"I know that finger"

A true story, from just a few weeks ago. David was an ice hockey player in his boyhood days. He is accompanying a friend to the emergency room after the latter has dramatically injured his hand. The hand surgeon comes in to take care of the friend, but pauses to shake hands with David. Never making eye contact, the surgeon does not let go of David's hand, but instead brings it up towards his face and says, "I know that finger. I fixed it in 1976 after it was sliced by an ice skate."

"You remember my finger?" says an astonished David.

"I never forget a finger," replies the surgeon.

Links

After reading about several blogs that have been discontinued, I recently checked out all the blogs to which I have been linking and have deleted those that no longer exist or have been inactive for a very long time. (By the way, here is a really interesting story about one.)

If I inadvertently knocked yours off or if you would like me to add a new one, please send it along and I am happy to consider it.

Many thanks to the dozens of you who link to mine. It is great to be part of this worldwide community.

What a difference 100 years makes

A friend sent me an article listing the major causes of death in the United States in 1907. I did a little research to verify. Here's what I found for 1907. They were:

Pneumonia and influenza
Tuberculosis
Heart disease
Diarrhea
Stroke
Kidney disease
Accidents
Cancer
Premature Birth
Senility

Today (or within the last few years), the leaders are:

Heart disease
Cancer
Stroke
Chronic lower respiratory diseases (emphysema, chronic bronchitis)
Accidents
Diabetes
Pneumonia and influenza
Alzheimer's disease
Kidney disease
Septicemia (systemic infection)

The shift shows, in part, progress in the use of antibiotics. In part, it shows the effect of changes in longevity. Between 1900 and 2004, life expectancy for males went from 48.3 year to 75.2 years; for females from 46.3 years to 80.4 years.

Uncomfortable growth

An editorial in today's Globe raises questions of several types with regard to a plan by Massachusetts General Hospital to expand its emergency department, surgical facilities, and beds. Charlie Baker, CEO of Harvard Pilgrim Health Care, also raises a number of issues on his blog.

I had trouble knowing what lessons to draw from this commentary. I understand the authors' concerns about the cost of new hospital facilities, but rest assured, no one in the hospital business builds expensive new space unless there is a reasonable assurance of the demand being there to use it.

Here are the trends we see. Even if population growth in Massachusetts is minimal or flat for the coming decade, demand for the services of tertiary hospitals is likely to grow. Why? As the baby boomers age beyond 50, they have an increasing demand for hospital services. In addition, their parents are living longer than ever, and they, too, are heavy users of hospitals. Not only are both groups displaying greater utilization of hospitals, but their ailments are of greater acuity, resulting in an increased demand for tertiary care. (And by the way, if the people in the younger generation do not change their ways with regard to weight control, they will be in the hospitals also for care of diabetes-related health problems like vascular and heart disease.)

While I have not asked the folks at Partners Healthcare about this, I am guessing it is this demographic wave that leads MGH and Brigham and Women's Hospital to plan expansion of tertiary care facilities. The same is true for BIDMC.

I know people get uncomfortable with an additional aspect of the issue: There is also a business imperative for this kind of construction. The insurance reimbursement system rewards increases in volume, especially high-end procedures and surgery. It does not reward preventative care, nor cognitive specialties in which doctors examine you and then make judgements about paths of care. It does not, in particular, provide sufficient income to primary care doctors to spend the extra time with patients that might avoid hospitalization.

So if you are running an academic medical center and you would like to be financially healthy to sustain and enhance your tri-partite mission of clinical care, research, and teaching, your business plan is simple: Grow, and expand your tertiary lines of care in particular. If you stand still, the inflationary costs affecting your hospital will soon outstrip your revenues.

Gee, in this regard, hospitals are not all that different from other businesses. After all, who would complain if any corporation decided to expand capacity in its more profitable lines of business in anticipation of increased customer demand?

But hospitals are different in that they do not sell directly to the public and are not judged every day on the quality of their service. The intermediaries in this field -- insurance companies, the federal and state government, and employers -- mask the costs of health care that you or I actually use. And, there is virtually no way for a consumer to compare the actual quality of care delivered by hospitals: Almost all the publicly available data is out of date, based on administrative rather than clinical information, and embedded in hopelessly confusing websites. So there is really no market-based set of checks and balances on hospitals of the sort faced by other types of corporations.

I fear all this is leading to an unsustainable situation and that the academic medical centers are the ones that will feel the public's wrath once that is apparent. Why? Because we are the high-cost part of the health care system. There are legitimate reasons for that, which we could discuss at another time. But those reasons will not hold sway when the bill to employers, subscribers, and taxpayers gets just too high to pay.

To me, the remedy is clear. AMCs have to become the places that set the standard for quality improvement and cost efficiencies. They need to demonstrate that their value to society goes beyond the clinical care, research, and teaching they offer. On the quality side, they need to establish the science of care as an academic discipline that informs health care providers everywhere. On the cost side, they need to engage and adapt principles of organizational efficiency from other industries to make a structural change in their production model. Meanwhile, insurers and government payers have to support both components of the solution by rewarding hospitals that improve quality and reduce costs.

Memorial Day Op-Ed

Robert Gibbons, interim president of the Mass Hospital Association, offered an op-ed on the topic of elections and union organizing in the Memorial Day edition of the Boston Globe. If you know Gibbons, you know he is no anti-union shill. And, his employer represents both hospitals with unions and those without. But Gibbons is talking about process. Excerpts:

I can remember as a child learning that one of the most important and fundamental pillars of our democracy is the right to cast a secret vote in an election.

We wouldn't think about holding an election for any office, from school committee to president of the United States, without the protection of a secret ballot.

Then why are unions in Massachusetts and throughout the country hellbent on circumventing the democratic election process, and supplanting the 1935 National Labor Relations Act, to impose what's known as a "card check"?

It's illegal for anyone to coerce an employee to sign a union card. However, it can be extremely intimidating for an employee, faced with someone waiting for them to sign an authorization form, to say no to such a request. There is no protection of the ballot box. Everyone -- particularly the union representatives -- knows who voted for the union and who voted against it.

Unions argue that secret ballot elections give management the ability to coerce people into voting against the union. No one would condone such tactics by any employer.

But there is something fundamentally anti democratic about a card check election. Even a majority of union members recognize that. In a 2004 Zogby International poll, done for the Mackinac Center for Public Policy, 53 percent of union members say they would prefer to keep the secret ballot election.

I have mentioned this topic below, and there was lots of interesting give-and-take in the comments. Check them out and draw your own conclusions.

On girls soccer

Dean Conway, a life-long soccer fanatic and my mentor in soccer coaching, once said that if he could only watch one more soccer game in his life, it would be an under-12 girls game. Having just officiated as a referee for several such games, I again find myself agreeing. There is something really special about that age, but truthfully, I'd watch almost any age group!

Here's a letter I wrote in July 2002 to a friend, Grant Balkema, after he sent me his team's yearbook summarizing one of those miraculous and a wonderful seasons he had as a coach with his high-school aged girls soccer team. He was also a fellow referee, and we had spent many, many hours on the fields together as coaches, referees, and spectators. He died suddenly and inexplicably in November 2004.

I often say that the girls who play soccer with us are the luckiest kids in the world. They get to go out and play a beautiful game with their friends in a safe environment with terrific coaches and parents who support them. But you recognized an additional bit of magic this past season, and it was reflected in one of the sentences in the yearbook. When the girls are on the field of play, they unconsciously adapt to one another’s strengths and weaknesses during the game, creating a seamless web of teamwork. As a coach, you see this happen, and all you can do is smile. You know you had something to do with it, but you also know that something has happened among the girls themselves. It is a beautiful and very special thing. They will remember it all their lives, but they will not know what they are remembering. They will think their fond memories of this season had something to do with their friendships or other social relationships or how much their coaches taught them or how exceptional the team record was. But it is not that. It is an elemental statement about the human condition: We are born to work and play together in teams, but we have to give enough of ourselves to let the filaments connect. Many people do not get to experience that sense of ensemble. You have, and your girls have, and it is very, very special. They are, indeed, the luckiest kids in the world, and we are likewise blessed in being able to share this time with them.

