We are all connected now

Honora Englander is back in Oregon after her service in Uganda:

I made it back to Portland after a long (38 hour!) journey. I'll leave you with a short story from my travels home.

On my ride across Uganda, my driver, Habert, talked to me about old age. He is 36 years old, middle-aged by Ugandan standards where the life expectancy for men is 42 years (per the WHO). “Will I reach 50?” he asked me rhetorically several times. He explained that many of his friends from football and childhood have died from a host of causes - traffic accidents, malaria, HIV. I noticed more than anything that he didn’t say this with much regret or grief, but instead with a kind of stoic acceptance of this is the way of life here. As we drove through roads lined by mud homes with tin roofs and stands selling mangoes, tomatoes, potatoes and bananas, I was curious to imagine what these communities looked like 50 years ago, 100 years ago, 36 years ago.

Habert shared with me differences that he remembers from his childhood compared with his own children’s. I asked what he thought the major drivers of change have been in his lifetime – has Uganda been affected most by relative political stability, HIV, Western presence? “Mobile phones,” he answered, without hesitation, and went on to explain. “Now, you can be a peasant farmer on a banana plantation in Uganda, and you can be talking on the phone with someone in Kampala, or someone in America. We are all connected now.”

Public reporting

From the Midwest comes this opinion about the value of public reporting of medical errors. As I have said elsewhere, if the medical profession does not establish its own standards in this arena, government will do so for us.

Speaking of Twitter

Did you read this story?

Twitter etiquette

As a relatively new member of Twitter, I was uncertain about one aspect of etiquette on this social media vehicle. The way Twitter works is that you "follow" certain people whose "tweets" you would like to read. A tweet is a 140-character message. Think of it as a very small blog posting. In turn, people follow you and read your tweets. You can find my page here.

People come to be followers in a viral fashion. They hear about you, search for you, or see your name on other people's lists of followers.

Last week, all of a sudden, dozens of people became my followers within a few hours. I was curious where they all came from, and so I tweeted a message: "I'm trying to figure out why I got a huge influx of followers within about an hour overnight. Can someone explain? Meanwhile, welcome all!"

Responses from around the world came in instantaneously. Guy Kawasaki had linked to a blog post that had a list of CEO Twitterers. I looked up Guy to discover that he had over 68,000 followers. He also was following over 73,000 people!

No wonder I had so many new friends, and so quickly. Thousands of people had read about me because of Guy. But his numbers left me wondering, and so I posed the question: "Survey question:Is it rude not to follow everyone who follows you? I c 2 patterns: Some follow all who follow them, some only follow a few." I have about 800 followers, but I follow only about 80 people.

Helpful replies again came back from around the world, and I offer them for those of you who might be interested.

kerplunker @Paulflevy I've read it's not rude, it's nothing personal. You should follow ppl whose tweets you'll actually enjoy reading/will be helpful.

movinmeat @Paulflevy you can't reasonably follow everybody; I have found that my twitter overload point is about 40 following.

leewhite @Paulflevy Following should meet your needs for connection and/or information gathering.

judsond @Paulflevy not rude, think of it like blogs, i read engadget, doubt they read my tiny blog, cool if so, but i certainly not rude if not.

john_chilmark @Paulflevy no it is not rude, some followers are just fishing.

Damjan_DeNoble @Paulflevy whatever makes you a more entertaining/insightful twitter user is the way to go... good blog habits apply too/ i.e relevant links.

MrElderCare @Paulflevy- I follow those with potential for mutual benefit. Follows are an oppy to build relationship only. Not an an obligation.

mdbraber @paulflevy I check out every new followers, evaluate their first page and only follow if they fit my interests.

jeanneendo @Paulflevy Your call who to follow. You're the 1 who has to keep up w/the msgs. People just need to understand that.If not, you can't worry.

And a DM (direct message) from a friend: "IMHO*: If you aren't a Social Media network (like Guy is), or an e-vangelist, intuition will be the best guide for whom to follow."

I am relieved! So, if you are following me on Twitter, and I am not following you, please know that I appreciate your company, but just don't have time to keep up with hundreds of people.

--
*IMHO = in my humble opinion

Matchmaker, matchmaker, make me a match

Here is another update from Dr. Honora Englander, providing service on assignment in Uganda. We pause with a break from medicine and express some concern that our doctor is delving into dangerous territory!

It is a beautiful morning here after a deluge of rain last night and the sky is particularly magnificent.

This past weekend was a welcome break from the wards. My friend, Joseph, who I met in Kampala last year and who is an intern in Gulu (in the far northern region of Uganda that has been plagued by years of violence from the LRA but is now relatively stable) made the 12-hour bus trip to Mbarara for a weekend visit. It was wonderful to see him. We ate leisurely meals and took a walk through the dusty roads on the outskirts of town. Our conversation wandered from the excitement and challenges of internship (he assured me that if I ruptured my spleen he could operate with confidence all on his own) to news of his brother's recent wedding to a discussion about the traditions and rituals of marriage. He explained the build-up to the wedding – the negotiation of an appropriate bride-price, in which his brother needed to acquire 6 cows, several goats, a spear, a sizable sum of money, and a number of other traditional items. This list was decided upon through negotiations between his brother's team (friends, uncles, siblings) and his now sister-in-law's team.

