Friday, December 13, 2013

23 and Me and

The FDA issued a warning letter to 23andMe on Nov 22, 2013. There followed a slew of articles, posts, tweets and commentary - amongst the many
And this piece on Forbes on the class action suit and this older piece that talked about the service before this news hit and then followed up with this piece "23andMe Saga Doesn’t Bode Well for EMR Genetics Integration" and David Katz: Return to Sender, Genome Unknown: Seven Reasons I Will Return My Personal Genome Kit

Declaration: I am a 23andMe customer - I liked the concept and was excited by the price point that made the service accessible and cost maybe that explains my quick reaction (per the K├╝bler-Ross model of grief of Denial, Anger, Bargaining, Depression, Acceptance) to many of the posts and negative feedback pushing back.

I am still processing the news and not sure exactly where I sit - personally I am glad I got in before the health information was blocked. Maybe this is a purely personal position coming from the privilege of being a physician. In fact this piece on Forbes/Quora: What Do Doctors Think About 23andme?
probably captures the viewpoint I have different from others. In fact the images summarize how many people might approach this
Hmmm - you can see the logic and while the point made that not all information is relevant or important my view is firmly on the side of the patient being allowed to make that decision themselves.  It is always worrying to me that someone else is filtering information and making decisions as to what they consider to be important to me - how can they know?

The example cited is one of a fit healthy individual making a decision based on genetic testing that suggests they might be at increased risk of cardiac disease that needs to be put int he context of them being fit and healthy
In fact they state
This is why every ethical healthcare provider follows this mantra: do not order a test or perform a procedure if it will not change your management of the patient, because doing so may cause needless harm/risk to the patient and will cause needless damage to the patient’s finances.
A reasonable position and one perhaps we might expect the FDA to support.....yet the FDA allows for direct to consumer advertising in the US.....? That seems at odds with the stance taken on genetic testing. There is no doubting that extra testing can cause additional stress and concern - putting everyone into an MRI is a bad idea since we identify around 20% "findings" many (may even be most) of which are incidental. I personally am delighted with my 23andMe results that include genetic details and insights that help me make my own personal health decisions.

I gave up personal genetic information to 23andMe who like any other cooperation could misuse it, may not protect it sufficiently or may share it with insufficient privacy protections to shield me from being identified. But that was my choice and in this instance I felt the risks outweighed the benefits.

But the cynic in me can't help but think that this may all be money related especially given the recent spat over the BRCA gene testing that was recently struck down but remains the tip of the patent iceberg.

This piece on KevinMD: 23andMe and the FDA: Did the government overreach? probably captures my basic views on the subject. As Dr Marroquin states
One worry is that people might undergo unnecessary tests and procedures based on the information 23andMe provides.  For example, critics worry that a woman who is found to have a false-positive BRCA mutation might have a prophylactic mastectomy inappropriately.  This seems to me to be an impractical concern.  It is difficult imagine a surgeon operating in such a situation without first verifying the genetic testing through another lab and extensively discussing the benefits and risks of such an approach with the patient.
Quite - it might create a worthwhile discussion between a patient and their healthcare provider. In another example the risk of Alzheimer's which a customer might feel powerless to prevent but I would suggest that this may not be true in the future and as one friend and colleague told me when he shared his results that showed an increase risk of Alzheimer's:
It just means I am going to play more sudoku as I get older
That seemed like a good strategy and attitude. It is also important to note:
It turns out, however, that people seem to be less psychologically devastated by adverse genetic test results than many of the experts anticipated.  For instance, a study published in the New England Journal of Medicine found that “in sample of subjects who completed follow-up after undergoing consumer genomewide testing, such testing did not result in any measurable short-term changes in psychological health, diet or exercise behavior, or use of screening tests.
On balance I'd rather have the choice than have the government make decisions about what data I can access. I say this with all due respect to my clinical colleagues who may disagree and the many that had exchanges with me in other social media forums.

I would also explicitly state that this is a personal view and does not represent that of my employer nor does it represent clinical guidance.

Friday, December 6, 2013

Peace #Inspiration Love - Nelson #Mandela - I'm a Rainbow Too #tribute

Nelson (Rolihlahla) Mandela or Mandiba as he was know to many

was an inspiration for many with his incredible strength and especially his compassion and moral courage despite his 25 year incarceration. His strength contributed to the Rainbow Nation. In the words of another early lost talent Bob Marley:

I Want you to know I'm a rainbow too

You can take the boy out fo Africa, but you can't take Africa out of the boy. Today I am proud to call myself an African and stand tall with the people of Africa at this time of sorrow

He managed to bring light into any situation and there are so many tributes across the web - you can read his biography here - hard to pick on any but I liked Richard Branson's here
and included this great version of the classic song by "Biko" that was performed by
Peter Gabriel performed Biko a cappella at the unveiling of Steve Biko’s statue and the whole crowd sang every word. He said: "I have been living with the words (of the song) for a long time. It is a sense of completion to be here." You could see tears in Madiba’s eyes - it was one of the most emotive moments of all of our lives.

and Time's 10 songs to remember Manndiba by

The Nelson Mandela Foundation posted its own message. But it was his words that summed it up for me and I have quoted many times:

What counts in life is not the mere fact that we have lived. It is what difference we have made to the lives of others that will determine the significance of the life we lead.” — Nelson Mandela

My deepest sympathies and condolences to the Mandela Family, the Nation of South Africa, the Continent of Africa and his friends around the world

Hamba kahle Madiba
(Go well/stay well)

Monday, December 2, 2013

Virtual Assistants in your Future - Personal Healthcare Delivered

You can always rely on Hollywood to take concepts and extend them into the future - sometimes correctly (cloaking, holographic TV, forcefields and eco skeletons with mind control), sometimes incorrectly (aluminum dresses, atmosphere that is completely controlled, suspension bridge apartment housing). We have had speech recognition and Spock's request:

So it was no surprise to find the latest Hollywood idea is the "Her" - a lonely writer develops a relationship with a newly developed operation system

Intriguing and challenging our current concepts with an exploration of artificial intelligence, voice and natural language technologies. These new styled avatars understand, listen and decipher what we say and something that Nuance has been developing and reinventing the relationship that people and technology can have. We can engage with our devices on our own terms and we have show these concepts in healthcare with our very own Florence - who is getting ready to launch in 2014

Ambitious you say - maybe but imagine the environment with intelligent personal assistants that hear you, understand you, know your likes and preferences – and in our world exist across your doctors office, the phone, surgery, hospital and elderly care and hospice. Cool? Liberating? Impossible?
If you’re Nuance, the idea is not only brilliant – it’s our focus and drive as we reinvent the relationship between people and technology. It is the chance to connect with your devices on human terms and presents infinite possibilities for intuitive interfaces that adapt to you.
Liberating our clinicians to focus on the patient and providing patients with someone they can talk to, interact with and who does have time for them. That future - coming to a doctors office near you:

Tuesday, November 26, 2013

Thanksgiving, Decency and End of Life - Be Thankful you had the conversation now #health

Patients deserve the same standard and car that doctors receive when they need treatment. But as I have said before (Doctors Die Differently and more recently Treatment Creep in Medicine - sucking Decency out of Patients) we remain challenged especially when it comes to dying.

