The Harvard Medical System

After a recent news story in which yours truly was seen to a bit critical of one of his hospitals, a trustee from Partners Healthcare System asked one of our trustees, "Are we competing or cooperating?" Our person gave the right answer, "Both."

There, in a nutshell, is the story of Harvard Medical School and its affiliated teaching hospitals. This is worth some explanation.

HMS is a research institution and a school for undergraduate medical students. Unlike many other medical schools, HMS does not own and operate a hospital. Instead it has affiliation agreements with a number of hospitals in Boston (BIDMC, MGH, Brigham and Women's, Children's Hospital, Dana Farber Cancer Institute, Joslin Diabetes Center, Mass Eye and Ear Infirmary, among others). Those affiliation agreements (amounting to a one-page letter between MGH and Harvard to longer documents for later arrivals to the system) state that the hospitals will train HMS students, will cooperate with HMS in other medical and civic responsibilities, and will follow the rules of Harvard University with regard to faculty and other academic matters.

The doctors and researchers in the Harvard hospitals are faculty members of HMS. Their promotion process is subject to the governing rules and processes of HMS. They are subject to stringent HMS conflict of interest rules. They have certain HMS civic responsibilities, notably to teach undergraduate medical students. Like faculty at the University, they are expected to be among the best in their field and to have a national and international impact on clinical care, research, and/or teaching. Indeed, when a search is undertaken for a new department chief at one of the hospitals (e.g., Chief of Medicine at BIDMC), the search committee is appointed by the Dean of HMS and comprises high-level faculty members from a number of the hospitals.

But, with few exceptions, the faculty are not paid by Harvard. Their salaries are paid by the hospitals or by the physician organizations in the hospitals -- based on clinical, research, teaching, or administrative activity.

This somewhat informal arrangement has worked well for decades, has created tremendous loyalty within the system, and has contributed to the strength of both HMS and the hospitals.

But, recall that the hospitals are independent non-profit entities, each with its own public charter, and each governed by a community-based board of trustees with a fiduciary responsibility to their institution and to the public. Part of that fiduciary responsibility is to stay financially healthy -- which in the marketplace of health care mean to compete successfully.

The result is a curious mix of cooperation and competition among the Harvard hospitals. As loyal members of the HMS system, we cooperate fully in recruiting, evaluating, and promoting faculty members; in educating medical students; in designing multi-institutional research programs; in sharing basic science and clinical research results; and in carrying out joint programs to improve patient quality and safety. But in the arena of clinical care, there is intense competition for market share, to be the most attractive place for patients for cardio-vascular services, organ transplantation, cancer treatment, or other important types of tertiary care.

This means that we vie to be the first choice for patient referrals by primary care doctors and specialty physicians in the community. After all, most patient visits to hospitals are the result of those referrals, not individual decisions by consumers. Thus, each hospital tries to create a referral network -- either by ownership, insurance contracting, or personal relationship -- that will enhance the flow of patients to that institution. Each hospital, too, engages in marketing to strengthen those same referral patterns. (By the way, this is not limited to the Harvard hospitals. New England Medical Center, St. Elizabeth's, and Boston Medical Center join in the region-wide competition.)

Since all of the Harvard hospitals provide excellent care, newspaper reports and other public commentary tends to focus on these battles for referrals. Look for that to continue.

But, also look for whole-hearted cooperation to continue among the HMS "cousins" -- in areas that are ultimately more important than the forays over market share.

Infectious behavior

The Globe yesterday ran a story on hospital-acquired infections, noting that the Commonwealth of Massachusetts might require hospitals to report their statistics on this matter. This is a good thing, part of a trend slowly spreading across the country.

It is good for two reasons. First, the public has a right to know about fundamental measures of patient quality and safety in institutions in their communities. Second, as a management tool, there is nothing more effective for hospital administrators than to be able to remind their staffs that actual clinical results will be made public.

But, here is the subtle and very important point. If public reporting devolves into a culture of blame, it will undo all the good that would otherwise be done. Here, reporters and politicians need to be very careful.

The idea is to use data to bring about constructive change and improvement. While some hospital-related infections, injuries, and death are the result of a doctor's mistake, many are the result of systemic problems that take analysis, understanding, and thoughtful problem-solving to fix.

