Connecting The Dots of Healthcare tray dunaway md: speaker : author : surgeon : educator : dotsultant : visionary Fri, 14 Mar 2008 16:22:47 +0000 en © () tray dunaway md: speaker : author : surgeon : educator : dotsultant : visionary No no Connecting The Dots of Healthcare 144 144 Latest “Dot” of Healthcare… The “Nocturnist!” Fri, 14 Mar 2008 16:17:11 +0000 admin There is no time lke noneLike most physicians, I get a steady stream of recruitment mail. Most of it is predictable and after a while, you can read between the lines. Whey they state the practice opportunity is in “God’s Country,” you can assume that generally means within 50 miles of the Canadian border… bring your long underwear! When they state you will join a “small team of dedicated healthcare workers,” you’ll be the only doctor and on call 24/7/365. (Good luck!) My wife usually tosses them, but she was reading one because the text compelled her to read… when you open the fold-over brochure, it starts off “… herding cattle, families and their dreams.” OK… sounded like a HMO to me. You know, the “herding” part. Maybe they give the clinic nurses cattle prods.

 It’s actually an opportunity to practice in Las Vegas. Wouldn’t even need cattle prods… could just use old used syringes with needles from recent news.

 They were looking specifically for hospitalists, (the fastest growing segment of medical practitioners in the country, devoted to inpatient care, and benefiting doctors by controllable shift-work hours). So here’s the quote with the new term:

Full time Nocturnists are paid additional compensation to cover nights.”

A “nocturnist” therefore must be a hospitalist who works at night. Interesting derivation. A “nocturn” is any of the three canonical divisions of the office of matins. It derives from the Latin nocturnus, meaning “of the night.” Well, who would have thought that hospitalists, especially in Vegas!, would be deriving shift work from canon law of the Catholic Church.

Leave it to Vegas, I suppose. New York has the Phantom’s “Music of the Night”… Well, I suppose, Vegas has Phantom also now,… and Vegas most certainly does have their share of  Ladies of the night, another form of “nocturnists” I suppose…. and now Doctors of the night!

 It’s a bunch of new stuff we’ve got to learn, I guess. But fear not, if Monks can figure it out, I’m sure we can too. Here’s how it works:

The Church, (prior to the Second Vatican Council), divides up each 24 hour period of time into eight “hours”:

  • Matins (during the night), also referred to as Vigils or Nocturns… but now, for I’m sure obscure reasons, now called the “Office of Readings.”
  • Lauds or Dawn Prayer (at Dawn)
  • Prime or Early Morning Prayer (First Hour = 6 a.m.)
  • Terce or Mid-Morning Prayer (Third Hour = 9 a.m.)
  • Sext or Midday Prayer (Sixth Hour = 12 noon)
  • None or Mid-Afternoon Prayer (Ninth Hour = 3 p.m.)
  • Vespers or Evening Prayer (”at the lighting of the lamps”)
  • Compline or Night Prayer (before retiring)

So technically, a “nocturnist” could also be called a “vigilist.” But I suppose that’s too close to “vigilante”…. and that might send the wrong message to patients filling out HCAHPS surveys.

And we could simply throw out “complinists”… besides sounding a lot like “complainists,” (that woudn’t fly from the office of hospital public relations, now would it?). And besides, it would refer to  a hospitalist who is retiring for bed. Might give people the idea that hospitalists are paid to sleep. Can’t have that.

So that leaves, Laudsists, Primists, Tercists, …. hmm…. not so sure about Sextists, especially since we’ve done so much to get away from the “good old boy club” perception of medicine…. and I’m not so sure about being a Noneist. Of course, if you decide to go with “sextists,” I suppose you could have “nunists” for women wanting to basically work afternoons.

Think how “noneists” might screw up employment statistics: “When do you work?”  Answer: None.

 And naturally, the Vesperists, in addition to working evenings, could also flip on the lights for everyone. Guess the incoming Laudists would have to turn them off.

 What do we call all of this? Hospitalists of the Hours?

 Which, in a rambling way, brings me back to my point. How can “nocturnists be paid additional compensation to cover nights?” I mean, you could simply pay nocturnists more, because they’re working nights. But you would give nocturnists ADDITIONAL COMPENSATION to cover days!

 If this is confusing… well, that’s why there was Vatican Two!

By the way, here’s a quick trivia question I heard on The Tonight Show.

Q: Who lives in the Vatican?

A: Vaticans!

