Studies in Sleep, Success in Handoffs
Vineet Arora, MD
Vineet Arora, MD, MPP, FACP, an associate professor of medicine at the University of Chicago’s Pritzker School of Medicine, says she was always interested in finding out why things work—or don’t—in healthcare, and that inquisitive nature led her to sleep.
Not necessarily her own sleep, mind you, although Arora will tell you when she was a resident she had her share of sleepless nights like many of her colleagues.
Arora, also assistant dean of scholarship and discovery at the Pritzker School of Medicine, is leading research that is reshaping sleep schedules for residents to improve quality and safety of patients.
“You don’t want doctors fatigued to the point they are hurting anybody,” she says.
“It’s a fascinating area to work in. It’s complex. If you change one thing in the system, you can change a lot of things. Everybody needs sleep. It doesn’t matter who you are. You can’t function without it. You’ll die.”
Arora also has concentrated on studying handoffs from one physician to another in hospital settings as they change shifts, with a specific emphasis on communication procedures. In the 1990s, “when I was a resident, you never had to hand off anything,” she says. “A good handoff was no handoff. That meant you stayed until your work was done. People are now aware it’s a problem, and the challenge to the system is to make better handoffs.”
Arora’s resident days are long gone. “My husband will tell you, I always try to get enough sleep.”
The Innovator’s Frustration
Clay Christensen’s writings about disruptive innovation—the concept that new technologies often have the potential to turn industries upside down, yet are exceedingly hard for established companies to recognize and harness—gave the Harvard Business School professor status as a management guru in the late 1990s. Manufacturing and technology executives, in particular, read Christensen’s books and sought his advice. Hospitals weren’t part of the discussion, for the most part.
But Christensen always saw the U.S. healthcare system as ripe for disruptive innovation. In 2009, he coauthored a book, The Innovator’s Prescription, and entered the public debate on how to fix healthcare. Simultaneously, he experienced a series of illnesses that gave him an unwelcome firsthand view of the healthcare system.
Disruptive technology has altered the practice of medicine many times over, yet the structure of healthcare institutions and the healthcare system has resisted change, to its detriment, Christensen says. “Over time, we’ll need fewer and fewer hospitals. Boards of those institutions need to just remember that the scope of what they need to do is to be responsible for the health of people, not the preservation of the institutions,” he says.
Christensen finds that the national healthcare debate is unhealthy. “I’m frustrated,” he says. “It’s the politicians—it’s not that they are inert or that they don’t want to do it, but they don’t have time to sit down and wrap their arms around the problem or the solution, and their mind-set is so fleeting that they want a simple answer.”
Developing Social Norms
Peter Orszag is part of the executive team at one of the world’s largest banks now, far removed from his time as director of the Congressional Budget Office and White House Budget director. But his thoughts are never too far away from healthcare.
Orszag was one of the chief proponents of the individual mandate being included in the legislation that became the Patient Protection and Affordable Care Act of 2010. Whether you love or hate the law, Orszag’s contention that the individual mandate is the linchpin of the success or failure of the legislation has gained traction on both sides of the political aisle.
“Clearly, the coverage impact depends on the degree to which individuals sign up and whether employers drop their existing coverage,” he says. “And the mandate influences that. But a lot will also depend on the social norms that develop around insurance. If you examine Massachusetts, everyone also thought the penalties were not high enough and no one would sign up. That hasn’t happened. Part of the reason that many people have signed up is because a norm was set that you’re supposed to sign up, so people do.”
If that seems like shaky ground upon which to build a healthcare system that lowers costs and improves outcomes, Orszag draws an analogy to seat belt use.
“The social norm has developed in a way that you’re just supposed to wear your seat belt … That type of dynamic is going to turn out to be very important in the coverage impact of the health bill. Financial incentives are important, but expectations and norms matter, too.”
