Monday, February 13, 2017

NHS Original & Mayo: World Class Health Care!

This is a re-working of a previous post on The Mayo Clinic: a sincere plea to the government to revert back to NHS Original which has all the ingredients in place for a world class Health Care System.

This is not Mayo Clinic © Am Ang Zhang 2009

The main features:

The needs of the patient come first. 

An Egalitarian Culture.

Healthcare is not a commodity.
A Fully Integrated System.
Private or Charity Patients are Equal.
No over treating at Mayo.
Competition does not serve patients’ interests.
Disincentive system that works.

What Makes the Mayo Clinic Different?

by Maggie Mahar

October 21, 2008

The needs of the patient come first. 

“At Mayo the focus is on the patient. The needs of the patient come first.  I think one of the Mayo brothers originally said it—and here, that really is the case,” says Patterson. “We also do high quality research at Mayo, and we have a graduate school of medicine.  But research is not the primary focus.

At Mayo, on the other hand, stardom is frowned up. “Mayo has been, from the beginning, a group practice,” says Patterson. “You really have to be a team player. People in administrative positions understand that everyone is an important member of the team.”

An Egalitarian Culture

You may have heard that at Mayo, doctors collaborate. But did you know that after their first five years all physicians within a single department are paid the same salary?  During those first years, physicians receive "step raises" each year. After that, they top out ,and "he or she is paid just the same as someone who is internationally known and has been there for thirty years,"  says Patterson. ("Most could earn substantially more in private fee-for-service practice." he adds.) 

“It doesn’t matter how much revenue you bring in,” Patterson explains, “or how many procedures you do. We’re all salaried staff—paid equally.

“Turnover is very low. It’s unusual for people to leave here, and when they do, many like me, wind up coming back.  You would be surprised—we celebrate many 35 and 40 year anniversaries. That fact that people stay so long is important to the success of the organization.”

Patterson does not sound as if he’s boasting. He didn’t found Mayo. He didn’t create the culture. He merely works there—and he is telling me why he likes it. 

Yet I believe that there is much that health care reformers can learn by studying how Mayo operates.

There is, after all, a difference between healthcare and hamburgers.  Healthcare is not a commodity.

Healthcare is not a commodity.

Yet—and this is key—although Mayo’s doctors are not worrying about the dollar value of what they do, they are not more extravagant than other doctors  in dispensing care.  Quite the opposite:  Extensive analysis of Medicare records done by researchers at Dartmouth Universityreveals that treatment at the Mayo Clinic in RochesterMinnesota costs Medicare far less than when very similar patients are treated at other prestigious medical centers.

Yet no one would suggest that Mayo scrimps when treating patients. The Clinic received stellar marks on established measures of the quality of care, and both patient satisfaction and doctor satisfaction were higher than at UCLA. 

…………when it comes to healthcare, lower costs and higher quality often go hand in hand. Mayo’s patients are not hospitalized as long as patients at other medical centers—and don’t see as many specialists—because resources are used efficiently, and diagnoses are made quickly.

A Fully Integrated System

“Here at Mayo, we can do things in a week that take several weeks to organize in New York,” says Patterson.  This is because Mayo is an integrated medical center.

For example, “In New York, each division has its own staff to make appointments.  If I wanted several specialists to see a patient, I had to go through each of those divisions. At Mayo, we have a pediatric appointment office that makes all of the appointments for pediatric patients.”

Meanwhile, at Mayo, “We have a unitary medical record and a very effective IT department,” says Patterson.  “We developed our own software, and we can we dictate notes—we don’t have to type.” (This is a boon because, believe it or not, many doctors don’t know how to type.) 

“In the hospital, what we dictate can be transcribed within about an hour.” Patterson adds. “In the clinic, it’s done by the next half-day. In the meantime, if someone needs to access your notes, they can dial in and listen to the dictation.”

Private or Charity Patients are Equal

The Mayo Clinic in Minnesota sees many local patients.  “And like New York, we have minorities—just different minorities.”