Joseph explained that in the past, this ritual was more feasible, when cows were abundant (they have since been stolen by nomadic tribesmen) and when gifts were a gesture of respect to the bride's family. Now, with such expensive demands and money changing hands, to Joseph, it feels too much like the family is selling the woman. He explained that he doesn't want to receive a bride price if he has daughters, but suspects that he too will go through this ritual of negotiation, bargaining, debt acquisition, and expense for a bride. At the end of the weekend, I couldn't help but introduce Joseph to one of my favorite students who is also from the North, and who might someday make a lovely bride for him. (The matchmaker in me just couldn't resist, and the romantic in me has a good feeling about their future!)

Innocent until the SEIU says otherwise

Given the inclination of the SEIU to run roughshod over freedom of speech and to undermine the use of elections, I guess I shouldn't be surprised when it attempts to ignore the "innocent until proven guilty" premise of American life, as well. The Executive Vice President of the union sent a letter this week to our Board of Directors, and later released it to the press, naming one of our Overseers by name and suggesting that the Board "conduct your own investigation" to determine whether this person is still suitable for membership in this organization of lay supporters of the hospital.

I am reminded of a quote from another setting and another era: "You've done enough. Have you no sense of decency, sir, at long last? Have you left no sense of decency?"

Let me explain. The Board of Overseers is not a governing body. It has no fiduciary responsibility for the hospital. People who volunteer to serve on our Board of Overseers do so out of loyalty to and affection for our hospital. Some are recent members and some have been members for years. They contribute time, money, good will, ideas, suggestions, and energy to the public service mission of the hospital.

Sometimes, people on our Board of Overseers go through hard times in their lives. They might have financial troubles, marital troubles, and even legal troubles. When they do, we stand by them as they have stood by us. We consider them members of our extended family. From time to time, an Overseer might resign because he or she feels that they can no longer ably serve the institution. Our practice is to let people make that decision because we know that they have tremendous loyalty to BIDMC, and we trust their judgment on such matters.

We do not and will not conduct an investigation of anybody on our Board of Overseers. Contrary to the SEIU's suggestion, we do not pretend to arrogate to ourselves the powers of law enforcement or regulatory bodies. Those bodies are given their statutory authority by the Constitution or by law, and we trust them to do their job well.

We also do not issue press releases suggesting that any other organization -- hospital, business, or union -- conduct an investigation of one of their members or one of their advisors. To do so would simply be indecent.

English Works

I attended a lovely ceremony today, hosted by Wainwright Bank in Boston and organized by the MA Immigrant and Refugee Advocacy Coalition. (MIRA's executive director, Eva Millona, is shown here.) It was an occasion to recognize a number of employers who had supported workers by offering English for Speakers of Other Languages (ESOL) classes. BIDMC has joined Brigham and Women's Hospital and Boston Children's Hospital in offering this kind of on-site training program.

The classes are taught by people from Jewish Vocational Services, who offer language training at four consecutive levels. There is a rigorous assessment program, so that people only progress when they are ready and so they can be accurately placed into the appropriate level. Classes are 2 hours per day, twice a week, for a semester. We currently have 26 people enrolled from BIDMC, including those shown here -- Marie L. Lambert, Maria Carter, and Ababu Tolla -- who were on hand for the award ceremony.

Boston's Mayor Tom Menino presented the awards, thanked those employers who currently offer ESOL programs, and urged us to encourage other employers to do likewise.

Webinar available for listening

Thanks to Francois Gossieaux for inviting me to be his guest on a webinar today. We covered a variety of topics. You can pick up the link at CMO 2.0 Conversations and listen. There are some familiar topics for my regular blog readers, but there is also a tilt towards marketing issues, which, after all, are Francois' specialty.

A political crocus

The award for best timely metaphor of the year goes to Massachusetts Liberal for this sentence about the possible political aspirations of HPHC's CEO Charlie Baker: "And, just as spring is rumored to be around the corner, a political crocus is popping its head through the soil."

It is a long time to the next gubernatorial election in Massachusetts, but things start early around here! This could be interesting for both health care and state politics.

P.S. Charlie, as many know, is also a blogger, here. If he is going to run, he'll have to move to Twitter and Facebook, too, if the Obama campaign is any indication!

Thank you, HSPH students!

Many thanks to the Student Advisory Committee (some seen above) of the Division of Public Health at the Harvard School of Public Health for inviting me to give a lecture today in the Barry R. Bloom Public Health Practice Leadership Speaker Series. Barry served as Dean for the school from 1998 to 2008, and it was a honor to speak in a series named after him.

The topic was "creative leadership in times of change". Not to quibble, but there is lots of redundancy in that title! Leadership without creativity is not really leadership. And all times are times of change. Nonetheless, this gave me wide range to cover any topics I wanted. Regular readers here will easily guess what those were. If in doubt, first read this, and then read here and here.

A conundrum

Milt Freudenheim's story in yesterday's New York Times is about ranking physicians in a Zagat restaurant-style manner. Indeed, the venture is being run by Zagat. The final sentences caught my eye:

Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania, said he was skeptical about open forums evaluating doctors.

