Dalai's PACS Blog

April-17-2014

13:04

Dear Accelarad customer,You should have received an email from me on Monday of this week, when I provided our customers an early insight into the announcement that Accelarad is now a part of Nuance Communications. At this time, I wanted to provide you some additional information and invite you to learn more.

You can read the full press release here: (Nuance Unveils PowerShare – April 17,2014)As discussed, this new union brings together our cloud-based medical image sharing technology and Nuance’s PowerScribe radiology reporting and communication platform. The partnership will give you, our valued customer, access to Nuance’s expansive healthcare technology and professional services, while continuing to provide you with the proven software and solid relationships you have come to expect from Accelarad. With this partnership, Accelarad’s SeeMyRadiology solution has been rebranded to align with the Nuance diagnostic brand, and will be part of the Nuance PowerShare Network. To learn more about PowerShare | Image Sharing, sign up to join one of our webinars.

Most importantly, know that the products and people you have come to rely on will not change. Accelarad's leadership team and valued employees will be deeply involved in creating a smooth transition for our customers, and our focus remains on making sure you continue to receive the excellent service you deserve.

Thank you again for your support and confidence in us. We will keep you informed about any incremental changes along the way and are open to your feedback.

Sincerely,                

Willie Tillery, CEO, Accelarad 

Rodney Hawkins, General Manager, Diagnostic Solutions, Nuance
For your viewing pleasure, here is the press release:

Nuance PowerShare Network Unveiled for Cloud-Based Medical Imaging and Report Exchange
Industry’s Largest Medical Imaging Network Helps Providers and Patients Coordinate Care and Share Information Across Distances and Disparate Healthcare Systems

BURLINGTON, Mass., – April 17, 2014 – Nuance Communications, Inc. (NASDAQ: NUAN) announced today the immediate availability of Nuance PowerShare™ Network, the industry’s largest cloud-based network for securely connecting physicians, patients, government agencies, specialty medical societies and others to share essential medical images and reports as simply as people exchange information using social networks. Nuance PowerShare Network promotes informed and connected physicians and patients who can instantly view, share and collaborate while addressing patients’ healthcare needs.

“Organizations are being tasked to communicate efficiently both in and out of their networks to provide clinical insight to physicians beyond one person or office to a much broader team involved in the continuum of care,” said Keith Dreyer, DO, PhD, FACR, vice chairman of radiology at Massachusetts General Hospital and Chair of the American College of Radiology (ACR) IT and Informatics Committee. “Nuance PowerShare Network addresses the information sharing challenge physicians face today with a network that supports things we’ve dreamed of doing for years,” he adds.

Fully Connected Patients & Providers
Nuance PowerShare Network is already used by more than 1,900 provider organizations for sharing images via the cloud using open standards. Made possible through the acquisition of Accelarad, this medical imaging exchange eliminates the costly and insecure process of managing images on CDs and removes silos of information in healthcare that inhibit providers from optimizing the efficiency and quality of care they provide. Anyone can join the network regardless of IT systems in place to instantly view and manage images needed to consult, diagnose or treat patients, enabling clinicians to more seamlessly evaluate and deliver care for patients who transition between facilities or care settings.

Nuance is already used by more than 500,000 clinicians and is a critical component within the radiology workflow and a trusted partner for 1,600+ provider organizations that rely on Nuance PowerScribe for radiology reporting and communications. Healthcare organizations that use Nuance PowerScribe, a group that produces more that 50 percent of all radiology reports in the U.S., can immediately leverage their existing investment and begin sharing radiology reports along with images, such as X-rays, MRIs, CT scans, EKGs, wound care images, dermatology images or any other type of image. This simplifies secure health information exchange between multiple providers, patients and disparate systems without costly and time-consuming interfaces, CD production or the need to install additional third-party systems.

“The challenge of sharing images with interpretive reports is something we’ve heard about consistently from our customers and EHR partners, and we know Nuance PowerShare Network will overcome this major obstacle, helping physicians treat patients more efficiently and effectively,” said Peter Durlach, senior vice president of marketing and strategy, Nuance Communications. “This nationwide network, one that is fully integrated into the EHR workflow and already connected to approximately half of all clinicians producing diagnostic imaging information, is a ground-breaking solution that delivers immediate benefits at an unprecedented scale to our healthcare system.”

