Finding out how to cause bacteria to dye

A new book by Thomas Hager titled "The Demon Under The Microscope" is reviewed in today's WSJ ("Medicine's First Miracle Drug" by Paul McHugh). It's a description of how the first miralce drug was discovered. All along I thought this was penicillin, but the drug here -- sulfa drugs -- actually came first.

From the the 1870s, thanks to the work of scientists Louis Pasteur, Joseph Lister and Robert Koch, the germ theory (that germs cause infections and disease) was becoming accepted, but nobody had a clue of how to prevent or stop germs. At the turn of the century, a German scientist named Paul Ehrlich "proposed that chemical compounds -- "magic bullets" -- must exist with a selective capacity to kill germs in the body. After all, he noted, certain dyes selectively stained bacteria. Why couldn't certain dyes be made to kill them, too?"

Then a group of German physician-scientists who believed in the truth of Ehrlich's theory, perhaps for lack of a better alternative theory, began working during the post-WWI period at the "dye conglomerate IG Farben."

Year after year the team infected mice with streptococci, the bacteria responsible for so many deadly infections in humans. The researchers then treated the mice with various dyes but had to watch as thousands upon thousands of them died despite such treatment. Nothing seemed to work. The 1920s turned into the '30s, and still Domagk and his team held to Ehrlich's idea. There was simply no better idea around.

Then one of the old hands at IG Farben mentioned that he could get dyes to stick to wool and to fade less by attaching molecular side-chains containing sulfur to them. Maybe what worked for wool would work for bacteria by making the dye adhere to the bacteria long enough to kill it.

Sulfanilamide, called sulfa by the chemists who synthesized it around 1900, sat on all dyers' shelves, the proprietary patents having long expired. In October 1932 Domagk began using dyes with sulfa attachments and promptly his mice began to survive -- indeed many started "jumping up and down very lively," he noted. At first the investigators couldn't believe the results. But repeated experiments showed again and again that sulfa-augmented dyes protected the mice from infection.

In February 1935, after a variety of trials on humans, Domagk announced to the medical world his discovery of the drug he called Prontosil. It was a common nitrogen-based azo dye with a sulfa side-chain, and it cured bacterial infections. The news spread quickly.

It's amazing that such a simple theory, that is not intuitive and certainly unconventional (even today people would find it hard to believe that a dye can kill bacteria), worked. What's even more amazing is the serendipity involved, for it wasn't the dye that did the deed.

The German scientists -- all of them Ehrlich disciples -- thought that the power to cure infection rested in the dye, with the sulfa side-chain merely holding the killer dye to the bacteria. The scientists at the Pasteur Institute, though, showed that the sulfa side-chain alone worked against infection just as well as the Prontosil compound. In fact, the dye fraction of the compound was useless. You could have Ehrlich's magic bullet without Ehrlich's big idea! This bombshell rendered the German patents worthless. The life-saver "drug" turned out to be a simple, unpatentable chemical available in bulk everywhere.

Still, the lesson of this story (as in so many, especially in medical science) is that being determined about and working hard for a goal may yield big results, even if it's not due to the belief you had behind the goal. "Gerhard Domagk was embarrassed that he missed the final analytic step, allowing the French to carry the day. But without his dedication to Ehrlich's idea, no one -- German or French -- would have used sulfa in a medicine, let alone fought infections with it. Domagk deservedly won the Nobel Prize in 1939."

Technology, technicians, and shortages

Just last night I was having dinner with a couple med school buddies when one proposed that a technician can do a colonscope procedure as well as a GI doctor. He meant the preparing, inserting and scoping around of a person's lower GI tract. One doesn't need an MD-level training to do that he said.

My other friend disagreed: the countless times a GI fellow scopes patients leads to a high level of skill. While the first friend agreed that a physician does need to observe, interpret what they see from the scope and determine a management & treatment plan, he was still convinced that the physical labor can be done for much cheaper, saving patients and more so insurers money on this procedure.