“There is no correlation between a doctor being an inept danger to the patient and his popularity,” Professor Caplan said. Reviewing doctors is “a recipe for disaster,” he said.

I think we can agree that this kind of ranking has very little substantive validity with regard to the relative ability of doctors to diagnose and treat patients. But where does that leave us? Should there be a more systematic appraisal of these skills? Should it be available to the public?

What happens now? Well, informal conversations form the basis for physician reputations.

I know of one primary care doctor, for example, who has an outstanding reputation among his patients but who is regarded much less highly by his peers. Who is correct?

The same is true among specialists. There are some surgeons and other specialists who are very highly regarded by referring doctors especially because they are good at making themselves available when requests come in to see patients. But, those referring doctors have no substantive basis for knowing whether the outcomes experienced by their favorite specialists are better than, equal to, or less good than others.

Should we care about this at all? For referring doctors reading this, what criteria do you use for making recommendations to patients? Are you satisfied with the information you have?

Honora continues to inspire

What is it about Honora Englander's plain-spoken dispatches from Uganda that make me smile and feel good about the future of medicine? I hope you feel the same way. Here's an excerpt from her latest:

The time here is flying by; my days are full and each day holds something new and unexpected. Some days I am wakened as early as 5:30 am by trucks barreling by my window or by the howling choir of neighborhood dogs. At 6:00 I can hear the beautiful morning prayer from a nearby mosque, and this is followed by the birds' dawn. I've been rounding on the wards with residents and students from 9 until about 1:00 or 2:00, and then teaching in the afternoons for several hours. Monday was diabetes and chest x-rays, Tuesday physical diagnosis rounds, and today was a marathon lecture on EKGs. The students are bright, well read, caring, and very eager.

Though likely of less interest for those not in medicine, I suspect that many of you will find some of the patient stories and diseases we see here fascinating. In the first bed on the left is a 31-year-old man with newly diagnosed HIV/tuberculosis co-infection who presented with cough and weight loss, and developed seizures on his first hospital day. He stopped seizing after benzos and a dilantin load, but we've been unable to establish a clear diagnosis due to his reluctance to have a repeat lumbar puncture (the first was lost after being sent for India Ink which was negative). A chest x-ray showed miliary TB and is gradually improving on empiric therapy for TB and bacterial meningitis. His mother and father tend to him daily, and their faces appear increasingly relieved as the memory of his seizures fade and he gains a small amount of strength.

In the next bed is a 66-year-old man with refractory hypertension, anemia, melena, and a pleuropericardial friction rub of unclear etiology. He speaks English well, which is a luxury for me, as so much history is lost using students as translators. Many students are from the region and thus speak the local language, but many come from other parts of the country and their comfort in Riankole is variable.

In the next bed is a 14-year-old boy who presented with lightheadedness and gum bleeding several weeks after a dental extraction, and is found to have a WBC of 1.1, Hemoglobin of 2.7 and platelets of 8. His spleen is enlarged (grade III) but other than a slight S3 and looking young and frightened, his physical exam is unremarkable. We are ruling him out for infection (TB, brucella, typhoid, severe malaria) but are all concerned about a likely lymphoma. In the meantime we are treating with antibiotics, antimalarials, packed red cells and vitamin K, and today there was a suggestion that we get platelets from Kampala while we wait for a bone marrow biopsy.

Next to him lies a young man who was transferred from the psychiatry ward where he was said to have had a psychotic episode after newly learning is his HIV positive, however his clinical course and exam suggest a chronic meningitis, and thus he was transferred to our ward. In the bed next to him is a charming 84-year-old man who was admitted with dysphagia. There was talk of endoscopy but the cost is prohibitive, so instead we are waiting for his son to arrive from the village with money so that he can get a much more affordable barium swallow. In the mean time he is cared for by a wife and young daughter who can't be more than 10 years old. Their dress suggests that they are Muslim, and each time I see his daughter in the halls she smiles shyly and then kneels.

While there are few specialists, the team of physicians here is a tremendous resource. Some days I round with a Ugandan attending, but often I am alone with my team of a first year resident and the students. The providers that I lean on most are a mix of Ugandans (mostly PGs - i.e., residents) as well as the exceptional group of European and American doctors who are here. The extent of disease, decisions around testing in the face of limited resources, and the social and cultural aspects of care are both challenging and fascinating.

My evenings are often quiet and provide down time to relax, have a leisurely dinner, read, or turn in early. Tonight on my evening run I smiled as I was passed by four waving, knee-high children in school uniforms who were crammed on the back of a boda-boda (motorcycle), and I was struck by the mix of new and old traditions that coexist here. I passed a 2-inch wide ribbon of ants crossing the road and cows grazing in the pasture. Just adjacent was the golf course where a group of Ugandan men were teeing off and barefoot children played soccer with a ratty deflated ball. A woman sped by talking on her cell phone, and just minutes later I watched a woman who was learning to drive harmlessly careen off a gravel road into some hedges (hitting the accelerator instead of the brake!)

It is near 9:30 now and I'm ready to turn in.

