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VIEWS

This isn’t a debate about vaccines.

The fight here has nothing to do with that. For the record, I strongly support the concept of vaccination. Public health is better in the 21st Century because of it. Measles? Mumps? Oh, I can find you in the United States, but we aren’t living our lives every day petrified of an outbreak. Smallpox? Polio? Where did you go? Not here, that’s for sure. And, what if you had lived in West Africa in mid-2014? A proven vaccine for Ebola would have been a godsend.

No, this isn’t about vaccines. But, I’m still going to mention one, and it’s the one that protects you against the influenza virus. You can get it in a mist form, but you really know it best as the flu shot.

Up to 1 in 5 people will get the flu (caused by the influenza virus) each year in the United States. I’d give you a bunch more statistics, but if you survey most people, statistics bore them. Just know that the flu puts a lot of people in the hospital, and tens of thousands can die every year in America related to it. That’s why we try to prevent it with a vaccine. And, the rule of vaccines is simple: they are only helpful if given, and if providing it to one person, helps one person, providing it to many, helps many.

Admittedly, in 2014, the flu vaccine has been disappointedly much less successful. Predicting the flu strains each year can be hard, even for a bunch of smart people whose sole task is to get that right. But, I won’t kick them when they are down, because these folks aren’t the issue either.

The real problem has become the timing of when you get the flu shot, and this relates to processes that are now in place, as part of our so-called healthcare reform, to assess quality in medicine. Basically, who decides how quality is measured in healthcare anyway? Who is the one determining how it must be delivered? And, better yet, where’s the common sense in all these processes?

THE IVORY TOWER OF MEDICINE

Common sense, by the very root of the word, comes from commoners. These people truly understand what goes on at the human level of interaction and delivery. And, that’s why their sense actually makes sense.

In healthcare, commoners are really the folks with their boots on the ground working in clinical medicine–the physicians, nurses, and other providers truly on the front lines of patient care. Entire healthcare systems used to be designed around these people. Medical providers previously were the centerpiece of healthcare delivery, and systems were built around them to offer support.

But, the times have dramatically changed. The system itself has now become the centerpiece of medicine. Providers are an afterthought, stuck like gum to the outside of a bureaucratic wheel that’s being operated from somewhere up in an Ivory Tower. And, unfortunately, the nonsense that keeps originating from within the Ivory Tower is affecting almost every area of healthcare. The worst part is that this tower  has become so tall, that the people in it either cannot hear the physician practitioners offering up common sense, or maybe, they are just flat-out refusing to listen.

MEETINGS, MEETINGS, AND MORE MEETINGS

I’ll make you aware of the obvious: the Ivory Tower is exceptional at scheduling meetings and organizing all types of workgroups and task forces. In fact, the words “Workgroup” and “Task Force” usually get capitalized, because the people living in the Ivory Tower believe that they are doing important things. And, some days, they really are working hard on challenging issues. It’s just that their focus has become misdirected. I’ve already told you, they’ve lost their common sense.

I can give you dozens of examples, but I’ll give you one today that deals with the flu vaccine.

In 2006, a “Workgroup” was assembled that recommended that the flu vaccine be given to all patients in the hospital regardless of their medical diagnosis. One year later, a “Task Force” rediscussed this idea, and ultimately the Center for Medicare and Medicaid Services (CMS), working with another so-called quality organization, The Joint Commission (read more about them in my book), came up with a healthcare quality measure that involves the flu vaccine.

The flu quality measure is known to your hospital as IMM-2. If I write much more about these hospital quality measures, I’ll lose you. But, just know that as part of our current healthcare reform measures, hospitals ultimately lose money that they have really earned if they don’t get high scores on their quality measures. IMM-2 is one of these.

IMM-2 is really a simple ratio. This ratio reveals the percentage of age-appropriate people admitted to a hospital during flu season who receive the indicated flu shot prior to hospital discharge. IMM-2 was created so that you would catch more people who might benefit from receiving this vaccine.

On the surface, it’s not a bad idea. But, if giving more flu shots is your only goal, there are plenty of better ideas. Why not incentivize every age-appropriate person eating at McDonald’s to get the flu shot before their order is delivered? That would actually reach many more people than IMM-2 will ever do. Add up the number of hospital discharges in the United States each year. Now, double it. That’s how many people McDonald’s feeds in a single day!

Besides, there are other ways to prevent the spread of the flu. How about approve a commercially available over-the-counter flu test? Like a pregnancy test, but for the flu. If it comes back positive, the kit would even include a little mask for you to wear when you go into the lobby of your doctor’s office to await evaluation for your treatment plan. That’s got public health benefit written all over it!