Happy holiday

It looks like it will be a classic Memorial Day weekend here in Eastern Massachusetts. Sunny and warm, with thunderstorms mixed in.

I'm taking time off from this blog to do some of my favorite things, coaching my girls under-14 soccer team, refereeing boys and girls soccer games at a nearby tournament, and in between games, playing the same sport with a group of friends, and in between all that bike riding in preparation for the Pan Mass Challenge in August.

Have a terrific weekend, and let's all take a moment at our cookouts to remember why we call it Memorial Day. People have died to protect our right to have the kind of friendly and passionate debates you see on this blog and elsewhere in the public arena. A quiet moment to think of them fondly is well worth the time.

On nursing homes

Atul Gawande is a surgeon at Brigham and Women's Hospital and a thoughtful and compelling writer. In today's New York Times, he discusses life in nursing homes and the deterioration of spirit that occurs among many residents in this setting. Referring to a person he met, who picked her own high quality nursing home, he says:

The things she misses most, she told me, are her friendships, her privacy, and the purpose in her days. She’s not alone. Surveys of nursing home residents reveal chronic boredom, loneliness, and lack of meaning — results not fundamentally different from prisoners, actually.

Along these lines, a friend's mother left behind a letter with this advice to her family after spending several of her last years in a nursing home (yes, also a high quality one).

Try to find an alternative to nursing homes. People are segregated by age and they have very little in common. I have found them a terrible home. I’ve done the best I could but that’s not good enough.

In the "old days", elderly relatives would have lived with their extended families. That chapter is closed for most people in the US. In lieu of that, Gawande refers to "a small band of renegades" who have created alternatives aimed at replacing institutions for the disabled elderly with genuine homes.

These are houses for no more than 10 residents, equipped with a kitchen and living room at its center, not a nurse’s station, and personal furnishings. The bedrooms are private. Residents help one another with cooking and other work as they are able. Staff members provide not just nursing care but also mentoring for engaging in daily life, even for Alzheimer’s patients. And the homes meet all federal safety guidelines and work within state-reimbursement levels.

They have been a great success [and they are building these in] every state in the country with funds from the Robert Wood Johnson Foundation. Such experiments, however, represent only a tiny fraction of the 18,000 nursing homes nationwide.

I don't pretend to know the solution to this problem, but bravo to Dr. Gawande for bringing the issue to a large audience.

"Baseball" in Los Angeles

Heads up, Angelinos. You are not going to like this one.

I have heard of lots of promotions to encourage people to attend sporting events. For example, certain restaurants in Minneapolis offer coupons for Minnesota Twins games when you buy a meal.

But here is the best yet, from a friend of a friend:

I know you think I've gone soft livin' in LA instead of with you on Beacon Hill, but I just wanted to tell you two recent giveaway promotions at Dodger stadium which prove that we are a fierce, fightin' machine:

May 13: (I was there and might be able to track down an extra one for you if you want) Lip Gloss Giveaway -- First 25,000 -- Sponsored by Smashbox.

Also, May 22: "Dodger fans are invited to participate in the 2nd Annual Dodger Stitch 'n Pitch where fans will sit together and knit. There will be a teaching table prior to the event and a totebag giveaway to those participating in the Stitch 'n Pitch."

I don't want this to sound really snitty or snobby, but the idea that you would have to give a Red Sox fan something extra to go to Fenway Park is inconceivable. If they did a give-away, the likelihood of it being lip gloss is very, very small. As for knitting, I would fear for the public's safety if that kind of implement were available during a Red Sox-Yankee game.

Emma F. Levy -- Aug 13, 1920 - May 23, 2005

On the anniversary of her death, I can't think of a more appropriate public remembrance for my mom than to refer you again to this post and hope that this advice will prove helpful to you, your family, or your friends.

For Students -- Helicopter Parents

Not many questions from students this week, but I'll get back to those that have arrived in the future. For today, just one thought. I heard yesterday of stories of helicopter parents who actually write thank-you notes to their child's first employer, upon hiring of their offspring.

A piece of advice to students. Don't ever, ever, ever let your parents do any such thing! And parents, don't ever, ever do such a thing. Perhaps it should not have this result, but I cannot think of anything that would more quickly make me question my judgment about hiring someone than to get a note like that.

Mandate for change?

With thanks to Dr. Brian Jarman for sending this along, here is the latest Commonwealth Fund report comparing health care in several countries. The main conclusion:

Despite having the most costly health system in the world, the United States consistently underperforms on most dimensions of performance, relative to other countries.

Here is the chartpack with all the slides summarizing the data.

No doubt many will argue that this is proof of the need for a national health plan like those found in the comparison countries -- Australia, Canada, New Zealand, the UK, German, France, the Netherlands, or Japan.

Personally, I think it argues for broader insurance coverage in the US, perhaps along the lines recently enacted in Massachusetts. Plus, it argues for better reimbursement in the US for primary care physicians. Plus, it clearly argues for greater emphasis by US hospitals and physicians for more systematic implementation of quality control, perhaps with more than gentle nudging by government and private payers. (See chart #50 for the percentage of primary care doctors who report any financial incentive for quality improvement: The US is lowest at 30%).

But I recognize that many disagree, and my point here is not to get into that debate. (I have done that elsewhere.) Instead, I want to raise the question of whether there is broad political support in the US for a major change. Notwithstanding similar data for years and lots of speeches on the subject, there has not been movement along these lines. Why have there not been votes for passage?

Hidden away in these charts might be indications of why the national health plan idea has been politically unpopular in the United States. Chart #60 shows the percentage of "sicker adults" who had to wait more than four weeks to see a specialist: Germany 22; US 23; NZ 40; Australia 46; Canada 57; UK 60. Chart #61 shows the percent of physicians who feel that their patients often have long waits for diagnostic tests: Australia 6; Germany 8; US 9; Netherlands 26; NZ 28; Canada 51; UK 57. And chart #62 shows the percentage of people who waited four weeks or more for needed non-emergency or elective surgery: Germany 6; US 8; Australia 19; NZ 20; Canada 33; UK 41.

So, if you think about things in purely political terms, because of proximity and/or language, the US public is most likely to hear about the experience of Canadian and British citizens with regard to these aspects of care. "Everyone" has a story about a friend of a friend from Canada who choose to fly to the US for elective surgery because he or she would have had to wait months for that treatment in Toronto. In the US, there is an expectation that when you need or want treatment, you get it quickly.

In addition, chart #97 presents a fascinating story, the percentage of people above average income in the Australia, Canada, NZ, and the UK who have chosen to buy private insurance to gain access to care not provided by their national health plan -- 63, 81, 57, and 35 percent, respectively. This factor gives yet another indication that the rationing of care provided under the national plans is not viewed positively by those of better economic means.

Finally, charts #126 and #127 give an indication of physician dissatisfaction with their country's health system and their own practices. The numbers are all over the place, with no clear mandate for change in the US among physicians -- or at least no clear distinction on this point with those in other countries.

For years, the Democrats have pushed the health care agenda, citing the equity and access reasons inherent in this report. For years, the Republicans have not, citing the issues of personal choice and government rationing. While many polls have showed public interest in major change, those same polls have often showed that there is less interest among people who vote. Have the Republicans been politically astute by not pushing this agenda, or have the Democrats locked onto an issue that will finally have traction?

Laughable?

Another email ad, in case it didn't come across your screen. Who writes these things?

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Best regards,
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By the way, check out this deal on the linked site:

Try our SPECIAL ERECTION PACK! Two best ED medications in one super pack. Lowest price and FREE shipping. Time limited offer - valid till 23rd of May only!

Better hurry. But wait, if you cut and paste this section of the ad, you find the following code hidden within. I guess the must-buy-by date keeps changing!