I said this would not come to pass unless there was a crushing shortage of GI docs and too many patients needing to be scoped. Then pressures would compel some solution, which I think is a GI technician who would do scopes, leaving the truly medical aspects of the colonoscopy to the physician.

And then I saw this article in the 26 June 2006 Businessweek titled "The Doctor Is (Plugged) In." It's not as much about new technology allowing doctors to monitor patients remotely as it is how the problem of a shortage of ICU physicians and nurses is being resolved using technology.

The eICU technology, sold by Baltimore's Visicu Inc., lets hospitals leverage the scarce resources of specially trained intensive-care doctors and nurses. A single physician and nurse can support bedside caregivers for more than 100 patients at once. "We classify it as transformational because of what it represents," says Gartner Inc. analyst Vi Shaffer. "How do you do better with less, and how do you improve care when intensive-care specialists and nurses are scarce?"

Both Big Business and the specialty association are behind using technology to deal with specialist shortages.

The Leapfrog Group, a consortium of big employers, says 54,000 people a year could be saved if every U.S. ICU case were co-managed by a specialist. That's impossible without technology: It would take 25,000 specialists to staff
ICUs, and only 6,000 are available. "I've watched eICUs take off just in the past year," says Phillip Dellinger, past president of the Society of Critical Care Medicine. "It inherently makes sense."

Only 7% of American ICU beds are monitored using such technology, and the obvious limiting factor is cost. And this going to remain the limiting factor until prices begin to descend to more affordable levels, despite: "Sentara's Hochman says the system paid for its initial cost ($1.6 million) within six months."

At a time when organizations want to cut the "fat," meaning in one regard cut our layers of management, the eICU adds layers.

Indeed, the real advantage to the eICU is the change it allows in hospital management. Under Sentara's old system, a patient was admitted to a hospital by a nonspecialist doctor. That doctor made rounds in the morning, then went back to the office. For the rest of the day nurses handled whatever came up, alerting doctors when things got urgent.

The eICU system adds two more layers of patient management. An in-hospital team uses shared data to conduct its own daily case reviews. At Norfolk General, Medical Director for Quality of Critical Care William A. Brock rides a Segway through corridors as he directs a dozen doctors, nurses, pharmacists, and other professionals in reviewing each case in Sentara's cardiac ICU, ordering tests, and offering advice to admitting physicians. And from noon to 7 a.m., the eICU team offers specialized support to bedside nurses, who manage cases while patients' personal doctors do other work.

Despite high costs and increasing the layers of patient management, the payoff is there.

In two ICUs, deaths fell 27% the first year Sentara had the system up,
according to a study in the journal Critical Care Medicine. Based on death rates before and after the technology was rolled out systemwide, Sentara estimates that its eICU has saved 460 patients who would have died in traditional care. And the cost per ICU case also fell, by nearly $3,000, or 25%...

Much of the savings came from a dramatic plunge in complications such as hospital-acquired pneumonia and bloodstream infections, which occur more often when patients aren't monitored by experts who understand the meaning of subtle changes in their condition. If not treated immediately, they result in more tests, more treatments, and longer stays in intensive care, which costs about three times as much as the rest of the hospital. The system cut almost a day off the average ICU stay, from 4.4 days to 3.6.

I think it's just a matter of time until every ICU in the country is wired up this way. And it's not just new companies pushing the technology -- it's also patients demanding it. Hospitals may soon have to "factor in a question posed by Charlotte Pipes's sister-in-law, Janet Eiler: 'Patients' families are going to ask: "Why don't you have this?"'"

Quality of healthcare in the US improves

Or so goes the title of an AP article on the findings of National Committee for Quality Assurance, which accredits and certifies insurers.

For patients in private insurance plans, there was improvement in 35 of 42 measurements, including such categories as cervical cancer screening, colorectal cancer screening and the controlling of high blood pressure in hypertension patients.

Still, most insurers do not report objective healthcare data that would help build a more accurate picture of what's really going on.

One in four Americans are enrolled in health plans that collect and report data on the quality of care. However, more than 100 million Americans are enrolled in plans that report no objective quality data, the report said.