Great Danes

For those in the Boston area, here's a find. Some friends introduced us yesterday to a place called the Danish Pastry House, which has been in business for about 4 years. While there is a cafe in Medford, we went to the bakery, a tiny place stuck in an industrial section of Watertown. A friendly sales assistant introduced us to the many items available, including those shown here: Whimsical marzipan frogs, the decadent Flodeboller, and the signature Kringle.

But the highlight for our group was the traditional Danish rye bread, Rugbrød, which you may have seen thinly sliced and served with a thin layer of smoked salmon. In our case, though, we had it sliced more thickly and covered it with a really thick layer of cream cheese upon arriving at home. The Danish Pastry House version has no preservatives, so you need to freeze the portion of the loaf you are not using right away -- that is, if there is a portion that remains to be saved.

One of those reminders

I learned today that one of the participants in the Mumbai-Goa fundraising bike ride on which I went a few weeks ago died shortly after his return home. He was only 44 years old and leaves behind a wife and a young son. (I do not include his name or picture here out of an abundance of caution with respect to privacy for his family.)

What a feeling of sadness this brings. Even in just a few short days, you can learn enough about someone to know that he was a very fine, gentle man with a big heart and a generous soul. Even now, I can remember his warm greetings before we set out each morning and then at the conclusion of each day's ride.

A ride like ours -- 330 miles over six intense days -- creates a kind of cocoon environment. Unexpectedly strong relationships emerge, friendships totally out of proportion to the actual amount of time spent together. You start by sharing a purpose and a cause, but it rapidly becomes a joint experience -- the discomfort of being in a strange place, the wonder of amazing scenery, the near misses of aggressive bus and truck drivers, many shared delicious meals and a few less appetizing ones, passing the warm water bucket for the end-of-day showers, caring for the ill and injured, and inside jokes -- and you evolve into a close-knit community, a team of people ready to jointly conquer the next hill.

As I have said about a totally different setting, "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." This young man gave himself wholeheartedly to all of us, and I am grateful to have had the chance to know him.

Please suggest an answer

In the last sentence of the post below, I posed a question. Probably, readers thought it was a rhetorical one and therefore did not submit answers.

But please treat it as a real one on which I am soliciting comments, OK?

Here it is, with the preceding sentence:

"We are causing people to die who should not die. What would we call that if we saw it happening in other sectors of society?"

Sorry, but I think it is important to draw out this point. Think about companies in the following industries and fields -- automobile manufacturing, airlines, restaurants, pharmaceuticals, food processing, architecture, public transit, building construction. Please give your answer below and tell us why the same term should not be applied to hospitals.

Good and bad news about infection control

I have been writing for some time about our efforts to eliminate central line infections in our hospital, and we have been totally transparent about our progress in that regard. While I know you can always look these things up, I want to make it easier for you and give you some advance news -- especially in light of the most recent results.

During the first four months of this fiscal year, a period covering about 7000 patient days, we had only one CLI in our intensive care units. This represents a tremendous effort by dozens and dozens of staff people.

In early 2006, our hospital's rate of infections was about 2 per thousand ICU patient days. At that old rate, there would have been 14 infections during this same four-month period. Given a 12 to 25 percent mortality rate associated with such infections, 2 or 3 people would have died unnecessarily.

Do we need a better reason to engage in these programs?

Two years ago, I raised a question: "If I can post these rates for BIDMC, why can't people from other hospitals? ... I am seeking no competitive advantage here. This is an attempt to get past a culture of blame and litigation and persuade people that transparency works: Real-time public disclosure of key indicators like this ... can be mutually instructive and can help provide an incentive to all of us to do better."

Then, a short while ago, I asked the question in a more direct way, posing a challenge to all the Boston area hospitals to jointly engage in a program to eliminate these kinds of infections and share their progress with the public.

The response to my public and private entreaties in this realm has been silence -- from hospital professionals, from insurance executives who care about a transformation of this industry, and, indeed, from public advocacy groups who care about access to care and the quality of care delivered. Some observers attribute the medical profession's lack of engagement to an underlying fear of transparency. And yesterday, a world expert in this field, whose wisdom and advice I treasure, told me that he has come to accept gradual progress in quality and safety improvement, citing the kind of training doctors get, which does not emphasize these areas. That such a person has become content with gradual changes in the status quo is an indication of what it must be like to beat your head against this wall of recalcitrance for several decades.

My advantage, being without medical training and having had but a short tenure in this field, is that I retain a sense of outrage. Our collective failure to approach this problem using well established methods of process improvement -- including publication of current performance results -- represents a moral and ethical lapse by the clinical and administrative leadership of the medical establishment in this city. Why? Simply put, a profession that takes an oath to do no harm is, by inaction or incomplete action, doing harm. We are causing people to die who should not die. What would we call that if we saw it happening in other sectors of society?

Do you want the water?

A pause from hospital business to the "simple" matter of public health. A friend sent me this link telling the story of the arrival of fresh water to Boston in the mid-1800's. It was one of my favorite stories when I was in charge of the metropolitan area water and sewer system. It is so easy now to forget how the public provision of this essential commodity changed so much in the life of Bostonians, and how the community celebrated when the water arrived. There was a dramatic moment when Mayor Josiah Quincy yelled out, "Do you want the water?" and the people responded, "Yes!" and a fountain erupted in the Boston Common.