Like most academic medical centers, Mayo treats a fair number of patients who cannot afford to pay their bills. In 2007 it spent $182 million providing charity care and covering the unpaid portion of Medicaid bills—plus another $352 million on “quantifiable benefits to the larger community” which included “non-billed services, in-kind donations and education.”

That year, 100,000 benefactors gave the Clinic a record $373 million—enough to pay for the benefits the Clinic provided for the community, but far from the amount that would be needed cover the charity care Mayo provided.

When it comes to serving Medicaid patients, Mayo is generous with its time and talent. “Here, there is no distinction between Medicaid patients and other patients,” says Patterson. “I wouldn’t know whether they are on Medicaid, or have insurance from their employer. The business office knows that.”

At many academic medical centers, Medicaid patients are seen mainly by residents in a separate clinic. “At Mayo no one is seen only by residents. And we routinely spend 90 minutes with a new patent —going through X-rays, and a complete examination,” says Patterson. 

No over treating at Mayo.
It also is  important to keep in mind that, “contrary to popular assumptions, it’s the volume of services, not the price per service, that accounts for most of the variation in Medicare spending” observes Dr. Jack Wennberg, the founder of what is now known simply as “the Dartmouth research.” And as more than two decades of Dartmouth research have shown, it is the supply of hospital beds and doctors that drives volume—not patient demand. When more resources are available, as they are at UCLA, patients spend more time in the hospital and undergo more procedures. Yet outcomes are no better; often they are worse.

“UCLA knows it has a problem,” Wennberg confided in an interview last year. “But what are they going to do—close down beds and fire doctors? They need that stream of revenue that comes from the beds and doctors to service their debt.”  So Medicare spends more at UCLA—and some patients are over-treated. 

Competition does not serve patients’ interests.

The Mayos also made it clear that patients’ interests were not well served if doctors competed with each other. Late in life William emphasized that in addition to making a commitment to the patient, doctors must make a commitment to each other:  “Continuing interest by every member of the staff in the professional progress of every other member,” would be essential to sustaining the organization’s future.

More than one hundred years later, building a health care system that adheres to such a collective vision of its mission may be difficult. Perhaps it can only be done in Minnesota.

In the end, Mayo offers proof that when a like-minded group of doctors practice medicine to the very best of their ability—without worrying about the revenues they are bringing in for the hospital, the fees they are accumulating for themselves, or even whether the patient can pay—patients satisfaction is higher, physicians are happier, and the medical bills are lower. Isn’t this what we want?

Disincentive system that works.
Virtually all Mayo employees are salaried with no incentive payments, separating the number of patients seen or procedures performed from personal gain. One surgeon refers to this tradition as a ‘‘disincentive system that works.’’ Adds another surgeon: “By not having our economics tied to our cases, we are free to do what comes naturally, and that is to help one another out. .  .. Our system removes a set of perverse incentives and permits us to make all clinical decisions on the basis of what is best for the patient.”

These are values that can be traced directly back to William Mayo and Charles Mayo, who, together with their father, William Worrall Mayo, founded Minnesota’s Mayo Clinic in 1903. The Clinic was one of the first examples of group practice in the United States. As Doctor William Mayo explained in 1905: “The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, union of forces is necessary…it has become necessary to develop medicine as a cooperative science.”

Read the full article: What Makes the Mayo Clinic Different?

From: Leadership Lessons from Mayo Clinic

T e a c h i n g  f o r  T  o m o r r o w ’ s  P a t i e n t

Mayo’s combination of culture and technology is potent. The culture makes it okay for highly-trained providers to ask for help; the technology makes it easy to provide the help.
A Mayo Rochester internist speaks to the cultural influence: ‘‘The strong collegial attitude at Mayo allows me to call any Mayo  physician at any time and discuss a patient in a tactful and pleasant manner. I do not feel afraid or stupid when I call a world renowned Mayo surgeon. We respect each other. We help each other. We learn from each other.’’