"This past decade has demonstrated the benefits of measurement, reporting and accountability, but three out of four people don't enjoy those benefits today," said Margaret E. O'Kane, the president of the National Committee for Quality Assurance. "It's time to ask, 'Why not?'"

More video games created for healthcare

I’ve written about the power of video games to help people take care of their health before (here). Here’s yet another testimony, this time in an article titled “Not Just Child’s Play” in 6 August 2006 issue of US News & World Report.

Welcome to the upside of computer games. Their legendary powers of distraction and ability to create synthetic worlds are turning one of the most popular--and disparaged--entertainment media into a promising and potentially powerful medical tool. Long derided as the enemy of health for transforming children into weapon-loving, overweight zombies, computer games are now proving effective for everything from reducing pain and managing chronic disease to treating post-traumatic stress disorder and promoting fitness and exercise. Although these so-called serious games are still in their infancy, there's a growing body of evidence backing their health-improvement claims. "Games can be extremely motivational and useful in therapeutic and medical settings," says Albert "Skip" Rizzo, a clinical psychologist and director of the Virtual Environments Lab at the University of Southern California. "There are a lot of researchers looking at this technology because it makes things fun, and it's very engaging."

Some specifics from the article:

There is no clinical test for cool, but preliminary results from a yearlong study of 375 cancer patients ages 13 to 29 (including Patino) found that those who played Re-Mission opened their pill bottles 15 percent more often and had levels of chemotherapy drugs in their blood 20 percent higher than the nonplaying group. Players also said they had a greater sense of empowerment against their cancer. HopeLab distributes Re-Mission (http://www.re-mission.net/) free and wants to develop comparable resources for sickle cell disease, depression, and autism.

In a different twist on the video craze, there is Glucoboy, a blood glucose monitor that can be attached to a Nintendo Game Boy. The more a player regularly tests his or her glucose level--and it stays within an acceptable range--the greater the rewards like access to special games. The games are seeded with information on managing diabetes, including tips on diet, exercise, and monitoring blood sugar. Now awaiting Food and Drug Administration approval, Glucoboy was invented by a man whose son routinely hid his glucose meter to avoid the finger prick. "Diabetes is 90 percent self-management," says Richard Bergenstal, an endocrinologist and executive director of the International Diabetes Center at Park Nicollett in St. Louis Park, Minn. "If video games can be crafted to reinforce or enhance self-management, that's worth exploring."

There is video games, which many kids naturally become hyper-focused into, and then there is virtual reality, which is being used for both kids & adults.

Virtual environments are so all-consuming that the deeper someone is absorbed into the game, the less they can focus on their own pain," says Hunter Hoffman, director of the Virtual Reality Analgesia Research Center at the University of Washington and the cocreator of SnowWorld, a virtual reality game for burn patients. SnowWorld takes players into an icy realm of penguins, igloos, and snowmen; users negotiate the terrain and engage in snowball fights. In a study now under review by the Clinical Journal of Pain, burn patients who played SnowWorld reported significantly lower levels of perceived pain during wound care: moderate or 5.1 on a scale of 10, compared with 7.2 or severe for those who did not play. A previous study found that the parts of the brain that register pain were less active while patients resided in the virtual world.

In my writing about this I found a website named Social Impact Games that lists "serious games," among them games designed for health and wellness, designed by others.

What's a smart public health policy? Smoking bans.

The American Heart Association asserts that smoking bans in workplaces and in public buildings (here) and says it has more support from a study done in Pueblo, Colorado, where bans have “sparked a steep decline in heart attacks,” as reported in this AP article.

In the 18 months after a no-smoking ordinance took effect in Pueblo in 2003, hospital admissions for heart attacks for city residents dropped 27 percent, according to the study led by Dr. Carl Bartecchi, a clinical professor of medicine at the University of Colorado School of Medicine in Denver.

"Heart attack hospitalizations did not change significantly for residents of surrounding Pueblo County or in the comparison city of Colorado Springs, neither of which have non-smoking ordinances…"

…

The association said this was further evidence of the damage wrought by secondhand smoke.

