My Call Karma has turned for the worse. At least this is what I told myself as I drove home from the hospital last night. My last seven days has seen me at the deliveries for three infants with a combined weight of 1650g or about 4 lbs and in two other patents lose the battle in our teams fight to preserve a life. There is no doubt this has been trying for myself and for that matter the rest of the teams I have worked with during that time. In the field of Neonatology, members of our team would say this has been “a bad week”. For those that know me you would also say that this is quite surprising as I am known for having good “Call Karma”.
On that 20 minute drive home I had some time to think about that statement and the more I did, the more I questioned (possibly due to a sleep deprived state) why I and other colleagues utter such words. At some point or another I have heard most physicians I know speak in such terms or use the word luck in the place of Karma. What is Call Karma exactly for those of you who are really confused at this point? The concept of Call Karma is that some health care practitioners seem to have very uneventful times when on call and others plagued by the busiest shifts or weeks or service seemingly every time they are working. Before I go on, I will state the obvious, that this seems preposterous to anyone who has read so far and knows anything about statistics unless of course you believe that there are forces at work manipulating probabilities. Nonetheless, if you work in a hospital and listen for it you will hear people mention Call Karma from time to time when things are exceptionally busy or quiet in the NICU while someone is on call or service. This is also not something that is restricted to those with more or less experience, as I have heard it said many times over by people at both ends of the years of service spectrum.
As I was trying to settle myself after a rough night in the NICU I took to several literature search sites and tried to find an article on Call Karma. After spending more time than I would like to admit I came up with zero results. Twitter was more productive, as I came across many tweets on the subject with people referencing both their good and bad experiences in the hospital. What I did not find was a blog post or article on the subject anywhere, yet having worked in two hospitals and heard the expression used countless times it seems it is common vernacular wherever you find health care providers.
What is Karma? Karma as defined by dictionary.com using the Hindu or Buddhist meaning is:
An action,seenasbringingupononeselfinevitable results,goodorbad,eitherinthislifeorinareincarnation.
Applying this definition to being on call or service I believe explains exactly what Call Karma is. Women are not choosing when to deliver their infants based on our call schedules nor are babies deciding when and how sick they will get depending on who comes into the NICU that day in their scrubs to start call or service.
Call Karma exists in our heads and is the result of myopic views of our work life combined with confirmation bias and a healthy dose of support from those around us and is inevitable as the definition suggests above for some of us in this life (I will leave the reincarnation piece out of it!). Confirmation bias is the tendency to notice data that confirm our suspicions about the truth as we see it and ignore data streams that contradict that perception. Using the example of call, if five out of ten weeks of service are “busy” and five are more uneventful we will pay no attention to the calm times but accept the label of bad Call Karma when someone mentions it to us during those weeks that are particularly stressful. Myopia rears it’s ugly head in this situation, as we tend to look at the short term events as confirmatory during a bad week rather than remembering the last nine weeks and how they all went as well. We are slaves to the “here and now”.
Finally the last piece of the puzzle has to do with the above definition which includes the words”bringing upon onseself”. How we perceive and handle these busy weeks is just as important as the acuity as observed by others. Are you a health care provider who obsesses over details, likes to micromanage and feels the need to be present in the unit for fear that the people around you can’t be trusted to do as careful a job as you would? If so, your perception of your weeks will be quite different that the practitioner who takes the approach of being more trusting of those on call in the NICU and being more of a big picture person. Our minds can only handle so much information at once and if you have several babies sick at the same time and have a obsessive need to know every sodium, hemoglobin and CRP result trended over time for each patient you will in fact be busier than the person who takes a less micromanaged approach. Same patients, just a different perception of acuity and business and therefore stress. It is such type A behaviour that I believe is what brings most of the karma upon us. It doesn’t take much acuity to have those with such behaviours perceive that they are busier than others. Add to this, people around them who see them in the unit working tirelessly on service and then commenting that their karma is bad and…voila you have the perfect setup for bad Call Karma!
So as I prepare to start this day anew I conclude this post with the following. Call Karma exists but like anything the power to change it lies within yourself. Today may bring good or bad but statistics would say I am due for a break…or not.
Living in Canada we are privileged to have a universal health care system. Privileged in the sense that all citizens are entitled to the same level of care regardless of economic circumstance although the monetary costs to the tax payer is another story and forms the basis of most arguments in the US against adopting such a system down south. My goal of this post though is not to enter into a debate about which system is superior but rather speak of the dollars and cents attributable to being born too early or too small.