I think medicine is complex enough. We don’t need to create additional dots for hospitalists who work the night shift. After all, we already have “Baylor shifts” (Day/Night) in addition to the traditional Day, (7-3), Evening (3-11), and Nights (11-7). The nature of one appeal of inpatient medicine is control of personal time for physicians. It’s shift work. There’s nothing wrong with “shift work” that has been created to deal with the increasing economic demands and evolutionary forces that affect how we practice medicine.

 But imagine the confusion you could cause a plaintif’s attorney.

“Doctor, when did you first examine my client?”

“Well, that would have been the ‘ninth hour’…”

“Nine pm or nine am, doctor?”

“Well actually, 3pm by YOUR measurement of time.”

“Well, Doctor, why didn’t you simply say 3 pm to begin with?”

“Because, sir, as a noneist, we set our clocks by a higher authority than you do.”

Let’s all pray for simplicity in an already over complex healthcare system.

Doctor Shortage? You do the Math! Wed, 05 Mar 2008 16:29:30 +0000 admin Punxsutawney PhilLast week found me in the beautiful snow-scape of State College, Pennsylvania, speaking to the Pennsylvania Mountains Health Alliance, a consortium of 15 regional hospitals. There were a number of highlights… not the least included enjoying snow that we don’t see much of in South Carolina, having a great dinner with a number of the CEO’s of the hospital; speaking in the most technologically sophistocated venue I’ve ever had the pleasure of speaking in at Mount Nittany Medical Center;  meeting the new handler of Punxsutawney Phil, the Seer of Seers, Prognosticator of all Prognosticators; seeing my friend and health-care prognosticator, Jeff Bauer, Ph.D., and making a new friend, Dennis Pointer, Ph.D., a governance board expert.

Jeff was speaking about a variety of topics he forecasts for health-care but here was one nugget of information that really struck a chord.

Physicians coming out of medical school today are not interested in the practice style of physicians of past generations. Physicians who would basically work 24/7 schedules with call demands. Many recent graduates are more interested in working 12 hours on and 12 hours off.

Can you blame them? If they worked only five days a week, that would still be 60 hours a week. Don’t see any labor unions advocating this for their workers!

So factor in the percentage change of doctors who used to work 24/7 lives, or any physician reasonably choosing a lifestyle that works more than 12 hours a day, and try replacing them by physicians who only will work 12 hours a day, for five to seven days a week.

Do the math.

What do you get?

Instant physician shortage to meet the 24/7 needs of patients.

Simple math. Scary results.

If he’s got time to write USAToday a letter to the editor, how come he’s not writing on his blog? Tue, 04 Mar 2008 16:20:06 +0000 admin blog writer's burnoutI am recovering from blog-writing-burnout.

When I started my blog last summer, my travel schedule permitted, (read, “I had a very slow speaking schedule last summer”), daily entries. But, fortunately, my speaking schedule picked up…. and now is literally zooming. We just booked the 12th engagement for June yesterday. This summer will be my busiest ever.  ”But I should find time to blog anyway,” I say to myself.  And now I’m recovering… and aim to post an entry once, perhaps twice, a week.

USAToday LogoSo as a crutch, let me republish a letter to the editor that was printed in yesterday’s USAToday Newspaper.  Actually, it was edited a bit, so I’m printing the full text of what I wrote. Last week there was a headline article on the shortage of general surgeons in the US. Here’s my comment… and I’ll see what I can do about creating other blog postings over the next few days to get in a weekly rhythm. … Tray

To the Editor:

General surgeons are the canaries in the increasingly physician hazardous mine of health-care. Dedication to serving needs of patients is no match to the harsh overwhelming economic forces of reimbursement cuts, relentless unfunded governmental mandates, mounting malpractice premiums and other rising overhead costs determined by a free market system especially when physicians are denied free market pricing of their services by governmental and other third party payers. Even in a price fixed system you get what you pay for and if compensation isn’t enough, you simply don’t get.


The steady drumbeat of rhetoric for “universal health-care coverage” drowns out the footsteps of physicians leaving this most demanding medical practice and predicted shortages of general surgeons are exacerbated when medical school graduates choose less difficult clinical careers. Medicare can force general surgeons to accept pay cuts, but you can’t force medical graduates to become general surgeons or force currently practicing general surgeons to remain clinically active.


Achieving the political goal of universal health-care access and coverage will not occur until realistic funding for programs treats both patients and providers in a fair and equitable manner. Good health-care is expensive. Great health-care is more expensive. Nothing is free. Someone always pays. In a fragile health-care ecosystem devoid of general surgeons, patients will unfortunately pay the ultimate cost.