"The decline in the number of heart attack hospitalizations within the first year and a half after the non-smoking ban that was observed in this study is most likely due to a decrease in the effect of secondhand smoke as a triggering factor for heart attacks," it said.

And I thought the biggest benefit of the smoking bans was that my clothes wouldn’t stink of cigarette butts when coming home from a night out.

(This reminds me of a student who won a prize in my history of medicine class last year who, after reviewing Roman public health measures like aqueducts, concluded that public health measures does more to improve the quality of human life and on a broader scale than medical measures.)

Putting money where the mouth is...

There's an interesting trend in health insurance to cover dental care for a certain group of people during a certain time in their lives. Why? Well because a "number of studies suggest that early prevention and treatment of gum disease may result in significantly improved outcomes for pregnancy, heart disease and diabetes, often leading to substantial medical-cost savings."

Cigna Corp.'s Oral Health Integration Program, implemented earlier this year, covers additional deep cleanings known as scaling and root planing during pregnancy at no extra cost, or an additional regular cleaning (over the usual two a year) for pregnant women who don't require scaling and root planing. A similar benefit is available for patients in Cigna's diabetes and cardiac-care disease-management programs.

So far the biggest beneficiaries of this trend are pregnant women, as Aetna and smaller insurers are paying for commonplace items like antibiotic mouthwash.

"'We can save medical costs by getting people to have dental care at the right time in their lives,' says Glenn Melenyk, dental consultant at Blue Cross Blue Shield of Michigan in Detroit." BCBS has in fact signed up big corporations like Ford Motors -- companies that have been complaining about the rising costs of healthcare -- because they believe this preventive approach to healthcare will save them money in the long run.

(This comes from the 19 Sept. 2006 WSJ article "Health Plans Expand Dental Benefits" -- subscription required)

Primary care medicine - what'll save it?

Some people in medicine, like many of our professors, gripe about how we need more primary care doctors. Even the media cites how had it will be to see your local doctor when this impending shortage emerges, even though such predictions made by the AMA have been wrong in the past.

While I don't entirely believe in a primary care physician shortage because there's plenty of foreign medical graduates who fill the open residency slots every year, and despite conceding that there might be truth in the conclusion of a Dartmouth study that less doctors per capita may do the local populace some good, I assert that there is an ever-decreasing interest in primary care specialities (internal medicine, pediatrics, obstetrics/gynecology & family medicine) among students at my school.

Why? Because of pure and simple economics. Primary care doesn't pay as much as other specialties. So many, weighed down by the burden of student debt, are compelled to seek better paying options. And others just want to make plenty of money, which is hard to do in a primary care field because of the lack of insurance reimbursements, governmental & private, for the non-procedural kind of work these doctors do.

According to responses to a recent WSJ article, some feel that Medicare's bueracratically determined payments is to blame. "The physician shortage you describe in "Is There a Doctor in the House" (The Journal Report, Aug. 21) will worsen and spread as Americans age and as physicians increasingly opt out of Medicare to free themselves of Medicare's fee structure and tortuous regulations."

That same writer offers a plan for patients to get primary care in coming days when there'll be a shortage of such doctors, one different than the usual "tell Congress to stop the cuts in Medicare payments!":

Choose a physician who has opted out of Medicare. By opting out, a physician chooses to work directly for her patients and forgo Medicare reimbursement. Such physicians have fewer patients, more time and a strong financial incentive to deliver excellent care. Such an arrangement is better for doctors and patients and saves Medicare money.

Will this new (but really old actually) direct pay-for-service model take off?

$4 for a month's supply of generics

Wal-Mart's announcement last week was big. Big enough to influence the prices of drugstores downward by 7-9% on that day.

I asked a family friend who's a CVS pharmacist today in passing what he thought about Wal-Mart's plan. He said that his company isn't worried, largely because he believes they won't be able to sustain it. A pharmacist will fill about 10 prescriptions per hour and charge about $40 per hour in salary. So at $4 per prescription, they won't be making much margin. Or so his argument was.