Try our SPECIAL ERECTION PACK! Two best ED medications in one super pack. Lowest price and FREE shipping. Time limited offer - valid till function nextday(d){months = newArray('January', 'February', 'March', 'April', 'May', 'June', 'July', 'August', 'September', 'October', 'November', 'December', 'January'); today=new Date();var day=today.getDate();var month=today.getMonth(); day+=d;if(day>30){day%=30;month++;} var prefix = ((day==1)(day==21))?'st': ((day==2)(day==22))?'nd': ((day==3)(day==23))?'rd': 'th'; return day + '-->'+ prefix + '' + ' of ' + months[month];}document. write(nextday(2)); 23-->rd of May only!

Central line infection report

More in our continuing series on central lines infections. As always, these are presented as cases per thousand ICU patient days. Every single case undergoes a multidisciplinary review with department leadership present, after a review by the attending of record and primary nurse, as well as the Central Line Work Group which is overseeing this effort.

The chart above shows that the overall quarterly trend is in the right direction, but as you can see below, there is troublesome variation from time to time. The up's and down's, I guess, are normal, but we all wish they stay down.

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

Mar 07 ----- 3.17

Apr 07 ----- 1.22

International dateline

I want to take a moment to again welcome international visitors to this site. I have noticed visits from the following countries during the last few months. If yours is not listed, please let me know. Also, please do not be shy about submitting comments and giving your perspectives on the strange world of health care in the US.

Albania, Algeria, Argentina, Australia, Austria, Bahamas, Bahrain, Bangladesh, Barbados, Belarus, Benin, Brazil, Bulgaria, Burkina Faso, Canada, Czech Republic, China, Colombia, Costa Rica, Cote D'ivoire, Croatia, Denmark, Dubai, England, Egypt, El Salvador, Estonia, Ethiopia, Faroe Islands, Finland, Fiji, France, Georgia, Germany, Ghana, Granada, Greece, Honduras, Hong Kong, Hungary, India, Indonesia, Iran, Ireland, Israel, Italy, Japan, Jordan, Kenya, Republic of Korea, Laos, Latvia, Lebanon, Luxembourg, Macao, Macedonia, Malaysia, Maldives, Malta, Mauritius, Mexico, Mongolia, Mozambique, Nepal, Netherlands, Netherlands Antilles, New Zealand, Nigeria, Northern Ireland, Norway, Oman, Pakistan, Panama, Peru, Philippines, Poland, Portugal, Qatar, Romania, Russian Federation, St. Lucia, St. Vincent and The Grenadines, Saudi Arabia, Scotland, Serbia and Montenegro, Singapore, Slovenia, Somalia, South Africa, Spain, Sudan, Sweden, Switzerland, Taiwan, Tanzania, Thailand, Togo, Turkey, Uganda, Ukraine, United Arab Emirates, Vietnam, Wales, and Zimbabwe.

Blogspot glitch

Hmm, for some reason, the post below did not come with a comment link. If you want to comment on it, please do so here.

Visiting Patients

Margaret asks below: How do you decide which patient to visit? What do you talk about with a patient? Doing those visits is very wise I think.

At any given moment, we might have 600 patients in the hospital, ranging from very small babies to very old folks. So, of course, I can't visit everyone.

For a while I tried to visit people in a random way, just dropping in to rooms on different floors to check in. It turns out that this was not a good idea. It was just too jarring for most people to have a stranger walk in, even the president of the hospital, with no context for the visit.

So the simple answer to your question is that I visit people who are personal friends or colleagues; who are friends of friends or colleagues; who are on our boards of directors, trustees, and overseers -- or related to a board member. There are people in some of these categories who want privacy, though, and whom I do not visit. Sometimes, too, the nurses, doctors, or social workers tell me about someone who might appreciate a visit.

What do we talk about? Everything you can imagine. I often ask about and get reports on the quality of the experience -- doctors, nurses, transporters, housekeepers, food, cleanliness, clunky television controls. Sometimes we discuss the patient's personal medical progress and expectations. Sometimes it is about the business status of the hospital. Often, this being Boston, the main topic is the Red Sox, Dice-K, Mike Lowell, Manny, Papi, or their last win or loss.

If I am really close to the person and we both know the disease is terminal, we might talk about how it feels to be near the end of life. To be clear, this is a very rare occurrence and can only happen when we are very good friends. I sometimes have similar conversations with his or her spouse or partner. I never thought I would have the emotional wherewithal to do this, but it turns out that it is a marvelous gift to the patient or spouse (and to me, too) to have this discussion.

Topics that are absolutely off-limits with all patients: Conversations about donations to the hospital. Status reports on other patients.

The other people I visit are the babies in the neo-natal intensive care unit (NICU), when the parents are not there. The nurses have gotten used to this. I find it inspiring to watch a 1.5 pound baby breathe, sleep, and otherwise get used to life "on the outside". With these patients, there is not much talking, at least from their end, but these are some of the best conversations I have.

Take Pride

Every year, we at BIDMC hold an event to recognize people who have made significant contributions within the gay and lesbian community. Awardees may be individuals or organizations, employees or people external to BIDMC, or gay or straight. We look for candidates who advance the gay and lesbian agenda related to the workplace; volunteer time and effort on behalf of gay and lesbian initiatives; demonstrate leadership in advocating for gay and lesbian community; serve as a role model for gays and lesbians within the workplace; and/or make a positive impact on medical care to gay/lesbian/bisexual/transgender patients.

Each year, when we announce this event, I receive a note like this from one of our doctors:

From: The Committee to Restore Sensible Values and Perspective
To: Mr. Levy

We are again disappointed and frankly disgusted to see the leader of the medical center endorsing an inherently unhealthy, risky lifestyle. We remind you that this is offensive to members of the BIDMC who hold to moral principles and traditional values. But more to the point for a healthcare institution, is the fact that homosexual behavior involves well recognized higher risks of STD's, HIV and AIDS, anal cancer, hepatitis, parasitic intestinal infections, and psychiatric disorders. Life expectancy is significantly decreased as a result of HIV/AIDS, complications from the other health problems, and suicide. This alone should make it reprehensible to the medical community, regardless of your personal feelings for putting this on the politically correct list for "inclusion and respect." This action again jeopardizes the credibility of BIDMC as a healthcare institution and dishonors a large proportion of its community who continue to hold to the conviction that homosexuality is immoral, ungodly, unnatural, and of course unhealthy. As we pointed out in our letter a year ago, while the controversial effort to normalize homosexuality has clearly consumed the political arena, the health risks of homosexual behavior are well known and incontrovertible. Although the political world seems oblivious to these serious consequences of unhealthy behaviors, a healthcare institution should not be. It is all together inappropriate for BIDMC to endorse, affirm, or encourage these behaviors.

It's time to put our mission as a healthcare institution ahead of misguided zeal for political correctness and inclusiveness. After all, inclusiveness of the wrong values and behaviors only serves to dishonor and discredit BIDMC and the larger community it represents.

Last time, I started my response in this manner --

I am grateful to you for writing to me with such a clear exposition of your views. I respect greatly the range of views held by people on these issues, and I believe that one of the things that makes our country great is that we have the ability to live peacefully together and yet have a variety of viewpoints.

Then I made it very clear that this program will continue. Yes, every now and then, the CEO gets to make a decision. This one is easy.

If you would like to make a nomination for this year's award, please send an email before May 21 to egandelm@bidmc.harvard.edu or, for those inside BIDMC, go to our portal and download a nomination form.

Progress on medication reconciliation

One of the most bedeviling arenas for improvement in hospital care is called "medication reconciliation." As I have noted below, part of this standard means that we are supposed to discuss with all patients the medications they are taking before entering the hospital, and review their medications again upon discharge.

Here's part of problem. Many people do not know or do not remember what medicines that are taking, so a doctor who asks these questions while doing the patient's medical history will not get accurate information.

One way to work through this problem would be if we could get access to the records of pharmacies and get the list of medicines that have been prescribed and dispensed to patients.

