Nov 8, 2018

Please Don’t Hide the Forceps

This intriguing story of the Chamberlen family makes the case for sharing what has worked for us in healthcare improvement. Back in 17th century England, the Chamberlen family bucked the trend. Although most babies in those days were delivered by female midwives, the Chamberlen men were well-known for generations for their obstetric skills.

William Chamberlen arrived in England from France and worked as a pharmacist. His family was famous in the midwifery world for their ability to deliver babies safely. William’s son, Peter, attended the childbirths of the wives of King James I and King Charles I. The Chamberlen family was known for their skills in safely delivering babies who presented in the breech position. Back then babies in the breech position frequently died, and their poor mothers also died with them in child birth. The family was also well-known for their skills in managing difficult and obstructed labor. This was especially timely given the prevalence of vitamin D deficiency rickets back then, which caused pelvic deformities in women and subsequent problems with childbirth.

Peter Chamberlen
Turns out that the Chamberlen family’s success came from their proprietary obstetric forceps, variations of which are used to this day in difficult births. The family designed these forceps and subsequently kept them top-secret. They transported the forceps to the mother’s bedside stored in a large highly decorative wooden box, personally transported by the Chamberlens in a special carriage. The expectant mother was blindfolded to prevent her from seeing the box’s contents, the birth was conducted under blankets, and no one except the Chamberlens were allowed to enter the birthing room.

The Chamberlen obstetric instruments
The story ends with a sordid twist when the Chamberlen's obstetric instruments, including five pairs of obstetric forceps, were discovered hidden under the floorboards of the attic of their family home in 1813. After Peter Chamberlen died, his wife, Ann, stowed them away there for over a century. The instruments are now with the Royal College of Obstetricians and Gynaecologists in London.

I’ve spent the better part of the last decade working in health care quality and deeply appreciate communities of practices or quality improvement collaboratives in healthcare. According to one definition, “Communities of practice are groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly.” Communities of practice can exist face-to-face in physical settings (hospital wards, outpatient clinics) or virtually (online discussion boards, virtual learning collaboratives).

Regardless of the setting, my work as well as those of others has shown that the special sauce in communities of practice in healthcare is the clinician champion – someone who is a passionate advocate for advancing the cause, and believes in sharing and collaborative learning. How do we identify clinical champions? It’s more than expertise. Look for these behaviors - Someone who makes connections between different people, is an enthusiastic cheerleader for the innovation, has the resourcefulness to find and mobilize resources, is savvy about navigating socio-political environments, effectively communicates a compelling vision, gets things done despite resistance or inertia, and is not afraid of sharing what worked or did not work for them. Realize that these are not necessarily the loudest people in the room.

So please don’t hide the forceps. Share your work generously. Imagine how many babies and moms a Chamberlen clinical champion might have saved.

Leave a comment - How do you share what has worked or not worked for you in your healthcare work?

Dec 30, 2017

Have Van Will Travel

On a sunny Thursday afternoon, I pulled into the parking lot at Encina High School in Sacramento, California, to meet Anna Darzins the manager of the Health on Wheels (HOW) Van. A small group of mothers and their children sat at folding chairs and tables outside filling out clinic forms.

A 5-year old boy was being weighed by a medical assistant inside the compact, but surprisingly well-equipped van, run by Elica Health Centers. The van has two exam rooms, equipped to examine people of any age, a reception area and a nursing station. Reminds me of the model apartment at my local IKEA store that amazingly packs in everything a small family could need - including a bicycle, a baby crib, as well as the kitchen sink - into a compact 200-square feet.

The Health on Wheels Van started about four years ago in collaboration with the San Juan Unified School District in Sacramento. The mobile clinic visits several school campuses within its service area and offers primary care, preventive care, vaccinations, sports physicals, and other clinical services to uninsured students at schools for free four days a week during the school year.

Since its inception, the van has scaled up its services to provide street medicine to Sacramento’s homeless population, preventative screening at health fairs, medical care at refugee centers, and pre-employment physical exams to young adults at local community colleges. The van has a close relationship with law enforcement, and police officers can bring people in need to the van for health care services. The van has a veterinary program that brings care to animals at homeless encampments. Local nursing and physician assistant training programs use the van as a community-based clinical training site.

Effective strategies to improve population health extend care beyond the four walls of brick-and-mortar clinics and hospitals. Increasing access through mobile clinics reduces unnecessary emergency department use and helps vulnerable populations manage chronic conditions such as high blood pressure and asthma.

Mobile clinics run by health systems enhance their outreach efforts, increase their visibility in the community, and serve as a source of referral to brick-and-mortar clinics and hospitals.

Operating costs for a mobile health clinic are estimated at about $500,000 for the first year, factoring in the cost of the vehicle, and approximately $250,000 annually thereafter. Despite these expenses, mobile clinics provide effective and cost-effective care, primarily due to reductions in avoidable hospital and emergency department visits. For instance, The Family Van, a mobile health clinic that provides medical care to the poor in Boston, has a return on investment of $36 for every $1 invested.