“Integrated image and report sharing helps us deliver quality care and drive down costs especially when patients transfer from one facility to another. Whether at their desktop or on their mobile device, our physicians can see the study that was done along with the interpretive report, which provides the information they need to treat the patient and avoid duplicate testing,” says Deborah Gash, vice president and CIO, Saint. Luke’s Health System in Kansas City. “By integrating this with our EHR, PowerShare will enable physicians to manage inbound imaging through one point of access and login. Physicians in our 11 hospitals and 100-mile radius referral network see this cutting-edge technology as a way to deliver the highest level of patient care,” she adds.

To learn more about the PowerShare Network and the new image sharing solution, visit http://www.nuance.com/products/PowerShareNetwork to join one of our webinars. Connect with Nuance on social media through the healthcare blog, What’s next, as well as Twitter and Facebook.
Definitely an interesting constellation of services! I wonder where this might lead. Ironically, Rodney is also an old friend from the AMICAS days...

April-12-2014

15:02
A long time ago (November, 2005 to be exact), sitting in a radiology department far, far away from most of you, I bemoaned the problem of the "Portable Patient" in one of my early AuntMinnie.com articles:
Of the thousand daily frustrations I experience as a radiologist, perhaps the most painful is that of the "portable patient." You see, patients migrate from hospital to hospital, from clinic to clinic, and from office to office. They may be searching for a second opinion, a superspecialist, someone who will give them the particular answer they seek (some want to hear good news, some prefer bad news), convenience, drugs, or some combination of the above.

As often as not, they acquire a mountain of imaging studies along the way. When asked why they had a particular study at a particular site, the answer is invariably, "My doctor told me to have it there."

Add to that the dependence on our ERs for emergent (or maybe just impatient care, as I like to call it), and the ER's love of imaging studies. Put them together and you've got a collection of the patient's imaging studies spread across a city or even a state.
I was pretty smart back then, identifying a problem that many folks far wiser than I have been trying to solve since. And last year, I authored a follow-up article:
I've introduced you to a portable patient, and you can see what happened to her because no one knew about the examinations she had already undergone. She was irradiated, magnetized (probably less of a problem), and scared to death (arguably more damaging than radiation) because we have no way to connect the dots of her various studies.

Well, that isn't quite true. We do have ways -- we just aren't using them... Many years ago, when our old PACS needed replacing, I suggested to the IT types that the three hospital systems in our average town in the South combine efforts to create a single citywide PACS to serve all three hospitals and, particularly, all of their patients. I was told by the illustrious chief information officer that we couldn't even think of working with one of the other hospitals because it was "suing us" (which wasn't quite a lie ... they were challenging a certificate of need application). Millions of dollars and patient welfare down the toilet over C-suite egos.

There were and are other approaches. As an alternative to a central repository, connecting one PACS to another isn't that hard. The best way to do this -- and fulfill all HIPAA requirements in the process -- is to use an image-sharing system such as lifeImage (my personal favorite by a mile).

Don't even bother to suggest that CD-ROMs solve anything. They don't. They get lost, they get broken, they don't always load, the patient forgets to bring the disk, or the original imaging site forgets to send it, and darn, they're closed today...

At one of the clinics we staff, the clinicians come at me at least twice a day, every day, with an outside CD. After three years, I finally was able to convince the powers that be to load the damn things into PACS and merge the data with local exams. But the clinicians don't want to bother with waiting for the disks to load -- they want results now. In my opinion, CDs aren't even worthy of being drink coasters, given that huge hole in the middle. (And their older PACS rejects a significant percentage of the disks anyway.)

{snip}

Here's where I'm going to anger a lot of people, and this is of course why you like to read my rantings. The following is something that needs to be said, however, and I'm going to say it.

Given that ...
  • Not knowing that the patient has had prior studies leads to unnecessary imaging
  • Unnecessary imaging may expose the patient to unnecessary radiation, costs, and anxiety
  • Unnecessary radiation is bad for you, as is anxiety
  • We have ways to share prior studies
... then it stands to reason that today, in the 21st century, shirking our responsibilities to the patient in this aspect of medical imaging is malpractice. Yes, I used the "M" word. But that's exactly what it is. We are not doing what we should -- and what we must -- for patient care. It is high time to apply technology that has been around for a long time to unify patients' records, imaging and otherwise.

