Leaning together in North Carolina

Here's a heartening story from Alexandra Wilson Picci at HealthLeaders Media, entitled "NC Rural Hospitals Lean Together to Zap Waste."  An excerpt:

With the help of the North Carolina Hospital Association, a consulting firm, and a grant from the Duke Endowment, Caldwell Memorial Hospital teamed with four other hospitals to learn how to apply lean management principles. The hospitals shared ideas and resources, including funding and consulting services, and attended each other's learning events.

This is a great way to mitigate the expenses of a Lean program and share the enthusiasm.  As you have seen in examples on this blog, a portion of the Lean approach consists of rapid improvement events.  These focus on specific value streams within the organization, mapping out the entire work flow, identifying areas of waste, and experimenting with a new process. Here's a wonderful quote about how this kind of employee engagement works:

"It's remarkable to watch employees sit down and map out issues and discover possible solutions in a team environment and then have the wherewithal and the authority to implement these changes and see if they work," said Edgar Haywood III, president and CEO at Dosher Memorial Hospital, which is part of the new Eastern North Carolina Rural Hospital Lean Collaborative.  

Caldwell Memorial CEO Laura Easton added a key point:

"This is not something that you can delegate to one of your executives," she said. "I think Lean is only really appropriate if the CEO is committed to changing the way they operate the organization, and learning too, and being part of running their organization in a new and different way."

She is right, of course. As I have noted, like physical systems in which entropy takes over, consistently applied energy is necessary to maintain the process improvement system that we call Lean.  Without commitment from the top, the process will wither.  Congratulations to this group of CEOs for walking the walk.

Harvard medical residents are stupid

There, that got your attention.

Obviously they are not all stupid.

Just the ones who ride their bicycles in the Longwood area without wearing helmets.

And especially the ones who wear dark clothes at night while riding without a helmet.

But extra especially the one who was wearing dark clothes at night while riding without a helmet, while texting.

Do you know what we call these people?

Organ donors.

Hadassah and Panama

Hadassah's Dr. Miklosh Bala

An excellent example of international health care cooperation is evident in Panama City this week, where Hadassah Panama is hosting a seminar in trauma medicine at Hospital Santo Tomas.  Hadassah Hospital in Jerusalem has sent over experts in the field to provide a focused curriculum for Panamanian doctors and nurses.  In addition, those clinicians will spend time in the emergency room and wards, working side by side with local doctors and nurse to compare protocols and real-time delivery of care.

This is the fourth year this program has been run.  Clinicians from hospitals throughout the country have found value in these sessions.  Over 700 doctors and nurses attended the first session in 2007, a rate that has persisted each year. 

What's going on at Parkland Memorial Hospital?

A series of stories at the Dallas Morning News raised some serious questions about the quality of care at Parkland Memorial Hospital.  I draw no judgments about those issues.  But what comes across in these stories is something equally interesting:  A hospital that has chosen to take a hard line, dare I say stonewall, with the local press on issues of community concern.  In an era of increasing transparency, this approach is an anachronism.

Those of us a certain generation remember Parkland Memorial as the site of President Kennedy's trauma treatment and death in 1963, providing it an important symbol of high level care in our national consciousness.  But it is also a major teaching facility of the UT Southwestern Medical Center and is prominent in its own right for many reasons.

When a hospital with this kind of affection and reputation faces difficulties in the delivery of care, there are two possible approaches.  One is to be open and transparent about the nature of the problems, their causes, and the solutions being tried.  That approach is consistent with the high level of trust granted by the community.  The other approach is to hunker down and draw on powerful interests in the community to put pressure on journalists to back off from the story.  That may work for a while, but eventually fails, with an even greater loss of trust that would have been thought possible at the start.

It looks like Parkland has engaged in the latter kind of campaign.  The phases are disturbingly familiar.  After some highly visible cases, including stories of a patient care system heavily dependent on residents who sometimes work with little or no faculty supervision, federal regulators warned that failures in care at Parkland Memorial Hospital posed “an immediate and serious threat to patient health and safety,” and ordered it to submit a plan to remedy the problems within two weeks or lose federal funding.  The hospital administration described the report "as a collection of mainly 'technical violations.'"(Full story here.)

Meanwhile, conflicting explanations to the press emerge.  Here is an excerpt on a medical student issue:

Newly obtained records contradict UT Southwestern Medical Center's claims about unlicensed med students who were paid to work in Parkland Memorial Hospital's psychiatric ER -- and why the 30-year cost-saving practice ended this summer.

UTSW spokesman Tim Doke previously told me that the students were "administrative assistants" who "do absolutely no clinical, patient-care work" and had no formal job description. He also insisted I was misinterpreting a 2009 letter from four UTSW psychiatry professors that repeatedly called the students "clinicians" and never "administrative assistants."

But now a Texas Public Information Act request, filed right after we brought the unusual employment practice to light in June, has forced UTSW to release the students' job description. It says the students "provide experienced help" in Parkland's psychiatric ER -- they obtain the patient's history, perform a "brief neurologic exam" and "periodically assess patients."

  

Think about this.  The press was forced to file a freedom on information request to obtain job descriptions of students.  In fact, the hospital sued the Attorney General to challenge rulings that required this and other kinds of information to be provided. This is clearly a situation that has spun out of control.

