When Regina Holliday puts out a request for painted jackets for The Walking Gallery, the response is obvious: of course! A couple of years ago, when Twitter lists were just getting “hot,” Regina and I joked we should start a list of “patient safety advocate artists from Oklahoma” – a short list which would contain us both and that’s about it.  Because of this shared odd convergence of experience and interests, I’ve always felt an unique closeness to Regina, whom I’ve never met other than virtually. Take the time to read her blog and you will become acquainted with one of the most energetic and gutsy people I know.

The image I painted is based on the website Dead by Mistake, which estimates 200,000 people die due to preventable medical errors in American hospitals every year. Statistically, there is a broad range of estimates of how many preventable deaths occur in hospitals each year, and there is plenty of controversy over how to define “preventable” and “error.” However, the lowest estimate I saw was 32,000 -- even that figure should be enough to drive change -- and there is no controversy over how to define “death.”

But  Regina’s vision is to put the patient at the center of our healthcare, through the sharing of our individual stories. With that in mind, just one of the patient stories we can see on the Dead by Mistake website should be enough to drive our determination to improve healthcare. The image on my jacket is based on the imagery of Dias de los Muertos, when the spirits of our deceased loved ones return to visit us (and no, it’s NOT “Mexican Halloween”). My hope is the deceased family and friends of all  who view her will return to us, to empower us to keep working toward change and improved patient safety.

Thanks to Regina for the opportunity to participate in The Walking Gallery.

Becca Price

@Tully3000

Hello and welcome back! That's what posterous said to ME when I logged on. I'm impressed it remembered me, it's been so long.

Yes, we are still busy and all "free" time is going to a little project known as building a Baja hut.

As part of that process, when I am feeling especially well-rested and brave, I'll venture onto Craigslist searching for any of the numerous items necessary to make a Baja beach hovel into a cozy hut. And if you know us, you know barstools are not a luxury, they are a necessity. I found some Ikea bar stools that matched my collection on Craigslist....or DID I? Hard to tell!

This weekend's resulting melee' of stupidity really warranted a TIME OUT. TIME OUT and share this with the world.  Well, the small slice of the world that finds itself washed up here. I was so impressed with the level of dumbitude exhibited, I just couldn't bring myself to delete this email thread. It seemed like it needed to be documented, somehow. And then I remembered YOU, dear posterous. Thanks for being there when I need you, even when I have neglect you for so long. And no, I did not go look at the barstools. I thought I might cry if I did.

------------------------------------------

Subject: ikea stools
Date: Sun, 20 Jun 2010 15:48:17 -0700
 
Hi,
Are those really 29"? The link goes to the 29" bar stools but those 
look like the shorter ones.
Thanks
Becca

>>>>>>>>>

On Jun 20, 2010, at 4:12 PM, (DELETE) wrote:

Hi!

I don't really know the difference between 25'' or 29'' but my bar is quiet tall so I think those are 29''. Feel free to call me if you want to come to see!

>>>>>>>>

Subject: Re: ikea stools
Date: Sun, 20 Jun 2010 16:15:26 -0700

The difference is the height. Thanks.

>>>>>>>>>

  

yes I know !!! but their is no stickers anymore on it so i can't check !! 

are you interested to come to see it?

What have I been doing? Well, yeah, there's work. But lately work has been an annoying distraction from my current obsessive focus: building my Baja casita. Something I've been dreaming about for decades and I can hardly believe it is finally happening. Sorry to ignore the posterous! I've felt so guilt-ridden that I haven't even looked at this site for a while. Going back over older posts just now made me realize -- it's probably time to go back and relisten to Bill Moyers' prediction of watered-down healthcare reform.

The big news from the Ejido in Baja is the addition of mobile phones. This is a bittersweet development, since it will help us to get started on building our beach house, but it also brings the modern world one step closer to our hide-out from technology. We spent a warm sunny days/ starry sky nights kind of week until the rain started on Saturday, right when we were loading up to go home. That made the drive home a bit more challenging, and parts of Tijuana (the parts you have to drive through, you know-the streets) were flooded. But it's time to take a deep breath and dive back into the hyper-connected world. One more thing, though, some shots of last week, posted with great fondness and gratitude for my friends and for Mexico:
The Ejido held a local rodeo on Sunday. Quite the event for this poverty-stricken agriculture and cowboy-based society and it made for some beautiful shots:

We also held the 2nd annual Baja non-invitational commando golf tournie the day after Thanksgiving. Here is the first hole:

I signed up for BIL:PIL not that clear on the concept, but that's a position I'm comfortable with. I had heard a little about "unconferences," but not enough to really get it, and I certainly have never been to any gathering structured like that. Or un-structured like that. Now that I've done a little more reading about the development of the unconference (I've only had time to do a little reading at this point, but believe me, I plan to read much more), I'm so happy to have discovered the format and the community around it.