I can also assure you that, when a doctor makes a mistake, he or she already feels more remorse about it than you can imagine. There is no reason to pounce on people who have devoted their lives to helping us.

I believe that many doctors and hospitals do not want to post these data because they have little confidence in the ability and motivation of the press and elected politicians. They fear they will just be punching bags or targets for commercial or political gain.

So, yes, hospitals and doctors face a challenge in overcoming their defensiveness and reluctance to share in this arena -- but the rest of society faces an equally difficult challenge in using the information responsibly.

I have chosen to post BIDMC's data because I believe the only way for us all to learn how to do this well is to actually do it. I continue to hope that my colleagues in the Boston area hospitals will join in and that our journalists and elected officials will provide the kind of positive reinforcement that makes this truly infectious behavior.

On-line between doctors and patients

We have a nifty program called PatientSite that allows doctors and patients to exchange information on a password protected site. Doctors can send reminder notices to patients and updates on various items. Patients can use it to make appointments, get referrals, read test results, order prescriptions, and the like. (Yes, of course, the prescription orders go directly the your favorite pharmacy in your neighborhood!)

Our theory is that a lot of communication between doctors and patients can happen on-line, asynchronously. This leaves doctors free to spend time on the telephone or in person for the things that are more urgent or require more personal attention. It also means that you, as a patient, can send in a request at whatever time suits you.

Each doctor has the ability to customize the PatientSite features provided to his or her patients -- the clinician's schedule, the patient's allergy list, lab results, medication list, microbiology reports, EKGs, pathology results, X-ray reports. Most doctors offer patients most of these features, but, for example, some doctors prefer to talk to a patient about test results rather than having them available first on line.

You wonder how much this is used? Here are some statistics for those patients who have chosen to sign up for the service.

Clinical messages from patient to provider: 25 (per 100 patients)
Number of prescription requests: 4 (per 100 patients)
Number of appointment requests: 2 (per 100 patients)
Number of referral requests: 2 (per 100 patients)

Percentage of patients seeking technical support in the use of PatientSite: 2-4%

Percentage of enrolled patients who log in each month: 35-40%
Of those who logged in:

• Percentage of patients who looked at lab results: 31%
• Percentage of patients who looked at X-ray results: 20%
• Percent of patients who reviewed medications: 24%

Try the demo! I think you will be impressed.

Hike4Life

I'm just back from a trip to Madagascar, where I participated in a fundraising event called "Hike4Life" for Focus Humanitarian Assistance. FOCUS is an international group of agencies established in Europe, North America and South Asia to complement the provision of emergency relief, principally in the developing world. It helps people in need reduce their dependence on humanitarian aid and facilitates their transition to sustainable, long term development. FOCUS is an affiliate of the Aga Khan Development Network. The establishment of FOCUS by the Ismaili Muslim community was a result of a history of successful initiatives to assist people struck by natural and man-made disasters in South and Central Asia, and Africa.

Eighty people joined the hike, raising hundreds of thousands of dollars for this worthwhile organization. We were from the US, Canada, the United Kingdom, and France. The pictures above show our lead guide Roland, as he taught us about local wildlife, and also some our group as we hiked through Isalo National Park in south central Madagascar. (And to answer your question, yes, this activity accounts in part for my reluctance to make blog postings during the past two weeks. Web access is not so ubiquitous in Madagascar . . .)

Happy New Year

Best wishes to all for a Happy New Year. My New Year's resolution is to take another week off from writing this blog. After five months of writing, several times per week, I realize that my addictive behavior extends beyond Blackberries! I am going to see if I can refrain for a few more days.

But I promise that I will be back . . . .

Merry Christmas

A note from Linda Myers, who runs Windows of Hope, our oncology support shop:

Windows of Hope just received a wonderful donation of handmade scarves for us to give away to cancer patients along with a lovely monetary donation. The scarves were made by the staff of Deaconess 4-inpatient psychiatry and the psych consult nurses as a way to support cancer patients.

A staff member wrote to Linda:

We have all had our lives touched by this illness either through personal experience or by the experience of loved ones or colleagues, and it was decided that the "pink scarf project" would be a nice way to be supportive, serve as a rememberance, and as a tribute to the survivors in our lives. It was great fun. Some of us perfected our knitting skills -- there was a healthy competition for the " most knit" by two nurses -- some of us learned to knit, with a few tears and dropped stitches, others had their mothers or their daughters do the project. A few contracted the job out and some who couldn't knit perfected their shopping skills or bought the scarves so a donation to Windows of Hope could be made. All in all, it was a rewarding experience. WE WISH YOU WARMTH AND PEACE AS THE PINK SCARF KEEPS YOU WARM.