Prominent members of the community have publicly come to the defense of the hospital.  Staff from UT Southwestern Medical Center asserted that the newspaper has a "vendetta" against the school and its teaching partner, Parkland.  Also, the hospital has retaliated against the newspaper by removing its advertisements. This is the kind of nasty local politics that eventually backfires.

I don't know where this is all headed, but given Parkland Memorial's place in the country's consciousness, the next stage has to be the national media.  What a shame that the hospital's return to the national scene will be about these kinds of issues.  Wouldn't it be marvelous if it adopted a truly transparent approach to the problems and instead became a national example of that philosophy?

Free up the data, Commissioner

The Governor of Massachusetts has made an excellent choice for the new Commissioner of the Division of Health Care Finance and Policy.  He is attorney Áron Boros, who comes to DHCFP after serving as director of federal finance for the state’s Medicaid office since 2008.  Prior to working for MassHealth, Boros was an associate at the Boston law firm Foley Hoag LLP, where he worked with health care clients on a wide variety of issues.  His work included initiatives related to chronic disease management, health information technology, and evidence-based medicine.  His first day at DHCFP will be Sept. 15.

Let's hope that Mr. Boros makes good on the promises of his predecessor.  Under state legislation, the DHCFP has been assembling an all-payer claims database (APCD). It comprises medical claims, dental claims, pharmacy claims, and information from member eligibility files, provider files, and product files. It includes fully-insured, self-insured, Medicare, and Medicaid data and clear definitions of insurance coverage (covered services, group size, premiums, co-pays, deductibles) and carrier-supplied provider directories.

The existence of this database offers the potential for all parties to study the actual transactions taking place in the Massachusetts health care system.  It permits testing of hypotheses with regard to payment models, clinical affiliations, and a variety of other pertinent matters with regard to the state's health care policy agenda.  Because Massachusetts took the national lead with regard to health care reform, it also offers potential value to the country as a whole.

But transparency only works if the data are made available to all and easily so.  The previous commissioner made this promise over a year ago:  "That the database would be widely accessible, so that independent researchers, policy analysts, advocates, market participants, and others would be able to manipulate it to test hypotheses and assumptions."

Here is what the current regulations (114.5 CMR 22.00: Health Care Claims Data Release) say about getting this data:

22.03: Procedures for Data Requests
(1) Public and Restricted Use Files. The Division will create Claims Data Public Use Files and Restricted Use Files to which Applicants may request access in accordance with 114.5 CMR 22.03(2).

(2) Application Review Procedures. 

(a) Applications for Data.
1. All Applicants must submit a written application. Each Applicant shall:
a. specify the data requested, including Public Use Files and any restricted data elements requested; 

b. specify the purpose and intended use of the data requested, including a detailed project description that describes any other data sources to be used for the project;
c. specify security and privacy measures that will be taken in order to safeguard patient privacy and to prevent unauthorized access to or use of such data; 

d. specify the Applicant's methodology for maintaining data integrity and accuracy;
e. describe how the results of the Applicant’s analysis will be published;

f. agree to provide the results of all analyses, research, or other product of the data requested to the Division for the Division’s own use;
g. agree to the data disclosure restrictions in 114.5 CMR 22.04; and 

h. obtain prior approval from the Division to release any reports that used restricted use files prior to publication or other release.

Obviously, protection of patient privacy is important and required by statute, but several of the other requirements here are not.  Truly, this is "old style" government.  Say I am an academic researcher, exploring multiple hypotheses related to payments or clinical care management.  Why should I have to tell the state what other data sources I plan to use?  Why should I describe how the results will be published?  (Indeed, I probably cannot, in that my work may have to go through levels of peer review at multiple journals.)  For public use files, rather than restricted files, why should there be a need for any application at all?  I fear that these requirements act as an effective bar on public inquiry, well beyond that intended by the Legislature.

But maybe I am over-reacting.  I would love to be proven wrong.  Here's a test to see whether my concerns are valid.  This is the most comprehensive data set in the state on this topic, in a state filled with public policy researchers at multiple academic institutions and NGOs.  How many applications for data have been received since the regulations were adopted in July of 2010?  How many have been approved?  For the ones not approved, what reasons were given?

Eugene Eisenmann's living memorial

At the time of his death in 1981, the New York Times reported that Eugene Eisenmann was trained as a lawyer. He received his law degree from Harvard University in 1930 and was a partner in the New York City law firm of Proskauer Rose & Paskus until 1957, but he had a lifelong interest in bird studies. He became a leading ornithologist and a research associate in the department of ornithology at the American Museum of Natural History since 1957.  He was active in bird conservation and the author of the book ''The Species of Middle American Birds,'' a checklist of more than 1,400 species, and coauthor of ''The Species of Birds of South America.''

The Fundación Avifauna Eugene Eisenmann was created in his memory, with the objective of conserving the 1000 species of birds that reside and pass through Panama.  They created the Panama Rainforest Discovery Center as an ecotourism and environmental education project.  The centers has forty meter observation tower, constructed from recycled materials, that permits you to view various levels of the forest, and also a nice set of trails to view things at ground level.  There is an incredible diversity of flora and fauna.

Eugene was a kind, gentle, and thoughtful man, whom I remember well from my childhood in New York City.  I think he would have been pleased with this living memorial in Panama.  Even though he never lived in the country, his family history was centered there, as were his avocational ornithological interests.  As he never married, it is well that there is this kind of legacy in his honor.