This piece by Dan Gorenstein, How Doctors Die: Showing Others the Way touched on these issues in a moving a thoughtful way.

Dr. Elizabeth D. McKinley’s battled breast cancer for 17 years but this past spring discovered the cancer had spread to her liver, lungs and brain. Her choice was to undergo more treatment that would have potentially debilitating and mind altering effects on her or change course, accept death and work on getting the best out of what was left of her she put it
..time with her husband, a radiologist, and their two college-age children, and another summer to soak her feet in the Atlantic Ocean...“a little more time being me and not being somebody else.” 
And some of her fight was with her own family - the non-medical members
clinging to the promise of medicine as limitless
And the medical members of her family (her husband is a radiologist)
looking at her disease as doctors, who know the limits of medicine
Its not a difference in the effects of disease and death but rather an advantage of knowledge and information that lead to truly informed decisions "doctors have control over their quality of life before they die and this sadly is control that eludes most other members of society" and it would appear especially try here in the USA. More than half of deaths take place in hospital and not at home surrounded by people we love which is the way most say they want to "go".

So if you do nothing else this Thanksgiving - take the time to talk about the subject with the people you love and create and advance directive or living will. In many respects no better way to be thankful than to set out what is important and let everyone know, now when you are fit and healthy.

Wishing you all a very happy family and friend fill Thanksgiving

Tuesday, November 19, 2013

Treatment Creep in Medicine - sucking Decency out of Patients

This recent post on the Atlantic: How CPR Became So Popular reminded me of a piece I wrote some time back - Doctors Die Differently. As I said then:
Its not that doctors don't want to die, its just that they knwo they know enough about modern medicine to know its limits, importantly they have talked about this with their families as they want to be sure that no heroic measures will be used during their last moments in this reality
And the chart demonstrating the big discrepancy between what doctors want in life saving measures vs the general public pretty much said it all

So this piece in the Atlantic took it a step further - tracing the history of CPR from the 1960 at Johns Hopkins where the surgeons had
...successfully resuscitated every one of the first 20 patients they treated, 14 of whom (70 percent) survived without brain damage or other ill effects

But their source patients were not typical (young and mostly healthy) and when you extrapolate that out to an elderly population survival can fall to as low as 0% a variation in the effectiveness when performed in the real world
But it was Hollywood adn the media that pushed these procedures into the general awareness suggesting
...that two-thirds of all (fictional) cardiac arrests portrayed on ER (and other doctor shows) involved young patients who had suffered rare events like drowning or lightning strikes, rather than old people with heart disease (who account for 90 percent of cardiac arrests in real-life settings.....most of these fictional TV patients did well, unlike the vast majority of CPR recipients in real life
Dr Peter Benton was well known as all in life saving heroics

In fairness Hollywood was dramatizing some real life events - and they applied their pixie dust to this as they have to many other things.

But the problem remains and health care professionals need to help their patients understand their disease and make good choices, bearing in mind that heroics and life saving may well be a significant driver as it was for Stephen Jay Gould who was diagnosed with a rare and deadly cancer with a median survival of eight months...but as he said in his essay "The Median Isn't the Message".
this median survival means that one-half of patients die within eight months but the other half live longer. Most important, because the mesothelioma survival curve has a very long “tail,” a few lucky patients will live a lot longer
In his case his experimental treatment may have contributed to his 20 year survival past the original diagnosis...leaving a legacy of hope.

Monday, November 18, 2013

The Patient Story is more Valuable than Check Boxes

In a great expose of the value of the narrative Dr Regina Harrell explores Why A Patient's Story Matters More Than A Computer Checklist in a journey documenting one elderly patient with knee pain and underlying Dementia

Sadly Dr Harrell spends more time on technology than on the important aspect of patient engagement and clinical care:

At day's end, I review my meaningful use. I spent more time checking boxes than talking to patients and their families
There aren't enough physicians to see all the homebound patients in my area, so I try to visit as many as I can safely care for. I could see twice as many patients if I could write their notes at the bedside while visiting with them. I would happily do this using paper or an EHR that took the same amount of time, but these are not options.
I spend more time talking to the information technology team than I do answering messages from patients.

The underlying problem of technology not fitting the need - in this case demanding a typed note to capture the details could at least be solved with some speech enablement

But I was more troubled by the impact on teaching of our future generations

As a teaching doctor, my feedback to the residents now consists mainly of explaining how to document their visits so that we will all get paid, instead of teaching them how to take care of elders in their homes.

This may fall under the category of Unintended Consequences - but it is a big one...If we are focusing on the documentation at the expense of teaching clinical care then the problems we have today will be amplified dramatically as these new doctors enter the workforce.

Finding the balance between the need for digitizing medical notes and electronic medical records with the time necessary to spent interacting with these systems is still problematic - there are a number of technologies available including Speech Recognition with embedded Clinical Langauge Understanding (CLU) that can help ease this transition form paper to digital. But technology is not always the answer and finding the right balance between the needs to the system and the needs of the patient and their doctor will remain central to successful use and roll out of HealthIT in Healthcare.