View, in contrast, these pictures of women in an Indian village on the Konkan Coast picking up their daily supply of water from the village tap. Surely, a priority for local governments and for US aid to other countries should be the provision of this kind of basic infrastructure, but it is often neglected.

Is this the free part, or the fair part?

On January 27, 2009, the SEIU, the Area Trades Council, and Caritas Christi announced that they had signed an agreement for "free and fair" union election procedures at the hospitals in the CC system. Here's an excerpt from the joint press release:

Caritas Christi, known for delivering world class care in community settings, has reaffirmed the system’s commitment to patients, caregivers, the community, and Catholic Social Teachings by pledging without reservation that Caritas will allow free and fair voting conditions for its employees when they are deciding whether to form unions.

One of the union leaders said, "Caritas management and workers should both be commended for choosing a more enlightened path of labor relations, one that is based on shared values and mutual respect.”

Well, now I've had a chance to read the actual agreement. (No, I couldn't find it on the hospital system's website.) Here's an excerpt from the Standard of Conduct section, covering the period during which an election is pending:

The parties agree that the question of whether workers should be represented by the Union is one that the workers should answer for themselves. Except for the agreed-upon public announcements and language attached hereto as Attachment 1 [click on copy above to read it] to be handed out by managers on mutually agreed upon cards only when asked a question about unionization, no Employer officer, manager, supervisor, designee or agent shall make any comment, directly or indirectly, on this question.

In my view, this is a gag order, straight and simple. I am not sure if the prohibition covers only comments made in the hospitals, or if it also covers conversations that people might have outside the hospitals, in the grocery store, at the local pub, at a kids soccer game, or elsewhere. But, even if it only applies in hospital settings, it is unsettling. In their zeal to prevent any possibility of bad behavior by a supervisor, the parties have taken away the right of free speech on this topic from an important and engaged constituency in the hospitals. This does not feel like "shared values and mutual respect" to me.

In contrast, read this language and the other terms from the Code of Conduct adopted by our Board of Directors:

BIDMC has a strong commitment to its mission of community service in providing excellent clinical care, conducting medical research, and training future generations of medical professionals. As an academic medical center and prominent member of the corporate and civic communities, BIDMC is committed to an environment of respectful and open discourse and debate among its management, employees and physicians. It is of the utmost concern to the Board of Directors that this fair and unhindered exchange of points of view is maintained and supported during all times, including any attempt by unions to organize staff at BIDMC.

How was your visit?

A couple of years ago, I wrote about our use of mystery shoppers to evaluate how well we provide service in our ambulatory clinics. (You can also read more about it in this Boston Globe story by Liz Kowalczyk.)

Now, we are going the next step, not only conducting surveys of patients about their experiences in our clinics, but posting the survey results in those very same clinics. A portion of the survey is shown above. You will see three particular questions highlighted (just here, not on the actual survey). Those are the ones about which we receive the most complaints.

You also see above a mock-up of the kind of poster that will be prominently displayed in each waiting room, showing the performance results of that clinic for all to see. We believe this is part of "putting ourselves under the microscope." We have aspirations, not only to have an incredibly safe hospital, but also to rank highest in patient satisfaction in the country. We believe that you cannot achieve aspirations like this unless you hold yourself accountable by being transparent with regard to your progress.

I'd love to get comments from others out there, whether in hospitals or other businesses, as to whether you have tried this and what you have learned from it.

P.S. The mystery shoppers are still at work. We never stop learning from them.

Join Michelle today for an online chat

Join in from 12 p.m. - 1 p.m. Michelle George, MS, Health Educator/Family and Life Educator, will answer your questions on a variety of subjects related to relationships, stress, and communication. Click here to join.

Michelle is a health and family educator. She is responsible for delivering and implementing employee wellness programs throughout the BIDMC community. She has developed and lectured on a wide-variety of wellness programs such as stress management, parenting techniques, conflict resolution, and time management.

At the Hong Kong Eatery

A cell phone picture, through steamy windows, of poultry at the Hong Kong Eatery on Harrison Avenue in Boston. Leftovers available at our house . . .

More tales from Honora in Uganda

Some more stories from Honora Englander, a young American doctor in Uganda:

It has been a good week here – I've settled in well, and the shared routine and language of medicine, ward rounds, and patient care between the US and East Africa makes it surprisingly easy to connect with new people and fit into a familiar routine.

The structure of the day is where the familiarity ends, as the cases on the wards are markedly different from what we see at home. I am seeing cases of brucellosis, TB peritonitis with lymphatic enlargement enough to cause surgical bowel obstruction, severe malaria causing whopping cardiac murmurs, and profound malnutrition in the setting of chronic infection. I've been quite impressed with the students and the residents – eager, smart, and curious. And it is such a pleasure to get to learn together and to get to know them.

Yesterday I invited the students on my ward team to lunch after rounds. 8 in total – 1 man and 7 women – joined me for lunch just off campus. Initially conversation jumped from hobbies (they enjoy novels, tennis, the TV series "24," and laughing) to family to Obama and Africa's high hopes for him. The women uniformly described Obama as both inspiring and very handsome. They laughed when I heartily agreed, and one woman quickly offered me marriage to her brother, who looks "just like him."