------

This is such a nice sentiment that I think it deserves top billing on this blog for a few days. So, for that reason and as part of my continuing personal effort to avoid addictive behavior, I am going to take off a week or so off writing entries for this blog. I will still moderate comments, though, so please feel free to send them in.

First, kill as few patients as possible

That was the name of a humorous book by Oscar London, but there is a serious side to the concept:

For years, Don Berwick and his colleagues at the Institute for Healthcare Improvement have been proselytizing and working to improve care in the nations' hospitals. They conduct important research and offer training programs for all types of hospitals, medical staff, and administrators. Recently, they have offered a metric that is the grandaddy of all metrics, the
hospital standardized mortality ratio. This is a disease and procedure based, risk-adjusted single number that tells you how you are doing in term of deaths compared to the average and compared to other hospitals. According to IHI, "the HSMR, appropriately adjusted for multiple variables such as population characteristics and diagnoses, provides an essential starting point in improving care and reducing mortality. "

In shorthand, for us lay people, the metric gives a sense of your likelihood to die at a specific hospital compared to other hospitals. If your hospital has a value of 1.0, it is average. If you have below 1.0, it is better than average. If you have above 1.0, it is worse than average. [Note: See correction to this statement in my comment below.] As with all metrics, you can quibble with the components and argue with the calculations, but it is as powerful a tool as I have seen. It is rapidly becoming the touchstone for many hospitals as they review their safety and quality programs.

IHI offers this tool to help people do better. It is not meant for advertising purposes or punitive purposes. As they note: "Many hospital deaths could be prevented if all the factors that contribute to them were better understood. Each hospital death provides an opportunity for learning -- by understanding and addressing local conditions that contribute to mortality."

We recently asked a group of outside experts from places with the strongest national programs to review BIDMC's progress in patient safety and quality. We received a good grade, but we also received a number of thoughtful and helpful suggestions for improvement. We have high aspirations. Our goal is to set audacious targets for improvement in overuse, underuse, misuse, and waste in the care of patients -- to set plans and milestones for doing so -- and to manage towards those targets.

Academic medical centers have a special responsibility in this regard, to create within the safety and quality program an academically rigorous examination of what works and what does not in various health care settings. I have given you a few examples in the postings below, entitled "What Works". But no single hospital has a monopoly on ideas when it comes to this field, and the first step is for all of us to disclose publicly how we are doing.

This HSMR number is not published anywhere unmasked by name, but if you contact IHI they will give you your own data, which is what we did. To relieve your suspense, 0urs is 0.71, which just puts us in the top ten percent in the nation. (Frankly, if a Harvard-affiliated academic medical center were not better than average, everyone would have a reason to wonder why.)

I wonder if my academic medical center colleagues in Boston and around the country would similarly be willing to post their HSMR number publicly on their own and to authorize IHI to maintain a publicly available list on their website. With a national debate swirling about the cost of care and value of academic medical centers, what would be more powerful than a grand display of openness about our progress in trying to kill fewer people?

The SEC is on the phone

Report today on one of those Blackberry sites:

Slide for RIM stock

Here's yesterday's numbers for BlackBerry-maker Research In Motion's stock price.
Nasdaq (RIMM)- $132.24 a share, a decline of $3.27 cents (-2.41%) from Monday's $135.51 a share close. Tuesday's volume of 8.823 million shares was a little higher than RIM's three-month 8.310 million share daily average traffic.

For the record, I did not sell short before posting the item below!

But maybe the person on The FASTForward Blog did . . .

:)

Blackberry Cold Turkey

The most important attribute of email is the asynchronicity of the medium: The sender and the receiver do not have to be in contact at the same moment. This enables efficient communication. You can integrate emails into the fabric of your life. You originate a message when you want, and you reply to another's when you want.

Until the "revenge effect" occurs! How does this work? Email was invented. Then Blackberries were invented so we could be sure, when we are away from our computer, to receive emails as soon as they are sent and reply to them immediately. In fact, we feel compelled to read and respond in real time. Asynchronicity disappears.