Friday, November 15, 2013

Monday, November 11, 2013

Artificial Intelligence - Good or Bad

I received a link form a friend to this article Robots, Soldiers, & Cyborgs: The Future Of Warfare - I think in part because I post on the value and opportunity of the intelligent agent
In fact I just talked about this recently around the concept of smart shelves instead of selling shelves. It was this comment in the article that stood out
Are we at the beginning of an inevitable process leading to the rise of “killer robots” predicted by science fiction, or can robots actually make war less destructive?
We know technology can be used for good and bad but even with the concern of the possible super soldier ala Terminator and the Rise of the Machines in Judgement seen in the opening scene from Terminator 2

Remember folks - this is Hollywood. No battery or power issues amongst the many other challenging technical problems. There is a school of thought that we will reach singularity and artificial intelligence will have progressed to the point of a greater-than-human intelligence that will "radically change human civilization, and perhaps even human nature itself.
Critics are also concerned that advanced artificial intelligence (AI) could develop in directions not anticipated by scientists. Because of this unpredictability, the US military has indicated that it will never remove humans from the decision loop completely. While unmanned weapons systems will become gradually more autonomous so that they can carry out very specific missions with less human direction, they may never entirely replace human soldiers on the battlefield.
While there is some potential for the bad I remain optimistic that the inherent good prevails - we develop smarter, faster and better technology to deliver an improved world and a new era of Super Intelligence that will chaperone in a new and exciting era
Meanwhile adding medical intelligence to the systems we interact with to simplify the interaction freeing people up to focus on tasks and the individual - not the technology offers interesting and exciting potential and I found this latest piece Startup Gets Computers to Read Faces, Seeks Purpose Beyond Ads on reading faces another step toward intelligence which like the smart supermarket shelves can be used for good or bad....
Imagine the doctors office or even the hospital waiting area that is using technology to triage patents intelligently based on their needs not the time of their arrival.

Life is good - my glass is always full

Thursday, November 7, 2013

Remembering those First Moments as a Junior #Doctor #hcsm

It's a long time ago but in many respects that first shift is still fresh in my memory and it all came flooding back when I read this great piece by Deepak Chopra: My First Job: My Dark Night As A Real Doctor

He recounts his first night on call having arrived in to work in a 400 bed community hospital in New Jersey in the 1970's and his first patient - "an expiration"

I cast my mind back to Friday 1st August 1986 and my first day - the Friday was significant as I discovered, marking the beginning of a weekend on call that commenced on Friday at 9am and finished at 5pm on Monday 4th August - yes that 80 hours! I don't think I quite understood what that meant but I sure did by the end.

I was partnered with my medical school friend and colleague Niamh Anson part of my graduating class from the Royal Free Hospital School of Medicine. We were set to spend the next 6 months joined at the hip spending more time with each other than some married couples spend together. We would be each others support, backup, confidant and friend. I was lucky - she was the perfect balance to my brash youth and over confidence. She was a steady hand guiding through what were some very rough seas and although I did not know it at the time I was really lucky to be her partner offering me the chance to get to know her.

We worked for two consultants - Dr Woodgate and Dr Willoughby a cardiologist and a gastroenterologist and were joined by a dynamic registrar John Lee. Between us we took care of the cardiology patients, coronary care ward, coronary care monitoring unit and the gastroenterology patients day to day.  But come Friday afternoon took on medical responsibility for all medial patients, medical admissions through the Accident and Emergency Department (A&E aka as the ED) and the Intensive Care Unit. On top of that we (Niamh, John and I) were the code team - with the anesthetist (aka Gasman or Anesthesiologist) as the 4th member. I don't remember how many patients this covered but it was a lot.

Our first day was filled with taking on responsibility for the day to day activities finding out how to get things done, where things were kept and most importantly getting to know the nurses who were the key to surviving the ordeal since they knew everything, had worked there for far longer than you (and many others) and had more relevant experience that you needed to learn from. I was reminded of the "Doctor in the House" film with Sir Lancelot Spratt from years back:

To be a successful surgeon you need the eye of a hawk, heart of a lion and the hands of a lady

And while I don't remember all the nurses by name I remember all their kindness, support and actions that helped me survive the grueling assault course of medicine.

At 5pm we knew the patient load had changed as our "beepers" (aka pagers) started sounding like a cardiac monitor going off so frequently. There were missing orders for pain medication, tissued drips (a drip that was no longer working and needing to be re-done), admissions in the emergency department, patents with abnormal rhythms on the coronary care intensive unit, blood gases needing taken in ICU.....

Division of labor and unofficial coordination became the order of the day as Niamh and I split the work taking on admissions and ward coverage. I remember during that period working out my rate of pay based on the number of hours I did per week (typically 136 hours per week) and thinking that while I understood that I was inexperienced I felt worth a little more than the £1.36 per hour (roughly $2.20 per hour) given that I recall all the critical clinical decisions we made, the CPR we performed, the relatives we had to speak to give them the sad news that their spouse had died.

By Saturday afternoon we had been on call for 36 hours and there seemed no let up in activity. The nights were sometimes quieter but that was rarity. As a means of coping we split the night with either Niamh or I taking all the calls after midnight (except in the case of a code when it was all hands on deck necessary to cope with the high work load in these events). In one memorable night I remember 23 admissions coming through the emergency department - if I saw my bed it was never for more than a few minutes. The nurses were all familiar with the work load adn they knew when they paged us that even if we answered and said we were coming they would oftentimes have to page us a second and third time as we would answer but then fall immediately back to sleep. As for our performance and efficiency - I hesitate to imagine how poor we were at tasks and what our decision making would look like if it were assessed. The good news was that there were many experienced nurses involved who did not work the same hours so were not suffering the same chronic sleep deprivation and were checking up on our orders and activities, prompting and intervening as necessary to prevent errors

By Monday morning we were all frazzled - I'd lost count of the patients and problems we had dealt with, the patients who had died, the admissions and therapies started and the slew of clinical problems and disasters we had averted. We stopped taking call but our day did not finish then and for us Monday was a regular working day dealign with the normal work load of admissions, award rounds treatments and patient management. It was only at 5pm on Monday evening we finally stopped work and handed our patient cover over to the new on call team.

There was some solace in the genuine feeling that you were making the difference in people's lives but much like Deepak Choopra I struggled with what I was actually delivering - was this really healthcare

In the end, after six years of studying, medicine was turning out to have too little to do with healing and making people happy. It had to do instead with my work in the hospital, into their lives, pronouncing a few of them, the most unlucky ones, as expirations. I thought about myself a lot before I forced myself to sleep, but, on reflection, I didn't think about my patients much. We had all met and parted in a few moments. It would have been hard to look at them directly. 
What of the interaction as defined by Hippocrates

Even though a patient may be aware that his condition is perilous, he may yet recover because he has faith in the goodness of his physician...I will keep pure and holy both my life and my art.