(Here's the geneological link:  Eugene was the son of Esther Maduro Brandon, daughter of my great-grandparents, David Henry Brandon and Judith Piza Maduro -- making him my first cousin, once removed.  You may recall David as being the founder of the volunteer fire department in Panama City around the turn of the century.  The postage stamp issued in his honor is to the right.)

But back to Eugene's memorial park -- see how these family connections suck you in when you visit your ancestral homeland! -- if you would like to see more images from the Rainforest Discovery Center, click on this link to my Facebook album.  In the meantime, enjoy the ants in this video below.

(If you cannot see the video click here.)

Piva satisfies

It was August of 1967, and my great-uncle Elias Alvin ("Bill") Fidanque (the family geneologist) was giving me a walking tour of the old section of Panama City. We walked past a vendor, and Bill bought some interesting orange-colored nut-like things.  "Try it," he said, as he demonstrated the technique for eating piva (pronounced pee-vie for some odd reason).  These are starchy nuts from a palm tree -- Bactris gasipaes -- that are boiled in salt water and served at room temperature.

They are probably terrible for you, full of high cholesterol palm oil and an incredible number of calories per cubic centimeter (1000 per fruit), but they are delicious, especially if you add -- to make things even worse! -- mayonnaise.  This week at dinner at Bill's nephew's house in Panama City, I helped finish off the ones that had been prepared as appetizers that way, leaving uneaten these that were served with a touch of jelly.

The Infrastructure Chronicles -- Volume 11

There is a lot to be said about the history of the Panama Canal, a concept that piqued people's imagination almost as soon as the Europeans landed on the isthmus in 1501.  The first serious attempt to dig a canal was led by Ferdinand de Lesseps (honored here in a memorial in the Plaza de Francia in Panama City), who had successfully built the Suez Canal; but this was a different task altogether.  He was stymied by disease, the difficulty of construction, and a failure to secure (from the recalcitrant American owner of the trans-Isthmian railroad) or build an effective railroad link to carry workers, material, and supplies to and from the interior of the country.

After the French gave up, an American team began and ultimately had greater success.  First, though, they had to deal with Colombia, the owner of Panama, which refused to give America a franchise to build.  President Teddy Roosevelt, in a classic move of imperialism and practicality, helped Panama declare its independence from Colombia in 1903.  Shortly thereafter, the new government authorized French businessman Philippe Bunau-Varilla, to negotiate a treaty with the United States. The Hay-Bunau-Varilla Treaty allowed the U.S. to build the Panama Canal and provided for perpetual control of a zone five-miles wide on either side of the canal, creating the political and institutional framework for a successful project.  It was completed in 1914.

Plaque in Plaza de Francia

Plaque on Ancon Hill

Decades later, President Jimmy Carter decided it was time -- in part because of anti-American sentiment -- to divest American interests in the canal and transfer the canal and the Canal Zone to Panama.  A treaty was signed in 1977 which set forth the framework for the ownership and operational transition.  This was controversial in the American Senate, passing by split votes in both political parties.

(The first day cover below is of the last postage stamp issued by the Canal Zone, in 1978.)

From the collection of Henry Fidanque

Full Panamanian control occurred on December 31, 1999.  Notably, still feeling the pressure of American mixed sentiment, President Clinton did not attend the turning-over ceremony a couple of weeks before, nor did he send any high-ranking American officials to share the podium with the leader of Panama.  An assistant secretary of the Army represented the US in handing over billions of dollars in assets to Panama.

However, there remained an underlying design problem in the canal, the inability of the new generation of larger ships to fit through the locks, requiring containers to be unloaded at one end of the canal, transported by railroad (see below), and reloaded on the other coast.

Likewise, oil shipments are sent via pipeline from tankers in one ocean to those in the other.  But that is about to change.

The New York Times recently ran this story about the construction project to widen the Panama Canal.  Here's an excerpt:

COCOLÍ, Panama — For now, the future of global shipping is little more than a hole in the ground here, just a short distance from the Pacific Ocean. Ah, but what a hole it is.

About a mile long, several hundred feet wide and more than 100 feet deep, the excavation is an initial step in the building of a larger set of locks for the Panama Canal that should double the amount of goods that can pass through it each year.

The $5.25 billion project, scheduled for completion in 2014, is the first expansion in the history of the century-old shortcut between the Atlantic and Pacific. By allowing much bigger container ships and other cargo vessels to easily reach the Eastern United States, it will alter patterns of trade and put pressure on East and Gulf Coast ports like Savannah, Ga., and New Orleans to deepen harbors and expand cargo-handling facilities.

I was given a tour of the construction site today, and it is indeed a spectacular project.  Here's a short video:



If you can't see the video click here.  You can read more about the project here and see some images from the tour here on Facebook.

Future site of third set of locks, Pacific side

Must be high profit items

A friend received this phone call four times in the past week, at various times of the day and night:

This is CVS pharmacy.  Allergy season is rapidly approaching. It is important to be prepared for the season to prevent the onset of symptoms.  Please contact your local CVS pharmacist for the many ways we can help.  For guidance on the upcoming allergy season, please call the CVS pharmacy at . . .

