The Gift of Stories

...My first year of medical school was defined by the time I spent in anatomy. I spent hours probing through various anatomical structure and yet I feel like I only scratched the surface in my pursuit of medical scholarship. But what I did larn during those hours in anatomy lab, as I slowly built an intimate rapport with my first patient, was the invaluable lesson of the joy and fulfillment gained through listening to the stories of every bump, kink, and scar. It is the magnetic draw for these patient narratives that led me to inevitably mature from the dangerous narratives of attempting surgical procedures on myself to attending medical school and working towards becoming a doctor. Your special gift, my first patient narrative, is one that will always stay with me as I continue to learn and never stop listening...

Delivered at the University of Michigan Medical School Anatomical Donations Memorial Service (Sept. 15, 2010)

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Preparing for the Future

This summer, while I was traveling around Ghana conducting clinical quality and management research focusing specifically on the changes posting an OB/GYN specialist in district hospitals has on the hospital and the immediate community, my classmate Charlotte was busy administering a laparoscopic surgery training module to bring the technology of laparoscopy to Komfo Anokye Teaching Hospital in Kumasi, Ghana. Laparoscopic surgery, especially for gynecological surgeries, has been available to developed countries for at least 20 years, but this minimally invasive form of surgery has yet to become standard practice in Ghana. The benefits of laparoscopic surgery are many. It is cosmetically favored by patients and medically, reduces complications like hemorrhaging and has shorter recovery times. It is no exaggeration to say that Charlotte's work is ushering Ghana into a new surgical future that will bring a tremendous amount of public health benefit.

In 1910, Abraham Flexner's report titled, "Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching" ushered and shaped medical education into it's current form. The Flexner Report called for standardization of medical education that was rooted in sound and rigorous biomedical and clinical science challenging the American and Canadian medical education systems to train the highest quality of physicians. Flexner, not a physician himself, wrote a book-length report that was framed with the greater society in mind. He wrote, "The public interest is then paramount, and when public interest, professional ideals, and sound educational procedure concur in the recommendation of the same policy, the time is surely ripe for decisive action."

It has been 100 years since the publication of the Flexner Report and with 100 years of experience of modern medical education, we are due for some reflection on the alignment of the medical education system and the public interest. In an article published in Academic Medicine, Drs. Don Berwick and Jon Finkelstein write and discuss a, let's call it "Flexner Report 2.0", shaping a medical education system that will better prepare physicians to meet the needs of a today's world of health care. Read the article here.

In the article Berwick and Finkelstein outline new values that should complement the current emphasis on biomedical science we receive in medical school. These values include "patient-centeredness, transparency, and stewardship of limited societal resources for health care." There is no time in the current curriculum to add on training in these new skills, many educators would argue. Berwick and Finkelstein also review the innovative programs, including the IHI Open School, that attempt to provide medical students and residents with a foundation in these new skills, as well as outlining a new frame of reference for medical curriculum change that will incorporate these invaluable skills. I certainly can't reproduce Berwick and Finkelstein's eloquence, so I will leave the explanation of the fine details to the article. Definitely a must-read!

In the 100 years since the publication of the Flexner Report, the medical education system has trained millions of physicians who have dramatically transformed health care. It was this cohort of physicians that popularized laparoscopic surgery! Looking just at performance outcomes, we have made incredible gains in both the length and quality of life for our patients. However, there is much more we can do. If we adopt Berwick and Finkelstein's recommendations, we will be poised to create a new physician workforce adept at navigating and continually improving the complexities of health care to consistently meet patient needs. We all need to collectively reflect on and brainstorm innovative interventions to fold the skills of systems thinking into our current medical education system. If we can develop the technology of laparoscopic surgery, I'm confident that we too can succeed in reinventing ourselves to better treat our patients with the tools of quality improvement. In 100 years, the world will surely look very different. I'm imagining a modern metropolis not unlike the life of the Jetsons. But, what will medicine look like? What kinds of public health accomplishments can we celebrate in the next 100 years? Let's work together to reshape medical education so that we will have plenty to celebrate in the future!

What do you think of the Berwick and Finkelstein paper? Leave a comment!

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Project Fives Alive: Two Days of Energizing Inspiration

Karni QI Team

In typical last-minute Eva fashion, two years ago, I decided to defer from medical school for a year to work at the Institute for Healthcare Improvement (IHI). IHI can be best described as a fast-paced social change organization that operates like a cross between a think tank and consulting firm that focuses on improving the delivery of health care through spreading systems redesign tools and interventions all around the world, including Ghana. As much as possible, IHI practices what it preaches. In addition to encouraging health care systems and health care professionals to employ the model of improvement to make the delivery of health care more efficient, reliable, and effective, all of IHI’s own work is continuously evaluated for improvement. After living and breathing quality improvement for a year, the transition to medical school, where the focus sometimes felt like mindless memorization of volumes of facts, was difficult.