I did not have a good feeling about the interactions - the fleeting exchanges with these people who were trusting me with their lives and the lives of their family. And as technology and innovation continued its march the reality of the practice of medicine changed

Practicing medicine as we do now makes a doctor's life as nerve-racking as a soldier's. It consists of an endless struggle to conquer disease, and to keep at this, a doctor must deny to himself that disease, and to keep at this, a doctor must deny to himself that disease ultimately wins. If you feel called to practice medicine, these are not the kinds of thoughts you permit yourself. But doctors do face up to them from time to time and wonder what the work is for

I had some great experiences - I had some awful ones and I continue to be part of what I consider an honorable profession and one I am privileged to be a contributing member . In fact on a recent flight there was a request for a doctor - a lady suffering an attack of pancreatitis but fortunately we were not far from our destination and my contribution was small and mostly not medical in nature helping to control and comfort for the short period of time till we arrived and then hand the patient on to the ground emergency medical staff. That transition proved to be sub-optimal and it was well over an hour before she was taken care of - I stayed of course, wanting to be sure that her care was transferred to the healthcare team on the ground. The following day I received a note from one of the flight attendants that made my day. She had searched for my name and found me and sent a note to the Nuance Web site thanking me for my assistance and complimenting me for my "display of genuine heart". My contribution was not so much medical although that had played a part in the diagnosis, assessment and review of treatment options and the course of action. But what had made the difference was compassion - the focus on the person (and in this case there were two people and I ended up helping her companion navigate London Heathrow airport late at night to get her out to the accommodation they had booked). I had never doubted what I would do and was upset for this lady and her companion who's holiday was not starting off well. This is why I did medicine - I wanted to be the contributor, the person caring for the patient. It is this fundamental aspect of medicine we seem to be loosing site of - I can certainly accept some blame - I have a keen eye towards technology and possibilities it offers - but at its hearts medicine is about people caring for people and providing the support that in many cases is the difference between a good or bad outcome (at least perceived by the patient anyway). In fact I tweeted something along these lines earlier this week:

People forget what you said and what you did but they remember how you made them feel

As Deepak Choopra quotes:
Rejoice at your inner powers, for they are the makers of wholeness and holiness in you,
Rejoice at seeing the light of day, for seeing makes truth and beauty possible. 
and he ends with

a physician must trust in Nature and be happy in himself

As a guding light that works for me - hope it works for you too

Monday, November 4, 2013

Must we Move to ICD10 - Short Answer is Yes

The short answer is yes - but I hear occasional stories and push back from clinicians and sometimes other healthcare staff - is it worth the spend and investment. Why not just wait for ICD-11 (Check out the beta draft of ICD-11 here). Why not just use SNOMED CT

For the individual doctor taking care of the patients they often see no direct benefit from ICD-10….or from SNOMED CT, LOINC, RxNorm, APR-DRG’s, ICD-9, APC’s, HCC’s, etc. But in the healthcare continuum that requires more than a single patient to be cared for and whole populations to be considered we need evidence and data to manage populations that has enough detail that has kept up with the explosion of medical knowledge. Yes capturing the codes may be difficult but the good news is there is technology to help clinicians to capture it at the point of care - anywhere and offers realtime feedback to the doctor with the unique and innovative Computer Assisted Physician Documentation (CAPD). ICD-10 is no longer to be feared but should be embraced as a bright new future that will start to code information in sufficient detail that is more representative of the complex nature of patients and their clinical condition. No longer grouped together in broad categories that do not adequately take account of the complex cases offering a much more nuanced view of the severity of illness.

So what is the difference between the two systems and what makes ICD-10 the right choice? Some of this relates to terminology and classification - nicely explained here by Dr Peter Johnson explaining the SNOMED CT system. As he says
Classification system,
A classification scheme could be thought of as a collection of buckets into which a care provider throws a particular concept or record. And since there can only be one bucket into which a concept fits, the process of labeling the buckets often leads to catch-all terms like: ‘Disease X, unspecified’ or ‘Y, not elsewhere classified’. As a result, accurately classifying records is rightly seen by most care providers as a separate process from record creation and is typically carried out by specially trained coders who know how to apply the process.

Terminology System
..a terminology allows the user to specify precisely what they want to record. Specifically, a terminology doesn’t have any ‘not elsewhere classified’ bucket terms, but is designed to have the terms that a user needs to record what actually happened.

Which brings me to the problem with SNOMED CT as a replacement for ICD-XX - clearly described by Carl Natale’s in his post: Why SNOMED cannot replace the ICD-10-CM/PCS code sets. As Carl rightly points out:
Physicians are going to have to learn how to communicate with EHRs — which will be based upon SNOMED — to comply with Meaningful Use. So the transition to SNOMED-CT already is in the works.
We do need more specific documentation but as a colleague of mine has pointed out this is not the onerous task that it first appears to be - much of the data is already information we capture as part of a normal clinical interaction and the additional data requirement may only be one clinical element.
For the construct of an ICD-10 code we have 7 characters made up as follows
  • Section,
  • Body System,
  • Root Operation,
  • Body Part,
  • Approach,
  • Device,
  • Qualifier
In a single specialty building up the code is part of the natural clinical content that we capture when documenting the patent encounter. The clinicians should not be expected to construct the code but does need to include all the details to allow the coding to be completed accurately. For example:

Open reduction internal fixation distal phalanx right index finger with K wire
contains everything necessary to code this as
0PST04Z - which is made up of:

  • 0 - Medical Surgical
  • P - Upper Bones
  • S - Reposition
  • T - Finger Phalanx R
  • 0 - Open
  • 4 - Internal Fixation Device
  • Z - No Qualifier
As Carl points out
Basically, ICD-10 codes aren't the problem. It's the specificity of documentation that will be required one way or another. SNOMED should make it easier to document to the required specificity. It is then up to the EHR system to convert that data to ICD information. Hopefully the physicians won't know what level of ICD is being used. They will just need to know what needs to be recorded.
So what does this look like in the clinical setting - this video offers a peek into the new world of documentation and how Healthcare technology, Clinical Language Understanding and integrated solutions will start to ease the documentation burden, allowing clinicians to focus on care and the patient and not documentation coding

Friday, November 1, 2013

A Paper Towel as a Medical Record - Really! #safety #HealthIT #EHR #hcsm

I ran across this posting on Mark Hindle's Twitter account:
The picture is shocking:

This is not just a hand written note as a simple reminder...this paper towel addresses the Pharmacy and says
"Please dispense Colecalciferol 20,000 units"
And it appears the pharmacy or maybe the nurses have dispenses this as evidenced by the "tick" over the top.