THE DECISION MAKERS HAVE LOST TOUCH

I want more people to receive the benefits of the flu vaccine. But, the timing of when it’s given is equally important to the actual physicians working tirelessly in patient care. I’m not sure when the people in the Ivory Tower last walked on the ground, but the one thing for which I’m certain is that they’ve lost touch with folks like me who do. They repeatedly keep proving this by creating bizarre healthcare quality measures for everyone to meet. In fact, the blind pursuit of these measures, for the sole purpose of checking a pseudo-box of quality, is actually complicating the management of patients.

I’ll give you a quick example.

I’m a heart and vascular doctor. Occasionally, I need to perform procedures on my patients in order to help them. My patient, in this case, has had a stroke before. He currently has a severe narrowing, known as a stenosis or blockage, in a blood vessel in his neck. This vessel is critical to supplying oxygen to the brain, and given the severity of this blockage, my patient is at high risk for having another stroke. I am able to treat this blockage by placing a stent (or small pipe) inside his neck artery to improve blood flow to the brain.

My patient has been admitted to the hospital, and he undergoes this procedure by me successfully. He is observed in the hospital for a couple of days. Potential complications of the procedure include a number of things. Development of an infection with associated fever is one of them.

On my patient’s day of discharge, he is delayed getting out the door for hours, because the hospital is trying to locate its supply of flu shots in order to satisfy the IMM-2 measure. My patient doesn’t need the flu shot right then. He needs to go home and rest. He needs time to have the inflammation in his body related to my procedure alleviate itself. Instead, he gets a flu shot. And, he gets it on discharge precisely for two reasons: (1) because that’s the protocol recommend by some “Workgroup” last decade, and (2) how much the hospital ultimately gets paid depends upon it.

Here’s the real irony. There is absolutely no workgroup around in the middle of the night to take care of my patients. There is no task force available to assist me when my patient calls 36 hours later with a very high fever. You see, this fever might just be related to the timing of that flu shot, and if that’s the case, it’s a self-limiting and non-severe type of thing. Or, this fever may indicate that something life-threatening is going on with my patient, like a serious blood infection related to the procedure that I performed. Basically, the scenario is the equivalent of the patient either having a hangnail (nothing to worry about) or a potentially deadly process. That’s what I get to sort through in the middle of the night because of the flu shot.

Workgroup? Task Force? Where are you when my patient needs help? I know. The Ivory Tower. Actually, I suspect most of the people from that original “Workgroup” in 2006 are now retired from clinical medicine. They were probably sleeping when my patient called me. Why? Because everyone that I know who usually joins these types of workgroups are in their twilight years and on their way out of clinical medicine.

But, I don’t want you to miss my point.

The issue with the Ivory Tower is not a lack of intelligence. Quite the contrary. Very smart people live there. The problem is that the people have become disconnected with the heart of medicine. The Ivory Tower still has its virtue, but it has completely lost its common touch.

You see, the Ivory Tower keeps scheduling more meetings about more things that don’t matter to folks like me trying to provide value to patients. In fact, they’ve become so far removed from us commoners, that they’ve lost their common senseWe really don’t need any more Institutes of Medicine, National Clearinghouses of Quality, or more Task Forces of Futility. What we need is an Institute of Practitioners, made up of physicians actually working on the front lines in patient care. This is the only group with enough sense to save our system.

LOOKING FOR A SOLUTION TO THIS CRISIS?

Last month, I took my immediate family to Walt Disney World for the first time. It’s a crowded place, but that’s only because everyone else thinks there is value there too. And, I must admit, I agree with everyone else in this regard. Walt Disney World is a magical place.

In fact, I want to tell you about a group of employees who work at a store in the Magic Kingdom. The store is located on Main Street USA, an area having numerous fairytale-like restaurants and shops. The job of these employees is to bake and design all kinds of candies and desserts. The store smells heavenly. The food designs are amazing. They take an apple, and dip it into this sauce to color it, then attach marshmallows and other goodies to form the shape of Mickey Mouse’s ears, and so on. You may say this is just a candy apple, but it’s really an artistic masterpiece on steroids.

How do these employees make these food designs? The line is out the door to buy any of them. I was so impressed with their ability to generate “value” to so many people that I watched a video about it.

I’ll tell you what they do. There is not some animated design engineer, wearing a suit, working in a downtown high-rise building in Orlando typing up memos telling these dessert employees what they should be making. Instead, the design engineers wear shorts and flip flops, and they come down themselves to Main Street USA. They spend days with the employees who actually make the desserts. They learn about their supplies and their individual capabilities. And, get this, the design engineers then develop ways to further assist the dessert employees with their own creations and efficiency. The engineer and the person delivering the product actually work in conjunction together. And, let me tell you, that’s why their products are phenomenal.

You see, it’s not that complicated. All we need is more Disney in medicine.

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