The good news here in Massachusetts is that we are the #1 user of e-prescribing. Under this system, when you need a medication, the doctor sends the order electronically to your pharmacy of choice, and you pick it up there. No more scripts, no more handwriting.

The program involved lots of folks, with support from Blue Cross Blue Shield of MA, Harvard Pilgrim Health Care, and Tufts Health Plan, and is done in cooperation with Surescripts, an organization founded by the pharmacy industry in 2001.

BIDMC is one of the first hospitals in the country to use this advanced technology. We've been live with Surescripts routing on our web-based online medical record system since last year. Now, the plan is to use the capability in reverse -- to be able to query the Surescripts system and other stakeholders with pharmacy databases (e.g., Rxhub, which connects mail order pharmacies). So, when you showed up for surgery or another visit, we would be able to download a list of your current medications from the database of pharmacies. Even if you lived in Nevada and showed up at our emergency room in Boston, we would have access to this national database and make sure we were not giving you a medication that interacted badly with one you are taking.

We are hoping to go live with this by September 15 and, of course, will share our experience with all others in the region and beyond.

This approach does not solve all the issues around medication reconciliation, but it is an example of where the creative use of information technology can help enhance patient safety.

Orwell revisited: "Down with inefficient and unfair secret ballots!"

Excerpts from a report from the State House News Service, written by Michael P. Norton.

UNION FORMATION BILL ADVANCES IN HOUSE AFTER ROBUST DEBATE OVER PROCESS

STATE HOUSE, BOSTON, MAY 16, 2007. Legislation changing the way public employees can form unions stirred vigorous debate in the House Wednesday, a discussion that ended with a familiar result: Democrats outvoting Republicans to advance a bill backed by unions.

The bill approved by the House on a party-line 135 to 19 vote replaces a process under which employees considering creating a union would vote on the idea on a secret ballot with a process under which a union could be formed if more than 50 percent of affected workers sign cards indicating their wish to do so. An identical bill died last year after Gov. Mitt Romney vetoed it. Its supporters hope that Gov. Deval Patrick, a Democrat, will sign off on it.

"It comes down to employees who want to organize should be allowed to do so without impediment," bill sponsor Rep. Robert DeLeo (D-Winthrop) said during floor debate on the bill. "This creates a new system by which they can do so and that system is efficient and fair and should be adopted."

For Students -- Success and Succession

Wednesday is response-to-students day. EB, below, is not quite a student, but his question is a good one and relevant to those thinking about careers in health care. I include excerpts and then reply.

Being in my early 30s, I have had the opportunity to hold various middle management positions in administration at hospitals in major US cities. My motivation for leaving each of those roles was due to the lack of perceived opportunity to ascend to more progressive levels of responsibility and in time, move to higher positions within the organization. I often found myself questioning why there seemed to be a large gap in age between myself and others in middle management. And then it dawned on me. I found in these 3 separate organizations, there was not much evidence of commitment to leadership succession and growth/development of earlier careerists.

With all the challenges the hospital industry faces in the upcoming years:a) where will the hospital leaders of tomorrow come from?b) How can hospital attract a qualified entry level and middle management workforce when other industries (banking, finance, law) offer more competitive salaries/benefits?

How are you thinking about addressing the situation that some mid-level managers in hospitals perhaps face, as I did, and future succession planning efforts such as those I mention above?

One job of all senior level managers is to prepare to make themselves dispensable by ensuring a good succession plan. EB is correct that this is often neglected in large organizations, and health care is no exception. This is a shame because an organization spends a lot of time and money hiring, training, and grooming mid-level executives, and if you give them no sense that there is a career path in your own organization, they will eventually leave for another.

We recently created a program for several of our mid-level top performers, people we view as having the potential to run the hospital in the next few years. We call them Sloane Fellows in honor of our previous Board chair, Carl Sloane, one of the country's preeminent management experts, who was kind enough, too, to help us design the program. We sought nominations from our senior-level folks for this program and choose 19 -- out of 50 very good nominations. These folks have just completed an 18-month program of intense individual and team development. Perhaps some of them will want to add comments to this post to talk about their experiences.

I offer this as just one example. There are more subtle things we do, too, to prepare people for succession. In addition, we always attempt to promote from within the organization to reward successful managers with further career opportunities. Nonetheless, this is an area that needs continued work.

Meanwhile, on the clinical side, I would have to say that the academic departments generally do a very poor job with succession planning. This shows up in the following way: When a chief of service resigns, the likelihood that his or her successor will rise from that same department is small. With a few exceptions, department chiefs do not do a very good job grooming their division chiefs and other prominent faculty to be their successors. I am starting to see some changes on this front, but this is an area that needs more attention.

Monster Dolls

People entering my office are often surprised to see this two-headed creature. This and the other are creations -- in fabric, polymer clay, wood, and acrylic paint -- of a very talented young artist named Jennifer Feller. Jenny is a graduate of Mass College of Art and is trying to get her career started as a professional artist. I was happy to help her along with her first sale (personal money, not hospital money!) Check out her full portfolio at http://homepage.mac.com/mikefeller/jenny_feller/.

Powerful MDs

Modern Health Care presents its list of the 5o most powerful MDs in America. Four come from our little corner of the world.

#2, Jim Mongan, CEO of Partners Healthcare System
#3, Don Berwick, CEO of the Institute for Healthcare Improvement
#13, John Halamka, our CIO
#42, Gary Gottlieb, CEO of Brigham and Women's Hospital

You never know what criteria are used in these kinds of selections, but I have decoded this process in part. Last night, I explained to our Board of Overseers that John was not selected for his success in establishing national standards for interchange of health care data, nor for his accomplishments in creating exceptional clinical information systems at our hospital. No, it is because he has the technical skills to hack into every email system in the country and therefore has blackmailable material on every doctor in America!

What I did at work today

The "Open letter to Mr. Levy" questioning my use of time writing this blog led me to think that lots of people out there might wonder how I actually spend my time, not so much because of interest in me personally, but because most people don't get to be a CEO, and you might just wonder what this is all about. So, here's a sample day. "Empty" time between meetings is for talking with staff in the hallway, phone calls, emails, and bodily functions. Let me know if this is at all interesting -- I sort of doubt it -- but I will provide other days if enough of you think it is.

Today, Monday, May 14
8:30 -- Welcome new staff at new employee orientation and provide background on the hospital's mission and values.
9:00 -- Meet a candidate for the hospital's Board of Overseers, one of our governing bodies.
10:00 -- Review aspects of the hospital's pastoral care program.
11:00 -- Meet with a physician about a possible recruitment of another physician.
12:00 -- Meet with senior vice president for health care quality for an update of our safety and quality programs.
1:00 -- Meet with senior vice president for human resources for an update on a variety of topics.
1:30 -- Visit a patient.
2:00 -- Meet with senior vice president for development, CFO, and senior vice president for facilities to ensure there is an integration of our capital investment programs with our fund-raising efforts.
3:00 -- Meet with COO for an update on a variety of topics.
4:30 -- Meet with representatives of the Longwood Symphony Orchestra (which comprises area doctors and others) to get a progress report and receive requests for assistance.
5:30 -- Short update from senior vice president for network integration regarding a relationship with a group of referring doctors.
5:40 -- Write this post.
6:00 to 8:00 -- Attend Board of Overseers meeting.

Inflation in health care costs

Shown above is a bill that shows the cost of a visit at Beth Israel Hospital. We think it is from 1961, but it might be from 1951. It is a little hard to read, but you can note that the daily room rate was $28, and the operating room charge was $30. Today, both would be a little higher . . . .

Aftertaste

Apropos, in part, of the posting below, an essay written by my daughter, Sarah Inez Levy, that appeared in a magazine called Edible East Bay late in 2006. Yes, she's the one who wrote me about the eggs. (Her sister Rebecca has a different set of talents as a dancer and choreographer.)

Aftertaste

One day I ate a Pop-Tart outside Chez Panisse. Wracked with guilt, I hid the wrapped toaster pastry in my coat sleeve and nibbled as inconspicuously as I could, all the while praying that Alice Waters wouldn’t look out her window to see me blaspheme in the Gourmet Ghetto.