Worse, manners disappear. We sit in meetings and, at best, try to look at our handheld screen without appearing to be distracted from the conversation. You have seen the maneuvers -- a casual glance towards the crotch where fingers are quickly at work -- a sudden excuse to go to the restroom -- a coughing fit so the person can turn away from the table and check the Blackberry. At worst, we just put the device on the conference table in front of our face and divest from the conference.

Worse still, relationships disappear. A couple sits side by side at an airport, each reading and writing email on their two machines. A child impatiently waits to talk to a parent while the driver hurriedly answers an email while stopped at a red light.

I write from experience. I was a "Crackberry" addict. As I look back and see how often I was rude or inattentive, I am embarrassed. As I look back and see how often I responded in haste to an email in the midst of other activities, I am appalled.

But, I have given it up. The impetus was when Cingular wrote in November to tell me that my bare bones Wireless Mobitex data service was going to be discontinued, but that I could "upgrade" to one with a higher price with more functionality, if I also bought a new Blackberry or Treo. I had until December 31 to make the switch: "All Mobitex devices on your account will be unable to send or receive messages after that date."

I read that sentence and had quite a different reaction from that hoped for by the Cingular marketing department. Gee, if service will end on December 31, why wait? Let's end it sooner. So, I did. I called that 800-number and shut 'er down that very day. Blackberry cold turkey.

I have since discovered marvelous things. The sun rises in the morning and sets at night. Airport lounges are great places to visit with friends or read a book. Red lights are an excellent excuse to stop driving, look around, and see what's happening on the streetscape. People in meetings pay more attention to you if you pay more attention to them. The email that arrived three hours ago is still relevant -- or better yet, no longer matters!

What Works -- Part 4 -- Central Line Infections

Central line-related bloodstream infections are a serious problem in hospitals. A central line is a port installed directly into a major blood vessel to permit a catheter to be used for the quick delivery of medication for patients in ICUs and in other settings. Because of the direct connection to major blood flow, an infection associated with the installation will flow quickly into the blood stream and to major organs. This article from the Centers for Disease Control attributes a mortality rate of 12 to 25 percent (!) for each infection -- not to mention increasing costs by about $25,000.

The Institute for Healthcare Improvement likewise notes that "up to 4,000 catheterized ICU patients die each year in the US from avoidable infections and organ failure (sepsis) related to central venous catheters (CVCs). . . . Forty-eight percent of ICU patients in the US have central venous catheters, accounting for 15 million central-venous-catheter-days per year in ICUs. . . . Within this population, studies indicate an estimated 4% to 20% (500-4,000) of patients will die from catheter-related bloodstream infections."

Like others in the country, the medical leadership at BIDMC decided that our current rate of central-line infections was too high and set about to change it. When we started, our average rate of central line infections per thousand patient days in the ICUs was about 3. This was better than what we often see nationally, but our doctors were impatient to improve it. After all, each case has a high potential for serious patient injury or death. So the goal is to get to zero.

This turned out to be a multi-faceted problem. Central lines are often inserted by residents who have been trained how to do the insertion by other residents. (Dr. Atul Gawande provides a vivid description of this learning process in his book Complications: A Surgeon's Notes on an Imperfect Science.) Beyond the insertion process, decisions must be made about how long the line should stay in, and how often it should be maintained. Very often, there are only informal rules of thumb in a hospital for these determinations -- and there is often wide variation even within a single hospital.

Our folks set about to make this process more rigorous, analytical, and controlled. Sessions were held among surgeons, medical doctors, anaesthesiologists, nurses, and residents to reach a consensus on the proper method for inserting a central line. A specific kit was designed, so that anyone inserting a line had the full complement of supplies at hand. Detailed rules were established for the protocols surrounding maintenance of the line and its withdrawal. And, a system was set up so that every single infection that occurred would be analyzed to determine its cause -- so corrective measures would be taken going forward.

Here are the month-to-month results for the first year of the program:

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

As you can see, the figure goes up and down, although progress is good. The key thing is that every single case of infection is analyzed thoroughly, with the results shared across the broad range of hospital staff in the ICUs. What goes wrong? As many things as there are people. For example, one day, our chief of medicine happened to go by as another member of the staff was not following the protocol. When he pointed it out -- and none too gently! -- the person was embarrassed and really had no excuse for doing it wrong. So human nature often comes to play. Sometimes more technical factors arise. Regardless of the cause, each case is used to reinforce the program.

