What Works -- Part 7 -- Vascular Surgery Successes

This is one of the posts in which I simply brag about the excellent clinical work I see at this hospital.

We see many, many patients here with diabetes. Notwithstanding improved care of diabetic patients, one of the unfortunate problems they face is vascular disease, particularly in the lower extremities. So patients sometimes show up with the prospect of needing a foot or limb amputation.

It turns out that our vascular surgeons are extremely competent at fixing malfunctioning blood vessels, either by grafting new ones or inserting stents to reopen the original ones. There have been many cases where patients have learned that they could retain their foot after this surgery. I have had a chance to watch these procedures, and you really have to marvel at the ability of surgeons to repair extremely tiny blood vessels in the lower leg.

Here is a summary of activity in our Vascular Surgery division. Over 4000 revascularizations have been performed since 1990. The overall mortality rate is 1.1 %, which is substantially less than reported across the country at high volume centers (4.9%) .

The effectiveness of graft surgery is measured by patency, "the state or quality of being open, expanded, or unblocked." The first chart above shows the record for our hospital for bypass grafts to the foot. (On the chart, primary -- meaning no further intervention necessary -- is shown below; secondary -- meaning some revisit for clotting or another problem, is the line above above). Randomized trials elsewhere show one year patency of about 60%. We show similar results five years after surgery.

Another measure of success is the ability to save limbs over an extended period of time. The second chart above shows the results on this score for our surgeons. Many other institutions show 50 to 80% limb salvage after one year. Our place shows 78% after five years.

Notes from an American doctor in Kenya

Here is a report from my friend Honora, who is a newly minted doctor spending some time in a service program in Kenya.

Hi guys,

I just wanted to send you all a quick note to check in from Kenya. I feel at a loss for words of how to relate some of the experiences that I have had in just a few days, but I will make a brief attempt...

Yesterday was my first day on the medicine wards. I am working on the women's side of the hospital, and caring for about 40 patients. They suffer from diseases of poverty; the pathology is astounding. I have the true privilege to work with Kenyan residents (registrars), interns, and medical students, as well as a few incredibly bright and capable med students from Indiana University. I am considered a visiting "consultant" or attending, and today the Kenyan consultant will also be on rounds.

Though there are barriers of language with patients, and my knowledge of infectious diseases feels so limited, I was amazed at how the familiar experience of hospital rounds quickly gave me a sense of connection and ease amidst the chaos. The afternoons are less structured, and yesterday afternoon when I returned to the hospital to give a talk on the request of a few students, I passed by another student looking at a chest x-ray. Glancing at it, I noticed an enormous tension pneumothorax (for those not in medicine, this is when the lung pops and air builds up in the chest, causing the lung to collapse and push the contents of the chest to one side -- it can be quickly life threatening). Together we quickly gathered more history and found out that our patient was ISS+ (immune suppressive syndrome -- they don't say HIV+ because of the stigma, which is a whole separate discussion...) and likely had PCP pneumonia. She was stable enough for me to consult my Kenyan intern as well as the group of others around us, and we were all clear that she needed an emergent procedure. I will spare you the details of the rest; however, it took several hours to secure clean supplies to perform a definitive treatment. I will share that in all of my residency training or work [in the US], not once was I in the position to be the most senior person to perform this kind of procedure. The severity of illness and extent of disease is mind blowing...

It is clear to me that the vision of this program is so well-aligned with solid values of respecting and learning from local culture and needs, and that by providing public health education, community organizing, HIV/primary care, and sustainable farming, there have been real positive changes in this community.

What else - at grand rounds yesterday, the presenters were congratulated on their presentations with a series of 3 claps and 3 stomps by a room full of Kenyans that was led by the very dynamic facilitator. It was the best applause I have ever participated in. The food is great, the people I am living with (all Americans) are interesting, bright, compassionate and welcoming, and there are beautiful flowers and true African skies...

Benefit Dance Concert Tomorrow

Healing Blue
Sunday, April 29, 2007
4:00 PM to 6:00 PM

The Lineage Dance Company presents Healing Blue, a performance inspired by the stories of seven women and their fight against breast cancer. All proceeds will benefit the Beth Israel Deaconess Medical Center Hematology/Oncology Judy's Hope Fund.

Also, Monique Spencer, author of The Courage Muscle, A chicken's guide to living with breast cancer, will be present to autograph copies of her book.

Massachusetts College of Art, Tower Auditorium Boston, MA

Tickets are $50. Show up at the door or reserve a seat by calling Sarah Higgins, 617-667-3345.

Three centuries worth of blogging

I've passed two milestones that I never could have imagined in August, when I started this blog.

First, I have now filed over 200 posts. Not bad for the first nine months of gestation.

Second, I have now had visitors from 100 Massachusetts cities and towns -- not to mention almost as many countries and virtually all states in the USA. (Will someone from South Dakota ever show up?)

The first statistic says something about narcissism. The second is more interesting in that it says something about people's interest in this topic.

Many thanks to all of you for your support, really great comments, thoughtful questions, and enthusiasm.

Is there any chance you are pregnant?

A story for all who have been through the multiple rounds of medical histories upon entering an emergency department.

A good friend found herself in a local ED with symptoms of appendicitis. The first medical history was taken by the triage nurse. Then, another nurse. Then, an intern. Then, a resident. Finally, the attending arrived, and he started the process again, writing while talking and making no eye contact.

By this time, my friend had memorized all the questions, and she figured she could speed up the process by anticipating the next questions and giving the answers in advance of their being asked. "Have you ever had abdominal surgery?" "Yes," she replied, and proceeding to the next as yet unasked questions, offered, "It was a complete hysterectomy, and it was three years ago."

Without pause, and without thinking, he said, "Is there any chance you are pregnant?"

She, feverish and in pain, raises up one elbow, looks directly into his eyes and says, "Either you are trying to introduce some levity into this situation, or that is the dumbest question you ever asked."

He turns deep red and leaves the room without another word.

Moral of the story: In a busy environment like an ED, it is all too easy for providers to go on "automatic pilot" and not really pay attention to what the patient is saying.

World Series Ring for Sale

What is a Red Sox World Series ring worth? One is up for sale on EBay.

Here's a way to gauge the value. I had one of these rings, given as a gift from the team. I auctioned it off at a charity event to benefit the women's health program at our community hospital in Needham, MA. Here's the full story.

The winning bid was $100,000.

For Students - How will you get paid?

This is the next chapter in my Wednesday is Student Day series. Rocky, a medical student, asks below: "What is your take on pay for performance, and will it be integrated into BIDMC?"

My economics professors in college set forth a series of theories and formulas that described the functioning of the free market. We all knew that this formulation was unrealistic, in that most markets are imperfect. There is often "friction" between parties in a marketplace that result in imbalances between supply and demand, that result in uneven knowledge between and among buyers and sellers, or that otherwise gets in the way of an economically efficient equilibrium condition.

But it was not until I joined the health care world that I discovered the extent to which an economic system could be so convoluted that there is virtually no relationship between the value of services provided and the compensation for those services. In health care, there are not only intermediaries between the procurer of a service (i.e., the patient) and the supplier (i.e., the doctor or the hospital), but the actual pricing of specific services is often based on the wrong premises.

I think that most people would like to think that a doctor or hospital would be paid based on the quality of the service provided, but that is not so. Most recently, insurance companies have introduced surrogates for real measures of quality. They attempt to reward providers with "extra" payments for certain accomplishments -- administrative or clinical -- that are deemed to be of value to the insurance company in the plans it offers to its subscribers.

This is a crude system in several respects. For one, the measures chosen do not always add quantifiable value. For another, even when they do add value, the amount of the performance bonus is not related to the value. For another, the bonus does not necessarily pass through to the specific providers who deliver specific services to patients. For another, the bonus is often not really a "bonus" that provides extra revenue to the provider. Rather, it is often in the form of a withholding of a portion of the fair compensation to which the provider is entitled even if the chosen metrics are not accomplished.