Thirty years earlier, on that very street, the hippie soldiers of Berkeley’s food revolution changed the way a nation thought about food. Their political ideals provoked allegiance to pure, seasonal flavors and chanted in peaceful protest from every inspired meal. Those of us too young to remember that taste revolution undoubtedly take its delicious consequences for granted. But the food fighters did leave us a legacy of their activist mentality: We are still keenly aware that what we choose to eat has consequences beyond our stomachs.

Since before organic was something to purchase, before Gandhi promoted vegetarianism and Marie Antoinette ate cake, back to when Eve sank her pearly whites into that fateful apple, food has been one of our most powerful symbolic tools. Because the need to eat is one of the few things shared by all humans, everywhere, the way we eat is what distinguishes us from one another. Food choices can set us apart from or express our affiliation with a culture, a region, a religion, a political agenda. In Berkeley in the 1970s, those choices drove a revolution.

Today in the East Bay, we are faced with more food choices than ever before. A trip to the market alone demands an extensive food vocabulary. Even with that, the selection may be baffling. Nevertheless, or maybe as a result, what we eventually place in our baskets makes a statement about our personal values. When I choose an organic peach over a conventionally-grown one, I may be expressing my concern for the earth or the health of farm workers. I may also be trying to give the impression of concern, or healthiness, or simply making a decision that I assume is the right one, without actually knowing what organic means. When I choose an organic peach over a locally-grown one, I face an entirely different set of ethical, environmental, political, culinary issues. That peach is never simply a peach because, as the revolutionaries understood, food carries meaning beyond its chemical makeup.

I mused upon this idea as I walked home that day, dusting crumbs from my lips as a criminal might scrub away incriminating fingerprints. The problem, I thought, is that while buying or eating particular foods might demonstrate our support for certain causes, we don’t always eat to support a cause. Sometimes we eat because of cravings or out of nostalgia for a taste memory. Most of the time, we eat what we can afford. So even though I chose that Pop-Tart because it was cheap, and I was hungry, and ultimately because I loved its unassuming, gooey sugariness, I felt as though the shiny silver wrapper and immaculately rectangular morsel in my hand were broadcasting to the world some anti-fresh, local, seasonal opinion that was not my own.

I believe in eating locally, in supporting family farms and production that sustains and replenishes the earth. Most of all, I believe in the flavor of the freshest, ripest foods. But I also like Pop-Tarts and brand name chunky peanut butter. Sometimes I buy mangoes off-season and enjoy every juicy, sinful bite. I can’t always afford to buy organic or eat in restaurants that share my values. The hardest part of being a post-revolutionary foodie may be figuring out how to reconcile my principles with my food whims at a time when we have more food choices and more freedom to choose what to eat than ever before.

Walking along the streets of Berkeley, Pop-Tart in belly, I felt dissatisfied and guilty – and it had nothing to do with the empty calories. I was feeling what the revolutionaries had thirty years ago: that food as a powerful symbol can affect emotions and therefore affect change. The difference this time around was that I didn’t want to produce change. I didn’t want to make a statement. I only wanted to taste. But maybe it’s too late. Maybe taste is my statement. And with this breakfast manifesto, the change has already begun.

Deep thoughts about fat

Stephanie Ebbert writes in the Globe today about an effort in the Town of Brookline to ban the use of trans fats in restaurants and schools in the town. New York City has done this, and there is also a bill pending in the Massachusetts legislature to do this statewide.

I can understand why a municipality would want to vote on this kind of matter for school meals. After all, the town has a responsibility for the quality of food served in its buildings, and students don't have a choice of cafeterias when classes are in session.

But I guess I have a bit of a libertarian streak when it comes to the restaurants. I agree towns should have authority over cleanliness and food protection standards in restaurants (and smoking, too), but I am bothered by the idea that they would legislate what we are allowed to eat. For one thing, is it really the town's business? For another, even if it is, how and where do you draw the line?

Every few years we are told about something that is bad for us based on the latest scientific studies. If I recall properly, I remember this happening at various times with white flour, eggs, avocados, nuts, coffee, processed meats, red meat, pork, fish, shellfish, and chicken. It often feels like this advice is rescinded, or even reversed, after more studies are done.

I am reminded of one of my favorite movies, Sleeper, in which the Woody Allen character wakes up after a 200-year hibernation. His attending scientist caretakers have the following dialogue:

Scientist 1: This morning for breakfast he requested something called wheat germ, organic honey and tiger’s milk.

Scientist 2: [laughing] Oh, yes. Those were the charmed substances that some years ago were felt to contain life-preserving properties.

Scientist 1: [astonished] You mean there was no deep fat? No steak or cream pies or hot fudge?

Scientist 2: [shaking head gravely] Those were thought to be unhealthy, precisely the opposite of what we now know to be true.

Scientist 1: Incredible!

Open letter to Mr. Levy

Open letter to Mr. Levy:

How is it that you have the time to blog while running a hospital? Have you run into any negative reactions from the faculty or others within the hospital? It would seem fairly high risk when attempting to gain and retain respect with employees, peers, and others who inevitably may be affected or left with an impression by your musings. As a member of senior management in an investment firm in the private sector, I can undoubtedly state that the reaction to my taking the time to be on the Internet each day would be perceived as unacceptable by my colleagues, my Board, and by shareholders. Indeed, I can't even risk writing my full name here. Sharing one's thoughts within one's own organization is vital and important, but opining in stream-of-consciousness fashion on all things publicly seems somewhat reckless and is easily (mis?)interpretable as narcissism. Have you encountered this opinion before from your colleagues or others and what has been your response/ explanation? It's fascinating to me that you would feel the compulsion to do it.

Kind regards,
Dave

Dear Dave,

Here are some specific answers to your questions.

How is it that you have the time to blog while running a hospital? If you note, most of my posts are filed early in the morning or late at night, when I am at home. The real question should be, "How is is that you have time to blog when you should be doing the laundry?"

Have you run into any negative reactions from the faculty or others within the hospital? Not once. Our place celebrates diversity of opinion.

It would seem fairly high risk when attempting to gain and retain respect with employees, peers, and others who inevitably may be affected or left with an impression by your musings. Musings!? These are rigorously supported conclusions, arrived at after years of scientific inquiry. After all, I work in an academic medical center, where everything I post has been subject to peer review.

I can't even risk writing my full name here. That may be the saddest thing you have written, saying much more about your life and place of employment than mine.

Sharing one's thoughts within one's own organization is vital and important, but opining in stream-of-consciousness fashion on all things publicly seems somewhat reckless and is easily (mis?)interpretable as narcissism. Blogs are inherently narcissistic. I admitted that from the start. As for "stream-of-consciousness", please read the posts more carefully. As for "reckless," you don't know me personally, but those who do know that I say the same kinds of things in person.

Have you encountered this opinion before from your colleagues or others and what has been your response/ explanation? This blog is subject to disdain by my colleagues in some other hospitals. Really. You can see it on their faces when the topic is raised in their presence. They are deeply offended by it and think it unacceptable for the CEO of a Harvard hospital. Of course, they have never said anything to me directly. Then, they would have to admit that they read it.

It's fascinating to me that you would feel the compulsion to do it. It is fun. Apparently, too, it is informative and interesting to others, and shouldn't it be part of my job to inform people about the many issues facing hospitals? Who else is better equipped to explain what we do, how we do it, what makes it hard, and what makes it rewarding? CEOs give interviews to reporters, who then filter the information and put it through the wringer of an editor who wasn't even at the interview. Is that a better way to tell the world what happens in a hospital? Similarly, when was the last time you actually read the letter from the CEO in a corporate annual report?

Dave, at latest count, there are 71 million blogs out there. At least a few are posted by CEOs of large organizations. The reason to write a blog is that you think you have something worthwhile to say. The market test is whether people read it.