If you are new to unconferences, let's just go with Wikipedia, which says it is a facilitated, participant-driven conference centered around a theme or purpose. From what I could tell, BIL:PIL 2009 in San Diego had a few more scheduled speakers than one would normally expect at an unconference, but the atmosphere was informal, all comments and ideas were open for debate, and everyone attending was inspired in many ways. I suspect many of us attendees are struggling to put some structure around the unconference unstructured experience at this point.

I'm relatively new to blogging, but happily, not very new to thinking. Hey, it's always been one of my favorite hobbies. Because I didn't have any idea what to expect at the unconference, I was very happy to connect with folks who seem to be thinking about the same things I have been thinking about lately. I was even happier to hear from folks who were thinking about things that had not even occurred to me yet. I guess that's entirely the point of an unconference. While pondering how to put enough structure around the experience to capture any of it in a blog, it occurred to me that some of the high points for me related directly to my recent blog entries, and of course that makes sense I suppose. 

I started my own small call to action to support primary care in my previous blog post. I asked for us all to pay more attention to the role of the primary care physician as we consider alternate models of healthcare delivery and payer systems. At the time, I had read a little about Care Practice but having the time to sit down and hear directly from its founder and Medical Director, Aaron Blackledge, really got the wheels turning more. Aaron speaks in a thoughtful deliberate way that does not mask his passion for delivering efficient patient-centered care by carving out waste to trim costs. His model has proven successful in San Francisco, and we were all wondering about the possibility of replication of the model.

Of course, it's always great to hear a success story. Dr. Blackledge had to make decisions -- big financially difficult decisions that were true to his gut, but completely counter to the trends the industry told him to focus on at the time. He is humble about it, but that takes courage and it's paying off.  However, the real power of his story comes from understanding just how broken primary care is in our country. It is the camel's back on which all the straws of healthcare and healthcare reform are being stacked, and we are at a critical crossroad; do we build up some kind of support system to keep that camel standing just a little bit longer, or put that last straw on its back and watch it collapse? Meanwhile, what are we doing to develop sustainable models of care?

Aaron gave a lot of credit to  L. Gordon Moore, MD, and his concept of Idealized Medical Practices as a major influence on Aaron’s practice. So of course that inspired me to find out more about Idealized Medical Practices and in so doing, I found a soldier who had long been fighting the fight I just began to mention on my last blog.  We need to pay attention -- now -- to the critical role of primary care as we reform healthcare and develop new models of healthcare delivery. As Dr. Gordon writes: "If we are ever going to see real healthcare reform in our professional lifetime we must help policy makers in D.C. understand there is a real constituency for change. We're going to keep working with you and as many folks as we can get signed up with us.  We're working hard to make it easy for folks like you to be heard."

If you are intrigued, read some more. If you agree, please sign up to support primary care.

OK, so that was one thread pulled. Just one of the many threads of ideas that began to unravel and re-weave themselves over the two days of BIL:PIL.  There’s so much more to say,  but I'm getting on a plane, and those stories will have to wait for another day. Thanks to everyone who conceptualized, actualized, and prosthelytized BIL:PIL. We are all looking forward to the next adventure in healthcare innovation-and setting healthcare free.

With the current focus on healthcare reform, we have an unprecedented opportunity to shape a new healthcare delivery and payment system. However, the schemes are complicated and some concepts overlap, which can make it difficult to follow the discussions.  This list of health delivery reform concepts published by AMHealth is a good resource to help us understand the several potential healthcare delivery systems under discussion:

Accountable care organization (ACO): A collection of primary care physicians, hospitals, specialists and potentially other health professionals accept joint responsibility for the quality and cost of care provided to its patients. If the ACO meets certain quality and cost targets, its provider members receive a financial bonus.

Performance-based care coordination: Physicians earn a bonus for curtailing growth in the cost of health services by better managing treatment across care settings and by pursuing quality targets. A care-coordination model may be structured differently from an ACO and may also use different methods to calculate shared savings.

Payment bundling: Similar services are grouped together and are compensated using a single or global payment. Services could be grouped according to the care provided by a single doctor or multiple doctors.

Patient-centered medical home: Primary care physicians receive additional monthly payments for effectively using health information technology and other innovations to monitor, coordinate and manage care.

Gainsharing: Hospitals share with physicians any savings resulting from system changes that lead to lower costs.

Critical to the success of each these concepts is the primary care physician responsible for managing the utilization of resources. That seems reasonable, assuming there are an adequate number of physicians ready and willing to assume that responsibility. The problem is, there is already a shortage of primary care providers, a shortage that experts expect to worsen with  the increased access to care following healthcare reform. Reuters reports: "The United States already has a shortage of between 5,000 and 13,000 primary care doctors, according to the Robert Graham Center. Add millions of previously uninsured people and the shortfall will balloon to as many as 50,000 doctors."

The development of ACOs and its medical homes (the primary organizer of care for the patient), as well as the other delivery and payment models, increase the importance of attracting more medical students to the primary care specialties. Secretary Sebelius responded to this in July by announcing the availability of $200 million in recovery funds to expand the training of healthcare professionals.  Of this $200 million, the government earmarked $47.6 million to support primary care training programs. There is a problem with this approach, though: it does not get to the root cause of the shortage. Increased funding for training is of little use when our best and brightest are not attracted to primary care as a career in the first place.