Connecting Human Networks and Human Health
Nicholas Christakis, MD
Trained as both a physician and a social scientist, Nicholas Christakis, MD, PhD, MPH, says his intellectual toolkit spans a broad set of concepts and materials. “I live my life at the intersection of different ideas. I try to see if there are ways to bring knowledge from disparate fields to improve public health and public policy.”
Christakis is a professor of medicine and medical sociology at Harvard Medical School, and is the scientific founder of Activate Networks, Inc.
For the past decade Christakis has been studying human social networks and their effects on health. These aren’t Facebook networks. Christakis analyzes the old-fashioned, face-to-face networks that people form with friends, families, neighbors, coworkers, and others.
Christakis says the overarching idea of his social network research is that “people are connected, so their health is connected.” Your individual health depends not only on your own choices and behaviors, but also on the people who surround you, including people you know and people you don’t know. Within a network, the fact that a person unknown to you has the flu has meaning for you, explains Christakis. “What this suggests is that we need to think about health interventions in a way that’s more collective and not as individualistic.”
Christakis says studying networks is not just an intellectual exercise. “What can we do with this knowledge? We know that germs flow though networks, ideas about drug prescriptions and health practices flow through networks, and behavioral phenomena such as weight gain or smoking cessation flow through networks. How can we exploit this knowledge to intervene in the network to make the world a better place?”
—Margaret Dick Tocknell
The Nurse Practitioner–Run ED
Robert D. Donaldson, NPC
There are times when patients are ushered into the emergency department in tiny Ellenville Regional Hospital in Upstate New York, and they ask: Is there a doc here? “There are no doctors here in the ED. I’m the one you are going to see,” says Robert D. Donaldson, NPC, in his well-worn refrain.
Donaldson is a nurse practitioner, as is every member of the ED staff at the 25-bed critical access hospital, which is in the Catskill Mountains, about 40 miles from Kingston, NY.
So is this really working, a nurse practitioner in charge of the ED staff at the 25-bed critical access hospital? “Yes, there is an answer to that. We are admitting patients, making money for the hospital, and the hospital is in the black year after year. What does that say? The hospital has received an award for its emergency department for patient care. What does that say?”
Donaldson, 68, came to Ellenville in 2004 at a time when the hospital was ailing financially. In 2009, he became medical staff president with 70% of the vote. He could not even vote for himself; only physicians could vote. He says he was becoming popular with the physicians because he did “the entire workup for them, and essentially managed their patients prior to admission. It goes a long way and makes their job really easy.”
While Donaldson has certainly made inroads in how nurse practitioners are perceived in Ellenville, it’s still a national problem, he says. He’s says he’s still fighting turf wars. “There’s a huge medical lobby out there, and they got a huge amount of dollars; they don’t really want to hear that nurse practitioners are doing what docs have done,” Donaldson says.
Breathing Easy: Simple Research Solutions
Thomas Hansen, MD
His goal as CEO is to breathe new life into the patients of Seattle Children’s Hospital. But that’s not enough for Thomas N. Hansen, MD, the brainchild behind the Hansen ventilator, a device that could lead to low-cost care for infants in impoverished places the world over.
Developing countries with limited resources currently lack an alternative for costly mechanical ventilators that can save thousands of infant lives. Hansen’s option is a ventilator with fewer parts, but that provides babies with a small increase in air pressure above atmospheric levels and stabilizes the lung. The result reduces the work of breathing and can cut down infant mortality rates.
The project, though consuming, remains a priority for Hansen. If friends could use one word to describe him, it would be workaholic, Hansen says. He spends 60-plus hours a week working as CEO, but still makes ventilator research a priority, dedicating time every Monday for work in the lab.
“The intellectual stimulation of doing research—I can’t live without it,” Hansen says. “It’s very exciting and an opportunity to change the outcomes for patients all over the world. It’s a passion that keeps you fresh and enthusiastic and prevents you from being burned out.”
Hansen and his team are submitting the ventilator for Food and Drug Administration approval in March, with the goal of releasing the device for use in developing countries by 2014.