It is my hope that, over time, insurance companies will actually base payments on accurate and measurable levels of service quality. It is also my hope that the current imbalance in payments between "cognitive" specialists like primary care doctors, neurologists, and nephrologists and "procedural" specialists like surgeons and interventional cardiologists will some day be set aright. In the meantime, places like BIDMC live with the rules that are decided by the insurance companies. There really is no other choice for us, for, in the parlance of my economics professors, we are price takers. (By the way, the same is true regarding our payments from Medicare and Medicaid.)

Who can blame him?

From a friend, who was looking for a referral to a new surgeon:

I cut myself on a shattering glass jar with high force, so that the glass penetrated about 3 centimeters into my right hand, on the side, below the little finger. I went to my college's medical center, where the nurses stitched up the wound but did not clean it past the outside or check for foreign bodies.

One week later I went to get the stitches out, and complained that part of my little finger was numb, and that certain motions of my hand and arm caused sharp pain near the site of the wound and along the whole length of my arm.

The nurse on duty suggested that I may have nerve damage, and, due to my concern over the possibility of glass shards in my hand, the nurse on duty ordered a CT scan of my hand. The radiologist report indicates that there are several 1-mm fragments of glass on the dorsal side of the metacarpal-phalangeal joint of my little finger, as well as one smaller 0.8mm shard on the other side. Based on this duty, the nurse referred me to a plastic surgeon, Dr. X.

I went for a consultation with Dr. X at his office at X Hospital. He said that I likely had nerve damage, and that he would do the following:

A. Perform exploratory surgery
B. Repair the nerve with microsurgery
C. "Dig around" to see if he could find the glass, which he assured me "was like looking for a needle in a haystack".

I told him that a CT scan existed showing the location of the glass.

He asked me to go to radiology and pick it up. When I returned with the compact disc holding the scan, he asked his secretary to bring it up. The two of them looked at the computer in the office for about three minutes, then he informed me that he could not see any glass, but that he would have a consultation with the radiologist to verify his conclusion, and that, in any event, "foreign bodies of any significance will make themselves known." He then muttered that he was "supposed to be out of here by 1:00 PM today," and the appointment was over.

Surgery is scheduled for May 2.

After this consultation, I went down to radiology and got another copy of the CT scan CD. I returned to work, placed the CD into my computer, and within about five minutes was looking at a detailed diagram, annotated with arrows, showing the exact location of the glass shards in my hand. I am perplexed as to how Dr. X could possibly conclude that there was likely not glass in my hand, and can only conclude that he was lying to me in order to get out of the office by 1:00 PM.

This has made me very reluctant to have him operate on me.

Lionel Messi y Diego Maradona

Enough about hospitals and medicine. Let's turn to things that really matter.

Many soccer (i.e., futbol) fans have already seen these two clips, but if you have not, you have to watch them.

When you mess up, just admit it

A letter of complaint, and the reply from our SVP for Ambulatory Services. Fully justifiable complaint, and the right kind of answer: Not defensive, respectful of the patient and her niece, and with a promise of appropriate follow-up. With 500,000 ambulatory visits per year, we cannot necessarily expect perfection each time, but we keep trying. This kind of letter is really helpful to us in finding holes in our service. It supplements our mystery shopper program and patient satisfaction surveys.

Dear Mr. Levy,
I have an 84 year old aunt with a slow moving lymphoma and have been bringing her from New Jersey, where she lives, to an oncologist at BIDMC, who she likes very much. This past Wednesday we had an appointment at 11 a.m. We had not even been called to an examining room by 1:00, at which point I had to insist to a somewhat annoyed person in the reception area that we page the nurse. As a result, by 12:40, the nurse had examined my aunt.

Still we waited for the doctor, who we had seen in the halls of the clinic a number of times since we'd arrived. At 1:40 I finally had to leave my aunt in the examining room, because I had to get to a 2:15 appointment at work. I arranged for my husband to pick her up when she called to say she was ready. Later I found out that the doctor had not seen my aunt until after 2:30.

The reason I accompany my aunt to her appointments is that she does not remember things well and this time she didn't either, including when she should make her next appointment and when to stop her current medicine. She did say the doctor told her something about patients who were late that morning which accounted for the wait. This might have made the event somewhat palatable except for the fact that we have always waited at least two hours and sometimes three for this doctor, whom we have seen about five times.

This time, booking six weeks ahead, I tried to get an early appointment but they were all booked for the week. I am not surprised. I'm sure you'd agree that something is wrong with this picture, and I wanted you to know.

Thanks for reading.
Sincerely,
**
-----

Dear **,

On behalf of the Oncology Clinic, I apologize for your Aunt's delay in this visit and all her other visits. I also am sorry it impacted your schedule, too. As you are aware, we are very busy, but it is no excuse for this type of delay with this physician nor the clinic.

It seems from your email that this happens as a regular process for this doctor. I will follow up with my directors, and they will get in touch with you to get any additional information and share with you our current plans to improve the flow and physician's time/efficiency in the clinic.

As well, the next time you and your Aunt are here, I would like to pick up your parking and lunch if I may. I will work that out also via my directors.

Again, my sincere apologies, and I look forward to hearing your next visit is a quick and ON TIME one!

Warm regards,
Jayne Sheehan

A window on MA state government

A great new step in more transparent government, here in Massachusetts. It is called OpenMass. Here is the description from Blue Mass Group, written by a person named Jim Caralis:

Today I am launching OpenMass.org, a non-partisan and non-profit effort to help inform and empower civic engagement in Massachusetts. OpenMass.org brings together government data with news and blog coverage to give you the real story behind what's happening on Beacon Hill.

OpenMass.org is modeled after OpenCongress.org, a free, open-source, non-profit and non-partisan web resource with a mission to make Congress more transparent and to encourage civic engagement.

Some of the things you can do on OpenMass.org include:
1. Find your State Representative and Senator and see all the bills and earmarks they have sponsored, campaign contributions they have received and lots more.
2. Track which Bills, Representatives and Senators are most popular.
3. Easily track Bills through the legislative process.
4. Keep up to date on "Hot Button Issues".
5. Keep updated on public issues that matter to you on the Public Hearings page.
6. Watch For Newly Signed Laws. OpenMass.org tracks bills signed into law by the Governor.

What you'll see today is just the beginning. With your feedback and guidance we can continue to push the envelope of civic engagement.

Congratulations to Jim.

Which gets me wondering...

...who are my readers in the hospital?

Please post an anonymous (or not) comment if you work at BIDMC and let us know what you do, where you do it, and how long you have worked here. Please make suggestions for anything you would like covered in future posts on this blog.

I think they are reading this . . .

While I know that lots of you out there from all over the world are reading this blog, I really don't know how many people inside BIDMC are. But, every now and then, I get word that someone is and has used what I have said to help motivate their own folks. As I have noted below, in an academic medical center, you are highly dependent on individual motivation to make improvements.

Here's the latest, from one of the leaders of the Emergency Department to every person working there:

From: Tracy,Jason A (BIDMC - Emergency Medicine)
Sent: Sunday, April 15, 2007 1:53 PM
To: Emergency Attendings; Emergency Residents; Emergency Techs; Emergency Nurses; Emergency Registration; Emergency UCO
Subject: Our CEO & "Dirty" tickets

Please note our CEO’s concern about hand washing & infection control at BIDMC: http://runningahospital.blogspot.com/2007/04/i-want-to-be-proud-but-i-am-not.html

Contaminating a vulnerable patient with a methicillin-resistant staph can result in a disastrous outcome. Hand washing is needed to keep our ED patients safe.

ED hand washing initiatives include:
- Improved signage & education – signs are posted throughout the ED (thanks Sue) and an educational campaign has started
- Peer-review and feedback – please help educate your peers, off-service rotators, students, support staff, etc.
- Spot checks & mystery observers (by ED team members and ID staff) – these “secret” checks are for statistics and feedback
- Cal-stat usage checks – the hospital tracks how much Cal-stat we use and analyzes usage based on patient encounter models
- “Dirty” tickets – these hand washing violations (tickets) will be given to violators to be signed by their supervisor

Yes, it is very difficult to wash/Cal-stat so much. Yes, it takes extra time. Yes, there are other safety issues to focus on. Yes, it’s fast-paced in the ED.

However, for all the reasons stated in our CEO’s blog, it’s not optional and we must do better.