We are harming our patients out of ignorance, out of hubris (why would they go to any doctor/hospital/clinic other than me/mine?), and out of greed (I get the revenue if I repeat the study!). This is completely unacceptable...
Forgive the massive regurgitation of the last post, but you must acquire (or reacquire) the mindset of the necessity of image-sharing.

If you wondered if exams were really repeated under the "portable patient" scenario, let me assure you that they are.

A study from western New York showed:
(A)pproximately 90% of duplicate and potentially unnecessary CT scans were ordered by physicians who have little to no usage of the HIE when combining slices of users with less than 500 queries in 18 months. An opportunity therefore exists to reduce the number of duplicate CT scans if the physician is utilizing HEALTHeLINK to look up information and recent test results on their patients prior to ordering more tests. In addition, this also highlights a need to get more physicians participating and using the HIE in a meaningful way as more than 70% of duplicate CT scans were ordered by physicians who did not query HEALTHeLINK.
Another study from the University of Michigan found:

RESULTS:
In our sample there were 20,139 repeat CTs (representing 14.7% of those cases with CT in the index visit), 13,060 repeat ultrasounds (20.7% of ultrasound cases), and 29,703 repeat chest x-rays (19.5% of x-ray cases). HIE was associated with reduced probability of repeat ED imaging in all 3 modalities: -8.7 percentage points for CT [95% confidence interval (CI): -14.7, -2.7], -9.1 percentage points for ultrasound (95% CI: -17.2, -1.1), and -13.0 percentage points for chest x-ray (95% CI: -18.3, -7.7), reflecting reductions of 44%-67% relative to sample means.

CONCLUSIONS:
HIE was associated with reduced repeat imaging in EDs. This study is among the first to find empirical support for this anticipated benefit of HIE.
That's a lot of repeat studies. And a lot of excess radiation. We can wait for the study to be delivered from the outside place, or the outside CD to be loaded ("Film at Eleven") or we can redo the study. None of these choices are optimal. We can all see that.

So...Now that you've gone through the indoctrination, we can proceed.

I've known Hamid Tabatabaie for many years, starting back when he was CEO of AMICAS. (I guess that dates me. Like Mrs. Dalai's grandfather who died at 93 after having outlived 5 of his internists, I've gone through two subsequent AMICAS CEO's and I'm on my second or third Merge CEO. Justin, you'd better hope I get out of this business soon!) Hamid is one of the visionaries behind web-based PACS, of which AMICAS Merge PACS is still one of the best examples. Today, he heads lifeIMAGE, my favorite among the image sharing companies out there.

The story is making the rounds that Nuance, one of my least favorite companies, is diving into this arena, with the purchase of Accelarad. From Hamid's blog (I guess everyone has one now):
I spoke with a friend today who is now the sixth person to have heard rumors about Nuance entering the image sharing market. He thinks it will announce the acquisition of a small Atlanta-based company imminently. I know the target company rather well, think highly of the founders, and I’m happy to see them finally reap some benefit from their 15-year-old startup odyssey. They started out as a small PACS company and then carved out a niche by selling data center based teleradiology PACS, which I think delivers the great majority of its $6M or so annual sales.
This little company is apparently Accelarad. More on them in a moment. Back to Hamid:
We (lifeIMAGE) started out working with innovators and early adopters who believed in our cause. We believe in eliminating duplication of imaging, avoiding delays in care and excessive radiation, and improving quality of care for patients. To realize our goal, we build software that helps make medical images part of a patient’s record and helps physicians access imaging histories conveniently, from any setting. We’ll soon announce our fifth anniversary as a well funded, privately held company, with many remarkable results that make our team very proud...