My main motivation for coming to Ghana this summer to work on clinical quality and management research was to return to the field of quality improvement of health care. For the most part, my research has been very fulfilling as I have delved into answering the questions: what kinds of improvements can be made at the level of a district hospital to improve maternal health and how can those improvements be made? Since data is the backbone and currency of quality improvement, sometimes answering my objective questions has been frustrating because I continuously run into underdeveloped data and information systems. On the days that I felt particularly beat by data available to me, I’d wonder how IHI functions in Ghana.


Lambussie QI Meeting

IHI has three developing countries programs: Ghana, South Africa, and Malawi. In Ghana, Project Fives Alive, a partnership with the National Catholic Health Service (NCHS) and Ghana Health Service (GHS) is working towards reducing under five mortality through quality improvement. While I was working at IHI, the CEO, Don Berwick, made a short visit to Ghana and collected the most inspiring stories. Thanks to Nana Twum-Danso, Project Fives Alive director and Ernest Kanyoke, Project Fives Alive Project Officer, I had the opportunity to be inspired too.


Piina QI Team

Last week, I traveled to Wa in the upper west region of Ghana to join Project Fives Alive on two days of quality improvement (QI) meetings at various health centers and CHPS zones. It was a difficult journey up to Wa from Kumasi, but those troubles immediately melted away when I met Ernest. If it were possible to anthropomorphize quality improvement, Ernest would be the perfect model. He is brimming with energy and is whole-heartedly committed to quality improvement in his work and his everyday life. Upon arrival, when my hotel reservation was not processed correctly, Ernest immediately evaluated that this was due to a problem in hand-offs and he said he wished had time to help by first collecting data on how often this occurs. At the very least, seeing Ernest carry around a flip chart and colored markers conjured up feelings of comfort. IHI truly is flourishing in Ghana.


Lambussie Health Center

Because I arrived in Wa around 2:30AM and had to be up and ready for site visits at 7AM, Thursday’s meetings were tough. Immediately after Ernest’s more than deserved introduction of myself to the QI teams, I’d invariably fall asleep. I am still so ashamed that in response to the amazing work that these health centers are doing to reduce neonatal deaths, all I could give them was an inattentive, silent, sleeping Eva. Thankfully, even while sleeping, I think my brain was still alert and I gathered some truly remarkable accounts of the QI work being done by midlevel providers (midwives, community health nurses, and local support staff) to drastically improve the processes that can reduce neonatal mortality.


Samoa QI Team

For example, in Samoa, the two CHPS Zones have greatly improved their skilled delivery rate by making small changes to make delivering at a health center attractive for mothers. These changes include offering traditional porridge to the women after delivery. This small change does not just represent a inventive adaptation of traditional practices, but also sends the message that the health care staff cares about the well-being of the mother and that the health centers are welcome institutions. In Karni, the QI team discussed the progress of their intervention to reach out to women and develop a pregnancy plan to increase their skilled delivery rates, which are at a laudable 90+% and a very effective mosquito net distribution program that has reduced their rates of malaria admissions.


Karni QI Meeting

What impressed me the most was not the outstanding results and outcomes that these health centers can celebrate, but the dynamics of the QI meeting itself. The health center staff have no formal training in statistics, yet after just a few learning sessions, are very data driven. Midwives and community health nurses take turns contributing to and facilitating the QI meeting to discuss and evaluate the rates of first trimester registrants for prenatal care and improving postnatal care follow-up visits. During the meeting, their various registers (the raw data), are always open right in front of them and they reference the data throughout the meeting. The connection between data and the individual patient success narratives they are experiencing is strong and solid. I can’t say that even providers in the US have made this connection. The foundations of QI have been laid for these teams and with that, I believe that they can take on any health care delivery challenge.


Exuberant Ernest Working His Magic

All of this progress, however, could not have been possible without the skillful facilitation of the project officers. The project officers not only have a deep understanding of the individual process and quality measures and interventions that each health center is undertaking, but are also experts at managing relationships. Project Fives Alive is a partnership with the NCHS and GHS are extremely important agencies to work with for the success of its work. The project officer has mobilized and empowered all of the necessary stakeholders to participate in the shared goal of reducing under five mortality. A representative from the GHS district health office traveled with us and was present at every QI meeting. All levels of staff were asked to open their registers and discuss and interpret the data. And then together, the QI team would set aims and deadlines to meet before the next QI meeting. My own research experience has proven that this is no easy task. Building confidence and a positive attitude among the providers is on an entirely higher level. The hospitals that I visited were still struggling with just making sure all of the necessary stakeholders that would work together to improve maternal mortality were all available on the same day at the same time to just discuss maternal deaths. These project officers, like Ernest, have just the right combination of encouragement and persistence to have led the QI teams to where they are now.


Run-chart at Piina

The four sites that I visited were extremely resource deprived in comparison to the district hospitals that I have spent most of my time working with—most of the health centers do not have electricity! Yet, despite these resource challenges, look how far a statement like, “let’s take a look at the data” can go. The run charts and meeting minutes posted on the wall is really the only technology I saw that these facilities were using to achieve their results. It’s phenomenal. The next waves of the project are to expand and replicate the work being done in the northern regions to the rest of Ghana. This kind of exposure to QI has so much potential that I know whenever I have the opportunity to return to Ghana, the health care delivery system in Ghana will be positively unrecognizable.