The Institute of Medicine published several studies including:

1999: To Err is Human
2001: Crossing the Quality Chasm

And the Journal of the Royal Society of Medicine Published a study in 2006; Poor handwriting remains a significant problem in medicine that stated:
Leape and Berwick called handwritten medical notes a ‘dinosaur long overdue for extinction

Yet here we are in 2013 and not only do we still have hand written notes but they are written on a paper towel......I'm left

Tuesday, October 29, 2013

The Future of Healthcare as Seen Through the Eyes of @kpTotalHealth with @Tedeytan #HealthIT

I posted a piece that was published on FastCompany site at the end of last month:

It included a link to an original concept from the innovative Kaiser founder Dr Sidney R. Garfield

I shared this with my wife who is an accomplished midwife (she stopped counting her deliveries after she hit 1,000) and we both shared a laugh but as she pointed out - at the time it was a brilliant compromise between two competing interest:

On the one hand you have healthcare wanting to help mothers rest after giving birth
On the other hand you have mothers who's genes are screaming at them - be with your baby

In this particular instance the National Health Service (NHS) in England was ahead of its time, guided by an experienced and well respected cadre of midwives who promoted and encouraged rooming in of babies when they were born. We experienced this with our children but our youngest was born here in the United States and at the time it was a fight to stop the nurses from removing our daughter from the room

I had the privilege of visiting the Kaiser Total Health facility and spent an invigorating few hours with Dr Ted Eytan, Physician Director in the Kaiser Permanente Federation (@TedEytan and his blog)

He was kind enough to reply to my article in a tweet:
And the details even appeared in the wall of knowledge with the background that I captured here:

Ted shared a link to the original history
KP’s ‘Baby in the Drawer’ Helped Turn the Tide Back to Breastfeeding Babies after World War II Which tells the story of the driver on this innovation centered around better outcomes from keeping mothers and babies together:
Sidney R. Garfield he had read an interesting article about the now famous Yale University School of Medicine research experiments with rooming-in for mothers and babies
Kaiser Permanente has continued their continued innovation - Small Hospital, Big Idea which continues and contributes to their impressive growth:
An Impressive and consistent increase in Patients

All this is embodied in the Kaiser Total Health Center that brings together existing and new technology in innovative ways. Everything from the large screen introduction:

 Through to the handheld ultrasound device:

It includes patient education with the explosion of the obesity epidemics - captured in this video graphic

The mock up health room 
Mock up Patient Examination Room

and placed working technology in the reach of innovators, patients and clinicians

3-D Visualization for Patient Engagment on Medication
 and simple technology - but so important - two hand sets for one phone so patient and health care worker can both listen in to the same conversation with immediate availability for language translation (I'm willing to be we won't need a telephone for this simultaneous translation in the near future)

and the room and facility continues to be updated:

No doubt Ted who is is currently exploring the GoogleGlass Innovation (you can read about his exploration here in his blog "The USA #ThroughGlass") will be including some of his google glass experiences as they learn more about this innovation

I believe

Paper and manilla folders will become a thing of the past relegated to museums

this will be true and perhaps when I am lying in my hospital bed will look back at this age and think
Mostly, I know that someday, someone in my same CMIO and MD shoes will think how silly it was that doctors actually hand-typed patient notes

Friday, October 25, 2013

Want to See #Mobile #Health Success - Look to #Africa #mHealth

I've said it before - Africa like many of the under developed countries is exploding with great use cases for mHealth. This piece: Kenya Has Mobile Health App Fever tracks the explosion of #mHealth.
Promoted and supported by the Kenyan Medical Association and Shimba Technologies the latest release MedAfrica offer ready access to medical information and verifying clinicians in the field and even a tool to verify the authenticity of drugs.

With over 50% of banking done by mobile phone in Kenya they are clearly adopting the platform in large numbers (Kenya is rich in mobile phones, with 25 million subscribers; Africa has more than 600 million of them). Applying #mHealth to the slew of health problems is exciting and rewarding. The size of and range of health challenges is daunting:

Many Kenyans have serious health problems; for example, according to the World Health Organization, more than 30 percent of children under age five show stunted growth. At present, only 7,000 doctors serve a nation of 40 million people. 

All this out of a company that was founded by Stephen Kyalo and Keziah Mumo, with $100,000 in seed money from a European VC

Seen here Steve Mutinda Kyalo
And its not just Kenya:
Mobile health platforms are making a strong showing in other parts of Africa, too. In South Africa, efforts include platforms that give HIV-infected patients automated ways to receive health information and reminders about upcoming doctor visits. In Johannesburg, 10,000 people infected with HIV have taken on these SMS-based alerts, resulting in big declines in missed appointments.
In Ghana and Liberia, a group called Africa Aid is experiencing strong success with MDNet, a system that allows users to call or text doctors for free. Since its founding in 2008, 1,900 physicians in Ghana have logged more than a million calls to patients, the group says.

Having real impact with that funding - awesome

Nkosi Sikelel’ iAfrika

You can take the boy out of Africa, but you can't take Africa out of the boy

Tuesday, October 22, 2013

Interview from #Health2Con with @DocWeighsIn on #speechrecognition #HealthIT #NLP and beyond

Loved spending time with Dr Pat Salber (@DocWeighsIn) from the Health 2.0 conference that took place a couple of weeks ago

I had the privilege of watching her in action as she blended social media with the sessions at Health 2.0 and tweeted a picture of her in action

We spent some time afterwards talking about innovation in HealthIT and documentation on subjects as wide and varied as Florence and INtelligent assistants through Speech Recognition and Natural Language Processing (NLP) or Clinical Language Understanding (CLU):

Monday, October 14, 2013

If We can Build Smart Shelves to Sell more can we do the Same to be Healthier?

This company is building "smart shelves," to help them identify people and sell to them more directly targeted adverts and products....

new display units located by checkout counters, that will use sensor technology to identify the age and sex of the would-be snacker, analytics to determine what type of guilty pleasure best appeals and a video display to deliver custom advertisements. "Knowing that a consumer is showing interest in the product gives us the opportunity to engage with them in real-time," 

THis seems like ideal technology to use in a medical setting to help influence patient behavior for positive effect and perhaps even in the home to positively influence good healthy behavior?

Monday, October 7, 2013

Consumer Reports on Healthcare - Can #HealthIT Fix the Problems

Consumer reports published a Medical Gripes report What bugs you most about your doctor?
We asked 1,000 people about their biggest medical gripes recently

It included the chart "Grip-o-Meter"
What struck me was the number of elements that could be addressed using Healthcare Technology (HealthIT). While technology may not be a panacea it is a tool to help resolve problems, improve efficiency and ease communication and flow of information

For example - "Test Results not communicated fast". In the current day and age of instant communications, mobile phones and messaging why is it patients are left waiting hours, days sometimes weeks to receive a test result. There has been some push back by the medical profession on releasing results without allowing the doctor an opportunity to explain or contact the patient. IN one site they offer this compromise - test results are held for 24 hours maximum to offer the doctor a chance o reach out to the patient but if they have not the results are automatically released anyway.