M. Tray Dunaway, MD, FACS, CSP

Camden, SC

You can read the published version through this link: MARCH 3 Letters to Editor USAToday

TV Writer’s Strike — Not the end of the world!!! Tue, 18 Dec 2007 15:43:34 +0000 admin I watched the news last night and was surprised to discover the writer’s strike, (that I did hear about a few weeks ago), is still continuing. Some programs, the report announced, had been cancelled and “classic programs,” (euphemistic for ‘re-runs’), were to be aired.

Although I really was surprised to find the strike continued, I was absolutely AMAZED that it has had little, no … ZERO, impact in my life.

Strike away!

I watch so little TV, (generally I prefer a movie), that it didn’t matter. Most of my news comes from the internet. Even when a movie is available on the TV, I prefer to rent it. No commercials. Don’t even need a Tivo to skip through commercials. “But how do you watch things like ‘The Office’,” my friends say?

Easy… you can rent a whole season at Blockbuster’s. If you want to spend a whole evening in front of the TV, you can see an entire season, commercial free, at once.

“But what about movies… if the screenwriters go on strike they won’t make movies anymore,” friends counter.

“Have you seen a video store recently?” I ask. “Do you really think we will run out of movies to see anytime soon?”

Let ‘em strike. They want more money? Let ‘em strike. They want royalties from video’s? (I think they deserve royalties from this spin-off… only seems fair.) Let ‘em strike. Cause things will perk along just fine. It’s not like someone is bleeding.

Hey, but there’s a thought. If healthcare continues to struggle with rising malpractice costs and doctors continue to leave medicine in record numbers, could a strike be the solution? But we’re not the “striking” types. We subscribe to a covenant, not a “contract” in healthcare. It’s why our patients are “patients” and not “clients.” But when things get so frustrating, we retire early, or find something else to do, or simply MOVE to a state with better prospects.

I was speaking in Ohio a few years ago. A small town once had five, count ‘em, FIVE, general surgeons. Because primarily of rising malpractice coverage expenses, three moved. One of the remaining two had been planning to retire, but stayed on… but not indefinitely. The other surgeon who had not moved, and wasn’t planning on a retirement, was planning to stay on.

Stay on call, solo call, for HOW LONG?

The most recent of the three surgeons who moved to another state to practice left because his ACCOUNTANT told him he had to.

Here’s the deal. Malpractice coverage comes in two varieties. One, like in South Carolina, covers you for any claims made long after you retire or stop practicing based on the premiums you’ve paid over time. But the other variety, like in Ohio, is different. When you retire, you’ve got to buy a “tail” to cover you against any future claims. Well, like all malpractice premiums, the cost of the “tail” has also been rising. Rising to the degree that this one doctor’s accountant told him that if he didn’t move soon, he’d never be able to afford to pay the “tail” fee.

Let’s say you live in this town in Ohio. And YOU’RE bleeding. And you don’t have five surgeons who could care for you. Maybe you’re down to one… and he’s tied up. Or maybe, just maybe, he got tired of practicing solo in a town that once had five, count ‘em, FIVE general surgeons, and he’s moved across the line to West Virginia to practice.

Now someone IS bleeding.

Now I like the Tonight Show as much as anyone else. But if I see a re-run, it’s not the end of the world. Because I’m not bleeding.

But if you ARE bleeding, and can’t get the medical care you need… it really could be the end of the world for YOU!

Has it really been that long? Tue, 18 Dec 2007 15:19:57 +0000 admin I’ve had a number of friends inquire… “Where have you been? You haven’t blogged in a while… are you O.K.???”

 I appreciate the concern and am flattered that you miss my blogging…

 But, sadly, it seems I’ve run out of ideas.   Can’t think of anything new.

 Everything I’ve thought of seems to have been thought of before. And with the Democratic and Republican Presidential candidates running for office, obviously, they’ve already got things figured out.

 S0 I’ve been just hunkered in my bunker.

 Actually, that’s not really true. I’ve simply been incredibly busy. Here’s what I’ve been up to.

 I have just finished my busiest season speaking…. ever. October and November has had me visit New York, Kansas, Georgia, California, Michigan, North Carolina, (twice), Utah, Ohio, South Carolina, Alabama, and in between, two audio conferences.  From Keynoting for a Duke Endowment sponsored multi-state hospital meeting to a Dillon, Montana to speak at a fund raiser for the Barrett Hospital Foundation’s annual meeting.  A brand new keynote for a multi-state Hospice meeting and a (They wanted me to put the “fun” in FUNd raising.) I’m grateful that business has been bountiful and my messages have been well received.

