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

Feb 6, 2017

Building bridges at ISQua 2016 in Tokyo

Rainbow Bridge, Tokyo
“The older I get, the more clearly I remember things that never happened.”
 Mark Twain

I try and distill my three main action items after conferences as soon as I get back home, so that I can commit them to memory, or at least to paper. This report on The International Society for Quality in Health Care (ISQua) 2016 conference, as you can see, took a little longer to write! I would like to think that it was because I was still basking in the warmth of Japanese hospitality, or was busy networking with all the fabulous people I met at ISQua for months afterwards.

Why memorialize just three things, given that I learnt tons of new information over a span of 5 days at ISQua Tokyo? The rule of three says that messages or action items in threes are more likely to be remembered. Examples that come to mind are the Three Musketeers, Goldilocks and the Three Bears, Three Little Pigs, and Three Billy Goats Gruff. Messages such as Stop, Drop and Roll (fire safety), and Faster, Higher, Stronger (the Olympic motto) follow the same principle.

So here are my three action items from the 2016 ISQua conference - better late than never…

(1) Check out Charles Vincent and René Amalberti’s open access book. ‘Safer Healthcare - Strategies for the Real World’.
The book refocuses our attention on patient safety from the lens of the patient's environment - instead of focusing solely on healthcare professionals and hospitals. The authors urge us to think in terms of the management of risk over time over the course of the patient’s journey. This includes contexts other than the inpatient setting – outpatient care, nursing homes, the home environment, and the patient’s community. As a primary care pediatrician, I especially appreciated the book's attention to risks in outpatient settings, an area that has relatively recently been attended to in the world of patient safety. 

(2) Involve health professions students and trainees in reducing overuse of medical care.
Wendy Levinson, Chair of Choosing Wisely Canada, spoke about involving medical students in reducing overuse. Too much health care is harmful to patients and the healthcare system. More is not always better. So why is it so hard to change clinical practice? It starts with medical education. A fundamental problem with the culture of medical education is that trainee doctors are rarely challenged for over-ordering tests and are more likely to be criticized for not ordering them. About 20 countries so far are involved in the Choosing Wisely campaign. Dr. Levinson urged us to encourage students and trainees to question overuse and to have them consider if a test, treatment or procedure will change the patient’s clinical course and if there are less invasive options. Dr. Levinson’s session ended with this video parody of Pharell Williams' song, Happy.

(3) Discuss supplier-driven variation when I talk to clinicians about the problem of healthcare costs.
David Goodman’s plenary talk on variation covered supply-sensitive care. This is when the supply of a service or resource has a major influence on utilization. Dr. Goodman showed us how variation in care is frequently due to differences in local capacity. In areas where there are more hospital beds per capita, patients are more likely to be admitted to the hospital. In areas where more CT scanners are available, patients are likely to receive more CT scans. Even though patients may receive less numbers of procedures or tests in areas where there are fewer medical resources, there is no evidence to show that these patients live shorter or less healthy lives compared to patients in higher-spending higher-utilizing areas! This is further compounded by perverse payment incentives that ensure that capacity is maximized.

Improvement Science Panel
With 1200 attendees representing 60 countries, ISQua 2016 allowed me to make new friends and catch up with old ones. The panel on Improvement Science that I facilitated was international and diverse, with quality and safety researchers from six countries. I also led a seminar with experts from Australia, Ireland and Japan on designing education to change quality outcomes.

Between sessions I found some time to enjoy the amazing food and culture of Japan, and even bought a kimono! Arigato gozaimasu ISQua and Tokyo for an amazing and memorable learning and cultural experience.

- Ulfat Shaikh

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 m...