..(I)mage sharing for serving radiology, with 25,000 or so US radiologists, where Nuance has its major presence, has been around for a long time. Innovations in teleradiology are well past their prime, so, we at lifeIMAGE do not see a disruptive opportunity to innovate in that area. We are focused on the far broader need, which exists among large health systems that need to avoid the cost and problems associated with repeat imaging orders. Their ordering physicians, our end-users, are non-radiology image intensive specialists who need access to patients’ imaging histories in order to reduce the rate of repeat exams. 
The cure for the portable patient indeed.
Recently, I’ve been fascinated with what professor Everett Rogers called “the law of diffusion of innovation.” It basically spells out that there is a point at which an innovation reaches critical mass. “The categories of adopters are: innovators, early adopters, early majority, late majority, and laggards.[1]” The early majority buy into a technology when it’s been well vetted by innovators and early adopters first. Every innovative and disruptive company looks for the sign that its technology has started to be adopted by the “early majority.” Nuance’s entrance into the image sharing market is an indication for me that the market is getting ready for broad adoption, validating what we already see in the lifeIMAGE customer statistics. Professor Rogers suggests that once 16% of the market has signed up for a technology, that’s when the early majority starts to adopt. Current lifeIMAGE customers represent nearly 16% of all US physicians...

lifeIMAGE is the most utilized image sharing network, designed for use by physicians across a wide range of clinical disciplines—neurology, orthopedics, cardiology, oncology, surgery, etc. Our position is unique in that our engine of innovation is fueled by this population of doctors, who encounter patients with outside imaging histories on daily basis. We also help providers with patient engagement strategies and lead the way in providing access to patients who can in turn share their imaging records with providers of their choice. So, indeed new market forces may very well validate the market and expedite adoption of our disruptive and expansive technology, innovation for which is guided by multi-disciplinary specialists, including radiologists....

When I was CEO of AMICAS, our team spent some time studying the concepts around disruptive technology. Its definition in Wikipedia is, “A disruptive innovation is an innovation that helps create a new market and value network, and eventually disrupts an existing market and value network (over a few years or decades), displacing an earlier technology.” That is what our web-based PACS was back in 1999.
To me, being rather more concrete than some, a "disruptive" technology is one that interrupts my workflow, and nothing could fit that definition better than what Nuance is really known for: Speech Recognition, also incorrectly known as Voice Recognition. Here we have a technology that displaces the human transcriptionist, freeing the hospital from the tyranny of employing said human and paying their salary and benefits. It dumps the work of transcribing and editing onto the radiologist with no increase in pay for the effort. And it barely works. A friend who is totally enamored with SR tried to show me how wonderful it functions in his enterprise. I watched him focus his entire attention onto the report screen, which was three monitors away from the radiographic image he was supposed to be interpreting. Yah, this is great and wonderful stuff. Now it does speed things along. My friend claims to be able to read 300 exams in 8 hours with <1% error-rate because of his beloved SR. I'll simply say that it wouldn't work that well in my hands.

I'm digressing, but for a reason. Nuance and the other SR vendors have made inroads into hospitals and other imaging emporiums with their disruptive technology. They ride in on the white horse of decreased turn-around time (TAT) which warms the cockles of the administrative types who live and die by picayune metrics like that. In addition, they convince these folks that it's CHEAPER to have the computer do the job than a cadre of benefit-sucking humans, and that's all they need to say.

I'm sure Nuance wouldn't enter the image-sharing market if they didn't think it would be lucrative. Few in this business (including me) do things for free out of the goodness of their hearts. As Hamid implies, Nuance's entrance to this space validates the concept, and I think validates lifeIMAGE as well, which I maintain does it better than anyone.

Accelarad seems to have the basics down, and Nuance has apparently made the GE-like choice of buying the technology en bloc rather than developing its own. Fine with me. Here's their description:

Our medical imaging solution combines the ease of social networking with the clinical precision and security that medicine demands, making medical image sharing with patients, colleagues and other organizations easier than ever. Accelarad allows you to quickly and securely upload, access, manage and share medical images from any Internet-connected computer, mobile device or via our app. So you have images and reports from any originating institution, physician or system at your fingertips from a single portal, allowing you to focus on what you do best–delivering patient care.



They say all the right things, and I'm sure the product does what it says it does. However, I'm equally sure that lifeIMAGE does it better:



Don't just take my word for it. Look at their website and arrange a demo.