The Annals of Internal Medicine reported more than half of 422 physicians in 119 clinics feel time pressure during office visits, while 48 percent said their work pace is chaotic and 78 percent said they have little control over their work. These conditions were strongly associated with low physician satisfaction, high stress, burnout, and intent to leave. In addition to facing a career marked by dissatisfaction and burnout, a medical student choosing to study primary care today has to accept the fact that she will earn significantly less over her career than physicians in other specialties will. 

Primary care specialists have historically lacked our respect. As medicine became increasingly specialized and highly technical, we came to see primary care specialties as the choice of medical students with no choice. Fewer medical students have been choosing that career path, resulting in a lack of access to primary care that already exists. Even well-insured Americans are often frustrated with long wait times to be seen and many primary care physicians’ practices are closed to new patients.

As we debate various healthcare delivery and payment models, we must also challenge our basic assumptions about physician compensation and work/life balance. Americans must start recognizing the important critical role of our primary care physicians, and healthcare systems must be prepared to provide competitive compensation for their primary care physicians. Meaningful healthcare delivery reform relies upon a change in our appreciation, both emotionally and financially, for the increasingly important role of our primary care providers.

These days, no one is surprised when the news contains yet another report underscoring the conflicts of interest influencing the approval process for drugs or medical devices.  The latest scandal became known when the FDA announced  that four congressional representatives influenced the approval process for a patch used to surgically repair injured knees.  The FDA overruled input from its own researchers who reported the device had failed, requiring a second operation.  The representatives who pushed for approval of the patch reportedly had received significant campaign contributions from the product’s manufacturer.

This is the first time the FDA has ever publicly questioned the process behind one of its approvals, and it has asked the Institute of Medicine (IOM) to review the agency’s approval process. There are several other methods intended to uncover conflicts of interest in the medical device and pharmaceutical industries already underway.

But there’s a stakeholder in these scandals who is consistently overlooked – the patient. Think about it: you are recovering from surgery using this $3,000 patch to repair your knee, and now you are facing the possibility of a second surgery.  Additional surgery exposes you to additional risk of infection and other severe complications.  It also means significant economic loss to you, since you are unable to return to work, and to your payer if you are lucky enough to be insured. The official advice for you is to wait for the agency’s review of the device’s approval, with an admonishment “not to panic.” You’re left hoping for the best, which no one would consider an optimal medical outcome.

While we wait to see if the government’s transparency improvement efforts succeed in driving out conflicts of interest, we have a responsibility to participate more actively in our own care.  This starts with educating ourselves about our medical care, and the good news is there are more ways to do this than ever before.  Governmental agencies such as The Agency for Healthcare Research and Quality (AHRQ), which has launched a new patient-centered campaign called “Questions are the answer,” are looking for ways to empower patients and involve them in their care.  Major healthcare systems such as Aurora in Wisconsin and Group Health Cooperative in Washington provide extensive valuable educational resources for their patients. Several private efforts like WebMD are also one-stop shops for patients seeking diagnosis-specific information.

 In addition to educating yourself about your diagnosis, start asking your medical care providers about their relationships with the drug and medical device industries. Ask them about treatment alternatives and the clinical research data supporting their recommendations. Then collaborate with other patients to understand your medical care better, to share what you have learned, and to find out what others know. When educated patients join forces it will bring about changes in the way medical decisions are made and medical care is carried out. This powerful patient collaboration, especially in conjunction with governmental efforts, will result in the increased public awareness necessary to drive transparency in clinical research. Our government clearly can’t do it alone.

An article in yesterday's New York Times discusses research which seems to show exposure to the absurd improves our pattern recognition abilities. Readers of this blog will recall my (non-scientific, observation-based) theory that the trait for pattern recognition is undergoing an accelerated rate of evolutionary natural selection. This is because our individual success is increasingly dependent on our ability make sense of the chaotic barrage of information we are exposed to every day. Those who can manage to find sense in the nonsense will survive.

And, hey, there are actual scientists who agree with that theory (not that I thought it was original):

In a series of new papers, Dr. Proulx and Steven J. Heine, a professor of psychology at the University of British Columbia, argue that these findings are variations on the same process: maintaining meaning, or coherence. The brain evolved to predict, and it does so by identifying patterns.

Apparently, when your brain is asked to deal with nonsense, fal-de-ral, and fiddle-dee-dee non-sequiturs, it emerges ready to kick it up a notch when faced with real world problems.

So what's the moral of the story? To improve your chances of success, make more time to play around. Make time for art; hell, make art! Makes me wonder if the sub-title of this blog, "tracking down the next non-sequitur" is even too restrictive. But then again, it does call for a commitment to the pursuit of the odd....and the impossible.

Impossible? Things are happening everyday!