Musings of a Cancer Doctor

Wide-ranging views and perspective from George W. Sledge, Jr., MD

Sunday, September 4, 2011

Lives Lost

This morning my car was trapped in the last block before the parking lot, like it is every morning. Unfortunately I was trapped inside it.  To pass the time I was listening to Steven Levy’s In the Plex, a wonderful exploration of Google and its effects on the Internet and our lives.


One of the core principles of Google is processing speed.  This is a company that genuinely cares about time, and ruthlessly looks for ways to shave excess time off of every process. This comes all the way from the top: one of the two founders is able to measure a 200-millisecond difference when he evaluates a program. Latency -- page load time -- is the enemy, and every millisecond counts.


The metric used by Google insiders is one of “lives lost.”  The principle is straightforward: count up the number of seconds in the average person’s life. If a Google app takes an extra second to load, and if ten million people are using that app every day, well then you have used up X number of lives -- you can do the math. Google developers even have a “cap and trade” system in “lives lost” that restricts wastefulness. They have made untold billions for a reason: they are far more efficient than most of us, and they believe that their products should be efficient. They are kind enough to save our time as well as theirs.


What a powerful concept. I sat at the light at the northwest corner of the lot, drove (slowly) down the street to the next light, sat waiting for that light to turn, turned left, hit the stop sign at the next corner, turned left again, then crawled into the parking garage, waiting for the cars ahead of me to swipe their garage cards.  The whole process takes five to ten minutes every morning, and there are hundreds of cars entering that parking lot between 7 and 9 am every day. Multiply the average number of seconds lost per car daily in that last block; multiply by the number of cars, and that by the number of work days in a year. Lots of lives lost, and I have not even reached my desk yet.


What if medical systems were held to Google standards? Hospital systems are incredibly wasteful of their workers’ time. Not to pick on my hospital system (well, yes, let’s), but consider dictations. Our hospital dictating system used to be minimally burdensome: an in-house number, a doctor’s number, the patient’s hospital number, and you were dictating.  Then “lives lost” crept in.  We merged with another hospital, and suddenly the phone number was an external number, and as such a couple of digits longer, and (it seemed to me) a longer number of rings before it connected.  Then they added a hospital code number (our system keeps adding hospitals), a code for dictation type, and one for medical specialty, and before long the string of numbers was considerably larger than the total number of atomic particles in the universe.


What is worst about these time-wasters is that they are always sold as serving some higher organizational purpose. It was economically rational to centralize dictations, and once you did that you needed a hospital code, and the billing people thought the practice type and dictation type made their job easier, and so on.  Every step in the chain was rational, and every step totally wasteful for the person dictating. I added things up one day, and discovered it was taking me an average of 40 seconds a dictation just to start dictating. Multiply that by 2400 patient visits per year, and I was spending three workdays of my life per year just getting started with dictations.  Multiply that by all of the doctors at my healthcare system’s many campuses, and the number of “lives lost” is amazing. I promptly switched to a hand-held dictaphone.


As for the dictation itself, the one I do today is far longer than the one I did when I started the practice of medicine.  Why? Because, like Charles Dickens writing for some 19th century literary magazine, where payers paid authors by the word, the insurance system (largely Medicare-driven) requires us to check off so many boxes as documentation of effort.  Information technology now allows one to game this system by automatically populating parts of the follow-up dictation with elements from previous dictations. Has this mindless reduplication improve healthcare? I doubt it.  But it certainly takes me longer to read a dictation from a referring physician. More “lives lost.”


And that is only the beginning. Take the computer systems populating the healthcare system. How many passwords do you have?  I have a bunch (I operate out of three hospitals with three different IT platforms with multiple subsystems), and many have to be changed every three months in the interest of patient privacy and system security. Never mind that the proliferation of passwords means that I, like every rational human being, write down the password and store it in a convenient (i.e., easily discovered) place in my office, which can hardly be more secure than a single unchanging complex password committed to memory. 