Note that this is not a matter of patient adherence with prescriptions.  This is just out-and-out marketing based on a customer's previous purchases.

By the way, the friend didn't need to be reminded.  Fall allergy season is not approaching.  It has landed.

Using EHRs to wag the dog of corporate mergers

The New York Times reported this week that the Federal Trade Commission has raised concerns in Ohio and elsewhere about anti-competitive effects of mergers in the health care sector.  Those involved in the deals, though, state that the intent of the recent health care reform act was to enable and encourage such consolidation.

I covered this topic a year ago and then in November, predicting the arguments that would be used by the proponents, just as seen in the Times story:

Randy Oostra, the president of ProMedica, said the merger would benefit patients in many ways. “We could coordinate care,” Mr. Oostra said. “We could improve quality at St. Luke’s by adopting electronic health records and using clinical protocols to standardize the delivery of care. But the F.T.C. has stopped us in our tracks."

Of course, it is possible and desirable to coordinate care and improve quality even without creating behemoths of market power.  Corporate integration and common ownership is in no way a necessary condition for such improvements, whether the parties are non-profit or for-profit.  Requiring all electronic health record systems to be mutually compatible would also go a long way to ensuring that proprietary information systems do not become the tail that wags the dog of corporate consolidation.

The Hub of the Universe

Most humorous comment about yesterday's magnitude 5.8 Virginia-centered earthquake, from Boston's Peter Shelley on Facebook:

"For all my friends who are worried about me, I rode out the big quake at my desk.  It interrupted my afternoon nap."

Comment:  "Where are you?"

Reply:  "Home now, recuperating."

Comment:  "I hope you are feeling better."

Reply:  "Just a little shaken up.  It'll pass soon."

Classic Boston-centered headline (from Boston.com):

The Washington Post was nicely descriptive in its coverage:

The first warnings of the earthquake may have occurred at the National Zoo, where officials said some animals seemed to feel it coming before people did. The red ruffed lemurs began “alarm calling” a full 15 minutes before the quake hit, zoo spokeswoman Pamela Baker-Masson said. In the Great Ape House, Iris, an orangutan, let out a guttural holler 10 seconds before keepers felt the quake. The flamingos huddled together in the water seconds before people felt the rumbling. The rheas got excited. And the hooded mergansers — a kind of duck — dashed for the safety of the water.

For people, it was a lovely, sparkling day for an emergency evacuation. Much of the capital’s workforce had gathered on sidewalks by 2 p.m. The federal government later urged agencies to send non-emergency workers home.

The emperor remains unclothed

I guess I shouldn’t be surprised when two of the architects of the health care reform act write an op-ed that continues in the deception that the law would deliver access, choice, and lower costs.  But that is what Ezekiel Emanuel and Jeffrey Liebman offer in their New York Times article, “Cut Medicare, Help Patients.”

The authors start by saying some things that make a lot of sense.  They point out that it would be smart to “eliminate spending on medical test, treatments and procedures that don’t work -- or that cost significantly more than other treatments while delivering no better health outcomes . . . [and that} can be made without shortchanging patients.”

But they quickly give up that fight:  “The sad truth is, Washington is never going to do a good job of making smart cuts to Medicare.  Elected officials hate being blamed for directly restricting access to medical treatments -- even when those treatments are proven to be worthless.”

So then they revert to their underlying bias, er, theology:  “The responsibility for ending unnecessary medical spending needs to be placed in the hands of doctors and hospitals.  This can happen only if we change our fee-for-service payment system.”

How much damage is being done and how much time is being lost by our society by a religious belief in a payment scheme that has not been proven and that has many inherent difficulties?  As I have noted, not the least of the difficulties with capitation is in deciding the transfer payments among the different medical specialists.

And then to add salt to the wound, they say:

“These seeds of a solution lie in the accountable care organizations, medical homes and bundled payment reforms that were authorized by last year’s Affordable Care Act.”

As I have discussed, the ACO framework prescribed by Congress is inherently flawed because Congress could not and will not limit patient choice.  An ACO cannot manage patient care if there is a PPO structure in place, allowing patients to shift care not a non-ACO provider at will.  Meanwhile, the ACO framework also has risks of market concentration that are drawing the attention of federal antitrust regulators.

This whole discussion is incredibly painful to watch, especially when Emanuel (or was it his brother?) admitted privately during the Congressional debate on the ACA that the costs of providing universal insurance access were well above those that were being publicly projected, and that, ultimately, the US would be forced to pass a value added tax to cover the health benefits that were the result of the law.  What’s the chance of that during this political environment?

On this blog, I have talked about things that can work and that are within the power of Medicare to implement.  The most powerful would be to change the relative fees paid to primary care and other cognitive specialists, compared to proceduralists.  Giving a primary care doctor the ability to spend more than 18 minutes with a patient could change the nature of those doctors from having a triage function to allowing proper management of care.

Medicare can also engage in real clinical transparency, insisting on the publication of real-time information about infections and other important aspects of quality and safety as one of its Conditions for Participation.

But, we must also find fault with the nation’s doctors and hospital administrators who fail to lead process improvement in their institutions, even in the face of documented quality and safety enhancements and cost savings in exemplary hospitals.  Medical schools, too, have systematically failed to teach young doctors about the science of improving care delivery.