Please send me any other ideas to improve compliance (short of a Cal-stat dispensing bedside turnstile) and/or interest in helping with this initiative.

Best quotes of the day

From today's Boston Sunday Globe:

Red Sox second baseman Alex Cora about slugger David Ortiz, "Shakespeare." "Shakespeare?" asks reporter Gordon Edes. Cora replies, "He hits home runs, he writes books."

Betsy Wall, executive director of the MA Office of Travel and Tourism, on the secret to a smooth road trip with her two kids, ages 10 and 13. As quoted by reporter Cindy Atoji, "I'm a firm believer in packing candy.... I also bring fruit, which is usually untouched, but I feel better about myself."

Seven minutes is a lifetime

In medicine, a "miss" is not good. It means that your diagnostic test has missed a potential problem. The case in point today is when the doctor misses a polyp, or adenoma, during your regular colonoscopy and you find yourself with colon cancer a few months later. According to one article I have read, several published studies have reported colonoscopy adenoma miss rates ranging from 6% to 27%.

This happened in our place to one of our most experienced GI specialists in late 2005. A very sad story for his patient, who showed up with colon cancer several months after a routine screening found no polyps.

Just a few months later, our folks were at a GI conference and noticed a paper abstract that suggested that the amount of time spent withdrawing a colonoscoscope would be directly correlated with the likelihood of seeing polyps on the way out. The suggestion was made that doctors should spend at least 7 minutes withdrawing the scope.

Even though this was just an abstract of a paper that would not be published in full until much later that year, it became the subject of one of our faculty meetings in April of 2006. Based on that discussion, our staff set out to change their practice. Improvements ensued, based on each individual's good intentions, but compliance with the seven minute standard then reached a plateau that just wasn't good enough.

So, the group then held another faculty meeting in January of 2007 at which they decided to give regular reports to each faculty member about his or her individual performance, compared with the anonymous values for the other doctors in the group. This led to still further improvement.

The chart above shows the results for our GI folks. Obvious good progress, with over 90% compliance. And, by the way, you only "pass" if you spend at least 7 minutes withdrawing the scope, so 6 minutes, 59 seconds doesn't count.

I offer this as an example of (1) enhanced attention to a problem after a bad clinical result; (2) an aspect of academic medicine, in that people are likely to attend conferences and notice new research results; (3) a thoughtful response even before the final data were published; and (4) the importance of providing individual data, even to experienced physicians, about their own performance relative to others and to a standard.

An update on April 24 from Naama in the Department of Medicine. We just finished analyzing the Mar. '07 data on colonoscopy withdrawal time: Compliance rate (W.T. => 7 min.) is up from 63% (Feb. 06') to 98% (Mar. 07')! We thank the entire GI faculty and the outstanding nursing staff for the wonderful work you have been doing to improve patient care. This project will go on ... with the hope that we reach and sustain a 100% compliance rate.

Is there anyone out there from {AK, KS} SD, or {WV}?

In my license plate game below, I am only missing visitors from Alaska, Kansas, South Dakota, and West Virginia to round out all 50 states and DC. {Update on 4/21: Only South Dakota is now missing!} {Update on May 4: South Dakota has been found!}

Please submit a comment if you are from one of these states so I can end this madness . . .

and instead focus on getting visitors from all 351 Massachusetts cities and towns (90 of those as of today.)

BlackBerry jam

As many people similarly experienced, our Information Systems Office sent out the following email message yesterday:

The RIM Company, which stands for Research In Motion, said its infrastructure failed around 8 p.m. Tuesday and was out until about 7 a.m. Wednesday. E-mails were not being pushed to portable BlackBerry devices.

Officials with RIM said they tried to reset the system and they were concerned that the backlog of data could cause a bigger problem as it rushes through now that the system appears to be online. RIM officials said messages would be sent out in stages so the system does not crash.

RIM officials recommend all who depend on their BlackBerry as a major way of communication should make some back-up plans in case more problems occur Wednesday morning.

(Of course, if you couldn't get messages on your BlackBerry, you might not receive this message, which created a problem in itself.)

I was really proud of our hospital during this national disaster. We set up our crisis center and opened emergency clinics for our doctors and administrators throughout the facility, staffed by our Psychiatry Department. Cases of withdrawal were handled expeditiously and, I am told, with a minimal use of antidepressant drugs. The maintenance staff, though, reported a surge in activity as administrative assistants requested repair of damaged walls and broken windows, at which and through which many devices were vigorously thrown. Apparently, many people never made it through the the cycle of denial, anger, and acceptance.

Ah, if they had just followed my lead months ago!

No Irish need apply

America is a great country, with opportunities galore. However, it is also a country that periodically falls into the slough of discrimination. Here are two stories, one from the 1960's and one from the 1970's.

1 -- A Jewish boy from New York meets with the admissions director of a prestigious New England liberal arts college in 1967. The interview lasts about a minute, with the director saying, “The chance that someone like YOU would be admitted to a school like THIS is like a snowball in Hell.”

2 -- A Jewish summa cum laude college graduate from Natick, MA, applying for admission to a fine New England medical school in 1976 is told, "If we let all of you academic super stars from New York in here, you'll tear each other apart."

The first story is about Dr. Jerome Groopman, who has since become one of the most respected doctors in America for his clinical care, research, and publications. The second story is about Dr. Mark Zeidel, our chief of medicine, another national leader in the US, who is known in his own right for superb research, clinical care, and teaching.

What's my point? Well, the Beth Israel was established in 1916 because of discrimination against Jewish doctors. I bet it is hard for people to imagine that discrimination against Jews in college and medical school admission still persisted in the 1960's and 1970's. (In case you don't get the second story, "New York" is often the code word for Jewish.)

I don't mean to claim some special status for the Jews. Other people have faced their own types of discrimination based on race, ethnicity, religion, sexual orientation, age, weight, and so on. Many acts of discrimination are more insidious, hateful, and dangerous than these two examples. Unlike these two guys, some folks never recover from it.

If you are willing, I would like you to write back and comment on an instance of discrimination in your own academic or professional life. I don't see a purpose here in naming the institution or company, but please give the year, the type of institution, and the nature of the insult -- and how it affected your plans or life thereafter.

For Students -- Reading matters

Remember, each Wednesday, I respond to a question posed by a student. Please submit one or more if you would like. A student asks below:

If you were to introduce a few must-read books/papers in the field of health care management/policy, what were those be? What are the journals you frequently read and find useful?

This is hard to answer honestly and not sound really arrogant. I have yet to read any books in the health care management field that are worth reading through in their entirety. By the way, this is true of management books in general. It is my experience that management books have a germ of a good idea or one or two creative thoughts. You can get the main point by reading the introduction or maybe the first chapter. After that, they are extremely repetitive and often poorly edited.

My theory is that the people who write management books who are professors in business school need to produce a document that looks scholarly enough for them to get academic "credit". Or they are former business leaders or management consultants who need to produce a book with enough physical heft to charge a high price. Both types of people load up their books with tons of case studies or examples from various situations, all of which are designed to prove their underlying thesis. They seldom give examples that are counter to their stated premise or point of view and then have the rigor and discipline to present a persuasive argument that their thesis is correct nonetheless.

So, if you are looking for interesting observations about health care management, avoid the books and look for the shorter version in articles in the Harvard Business Review or the other management magazines. Read the New York Times and the Wall Street Journal to find stories of national interest regarding health care economics and policy. Your local newspaper may have some, too. Here in Boston, we are fortunate to have a newspaper, the Boston Globe, that has devoted significant reportorial resources to health care. They often provide perspectives on broader issues, but based on local examples. Finally, the Economist magazine often has good articles and offers the advantage of a global perspective. Their stories are usually very well researched and concisely written.

Among medical journals, JAMA and the New England Journal of Medicine will often have thoughtful articles about management and policy issues, usually written by and from the point of view of doctors.

Suggestions for our student from others out there?

Two good articles

1 -- In a post below, I talk about Comes the Peace, a wonderful book by Daja Wangchuk Meston. Today's Boston Globe has a nice article by David Mehagan about Wangchuk. Please check it out.

2 -- This one is a little bit self-referential, especially the sequel about blogging, but it also has a very good summary of the issues faced by hospital CEOs. It is from HealthLeaders News.

