Posts by Bob Wachter

The Patient Will Rate You Now

These days, I’d never consider trying a new restaurant or hotel without reading the on-line ratings on TripAdvisor or Yelp. I seldom even bother with professional restaurant or travel critics. Until recently, there was little patient-generated information about doctors, practices or hospitals to help inform patient decisions. But that is rapidly changing, and the results may be every bit as transformative as they have been in traditionally consumer-centric industries like hospitality. Medicine has never thought much of the wisdom of crowds, but the times, as the song goes, they are a-changin’. Even if one embraces the value of listening to the patient, several questions arise. Should we care about the patient’s voice because of its inherent value, or because it can tell us something important about other dimensions of quality? How best should patient judgments be collected and disseminated – through formal surveys or that electronic scrum known as the…

Cutting Healthcare Costs: Searching – Ever So Gingerly – For the Right Words

During my med school psychiatry rotation, I was taught not to shy away from discussing suicide with a depressed patient. “You won’t be suggesting something they haven’t thought about,” my professor told me back in 1982. “By not raising it, you add to the sense of stigma and it just becomes the elephant in the room.” I later came to appreciate that discussing dying with patients nearing the end of life is much the same. From these experiences, I learned that while it’s completely natural to tiptoe around difficult issues, it’s sometimes the wrong approach. I wonder whether we’re making this mistake when it comes to discussing healthcare cost reduction. As with the depressed or dying patient, speaking in code is always risky, since it gets in the way of honest, straightforward dialogue. Moreover, in this case, using squishy language may open the door for misunderstandings, even obfuscation – such…

In Search of a New Rhythm on Today’s Wards

When I was a medical student, I remember wondering what my attendings did when they weren’t on the wards. As an attending now myself, trying to cram three half-month ward blocks into my hyperscheduled life each year, I find that sentiment charmingly naïve. I – like most of my faculty colleagues – am awfully busy these days, both on and off the wards. But one thing that makes the wards doable is that there is a certain rhythm to the experience. Check that: made and was. Until last year, the ward team (consisting of a resident, a couple of interns, and a med student or two) admitted new patients all day and all night, every fourth day. As their attending, I might have seen a couple of new admissions during the on-call day and chatted with the resident overnight about the most complex cases. But the team was mostly on…

A Pay Within a Play: The Awkward World of Private Insurance in the UK

I remember reading an article that observed that systems of universal insurance – which need to put their energy into providing a “decent minimum” for the masses – must also offer a “safety valve for the wealthy disaffected.” Canada bans private insurance for basic hospital and medical care services. So, when affluent Canadians want “the best,” some of them pop across the border to Cleveland or Ann Arbor. But from the time of its founding in 1948, the British National Health Service has allowed – and, depending on which party is in power, promoted – a private insurance market. Private insurance in a single payer, government run healthcare system is a funny animal: one part incest, one part conflict of interest, and three parts strange bedfellows. And it’s infinitely fascinating. Here’s how it works: The insurance part isn’t too difficult to understand. People living in Britain can obtain private insurance, and about…

The Crash of Air France 447: Lessons for Patient Safety

From the start of the patient safety movement, the field of commercial aviation has been our true north, and rightly so. God willing, 2011 will go down tomorrow as yet another year in which none of the 10 million trips flown by US commercial airlines ended in a fatal crash. In the galaxy of so-called “high reliability organizations,” none shines as brightly as aviation. How do the airlines achieve this miraculous record? The answer: a mix of dazzling technology, highly trained personnel, widespread standardization, rigorous use of checklists, strict work-hours regulations, and well functioning systems designed to help the cockpit crew and the industry learn from errors and near misses. In healthcare, we’ve made some progress in replicating these practices. Thousands of caregivers have been schooled in aviation-style crew resource management, learning to communicate more clearly in crises and tamp down overly steep hierarchies. Many have also gone through simulation…
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