A Mayo surgeon recalled an incident that occurred shortly after he had  joined the Mayo    surgical staff as the most junior member. He was seeing patients in the Clinic one afternoon when he received a page from one of the most experienced and renowned surgeons on the Mayo Clinic staff. The senior surgeon stated over the phone that he was in the operating room performing a complex procedure on a patient with a difficult problem. He explained the findings and asked his junior colleague whether or not what he, the senior surgeon, was planning seemed appropriate. The junior surgeon was dumb-founded at first that he would receive a call like this from a surgeon whom he greatly admired and assumed had all the answers to even the most difficult problems. Nonetheless, a few minutes of discussion ensued, a decision was made, and the senior surgeon proceeded with the operation. The patient’s problem was deftly managed, and the patient made an excellent postoperative recovery. A major consequence was that the junior surgeon learned the importance of intra-operative consultation for the patient’s benefit even among surgeons with many years of surgical experience.

No Internal Market, no silly cross charging.

Dr. Charles H. Mayo and Dr. William J. Mayo

“…….Mayo offers proof that when a like-minded group of doctors practice medicine to the very best of their ability—without worrying about the revenues they are bringing in for the hospital, the fees they are accumulating for themselves, or even whether the patient can pay—patients satisfaction is higher, physicians are happier, and the medical bills are lower.”

                                                                                   NHS & The Mayo Model: What if!

7/2/11 7:19 PM

Friday, February 3, 2017

Kindle & Vacation: The Cockroach Catcher @$0.99 on Kindle!

Today is the 7th day of the Year of the Rooster, Everyone's Birthday according to Chinese Tradition. I am offering the Cockroach Catcher for free for three days on Amazon after midnight Pacific Time. Afterwards it will only be $0.99!

Click Here: Amazon Kindle       Please review at Amazon!

Patagonia ©2015 Am Ang Zhang
It is always nice to be somewhere remote to see different landscapes and stimulate the brain, but there is one drawback: you do not have luggage to carry lots of books to read.!

This is where Kindle comes in handy. Yes a 3rd generation gadget that allows you to store and read books and other printed material.   You can pack with you many books on this device that weighs less than a paperback.

This has inspired me to launch a Kindle edition of The Cockroach Catcher (yes, the book).   More importantly, the Kindle edition costs a fraction of the physical copy.  If you do not yet own a Kindle, you can simply download the free Kindle software and read Kindle books on your iPhone, iPad , iPod touch & your Personal Computer. You can read the book within seconds from ordering.        US Verson

Here are some reviews:
on August 10, 2014
Format: Paperback|Verified Purchase

From a doctor friend:

The Cockroach Catcher has evoked many images, memories, emotions from my own family circumstances and clinical experience.

My 80 year old Mum has a long-standing habit of collecting old newspaper and gossip magazines. Stacks of paper garbage filled every room of her apartment, which became a fire hazard. My siblings tricked her into a prolonged holiday, emptied the flat and refurbished the whole place ten years ago. ……My eldest son was very pretty as a child and experienced severe OCD symptoms, necessitating consultations with a psychiatrist at an age of 7 years. The doctor shocked us by advising an abrupt change of school or we would "lose" him, so he opined. He was described as being aloft and detached as a child. He seldom smiled after arrival of a younger brother. He was good at numbers and got a First in Maths from a top college later on. My wife and I always have the diagnosis of autism in the back of our mind. Fortunately, he developed good social skills and did well at his college. He is a good leader and co-ordinator at the workplace. We feel relieved now and the years of sacrifice (including me giving up private practice and my wife giving up a promising administrative career ) paid off.

Your pragmatic approach to problem solving and treatment plans is commendable in the era of micro-managed NHS and education system. I must admit that I learn a great deal about the running of NHS psychiatric services and the school system.

Objectively, a reader outside of the UK would find some chapters in the book intriguing because a lot of space was devoted to explaining the jargons (statementing, section, grammar schools) and the NHS administrative systems. Of course, your need to clarify the peculiar UK background of your clinical practice is understandable.

Your sensitivity and constant reference to the feelings, background and learning curves of your sub-ordinates and other members of the team are rare attributes of psychiatric bosses, whom I usually found lacking in affect! If more medical students have access to your book, I'm sure many more will choose psychiatry as a career. The Cockroach Catcher promotes the human side of clinical psychiatric practice in simple language that an outsider can appreciate. An extremely outstanding piece of work indeed.