 And really, I simply took a break from blogging. I know, I know, that’s not what you’re supposed to do… supposed to crank out a string of postings so the search engines know you publish frequently, but this blogger needs time to recharge. I don’t want to burnout… and I’m not talking work/life balance… (actually, I have a hard time deciding what I do is actually “work” or “life”… ) I have fun no matter where or what I’m doing… but with children, I know they’re not always going to be home… so I really enjoy my time with them. Even if it’s simply watching a late night movie.

And I’m gearing up for another busy season. This spring, Press Ganey, a long time client, has asked me to headline their series of spring conferences… so I’ll be all around the country from March to June with a program on customer, (patient), satisfaction, physician satisfaction, and staff satisfaction coupled with clinical excellence. New keynotes for homecare and medical sales are percolating along with my two columns for Caring and Respiratory Therapy and a new corporate keynote for not-for-healthcare audiences have consumed a fair amount of time.

With both college kids home for Christmas Break, and my eighth-grader getting finished with exams this week, we’ve put up the Christmas Tree and decorated the house. Here’s the house at night. 

Camden, SC Christmas at the Dunaway’s

 Jane wanted to go with a slightly less secular front door look so Santa has been relegated to the back porch.

Secular Santa Religated to Back Porch

And speaking of lighting, I’ve just put the finishing touches on my audio, and yes, VIDEO, podcasting studio. With the help of pvc pipes suspended from the ceiling of my office and a few par can lights, the project I began late in the summer is almost completed.

When I began blogging, I managed to crank out a new blog a day but it proved to be pretty time consuming. So one of my new year’s resolutions is to get out a blog no less than once or twice a week, but I doubt I’ll be a daily blogger since I now have three, count ‘em, three of them! And a good deal of the time will be spend with audio blogging, (, for your listening pleasure.

Just thought you might like to know…


100,000 Lives Campaign “Failure” Wed, 31 Oct 2007 15:09:58 +0000 admin Well it hasn’t been. It’s been an amazing success. But why? To a large degree it’s been from the formation and use of rapid response teams. RRT works like this: ANYONE, from a housekeeper to a physician, from a nurse to an administrator, can call a RRT effort. But embracing “failure” has been key to its ultimate success.

Here is what is critical about the RRT. If ANYONE sees, hears, or even feels a patient is in trouble. ANYONE is empowered, and encouraged, to call a RRT event. This has dramatically decreased the number of out of ICU code situations and has been shown to save countless lives of patients in hospitals.

Here’s the acceptance of “failure” part. If it was a “false alarm,” that the patient wasn’t “really” in distress, there is NO STIGMA to the RRT initiator. You don’t get into trouble, there’s no second guessing, rather, the person who initiated the RRT is thanked, complimented, and encouraged to do it again if THEY think it’s the right thing to do. (Not if ANYONE ELSE thinks it’s necessarily the right thing to do.)

We must accept “failure” from others trying to do the right thing for patients. By allowing people to do the right thing, even if later circumstances prove otherwise, people are encouraged to continue to “do the right thing.” simple as that. By removing the “failure factor,” the reprimand for “wasting everyone’s time,” the ability for the individual to call another RRT will not be mitigated by the uncertainty and worry if their action could cause them to suffer any consequence.

Empowering ALL dots of healthcare in other spheres of healthcare innovation for improving patient centric care through open communication without fear of retribution of criticism is the lesson we can all take, and use, from the RRT principle.

Healthcare’s 11th Commandment: Thou Shall Not Fail Tue, 30 Oct 2007 02:24:40 +0000 admin Over the past weeks, I’ve had the “perfect storm” to think through a few ideas. I’ve shared the platform with Lt. Col. John Nance, who speaks on adopting aviation safety ideas to healthcare, Dr. Jeff Bauer, a healthcare futurist, and also listen to a variety of speakers in a symposium on innovation. And combining these ideas with my construct of MVI, mutual value integration has been a fertile experience.

At the heart of it is my often stated 11th commandment in healthcare, “Thou Shalt Not Fail.” This week I’ll blog just a bit on some thoughts about our 11th Commandment and the need to qualify “failure.”

It is the nature of healthcare, and physicians, to eschew failure. But this has created the “halo effect” that Lt. Col. Nance refers to. That people in a position of healthcare authority are perfect and incapable of failure.

Well, of course, that’s nonsense. It’s the nature of people, even highly elevated people in healthcare, to fail. That’s human nature. And, although some have a hard time admitting this, we’re all human. But although intellectually we can all agree on this, in practice, especially in healthcare, we insist on our revered individuals to be perfect. 

To survive the future of healthcare will require innovation and adopt ideas from non-healthcare environments of business, product development, and service.

But to innovate and develop creative solutions for future problems, we must learn to allow ourselves to fail.