Conversation turned to questions about details of medical education in the US, presumably in part because so many of them hope to someday practice outside of Uganda. "How many years of school it takes to be a doctor in the US?" "What the training is like?" "What diseases do you see? Do you see much HIV?" One particularly sharp young woman, Marjorie, asked me my thoughts on why HIV is so rampant here. Though national statistics quote 6% prevalence, my estimate is that at our referral center, roughly half of the patients on the wards have HIV.

"Why has AIDS spread so much in Uganda?" she wanted to know. "What do you do differently in your country that you see so few cases?" We were towards the end of lunch, and the group had a 2PM lecture, so Marjorie and I continued as we walked back towards campus. Briefly, we touched on politics and policy, education and culture. "Do you think literacy level could affect someone's risk of HIV?" she asked.

We talked about the role of women in society, and she described what I have heard expressed repeatedly in different ways both here, in Kampala, and in Eldoret; if a man marries a woman, his father and brothers also have the right to "use the woman." She wondered if teaching people about the risks associated with this practice would help; I wondered if this is so much a part of people's culture, can society "teach it" out of them? We talked a bit about prevalence, and I was amazed to hear Marjorie quote HIV prevalence of 70% amongst students at MUST (Mbarara University of Science and Technology). I couldn't (and still don't) believe the numbers are nearly that high, but she quoted a recent study whereby they screened blood donors from the university. After that, the newspapers reported 70% of students are infected. When I asked if she knows students who are open about their HIV status, she reported: "Definitely not. Too much stigma." But she explained that in the dorms she sometimes sees ARV pill pack wrappers in the trash, and that she knows that there are students who hide their HIV status.

I explored some of these ideas further with a group of students in the first Art of Medicine today. Earlier in the week I was introduced to Dr. Maling, a faculty member in Psychiatry who is getting a masters in medical education and who is doing his thesis about stress amongst healthcare workers. We share common interests, and he was eager to have me hold Art of Medicine discussions – case-based discussions focusing on the nonclinical aspects of doctoring – with his psychiatry students. He also asked that I hold a session with his own team of doctors, nurses and support staff. During today's Art of Medicine we talked about the case of a student who feared getting a needle stick from a delirious patient with HIV. Many of the themes that I have heard in the past when discussing this case surfaced. Student expressed worry that patients might be vindictive towards doctors and try to infect them, they said that caring for dying patients with HIV reminds them of their own family members who have died from HIV ("every family has someone who has died of HIV"), and described a collective sense that there is tremendous stigma against HIV, both within and outside of the medical community.

New in this discussion compared with past years was that students talked about the role of the church, both in promoting education and affecting stigma. Some students blamed the church for stigma, explaining Uganda is a religious country, and that the church suggests that people with HIV are sinners. They explained that the church supports "A" and "B" (abstinence and "be faithful") but not "C" (condoms). This is so embedded in the culture that people are ashamed to buy condoms. One student said that if he were to buy condoms, people would think he had HIV or was very promiscuous. Other students argued in support of the church's stance, saying that the church has a role to promote morals, and that it is their duty to speak out against premarital sex. They felt it was okay to ignore or even shun condom use because a married couple that is faithful won't get HIV. It was a hot debate.

At one point, I started to get uneasy, watching the passionate opinions in the room and remembering the quote of 70%. Though the number is likely exaggerated, certainly there might be HIV+ students in the room who could feel uneasy. In general, I try to anticipate this by introducing each session with notice that the conversation can often engender strong feelings, and I try to give people the choice to opt in or out, but one never knows for sure what people are feeling. I asked the students what they thought about the 70% statistic that I had been quoted, and the room erupted with shouts of disagreement. They too had heard this number before, and most vehemently disagreed with it. One student explained – "That is the press. A dog might bight a man, but the press will report that a man bit a dog to sell papers." One woman, however, pointed out that the strong reaction in the group suggested fear amongst the students.

Numbers aside, we continued talking, assuming and acknowledging that HIV exists within the student community. This shifted the tone some, and students were slightly less confident about their assumptions of right and wrong, culpable and innocent. One person raised a comparison between having HIV and malaria, and I challenged them to consider how it might be if HIV shared no more stigma than malaria. They agreed with me when I posited that anyone is at risk for HIV, that we've all made choices we regret or had lapses in best judgment, and that their family members and friends who have died are no more sinful than those who have suffered from malaria. Still, as they continued talking, they quickly switched back to language of blame, suggesting that it was a stretch to let go of the stigma that is so deeply embedded in their community.

Uganda has been praised as a leader in Africa in its efforts to raise awareness and be forthcoming about HIV/AIDS. When, as late as the early 2000s the South African government was denying that HIV causes AIDS, Uganda was promoting AIDS education throughout the country. And yet still, on the wards we say NYY (No-Yes-Yes for HIV+, as compared to NYN (HIV-) or NYU (unknown serostatus)) and nobody uses the word HIV with patients. Still, the stigma is so entrenched. I feel hopeful by the voices that respond openly when asked to question this, and I continue to believe that there is a role for open discussion of these issues, both as a way of changing attitudes and improving health care here.