Most recent one from Chez Sam’s:

And CC, your book is amazing! I am only on page 44 but so far, so wonderful. I think how you turned this anorexia patient around just goes to show what human interaction rather than tick box protocols can do in a short period of time and at low cost too. This is an exemplary illustration on perhaps one of the reasons why a good health system like the one in Singapore can not be fully implemented in Britain. it's the change of perceptions and methodology to suit that's difficult.

And, as a city girl, I found your early life in villages fascinating and very enriching for a bright child like yourself, I suppose, had I been your mother, I too would have not asked you any questions when you were told to leave that school ... but the school supplier of cockroaches! [shiver]Dearime! I run a mile when I see one, let alone catch them and dissect them! boys will be boys after all, now that I know that you weren't joking. you are a cockroach catcher, not only of the soul, but for real! @@

The book is a must read doc, I am really enjoying it :-)”

More here>>>>>>

Zhang laments the dawning of the age of red tape in psychiatry, which is the same all over the world. The emphasis on "guidelines", also known as "evidence based medicine", and artificial restraints on access to services, have changed the landscapes of our practice. If everyone practices cookie cutter type of medicine, where will we find new thinking and new treatments? 
This book is a "must read" for all professionals in the mental health field, and for all interested individuals. It is a kaleidoscope of life seen from the eyes of the therapist who genuinely cares about his patients as people. Zhang provides an in-depth understanding of the human condition. 
In my view, this book gives us a glimpse into the soul of psychiatry, into holistic medicine at its best.

Thursday, February 2, 2017

Sadness & Abuse: As You Like It.

Abuse Abuse Abuse

All is not well in this beautiful part of the OLD WORLD that is Austria.

Salzburg, Austria ©2008 Am Ang Zhang

Josef Fritzl, an engineer in his seventies was found to have kept his 42-year-old daughter locked in his cellar since she was 19. The woman, who bore her father seven children during her captivity, was discovered only after one of the children she had with her father fell into a coma in hospital.

Austria does not have the monopoly of family abuse.

I can only quote from Chapter 27 in The Cockroach Catcher:

And your experience makes you sad:
I had rather have a fool to make me merry
than experience to make me sad…..
(from: As You Like It - Act II, Scene 7)

With so many quotable quotes from As You Like It you may wonder why I would chose to pick this one.
      Perhaps it is a warning to young doctors to enjoy the blessings of inexperience. Luckily for me sadness brought about by experience from my clinical work is mercifully little but I would be either dishonest or heartless to say that there has been none.
      As You Like It happens to be one of the few popular plays of Shakespeare that are often performed in schools, maybe apart from Dreams, and for most it is basically a comedy with a happy ending.
      My wife and I went to a recent production at BAM (Brooklyn Academy of Music) by none other than Peter Hall with his daughter playing Rosalind – their New York debut.  Few would imagine Sir Peter picking Brooklyn for his debut but in the end it was a great experience. The New York Times said that it was more reviving than spending a week in the Caribbean. Having been an accidental resident in the Caribbean for two years I would dispute the comparison but totally agreed with the sentiments expressed.
      At the BAM, it was like walking into a renovation site and in many ways I hope they leave it that way as it was rather charming. It was a most fitting setting for Shakespeare. I accept that they have to make sure it is safe.
      It was at the start of my psychiatric training in England when I asked one of my gurus about reading matter.  Apart from Shakespeare, he recommended Ibsen.  I have since read Ibsen's plays but still come back to Shakespeare, who seemed to be able to pick up so many strands of human experience.
      My ideal Shakespeare is indeed one that can be performed on a bed sheet with a few broomsticks for prop and without wanting to sound derogatory, I would say that this was exactly the approach adopted by this production.
      Much was left to the imagination and it worked.

