Category Archives: Healthcare

To Those Whom Much Is Given…

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96. everything is power-law distributed

97. everything is power-law distributed

When someone writes about 137 life hacks and two of them are a) identical and b) something you have never heard of, you can’t help but dive down that rabbit hole… 

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So, what is a power-law distribution? 

A power-law distribution is the statistical description of change that is proportional to the power of the change, in other words, change that is logarithmic, not linear. One of the classic examples of a power-law distribution curve is how income is distributed in society. 

Although there are many uses for this principle in the world of finance and economics, power-law distribution can also serve as a mental model to help us understand ourselves, each other, and the world we live in.

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For those who are healers, or who are studying to be healers, there are three uses of this mental model that I think are particularly relevant: 

1) Hacking your studying

2) Investing in your future

3) Understanding inequities 

Hacking Your Studying

I unknowingly wrote about power-law distribution when I explained the “forgetting curve” in this post: “How to Ace the NBME Shelf Exams, In-Training Exams and Your Boards”. I recommend you read the entire post, but the take home message is this: Cramming never works if your goal is learning how to heal. What works? Repeating information you want to learn at least five times in gradually increasing intervals (ok, you type A folks… get out the spreadsheet).

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The best time to plant a tree was last year. The second best time is today.

The power-law distribution also helps you understand why you need to start investing for your future – today.  The chart below is what happens if you invest $100 a month starting as a new grad and keep doing it for 35 years (assuming a 6% return on your investment) 

p.s. Here’s the website to do this calculation with different variables-  investor.gov calculator

This kind of “investment strategy” also works for exercise. Wow, do you gain strength and fitness fast at the beginning… and how sad that it only takes about six weeks to lose most of what you previously gained if you stop (both are examples of power-law distribution). Like financial investment, investing in your body with small “doses” of consistent exercise is the best strategy. For most of us who work in a hospital, the amount of walking we do at work is close to the recommended minimum for fitness (#GoodNews). Just accumulate a few more minutes at a higher heart rate (take the stairs, speed walk to the next consult, etc), add some body weight strength exercises like pushups, and you are good! 

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Understanding Inequities

Investing for the future and how to hack your studying are important, but there is an even more important use for this mental model… It can help us better understanding the inequities in our society and in our work. 

It’s easier to accumulate resources if you start with more. This principle is why young faculty members with limited mentorship or disproportionate service at home or at work end up not advancing. It’s why marginalized youth without resources to obtain education or connections struggle to break free from the cycle of violence and poverty. It’s why those who “have” (money, education, privilege) end up with disproportionate success (or access to care) when compared to those who started with less. Yes, there are exceptions, but they are just that… exceptions to the powerful force of power-law distribution. 

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There are hundreds of examples of power-law distribution including the beauty of fractals like the pattern in this beautiful head of romanesco broccoli or the curve of a beautiful seashell. (It’s worth looking at the list… some of them are fun!)

Maybe Alexey Guzey is right…

96. everything is power-law distributed

97. everything is power-law distributed

#BanTheBouffant

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If you don’t work in an operating room, you may not be aware of the controversy going on about OR caps.  To get right to the point – the surgeons think they should be allowed to wear the cloth hats they have worn forever.  The Association of Operating Room Nurses (AORN) developed guidelines which included covering the ears and all hair (which means a bouffant paper hat). These guidelines were then implemented by JACHO which means they became “law” in every hospital in the United States.

Anonymous surgeons demonstrating extremely effective covering of all hair with bouffant hats.

I’m a real believer in evidence based medicine (and policies) so I decided, like others, to look into what is really known about the issue.  Because it is a conflict of interest, I need to disclose that I can’t stand the bouffant hats and I really, really miss my (clean and washed) cloth hats. (which BTW cover all my hair!)

What do the data say about the use of bouffant hats and infection rates?  

 

Why don’t surgeons like bouffant hats?

It’s harder to keep them in place when wearing loupes or headlamps. If the goal is to keep the hair covered, this is a real problem.  When moving headlamps, operating microscopes or loupes, the bouffant hat often moves substantially – or even comes off entirely.

They are hot. Many surgeons feel (me included) that the bouffant hats are uncomfortable and are hot.  One can argue that anything that increases surgeon discomfort could affect concentration, which might be reflected in less focus on the operation.

Bouffant hats are expensive and bad for the environment.  On Amazon, 100 bouffant hats cost $7.45.  There were 48 million inpatient operations performed in 2009.  When you add the 48 million outpatient procedures performed, that means there are roughly 100 million operations performed per year.  (Mind you, these data are almost 10 years old, so it’s likely to be more now).  If we assume an average of 4 cases/day by an average surgical team (nurses, CRNA, anesthesiologist, assistants/resident) and they all wear their hat for the day, the number of hats needed per year would be 100 million cases x 6 members of the team = 600 million hats/yr. 600 million hats divided by 100/box = 6 million boxes x $7.45 = $44,700, 000.  Over 44 million dollars a year for the bouffant hats… all of which (600 million/year) end up in a land fill or are incinerated.  p.s. Given that hats are often changed during the day, this number is probably on the low side.

