ICU medicine statistics

Taken from Atul Gawande’s Feb 2010 article in the New Yorker

-On any given day in the United States, 90,000 in intensive care (5M annually)

-Brigham hospital, 150/700 are ICU

-Average stay I.C.U. patient is four days, and the survival rate is eighty-six per cent

Ellison Pierce and Bill New – who had more impact?

Up to the 1960s and 1980s, Anesthesia deaths occurred 1/10,000 procedures. In 1972, Jeffrey Cooper observed anesthesiologists and observed lack of standardization in the machine which administered anesthetics and then using critical incident analysis studied 359 different errors and published a paper known as “Prevent Anesthesia Mishaps: A study of human factors” in 1978. It took until 1982 when Ellison Piece was elected VP of the ASA that he established a committee on patient safety and in collaboration with Cooper persuaded the FDA to produced a checklist and patient safety videos to be distributed through pharma companies and then started an ongoing international symposium on anesthesia patient safety. He then established the Anesthesia Patient Safety Foundation with a newsletter, funds and channeling grants for use in patient safety research.

This led to redesign of machines, monitoring devices and dropping error rates with 139 papers published by 1995. This launched the field of Patient Safety and anesthesia-related errors had dropped to 1/200,000 cases.

It is very interesting to couple this development with a fairly concurrent development in the traditional entrepreneur model in the development of the pulse oximeter by Bill New

The following is excerpted from an article by Pole, Y. “Evolution of the pulse oximeter” International Congress Series 1242 (2002) 137– 144

Credit for the present enormous interest in pulse oximetry belongs to the anesthesiologists William New and Mark Yelderman of Stanford University Medical School. New recognized the potential importance of and market for a convenient, accurate oximeter in the operating room and all other hospital and clinic sites where patients are sedated, anesthetized, unconscious, comatose, paralyzed, or in some way limited in their ability to regulate their own O₂ supply. New, with engineer Jack Lloyd, founded Nellcor, which began the mass manufacture of the Nellcor pulse oximeters. The Nellcor pulse oximeter was evaluated by Yelderman and New, the manufacturers in 1983 [2. M. Yelderman and W. New, Jr., Evaluation of pulse-oximetry. Anesthesiology 59 (1983), pp. 349–352. View Record in Scopus | Cited By in Scopus (77)2].

After an initial period of scepticism, as of 1988, the Association of Anaesthetists of Great Britain and Ireland recognized the pulse oximeter as their standard for intraoperative monitoring, and 2 years later, as of 1990, the American Society of Anesthesiologists recognized it as their standard for intraoperative monitoring.

By 1993, there were about 40 companies making and selling pulse oximeters, and over 750 books, reviews, and papers concerning pulse oximetry were published. Nellcor was founded in 1981 and sold in 1995 for $2 billion.

Which of these is a more powerful impact for the social good? According to a meta-analysis by the Agency for Healthcare Research and Quality which monitors healthcare quality, the available studies do not automatically attribute an improvement in outcomes to better monitoring. In fact, in a multicenter, randomized, controlled trial of 20,802 surgical patients, Moller et al studied the impact of perioperative pulse oximetry on patient outcome. Despite the large sample, the authors were unable to show a difference in in-hospital mortality or postoperative complications. During anesthesia and in the post-anesthesia care unit (PACU), more episodes of hypoxemia and myocardial ischemia were detected in patients monitored with pulse oximetry.

http://www.ahrq.gov/clinic/ptsafety/chap24.htm

Moller JT, Johannessen NW, Espersen K, Ravlo O, Pedersen BD, Jensen PF, et al. Randomized evaluation of pulse oximetry in 20,802 patients: II. Perioperative events and postoperative complications. Anesthesiology 1993;78:445-453.

Rowland Hill

This man invented pre-paid stamps

In 1840, Hill noticed postal revenues failed to increase despite growth in the economy and analyzed the cost structure of mail delivery 12 cents a letter which was too high for everyone. He found that the majority of the costs were due to time for clerks to appraise how to price the mail by weight. The actual conveyance costs were a fraction of this price. He simplified the process by charging a uniform prepaid “Penny post” price which led to annual mail delivery to rise from 76-642 million letters over the next 25 years.

Fun Quotes about Entrepreneurship

“There is one thing stronger than all the armies in the world, and that is an idea whose time has come”

-Victor Hugo

“groups resist change with all the vigor of antibodies attacking an intruding virus”

-James O’Toole

Insights from the Dartmouth Summit

I just organized what looks like the first of many Dartmouth Summits on Healthcare Delivery.

http://mba.tuck.dartmouth.edu/healthcare/summit.html

It was a big success highlighted by Michael Porter teaching a roomful of business, medical school, graduate school and undergraduate students an HBS case about the Dartmouth Hitchcock Spine center. We even had a faculty workshop in which three of the top professors from TDI, Tuck and Dartmouth Hitchcock will be leading case-writing teams of faculty and students.