With about 1600 ICU patient days per month at BIDMC, the difference between an infection rate of 0.0 and one of, say, 2.5 is 4 actual people. Over the course of a year, that same difference amounts to 48 people who either get or do not get an infection. Applying the CDC's cited mortality rate of 12 to 25 percent, the difference amounts to saving the lives of 5 to 12 people -- just at our hospital.

When you look at numbers like those, you can see why our medical staff -- and people around the country -- are rabid about making this improvement real and permanent. Doctors and nurses devote their lives to alleviating human suffering caused by disease. They are heartbroken by the thought that their own well-intentioned actions might lead to death, and they are driven to get better and better at what they do.

A holiday gift

I am posting an email sent by one of our doctors to his colleagues in our Ob/Gyn department this past week. (He said it would be all right.) I think it is beautifully written. 'nuf said:

Subject: Holiday Greeting

As we get closer to the beginning of the December holidays, I want to wish everyone a wonderful holiday season. I also want to take the opportunity to relay to everyone a personal experience that I recently had and how it helped me have a new perspective on my role as an Ob/Gyn. I hope not to offend anyone by what they may see as an inappropriate use of this e-mail forum, or may see this as a bit self indulgent. If you do, I take no offense, and feel free to click the delete button and move to your next e-mail. If you wish to read, continue on.

Some of you know that I attended a wedding this past weekend. Now, we have all been to weddings, some of us can even remember our own wedding. This one had the usual trimmings of outlandish outfits and outlandish behavior. And of course, it had the usual consumption of various types and quantities of libations. However, the wedding stands out as something special because of the emotional issues that the bride and groom brought together under the wedding canopy. The bride was widowed on 9/11. Her husband had been a passenger on one of the flights that was crashed into the Twin Towers. At the time, she was pregnant with her third child, and delivered that child the following spring here at BIDMC. Every time I have been in the presence of this women I have been truly amazed at how she has dealt with this incomprehensible tragic loss, and how since 9/11 she has created a warm and loving environment for her children. What she has done with her life since this loss goes beyond inspirational (see Beyondthe11th.com), but what she did this weekend is the ultimate goal a person can have when dealt with such a loss as hers. She and her new husband have brought love, happiness, and the thirst to enjoy life into her soul once again. I would imagine this would be my most difficult accomplishment if faced with a tragedy such as hers. At the wedding she talked openly about her loss, as well as her rediscovered love, and I feel blessed that I was able to be a witness to such a beautiful moment.

I thought about my own little meaningless personal battles that I have every day, and the battles we all face both in our professional and personal lives. The struggle to balance family and career, and trying to find ways to pay the bills. In our professional and personal lives, we all deal with loss on a daily basis- infertility, miscarriage, recurrent miscarriage, still births, birth defects, cancer, and the list goes on. We face many obstacles in our goal to keep a positive attitude -- angry patients, ungrateful patients, emotionally unstable patients, anxious patients, pissed off colleagues, depressed colleagues. It becomes too easy for us to become a scientist to our patients and not health care providers, keeping us emotional detached from ourselves as well as the needs of our patients.

But for some reason, we have chosen this profession, or maybe let the profession chose us. And this profession gives us a tremendous gift. The gift to give something of ourselves to other people. Each day we are given at least one moment to realize how lucky this gift is. Sometimes it is obvious such as when we get a good baby after a month in the hospital on bedrest, or sometimes small such as when a colleague or patient says a simple thank you. We have been given the gift of being able to help people through some of their most difficult, frightening, and tragic moments. We help them with our skills, our insight, and our kindness. And then we are given the bonus gift of being able to witness one their most joyous moments, the birth of their children. I have an opportunity each day to recognize the value I add to other peoples lives, and if I can recognize that value it can help me get through the rest of the crap I face on a daily basis. I can fill part of my soul with the joy people feel when I help them, and then incorporate that joy into my interactions with the world around me.

And so this is the gift I give to myself this holiday season. The gift to continue to enjoy the profession I have chosen for my life, and how valuable it is to those around me as well as to myself.
Peace,

Western style sex and humor?