Furthermore, pharmacists won't work more than they're accustomed to -- and so there won't be higher volume of sales to offset the loss in margins. And many consumers will value convenience over price since it will now take hours in his mind for a Wal-Mart shopper to get her prescription filled.

But even he admitted he doesn't know exactly how things will play out, and conceded that if Wal-Mart is successful, then the market (i.e., his company and others) will have to adjust.

It will be fun to watch on the sidelines if the innovations Wal-Mart has used to lower prices on many goods not just in its stores but across the board will allow the company to sustain generics and their current system of dispensing medicines -- or if they'll have to give up, or even come up with new innovations to keep the low prices rolling.

Gaps in unbiased medical information can be painful

This NY Times essay by Jerry Avorn titled "The Sting of Ignorance" presents the problem of information gaps in healthcare that instead of re-interpreting what he wrote I'm just printing his essay in its entirety below.

LATE on a summer afternoon not long ago, the water at Lucy Vincent Beach on Martha’s Vineyard was warm, and the toxic jellyfish that had plagued bathers weeks earlier had floated out to sea. Body-surfing in on my last wave, I suddenly felt as if someone had whacked my leg with a lead pipe studded with nails. On the 1-to-10 pain scale we use with patients, I would have called it a 14. When I rubbed the area with my hand, my whole palm stung. Apparently those toxic jellyfish hadn’t all left.

A crowd of passers-by gathered to offer tips from the tainted well of conventional wisdom. “Use ammonia.” “Rub in some meat tenderizer.” “Apply vinegar.”

Soon a small army of bronzed youths in official-looking tank tops arrived carrying enormous medical kits. One poured sterile water on the sting area; another rubbed it with an ice pack. A third worked an alcohol-based anesthetic into the wound. Each treatment made the pain worse.

Eventually our group attracted the attention of a nurse strolling down the beach. A year-round Vineyard resident, she had seen her share of vacation-related medical emergencies. “You’ve removed the tentacle, haven’t you?” she asked matter-of-factly. No one, including the medical-professor patient, had thought of this. She took a piece of gauze and pulled off a slimy, transparent string laced with neurotoxins. It had continued to send those toxins into my leg for the first 20 minutes of my care. They are particularly activated, I would later learn, by distilled water, by mechanical pressure (as from an ice pack), and by alcohol-based topical medicines — all the treatments I had so earnestly been given.

Now the pain began to abate. I drove home and reached for three of the most useful medicines I know: aspirin, acetaminophen (Tylenol) and the Internet. As the first two began to take effect, the third revealed a study published in February in The Medical Journal of Australia.

The clever Aussies (whose beaches are also infested by toxic jellyfish) had conducted a clinical trial that randomly assigned sting victims to application of hot water (to deactivate the poison) or icepacks. The trial was stopped halfway through because the hot-water group did so much better that it would have been unethical to continue. I didn’t discover this through any proprietary medical search engines. I used Google and Wikipedia, and it took about two minutes.

Coincidentally, much of my work is about defining which medications work best for which conditions, and how to close the gap between that knowledge and the care patients typically receive. My research group constantly comes across effective treatments that are underused, and poor-choice drugs that are widely prescribed. Even when good clinical trial data on a regimen or medicine exist, no coherent system ensures that the message gets out to doctors and patients. As a result, many treatment choices are driven by habit, old information or glitzy promotional campaigns.

My aquatic encounter was a small example of what millions of patients confront daily, in much more serious circumstances. The nation faces two yawning medical information gaps. First, we need more studies comparing treatments to each other, as that simple Australian trial did. Drug companies don’t usually do such tests, preferring to evaluate their new products by comparing them to placebos. (The drugs usually win.)

The National Institutes of Health, facing its first real-dollar budget cut in generations, isn’t likely to expand its mandate in this direction. But what about the insurers, private and governmental, who pay such a large share of the nation’s $220 billion annual drug bill? They could support such studies with the rounding error of their annual budgets — and then save billions if the findings were put into practice.