Are there any downsides to mobile clinics? If they provide only sporadic care instead of facilitating continuity of care, they serve as temporary solutions to a more pervasive access problem. This potential drawback can  be mitigated by strong connections to community resources and local clinics that can provide additional resources to their patients.

There are approximately 1500 mobile clinics in the United States. These clinics get 5 million visits patient visits each year. Mobile clinics are quite literally, an alternative vehicle to bring health care to the under-insured and uninsured, and to people who have trouble accessing healthcare due to health status, language barriers, homelessness, lack of transportation, or their geographic location.

- Ulfat Shaikh

Aug 20, 2017

My visit to the Royal College of Surgeons Ireland... In which I delve deeper into the intriguing history of barber-surgeons

“All things change except barbers, the ways of barbers, and the surroundings of barbers. These never change. What one experiences in a barber’s shop the first time he enters one, is what he always experiences in barbers’ shops afterwards till the end of his days.”
 - Mark Twain, in About Barbers.

All I learnt about barbers from Mark Twain was about to be proven wrong during my up close and personal tour of the Royal College of Surgeons in Ireland (RCSI), graciously provided by Frank Donegan, Head Porter of RCSI.

A big thank you to my gracious hosts, Siobhán McCarthy and Ciarán O'Boyle from the RCSI Institute of Leadership. It was fun talking to your students and faculty about building a career in health care quality improvement and patient safety.

The historic RCSI building on St. Stephen’s Green was seized by rebels of the 1916 Easter Rising. Reminders of the revolution can still be seen here in bullet holes in the façade of the building and in a door that I found myself standing too close to. 

Having been the unfortunate victim of a Colles’ fracture when I was 8 years old, I attempted to gain some closure on that traumatic experience by visiting the Abraham Colles Room at RCSI. Colles was elected president of RCSI in 1802 when he was only 28 years old, where he served as a professor of anatomy, surgery and physiology.

Perhaps the most intriguing part of my tour was learning about the history of the barber-surgeons. Back in the good old days, barbers provided haircuts, trimmed and shaved beards and heads, picked lice, and cleaned ears. Barber-surgeons were medical practitioners who did all of this, and additionally performed bloodletting and minor surgeries, cut out hangnails, set fractures, lanced abscesses, administered enemas, pulled teeth, conducted autopsies, and embalmed the dead. Bloodletting as a skill was in hot demand back then, and was used to treat a whole host of maladies, such as fevers, headaches, and constipation. Although barber-surgeons frequently had no formal education, they were training through rigorous apprenticeships, some lasting up to 7 years. Barber-surgeons were a popular bunch, since they ran a one-stop shop and their prices were considerably cheaper than those of physicians.

To advertise their services, barber-surgeons placed bowls of their patients’ congealed blood in their windows. However, this grossed out some people, and in 1307 a law was passed in London that declared that “no barbers shall be so bold or so hardy as to put blood in their windows”. Instead they were ordered to discard the blood into the River Thames! The barber-surgeons then devised the barber pole as a way of advertising their services. The pole represented the staff that the patient gripped tightly during bloodletting to make their veins more visible. A brass ball at the top symbolized the container that collected blood. The red and white stripes on barber poles signify bloodied and clean bandages used during procedure.

In 1540, the Fellowship of Surgeons and the Company of Barbers were integrated by Henry VIII to establish the Company of Barber-Surgeons. The surgeons demonstrated their elevated status by wearing long robes. Barber-surgeons wore short robes and were known as “surgeons of the short robe”. The barber-surgeons’ guild negotiated contracts to prevent other craftsmen from encroaching upon their scope of work and ensured the delivery of high quality services by employing inspectors to verify skills of its members.

In 1745 the two groups split up due to ongoing tensions, and barbers who cut or shaved hair were no longer permitted to perform surgery. To distinguish their services, barbers used blue and white poles, and surgeons used red and white poles. Our local barber in Davis has a red, white, and blue barber pole outside his door. My interpretation is that he is proud to be American. Another more common interpretation is that red symbolizes arterial blood, blue represents venous blood and white represents bandages. Spinning barber poles move in a direction that symbolizes the downstream flow of red arterial blood.

And finally, here’s a little tidbit that nicely illustrates the eccentricities of the medical world. Since many physicians back then believed tasks such as bloodletting to be beneath them, those with university medical degrees who treated patients through more cerebral methods referred to themselves as “doctor”. Barber-surgeons and surgeons (who back then had no formal medical education) were referred to as “mister”. This history is responsible for the still-existing curious practice in the United Kingdom and the Republic of Ireland, where new doctors are called Doctor but once they become surgeons, they go back to being addressed as Mr., Miss, Ms., or Mrs!

- Ulfat Shaikh