Here is a story from MSNBC about a restaurant in Arizona with waitresses dressed up as scantily clad nurses. One of our nurses mentioned it to me and expressed her feeling that this was not only demeaning to the women in the restaurant but also to nurses and the nursing profession.

The owner says, “If anything, I think it glorifies nurses to be thought of as a physically attractive and desirable individual. There’s a Faye Dunaway, Florence Nightingale hipness to it. Nobody wants to think of themselves as some old battle ax who changes bedpans for a living.”

It goes without saying that this kind of place would never survive in Boston or indeed anyplace east of Minneapolis. (I hope! Tell me if you think I am wrong.) Even accounting for the free spirit of the wild West, I am having trouble with this one. Beyond the obvious pornographic aspects, it is demeaning to the profession and the people in it. The guy's comments just add to the insult.

You don't buy that? Think about it this way. Some guy habituates this place and gets used to seeing "nurses" in this outfit and flirting with them. Later, he is in a hospital for real. Does anyone out there think that he will not look at and regard the hospital nurses in the same way?

Hip Fractures

This past weekend, the Boston Globe began running a three-part series examining the impact of hip fractures on the lives of elderly patients. The articles focus on the life-altering experience that this injury often proves to be, demonstrating its impact on patients and their families as well as on the health care system.

Over the course of the past 18 months, Globe reporter Alice Dembner and photographer Bill Greene followed a number of hip-fracture patients beginning with their admission to BIDMC, through their surgeries and hospitalization to their post-operative recovery in rehabilitation and nursing home settings, and finally, in their homes. (Of course, the patients and families gave permission to be followed in this way, and then written about.) Among the current BIDMC physicians participating in this long-range project were orthopedic surgeons Doug Ayres and Edward Rodriguez and gerontologists Suzanne Salamon and Katy Agarwal.

The series began on Sunday, Dec. 10 and appeared both in print and on the Globe’s website, boston.com (where extra features are available.) As part of the project, Dr. Salamon will also participate in an online "web chat" Tuesday, Dec. 12 from noon to 1 p.m. This web session is expected to kick off a new Globe/boston.com weekly feature entitled "Ask the Doc." Here are the links to Part I and Part II and the sidebar features associated with the main stories.

I think you will agree that this is a powerful set of stories, laying raw human emotions in front of all us to see. Congratulations to the Globe for allocating the resources to this project and to the reporter and photographer for presenting it in an incredibly thoughtful and sensitive way.

The Real Beth Israel

Please be sure to read the second comment under my posting "All are above average," below.

More Links

I have added links to two other health care blogs (on the right), one called Kevin M.D. and the other called Med Chatter. There are a gazillion blogs in this field, and I am trying to be selective about those I suggest to you. I have included those that I have found to be thoughtfullly written, up-to-date, and helpful. Please visit and see if you agree -- but please don't forget to come back. :)

I heard a presentation yesterday where someone mentioned how many blogs per day are being created. The number apparently doubles every six months or so, several thousand each hour. It is impossible to keep up with the 50 million+ sites.

Those more expert than I could offer perspectives on all of this. When you get to 50 million blogs, is this just a lot of noise out there? Is this just an ephemeral posting and scanning of news items and observations? Or is it really the thoughtful engagement of millions of people per day? Television stations now design their news stories to catch the attention of viewers within the first seven seconds. Do blogs do any better? Does it matter?

Are we all better informed, or do we just have the feeling that we are? Is it more democratic? Certainly so on its face -- but don't wealthy and powerful corporations, unions, interest groups, and politicians have more resources to devote to this medium than individuals? Can't they cleverly boost the "ratings" of their blogs while giving the impression of just being like the rest of us? We know that they all create not just one blog to push their agenda, but many different ones to appeal to different population segments. We know, too, that they use "fronts" in which their names and agendas are not immediately evident. We know, too, that they have staff and money to enhance designs and messaging and post supportive comments and create momentum for their causes.

Over the centuries, those with power have always figured out how to maintain it, and those temporarily out of power have always figured out how to get it back. Are political and economic cycles essentially immutable, or do we think the blogosphere has changed that?

All are above average

BIDMC doctors and nurses help women deliver 5000 babies per year. I like to joke with parents that all of our babies are above average and that we offer an SAT guarantee: If the kid's college entrance exam score is below average, the parents should find me for a complete refund.