I have often asked the question, “What does it take?”, suggesting that a failure to proceed with such changes and to engage in full-hearted transparency is unethical behavior -- in the most fundamental sense -- on the part of the medical community.  As long as the medical profession fails to demonstrate its own ability to improve results and lower costs and engage in patient-driven care, you can count on officials in Washington and in other jurisdictions to offer prescriptions that simply will not work.  The resulting resentment and anger on the part of the profession then feeds a negative vicious cycle.

Time’s a-wasting, folks.  Let me make this very personal, and perhaps uncomfortable to some of my readers.  As e-Patient Dave likes to say, “Patient is not a third person word.”  We will all be patients some day.  What kind of system do you want in place when you are in the lying in the bed rather standing next to it, or when a loved-one is there?  Chances are that it is not the system that you are helping to run right now.  You can rationalize your inaction and compartmentalize your thinking all you want, but a failure by you -- if you are a medical or administrative professional -- to demand and lead improvement is, in fact, a deadly decision.

Peter Pronovost is a liar. He must be. Isn't he?

Peter Pronovost and his subversive friends are at it again.  Imagine, first they assert that implementation of a standard protocol and checklist could reduce the rate of central line associated bloodstream infections.

"It wouldn't work here.  Our patients are sicker."

Then, to make matters worse, they go and contend that reducing the rate of central line infections saves money.  Here's the abstract from the American Journal of Medical Quality:

This study calculates the costs and benefits of a patient safety program in intensive care units in 6 hospitals that were part of the Michigan Keystone ICU Patient Safety Program. On average, 29.9 catheter-related bloodstream infections and 18.0 cases of ventilator-associated pneumonia were averted per hospital on an annual basis. The average cost of the intervention is $3375 per infection averted, measured in 2007 dollars. The cost of the intervention is substantially less than estimates of the additional health care costs associated with these infections, which range from $12,208 to $56,167 per infection episode. These results do not take into account the additional effect of the Michigan Keystone program in terms of reducing cases of sepsis or its effects in terms of preventing mortality, improving teamwork, and reducing nurse turnover. 

"No, it can't work that way unless we get rid of fee-for-service payments and go to capitation.  We all know that nobody will act to reduce infections because they will get paid less."

And then he has the nerve to tell us that reporting of central line infections is highly variable across the United States.  Here's the abstract from that study, again from the AJMQ:

The authors searched state health department Web sites for publicly available CLABSI data. Fourteen states, all with mandatory CLABSI monitoring laws, had publicly available data. The authors identified significant variation in the presentation of infection rates, methods of risk adjustment, locations and care settings reported, time span of data collection, and time lag to reporting. The wide variation in availability and content of information illustrates the need for standardized CLABSI monitoring and reporting mechanisms.

"We'll publish our numbers in a real-time, standard way when we are good and ready, but our numbers are better than their numbers."

Eastern MA mushroom crop

At Broadmoor Wildlife Sanctuary in Natick

This has been an excellent growing season for mushrooms in Eastern Massachusetts, with lots of steamy warm weather.  They seem to pop up everywhere. I think Dr. John Halamka would tell me that these are all polypore mushrooms.  The one above was seen at the Massachusetts Audubon sanctuary in Natick.  The one below is growing out of a tree on Marshall Street in Brookline.

In Brookline

And the ones below, well, they are growing in my back door, which was poorly installed and wicked water into its core.  I think this is what is known as "Massachusetts grown . . . and fresher."  Pretty, but not enough for dinner.

On the back door

Decision Fatigue. For doctors, too?

This article by John Tierney in the New York Times suggests that humans suffer from decision fatigue, the tendency to make worse decisions as you make a series of hard decisions as the day goes along.  Here are some pertinent excerpts:

No matter how rational and high-minded you try to be, you can’t make decision after decision without paying a biological price. It’s different from ordinary physical fatigue — you’re not consciously aware of being tired — but you’re low on mental energy. The more choices you make throughout the day, the harder each one becomes for your brain, and eventually it looks for shortcuts, usually in either of two very different ways. One shortcut is to become reckless: to act impulsively instead of expending the energy to first think through the consequences. The other shortcut is the ultimate energy saver: do nothing. Instead of agonizing over decisions, avoid any choice. Ducking a decision often creates bigger problems in the long run, but for the moment, it eases the mental strain. You start to resist any change, any potentially risky move. 

Once you’re mentally depleted, you become reluctant to make trade-offs, which involve a particularly advanced and taxing form of decision making.

“Even the wisest people won’t make good choices when they’re not rested and their glucose is low,” Baumeister points out. That’s why the truly wise don’t restructure the company at 4 p.m. They don’t make major commitments during the cocktail hour. And if a decision must be made late in the day, they know not to do it on an empty stomach. “The best decision makers,” Baumeister says, “are the ones who know when not to trust themselves.” 

All of this led me to wonder whether there is any evidence that there is a higher rate of medical errors later in the day, after doctors have made dozens of decisions.  So, in tune with the times, I crowd-sourced the question, posing it this way on Twitter and Facebook:  "Query: Has anyone seen studies linking surgical error rate to the time of day?"

Bobby Ghaheri, MD (@DrGhaheri) tweeted, "That's why I insist on operating in the morning."