If you go to the very bottom of this blog, you will see a number: That is the number of "unique visitors" who have chosen to drop by since I plugged into StatCounter in October. Also, click on "blogs that link here" to see who else refers people to this site. Both are not huge numbers by blogosphere standards, but, as you know, my readers are very high quality people.

Many thanks for taking the time to write,

Paul

I'll take two!

An ad I received yesterday. A glimpse at hospital billing for those of you unfamiliar. I think I'd better buy the one with the answer key! (That's me in the chair to the right after a briefing on these matters by my CFO . . .)

The Official Guide for Enhanced Revenue Cycle Management

The first textbook that helps HIM professionals, college instructors and students understand the differences between the UB-04 and the UB-92 and provides a global view of how the billing function should work in conjunction with the coding department. The Handbook provides accurate and timely information about the UB-04 and explains how and why ICD-9, CPT and HCPCS code conventions must be integrated with UB-04, HCFA-1450 and CMS-1450 billing conventions. It enables hospitals and other health care provider organizations to maximize claim processing performance and revenue recovery and better manage their revenue cycle process.

The Handbook shows how to complete a facility UB-04 billing form, and contains vignettes that explain the billing office process, its components and reporting nuances. It contains 65 quizzes that can be used for self-testing, for performance evaluations or classwork assignments.

The UB-04 Handbook will help HIM staff understand that coding conventions for billing are as important as ICD-9 coding conventions when sending a claim to an insurance company or payer and ensure that members of accounting, admitting, quality management departments understand how their contributions to the revenue cycle must be translated by billers to fit changing UB-04 Form Locator codes.

A Facility Billing, Charging, and Reimbursement Reference & Training Manual for: Hospitals, Skilled nursing facilities, Durable medical equipment agencies, Behavioral health & chemical treatment agencies, Surgery centers, Ambulatory surgery centers, Subacute and LTC facilities, Hospice organizations, Health Plans

Available With & Without Answer Key
UB-04 Handbook for Hospital Billing, With Answer KeyAHA Order Number 061177403 pages, 8.5 x 11, soft coverISBN: 978-1-55648-346-2$125 (AHA Members, $109)
UB-04 Handbook for Hospital Billing, Without Answer KeyAHA Order Number 061178368 pages, 8.5 x 11, soft coverISBN: 978-1-55648-347-3$110 (AHA Members, $99)

State House news

If you didn't already think that I was weird, I have confession to make: I love the process of state government. In particular, I love seeing the legislature in action.

I have a high regard for legislators. I know this is not universally shared. But, to me, these are folks who are really committed to helping their constituents and the state as a whole. They listen to one another and to lobbyists and private citizens and do their best to make judgments in the public interest. They are also interesting and thoughtful people from a wide variety of backgrounds, who truly enjoy being with other folks.

Finally, I have found legislators to be trustworthy, people who stand by their word and their promises. The coin of the realm in a legislative body is honesty. If you go back on what you have said, your effectiveness is harmed for a long, long time.

So, yesterday, I had a chance to testify on a bill concerning how to get better coordination of state programs in the area of workforce development and training. And here's where the legislative process is also so engaging and wonderful. I found myself on a panel with a representative from the SEIU, a labor union, joined together in supporting this particular bill.

This must have been a marvelous moment for the legislators, seeing us allies on this matter -- while recalling previous visits from the SEIU describing me in extremely unflattering terms because of our differences about union organizing approaches. As legislators, they understand that alliances often shift, and they know that agreement on one day on one issue does not necessarily portend more of the same on the next.

On this issue, though, we stand united. Health care employment opportunities in Massachusetts are likely to grow over the coming years, presenting a chance for a great variety of people to have satisfying jobs at good wages. If the state can provide better planning and coordination among its educational institutions and other agencies, this opportunity can be enhanced.

A world of difference

I just returned from an event to support the Anti-Defamation League, which has a terrific program for school kids to teach them about bigotry and prejudice. It is called A World of Difference Institute, and by the end of the training program the children take the following pledge:

I pledge from this day onward to do my best to be aware of my own biases against people who are different from me. I will ask questions about cultures, religions, and races and other individual differences that I don't understand. I will interrupt prejudice and speak out against those who initiate it. I will reach out to support those who are targets of harassment. I will identify specific ways that my peers, my school, and my community can promote greater respect for people and create a prejudice-fee zone. I firmly believe that one person can make a world of difference and that no person can be an "innocent bystander" when it comes to opposing hate.

Good sentiments all, I say. It takes real guts to "interrupt prejudice," as it is much easier to stand quietly by. Of course, doing the latter just legitimizes the bad behavior.

For Students -- Breaking into the club

Our Wednesday series continues with responses to questions from students. Erik asks below:

I have just finished my undergrad in Sociology and will be pursing an MSc in Health Management this fall. As one of the few students in the programme coming directly from undergrad (and without a medical background), I decided to intern with Senior Management at a hospital.

One of the issues for me is that everyone, except for the CFO, comes from a clinical background. When I look at many of the VPs, much of their learning progressed as they moved through various clinician roles and eventually into Senior Management. As someone who will not move through these clinician roles, but is nonetheless interested in working in hospital management, what core competencies should I be focusing on during this short (6 month) internship?

I do not think that someone is going to be trained in core competencies during a six-month internship. I think you take an internship to get exposure to a certain type of institutional situation, to meet interesting people, and to have a chance to "show your stuff." Rather than trying to learn one specific thing or another, go into an internship that provides you with an opportunity to take on a specific project, where you will have responsibility for a reasonably hard, but doable, assignment -- and then get it done well.

You will, of course, learn things along the way, but the more important thing will be that you will demonstrate to a set of senior managers that you are thoughtful and competent. This very often leads to a request to stay with the organization in a more permanent capacity. If it does not lead to that, it nonetheless provides you with a credible reference for your job search.

On the larger issue, there remains a prejudice against hiring non-clinical people in hospitals. This stems from several ill-founded beliefs. The same phenomenon occurred in many industries and only changed over time because the supposedly "expert" job candidates were found to be incapable of guiding their companies through the shoals of structural change. This was because they were promoted into positions of authority based on the qualifications of their discipline rather than the needs of their organizations. I have watched it happen in electric utilities, telephone companies, water utilities, steel companies, auto companies, and many others.

I'm not saying that non-clinicians are necessarily superior managers in a hospital setting. (The jury is still out in my case, for example.) I am saying, though, that non-clinicians can bring a useful perspective and aspects of managerial experience even in the highly technical world of medicine. The way for you to prove that, though, is to get into some position -- virtually any position -- in a hospital and prove your merit. Trust me, you will be noticed, and you will advance.

(By the way, isn't it interesting that the last positions filled for CEOs of three Harvard teaching hospitals -- BIDMC, Massachusetts Eye and Ear Infirmary, and the Joslin Diabetes Center -- were not doctors? All three places faced major structural problems, and the Boards felt that managerial experience trumped a medicine degree in their selection process. We'll see if they made wise choices.)

There's nothing remarkable about it

Johann Sebastian Bach reportedly said, "There's nothing remarkable about it. All one has to do is hit the right keys at the right time and the instrument plays itself."

Sometimes I think that running a hospital is just the same. Treat every patient with exactly the right mix of clinical excellence, service quality, kindness and respect and "the instrument plays itself."

Of course, the ability to do that resides in the coordination of well-intentioned, thoughtful, and supported people working in harmony and cooperation.

Recently, we had a chance to spend some time with people from a group called Value Capture. They relayed the content of speech by former Secretary of the Treasury Paul O'Neill at the Harvard Business School. He outlined the three questions every employee should be able to answer affirmatively every day in order for an organization to have the potential for greatness:

Am I treated with dignity and respect by everyone I encounter, regardless of role or rank in the organization?

Am I given the knowledge, tools and support that I need in order to make a contribution to my organization and that adds meaning to my life?

Did somebody notice I did it, i.e., am I recognized for my contribution?