This was a very revealing event to me in terms of my own leadership in many ways. Most of all, it helped me to realize that the reason why all the grey-hairs keep telling us juniors that “its all about finding your passion”. Passion leads to ownership and commitment to what you are doing and enables you to have the energy and ability to move people. It doesn’t matter if you are an engineer, a doctor, or a student trying to move an institution forward, passion is always your best competitive advantage.

It also made me realize that when you do something significant, there is enough credit to go around so it almost doesn’t matter who gets the credit. This has not been easy for me at times because I often felt like I had to take on disproportionate work yet deferred the credit from myself to the students who will be staying behind and taking on this event next year. Taking my leadership to the next level will depend on my ability to subjugate my own ego for the objective to create something that sustains and goes on.

I also realized that having a platform matters. Having a position of influence buys you credibility such as being an MD/MBA student at Dartmouth or a future resident at Hopkins. However, credibility must be paired with delivery of an outcome for you to realize the value from that relationship. You can get anyone in the world to help you by having the right introduction, appealing to their interests and a demonstration of competence.

I learned how much one’s gut really does matter in choosing the right people and that giving people an opportunity to declare their abilities and motivation early is key.

Finally, I realized the importance of knowing one’s environment, knowing the players, knowing where the levers are as well as which to pull is critical. I think I am starting to see the advantage to settling down somewhere and building a network which will allow me to build things and have an opportunity to lead.

A framework for career decisionmaking

I recently thought up a good way to frame decisionmaking about what I would like to do with my life. I think I value 3 qualities in a profession. In no particular order these are:
1) Impact meaning the impact of my work on people’s lives as defined by some measure of quality improvement in someone’s life times number of lives affected.
2) Independence – by this I mean both the personal and professional flexibility to be creative with my day and as Krishna would say determine the “texture” of my day.
3) Wealth and Profit – I am a big believer that value can always be measured in $ and that no matter what people say about the advancement of nonprofit, it takes the profit motive to really add the scale, permanence and continuous innovation and competition that we see in mature markets. Take adoption of Hospice care for example which was a movement by nursing to make end of life care reimburseable and when the route of advocacy, changing government legislation and endless policy briefs. It took approximately 40 years starting in the 50s and to finally get reimbursement in 1995 and full adoption of Palliative care as a field is still ongoing process. Then take microfinance which discovered an untapped market which took almost as long 30 years to become mainstream starting in the mid seventies and culminating with Muhammed Yunus winning the Nobel in 2006. Compare this to the launch of the iphone in 2007 which this year projects to hit 58million units just 3 years later.

So using this framework, I have analyzed the following career options Academic physician, Entrepreneur, Venture Capitalist, Corporate Exec.
AP VC E CE
Impact H L M M
Freedom H H H L
$$$ M H L M

The conclusion? I should be an academic who is also a VC.

Question for a Leader

Really interesting question to help tease out leadership characteristics from passionate people:
How have you made a tough decision based on data?

Big Idea of the Day (BID): Allocating decision rights

Zimmerman frames the dilemma of allocating decision rights in a company as consisting of three dimensions
1) Who has decision rights?

2) What are the performance measures that we will use to know how we are doing?

3) What reward systems will we put in place to reward our people?

Passion – the ultimate competitive advantage

After 5 years of graduate school and thinking about my future career, there is one piece of advice that keeps coming up over and over. “Find your true passion” says all of the mentors, supervisors, coaches and peers that have advised me over the last several years. Yet I’ve struggled at times to reconcile this advice with the much more tangible signs of success (money, fame, prestigious job titles) that the very people who champion the “passion” line possess. Recently however, while listening to Alan Pesky who founded the Lee Pesky Learning Center, a very successful non-profit which tackles learning disabilities, I realized that the reason for his success was precisely because of his passion. Beyond his business model, decision making, management and people talents because he had a child with learning disabilities, he had a passion that led to a success that money could not buy. For example, in 12 years the Pesky center has been funded by $16M compared to similar now-defunct efforts started in the same time, the Schwab center ($200M invested) and the Cosby institutes for learning disabilities.

I suppose the next question really is what exactly is my passion then. I really don’t know and I think part of what gets me up in the morning is the excitement of not knowing precisely what is going to happen that day. That said, I do know that I love medicine and the promise of helping people, I love making that connection with needy patients. I love the excitement of learning something new, the excitement of building something new and lasting. Its interesting to be in the presence of people like President Kim who have devoted their whole lives to good work and being a great leader who has devoted his life to all those things and realizing that the one thing that is missing for me in a career like his is the instinct to have to make money.

It is interesting to hear President Kim talk about his struggles with his identity and confronting his privilege.

http://www.washingtonpost.com/wp-dyn/content/video/2010/03/31/VI2010033100606.html

Could it be that the socialization by my family and society in Taiwan may be a barrier to my eventual ability to be that transcendent leader that I could otherwise be?