The Globe reported, though, on a particular case that made even us take notice. I have total confidence that this girl will be at the top of her class!

Welcome to the Club, John

The Massachusetts Eye and Ear Infirmary, one of the nation's preeminent research and clinical centers in that field, has designated a new CEO. His name is John Fernandez, and he comes to MEEI after a distinguished administrative record at Brigham and Women's Hospital and elsewhere. Here's more about him from a story in today's Boston Globe.

Welcome to the Harvard-affiliated-academic-medical-center CEO club, John! We all wish you well.

(I've sent John instructions on how to set up a blog, but he says he might be too busy for a while . . . .)

What Works -- Part 3 -- New GI Therapy

A number of people suffer from GERD (gastroesophageal reflux disease), aka acid reflux from the stomach that rises into the esophagus and creates heartburn. We all see lots of ads on television for purple pills and other medications that are designed to help with this problem. Those work for some people, but for others the problem is not alleviated through medication.

Some of our doctors have been using an alternative technique, called endoluminal therapy. The technique is to reach down into the esophagus with a device that pulls up some of the tissue at the boundary of the stomach and the esophagus and clips those tissues together to strengthen the sphincter. The procedure takes 10 to 15 minutes.

The results have been very good. A large percentage of patients have been able to get off medication or reduce their dosages considerably, and the holding power of the therapy also looks positive, with consistent results many months after the procedure.

I think this is an interesting example of how clinicians in academic medical centers often look beyond current therapies and conduct research and try out new ideas that hold promise for patients.

In making this post, I also want to disclose that one or more of the BIDMC doctors have been involved in the development of some of the technology that is used for this procedure and hold equity positions in one or another company than produces them. That, too, is a practice in academic medical centers that is authorized under various federal regulations as a way of moving conceptual ideas into the marketplace. Doctors in the Harvard system have a strict conflict of interest policy to which they must adhere when engaged in these kinds of activities.

A modest proposal

Yesterday, I learned of a program being run by Aetna that prompted me to think differently about the medical records issue. While there is a general belief that interoperability of electronic medical records among health care providers would be of great value to society, there are obstacles to that process that keep arising. Some of these are technical, some are based on privacy concerns, and some are based on corporate decisions to protect information to maintain market share. Here, from Aetna, is an approach that might suffice to skirt many of these issues and enable consumers to send information to whatever providers they would like.

Aetna has created a personal health record -- using the claims information it receives from providers -- that is placed on a secure website and is made available to its subscribers. So, for example, it will show your test results, inoculations, allergies, surgical procedures, hospital stays, chronic illness treatment patterns, and the like. Not only can a subscriber review information about his or her medical histories, but he or she can also authorize any provider to look at it as well.

Think about this. An Aetna subscriber does not need Hospital A to share its medical records with Hospital B: The subscriber can authorize this without an intermediary. Whether the patient has shown up at an out-of-town emergency room or just wants to visit a doctor or hospital in another provider network, the feature is instantaneously available.

I know this is not a complete medical record, but it contains enough information to be helpful in many cases.

Why can't we do this in Massachusetts? It could start with Blue Cross/Blue Shield, the largest insurer in the state, acting alone. Or imagine the power if BCBS, Harvard Pilgrim, and Tufts were all to create this program as a shared venture, but with a firewall between their systems so that data stayed with the subscriber's current insurer. If the underlying platform were the same, the subscriber's data could easily be transferred if an employer or the individual subscriber changed insurers.

I think this is an elegant solution that could help cut the Gordian knot of the interoperability problem. If we can solve 80% of the problem with a quick fix like this, it might be more valuable than waiting a decade to solve 100% of the problem. Maybe those of you out there who are more expert can tell me why I am wrong.

(By the way, Aetna also uses this information to conduct an evidence-based medicine review for patients with chronic problems to help reduce underuse and overuse of medical services. For example, if a diabetic patient is not keeping up with a treatment regime, the patient's primary care doctor is notified by Aetna's medical consultants to contact the patient. Sharing of this data is authorized by the patient when he or she becomes an Aetna subscriber.)

Cardiac Results

The state of Massachusetts announced yesterday that it is going to publish mortality rates, by individual heart surgeons, on a public webiste. Here is the story in today's Boston Globe on the topic.