In many ways, Nuance's entry presents an opportunity for lifeIMAGE to get its foot into (or back into) doors that might otherwise be closed. I've tried to become a lifeIMAGE customer. I believe in their system, and I know most of their people, many of whom brought me AMICAS years ago. But I cannot convince those that control the purse strings that image sharing is a critical necessity. They see that lifeIMAGE has a cost associated to it, nominal per patient though it is, which can be eliminated by someone sticking the CD-ROM that came taped to the trauma patient into a workstation. IF it works. IF it came at all. But happily, if there wasn't a CD-ROM to be found, well, gee, we'll just have to rescan the patient and CHARGE for the privilege. In other words, image sharing LOSES them money on both ends. But it is still best for the patient, and I'll stick to my inflammatory statement above: it is malpractice NOT to utilize it.

It may be that with Nuance pushing the concept using the sales force that sold the bean-counters on SR, proper consideration will finally be given to image sharing at places that shunned it before. Then, we can have the real discussion as to which company does it best. I've had many an argument with those who say only the large PACS companies will survive. In the image sharing space, there are no large companies as yet, although Merge's iConnect and Honeycomb are good starts. The entry of Nuance into the field could be a game changer...for the company that does it right. We'll see. Film at Eleven.

ADDENDUM

I am without a doubt getting old and I'm not completely on my game, the game of paranoia, that is. Normally, I would have seen this possibility, but it took a friend to analyze the data and inform me of the consequences. Here is what he said (he wishes to remain anonymous for obvious reasons...):

I pushed hard for an "outside study" solution. We were regular victims of Philips PACS non-DICOM CD's every night from a particular hospital. We looked at both lifeIMAGE and Accelarad, and went with the latter and it works well for us. However, the Nuance purchase suggests to me that they want to be a complete 3rd party reading group, and replace groups like Optimal. Once they can share images well, dictate reports and disseminate results, they become a radiology department for anyone. I'll bet they start advertising over-reads/consults by big institution names before it's all over.

It just looks to me like they are assembling the pieces of the puzzle to become "Uber Radiology". The video mentions/shows a graphic for telemedicine; that screams 3rd party. Any site can be set up to just put their system as a destination on each modality. Boom, you send them your images, they can be read. It's not even a "PACS to PACS transfer" but a replacement PACS. No onsite storage is needed, just the Nuance cloud.. oops until the internet is down and you don't have your images anywhere...
Hey, just because you're paranoid doesn't mean they aren't out to get you...

And Yet Another ADDENDUM

Interesting coincidence...Nuance just hired someone to "document, share and use" clinical information per their recent press release:
BURLINGTON, Mass., – April 7, 2014 – Nuance Communications, Inc., (NASDAQ: NUAN) today announced that it has named Trace Devanny as president of Nuance’s Healthcare business. Mr. Devanny will oversee Nuance’s largest division and lead its efforts to deliver a more seamless approach for healthcare professionals to document, share and use clinical information. He will report to Paul Ricci, Nuance chairman and CEO.

“Our healthcare business presents a significant opportunity for innovation, leadership and growth in today’s dynamic healthcare environment,” said Paul Ricci, chairman and CEO of Nuance. “As a healthcare technology industry veteran, Trace brings a powerful skillset that combines operational excellence, team development, customer engagement and a strategic vision. I look forward to working with him to lead Nuance and our healthcare business through its next phase of growth.”

Mr. Devanny has more than 30 years of executive leadership experience in the healthcare IT industry, having held executive leadership roles in multi-billion dollar, international healthcare organizations. He joins Nuance from TriZetto Corporation, where he served as chairman and CEO. At TriZetto, he drove revenue and bookings growth in excess of 20 percent and led the organization through a business and sales model transition. Previously, he held several executive roles at Cerner Corporation, most recently as president, over an eleven year period where he was instrumental in growing the company and revenues from a $340 million business in 1999 to a $1.8 billion healthcare IT leader. Earlier in his career, Devanny was president and COO of ADAC Healthcare Information Systems and held a series of executive positions with IBM and its healthcare business. He holds a BA degree from the University of the South.

“Improving quality of care while driving down healthcare costs is one of the most significant challenges that providers face today. Nuance is advancing these initiatives through innovative solutions that make it easier for providers to deliver patient care,” said Trace Devanny. “I look forward to working with this talented and ambitious organization to build on our momentum and make an even greater impact on the healthcare system at this important point in its history.”
Only the paranoid would put this together with my friend's speculation and see anything interesting...  What? Me? Paranoid? NEVER!

April-1-2014

13:23
Courtesy Wikipedia

You may recall my earlier post declaring my retirement within two years.

