archie, ed, and deanarchives.hsl.unc.edu/bullitt-lectures/20170301-nussbaum.pdf · 2017-03-03 ·...

Archie, Ed, and Dean:How Carolina Basketball Can Fix

HealthcareBullitt History of Medicine Club

Chapel Hill, NCMarch 1, 2017

Abraham M. Nussbaum, MD, MTSChief Education Officer, Denver HealthAssociate Professor of Psychiatry, CU SOMwww.abrahamnussbaum.com

http://www.abrahamnussbaum.com

http://www.ucdenver.edu/

© 2012 Denver Health

Archibald “Archie” Cochrane

• 1909-1986• Physician & epidemiologist• Namesake of the Cochrane

Collaboration• 1917: Father killed in Battle

of Gaza• 1931-4: Psychoanalysis with

Theodor Reik (Vienna)• 1934-6: Medical student• 1936: International brigade,

Spanish Civil War• 1939-46: Captain, Royal

Army Medical Corps


Medical SchoolSpanish Civil War


The POW years


Credit: http://nfs.unipv.it/nfs/minf/dispense/patgen/lectures/files/disease_causality.html

Austin Bradford Hill


Hill’s Criterion of Disease Causation


“Under the best conditions one would have expected an appreciable mortality; there in the Dulag I expected hundreds to die of diphtheria alone in the absence of specific therapy. In point of fact there were only four deaths, of which three were due to gunshot wounds inflicted by the Germans. This excellent result had, of course, nothing to do with the therapy they received or my clinical skill. It demonstrated, on the other hand, very clearly the relative unimportance of therapy in comparison with the recuperative power of the human body. On one occasion, when I was the only doctor there, I asked the German Stabsarzt for more doctors to help me cope with these fantastic problems. He replied, “Nein! Ärzte sind uberflussig.” (“No! Doctors are superfluous.”) I was furious and even wrote a poem about it; later I wondered if he was wise or cruel; he was certainly right.”

Ärzte sind uberflussig

Ref: Cochrane 1972


A familiar debate? The NHS as model

Credit: http://www.dnms.no/index.php?seks_id=136413&a=1


The Catcher In The Rye?

• Advocated for reforming the NHS by embracing RCTs

• Provide only those interventions with favorable cost benefit profile

• Influenced generations of epidemiologists and policymakers

• Cochrane later regretted that he left out a third “E” from the title: equity


Iain Chalmers gathers the evidence

1988-1992 1989


Cochrane Collaboration


“Nein! Ärzte sind uberflussig.”


How do you operationalize a Review?

Ref: Nussbaum and Stroup 2008


Wm. Edwards Deming

• 1900-1993• Mathematician and

industrial engineer• Founder of QI• 1921: BS, Wyoming• 1925: MS, CU• 1928: PhD, Yale• WWII: Census bureau

Japanese Union of Scientists and Engineers

• ToyotaLEAN• Out of the Crisis (1986)


The Demings visits Japan

Credit: http://alexsibaja.blogspot.com/2014/03/quality-management-system-deming-14.html


Credit: World Health Organization


Ref: Leape JAMA 1994


D. Berwick + L. Leape1999

D. Berwick + L. Leape2001

Pres. Obama2010

D. Berwick running CMS

From IOM reports to Federal Law


CMS alone has 13 QI programs


These groups all require QI


Moneyball for Medicine???

Credit: Oliver Munday, NYT


Dean Oliver, UNC PhD 1994

Credit: http://www.nba.com/kings/blog/dean-oliver-talks-analytics-fivethirtyeight/


The 1st basketball usage stats


Dean Smith + math


• Introduction entitled “The Statistical Basis For the System” indicates how much Dean believed in analytics

• Even a Dookie (Jay Bilas) called it “the best book on basketball I have ever read…”


The kind of stats he kept and…


…the ones that meant the most


Credit: http://reesenews.org/2011/03/18/the-carolina-legacy/12104/


• Post-retirement leadership book

• Includes chapter “The Olympics: When Winning Was the Goal”

• Distinguished between playing for relationships and playing for wins


• Instead of Moneyball for Medicine

• Could you have a medicine which used analytics to spur innovation while also pursuing relationships and virtues?

• That, incidentally, produced great outcomes?

The Carolina Way?

• Quantification is “a technology of distance”

• Which devalues trust and relationships

• …So we encourage physicians to “count something” instead of “seeing someone”

Should we count or see?

Pursuing a disease or a person?

Credit: wikimedia

Platonic medicine pursues disease as an ontological entity. (What you have.)

Hippocratic medicine pursues understanding of a person.

(Who you are.)


How medicine works

Credit: wikipedia, prevention.com, correcttech.com

Trauma surgery:heal with steel

Infectious disease:heal with pills

Psychiatry:heal with relationships


Hippocratic Oath concludes…

“May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.”


References

• Berwick, Donald M. 1989. “Continuous improvement as an ideal in health care.” N Engl J Med 320 (1):53-6.

• --. 2014. Promising care: how we can rescue health care by improving it. San Francisco: Jossey-Bass.

• Blythe, Will. 2006. To hate like this is to be happy forever : a thoroughly obsessive, intermittently uplifting and occasionally unbiased account of the Duke-North Carolina basketball rivalry. 1st ed. New York, NY: HarperCollins.

• Brennan, Troyen A., and Donald M. Berwick. 1996. New rules: regulation, markets, and the quality of American health care. 1st ed. San Francisco: Jossey-Bass Publishers.