Braden O'Neill (@BradenONeill), an MD student in Calgary, searched the NIH literature and responded:  "There has been some work on time of day and surgical outcomes but it seems more about the cases themselves."  The article he cites does have some interesting conclusions, but is not supportive of my hypothesis:

After adjustment for patient and procedure characteristics, mortality had a moderately strong association with start time, but only for nonemergency cases starting 9:30 pm to 7:30 am. As for morbidity, after adjustment, operations starting 9:30 am to 1:30 pm and 5:30 pm to 9:30 pm were associated with a weakly elevated risk of morbidity, but those starting 9:30 pm to 7:30 am demonstrated a strong effect on morbidity.. Subgroup analysis showed this effect was largely a result of elevated risk of morbidity in emergency cases from this overnight time period.

David Rosenmann (@DavidRosenman) from Mayo Clinic noted: "A 2011 study suggested increased maternal morbidity when unscheduled cesarean sections took place at night."  But that may not help, in and of itself, because we don't know if the doctors handling those cases have been through many during the day, or whether it is a fresh crew.

Over at Facebook, transplant surgery fellow Kristin Raven reported, "The time of day organ transplants occurs is known not have any effect on outcomes."

A medical colleague who responded to an email supported Kristin's finding:  Surgery is interestingly less intense than clinic -- people are more complicated than bodies. So no consistent findings have emerged except that emergencies/late night cases have poorer outcomes, which is not a surprise. 

A few minutes later, he elaborated:  I should correct to say that it depends on the operation -- routine feeding tube placement vs Whipple -- and the clinic -- breaking bad news about a concern vs routine well baby visit. This is the complicated nuance about medical decisions that exists just as the nuance about financial decisions the article talks about matters.

Meanwhile, engineer Roberta Brown noted, "There are some solid safety statistics about the most likely times for accidents. If I remember properly, it's the half hour after lunch or a break."

But, pathologist Beverly Rogers suggested that I was probably asking about the wrong specialty:

This is a problem for pathologists too, and actually that would be a better measure - surgical error rates could be due to physical fatigue or other factors not related to decisions, whereas pathology or other diagnostic error is clearly related to decision-making (as well as interruptions, and other cognitive errors.)

I am left thinking that Beverly raised the question in a better context than I did.  We would need to look at specialists who need to make several difficult decisions in a row.  For example, here would be the hypothesis to test:  As pathologists look at dozens of tissue samples during the course of the day, making explicit decisions as to whether the cell patterns are evidence of disease, does their percent of positive findings change as a function of time of day and/or the number of cases reviewed?

Tierney describes an element of decision fatigue in terms of "crossing the Rubicon."  He notes:

The experiment showed that crossing the Rubicon is more tiring than anything that happens on either bank — more mentally fatiguing than sitting on the Gaul side contemplating your options or marching on Rome once you’ve crossed. As a result, someone without Caesar’s willpower is liable to stay put.  Part of the resistance against making decisions comes from our fear of giving up options. The word “decide” shares an etymological root with “homicide,” the Latin word “caedere,” meaning “to cut down” or “to kill,” and that loss looms especially large when decision fatigue sets in.

It would indeed be fascinating to know whether, notwithstanding their exceptional training, medical specialists like pathologists display any such patterns of behavior.  And, in the case of pathologists, would "not crossing the Rubicon" lead to more positive findings or fewer?

Perhaps this offers a research opportunity for a rising medical star.

My friend, the display ad

Those of us who view banner ads and other Internet advertising as annoying or just something to ignore may have missed important developments in this line of business.

For the first development, let me draw the comparison to Amazon.  It started out as a book selling website.  It later expanded into selling books for other bookstores.  It had become a distribution outlet for its competitors.  Its reach into various segments of the marketplace exceeded that, or complemented that, of bookstores and publishers.  When Tom Friedman wrote The World is Flat, he gave a hint as to this kind of development.  But it is stunning to see it in action.

Now back to Internet advertising.  We all know that Google is a whiz at this, placing ads on it search engine page that reflect your personal history and preferences.  It also scans the text of your emails on Gmail and sends you personalized ads based on some algorithm.*

Now, though, Google has out-Amazoned Amazon when it comes to reselling its competitors services.  I missed it over a year ago, but Google bought Invite Media, and now offers "The first universal buying platform for display media."  The company offers access to 99% of Internet users in selling advertisements.  For example, do you want an ad on Yahoo, Google's competitor?  They will sell it to you.

Why would Google's competitors put up with this?  For the same reason Amazon's do.  They are benefiting from their competitor's use of their platforms.  Once your spread is wide enough, you can enable your competitors to reach market segments that were previously out of reach.

But it is more than that.  In Google's words: "Real time bidding technology is an important part of this ecosystem. It enables advertisers and agencies to tailor their bids on an impression-by-impression basis, based on their own data, when bidding on websites that choose to make their ad space available through an advertising exchange."  Beyond this, they offer "real-time optimization system to maximize performance."  This is the equivalent of dynamic ad buying, based on the responsiveness by customers to the particular ad you purchase on each of the platforms.

Also, you can change the substance and frequency of ads at a moment's notice.  Heat wave approaching the Midwest?  Change the ads for Target stores in Ohio to focus on fans and air conditioners.  Here's an example from Teracent, another Google acquisition:

In the "old days," the closest you could get to this was represented by Bose Corporation.  Remembers those ads for the Wave® Radio on the back page of the New York Times Magazine?  Bose would test out different sales approaches on those ads.  Some would mention the price of the radio.  Some would mention the price per month if you bought on a time payment.  Some would have no price information.  Then, in old-day "real time," they would monitor the ads types for relative effectiveness.  But it would take weeks to see the results, and then more weeks to refine the ads to the most effective model.