No vacation for him

I ran into one of our primary care doctors last Friday. He said, "I'll see you a week from Monday. It's school vacation week [here in Boston -- hence a quiet time for his practice]. I'm off to New Orleans to work in a public health clinic. They still need lots of help there."

Inside "patient dave"

Regular readers of this blog will have seen a number of thoughtful comments by "patient dave", the most recent of which was related to public posting of hospital infection data and other quality and safety information. Well, I am sorry to report that Dave was recently diagnosed and is under treatment for renal cancer. This was one of those incidental findings during a routine X-ray for a shoulder problem, apparently a common way for asymptomatic kidney cancer to be discovered.

He is maintaining an on-line journal for himself and for friends who want to send him notes. He told me I could post it here. I am sure he would like to hear from other bloggers. www.CaringBridge.org/visit/davedebronkart.

Here is a recent excerpt from his journal.

DO YOU HAVE CANCER, OR DOES IT HAVE YOU?

If this question's new to you, think about it. When I first got the diagnosis, the cancer sure had me: I was at its mercy. Every change in my outlook came from outside me: it was something that seemed to happen to me, something over which I had no control.

I have a mental image for 'the cancer has me.' In that image, the cancer is like a big dog with a chew toy (me) in its jaws, shaking the daylights out of it and tossing it around.

The pivotal change came when I chose to get in action and do whatever I could, learn whatever I could. Mind you, who am I to know how to fight a cancer?? Do I know anything about the biology of cancer? No. But now my outlook is that I have a cancer in my life, and I'm doing what I can to manage it .... and I'm creating new ways to interact with it, beyond what others have thought of. (Your feedback here tells me that.)

I say it's vitally important that YOU realize what a difference this makes. Remember something I said back in February: citing a study, a nurse in my email group said 'If you're actively involved in creating your care, learning everything you can, and finding the best care available, then your outcome automatically moves to above the median.'

What's in a number?

I have been searching for meaningful and effective ideas to present our central line infection rate that might supplement the one we use. We use the ratio of cases per thousand ICU patient-days. This is a good and accurate metric, but the problem that arises when you have a consistently low figure like 0, 1, or 2, is that there will inevitably be variation around it that may not be helpful in analyzing or explaining how you are really doing over time. Plus, is there another metric that gives just a bit more incentive to improve?

I am not talking about what our goal is. Our goal is "zero." Whether expressed as a rate or a simple number, the virtue of "zero" is that it is indeed "zero" in both cases. As Paul O'Neill has often noted, "Setting zero errors as a goal encourages breakthrough thinking, orients work cultures towards continuous improvement, and keeps people pushing toward the goal."

In factories, you often see a sign saying "x days since our last accident" that motivates people to pay attention to safety procedures and practices. We could do that for our hospital, i.e., "X days since our last central line infection," but I am not sure if it would be as effective. For one thing, we have several ICUs dealing with different kinds of patients and different degrees of difficulty in avoiding central line infections.

For example, we have heard an excellent report from folks in Pittsburgh championing a year without a line infection, but this was for their cardiac care unit only. In our CCU, they are past the 300 day mark without a line infection, but CCUs are lower risk than other ICUs.

Of course, this problem already exists for our composite ICU rate, too. And people will point out that factories have lots of different manufacturing sections with variation in risk. A company-wide figure creates both an overall sense of pride and community and internal peer pressure among the various corporate divisions to not let the whole group down by being the site of an accident.

Would that work within the setting of academic medicine? What's the verdict from those of you out there? Have any of you done this? Did it make an appreciable difference in how people behaved? In public perception of your institution?

Would it matter to you as a prospective patient? If you read a website saying "60 days since our last infection", would you say to yourself, "What an excellent hospital" or would you say "That's a long time -- there is bound to be an infection soon, and maybe it will be me"? Does it work better or worse than posting an infection rate of "1.2 cases per thousand ICU patient-days"?

Even Harvard can do it

Those of you familiar with Boston and the degree of competition among the Harvard hospitals may have trouble believing this, but is it true. Sometimes, even the Harvard affiliated hospitals can do it. What is "it"? Cooperate.

The prime example is the Dana-Farber/Harvard Cancer Center, the largest hospital-based cancer research program in the United States. The Center is funded by a grant from the National Cancer Institute and comprises more than 900 researchers with a unified goal of finding new and innovative ways to combat cancer.

The members of DF/HCC are BIDMC, Brigham and Women's Hospital, Children's Hospital Boston, Dana-Farber Cancer Institute, Harvard Medical School, Harvard School of Public Health, and Massachusetts General Hospital. There is a shared governance structure and an organization of the research across different types of cancer (e.g., breast, prostate, leukemia) and scientific areas of inquiry (e.g., genetics, imaging, epidemiology). There is also a strong inter-institutional clinical trails program.

I have addressed the general relationship among the Harvard affiliates below. DF/HCC is an excellent example of well-intentioned people putting aside their competitive instincts to work together for the public good.

The truth about dogs (but not cats)

Based on the experience of several other hospitals (including our colleagues at Boston Children’s Hospital, Tufts-New England Medical Center and MGH), we recently started a pet therapy program in selected areas of the hospital. This is a collaborative program between the Departments of Volunteer Services, Social Work and Nursing. You may not believe this, but research studies suggest that interaction with healthy, well-behaved pets (specifically, dogs) can improve a patient’s mood, lower blood pressure and heart rate and stimulate other factors favorable to healing.

These have to be trained dogs. Ours come from a group called Caring Canines. A volunteer team (the owner and his or her dog) will spend 1-2 hours a week visiting hospitalized patients who give written consent to such visits. Family pets and other animals are not part of the visiting program. Obviously, there are very strict rules designed to protect against infection risks.

I can tell you are skeptical! But here is a story from the first week of the program from Terry Morgan in our Volunteer Services office:

This morning when I got to my office I was greeted by a doctor who I encounter on a regular basis. This morning instead of his cheery self and our talks about jazz, he was very serious and asked me if it was my idea to have the dogs come to visit. I told him it was a group effort and cited as many names of people as I could remember who drove this program forward. I told him it had been very well received. He still looked so serious, and I was afraid he was going to tell me he was not a fan.

The doctor told me that on Wednesday he had just told a patient that she had a serious life-threatening illness. He went back to see her after giving her this news and found her surrounded by three dogs, kissing her, loving her, cuddling with her -- a golden, a lab, and a pug. She told him about her dog at home that has diabetes and she said, "This visit made me so happy."

Then the doctor and I shared a hug and a few tears and then he said, "This program is a real mitzvah. I hope it continues and I wish you the very best with it."

I told the doctor that we hope to be upstairs every Wednesday. He said that was a very good day to come because he gets his patient lab results on Tuesday and usually gives his findings to patients on Wednesday.

Now, are you persuaded?

I want to be proud, but I am not

I had hoped never to have to say such a thing. BIDMC is a wonderful hospital, full of warm, well-intentioned, and competent people who achieve excellent clinical results and even the occasional miracle. But I saw numbers recently that make me cringe. So it is time to let you know -- and to let my staff know -- that enough is enough.

I am talking about hand hygiene. I have raised this topic before and have referred to the national problem. Medical staff can't seem to remember that germs can be carried from one room to another, and one patient to another. OK, they know this, and they believe it. But they can't seem to toss off bad habits and adopt ingrained behavior to make sure they practice proper hand hygiene.

I like to think that things have improved from the 1840s:

Ignaz Philipp Simmelweis, while working as a doctor in Vienna from 1844 to 1850, determined that ... childbed fever was being spread in maternity hospitals by dirty hands. He proved that a chlorine hand wash reduced deaths from 18.27 percent to 1.27 percent. His superiors scorned his findings and eventually he lost his position. In the city of Pest, he repeated the hand washing measures, reducing mortality due to childbed fever to an average of 0.85 percent while elsewhere the death rate was 10-15 percent. Despite acceptance of his work by the young medical students and by the government of Hungary, and being published in medical journals of the time, his work was disdained by the academic authorities of the time.

But, maybe they have not improved. How else to explain the lack of compliance with well established principles of hand hygiene.?