Fuggedaboutit.

I had attempted to start my retirement clock, and we had some long discussions on the topic. In the course of the discourse, various factors were mentioned, introduced, revealed, discovered, or otherwise made to appear which had not been present before. The cost for officially entering the short-term glide-path became more onerous than I thought it should.

Therefore, my request is now withdrawn. When my numbers and the stars align properly, I'll be giving my 90 day notice. That might be tomorrow, or it might be 10 years from now. So much for a heads-up to allow for planning, hiring, etc.

And this time, you may disregard the date of the post.

February-21-2014

9:30
In my daily barrage of email came this announcement from Merge, which you can also find on Yahoo Finance:
CHICAGO, Feb. 21, 2014 (GLOBE NEWSWIRE) -- Merge Healthcare Incorporated (MRGE), a leading provider of innovative enterprise imaging, interoperability and clinical systems that seek to advance healthcare, today announced that its Board of Directors has appointed William J. Devers Jr., president of Devers Group Inc, as a director, effective immediately.

"We are very fortunate to have a new director with such a considerable amount of business and software experience added to the Merge Board of Directors," said Merge Chairman Dennis Brown. "Bill's knowledge and vision will make him a significant contributor to helping Merge execute the business plan it has formulated to increase its market position in enterprise imaging and interoperability. We believe that his strategic insights and guidance will be critical as we look to increase shareholder value."

Devers was the CEO of Trans Union Credit Information Company. He left Trans Union in 1983 and started Devers Group as a vehicle for his private investments. Devers group began with an acquisition strategy, acquiring software companies in various vertical markets. Prior to divestitures, Devers Group had revenues of approximately $100 million and employed approximately 700 people.

Over the past 30 years, Mr. Devers has bought and sold over 20 software concerns, including sales to EDS, Klopotek (Berlin, Germany), DBS Systems and others. Currently, Mr. Devers manages DGI Private Equity Ventures, LLC, serves on the Board of Directors of Ryan Specialty Group, Lurie Children's Hospital of Chicago, the Big Shoulders Fund and is a less than 3% non-voting shareholder of Merrick Ventures. In addition, Mr. Devers serves on an Advisory Board at the University of Notre Dame and is a Trustee of the Museum of Science and Industry in Chicago.
Italics are mine. Mr. Devers sounds like an excellent addition to the Merge team. But I'm a little intrigued by the mention of the buying and selling of software concerns. Are we announcing more than we are announcing?

Hat tip: TOAOPM

February-12-2014

14:39
From Aeon Magazine comes an interesting and somewhat overdue piece on one of Medicine's worst-kept dirty little secrets: Doctors (and nurses) can be mean, and that impedes patient care. 

The author, Ilana Yurkiewicz is a third-year medical student at Harvard,  and blogs for Scientific American. She does bioethics research at Harvard, and her work has been published in the Knee-Jerk (I mean New England) Journal of Medicine. Clearly, she has the credentials to speak of what she speaks.

Her Aeon article, Why Rude Doctors Make Bad Doctors, is a must-read for anyone in this business. Ms. Yurkiewicz bemoans the culture that allows and even encourages bad behavior, and points out how it might end up damaging the patient, not just the tender ego of a doctor-wannabe.  
One doesn’t have to work in a hospital long to experience or observe some form of disrespect. This is hardly a secret. The bullying culture of medicine has been widely written about and portrayed in popular media. In one study, published in 2012 and conducted over the course of 13 years at the David Geffen School of Medicine at the University of California, Los Angeles, more than 50 per cent of medical students across the US said they experienced some form of mistreatment. Behind closed doors, we share advice on whom to hang around and whom to avoid.

At the start of my third year of medical school, when we would finally enter the hospital wards, we had an orientation: ‘Wear a raincoat,’ the doctor standing at the podium advised. I could expect to get rained on.
Those of you reading this who are not directly part of the health-care universe might not be able to relate. But most of you will understand. The myth of the malignant surgeon throwing instruments is not all that far from the truth. These days, the flying projectiles are mostly verbal, and sometimes subtle, but they cut just as deep.
Most of my friends in medicine have witnessed flagrant episodes of hospital bullying and have juicy tales to tell. But medical disrespect is usually far less dramatic, dished out in the form of ‘micro-aggressions’: exasperated sighs, a sarcastic tone, the dismissal of alternative ideas. It’s the subtle put-downs about a trainee’s competence that erode confidence; the public shaming for an incorrect answer on rounds; or the denial of simple privileges such as taking a chair or reading a chart. It’s the psychological effect of being called by your rank instead of your name, or having it made clear that your presence is a burden instead of a help. It’s being ignored. It’s other team members looking on when the disrespect occurs, afraid to challenge it and defend those lower on the totem pole. These are the acts that affect our state of mind in small but cumulative ways. This is the stuff that creates a culture.