The second problem is that much of the knowledge we do have is not communicated to the people who need it. Drug companies are adept at barraging doctors and patients with slick messages touting their most expensive products — even if they are no better than older, more affordable standbys. Maybe if Merck held the patent on hot water, my well-intentioned beach squad would have known all about the Australian study. But that’s a poor way to ensure that patients receive the right care.

We need an unbiased, efficient system to get the word out to practitioners on what works best. My colleagues and I have done pro bono research aimed at developing such an approach. Because the drug industry is so adept at changing beliefs and practices, we’ve taken a few leaves from its book.

In a program financed by the Commonwealth of Pennsylvania, called the Independent Drug Information Service, we scan the medical literature for the best evidence on how to treat a given medical problem (like high cholesterol or arthritis), boil it down into user-friendly packets of information, and then send nurses and pharmacists out to doctors’ offices to recommend optimal treatments. The information we provide is unbiased and noncommercial, and we don’t offer free trips to golf resorts. The resulting savings from more cost-effective prescribing could more than cover the costs of programs like this.

The approach has been adopted in several Canadian provinces, and Australia runs a continent-sized program to update its primary care doctors (though I don’t know if it addresses jellyfish injuries). The government covers expenses, but scientific content is determined by nonprofit professional organizations. Their recommendations are transmitted in person by “outreach educators,” in concise newsletters, and electronically to doctors, health workers and patients.

If the Vineyard beach first responders had known of the latest research results, they wouldn’t have done everything they could to transfer toxin from the jellyfish tentacle to my leg. All of us need access to current, noncommercial medical information. Besides helping to contain our runaway medication expenditures, programs of this kind could prevent a lot of needless suffering — by patients and doctors alike.

(I bolded certain lines to emphasize the main points.)

How one state fights childhood obesity

When I write about "healthcare innovations," I use the broadest definition of the word 'healthcare.' That's why I write about the innovative way the state of Arkansas has been dealing with obesity as reported in the NY Times.

Gov. Huckabee and his government has been trying to make a healthier lifestyle a more attractive choice. "Many of his policies include incentives like exercise breaks for state employees. He has expanded state insurance coverage to cover obesity treatment."

However, he has used his power to restrict choices too.

The policy that has brought the most attention to the governor, however, was not his initiative. In the spring of 2003, Herschel W. Cleveland, then the Arkansas House speaker, introduced a bill to remove vending machines from elementary schools and send home the body mass index report cards.

The bill passed easily, but the public generally did not notice until Mr. Huckabee had become the health governor. The news made national headlines and brought vehement objections from parents concerned about government intrusion and fragile young egos, recalled the sponsor, State Representative Jay Bradford, a Democrat...

Plus in the South, eating fried foods filled with fat is considered a birthright.

Mr. Huckabee knows what he is up against, namely all-you-can-eat buffets, cheese grits and a local ice cream flavor called Woo Pig Chewy. One of his own family dogs is named Sonic, after the fast-food chain whose cherry limeades are favored by his wife, Janet.

“It’s not just your culture,” he said, speaking in his office in the Capitol building. “It’s your comfort.”

And the state's policis have done little to change waist sizes so far, since "in three years of recording children’s body mass index and reporting it to parents, the number of children at risk of obesity has decreased — by half of 1 percent."

Still, he believes he can -- through smart, and sometimes forceful and quite unpopular policies -- change hearts and minds. "But Mr. Huckabee insists that a lifestyle revolution can happen, citing four behaviors that have been reshaped over the years by concerted government effort: littering, seatbelt use, smoking and drunken driving."

Is it too hard to figure out what incentives change doctors' habits?

The answer is probably yes. The authors of the book Freakonomics wrote a NY Times Magazine piece on how L.A.'s Cedars-Sinai Medical Center got its doctors -- who had the worst rate among hospital staff of cleaning their hands before attending to patients -- to change their ways.

The concept that doctors washing their hands regularly would saves patients' lives was established in 1847 when Dr. Semmelweis found:

The mortality rate in the doctors’ clinic was nearly triple the rate in the midwives’ clinic. Why the huge discrepancy? The doctors, it turned out, often came to deliveries straight from the autopsy ward, promptly infecting mother and child with whatever germs their most recent cadaver happened to carry. Once Semmelweis had these doctors wash their hands with an antiseptic solution, the mortality rate plummeted.