In the US such measurements are simpler as costs are more easily measured in a private health care system but each health care region in Canada can measure to a certain degree the costs associated with a hospital stay. Certainly the story of Raquena Thomas made this clear to me. In 2007 she was born in Edmonton after her mother left Jamaica for a visit with family in Edmonton. After delivering she was found to have hypoplastic left heart syndrome (HLHS) and went on to have the first stage of the Norwood procedure. What followed was a bill to the mother for $162576 and for commentary on the discussion that ensued about who should pay the bill see the article here. As I was working at the Stollery Children’s Hospital at the time and cared for this infant it was clear to me after this experience that the hospital indeed has a clear method to calculate costs even if we the taxpayer are blind to such calculations.
In this period 1 in 7 babies was born either preterm or small for gestational age. If specifically looking at infants < 2500g defined as low birth weight this represented 6% of all babies born. When you factor in that there were 350000 babies born in that year in Canada we are looking at about 21000 babies nationally. Looking at the costs for these infants one sees a direct relationship between decreasing birth weight and increasing costs in the hospital. This should not be surprising to anyone. It should be noted though that the paper provides average costs only without standard deviation or ranges. As you would expect, the costs for a patient with severe HIE or NEC would be higher than the 26 week infant who has a very smooth course and does not have a symptomatic PDA, severe IVH or any other significant disability during their course.
The data looking at such costs is scare with respect to the Canadian landscape and even more difficult to determine has been lifetime costs or at least incremental costs after leaving the hospital environment. I was delighted to see that former colleagues of mine in Edmonton have published a new paper examining both the extent of health service utilization (HSU) attributable costs in the year following discharge of both LBW and normal birth weight peers in Alberta (abstract here). Not surprisingly, smaller babies have more medical needs. In this study LBW patients had an average of 5.9 outpatient services and 1.1 visits to the ER in the first year of life compared to 2 and 0.9 in the normal birth weight peers. Physician services were double with 22.7 office visits compared to 11.9 in the NBW group. The costs to the Health Care system overall are represented in the table below which demonstrates that the LBW infants make up 37% of the total health care costs of newborns yet represent only 6% of the population. In terms of risk factors for LBW they were high prepregnancy weight, aboriginal women and low socioeconomic status. Efforts to lessen the incidence of the first and third factor in our pregnant population would be a good target for public health efforts. Bear in mind that the costs outlined below are in addition to the costs in the hospital.
Cost per patient
Cost to System (millions)
1500 – 2499g (MLBW)
1000 – 1499g (VLBW)
< 1000g (ELBW)
The analysis provided in this paper does not specify out the costs by certain conditions such as NEC or BPD so all we have to go on are averages for HSU and cost. It does however raise a point which I believe is crucial to any discussions with respect to expanding programs within the hospital. We need to refocus administration at both the hospital level and at the funding source (our provincial governments) as to the true costs of the conditions that we are trying to prevent. It is only through looking at the costs of both the hospitalization and after discharge that we can truly come to understand the cost effectiveness of expanded programs or new treatment modalities.
Donor breast milk is one that I believe serves as a good example of a program that is in need of expansion in many places in the country but is hampered by the perception of high up front costs. The average cost of this milk is about $4 per ounce. I will simplify the math a little as there would be a phase of escalating the volume per day and a wean at the end but let’s say we have a 1.5 kg infant that we want to treat with DBM for a period of 4 weeks. The cost to do this assuming a TFI of 150 mL/kg/d would be a little over $800 per patient so with the increasing phase, wean and adjusting for some weight gain let’s say $1000 per patient. If there were 200 such patients in your hospital each year the annual cost would be $200000 which on the surface seems like a lot of money. From the most recent cochrane review though comparing formula to donor milk the risk ratio to develop NEC is 2.77 meaning that a preterm baby who receives formula is nearly three times as likely to develop NEC. Ignoring differing rates of NEC by hospital let’s just use the concept that we could prevent one case of NEC a year with such a strategy. The cost of medical NEC is somewhere between 100-140K while surgical is 200 – 240K. The in-hospital costs of preventing just one case nearly pay for or exceed the cost of the entire years supply of DBM. If you add to this the cost of the following years of physician visits, consultants, testing, special diets and investigations and procedures these patients receive the costs are more than covered from just one patient.
Health care budgets are no doubt a difficult thing to balance but the point of all of this is that when determining whether to spend our precious health care dollars we must look at not only the impact during the hospitalization but for years after if we truly modify future risks as well.
If you are from North America and watched Tom Cruise in his heyday then you have seen Jerry Maguire and recognized instantly the second part of the title of this post. If you haven’t seen the film it is worth watching. Even if you have you can see a short clip from the film that inspired the title of this post here and it is really worth watching!
Why such a title for a post? I am always intrigued when I see a spike in viewership from a particular country which today happened to be France and yesterday Argentina. For previous posts it has been such countries as Oman, Great Britain and yesterday Brazil. This leads me to wonder what is it about some posts that light a fire and others that only generate a little smoke? There is a world of Neonatology to talk about and as the writer of this blog I do my best to find topics that I believe will be of broad interest to many.