You learn to deal. This is how it is. That’s the system. It’s ingrained. You excuse bad behaviour with the platitude: ‘That’s just the way (s)he is.’ You appreciate from your elders that it could be much worse – at least they can’t throw scalpels at you anymore.
And it was bad enough in my day. I dodged a lot of it, but I felt, saw, and heard enough to confirm Ms. Yurkiewicz's observations. As a medical student, and even as a Radiology resident, I have seen the snide looks and snarky remarks flowing like sewage from the more arrogant and nasty of residents and attendings downhill to the objects of their scorn. And I've been the victim of this, often deservedly, often not.
But it is also much more dependent on the communication and relationships among different members of the team. Now, enter the culture of disrespect. Suppose an attending physician makes withering critiques or unreasonable requests. A resident, hoping to avoid such abuse, slowly but surely starts to hold back. She holds back some questions for fear of burdening and, under the constant stress of being scolded, becomes immersed in details of efficiency. Whether she intends it or not, she gives off vibes of unavailability, spending hours hunched over a computer in the physician’s conference room cranking out progress notes and scheduling patient appointments. Meanwhile, a patient starts to take a turn for the worse, but it’s not completely clear-cut – his vitals are just a bit off, his belly seems distended, and he complains of abdominal pain but is also known to the team as someone who complains. The nurse hesitates to voice her concerns to the resident, who is swamped doing paperwork and updating discharge summaries exactly the way the attending prefers. The patient continues to go downhill, and by the time word gets out the patient is much sicker – and needs to be treated far more aggressively – than would otherwise have been the case.
The more you fear being caught in a mistake, the more likely you are to make more, and to cover them up. Rather than worry about harming the patient, the young skull full of mush learns to dodge bullets directed at him, and the patient be damned.
When someone is unpleasant or demeaning, something switches in the minds of those on the receiving end: they sacrifice honest communication to save face. I’ve seen it in action so many times that the pattern has become predictable. Preoccupied with fear of appearing incompetent, team members keep uncertainties under wraps.

{snip}

The link between harsh words and medical errors was reignited in 2012 when Lucian Leape, professor of health policy at the Harvard School of Pub­lic Health, published a two-part series in Academic Medicine. ‘A substantial barrier to progress in patient safety is a dysfunctional culture rooted in widespread disrespect,’ Leape and his co-authors asserted. ‘Disrespect is a threat to patient safety because it inhibits collegiality and co-operation essential to teamwork, cuts off communication, undermines morale, and inhibits compliance with and implementation of new practices.’

It’s not that jerky personalities are reserved for those at the top. There are nice people and mean people at every rank. But in a system dependent on the proper functioning of hierarchy, it works like this: when anger and intimidation flow down, information stops flowing up. The chain of communication becomes clogged.
It bears repeating in large font:
In a system dependent on hierarchy, it works like this: when anger and intimidation flow down, information stops flowing up.
And THAT is when the mistakes propagate further and faster, and the patient is the one that suffers. Ironically, the perpetrators often realize that this is the case:
In another study by Rosenstein and O’Daniel, nurses and physicians self-reported behaving badly in near-equal numbers. Most felt this behaviour resulted in increased errors, lower quality of care, and lower patient satisfaction. Seventeen per cent could name a specific adverse event that occurred as a direct result of disrespectful behaviour.
You are probably asking at this point, "WHY does this happen?" The answer, like so many in medicine, is TRADITION. For many years, interns, residents, and even medical students were kept up for days on end, struggling just to stay awake, let alone actually learn something and treat sick people. This tradition lasted for years and years, mainly because their elders did it too. Medicine, being more of an apprenticeship than anything else, can sometimes ignore facts that contradict long-held opinions:
Yet despite such (bad) outcomes, many in medicine actively protect the culture of disrespect because they hold a fundamentally flawed idea: that harshness creates competence. That fear is good for doctors-in-training and, by extension, good for patients. That public shaming holds us to higher standards. Efforts to change the current climate are shot down as medicine going ‘soft’. A medical school friend told me about a chief resident who publicly yelled at a new intern for suggesting a surgical problem could be treated with drugs. The resident then justified his tirade with: ‘Yeah, yeah, I know I was harsh. But she’s gotta learn.’
Bottom line, this crap kills. And it needs to change.
We can no longer deny the facts. Bad cultures lead to bad outcomes. Jerks do not make good medicine. They foster a backwards atmosphere that degrades trust, tarnishes open communication, and promotes cover-ups.