Never mind that -- this rant isn’t about password security. That’s a different rant for another day. No, think of the time that each separate password costs you as you shuffle through papers on your desk, the time it takes you to enter the password and click, the time it takes for the system to respond, and multiply by however many people use the system. I also spend an inordinate amount of time calling up hospital help desks. The IT boys (what fun-loving jokers they are!) are always cancelling my old password without telling me --like I can actually remember when all these passwords need changing.


Or -- computers again -- consider the CD’s I get with outside CAT scans.  Half the time they don’t open on my clinic computer -- system incompatibility -- and even when they do they take five minutes to load.  In the old days I tossed two films up on the light box, looked at the tumor, and knew in seconds whether the tumor was growing or shrinking.


And don’t even get me started on the innumerable and increasing mandatory online surveys, courses, reaccreditation forms and tests required to “stay current” in the average medical center. Each of these, individually, seems rational and justifiable, but collectively they are significant time killers.


And forget the insurance companies, and their “peer to peer” phone calls in which I justify basic laboratory tests to another highly paid, and totally bored, disembodied voice on the other side of the country after they have already wasted an hour of my nurse’s valuable time. Could North Korean party apparatchiks design a more wasteful system? Huh. Maybe they did: treacherous fellows, trying to crater the American healthcare system with a “lives lost” conspiracy. Note to FBI: please investigate.


I’m sure I could come up with 20 other examples. But this isn’t about me, as much as I enjoy whining. Think of all this again in terms of “lives lost.” At a national level, the opportunity cost of this grit in the machine must be tremendous. Time’s arrow points in only one direction -- the second law of thermodynamics -- and time lost is never regained.  These are platitudes, I know, but they also happen to be true. The Google folks are right: the cumulative weight of those lost milliseconds and seconds, cascading into minutes and hours, crushes the breath out of our lives.


The question is why we tolerate these inefficiencies. Time is money (another platitude, also true), and wasting the time of the hospital’s second most highly paid employees (after hospital administrators) cannot represent efficient management practice.  But I have yet to meet a physician who doesn’t complain of a myriad of minor indignities inflicted by their healthcare “system,” and I have yet to meet a hospital administrator or insurance executive or federal health administrator who has made it his life’s work to root out such wastefulness, with anything approaching Google-like passion.


Why, ultimately, does all this happen? Partly it is technology run amuck, partly the natural officiousness of petty tyrants at multiple levels, partly perverse incentives built into modern medicine, but mostly it is because each one of these self-inflicted cuts is a shallow one.  Because no individual time-wound cuts deep, and because the cuts are coming from so many different directions, we feel helpless to fight back and overcome them. Many of them we do not even recognize.  So we bleed time, silently, and consider it normal.


We are sheep-like or (if our tempers are up) passive-aggressive when we should be systematically obnoxious, and perhaps creatively obscene, with those who inflict these entropic catastrophes on us. We should allocate bonuses to hospital and IT system administrators who measurably reduce “lives lost” rather than rewarding imaginative new ways to waste our time. We should require “environmental impact statements” of them before they place new dams in the flow of our daily lives. We should require system administrators (hospital and computer and payer) to think, well, systematically. We should realize that the vaunted “economies of scale” justifying our increasingly larger systems are illusory if purchased with our time.


Google deals in metaphorical “lives lost.” We deal in real “lives lost.” Is there a relationship between the two?  Ask yourself: Would I be a better physician if I could focus on what is actually important in healthcare? Might I be a better researcher if I spent an extra day or two or three a year on reading the scientific literature and designing experiments? Asked that way, I think we all know the answer.


For that matter, wouldn’t you rather have an extra ten minutes today in which you could read a blog by your favorite medical writer? All right, maybe that’s pushing things a bit far. But you get my basic argument by now. If not, you are required to go to the top of this essay, read every word again slowly, out loud, and then take the mandatory online post-test. Your password is out of date, but a new one will be emailed to you in ten minutes if you fill out the attached form telling us your favorite color, your mother’s maiden name, and the street number for the house you grew up in. A post-test survey will be sent to you tomorrow and is required for you continuing hospital accreditation. Get started now.


Anyways, dear readers, I’ll be thinking of you all as I sit in my car in that last awful block before the Vermont Street Parking Garage.