Given the pressure of time and the challenges we face with resources and the too frequent occurrences of missed communication of results sometimes resulting in poor outcomes it would seem offering an automated results communication tool to all patients would be a simple step in improving satisfaction? If I can get an automated alert when my favorite team is playing, when the score is close capturing a cell phone number when we carry out a test and using this for outbound messaging seems like an obvious step and one that #HealthIT could play a role.

I bet others could see ideas based on the other "Gripes" - send me a note or leave a comment and I'll pull this together into a more detail post

Friday, September 20, 2013

Technology and Focusing on the Patient

Always enjoying talking with John Lynn (Founder of the (he goes by @techguy and @ehrandhit) and great discussion yesterday on "Technology and Focusing on the Patient" using a Google Hangout




Tuesday, September 17, 2013

Hanging out with Congresswoman Marsha Blackburn & Dr Susan K Newbold at Summit of the Southeast

Hanging out with Congresswoman Marsha Blackburn & Dr Susan K Newbold at Summit of the Southeast #HealthIT

Susan K Newbold, PhD RN-BC FAAN FHIMSS CHTS-CP, 443-562-0502 cell

Sent from my iPad

Friday, September 13, 2013

21 Bow Tie Salute to Farzad Mostashari

Like many in the healthcare IT industry, I was saddened by the announcement that Dr Farzad Mostashari (@Farzad_ONC) would be retiring. I would suggest as famed football legend Vince Lombardi said

"The strength of the group is the strength of the leaders"
And, for healthcare technology, Dr. Mostashari has been a great leader. I’ve outlined below some of the many contributions he has made to healthcare.

Dr. Mostashari joined the Office of the National Coordinator (ONC) in 2009, and has had a huge and positive impact on the implementation, development and overall perception of healthcare IT.  Personally impacted by the state of healthcare when his mother was admitted for arrhythmias, after having asked for the paper chart, he admitted;
I couldn’t even read the cardiology consult’s name
Perhaps this is one of the reasons he like me is a proud member of Regina Holliday (@ReginaHolliday) "Walking Gallery". This difficult, and highly personal, situation likely galvanized his vision as he took on the daunting tasks demanded by the role of the ONC. He inherited a department that had, in effect, been pushed over the edge of the luge and, whilst speeding wildly along this track, was expected steer a course that would deliver on a range of programs in record time:

  • Meaningful Use of Electronic Health Records (EHR)
  • Certification program for EHRs
  • National Standards
  • Grant programs
  • Regional Extension Centers
And that was just what he knew about coming in. The team endured the challenges, weathered the storm in the "Office of No Christmas"

He rapidly earned a reputation as a leader who listened and was engaged.  He made many appearances and, although he may not have been the first, he was certainly an early adopter of social media and online engagement – clear indicators of his heartfelt passion to be part of the solution. As a customer service representative I recently encountered very astutely pointed out:
I can't do anything about the past, but I can help improve the future

It is hard to pick individual highlights from such an impressive record, but here's my list of Dr. Mostashari’s top 13 achievements and quotable/notable moments from his time in office:

  1. Successfully delivering on the Stage 1 Meaningful Use, despite frustrations and the challenges of a fickle and change-resistant healthcare profession.  He gracefully offered a personal hand to help steer his colleagues:
    "Meaningful use is the best-we-could-make-it roadmap to prepare for delivery of higher quality care and mitigating some of the costs toward getting there, if it's a distraction we need to change it, and I want to hear from you personally."
  2. Creating a viable technical assistance program that has touched many providers and hospitals through regional extension centers (REC).
  3. Driving the successful adoption of electronic health records (EHRs) and electronic medical records (EMRs).
  4. Interoperability (see note below on focus for the future)
  5. Pushing for patient empowerment (He, like me, is a proud owner and runway model for the Regina Holliday Healthcare Collection).
  6. As he said: "We’re on the right track to make meaningful use of meaningful use
  7. ePrescribing
  8. And as if to prove the point about his use of social media, this from his twitter feed: “We've made more progress with EHRs in the past 2 years then we have in 20"   
  9. Championing the patient engagement he stated: "We cannot have it be profitable to hoard patient information"
  10. Nailing the coffin shut on paper he said: "Once you close a paper file it's dead. You’re not able to move it or learn from it"
  11. While this may not be his own personal quote but he applied cyberpunk science fiction, William F. Gibson famous quote to healthcare: “The future is already here – it’s just not evenly distributed.” by pointing out that we do have the technology - its just not being applied
  12. Piloting Meaningful Use stage 2 criteria, which built on the success of stage 1, and pushed towards interoperability including standards for data sharing data, quality improvement, and quality measures that foster  patent engagement. As he put it: "We are using every lever at our disposal to increase the sharing of information" and "Patients need to care for themselves and become partners in their care"
  13. Successfully weathering the storm of the controversial (or as he put it "headline grabbing") Health Affairs article based on data from 2008 that suggested that EHR technology was increasing the costs of healthcare.

The Future:
To the lucky individual taking the reins, I offer five suggested  areas of focus:

2. A friend once said to me: "You've put us on the horse, you might as well give us the ride." The same can be said of payment reform, which must shift from quantity-based to quality-based payment. And taking a sheet from Dr Mostashari's play book, every journey starts with a single, small action, so even a small dent would be a welcome shift.

  1. Continue the engaged and inclusive discussion with all the constituents and make social media a central part of that strategy both for ONC but also for the healthcare industry.
  2. A friend once said to me: "You've put us on the horse, you might as well give us the ride" The same can be said of payment reform, which must shift from quantity-based to quality-based payment. And taking a sheet from Dr Mostashari's play book, every journey starts with a single, small action, so even a small dent would be a welcome shift.
  3. I must include a shout out for patient engagement. Nowhere else in the industry will you find such a large and untapped resource that is ready, willing – but perhaps not yet able to participate in the change. As I have stated many times:  when a doctor and patient are in a room, there is nobody, I repeat nobody, more interested in successful outcomes than the patient. Give them the tools and make them part of the solution.
  4. Occasionally, the issue of Tort and Medical Negligence is raised, but it appears to have the "third rail" syndrome. Unless this is addressed, we will continue to see "defensive medicine" practiced. As I recently blogged in Science, Evidence and Clinical Practice, despite clear data that shows intensive monitoring causes more harm in normal care deliveries, we continue to see almost universal rates of this high-level monitoring.  While some may be attributable to the payment system, I believe a large part of this volume stems from the general inertia of and fear of litigation.
  5. Above all - have fun. I made this point at every soccer practice when I was a coach. If you aren't having fun, there is little incentive to do well or, for that matter, to do at all. I know I am constantly amazed at the great fortune that finds me at this intersection of medicine and technology. I constantly have that feeling as if I paddled for the wave just at the right time:
"Surf's Up dude - ten foot waves of the Pier"

The Making of the 21 Bow Tie Salute

Dr Farzad Mostashari has been an incredible role model, a source of inspiration and a true visionary who has helped others see what the future of healthcare can look like. And so, in extreme appreciation of all that he has accomplished, I offer this 21 Bow Tie Salute.  