So why am I upset? After months of intensive effort and various education and other campaigns, our compliance with hand hygiene has risen from 52% on our medical-surgical floors to 57%. Sure, it is great to see it rising, but does this result provide confidence to anyone out there that the message has sunk in? And, some floors remain at or below 40%. The results are better in the ICUs, rising from an average of 60% to 71%. But, in the words of our Quality and Safety staff, "opportunities remain for performance improvement and sustainability of improvement."

The results on one particularly noncompliant floor have prompted one of our Chiefs to write to his physicians:

THIS IS ABSOLUTELY INTOLERABLE!
It is bad patient care.
It increases our post op infection rate.
We should be setting the example for the students and nurses.
I have asked [the nurse manager] to have the nursing staff call attention to any physician, resident, staff, PA, med student, fellow, etc) on the ... service who does not wash his or her hands. This is meant to remind you. If I hear of anyone reprimanding a nurse for such a reminder, you will hear from me and it won't be a friendly call. I have no problem with you reminding the nursing staff if you see a lapse as well. Together we must achieve 100% compliance. There is no reason not to.

There is no reason not to. Dear BIDMC, please make me proud.

Falls

Hospitals do all they can to avoid patient falls. Falls can lead to minor cuts and bruises, but they can also cause serious injuries. It is a cruel irony to be injured in a fall when you are being cured in a hospital.

All falls are recorded to evaluate what happened and why. One of our folks was recently looking through our reports and noticed a pattern. Three people had recently suffered falls just as they were about to be discharged. No, not after they left their room and were heading home. But while they were sitting on the edge of their bed, fully clothed, ready to go.

What was happening here? We think that our staff members were receiving a subliminal message: They would see a healthy, dressed person in the room and might not have paid the same degree of attention to the patient as they would have an hour earlier when he or she might have been sitting on the edge of the bed in a hospital gown. Slight dizziness or instability of this person would then lead to the fall.

So, now we have circulated the word to the floors to be alert to this possibility, and we are hoping to see a difference. This takes no major effort, just an extra bit of attention at the right time.

Unexpected problem, good analytical pickup by one of our quality and safety staffers, and a simple solution. Not all safety improvements require a huge effort.

I'm curious whether other hospital folks out there have seen this particular phenomenon, too, and, if so, what you did about it. Ditto for other types of safety and quality observations.

You, too, Canadians!

You are not going to let another part of the Commonwealth beat you out, are you? You don't have to wait until Delhi in 2010 to show your stuff . . .

So far, we have had visitors from Alberta, British Columbia, Nova Scotia, Ontario, Newfoundland and Labrador, Quebec, and Saskatchewan. We have not yet heard from Manitoba, New Brunswick, PEI, Yukon, the Northwest Territories, and Nunavut.

Please submit a comment if you are from one of the unrepresented provinces or territories.

Calling all Aussies!

Dear Aussies,

Please help me out. I am trying to "collect" viewers from all of the states and territories of Australia. See below. (I LOVE the worldwide nature of this medium.)

So far, I have heard from people in the Australian Capital Territory, New South Wales, Northern Territory, Queensland, South Australia, Victoria, and Western Australia. I am still missing Tasmania. [Update on May 18: Tasmania has arrived!]

If you are viewing from any of those areas, please comment and let me know, along with the city or town.

Thanks.

Query to other bloggers out there

Like many of you, I enjoy checking the status of my blog on Technorati. It's fun to see how many blogs have linked to you and what they are -- and then trace them back and read posts and leave comments.

But here's the issue. Once you are discovered by the porno sites and they link to you, they clog up the entries on Technorati. This makes it difficult to sort through and find real sites that might be of interest. Is there anything you can do about that, or is that just life in the blogosphere?

Central Line Infections, both better and worse

Here are our latest figures for central line infections, measured in cases per thousand ICU patient days. The average over the last several months remains better than for the previous year, but the rate for February comes from two actual cases, worse than January and with 100 fewer patient days. As always, we treat them as sentinel events and try to learn what went wrong and why.

Our folks are really serious about this and, in my opinion, deserve a lot of credit. A friend of mine was recently in the hospital and had one of these lines put in his chest for delivery of an anti-cancer drug. His wife, a medical professional, watched the doctor and nurse insert the line and was very impressed with their understanding of, and rigorous application of, the protocol. (And no, my friends did not mention to their providers that they had read all about this in my blog.)

Month ----- Infection Rate
Oct 05 ----- 1.67
Nov 05 ----- 1.28
Dec 05 ----- 2.43
Jan 06 ----- 3.07
Feb 06 ----- 1.40
Mar 06 ----- 1.07
Apr 06 ----- 0.00
May 06 ----- 0.59
Jun 06 ----- 1.15
Jul 06 ----- 0.57
Aug 06 ----- 3.03
Sep 06 ----- 2.50
Oct 06 ----- 0.00
Nov 06 ----- 2.38
Dec 06 ----- 1.87
Jan 07 ----- 0.00
Feb 07 ----- 1.15

More on cowbells

I told you about the cowbells, below. More timely than I thought.

Check this out and note my comment, the third one down:
http://www.universalhub.com/node/8337

For Students: Don't Collect Degrees

[2015 add-on: And when it comes time to negotiate that new job offer, check out our book on salary negotiation and more: How to Negotiate Your First Job!]

It is Wednesday, so it is time to respond to a student, "college kid", who asks below:

As someone who is in on the business/medical/policy of today's health care system, what do you think about the career prospects of those pursuing a joint JD/MPH? Is it worth it?

On the JD (Juris Doctor), the answer is simple. Don't go to law school unless you plan to become a lawyer. Here comes my gross generalization: Law school is not a place to expand your horizons and become better educated. It is a place to learn the trade of law. The curriculum is focused on giving you the tools and techniques and resources to be a lawyer. (And then you have to study for the bar exam, anyway.) The course of study is not designed to teach you public policy, health care policy, public management, corporate management, empathy, or most other things that would be helpful to you in a corporate or non-profit setting. If you are lucky, there will be some good courses on negotiation, arbitration, mediation, and dispute resolution -- but on that front you would be better off just enrolling in a really good negotiation course somewhere.

Some people think it is handy to go to law school if you plan to run for legislative office, either state or federal. But if you are ambitious in that direction, spend the three years you would otherwise pay tuition working for a legislator or Congressman. Get the hands-on experience. Once you are elected, you can always hire a good lawyer to work on your staff.

On the MPH (Masters in Public Health), I am sorry to say this because I don't believe it ought to be the case, but the degree is sometimes not valued in hospital settings. I have tried to figure this out. I think it is because hospitals are dominated by doctors, who often view an MPH as a poor substitute for a medical degree and think people who get one were not smart enough to get into medical school. Also, people in hospitals do not view themselves as being in the public health business: They are in the acute care business.

Please don't blame me for being the messenger on this point. I personally do not agree with either characterization. In fact, I find that many MPH graduates have a breadth of interest and experience that is really attractive. If you want to get an MPH as a precursor to working in a hospital, use every possible opportunity to do internships in hospitals where you actually have responsibility for planning and completing specific projects, and use term paper assignments to write about hospital management issues. Then, send me your resume.

A final point. Life in college is really good. Ditto for life in graduate school. These are seductive and comfortable environments, and it is easy to persuade yourself that time is better spent there than being on the outside with a job. After all, too, your role models are professors who have chosen to live their entire lives in academia. So, some people have a tendency to collect degrees, moving directly from one program to the next.

Graduate school is usually a good idea, but many people find it more valuable after they have spent some time working. That serves to focus your interests, which will help you get more out of an advanced degree. So, get out and see the world and experience some of its discomfort and uncertainty. See what it is like to have to earn enough money to pay for food, rent, utilities, school loans, and insurance. You will meet a wider variety of wonderful, interesting, practical, and thoughtful people, including generous, intelligent, kind, and well-meaning folks with no degrees at all, and you will learn from them in a tuition-free setting.

[2015 add-on: And when it comes time to negotiate that new job offer, check out our book on salary negotiation and more: How to Negotiate Your First Job!]