Though all of this may sound a bit overwhelming and grim at times, being here is fascinating, rich, and often quite fun. This morning on my run I smiled as I was passed by a boda-boda (motorcycle) with one driver and 4 small children on the seat. They were dressed in school uniforms and smiling, clinging to one another on their way to school. The countryside is beautiful and I have had quiet evenings to read medicine or unwind. I am happy to be here and am so grateful for the experience.

More help from Monique

It has been several months since I wrote about Monique Doyle Spencer's campaign to inform people of how the application of henna has helped her and others ameliorate the effects of hand foot syndrome caused by the anti-cancer drug Xeloda. Today, she writes: "I am finding that people need a simpler sheet of instructions, so here's a new PDF for your use." You can also find it on her blog.

Celebrating Partnership

Yesterday we celebrated the designation of two of our folks as members of the new class of Boston Associates of The Partnership, Inc. They are Earl Stephen, Practice Administrator in our Labor and Delivery section, and Wayne Rhymer, Clinical Lab Control Manager in our Pathology Department. Beyond demonstrating great managerial expertise and potential at BIDMC, these two gentlemen are deeply involved in community activities -- Earl with coaching and directing a youth basketball league, and Wayne with mentoring a young boys group and helping the Children's Choir at his church.

This is a year-long leadership development program for professionals of color. Wayne and Earl have been placed in small groups called "pods", with about eight people per group. The Associates program has about 70 people from organizations all around Boston. They go through workshops both in pods and also in the larger group. Here is a sampling of the workshops:

• Leadership Assessment Experience
• The Efficacy Experience
• Coaching Sessions
• Your Personal Brand: Tools for Optimizing Strengths and Attributes
• Masterful Mentoring - Best Practices for Being Mentored
• Influence Skills and Strategies
• Strengthening Personal and Professional Connections
• The "Partnership" Workshop - Understanding Partnerships & Organizational Life
• Strategic Development Forum
• Leadership Presence

Glad to be an alumnus

Thanks to Professor Ernst Berndt for inviting me to address his class, "Economics of the Health Care Industries," at MIT's Sloan School of Management tonight. There were lots of great questions from the group of graduate and undergraduate students. In fact, the level of questioning made me thankful that I went to college years ago and did not have to compete against this group for admission to the 'Tute!

When you have a hammer . . .

MIT's Steve Spear makes the point again. "We can provide much better care to many more people than we currently do at less cost and with less strain on providers." How? By engaging in a real effort to reduce harm to patients by redesigning the work flow and patterns in America's hospitals.

Why do so many observers insist, in contrast, that changes in the reimbursement system or other structural changes in the health care industry are the answer? Well, if you are an insurance company or public agency payor and have the "hammer" of insurance rate design, every problem looks like a "nail." You seek to influence behavior with the tool at hand.

If you are an employer and have the "hammer" of plan redesign, every problem looks like your kind of "nail"-- raising co-pays and reducing benefits.

Meanwhile, if you are a union, your solution is to lobby the government for an increase in costs. When you have the "hammer'" of thousands of members, you use your accumulated union dues to engage in a public relations campaign and the implied power of that constituency to pound the legislative "nail."

Doctors, nurses, and hospital administrators know that these methods are crude and poorly constructed to solve underlying problems. For the most part, they mainly shift risk and costs.

Yet, who can blame the others for their attempts to use the tools they have, when the health care professions have abdicated their role in solving the cost problem? The solution, as Spear notes, is literally in the hands of the very people who deliver care.

Honora is back in Africa

My friend, Dr. Honora Englander, is on assignment again in Uganda. She always has wonderful observations and has given me permission to share them with you. Here are excerpts.

Dear friends and family,

I am sitting on the veranda in front of the guesthouse where I am staying. Hibiscus flowers are blooming all around me, there are beautiful iridescent blue birds chattering and darting from tree to tree, and there are couplets of butterflies meandering from one long blade of grass to the next. The sun feels great on my pale skin, and I am so glad to be back in Africa.

Yesterday was quite a day – I couldn't have asked for a better introduction to Mbarara, or at least the mzungu part of life here. I woke early, still in Entebbe having just arrived the night prior. Despite being exhausted, I was unable to sleep much of the night; tossing and turning due to a whole mix of anticipation and excitement, jet lag, and lingering worries about parts of life at home that are starting to feel continents away.

I arrived in the lobby of my hotel to meet my ride that was slated to come at 8AM. Imagining that 8AM would be much closer to 9 (as it was), I was happy to start up a conversation with the bellhop, a man named Robert who I soon learned is 34 years old and used to work in animal conservation but lost his job; for the last year he has worked at the hotel several hours by bus west of his home. Our conversation started with small talk – family, work, geography – but ended up where many conversations with strangers here do, centering around the AIDS epidemic and people's thoughts on the matter.

Robert is from a small village outside of Jinja in Eastern Uganda and is one of twelve or thirteen children, however his father had two wives, he explained. He is married with two children. I asked if he plans on having more wives, and he explained that he only wants one. He explained that he prefers one wife because he doesn't want to create a situation of jealousy between two women, and he worries about costs of supporting two families. He also prefers to love just one woman – for now at least, unless his wife misbehaves, he explained. I asked if he thought that the AIDS epidemic has played in at all to what seems to be a cultural shift from largely polygamous families to a trend towards monogamous marriage.