Here at BIDMC, we strive to treat each patient as though he or she is a member of our own family, and we try to treat one another the same way. We could all debate whether we should measure success in this way, or in the way stated by Mr. O'Neill, or by more formal statistically valid metrics of patient care and patient satisfaction. We know we are better on these fronts than many places -- and we know we have improved during the last few years --but better does not represent success and is not the standard we choose to set for ourselves. We still have lots of work to do on all fronts.

One reason I have published good and bad stories about our place is to let you know both where we are doing well and also how we are trying to improve. My aim is also to let our staff know that we freely and openly choose to be held accountable to the public we serve. I believe that shining sunlight on a organization tends to drive improvement.

Some people have told me that this is a risky strategy, that people will use this information against us -- for commercial purposes, political purposes, or otherwise. Our message to those who would try is that there is nothing we do poorly that we ourselves would not choose to improve. So if you have suggestions to make about how we can get better, we welcome them in that spirit. If, however, you choose to use this information for your own purposes, or in an unhelpful way or simply to gain advantage, we will nonetheless evaluate what you say as objectively as possible and still try to use it to get better.

"Hitting the right keys at the right time" is hard for someone playing a Bach minuet. It is arguably harder for an organization of 8,000 people taking care of 40,000 inpatients and 500,000 outpatients per year. In either case, though, the solution requires practice, practice, practice -- and it is especially effective when the practice is in front of an engaged and informed audience.

If you are just tuning in . . .

. . . after the weekend, please make sure to read the two posts below. I think you will find them really worthwhile.

Give thanks and pray

Further reflections from Honora, a young American doctor in service in Kenya. And please be sure to read Cameron's story in the next post.

Dear Friends and Family,

My first weeks in Kenya have been wonderful. The days are full, eye-opening, and often very rewarding. Yesterday was a truly wonderful day. The two prior were the most intense that I have ever had in medicine, and were quite hard. But I am doing very well, and feel balanced, supported, and so privileged to be here.

The wards are filled with young women; most of them aged 25-35, and most of them dying of complications of HIV or other diseases of poverty. There have been certain moments over the last few days that capture the gravity and intensity of it all; the combination of hopefulness, humanity, helplessness and desperation. The twisted and stirring mix of emotions and smells; one patient sitting at another's bedside, holding her hand or feeding her dinner, the rush of family members that fill the wards during visiting hours, the song of a preacher that hovers over the evening air that feels heavy with death.

I have been lecturing to the 4th year medical students several times a week, and also have had the chance to get to know the group of 4th and 6th year students on my team. I am compelled and intrigued by the students' response to my questions about how they see HIV/AIDS affecting their country and its future. My inner sense of shock and desperation is tempered by their practical impression that things are improving slowly. They hear the census numbers showing a decline in prevalence of disease and are reassured. I can't help but wonder if more people are simply dying, and thus driving prevalence down. I am surprised when their comments revealing an astute understanding of politics in the US are followed by their comment that HIV/AIDS is not a political issue. They explain that making HIV a political issue is a sure detriment to any candidate who broaches the subject, as who can win when they try to campaign on an issue like HIV? No one candidate can show that they have made a difference and it certainly won't make them popular, they explain.

This conversation over lunch followed by one students comment to me on rounds the next day, when we pass by many beds where a pillow is shared by one woman's head and another's feet. "AIDS is destroying our people," he tells me. Rounding on the women's ward, I am struck by how much AIDS has become a disease of impoverished women. I learned recently that when a woman has sex with an HIV+ man, she has a 1/200 chance of acquiring the infection. When a man has sex with a woman with is HIV+, he has a 1/700 chance. What a terrible biologic injustice that compounds the underlying and sobering disadvantages faced by a woman in the developing world.

Last night I ate dinner at a friend named Francis's house. I was invited there with my friend, John, who has lived here before and has many old friends in Kenya. Francis lives about 30 minutes outside of town heading west on Uganda Road . His home consists of a small wooden home with electricity where we dine. Next door is a separate shed with a mud floor and a wooden fireplace for cooking. While we sit in the living room, Francis's niece and wife prepare our feast. Francis works as a driver and transportation director for AMPATH, the HIV outreach program that has expanded to 18 clinics throughout the Western Kenya.

Over dinner, Francis tells me that he is the youngest of 13 children. He has the biggest and warmest grin of anyone I have ever met, his sparkling white teeth shining below his ebony skin, and his eyes and whole body radiating warmth. He explains that in his tribe, value is placed on the number of children that you have, and his parents had many children, even though they couldn't afford to feed or school them. His father was an alcoholic and would hit his mother. And at the age of 11 he left home for the streets. He has endured much in his life. But now he is married to a woman who is not Luya (an unusual thing to marry outside of one's tribe) and he has two children of his own. He has decided that two beautiful children is the right number for him.

At one point Francis asks if doctors in America show compassion for their patients, of if they treat the interaction like a business exchange as he has seen Kenyan doctors do. We speak about the time and resource challenges faced by Kenyan doctors, and one of the other Mzungus (white person) with me at dinner rushes to say that in the states there are many doctors who are also brisk and uncaring. It is different here, I argue. I have the utmost respect for most of the Kenyan doctors and students I have met here, and many are deeply caring. But most do not show the same kind of personalized care and compassion for patients that is expected in the U.S.. I don't know how they could. Daily, they see people dying from things that would be easily treatable at home; they know that their hands are tied, that there is often little that they can do. Before transferring a patient for an emergency operation one needs to check not only if there is an ICU bed available, but if there is a surgeon who will come from hours away to see the patient, if the ventilator is cleaned, and if there is oxygen available today.

I see the kind of care that Francis asks about as a kind of emotional contract between two people, a personal connection between patient and doctor by which both are affected, and where there is trust and hope. I think it is a rare Kenyan and a rare human being who can work in a system with such desperation and continue to show that kind of compassion. For me, this experience and these feelings are all time limited. My reality is one where patients have access to the most technologically advanced treatments; where they can afford hope and compassion. We then go on to talk about the stigma associated with HIV and I answer his questions about HIV virology and the hope for a vaccine.

His children dance. And at the end of the meal we sing Swahili hymnals, give thanks, and they pray. It is a beautiful night.

You lied to me

Here is an essay written by Cameron Page, presented with his permission. It recently won an award called the Marguerite Rush Lerner Award. This prize is given annually to a Yale graduate student in one of the health sciences.

“You lied to me.”
No one had ever said that to me in the hospital before.
“Why did you lie to me?”
Why, indeed?

I had met her the previous day, when she brought her son to Coptic Hospital in Nairobi, Kenya, where I was doing an infectious disease elective.

Her son was eight years old and HIV-positive. He had a fever and was breathing fast. Jason, the infectious disease fellow from University of Minnesota, listened to the boy’s back and looked at his X-ray. “Pneumonia,” he said.

While the son slept with an oxygen mask on, Jason spoke with the mother: “He is very sick. The first 48 hours are the toughest. It’s only after that that we can start to be optimistic.”

Jason excused himself for a meeting. I didn’t have a meeting. I sat at the foot of the sleeping boy’s bed, across from his mother, where the sheets were stamped “CH” in large faded blue letters. The mother put a thumbnail between her teeth; folded and unfolded her arms; looked at me and then away. She wore a flowery print dress with lace at the neck, as though she’d been suddenly called away from a formal ball.

“What will happen if he can survive this one?” she said to me.
“Well,” I hesitated, “it depends. He may be developing resistance to the anti-retroviral medicines, in which case we would need to switch him.”
She looked confused. “You give him new medicines?”
“Maybe. It depends on—“
“Better medicines?”
“Well, just different. He won’t be resistant to them.”
“The new medicines, they will make him healthy?” She was leaning forward now.
“Well, his viral load should drop, and hopefully his CD4 count will start to rise--“
She tossed off my jargon. “They will make him better?” Her eyes carried not just a question, but a plea.
I paused.
“Yes,” I said. “They will make him better.”