Creating a culture of respect is not just about feeling good, for its own sake. It’s better for patient care.
There are solutions out there, mainly dealing with individual, solitary incidents. But how do you change a culture?

...(W)e should put an end to the premium that the medical establishment places on saving face. This is a hazard. It feeds the egotistical environment that can lead to ignoring input and failing to ask for help. It creates doctors who value looking like they know what they’re doing at all times more than actually doing what is best.

(W)e should be getting to the root of the behaviour. Why do people behave badly? Some are just jerks. Some imitate jerks. But we also can’t ignore a system that takes loads of formerly ‘nice’ people and churns out jaded, bitter, and gruff ones. We have to call attention to the external factors that can contribute. The lack of sleep. The poor hours. The system that overbooks and overworks.
The suffering we see among our patients overshadows our personal pain, but...
Environments such as these persist in part because of our unique vantage point in taking care of others at some of the worst points in their lives. How can I say ‘I’m tired’ or ‘I’m hungry’ or ‘He hurt my feelings’ in the face of such profound human suffering? Yet it’s hardly absurd to ask for better working conditions. When working in a system that treats us all humanely, we’re more likely to be humane to each other, and to our patients.
I'm not the world's best radiologist, although I think I hold my own. This will sound like whining, and it is, but I truly think I would have been a better physician, and a better radiologist, had the culture been different. Had my many mistakes (and we've all made them in this business) been used more as teaching opportunities, and less as excuses for public humiliation, I think I would have learned more from them. To be honest, the majority of my mentors in medical school and residency were indeed wonderful teachers, with the gift of making you happy you had made the mistake they were correcting. But I had a few, and they tended to be the BIG NAMES in the field, who would take off after any answer and any action that was less than perfect. As one of the more mediocre trainees, I got a lot of that from these people.

In radiology, our mistakes are laid out for all to see, available at the click of a mouse. Arrogance has no place here. Every single radiologist has missed more stuff than any of us will admit. It is part of being human, and having by definition limited knowledge and limited perception. Some of us are certainly better than others, and I can tell you who in my group has the fewest misperceptions (not me) and who has relatively more (also not me, at least on good days). Pointing out the mistakes of others in the current climate helps no one but the trial attorneys. Sadly, a corollary of this whole discussion is that the same arrogant, nasty SOBs who think they are God's gift to humanity are quite happy to point out to their patients when someone they deem beneath them has not performed to their standard. Why do this? Because they can. Because the rest of us don't call them on it. Because sometimes they are right, and we did make a harmful error.

I've addressed this in a prior post, wherein I address those in the big medical Mecca who took it upon themselves to tell a patient I had missed something...when I had done no such thing. Some would advocate legal action for this libelous stuff, but I don't believe in social engineering via the legal system. What we have to change is indeed the culture of what boils down to bullying. As Ms. Yurkiewicz puts it:
Instead of looking away sheepishly when our colleagues are mistreated and apologising for bad behaviour with tired mantras, we should push back. Bullies have ripple effects. Medical students mimic the behaviour of residents who mimic the behaviour of attendings until a problem with attitude can extend from a few people to an entrenched culture. Instead of riding that wave, we could shun bad behaviour. This is easier said than done. But cultures change because people within commit to changing them; it won't come by decrees. A culture that shames bullying makes the bully look like the bad guy, rather than making the recipient look weak.
Of course, I'll be long-retired before we see this sort of sea-change in medical culture. But it is reassuring to know that it might be coming after all.
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