I was fortunate enough to have another wonderful role model, my father, take the time to teach me how to tie a bow tie, but for those of you wanting to learn the fine craft of tying a bow tie, instructions are included below (The 21 Bow Tie Salute was made with Real Bow Ties). 

Thanks Dad!

Here are some basic instructions:

News and sources include:

Wednesday, September 4, 2013

Science, Evidence and Clinical Practice

A recent article on the The Difference between Science and Technology in Birth on the AMA site demonstrates the challenges we still face in getting clicnal practice influenced by science and data. Studies and data may show the path for best clinical practice but as the authors note there are multiple instances of the clinical community - in this case the OBGYN - either knowingly or unknowingly failing to follow the best practices

For deliveries in the US evidence tells us that fetal monitoring in low risk pregnancies has a deleterious effect - yet it remains standard practice in most settings to place external scalp electrodes and intrauterine pressure catheters

Although we still see external continuous fetal monitoring employed in many low-risk pregnancies, “as a routine practice [it] does not decrease neonatal morbidity or mortality compared with intermittent auscultation…. Despite an absence of clinical trial evidence, it is standard practice in most settings to place internal scalp electrodes and intrauterine pressure catheters when there is concern for fetal well-being demonstrated on external monitoring” [3].


They list several other standard practices including

  • routing episitomy
  • Use of Doula's
  • Challenges with Epidurals

Reasons for these behaviors are varied but as the authors state:

Many well-intentioned obstetricians still employ technological interventions that are scientifically unsupported or that run counter to the evidence of what is safest for mother and child. They do so not because a well-informed pregnant woman has indicated that her values contradict what is scientifically supported, a situation that might justify a failure to follow the evidence. They do so out of tradition, fear, and the (false) assumption that doing something is usually better than doing nothing

Until we fix these basic issues there seems limited opportunity to implement intelligent medicine and real evidence or science based practices.


Thursday, August 22, 2013

Introverts and Extroverts and How to Deal with them

In a great piece on FastCompany titled: Are you an Introvert or an Extrovert? What it Means for your Career, Beth Belle Cooper explores what she considered a binary position or bucket to put people in but discovers this is really a continuum and one that we as individuals don't sit at one spot all of the time

As she describes - it is an Ambivert Personality Scale Continuum

An important aspect to healthcare in our interaction with the ever expanding teams that contain wide variations of individuals

But in thinking about work, health acre and interactions the 12 tips for dealing with the different groups seemed like great advice all round

12 Tips for Dealign with Introvert
  • Respect their need for privacy
  • Never embarrass them in public
  • Let them observe first in new situations
  • Give them time to think don't demand instant answers
  • Give them advanced notice of expected changes in their lives
  • Give them 15 minute warning to finish what they are doing
  • Reprimand them privately
  • Teach them new skills privately
  • Enable them to find one best friend who has similar interests and abilities
  • Don't push them to make lots of friends
  • Respect their introversion and don't try and make them into extroverts

10 Tips for Dealing with Extrovert

  • Respect their independance
  • Compliment them in hte company of others
  • Accept or encourage their enthusiasm
  • Allow them to explore and talk things out
  • Thoughtfully surprise them
  • Understand when they are Busy
  • Let them Dive Right in
  • Offer them Options
  • Make physical and verbal gestures of Affection
  • Let them Shine
I think what's interesting is most of us are in both camps at different times - the two lists seem like great advice all round

Monday, August 12, 2013

Technology as an Aid vs Hinderance to Doctors

A recent article in Becker Hospital Review:  Technology Should Aid Human Interaction: Q&A with Dr. Nick Terheyden, CMIO of Nuance featured some important points to make

Health IT needs to fade into the background. It needs to become part of the fabric of the office rather than the focal point, and then the interaction will change
  • Using the tools to allow the clinician to focus on the patient not the technology
  • Human beings deal in narrative and stories, patients want to tell their story and clinicians need the richness of the narrative to help guide medical decision making
  • Remove the Physical Barriers to the clinicians patient interaction
  • Healthcare is not the focus - the patient is

The key to our future and to the successful use of health IT will be turning the focus back on patient and the physician.

Thursday, August 8, 2013

Interview with HealthTech Vision

I had the pleasure of speaking with Alex Welz of Health Tech Vision last week and he posted the interview here - or you can listen to it below

The importance of bringing intelligent voice interactions to Health IT especially as medical technology moves to into the Mobile world. It is an exciting time with technology offering real hope

Wednesday, July 31, 2013

Presenting at Health2.0

See me at Health 2.0” src=Excited to be presenting at Health2.0

There have been exciting innovations in Cloud based Intelligent Speech Understanding and our new development tool set is offering a way to help healthcare providers transform patient stories into high-value clinically actionable medical information. No more burdening clinicians with data entry tasks.

See me at Health 2.0” src=Florence

You can see it here integrated by by

We have a mobile development platform with more than 750 developers signed up already

The mobile health platform is good at delivering information but the interface can be challenging and capturing the medical decision making difficult using on screen keyboards and point and click methodology.

Mobile speech enablement offers tools that facilitate the navigation and human device interaction and includes capture and clinical understanding services that turn narrative into discreet actionable data to capture the clinical decision making

You can see a brief demo here:

Hope to see you at Health 2.0

Monday, July 29, 2013

Running out of Time

All truly great thoughts are conceived by walking
Friedrich Nietzsche

Don't walk behind me; I may not lead. Don't walk in front of me; I may not follow. Just walk beside me and be my friend
Albert Camus

I met Regina Holliday a while back at one of the many conferences that she attends:

At this conference she was there to present and was also creating a painting. Her reputation had preceded her and I was excited to meet her in person and hear her story first hand. I had seen some jackets at conferences and had discovered the story behind the Walking Gallery. An idea that came from a tragic story in a healthcare system that is broken

Back in 2011 a video was made featuring many from the gallery filmed at the Kaiser Permanente Total Health Center:

The Walking Gallery from Eidolon Films on Vimeo.