This horse still has legs

There was a nicely written op-ed in the Boston Globe on the issue of public disclosure of consumer-helpful information. Much is about other fields, but there are some applications to health care. I like this quote in particular:

Information about deadly risks or the way schools, banks, or airlines treat the public is not accessible if it is buried in government files or technical databases. It is not accessible if it is a year old. Access means starting with how people make choices and providing information then and there.

How much more so for the performance of hospitals and doctors? You have probably heard too much on this from me by now, but this horse is not dead yet. Look at any of the existing medical performance data bases and provide me with an example of one that is current, accurate, and understandable. Compared to what exists today, it would actually be a step forward if the public reports were only a year old. And, as I note below, some of the best, most statistically valid data is not made available at all.

The license plate game -- MA only

A bunch of friends have told me that they really enjoyed the post below in which I evoke the old license plate game that we would play as our parents drove us on long trips. The object was to identify as many states as possible. (OK, I admit that I have weird and/or nostalgic friends.)

Here's the local variant, for those of you who live in this state. This the Massachusetts city-and-town license plate game. We are going to see how many cities and towns in the Commonwealth are represented by those of you viewing this blog. This could take some time, as there are 351 municipalities.

I'll start off the list with names I have recently seen. I will add those I see on StatCounter during the coming days. You can add to the list by submitting a comment with the city or town from which you are visiting. Here goes:

Amherst, Andover, Arlington, Ashland, Barnstable, Belchertown, Bellingham, Belmont, Beverly, Billerica, Blandford, Boston, Boxford, Braintree, Bridgewater, Brockton, Brookline, Burlington, Cambridge, Canton, Chatham, Chelmsford, Chelsea, Concord, Dracut, Dudley, Eastham, Edgartown, Everett, Fall River, Falmouth, Framingham, Franklin, Harvard, Holyoke, Hopkinton, Hudson, Ipswich, Lawrence, Lexington, Lowell, Lynn, Malden, Mansfield, Marblehead, Marshfield, Maynard, Medford, Melrose, Methuen, Middleboro, Milford, Millis, Milton, Natick, Needham, New Bedford, Newburyport, Newton, Norfolk, North Andover, North Adams, Northbridge, North Dartmouth, North Reading, Norton, Norwell, Norwood, Peabody, Plymouth, Provincetown, Quincy, Randolph, Reading, Revere, Rockland, Salem, Sandwich, Saugus, Sharon, Sherborn, Somerville, South Hadley, Springfield, Stoughton, Southwick, Swampscott, Taunton, Topsfield, Truro, Walpole, Waltham, Watertown, Webster, Wellfleet, Wellesley, Westminster, Weston, Westfield, West Springfield, Weymouth, Whately, Williamstown, Wilmington, Winchester, Woburn, Worcester, Wrentham. (107)

What's happening at the NHS?

As we in the United States debate the issue of national health insurance, it can be informative to "look in on" what is happening in countries that already have it. I have been enjoying a blog from the UK called "The Changing NHS" by a gentleman named Steve Pashley.

Steve is a management consultant and freely admits, "The initial reason I started 'The Changing NHS' was to try and attract more potential clients to my consulting site. But now, over 12 months in, I'd say that the main benefit for me flows from the need to be much clearer about what I think about change management and the NHS."

He provides insights like this:

The Healthcare Commission recently released the results of its’ annual survey of 128,000 NHS staff across England. According to the Guardian Society,only 42% would be happy with standards at their own establishment. A quarter said they would be definitely unhappy and 34% did not have a view. Just under half the staff in hospitals said care of patients was their trust's top priority, but 25% said it was not.

Check out Steve's blog, and draw your own conclusions. There is good and bad in the U.K. system, just like our own.

BlackBerry, Nokia, IPOD, and the RMV

The final paragraph in an email from a faculty member -- who suspected I would notice the tag line on her message: Sent from my Nokia Handheld with BlackBerry Connect -- remembering how I kicked the BlackBerry habit -- and also knowing that I believe it is rude to use one during a meeting:

BTW, if you are wondering about the Blackberry usage, I'm not doing it surreptitiously, or not so surreptitiously at a meeting. Rather, I'm at the registry of motor vehicles, where I am waiting interminably for my daughter to have her picture taken for her newly acquired driver license. After 30 minutes of chit-chat with her, she pulled out her IPOD and I pulled out my Blackberry. There are some uses for this device that are not entirely related to addictive/anti-social behavior :-).

Opening Day items

Two items that are frivolous and/or beyond understanding for those of you who are not part of Red Sox Nation.

Item 1:
Starting this week, we and our favorite baseball team have a new program called Red Sox Babies. From now on, whenever a baby is delivered here at BIDMC, the family will receive a baby cap and a canvas bag with our logo and the Red Sox logo. In addition, the newborn will get a certificate for a free tour for four of Fenway Park upon the fifth birthday of the child. (Addendum: Here is a great story about this in the Herald.)

Item 2 -- A note from Cyndi, one of our nurses:
Hi Paul,
You will love this.....
We are doing a surgical procedure on a nice mom today who has two children in the waiting room. Their names are Mary and Peter. Peter was wearing a Jeter YANKEES shirt..... I made him a sign that says "While my mom is in the hospital I will root for the Red Sox".

Charlie's able, Baker

A first in Massachusetts, a blog by a CEO of a health insurance company. Congratulations to Charlie Baker for Let's Talk Health Care. And he takes comments. Check it out.

One variation or another

A big topic in the medicine world is whether the variation in how care is delivered, particularly near the end of life, is symptomatic of overuse, underuse, misuse, and waste in the health care system. The Dartmouth Atlas Project, run by the Center for the Evaluative Clinical Sciences at Dartmouth Medical School, spends its time on the question of how medical resources are distributed and used in the United States. Here's the premise:

The project offers comprehensive information and analysis about national, regional, and local markets, as well as individual hospitals and their affiliated physicians, in order to provide a basis for improving health and health systems. Through this analysis, the project has demonstrated glaring variations in how health care is delivered across the United States.

Now, as someone trained in statistics, I get a little nervous when someone in academia talks about "glaring variations". It might suggest a degree of hyperbole that is not consistent with rigorous analysis. But upon further review, it is hard to find fault.

One study, for example, showed a six fold variation in per capita hospital spending on people with chronic illnesses who died between 1999 and 2003 in hospitals across the country. The spending was not correlated with the rates of illness, but seems instead reflect "how intensively certain resources -- acute care hospital beds, specialist physician visits, tests and other services -- were used in the management of people who were very ill but could not be cured." The authors' conclusion is that the Medicare system gives inappropriate financial incentives to take care of chronic care patients in a hospital setting, where overly expensive end-of-life care will be delivered. In essence, this suggests that we use too many specialists and high-priced equipment, tests, and other services for people who should really be taken care of in another setting.

This study points out the wide variation in cost of care for these end-of-life patients, and then it also points out that the hospitals that treat patients more intensively and spend more Medicare dollars did not get better results. In a variant on "if you build it, they will come", the report concludes:

The study paints a picture of the health care system in disarray over the treatment of chronic illness. There are no recognized evidence-based guidelines for when to hospitalize, admit to intensive care, refer to medical specialists or, for most conditions, when to order diagnostic or imaging tests, for patients at given stages of a chronic illness. Lacking this, two factors drive decisions:

Both doctors and patients generally believe that more services - that is, using every available resource such as specialists, hospital and ICU beds, diagnostic tests and imaging etc. - produces better outcomes.

Based on this assumption, the supply of resources - not the incidence of illness - drives utilization of the services. In effect, the supply of hospital beds, ICU beds, and specialty physicians creates its own demand, so areas with more resources per capita have higher costs per capita.

These conclusions are not universally accepted. While they acknowledge that some variation is the result of available resources, some observers feel that the variation in these costs is explained by other factors not captured in the folks at Dartmouth. Matthew Holt provides a nice summary of these arguments and commentary on them here and there are lots of thoughtful responses here.