It affects morale.  In a survey of young (<45 years of age) surgeons, 71.2% stated that the new rules had affected surgeon morale.

They are inferior in blocking bacteria when compared to other caps.  In a study of bouffant hats, disposable skull caps and cloth hats, the bouffant hat was the worst in preventing airborne bacterial contamination in the operating room.  “I expect our findings may be used to inform surgical headgear policy in the United States,” he said. “Based on these experiments, surgeons should be allowed to wear either a bouffant hat or a skullcap, although cloth skull caps are the thickest and have the lowest permeability of the three types we tested.” Troy A. Markel, MD, FACS

 

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I’m confident that in the very near future we will be back to wearing our clean, cloth hats.   When you look at the data, and weigh the pros and cons, it seems pretty obvious what needs to be done….

 

 

 

 

 

 

I have never seen a patient who did not deserve healthcare

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The other day, while I was looking at my Twitter feed, I came across this amazing thread by Dr. Jennifer Cowart. I was so moved by this heartfelt plea to our elected officials that I asked her permission to post it here.

Female doctor with the stethoscope holding heart

I have never seen a patient who did not deserve healthcare.

I have seen people, rich and poor, who do not take care of themselves. Who drink too much, eat bad food, smoke, use drugs, drive recklessly, etc. If you smoke and get lung cancer, or if you didn’t smoke and get lung cancer, you deserve healthcare.

I have seen people, rich and poor, who believed themselves entitled to whatever care they wanted, at whatever cost, whether it was evidence-based or not. It didn’t change the fact that they deserved appropriate healthcare.

In fact, it is interesting that “entitled” is an epithet more often thrown at an “undeserving” poor person than a rich person with the same behavior and attitude.

I treat “good” and “bad” people. People I wouldn’t let in my house. It doesn’t matter. I’ve treated registered sex offenders. I don’t ask what they did. I take care of their pneumonias, their heart failure, their cirrhosis. They deserve healthcare. My care.

I took my (healthy, neurotypical) baby to a specialist the other day. We passed many children with (visible) special needs. A girl with a trach in a push chair. A teenager escorted by her father with CP. Children with various genetic syndromes. They deserve healthcare.

That could have been us. If not for the luck of genetics, my children could be those children. Blessings, but also requiring significant care, time, money, and resources. Those children are worth as much as mine and deserve their healthcare.

To me, the fact that it will cost a lot of money to ensure everyone has healthcare coverage is secondary to the fact that everyone deserves it. If we decide everyone deserves it, we will finance it. Expensive things can be worthwhile. Healthcare is one of those things.

I have seen cancer patients lose their insurance and not know where their care will come from. Chemo regimens interrupted. Radiation not given. “Lost to follow up.” I have been in those rooms, held those hands, wiped those bitter tears.

When you’ve worked your whole life, had private insurance, got cancer before you are old enough for Medicare, get too sick to work, lose job, lose insurance, have to wait for disability/Medicaid to kick in… this is pain like you haven’t seen. Those people deserve healthcare.

I know there’s the flipside. People who never worked. Maybe they really were truly lazy, or maybe they were caretakers and never worked outside the home (doing invisible work). Some of these folks are rich, some poor. I treat them all.

Illness doesn’t respect your work history. “Bad behavior” may increase risk of bad outcomes, but we transplant a lot of livers into cirrhotics who drank. Cancer strikes a lot of folks who never smoked, who got HPV from their spouse, who did nothing “wrong.”

The only category I see that we consistently say as a country who doesn’t “deserve” their care are the poor. Sure, people judge alcoholics or people dependent on opioids, but we haven’t made huge moves to dump all of those folks off their healthcare programs.

Yet Congress tried to cut millions of people out of Medicaid. Give them the “freedom” to “choose” their care—which they can’t afford. They didn’t cut smokers off, or alcoholics, or diabetics who eat sugar, or heroin users. Just poor people, those “undeserving.”

We are still waiting for CHIP to be funded. Guess who’s children are covered under CHIP? Not the kids of smokers. Kids of working people who don’t make much, but earn too much for Medicaid. In other words, people who don’t have enough $ to “deserve.”

I reject the premise that money is what makes you worthy of my time and care. I understand that healthcare must be financed. My time is not free. I am not a volunteer. But if you have pneumonia, my worry is not how will you pay, but how to treat you.

So figure out how to pay for it, because everyone deserves to get treatment for their special needs child, their cancer, their pneumonia. To get that treatment, and not be bankrupted by it. Everyone deserves basic healthcare.

 

Jennifer B. Cowart, MD works as a hospitalist in Jacksonville, Florida.  She is a graduate of the The University of Texas Health Science Center at Houston and trained in Internal Medicine at Baylor College of Medicine followed by a fellowship in Clinical Pharmacology and Hypertension.  She then served as the Chief Resident in the Quality and Patient Safety (CRQS) program at the Michael E. Debakey Veterans Affairs Medical Center.