That’s a self assessment tool though. How would you identify a giver in your health team?

    T1: What’s your best qauge for identifying a giver?

    Dr. N graduated at the top of his class and trained in one prestigious center for his specialty. He went back to his home province and built one of the most caring physician practice ever built around the area. He sees patients the whole day and is known to revisit admitted patients at night before going home.  He instructs floor nurses to call him anytime, for any updates on his patients.  He refuses any other engagements if it meant leaving his patients behind. ” I just want to give patients the care they deserved. That is the standard right?” he once told a colleague. Dr. N also made it his personal advocacy to help care givers survive a health system filled with stress and grief.  One night Dr. N collapsed inside his apartment’s bathroom and suffered a myocardial infarction. A colleague noticed he wasn’t answering calls and sent a hospital’s emergency response team to his apartment. He survived that event and slowed down for a while in his practice.

    T2. How would you cultivate an environment supportive of a giver?

    “Code! Bed 4!”  The floor nurse just called. The ward team on duty sprang into action, initiating ACLS with clockwork precision and reviving B4 within minutes from the call.  Besides patient Bed 4 is a grief stricken and apologetic Ms. R, the 45 year old companion of patient bed 4. “I’m sorry doctor, I fell asleep”. Ms. R has been manually “ambubagging” patient B4 for more than 24 hours already. “My husband drives a pedicab to earn and take cares of our 4 children. My siblings went home to raise money for my father’s hospitalization. I left my work as a house help to take care of my father”.  Unfortunately Mrs. R husband left her and their kids. She had to take care of her dad and left her children with their neighbours. “At least I still have my dad and children.” She told me. Not a single word came out of my mouth…

    T3. How would you avoid or resolve giver fatigue in your team?

    Mrs. H, Dr. N and Ms R are examples of what many call “givers”.  Givers help institutions, communities or families thrive, in the long run. The healthcare industry is full of giver stories that exemplifies the caring and giving characteristic of the profession. Whatever motivate givers is the subject of studies nowadays but for the most part, it is virtually unknown. Motivation is also the least of giver’s concern. Most givers are so consumed by the act of giving even their personal lives suffer in the short run.

    Since givers are desirable part of any team, how do we help them thrive in the healthcare environment? Join #HealthXPh chat this Saturday November 25, 2017 9PM Manila Time to discuss ways on helping givers thrive in the healthcare industry. Here are our guide questions for the chat:

    T1: What’s your best qauge for identifying a giver?
    T2: How would you cultivate an environment supportive of a giver?
    T3: How would you avoid or resolve giver fatigue in your team?

  • How healthcare social media campaigns may improve provisions of health in a devolved health system

    The lack or ineffective social marketing strategy (supply side barrier) and lack of information on benefits and availment process (demand side barrier) are a few of the identified restrictions to the use of health services in complex decentralised health systems such as the Philippines.

    The Department of Health (DOH) is the lead agency responsible for the regulation and supervision of the country’s health system. It manages national policies, develops national plans and establishes health technical standards and guidelines to regulate the country’s health sector.

    The Local Government Code of 1991 devolved the provision of health services, particularly at the primary and secondary levels, through the local government units (LGUs). Hence, health service in the Philippines is managed through provincial, municipal and barangay local government offices. Provincial and district hospitals are the responsibility of provincial governments while the Rural Health Units (RHUs) and Barangay Health Stations (BHS) are managed by municipal government units.

    Complex internal developmental differences among geopolitical regions hamper provisions of health two decades after the implementation of the local government code. Less developed regions usually suffers most of the negative effects of institutional fragmentation. These least developed regions also is the least likely to recover or lags behind because it lack or poorly manages resources and is usually inefficient in allocating health resources.

    Cetrángolo et al identified supply and demand side barriers that restrict the use of health provisions in the Philippines. The lack or ineffective social marketing strategy and lack of information on benefits availment process are included in these restrictions. Grundy’s echoed the same observations in a local study.

    This author has practiced for more than ten years in areas with health units ran by local governments and in urban center with health institutions ran by DOH. While there are LGUs with efficient and effective local health councils who clearly benefitted from the devolution of health, other regions aren’t as fortunate. Case in point,  the WHO Safe Surgical Checklist.

    The WHO Safe Surgical Checklist 2009
    The WHO Safe Surgical Checklist 2009

    The WHO Safe Surgical Checklist is the single most cost effective way of minimising post operative complications reducing death and morbidity by at least 36% on the average. No other cheap, readily and sustainably implementable guideline (except maybe the handwashing guide) had so much impact on health as this checklist.  It has been incorporated into standard DOH standards operating room “toolset”, requiring every hospitals with operating rooms to incorporate such checklist in their standard operating room manuals. Yet many hospitals who have operating rooms rarely take advantage of this readily available and cheap guideline. Why is that?

    Cognisant of these complex problems, efforts has been made in the past two decades to either strengthen  or amend the local government code that devolved health provisions to LGUs. Bills calling for returning provisions of health back to the national lead agency (DOH) are now pending in the House of Representatives. It is not the purpose of this article to weigh the complex pros and cons of such amendments. Until such amendments or repeals are enacted into law, we have to deal with effectively delivering health down to grassroots level in the context of a decentralised health system.

    An effective social media campaign may narrow regional differences in the provisions of health and address the two barriers I mentioned at the start of this article.

    Join #HealthXPh this Saturday August 26, 2017 9pm Manila time as we discuss how a social media campaign may improve provisions of health in the context of a devolved health and regional developmental differences.

    • T1. Is there a role for social media as social marketing strategy for effective provisions of health in a decentralised health system?
    • T2. If you are the chief social media strategist what will your primary strategy be?Targeted? Regional? National?
    • T3. How would you measure the effectiveness of such healthcare social media strategy? Indicators? 

    Please give your final thoughts on ways by which social media could be a part (or not) of the social marketing strategy for health units or agencies in a decentralised health system like the Philippines.

    References:

      1. Cetrángolo,O., Mesa-Lago,C., Lazaro,G., Carisma,S. Health Care in the Philippines: Challenges and Ways Forward. 2013
      2. Grundy J1, Healy V, Gorgolon L, Sandig E. Overview of devolution of health services in the Philippines. Rural Remote Health. 2003 Jul-Sep;3(2):220. Epub 2003 Jul 1.
      3. Haynes, A.B., Weiser, T.G., Berry, W.R., Lipsitz, S.R., Breizat, A.H.S., Dellinger, E.P., Herbosa, T., Joseph, S., Kibatala, P.L., Lapitan, M.C.M., Merry, A.F.: A surgical safety checklist to reduce morbidity and mortality in a global population. N. Engl. J. Med. 360(5), 491–499 (2009)
      4. Atienza, Maria Ela L. 2004. “The Politics of Health Devolution in the Philippines: Experiences of Municipalities in a Devolved Set-up.” Philippine Political Science Journal 25 (48): 25–54.10.1080/01154451.2004.9754256