With the new medicines, I said, her son wouldn’t get sick as often. He wouldn’t need to take prophylactic antibiotics every day. I told her about other children I’d seen, just as sick as hers, who had made complete recoveries. I described their weight gain, their increased energy. How they played soccer in the playground after school, just like the other children.

Her smile was a tiny burst of joy, like the hug of a small child.

When I left, she squeezed my hand. “You are a good doctor,” she said. I brushed away the compliment. I told her I would talk to the pharmacist about the new medicines.

The boy died later that night, while I was eating dinner at a Korean barbecue restaurant.

The next morning she was waiting for me. Her face told me more than the empty bed did. Her eyes tore at me with unfocused rage, and despair.

When she called me a liar, I thought of defending myself, reminding her that she had asked me to speculate. It was her hypothetical question to which I’d responded. But I stopped before I opened my mouth, because that would have been another lie.

The truth was that I had indulged in the fantasy too. I had taken comfort in imagining her son’s long, happy life. Our bedside chat was as much for my benefit as hers.

She lectured me, yelling in my face. What about the weight gain? What about the soccer in the playground? She was firm, business-like. She wanted an accounting for every misleading statement I’d made. Rigors of anger and injustice swept across her body.

She had asked me to comfort her, and I had built that comfort from the only material I had: hope. I had done it unthinkingly, instinctively. I had not considered that hope is a shaky scaffolding, and when it collapses, the fall to earth can be long and the landing hard.

A thousand fits of rage would not bring her son back, and she seemed to realize that suddenly. Her hands dropped to her sides, and she wept.

We'd had no right to be hopeful so early. Jason had been cold, but right.

In the end, all I said to her was “I’m sorry.” I said it over and over. I was sorry for her son’s death. I was sorry that I wasn’t there when he died. I was sorry I misled her. Ultimately, I was sorry that I wasn’t a better doctor, a doctor who could understand that comfort is a double-edged sword, a sweet that can quickly turn sour.

An update from Kenya

Another email from my friend Honora, a young American doctor in service in Kenya. I think you can sense how drained she was when she wrote this.

Hi All,

I am doing well. I feel so good to be here and seeing this part of the world. I can feel myself learning and growing. Today was actually the hardest day yet. The wards are very intense, and this afternoon I felt overwhelmed by it all. The patients are incredibly sick, and they are poor and dirty and there are often at least 2 patients to the same twin bed, with about 10 beds per bay, and a total of 3 bays that I am caring for. I feel very lucky, as my team is really good. The resident is bright and takes initiative, and one of the interns is really great.

It is hard; my sense is that the doctors feel downtrodden, in part because they are lacking so many resources. I gave a talk to the 4th yr students about management of heart disease, and found myself teaching them about treatment "for the future, when they have the technology and resources" but doubting whether it matters at all. Even the simplest of treatments are often not available. Yet they get tested in the British system and have to know the latest treatment recommendations... It is definitely far from empowering for them.

That being said, there is a sense of hope in the country, and I see the worst of it, as those who end up in the hospital have by far the most advanced disease.

I have a Swahili lesson in a bit, so I'll sign off.

I want my doctor to be a spook

Several months ago, I dealt with several aspects of patient confidentiality. To supplement that, here is an interesting website that covers a number of myths about the requirements of HIPAA.

Many people think that the HIPAA regulations prohibit or discourage emails between doctors and patients. They do not. As stated on this website, though, the regulations require providers to use reasonable and appropriate safeguards to “ensure the confidentiality, integrity, and availability” of any health information transmitted electronically, and to “protect against any reasonably anticipated threats” to the security of such information. Therefore, a covered entity is free to continue using email to communicate with patients, but should be sure that adequate safeguards, such as encryption, are used.

I think most of us don't think about the insecurity of email when we send a note to our doctor. Sure, it is unlikely that some stranger out there will be scanning our emails, although I bet some MIT kids could figure out how to do it in a nanosecond. We forget, though, that employers have the right to snoop through our email on our corporate accounts. Also, it is quite common to insert the wrong "To" address when you are sending a note to someone.

That's why we offer and encourage the use of secure portals like PatientSite. All PatientSite messages are encrypted. Our resident geeks tell me that we use 128-bit DES encryption through SSL. I haven't had a chance to check it out with Maxwell Smart, but it sounds all right to me.

I vote "yes" on storefront clinics

Liz Kowalczyk writes in the Boston Globe about plans by the CVS pharmacy chain to open storefront medical clinics to provide certain primary care services to the public. Walmart and others have done the same.

We can expect that there will objections to this from people representing established health care practices or institutions. You can be sure that those objections will often be phrased in terms of protecting the public from substandard or uncoordinated care. That is always the first refuge of people concerned about protecting market share for established players. I have seen it before in many industries.

I think this kind of objection also stems from a belief that primary care must be provided by doctors. Yet, physician assistants and nurses can provide excellent and appropriate care for many issues. Their doing so may actually free up time for primary care doctors, who are in short supply, to handle more complicated cases.

Rather than objecting to this convenient approach to providing care, established providers should open their arms and do their best to make it easier to coordinate with CVS and others.

For Students -- Health care reform

This is the next chapter in my Wednesday is Student Day series. Students, you have been slow in submitting other questions. If you don't have any, I'll have to make some up . . .

Rocky, a medical student, asks below: "Do you see the new Massachusetts Healthcare Plan having the potential to increase access to good quality care? How will undocumented residents and current free care recipients be affected by the new healthcare reform bill. Will large hospitals retain their freecare pool?"

I have not spent much, if any time, discussing the new Massachusetts legislation on this blog, mainly because the topic is very well covered on John McDonough's blog and WBUR's. I suggest you read those.

I think it is important to remember what the new law is designed to do and what it does not do. It is designed to provide as many people as possible with insurance. An underlying premise and hope is that people with insurance will have better and more appropriate health care. For example, they are more likely to have a primary care doctor -- assuming they can find one -- and go to that doctor for preventative care and low-level emergent issues, instead of showing up at a hospital emergency room. Although hard work remains on this front, the law has already been successful in providing insurance to tens of thousands of people who previously had none.

The law does not do much about the cost and quality of care in the state, except to the extent that insured people will have a better chance of earlier diagnosis and treatment. Although a Quality and Cost Council is established, as far as I can see, it has little authority. Perhaps, though, it will exercise its moral authority to push hospitals along.

Finally, on your question about the free care pool, which is designed to support care for people below a certain income level, we expect to see a transition of patients from that category to Medicaid or to the insurance plans offered through the Connector Authority. Whether that is a net plus or minus financially for a hospital is unclear: The free care pool has never fully compensated many hospitals for their care of uninsured people, but the payment schedules under the new state insurance plans -- just like Medicaid -- do not fully compensate hospitals either.

Just to be clear, none of this affects how we treat patients, which is to do our best to provide excellent care regardless of a patient's income or insurance status. The financial impact is made up by private insurance company payments from other patients and by philanthropy.

Now we are six!

A lovely note, reminding me an early post back in October. A sweet message to the nurses and an inspiring one for parents in a similar situation.

My name is ** and my son was born on August 4, 2000 at 29-½ weeks.

He is now a 6 year old kindergartener who is doing fabulously!

The care that I received in the Antepartum unit and the care he received in the NICU was phenomenal! When I tell anyone the story of his premature birth, I can never say enough good things about BIDMC. The nursing staff especially on both units made a very, very scary and horrifying experience easier for myself, my husband and my family. I know that the week of May 6th is National Nurses Week, and I am hoping you can pass this email along to the Nursing Administration to let them know that even as 6 years have passed since my son's birth, I will never forget the care we received from the nurses. It was truly outstanding.

Also, I wanted to send along the good news, that with such a difficult, scary and uncertain beginning to his life, my son is doing remarkably! He is a smart, articulate, and funny little boy, doing all the things that little boys do. I am hoping that his success story can be an inspiration to others facing premature births. I know that for me, when we were going through everything, the one thing that I clung to was hearing a success story, they always gave me hope in a scary time.

Please feel free to share this with others at the hospital.

Thanks so much!