The Fearless Issah

My site visits and time spent with the Project Fives Alive team was the perfect burst of inspiration that I needed as I begin to undertake my last small project before I have to return to Michigan. Perhaps it was Issah’s adroit driving skills that powered us through sometimes as much as 300km of dirt roads to reach these communities, but after just two days with Ernest (and his highly marketable energy if only extractable) and the community QI teams, I’m excited for my own project with the confidence that QI works successfully in resource-poor settings like Ghana. With more opportunities for these community teams to share, evaluate, and celebrate their work and even greater individual engagement with data, the results that Project Fives Alive will produce I think will exceed the already achieved success. Three cheers for Project Fives Alive!

Thank you again to Nana Twum-Danso and Ernest Kanyoke for this amazing opportunity to join you all for two days. I look forward to following Project Fives Alive as it continues to grow and spread.

For more information about IHI and Project Fives Alive, here are some relevant links:
Project Fives Alive Website
Fives Alive Project Description
On the Ground Account When IHI's Jane Visited Ghana

For more blog posts about my summer in Ghana, visit "Eva Ghana Wild"

Costs of Care: Cost containment and unfinished business

Costs of Care: Cost containment and unfinished business

Healthcare reform's unfinished business

While the contentious healthcare reform bill enables access to health insurance for 32 million Americans, what about costs and efficient healthcare delivery?

The often-heard criticism of the 10-year, 1 trillion healthcare reform plan is that it simply does not do enough to rein in the cost of treatments. According to a government report released in February this year, healthcare spending grew to a record of 17.3 % of the GDP in 2009, $ 134 billion more than 2008, marking the largest one-year jump in its share of the economy since the government started keeping such records half a century ago.

The question then is, how does ObamaCare plan to deal with the American view of more care is better care? Given that the new healthcare overhaul requires the government to now pick up more of the healthcare tab, can we cope with that? Moreover, how do we convince patients and providers that new procedures, tests, drugs or devices that might save or improve lives really are not always necessary or worth the exorbitant prices?

A stark example of the inefficiency in the system was brought to bear in a recent study published in JAMA about the rise in unnecessary back surgeries. Despite the growing evidence that it does not really work well for patients and increases the likelihood of life threatening conditions like heart attacks, strokes and pneumonia,complex back surgeries have increased 15-fold between 2002 and 2007. In essence, more complex procedures mean higher payments for surgeons. The misaligned financial incentives, the paucity of patient education about less invasive treatment options and the trying-anything-and-everything mentality in medical practice even if we’re not sure it works are all part of the problem.

And it’s not just more back surgeries. More CT scans pose a problem too. A recent study demonstrated the significant overuse of such scans, projecting that 15,000 people die in a given year due to the radiation received from CT scans. Caesarean births have become more common, with little benefit to babies and significant burden to mothers. Men who would never have died from prostate cancer have been treated for it and left incontinent or impotent. Cardiac stenting and bypasses, with all their side effects, have become popular partly because people think they reduce heart attacks.

Overall, the consensus is that culture change is needed to move away from wasteful spending to more efficient healthcare. They include new making doctors more sensitive to costs of care, establishing new payment methods for doctors, more comparative- effectiveness research and penalizing hospitals for inefficiency. The hope is that the Patient-Oriented Outcomes Research institute established by the healthcare Bill, charged with setting the national agenda for the comparative- effectiveness studies, as well as providing more money and disseminating results, will bring some order into the chaos of practicing medicine. The hope is that it's studies will have an impact on healthcare delivery.

Shooting for "Sensemaking" in Health Care

Despite my lackluster sports careers in tennis and Ultimate Frisbee, I am a huge sports enthusiast. In college, I was introduced to basketball. My hometown team, the Miami Heat had fought their way to the 2006 NBA Finals. Like any good fan, my eyes were glued to the TV every game against the Dallas Mavericks. I gasped at every missed shot, held my breath during every free throw shot, and cheered for every point scored. The Miami Heat's journey to the championship was epic and I have been enamored with them ever since....

...As much as I love the Miami Heat and have faith in Wade's athletic prowress, I am not hopeful about tonight's game. Using Weick's own words, the Miami Heat are not a high reliability organization, an organization that operates under very trying conditions all the time and still manages to have fewer than their fair share of accidents, but should be...

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An Evening of Thanks

I have a little over a month left of my first of year of medical school...an unbelievable fact. One of the highlights of my year has been the Family Centered Experience program. I have written about the program in previous posts here and here. Closing up our year, all first year med students were asked to work in small groups and create an interpretive project using untraditional media to express our understanding of what we have learned from our patient volunteers. Tonight, all of our interpretive projects were on display and we spent the evening with our classmates and patient volunteers experiencing the reinterpretation of the struggles and triumphs of a life with illness...

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