Failure that allows avoidable death to occur is one thing. (And here we must hold to high standards that prevent these errors.) But in non-life and death situations, failure must be accepted, and even promoted.

At the heart of innovation, we must accept, no CELEBRATE, a degree of failure. Failure must be accepted as an essential step in stimulating innovation. Because that’s how we grow. If we punish failure and people who take the risk of thinking differently, we stifle innovation.

Healthcare is hierarchical. And therefore, a cultural shift to encourage EVERYONE to have a free flow of ideas and creativity, to acknowledge that EVERYONE should be viewed as a prospective innovator is daunting. But if we don’t allow failure, without criticism or ridicule, we will never harness the potential innovation power of any institution. Healthcare or otherwise.

High Tech vs. High Touch Fri, 26 Oct 2007 14:12:54 +0000 admin I was speaking at a regional healthcare summit that included five hospitals as well as a number of other businesses of healthcare. Jeff Bauer, Ph.D. spoke on the future of healthcare as becoming more and more high tech. That clinical trials have supported through evidence based medicine improve patient outcomes.

There was an under-rumbing of mutterings. ”High touch can never be replaced by high tech.”

I think the point was missed. I absolutely agree, high touch can never be replaced by ”high touch.” But “replaced” is not the right word. Actually, “vs.” is also incorrect.

Technology has made medicine better that it has ever been. And technology will continue to improve outcomes. But high tech is not mutually exclusive of “high touch.”

To give patients the kind of care they deserve, there must be a blending of clinical excellence and compassionate caring. Of high tech AND high touch.

If high tech can bring my patients more abundant life, that will give me and the families they love more opportunities to give them ”high touch” as well. 

Alternative Medicine vs. “Complimentary Medicine” Thu, 25 Oct 2007 15:22:15 +0000 admin There is a shift in western medicine that will open doors of exploration and discovery.

I’ve noticed, “alternative medicine” is now being increasingly described as “complimentary medicine.”

This is good.

It means that when physicians start looking at things they don’t know, they’re more inclined to stop labeling “alternatives” to western medicine, as “complimentary.” Something that may compliment western medicine.

The bottomline is medicine is medicine. It doesn’t really matter if it’s traditional western medicine, or if it’s medicine that is considered unconventional to western trained physicians. If something that’s not easily explained by science, but it’s safe, and if it’s effective, and it benefits patients, it’s good medicine.

I don’t understand acupuncture but I’ve seen it work on some patients. Amazingly well. Mind-Body intervention, traditional Chinese medicine, homeopathy? Who knows?

I don’t know.

When more physicians start saying “I don’t know why something may work, but let’s try. What do we have to lose?”… patients may start getting results western medicine can’t reach.

But there is a downside. Mainly on the part of the public… and non-discriminating physicians.

There has been, and always will be, charlatans. Recent data on the efficacy of copper bracelets on the myriad of disorders they manufacturers and retailers of copper bracelets failed to show any benefit. While good medicine is good medicine, “alternative” or “traditional,” ALL therapies should be subjected to the same scientific scrutiny and evidence based evaluation.

Acknowledging “I don’t know” by physicians willing to try someting “alternative” must be balanced by cooperative testing of the unproven. Once proved, factually and scientifically, it’s… well… proven.

Once proven, it’s no longer “conventional,” or even “complimentary,” it’s just medicine. But patients must remain vigilent, and also demand scientific testing, to make the determination between medicine and quackery.

Making Waves, (or Melting Ice) Wed, 24 Oct 2007 13:47:14 +0000 admin While in Liberal, Kansas, I presented some ideas to the board of directors and attended the public session of the board meeting. The director of maintenance made an request for an item that was not budgeted.

evidentially, this is not a pickup truck model of an agitator and flingerWith winter coming, they needed to replace what they currently use to apply salt and sand to the parking lots in the winter, to prevent visitors to the hospital from slipping on ice. It’s a device that attaches to the back of a pickup truck, and it’s two parts. The first part is called an “agitator” and the other part is called a “flinger.”

No foolin’.  It won easy approval.

Isn’t that just like life. To melt ice, to create change, to improve the safety of patients in healthcare, you’ve go to do a fair amount of agitation. Some people don’t necessarily like agitators, but if you don’t have agitators, no change will happen.

But it’s not just agitation. Once things are agitated a bit, you’ve got to start flinging ideas about. Otherwise the change will not spread and they’ll still be areas that don’t get the benefit of the change.

Kind of like when the proverbial you-know-what hits the fan.

If it’s not agitated and broken up before it hits the fan, it isn’t spread around enough to do good.

Got an idea to make things better for healthcare in a patient-centric way?

Get out there and agitate and then start flinging.