I come to this whole issue very late and after other people have dissected it to death. I'm not sure I have much to offer. Let's assume that the Dartmouth conclusions are correct and that much of the variation in health care costs is supply-driven. As a person involved in policy-making in other arenas, I am left wondering what one would actually do with this information if you could "pass a law". If you were in the government, would you act to apportion hospital and physician resources across the country? Highly doubtful. Would you change the method of reimbursement so that there would be a capitated payment for each type of chronic illness? I feels like that has been tried, and the public objected to someone -- anyone -- being the gatekeeper for how their care would be managed. Would you create a national standard on what services could be provided at the end of life, i.e., ration care? Politicians who have suggested that do not get elected. Could we adjust Medicare payments so that they provide ample payment for less acute care versus specialty care? That seems like a worthy goal for lots of reasons, but it is unclear to me how much it would do much on this front.

Please understand that I am not arguing against efforts to reduce overuse, misuse, underuse, or waste in any given hospital. I strongly favor that. I am just left wondering what I would do as a policymaker with this information. In the absence of other actions, I would, however, shine sunlight on these variations. Peer pressure and public exposure might be the best medicine.

Further, if I were a regional insurer I would start by publicly posting this kind of Medicare data to compare individual hospitals within my region with one another. In so doing, I would attempt to create pressure on my local institutions from the people (i.e., employers) who pay for most of the costs of health care. (Unfortunately, you can't post your own insurance company's cost data because it would demonstrate the unwarranted differences in reimbursement rates you pay to each of your region's providers!)

Are there other ideas from my thoughtful readers out there?

Moe's great photography

A note from my friend Moe Witschard, in Bozeman, Montana. Moe was my instructor on a NOLS sea kayaking trip to Patagonia a few years ago.

Today is a big day as I launch my new photography website which highlights some of my adventure, travel, and landscape images. I hope you get a chance to check it out and I hope you enjoy it! Be well.

He notes, further, for those of us is health care:

What I'd really love to do is put some big fine art prints in your hospital. Please keep me in mind if your hospital is shopping for art pieces. I've got several fine art images that can print to a very large size.

I think his pictures are really spectacular. Check them out. No, you cannot download them! (He is trying to run a business, after all.) But as a teaser, here is one he took of me that found its way into the NOLS catalog -- as an example of "older", ahem, students.

And, if someone would like to send a donation to our art fund, we'll buy one for the hospital.

(And thanks to Moe for adding Montana to our license plate game, below.)

The license plate game

Just for fun. Do you remember taking a long drive with your parents and trying to "collect" license plates from the different states as the trip progressed? The idea was to see how many different states' licenses you could see.

I want to do the same here. From my StatCounter program, I can look at the most recent 100 visits to this blog and see which state they came from. But, I miss a lot of them because I can't be checking every hour for the latest group of 100.

So, I'm going to the start the list of "licenses" that I have seen. If you are reading this, and you are from a state that isn't yet listed, post a comment and tell us which state, and I will add to the list. It will be fun to see how long it takes to get all 50 states, plus DC. (Note to Cambridge and Northhampton residents: You do not live in separate states. Nor sovereign nations. You might live in separate worlds, but you are still part of the Commonwealth of Massachusetts!)

We will also play this game for the provinces and territories of Canada, following the list of US states. Ditto for the states and capital territories of India, following Canada and the US. And, also, Australia. And, finally, in honor of my home town, the boroughs of New York City!

Here's the list of US States so far:
Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming (All 51, as of May 4!))

Canada
Alberta, British Columbia, Nova Scotia, Ontario, Newfoundland and Labrador, Quebec, Saskatchewan (still missing Manitoba, New Brunswick, PEI, Yukon, Northwest Territories, Nunavut)

India
Andhra Pradesh, Gujarat, National Capital Territory of Delhi, Jammu and Kashmir, Karnataka, Kerala, Maharashtra, Orissa, Tamil Nadu, West Bengal

Australia
Australian Capital Territory, New South Wales, Queensland, Northern Territory, South Australia, Tasmania, Victoria, Western Australia

New York City
Brooklyn, Manhattan, The Bronx, Queens (missing Staten Island)

Which came first, the free range chicken or the cage-free egg?

My daughter Sarah, who works in public relations in San Francisco, sent me the following note:

Hiya!

Have you considered transitioning to cage-free eggs in the hospital cafes?

I think that would be a nice thing to do. For the chickens, you know.

Burger King just went cage-free -- you HAVE to do better than that. The Humane Society of the US has a lot to say about it.

To which I thoughtfully responded:

Hmmm.

Her riposte:

Hmm? Think of the chickens! Plus, it could be a nice tie-in to the OB dept. "We don't keep you behind bars during labor, and we require the same humane treatment for chickens."

Here's your chance, again, to advise the CEO. I actually do not know what kinds of eggs we use, but I will find out. What do you think of her suggestion? In your answer, please indicate whether you buy cage-free eggs for your personal use and/or whether they do so at your place of business.

Surgical Gag Order

The American College of Surgeons, the preeminent surgical organization in the country, has developed a superb program to measure the relative quality of surgical outcomes in hospital programs. It is called NSQIP (National Surgical Quality Improvement Program) and is described in this Congressional testimony by F. Dean Griffen, MD, FACS, Chair of the ACS Patient Safety and Professional Liability Committee.

What makes this program so rigorous and thoughtful is that it is a "prospective, peer-controlled, validated database to quantify 30-day risk-adjusted surgical outcomes, allowing valid comparison of outcomes among the hospitals now in the program." In English, what this means is that it produces an accurate calculation of a hospital's expected versus actual surgical outcomes. So, if your hospital has an index of "1" for, say vascular surgery, it means that you are getting results that would be expected for your particular mix of patients. If your NSQIP number is greater or less than "1", it means you are doing worse or better than expected, respectively. (As I recall, too, an index is derived for each individual surgeon, but I might not be remembering that correctly.)

The program also gives participants a chance to see how they are doing relative to the other hospital participants. Are you in the top decile, the top quartile, or the bottom quartile.

This is a powerful and thoughtful tool, and the ACS deserves a lot of credit for their work in putting it together and making it available throughout the country.

But (and there is always a "but"), the ACS does not go far enough. Despite their assertions about a desire for transparency in medical matters, the NSQIP reports are not made public by ACS. Further, participants pledge not to make their own data public.

In an exemplary statewide program in Michigan, in which hospitals and Blue Cross Blue Shield of Michigan are cooperating on statewide implementation of NSQIP, we find the following:

Aggregate data on the impact of the project will be made available to BCBSM and provided in public reports about the project. However, the individual hospital data will be available only to the participating hospital and its surgeons for quality assessment and improvement purposes.

I do not know if there have been debates within the ACS on this matter, but this decision seems to reflect a belief on the part of at least some surgeons that the public is not ready and cannot understand this kind of information -- that the NSQIP tool is very useful for quality improvement efforts within a hospital, but that it is not appropriate to share with the public.

Here is a recent conclusion from an article in the Annals of Surgery that exemplifies this point of view:

At this time, we think that, for most conditions, surgical procedures, and outcomes, the accuracy of surgeon- and patient-specific performance rates is illusory, obviating the ethical obligation to communicate them as part of the informed consent process. Nonetheless, the surgical profession has the duty to develop information systems that allow for performance to be evaluated to a high degree of accuracy. In the meantime, patients should be informed of the quantity of procedures their surgeons have performed, providing an idea of the surgeon's experience and qualitative idea of potential risk.

I think this aspect of the ACS program is wrong and leaves a lot of the value of this program on the table. I believe that the public has a right to know -- and can fully understand -- the NSQIP results, at the hospital level at a minimum. While I respect that there is a debate about the disclosure of doctor-specific data during the informed consent process right before surgery, I believe that this information should also be available to the public to help them choose surgeons well before they sign a consent form.

Perhaps someone from the ACS will comment as to why they have imposed this gag order. Perhaps individual surgeons out there will explain why a tool that is sufficiently valid to use for their own quality improvement programs is not sufficiently valid to present to the public. Further, why should a participating hospital be prohibited from displaying its own information to the public?

Students: The future is in primary care

An anonymous student asks:

I'm a third year medical student in Charleston, WV. I'm having a tough time deciding what to be when I grow up. "Do what you love." Is the most common comment I get. This is a problem for me because so far I've loved everything. When I started medical school I was set on family medicine or general internal medicine. I still think I'd be happy with either of these options. However, sometimes I feel it might be a mistake for me not to specialize so I will have a more valuable skill when I finish. . . .