Now, it can happen instantaneously.  Or to put it in other terms, "The technology takes the ad creative, breaks it up into pieces such as background and ad copy, and builds it to serve up the assembled creative to consumers based on data feeds."

These are not just ads.  They are part of a social structure more powerful than ads: 

While social networks have empowered customers to provide brands' feedback in real time, technology has enabled those same features in display ads. Integrating into display ads a variety of social elements such as product reviews and feedback could help marketers gain loyal customers, too. About 59% of all people online use social networks at least once monthly, Mohan says. "We are learning that the Web is social, just like real life," he adds.

Think about building brand loyalty by gaining a percentage of the 5 billion pieces of content shared weekly on social sites across the Internet, or a percentage of the 50 million tweets on Twitter talking about the company's products.

What does this mean for advertising agencies?  It is not good. Think of the term "disintermediation."  Back to Teracent:

Think you have to choose between the science your business demands and the art your customers crave? Think again. Take control of the look and feel of your display media ROI with Teracent’s proven advertiser solutions.

Aaron Shapiro at ClickZ notes:

For creative and media agencies, ad exchanges are a different story: ad exchanges promise to completely transform the digital agency business. ...The result is that core media agency competencies - buying and planning - become less important.

What does it mean for us at home?  Simply this.  There will be no escape from the onslaught of targeted advertisements to our homes and businesses.  I think I recall that in the pre-Internet days, a person living in a city was hit with about 3000 advertising images per day.  The goal during that time was to make your message pervasive and memorable by being clever, funny, or disturbing, or having a stick-in-your-head jingle.  The goal now is to make an ad part of your social structure, so comfortable and tailored that you don't even think of it as an ad; so convenient that you immediately click through and make the purchase; and so much a part of your life that you feel like you have had a warm conversation with a friend as s/he takes your money.

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* For a humorous take on the accuracy of the algorithm, read this New York Times op-ed by Seth Freeman, "Me and My Algorithm."  Excerpt:  I sometimes find myself wondering what the algorithm knows that I don’t. This was particularly true, and disconcerting, when a recent e-mail about earthquake coverage for my home, several miles inland from the ocean in California, prompted an ad for Clearance Swimwear.

Chump change

Carey Goldberg at CommonHealth provides an excellent presentation regarding capital spending and other issues related to the dominant provider group in Massachusetts.

Great quote:

An editor-friend prompted, “So it seems to you that Partners epitomizes almost everything that’s right and everything that’s wrong with the American health care system?” “Damn, you’re good,” I said.

A simple proposal on malpractice

An article this week in the New England Journal of Medicine concludes that there is a high likelihood that most doctors will face a malpractice lawsuit at some point in their careers.  Here's the chart that accompanies the article, showing the percentage of physicians annually, by specialty, who are sued.

Not all suits, indeed a minority, result in verdicts against the doctors.  Nonetheless, the disruption to a doctor's life during a lawsuit is substantial, taking him or her away from care of patients for weeks.  And, as I have discussed, the shame that accompanies these lawsuits -- even when not warranted -- is a searing experience.

Given the power of the litigation bar in state legislatures and Congress, and given the legitimate rights of people to sue for damages when real harm has been done, the likelihood of fundamental change to our system of malpractice law is unlikely to change.  Indeed, other countries -- like Israel -- are seeing a rise in their own malpractice experience as the plaintiff bar learns from the American experience.

If we try to insist on a global change in malpractice laws, we will get nowhere.  It is better to make incremental changes that are in the interest of both plaintiffs and defendants.

In that light, there are ways to improve the flow of these cases that preserve the rights of both sides.  The most sensible and politically feasible I have seen are designed to preclude or quickly eliminate unfounded and frivolous claims.

My favorite is a requirement to impose a notice or "cooling off" period.  This would require a potential plaintiff to tell the targeted doctor, nurse, or hospital of an intention to sue.  During that waiting period, there would be a greater chance that the parties would resolve their differences.  This raises the possibility of avoiding a formal lawsuit and saving the costs and lengthy time commitment by all concerned.

The advantage of this proposal is that all rights are preserved for all parties.  The plaintiff's bar should not object (versus, for example, proposals to limit damages) in that all the other provisions of the law remain in effect.  Indeed, under this approach, plaintiff attorneys face a higher likelihood of avoiding steep up-front costs associated with handling cases, costs that they must bankroll out of their firms' balance sheets on a contingent basis.

So cheap, I'll take two.

WBUR/CommonHealth reporter Rachel Zimmerman went shopping recently for a pelvic ultrasound.  She summarizes the results on a great new website called Healthcare Savvy.  Here's an excerpt:

I called each facility, and here are the prices I was quoted for a pelvic ultrasound:
–Mass. General: $2847 or $2563 (more on this later)
–Mt. Auburn: $971.96
–Diagnostic Ultrasound Associates: $516

All three quotes were for the imaging only and did not include professional services or other additional costs, I was told.

So, is it just me, or is a five-fold difference in price for the same procedure at three greater Boston facilities kind of shocking?