As I have seen such spikes come and go I have come to the realization that perhaps there are topics that are of immense interest to the people of one country and others that quite simply fall flat. Are they not pertinent as the technology being discussed for example is simply not available there or simply an uninteresting topic.
My goal has been and will continue to be to try and stimulate discussion or at least provoke some thought on a global basis and thereby create a global community for cross pollination of ideas. With that being said, my question to the readers of this blog is what would you like to hear about? I ask not because I am running out of ideas; on the contrary with each week of news stories and articles pertaining to Neonatology it seems like the topics are endless. Rather my question stems from the realization that as I sit in my North American city my scope of what is important or relevant to Neonatal practice is somewhat limited.
I welcome your comments and thoughts for future posts! Although my goal was to provide some education to people who took the time out of their day to read these posts I now realize that I can ask the same of my readership. Please educate me as to what is important or relevant to you! I can not promise to write about every topic I receive but I will certainly try and pick ones over time that I feel I can write about.
I would like to thank each and every one of you for your words of encouragement over the last three weeks since the inception of this blog. Today marked a significant event by surpassing 100 followers who receive an email with each blog post. As of tonight, there have also been almost 2000 viewings of these posts from at least 20 countries worldwide. I find these metrics informative as I really have no idea how many views happen on Facebook or Twitter but with the blog data I get a sense of how many of you are out there!
I have thoroughly enjoyed writing these pieces and really appreciate the feedback on each topic. The last few weeks have included correspondence with someone from another country who was unaware that Propranolol could be used for hemangiomas and a practical suggestion for starting children on propranolol in a day clinic type of environment. I look forward to the opening of such a clinic in our hospital in the next year or so. There is no doubt that the topic that garnered the most attention was the use of breast milk by body builders. Although this was a more playful topic it did raise awareness of the use of donor breast milk and who knows whether or not a unit somewhere may look into this through the communication that the post generated. The Sympathetic Note to the Anti-Vaxxers caused an explosion on Twitter that left me exhausted after 3 days of exchanges with people opposed to vaccination. I have to say that although it was tiring, the amount of websites, articles and information from that side of the argument that I was provided is worthy of a post in and of itself! I learned a lot from individuals on the other side of the promoting health coin and I feel as if I am a better doctor for it as I now have better insight into the basis for many of their arguments.
I have to say the pinnacle of this experience however was an exchange with someone who attributed their child’s autism to the MMR vaccine. After a bit of a lengthy exchange I was sent a picture of her beautiful daughter with a thank you for having given them some relief after reading the post on MMR. Their daughter was lovely as was the knowledge that I had helped someone who I would have otherwise never met if it weren’t for this medium.
Your support has kept my enthusiasm for writing up and on a local front I also want to thank the doctors, nurses, dieticians, RRTs and others who have encouraged this medium for education. I have really enjoyed being stopped in the NICU, IMCN or hallways to chat further about this post or that. It means a lot!
Moving forward I look forward to many more opportunities to share with you. I would like to add that I have created a twitter feed at @NICU_musings to talk about these and other topics not on the blog for those of you who are more bent on Twitter. There is also now a Facebook page at https://www.facebook.com/allthingsneonatalwhere discussion can also take place if you are more of a Facebook fan.
I will leave you with this news story I read tonight which reminded me of the power of community generosity that many of you know we have been blessed with here. Charitable giving is a very special and important thing and this story seemed right to finish off on a high note.
I have been reminded this past week of the ability of the internet to connect people who would otherwise never be able to meet or at least write to one and other. Not surprisingly the first responses to the blog came from Canada but within a day viewers in the US were soon added and to them many countries in the Middle East, Great Britain, Spain, Senegal, Turkey and Laos just to name a few.
I have been greatly encouraged by the feedback on the site and topics and your comments have led me to explore other websites and initiatives that I was naive to myself. I see an incredible potential to disseminate ideas and in the future even collaborate on projects that people may be inspired to create. There are approaches and technologies that are in practice all over the world that through sharing we may bring to our own shores.
I really just wanted to say thank you to the readers for your participation and I look forward to exploring the neonatal universe with you as we move along. I have received a few suggestions for topics and will be releasing the next post in the morning. Until then I thought I would leave you with a tease of what is to come by congratulating the University Maternal Hospital Limerick for their accomplishment which was certainly newsworthy this week and I hope is replicated more and more throughout the world. http://bit.ly/1AGYkPh
I hope you bear with me as I venture into the realm of blogging. I have no doubt there will be both good and bad but I hope with time less of the latter. The goal of this is to stimulate shared learning by putting my thoughts out and hopefully getting feedback in return. Thanks in advance for your comments and I hope that the journey is worthwhile.