I have a small family (wife, one daughter) and plenty of loans. I feel a little discouraged by the reimbursement disparity between general practice and specialty practice. Do you think this pay gap will get even wider? What do you see as the future of primary care medicine in America?

I am a contrarian on this issue, but I believe that the professional satisfaction that can come from being a primary care doctor will come to be enabled by an increase in salaries and better working conditions for those professionals. Here's why. As payors in the health care system face more and more financial pressure (either from employers or government legislators), they will seek to maximize the value of dollars being spent. PCPs are uniquely situated to deliver the goods for them.

Today, PCPs are dramatically undervalued and underpaid, relative to specialists. Fewer and fewer people are becoming PCPs. Yet, they remain the most trusted source of information for patients. (See, for example, page 12 of the recent Blue Cross Blue Shield survey on how consumers make health care decisions in Massachusetts.) Besides being trusted, PCPs are the gateway to the health care system, and they are needed to determine the most efficacious diagnostic and treatment paths for patients.

The current rub is that PCPs get to spend 18 to 20 minutes with each patient because the fee they are paid for visits is so low that they have to see many patients each day to make a living. There is no way they can do a really complete job, much less focus on prevention and wellness. In contrast, we see the assertions of doctors in so-called concierge practices who have more time to spend with the patient, asking personal and family-related questions, doing more physical diagnoses, and focusing on prevention and wellness. They claim they can actually reduce the downstream costs of specialty and hospital care.

Now, you might rightfully say. Prove this with a case-control experiment. I will not try. I will simply assert that common sense suggests that if PCPs are given more time to spend with patients, they will be able to do a more thorough job at prevention and diagnosis, with obvious downstream benefits. If you are Medicare, Medicaid, Blue Cross, or any other payor under pressure from those who send you money, sooner or later you will skew your reimbursement system to enhance this segment of the medical profession and encourage more, rather than fewer doctors, to become PCPs. You might, by the way, tie those salary increases to improvement in quality metrics. This recently happened in the United Kingdom.

Assuming I am right, our Mountaineer friend still has a dilemma. How long will it take for this transition to take place, and will he starve in the meantime? I do not know, but I am guessing that he will see the shift begin by the time he finishes residency training and accelerating thereafter. So, my advice is "Do what you love." Marcus Welby, MD would be proud of you.

St. Thomas Charoset

Here, in honor of Passover, is my grandmother's recipe for charoset. (That's her picture from 1980, with two of her two great-grandsons. Read below to learn who the man is.) The recipe was recorded by my mother. For those of you of Eastern European descent, it is like nothing you have had. This is a Sephardic (Spanish-Portuguese) recipe from Panama, passed over to the isthmus from St. Thomas and probably before that from other earlier settlements in the Caribbean. (You can save this for next year.)

Panama (St. Thomas style) Charoset

From Inez Brandon Fidanque (1892-1991)

Recorded by Emma Fidanque Levy (1920-2005)

10 oz. pitted dates
12 oz. dark dried figs (de-stemmed)
8 oz. raisins
2 apples, cored and peeled
4 oz. walnuts

Chop and blend (with no recognizable pieces, but not too mushy -- if you use a food processor, do 1/2 at a time).
Add wine or cherry cordial (preferably Cherry Heering) to moisten.
Sprinkle with cinnamon.

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Here's how the family arrived in St. Thomas, as set forth by Mordecai Arbel in Early Relations between the Jewish Communities in the Caribbean and the Guianas and Those of the Near East, 17th to 19th Centuries. As you read this, you probably begin to understand why controversy seems to follow members of our family!

In 1816, Joshua Piza . . . was invited to Curacao to serve as a cantor. . . . Born and educated in Amsterdam, he was already influenced by the customs and usages of modern European Sephardi Jews. His way of service clashed with the majority of the community members. On one side, angry voices called for his dismissal. On the other, he had a strong group of supporters. The rift degenerated into the secession from the established community of the protesters against Piza. They left the synagogue as well and prayed in private houses. Curacao Jewry broke into two communities with separate cemeteries, separate administration of Jewish laws (marriages, births, funerals, ritual slaughter, and so on).

The Jewish population of Curacao was an important part of this Dutch colony, and at times comprised over half of the white population of the island. Thus it was imperative that the rift be mended. By order of the Royal house of Holland and with the help of the head of the rabbinical court . . . reconciliation was achieved, but Cantor Piza had to go. The hunger for religious leaders was so great that Piza obtained a contract to serve the Jewish community of Charlotte Amalie on the island of St. Thomas where he remained for many years. His descendants became quite prominent in the Jewish communities of Panama and Costa Rica.

By the way, my grandmother's father, David Henry Brandon (the other picture above), led the fire department (cuerpo de bomberos) in Panama City and arranged for cisterns to be built in the city. They would fill up when the tide was high and remain filled when the tide went out. This provided water for fire protection even when the ocean was far removed during low tides. He was later honored on a Panamanian postage stamp.

It's not easy being green

I am finally going to write on a topic I know about. (This will come as relief to my hospital colleagues around town!) Most of my career has been in the energy and environmental fields, and I'd like to spend a moment on those topics.

An informative article in the Globe today talked about the new generation of hospital buildings and the attempt to make them more environmentally friendly. This is good, appropriate, and important. Hospitals are huge users of energy and other natural resources, and the best time to make sure they will be efficient is during design and construction. So kudos to the Brigham, MGH, Mt. Auburn and others for incorporating green principles into their new buildings.

But there is also work to be done on old buildings. As energy costs rise, there is a great impetus to control the use of electricity, steam, and chilled water. It is a good idea financially, but also good for the environment.

At BIDMC, we have no ongoing construction of new buildings, but we do have 3 million square feet of existing space and use over five million kilowatt-hours of electricity per year, 25 million pounds of steam, and 1.5 million ton-hours of chilled water. Over the past five years, we have invested $3.6 million in energy efficiency improvements (not counting improvements that are inherent in other renovations). The power of these investments is shown in their rates of return. Those returns range from 85% to 175%, with an overall payback period of less than one year.

Not one of these investments has reduced the quality of the work environment in the hospital. Quite the contrary. And, of course, we have made no changes that adversely affect the quality or safety or comfort of patient care.

The results, though, are pretty dramatic. We have 1000 more employees than we did five years ago. Given this expansion in staff, plus a steady 2% to 4% growth in patient volumes during this period and the installation of more energy-using equipment (computers, imaging machines, a complete surgical and medical simulation center, and the like), it would have been reasonable to expect a 3% to 5% "creep" upwards in electricity, steam, and chilled water use. For electricity, those trends are represented by the red and green lines on the graph above. Instead, electricity use has held virtually constant -- as seen by the blue line. The same pattern occurs for steam and chilled water.

And, it is a good thing that it has! With energy price increases, we will still pay $10 million more for energy this year than in 2002. Had we not taken these steps to reduce energy use, that would have been millions of dollars higher. During this period, electricity has risen 48%, steam 146%, and chilled water 36%. As prices rise, more and more energy efficiency investments become cost effective. So, of course, we are going to continue plowing funds into these areas. It is actually not that hard being green -- especially when you see red if you don't.

Call-in show today on transplants

Douglas Hanto, MD, PhD, our chief chief of transplantation surgery, will discuss a variety of topics during an hour-long call-in show on NECN, today, April 2nd at 4 p.m. The program, Wired with Jim Braude and Leslie Gaydos will examine the medical crisis caused by the shortage of organs for donation. Some likely topics will be a South Carolina proposal to allow prison inmates time-off for organ donation; “transplant tourism,” where people go to poorer countries to find donors; and a recent statement by the president of the American Society of Transplant Surgeons that it may be time to pay donors for kidneys.

To join the conversation, call 617-244-3344. The program can also be viewed after the fact at http://www.boston.com/news/necn/Shows/wired/ .

If you want to get warmed up before going on air, there have lots of interesting ideas discussed on these topics in the comments section of a post below.

Students, are you curious?

As mentioned below, I am happy to take questions from students. Undergrads, graduate students, medical students, others. Any topic. Answers to selected questions will appear each week on Wednesday. Give it a try.