• Chansky, Art. 2009. Light blue reign : how a city slicker, a quiet Kansan, and a mountain man built college basketball's longest-lasting dynasty. 1st ed. New York: Thomas Dunne Books.

• Chassin, Mark R. 2013. “Improving the quality of health care: what’s taking so long?” Health Aff (Millwood)32 (10):1761-5.

• -- and Jerod M Loeb. 2013. “High-reliability health care: getting there from here.” Milbank Q 91 (3):459-90.

• --, Jerod M Loeb, Stephen P Schmaltz, and Robert M Wachter. 2010. “Accountability measures--using measurement to promote quality improvement.” N Engl J Med 363 (7):683-8.

• Cochrane, A. L. 1972. Effectiveness and efficiency: random reflections on health services, The Rock Carling Fellowship,. London ,: Nuffield Provincial Hospitals Trust.

• Degani, Asaf and Earl L. Wiener, Human Factors of Flight-Deck Checklists: The Normal Checklist, ed. Ames Research Center. Moffett Field, Calif.: National Aeronautics and Space Administration, 1990.

• Deming, W. Edwards. 1982. Quality, productivity, and competitive position. Cambridge, MA: Massachusetts Institute of Technology, Center for Advanced Engineering Study.

• ---. 1986. Out of the crisis. Cambridge, Mass.: Massachusetts Institute of Technology, Center for Advanced Engineering Study.


References

• Education, Accreditation Council for Graduate Medical. 2013. Common Program Requirements.

• Gawande, Atul. 2010. The checklist manifesto: how to get things right. New York: Picador.

• Hagland, Mark. 2009. Transformative quality: the emerging revolution in health care performance. New York: CRC Press/Productivity Press.

• Halvorson, George C., and George J. Isham. 2003. Epidemic of care: a call for safer, better, and more accountable health care. 1st ed. San Francisco, CA: Jossey-Bass.Holden, R. J. 2009. "People or systems? To blame is human. The fix is to engineer." Prof Saf 54 (12):34-41.

• Institute of Medicine: Linda T. Kohn, Janet Corrigan, and Molla S. Donaldson, To Err Is Human: Building a Safer Health System (Washington, D.C.: National Academy Press, 2000)

• Institute of Medicine (U.S.), Committee on Quality of Health Care in America, Crossing the Quality Chasm: A New Health System for the Twenty-first Century (Washington, D.C.: National Academy Press, 2001)

• Kenney, Charles. 2008. The best practice: how the new quality movement is transforming medicine. 1st ed. New York: Public Affairs.

• Kohn, Linda T., Janet Corrigan, and Molla S. Donaldson. 2000. To err is human: building a safer health system. Washington, D.C.: National Academy Press.

• Leape, Lucian L. “Error in Medicine,” JAMA 272, no. 23 (1994): 1851–57.

• ---. 2014. “The checklist conundrum.” N Engl J Med 370 (11):1063-4.

• Makary, M. A., and M. Daniel. 2016. “Medical error-the third leading cause of death in the US.” BMJ 353:i2139. doi: 10.1136/bmj.i2139.

• Nelson, Eugene C., Paul B. Batalden, and Marjorie M. Godfrey. 2007. Quality by design: a clinical microsystems approach. 1st ed. Lebanon, NH: Center for the Evaluative Clinical Sciences at Dartmouth.


References

• Nussbaum AM, Stroup TS: Paliperidone for schizophrenia. The Cochrane Database of Systematic Reviews, 16(2): CD006369, 2008 PMID: 18425951

• --. 2016. The Finest Traditions of My Calling: One Physician's Search for the Renewal of Medicine: Yale University Press.

• Porter, Michael E., and Elizabeth Olmsted Teisberg. 2006. Redefining health care: creating value-based competition on results. Boston, Mass.: Harvard Business School Press.

• Richardson, William, Donald M. Berwick, J. C. Bisgard, Lonnie R. Bristow, Charles R. Buck, Christine K. Cassel, Mark R. Chassin, Molly J. Coye, Don E. Detmer, Jerome H. Grossman, Brent James, David Lawrence, Lucian L Leape, Arthur Levin, Rhonda Robinson Beale, Joseph E. Scherger, Arthur M. Southam, Mary Wakefield, and Gail Warden. 2001. Crossing The Quality Chasm. Washington, D.C.: Institute of Medicine.

• Smith, Dean, and Bob Spear. 1982. Basketball, multiple offense and defense. Englewood Cliffs, N.J.: Prentice-Hall.

• Smith, Dean, John Kilgo, and Sally Jenkins. 1999. A coach's life. 1st ed. New York: Random House.

• Smith, Dean, Gerald D. Bell, and John Kilgo. 2004. The Carolina way : leadership lessons from a life in coaching. New York: Penguin Press.

• Taylor, Charles. 1995. Philosophical arguments. Cambridge, Mass.: Harvard University Press.

• Teive, Hélio A. G. Guilherme Ghizoni Silva, and Renato P. Munhoz, “Wittgenstein, Medicine and Neuropsychiatry,” Arquivos Neuro-Psiquiatria 69, no. 4 (2011): 714–16.

• Urbach DR, Govindarajan A, Saskin R, Wilton AS, Baxter NN. Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med 2014;370(11):1029-38.


Questions?

Credit: Fritz Kahn

www.abrahamnussbaum.com

http://www.abrahamnussbaum.com

archie, ed, and deanarchives.hsl.unc.edu/bullitt-lectures/20170301-nussbaum.pdf · 2017-03-03 ·...

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