On the airplane I started reading a book by Helen Epstein called The Invisible Cure that references work suggesting that the high prevalence of concurrent relationships (i.e., polygamy or multiple concurrent long-term partners) and not promiscuity or other high risk behaviors, may explain the rapid spread of HIV in East and Southern Africa compared with the rest of the world. I am intrigued by this idea, which is supported by epidemiological and mathematical models, and was curious to learn more about cultural shifts from my new friend.

Robert didn't have much to say about whether AIDS is affecting marriage practice; he said monogamy is praised in church, but didn't say much else. He was, however, emphatic about the progress being made around HIV, and expressed a sense that AIDS can be a chronic disease and how people can live for so many years. He told me about AIDS education in the schools, and that though people may be reluctant to be tested, he thinks that that they overcome their fear and are getting tested. He explained how several years ago, he convinced both of his parents to be tested for HIV. He did so somewhat strategically and cautiously, first approaching his mother during a visit to the village. He explained that since she had given him the luxury of an education, it was now his duty to share what he had learned with her and that she should be tested for HIV. He even brought her a home HIV test, though recommended that she go to a testing center where she could get HIV counseling and subsequent testing. His father, he explained, was even trickier to cajole, but he too accepted. Both were tested, and were negative.

There was a moment in my conversation with Robert where I was struck by what seemed in one breath astonishing, and another so obvious. Over his lifetime, AIDS has changed so dramatically – it went from being unrecognized to rampant and shockingly devastating. In the past I have been suspicious of the reported lower rates of incidence, but he seemed to think both prevalence and incidence are coming down. My conversation with Robert suggested that amongst some lay people, there is a sense that Uganda is gaining in efforts to curb devastation caused by AIDS and in efforts to educate and promote testing. I was also somewhat amazed by his sense that HIV is can be a chronic disease, not because I disagree but because I hadn't heard that expressed here in the same way before. In my conversations, mostly with East African medical students, and in my own exposure here, we are so biased by seeing AIDS mostly in the hospital, where people's chances of survival often seem so grim.

Minutes before 9, a near bus-sized van with Mbarara University of Science and Technology arrived. Inside was a driver and two of his friends, and we were off, heading west through bumpy roads rust colored, verdant countryside and heavy rainclouds.

I made a quick trip into town, but the remainder of the day consisted of long conversations that meandered between lighthearted and fun and thoughtful and reflective, sharing a glass of wine or two as the evening creeped on. Though I am just meeting people, my sense is that this is such a special group of people – there are clinicians, researchers, volunteers and spouses, and each persons work and interests range from clinical medicine and education to PhD work around issues of trust and disease prevalence, fee-for-service vs. capitation payment models in Uganda, and cell phone use for dissemination of health information. Thus far, I have been so impressed with the maturity, understanding, generosity and kindness of this crowd. I feel so lucky to have landed here and to be welcomed with such open arms.

So, it's been a great start and I am eager to start on the wards tomorrow.

Missed calls

In light of the piece below, and stimulated by warm weather today to believe that soccer season may actually start within several weeks, I post for your amusement the following story that has made the rounds of the soccer referees' listserves:

At the end of a game, the referee was making his way to the parking lot when he heard a voice calling him in an urgent manner. "Hey, ref!".

Turning around he nervously noted one of the coaches approaching him. "Yes?" he replied, anxiously.

"I have your cell phone," said the coach, holding the phone out to him.

"How do you know it's mine?" he asked.

"Look! It says '10 missed calls'!"

Someone make me stop!

No, I am not asking the SEIU to have me stop writing about its use of corporate campaigns or its desire to eliminate secret ballot elections. No, I am not asking other hospitals in Boston to have me stop writing about transparency and reducing patient harm.

I am asking someone to make me stop talking on my cell phone while driving. I will admit that I am Jessica Lipnack's "one friend". I know the evidence is overwhelming that people are distracted and even have a lower effective IQ when talking on a cell phone while driving.

I remember a Boston Coach limo driver telling me that they are trained to look in their rear-view mirrors to see if the driver behind is on a cell phone. If so, they take extra precautions to avoid be rear-ended by the distracted driver. He said, "It our major cause of accidents."

But the Boston Globe editorial writers have it wrong when they say: "Cellphone use at the wheel is almost an addiction." Not almost. Is.

I do not use the phone because the business or personal purpose is urgent. In fact, just the opposite. I usually do it to fill the time.

I am reminded of teenagers I see in the mall or walking along the street who can not abide the thought of having quiet time in their head. They have to fill the void by calling their friends. Me, too.

I've tried turning on the car radio and listening to music. But it soon goes into the background. Ditto for the news. After all, it is pretty much the same thing all the time. So, let's use the "spare time" to catch up with friends or with staff members, just to check in or to say something I forgot to mention last time we were together.

If you are a friend or colleague who detects that I am talking with you on a mobile phone while driving, please hang up on me.

But we need more than that. Please, Governor Patrick and MA legislators. Pass a law with real penalties. Catch me in the act, and make me stop. And, while you are at it, stop everyone else, too.

Sweet Baby James

Thanks to Movin' Meat for a great reminder.