I called MGH back to make sure I heard right. Weirdly, on Wednesday, the ultrasound price was $2,847, but on Thursday it was $2,563. (Do I hear $2,000?) I called the hospital’s PR office for a comment on why it costs so much more. Here’s the statement they sent me from Sally Mason Boemer, Senior Vice President of Finance: “MGH typically benchmarks our gross charges with like institutions and find our charge levels to be consistent with other urban medical centers that have a significant amount of complex care, teaching and research missions, and a high uncompensated care burden.”

Trash talk

At this stage of life, it is best to acknowledge, yea, celebrate one's idiosyncrasies.  As my friends and family know, I cannot resist picking up trash from the sidewalks and streets as I am taking a walk.  But not all trash.  I focus on recyclable containers -- bottles and cans -- which I collect and put in the city's green recycling bins.

Here, for example, is a veritable kitchen sink of such items, collected in only a single one-mile walk on the way back from the grocery store.  It is an anthropologist's dream:  Small liquor bottles and beer cans tossed out by teenage or college drivers; water and sport drink bottles left behind by health and exercise fanatics; and so on.

My collection habit may arise from working for Michael S. Dukakis when he was governor of Massachusetts. MSD is an inveterate trash collector.  See this story from 2003 by David Abel.  The pertinent quote: "I mean, look at this crap!" he growls, finally snaring the offensive refuse. "It's appalling, disgraceful. There's just no excuse for it."

I had always felt the same way, and Michael, in essence, gave me permission to ply my craft.

At BIDMC, I was assiduous about picking up trash in the hallways, but this habit had another purpose.  The Boston Globe's Douglas Starr noted this in an article back in 2003:

"I subscribe to the Disney theory of cleanliness," Levy explains.  "If you leave one scrap of paper on the floor, it quickly becomes two."

This paper-scrap business has become a thing at the hospital, a bit of in-house schtick. . . . One day he and chief operating officer Dr. Michael Epstein were walking down the hall when both of them spotted litter on the floor.  Epstein looked at him and said, "Mine or yours?"

But back to my mentor, Governor Dukakis.  When he left state government in 1991, I found the perfect going-away present for him, an authentic trash pick-up stick, with a firm plastic grasp and a very sharp point.  Here is a duplicate, one I kept for myself.  But try as I might, I cannot yet bring myself to start spearing paper waste.  Maybe, he if has worn out his stick over the last 20 years of cleaning up Brookline, I'll recycle mine and send it over to the Governor.

How to rebrand a hospital

Hospitals often engage in rebranding exercises in the hope of stimulating business or overcoming adverse publicity.  Some might want to borrow from this experience, set forth in a blog posted by Chris Herron Design.  (Thanks to Matthew Carroll for posting the link on Facebook.)

To help Talia and others with Dravet syndrome

This is short video about life with Dravet syndrome and efforts to raise money to fund Dravet-related research. For more information, please visit www.TeamTalia.org.

If you cannot see the video, click here.

Time to talk for the common good

Over a decade ago, a common refrain was that there were too many tertiary care/academic medical centers in Boston.  Of course, that comment often came from the dominant hospital system and the most prestigious medical school in town, but not exclusively.  The conversation would then continue to the question of which one was surplus.  BIDMC was in financial trouble, so some assumed it would be the one to go.  Indeed, as I have related, the then-Attorney General was pressuring the organization to sell itself to a for-profit and drop its teaching and research mission.  Others assumed it should be Tufts-New England Medical Center, which also had had financial problems.  Still others assumed it should be St. Elizabeth's Hospital, the flagship of the Caritas Christi system.

By the way, the rationale for choosing "favorites" in this unfortunate race generally had no substantive basis.  All of those centers have experienced and dedicated and highly competent staff and excellent records of clinical care and academic programs.  Indeed, in another city without a tertiary hospital, any one of them would have been considered a highly desirable asset for the community.  But underlying prejudice, arrogance, contempt, and old grudges often formed the basis for many opinions on the matter.

Over the years, the ranking of candidates for extinction changed.  BIDMC has had a successful turn-around and many continuous years of profitable operations and has gained substantial market share, while expanding its research and education programs.  It is clearly out of the woods.  Likewise, strong administrative and medical leadership at Tufts Medical Center has stabilized that organization and created new clinical affiliations with referring physicians in the region.  But St. E's continues to show weakness.  Its clinical volumes are down, and residents reportedly need to go to other hospitals to get sufficient surgical experience to meet their training requirements.

But, none of this suggests that the initial premise was valid, that there are too many such facilities in Boston.  Each of these institutions brings something important to the region.  The question is not whether one should cease to exist.  The question is how to rationalize the mix of clinical care, teaching, and research across all of them to create increased value for the community.  Ultimately, that requires, too, a rationalization of the functions and services of the medical schools in the city, for the teaching activities of these tertiary centers are important components of their added value.

Would it be possible, among these highly competitive hospitals and medical schools, to share resources, to allocate clinical programs for the greater public good, and to engage in truly cooperative undergraduate and graduate medical education?  I don't know, but I am reasonably sure that, absent such a joint effort, the extinction of one of the members of this elite club is likely to occur.  Therefore, the conversation is worth having and should be at the top of the agenda of the university presidents and medical school deans, along with their hospital counterparts.