Mrs Coleman
      Now and again in our work we get an indescribably sad case.  Sometimes what started out as a rather straightforward case might begin to roll downhill so fast that we would be forever taking deep breaths thinking: can it get any worse?  We would question if what we were doing was making any difference at all to what seemed like a predetermined course where no intervention would be able to make any impact on the final outcome.
      One thing is for sure, real life is not like a play – you have only one chance to perform it and often not everything is clear.
      Mrs Coleman came to see me about her daughter within months of my appointment as a consultant.  With my new job came advantages and disadvantages. I used to be able to ask my seniors about cases, especially the difficult ones. Suddenly I was supposed to know it all. I used to have a big team working on a case, to the point that when the patient came to me there was hardly anything left for me to discover. Single-handed consultants are “on their own”. They are lucky to have a social worker and perhaps a psychologist. I had both but the psychologist was not really part of our team – she happened to be sharing the same building. She belonged to the old school, which meant she knew her field and she did not try to be a social worker.  For a while it became fashionable to blame everything on background and upbringing. Any disturbed child not performing well at school had nothing to do with teaching methods or intelligence but everything to do with social background. What were the implications for the social background of bright high achieving children?
      There was some excitement in the clinic when it was known that a shepherd’s family had been referred.
      Shepherds?  "As You Like It" sprang into my mind.
      We have lambs so we must have shepherds – so I thought.  It is true that we seldom had referrals from the farming community. I can only remember one other case and that was when I was a trainee. Shepherds also conjure up scenes of nativity and there is a sort of biblical romantic feel to it.
      What we did have was something quite different. As it was unfortunately the lambing season, the shepherd Mr Coleman, though making a valiant appearance, was as good as asleep during most of the session. Mrs Coleman talked through the session with her rather charming old Sussex accent.
      Mrs Coleman at the time had two children but it was the older daughter Laura of nine with whom she was having trouble.   Tom, some eighteen months younger, was a happy-go-lucky sort of boy. Laura had a whole range of behavioural problems. She had recently taken to soiling in her pants.
      It was often our practice for the social worker to do a preliminary home visit, and my social worker told me that she was most impressed with their home when she visited. They lived in a tied cottage on the farm. The children’s grandfather was a shepherd and he had two sons, the older one working on the dairy side. There was also a daughter, the children’s aunt, and her husband was the local milkman. The aunt had children similar in age to Laura and Tom. She worked part time in the local greengrocer’s and between her and Laura’s mother they split the fetching from school and childcare. The aunt unfortunately was recently diagnosed with breast cancer and was having different kinds of treatment at the local hospital. Luckily her husband was a milkman and could take over the afternoon part of the childcare arrangement whenever necessary. Mrs Coleman took the children to school on the days when the aunt had to go to hospital.
      The aunt was a strong lady, Mrs Coleman told me, and she was sure she would outlive her.
      It was an old cottage they lived in and my social worker told me that Mrs Coleman kept the place clean and tidy. It was therefore most upsetting to her when her nine year old daughter started soiling herself.
      It was mostly in the afternoon but not everyday.
      As my social worker had just started her training at the Tavistock Clinic on child therapy it was a good chance for her to take the girl on for some individual therapy sessions. Like my old consultant did when I was in training, it was now my turn to see mother.
      This seemed to be a simple enough family and I did wonder at the beginning if there was much to unfold.
      I was proved wrong.
      Within two to three weeks of Laura starting therapy, Tom the younger brother refused to go to school. It was natural for everybody to think that there was some jealousy involved. So I arranged for mother to bring him to see me. It was rather obvious from the start that he was not very bright and that his not going to school had little or nothing to do with Laura but more to do with the fact that he could not keep up with the work and was being teased at school very badly. He tried to hit back at one particular boy and was told off by one of the teachers on duty at play-time. He did not want to go back. I arranged for the psychologist to assess him.
      Yes, he was functioning at a much younger age and yes, he needed to go to a special school. In those days it was called an ESN school – school for the Educationally Subnormal.  The SSN school was for the Severely Subnormal.  In the 90s, it was deemed more polite to call the subnormal children “special”.
      Both schools were local and extremely well run. Tom was transferred and seemed to have settled down well there.