You can see her presentation on Slideshare here:

But there is nothing that could match the power of hearing this in person.

Regina offered to paint my story and it was months before I could pull together some photographs and sit down to articulate my personal journey in healthcare but that all came together a few weeks ago, almost in time for another walking gallery gathering. With so much going on Regina knew what she was going to paint but had not (as the picture shows)
 managed to download it quite yet

My journey to medical school and joining an honorable and privileged profession started when I was still at school and I remember the seminal moment that made me realize this was the pathway I wanted to take:

I was visiting my older brother in London we exited from Victoria rail station just as somebody had been run over by a bus. I watched as my brother pushed his way to the front of the crowd and he stooped own while very one watched - he was a doctor and knew what to do. As I stood on the sidelines watching I realized that I want to be doing rather than watching

I was a very young medical student and while I enjoyed medical school there was no doubting the fact that I was dealing with something that was really quite unique and challenging emotionally. Life and death was part of normal clinical activities and shortly after my 22 birthday I graduated

I have been heard to joke that the TV Series Doogie Howser was modeled on me as that was some years later - he was also the original blogger.

My Story
Running Out of Time

Practicing medicine in the United Kingdom in the national health service which while delivering great care placed an enormous burden on the people delivering that care. The environment was challenging, especially for a young junior doctor and I found myself questioning what I'd let myself in for. My first clinical job I worked 132 hours per week, I had Tuesday and Thursday evening off. At the time, that was the norm and all of my colleagues had the same work schedule as I did and I noticed that my senior colleagues not only had that working schedule but also took on more clinical responsibility. My weekends were hellacious, waking up on Friday morning and not finishing until Monday evening. I shared the work with a colleague and friend by the name of Niamh Anson. We would share the on-call work and split the activities, with one of us covering wards and the other covering the emergency department admissions.

The constant and chronic sleep deprivation took its toll and I repeatedly questioned the job I was doing and indeed whether I was even safe. The nurses proved to be our saving grace and several occasions when we made mistakes through simple tiredness they caught these mistakes and quietly corrected or prevented our errors. I don't remember a single time of being on call when I wasn't up most of the night and typically at leas every hour. Rarely did this not require a visit to either the ward or the emergency department. Many the time, I would walk from my living quarters to the emergency department angry at the system that would place such a burden on anyone and wondering if there was something wrong with me.

On one particular day my two team members were not at the hospital. Niamh was on holiday, one which had been booked many weeks ago but as is normally the case medical staffing had failed as usual to find replacement. By two in the afternoon, the emergency department had 17 patients waiting to be seen by me, there was a patient in intensive care on a ventilator that was having problems, and the cardiac care unit had a patient that was having a lignocaine reaction. I reached breaking point and called medical staffing, and told them I was quitting. Their reaction, humorous in hindsight but at the time not, was to tell me that my contract did not allow for me to quit. Fortunately the ward sister from the cardiac care unit intervened and quietly called my two attending's. The next thing I knew I received a call from one of them asking me to meet him in the emergency department. I thought my career was over and proceeded down to meet him expecting to be blasted and read the riot act. I was pleasantly surprised to find my two consultants there stuck into seeing patients and helping me out. One of them admitted all of the patients in the ED department while the other dealt with the patient on the intensive care unit in the coronary care unit.

Between us we were able to triage and treat all the patients by the end of the afternoon. Even now as I think back to that story I still find myself quite emotional about the experience and support from two outstanding individuals. They rounded it out by insisting that we went to the local pub for a drink (non-alcholic of course) and listened to me and provided counsel and support.

Sadly they were not typical of the senior staff in the health system and most took the view that they had suffered this level of overwork and therefore everybody else should experience the same. This was a recurring theme throughout my time as a clinician and I found most disturbing and many times very depressing.

If I am walking with two other men, each of them will serve as my teacher. I will pick out the good points of the one and imitate them, and the bad points of the other and correct them in myself.

I remember vividly one instance where the attending surgeon I was working for heard that I was taking a sabbatical and thinking about leaving medicine. He started by saying that I was terrible shame, and I thought he was about to offer some guidance/support and thoughts about where the system is wrong and how I might cope with it. Sadly he proved to be similar to many of his colleagues and peers and felt that the system was wrong in allowing me into medical school. The system should of been better at weeding me out since there was clearly something wrong with me not with the system. He like many of his peers believed the baptism by fire, sleep deprivation and the general demeaning of junior doctors was an essential part of training and character building. As he put it, he had experienced this in his junior doctor days and he'd survived and done fine. What he failed to appreciate was that at the time he was practicing as a junior doctor, emergency call was typically a Porter coming to his door knocking on his door to tell him that somebody was "going off" and leaving a cup of tea for him. He would dress himself, drink his tea and proceed to the ward, where the patient had either died or survived, but there was very little that he could do to influence the outcome. My experience consisted of being surgically attached to an emergency page that would bark out at me at all hours, telling me to go to a ward or location in the hospital for an emergency resuscitation the could take anywhere from five – 60 minutes.

There is no easy walk to freedom anywhere, and many of us will have to pass through the valley of the shadow of death again and again before we reach the mountaintop of our desires
Nelson Mandela

My friend and colleague Niamh Anson
had many of the same experiences and like several of my colleagues elected to move away from the system leaving the NHS for Australia, perhaps hoping that this system would be more bearable. Sadly some years later she committed suicide as too many of my colleagues and friends do.

So my Walking Gallery Jacket:

As Regina described the picture:

The sky represents the never ending shifts as does the hour glass. The medical students and doctors are all standing beside me, also exhausted. My friend and colleague Niamh Anson jumping off the hour glass due to stress....

In what can only be described as a "stroke of luck" the painting of my jacket was caught on Fox 5 News doing a piece on the Walking Gallery (right around 00:24 -> 00:50 and around 01:28):

DC News Weather Sports FOX 5 DC WTTG
Or if the vide does not appear you can click this link

My jacket coming at number 227 - I hope we get all of these together one day.

If you don't like the road you're walking, start paving another one.
Dolly Parton

Like everyone else - I too have an oath to wear my jacket and use it as a tool to spread the word and effect change:

No one saves us but ourselves. No one can and no one may. We ourselves must walk the path