But still today, the Semmelweis Rule is hard to enforce. Why? "[f]or starters, doctors are very busy. And a sink isn’t always handy... [and] even with Purell dispensers mounted on a wall, ... doctors didn’t always use them." In addition there are psychological reasons: there's "a perception deficit" (in an Australian study, "doctors self-reported their hand-washing rate at 73 percent, whereas when these same doctors were observed, their actual rate was a paltry 9 percent") and there's “[t]he ego [that] can kick in after you have been in practice a while."

According to the writers, the incentives "were not quite aligned with the hospital’s."

At first the hospital team assigned to the task sent emails and faxes, and put posters up. But none of it worked. So the team moved onto rewarding those docs who complied with the Semmelweis rule.

They started a Hand Hygiene Safety Posse that roamed the wards and let it be known that this posse preferred using carrots to sticks: rather than searching for doctors who weren’t compliant, they’d try to “catch” a doctor who was washing up, giving him a $10 Starbucks card as reward. You might think that the highest earners in a hospital wouldn’t much care about a $10 incentive — “but none of them turned down the card,” Silka says.

When the nurse spies reported back the latest data, it was clear that the hospital’s efforts were working — but not nearly enough. Compliance had risen to about 80 percent from 65 percent, but the Joint Commission required 90 percent compliance.

Eventually, the entire staff was compliant! But how? Well, one day "after [a group of doctors] finished their lunch, Murthy [the hospital epidemiologist] handed each of them an agar plate — a sterile petri dish loaded with a spongy layer of agar. 'I would love to culture your hand,' she told them."

They pressed their palms into the plates, and Murthy sent them to the lab to be cultured and photographed. The resulting images... “were disgusting and striking, with gobs of colonies of bacteria.”

The administration then decided to harness the power of such a disgusting image. One photograph was made into a screen saver that haunted every computer in Cedars-Sinai. Whatever reasons the doctors may have had for not complying in the past, they vanished in the face of such vivid evidence. “With people who have been in practice 25 or 30 or 40 years, it’s hard to change their behavior,” Leon Bender says. “But when you present them with good data, they change their behavior very rapidly.” Some forms of data, of course, are more compelling than others, and in this case an image was worth 1,000 statistical tables. Hand-hygiene compliance shot up to nearly 100 percent and, according to the hospital, it has pretty much remained there ever since.

The writers state this tale demonstrates how playing around with and using the right incentives can effectively change old habits. But "it also highlights how much effort can be required to solve a simple problem — and, in this case, the problem is but one of many."

Playing around with incentives, then, may be too much work. And technology could possibly help making it easier not so much to change people's mind and habits but to circumvent them. Which is why the writers conlude their piece by mentioning that Craig Feied, a "physician and technologist who is designing a federally financed 'hospital of the future,' is working with a technology company that infuses hospital equipment with silver ion particles, which serve as an antimicrobial shield."

You can teach an old doc new tricks, but it requires a lot of time and effort and a new way of looking at things called incentives.

Retail clinics becoming accepted by major insurers

The rapid rise in retail store clinics was something I wrote about in April. It started out as an all-cash business model, removing the third-payer out of the equation. But getting insurers to pay for services must have been too attractive a proposition to keep them out of the equation for long.

From the "Aetna, Humana reach agreement with InterFit" article printed on Sept. 1 in the Houston Chronicle:

"As we continue to increase the convenience and strive to increase the access through our convenient-care clinics, this is an important step, to add partnerships" with health insurance companies and others, [company spokesman] Hall said. "It gives patients another option for payment."

InterFit's RediClinic is only the second provider of its kind with which Aetna has contracted, Aetna spokeswoman Rachelle Cunningham said Friday.

Earlier this year, the insurer signed a contract with Minneapolis-based MinuteClinic.

To me this seems like the new clinic model is on the road toward mainstream acceptance.