      Not bad. I congratulated myself.
      Laura was getting on well with her new therapist. She was attending without any problem and was doing nice drawings, according to my social worker.
      Mrs Coleman was grateful that I sorted out her son.  Tom, who had always been a Daddy’s boy, had upset father very much with his escapade but as he had now settled in his new school father was rather pleased. He in fact went to the same school so he made it a point to turn up to thank me once everything settled.
      Mmmm, perhaps we are not escaping the genetics theory.
      As a precaution, we also tested Laura but she turned out to be rather bright.
      Genetics, you are wrong.
      Not so, Mrs Colman must have thought. She was rather perturbed when I told her. She started crying and pleaded with me to keep the secret she was about to tell me.
      Her husband was not Laura’s father.
      Mrs Coleman had worked at the local butcher’s since she left school and he was always all over her. Before long he was having intercourse with her at the back of the shop. He always gave her extra for that part of the service and she was happy with the extra bit of money. The butcher’s wife had a stroke a few years back and had been bed ridden.
      “It was not the money,” Mrs Coleman assured me. She did not want me to think of her as a slut.
      None of the mothers I saw wanted me to think badly of them and it often took a while before they would reveal their secrets.
      Mrs Coleman had also been seeing the shepherd but never gave him much thought as she felt he was rather stupid. The butcher was much brighter.
      Then one day some accident happened and she found herself pregnant. But the butcher was not going to divorce his wife. She was the one with the money.
      She decided that the next best thing was to let the shepherd sleep with her as long as he married her. He was so pleased with himself and they had a big white wedding in the local church. 
      So Laura was the butcher’s daughter and not her husband’s. Now that I had proved Laura was clever, she was afraid I might ask awkward questions although she doubted if her husband would ever really work it out for himself.
      Once a parent realised that you had ways to get to the truth, they often started revealing things that you wished they never did.
      The butcher had some idea that Laura was his and had been slipping even more extra money for mother to buy her things. He never had any other children.
      I never broke my promise and to this day I do not think that her husband ever knew.
      What was to unfold was what caused most sadness.
      I attended some special seminar on sexual abuse and at the time some rather ugly looking anatomical dolls were produced for the sole purpose of diagnosing Sexual Abuse. They were anatomical in that a whole family set including parents and grandparents, children and adolescent all had what was described as anatomically correct parts - females with breasts, nipples, vagina and anus; and males with penis and anus; and all the orifices were so to speak fully functional. These dolls all had proper clothes on and yet all the clothes could come off.
      The idea was that normal children played with them as normal dolls but abused children would perform with the anatomical parts.
      I had a full set ordered, having spent sometime persuading the managers that others had labs and X-rays and so on, but these were the only tools we required for the specific job.
      Laura was the first to discover them and before my social worker’s eyes one of the male figure’s penis was in the girl’s mouth. She told my social worker that was what Uncle Tom liked.
      What followed were special “disclosure” interviews conducted under camera. Uncle Tom was the milkman. It happened to both girls. When the boys were in the kitchen playing computer games on the TV, slowly the girls were made to suck him. That was when Laura started soiling.
      Mrs Coleman went berserk. Arrangements had to be made for alternative child care which really meant she had to cut short her hours at the butcher’s. Uncle Tom moved to his mother’s as a temporary measure pending Social Service investigation and Police enquiry.
      Mrs Coleman could not sleep at night and called her GP. He asked her to pray with him as she had to be forgiving. She was so angry and when she was cleaning around the house she managed to get some caustic liquid all over herself and had to be admitted to hospital. She was also referred to the adult psychiatric department.
      She started attending an anger management group at the hospital.  It was thought to be the best way to help her deal with recent events.
      One day when I went in to work, my social worker was already there and in tears. Mrs Coleman had just taken a massive overdose of Paracetamol and her liver was thought to be too far gone to survive.  She died a rather painful death and we were all deeply saddened.
      Could we have done any better?  Was the truth too much for Mrs Coleman to bear?  Would she still be alive if we had not discovered the sex abuse?  We would never know. We might have rescued Laura from sex abuse but now she had lost her mother. Mrs Coleman was right about one thing though, her sister-in-law did outlive her.
      As Shakespeare said, “…….And your experience makes you sad…..”
      I wanted to hide the dolls.