This is good, but I wonder again (as I have below), why the data can't be more current. Here's what I said on October 16, 2006:

... [T]he numbers are out of date and do not represent the latest volume of surgeries carried out by doctors. I have suggested to people in the state and to insurance companies that it would be very, very easy to have real-time information on these topics: The state could set up a website and give password access to each hospital, and we could update the website from our own databases virtually every day of the year. We all keep track of our doctors' clinical volumes.To keep us from "cheating" -- as if we would! -- the data submitted by us could be printed in italics and listed as unaudited until the state actually caught up with the figures in its own reports. At that point, the font could switch over to plain type.

Also, to persist with one of my favorite topics, why doesn't the website include results from solid organ transplants? These are easily counted and reported. Wouldn't you want to know these figures if you needed a new liver or kidney?

By the way, I have a feeling that Bill Clinton -- after he reads the MA cardiac surgery mortality rates -- will wonder if he should have had his heart surgery in this state rather than in NYC!

When is death?

A story in today's Globe about a current case at our hospital provides a thoughtful and balanced description of the legal, moral, and social dilemma that can be faced by hospitals, nursing homes, and other providers at the end of life. I'll let the reporter's accounting stand for itself, and I would welcome comments from those of you out there who have opinions on the issue.

Doctors, researchers, med students: Check this site

Here's a relatively new site called Healtheva, which is a kind of Myspace for physicians, researchers, residents, interns, and medical students. If you are one of those, I recommend you take a look.

December 1 and Prepping for the PMC!

I just returned from a 20-mile bike ride starting at 4am in balmy 63 degree (!!) New England weather. Who would have thought that I could be training for the Pan Mass Challenge at this time of year?

The PMC is the world's largest athletic fundraising event. This year 4300 cyclists raised $26 million for cancer research and treatment at the Dana Farber Cancer Institute. (You see a small portion of them in this picture.)

A group of us from BIDMC participate in the ride. One of our nurses, Marybeth, has ridden for 24 years of the 27 years of the ride's existence. We do this even though we compete in some arenas against DFCI -- because there is enough work to be done in cancer research that it will take lots of people working together to solve this problem. Indeed, BIDMC is part of the Dana Farber/Harvard Cancer Center, which comprises 7 Harvard institutions and over 900 scientists working on this disease.

Something (the calendar) tells me, though, that my chances for lots more early morning training sessions are about to disappear!

Please help me answer this

A law student from Wyoming has written and asked me a couple of questions. Before I write my answer to this young man, I thought I would ask you readers, who are much more expert than I, to suggest answers that I might include. So please submit your comments, and I will refer your replies to him as well.

Dear Mr. Levy:

In a May 1, 2006 speech, President Bush said, "In the past five years, private health insurance premiums have risen 73 percent. And as a result, some businesses have been forced to drop health care coverage for their employees."

I have contacted you to ask you why you think the price of healthcare has skyrocketed.

I do not have the premise of faulting hospitals. I am not a writer for your local newspaper. I would just like to be become involved in politics some day, and in order to do so, you have to know the reasons for the problems from the people who are most in tune with the problems.

I have talked to several hospital CEO's in Wyoming and they say that the cost of new technology is their primary burden, not medical liability suits.

In a nutshell, what do you think are the primary reasons for the rising costs and what can be done to lower the costs? Also, do you think that health savings accounts, as proposed by the President, will lower the costs of healthcare?

I thank you for your time and look forward to hearing from you soon.

Musings from our muse

I am sorry I don't know how to post an MP3 recording to accompany this essay from my friend Nancy. You will have to use your imagination, but it won't be that hard . . . . (Many thanks to our anonymous donor who makes it possible for us to offer this musical experience to our patients, families, and staff.)


Harp Musings
by Nancy Kleiman, Beth Israel Deaconess Medical Center, Boston, harpist

What is this phenomenon I have been experiencing all year as I bring the mysterious and magical sound of the harp to the corridors of this city of healing? How do its strings, like the fisherman’s net, capture and hold its catch for a brief moment of repose, then release to the ocean of hurried activity its weary yet refreshed traveler? Why are its invisible vibrations able to penetrate so precisely the hearts of those who resonate with its sound and create for them a space to center and smile, to breathe and awaken?

It matters little whether I’m playing in a lobby to a sea of passers-by, bedside for a dying patient, or within listening range of a family anxiously hovering while a dear one receives life-sustaining chemo. The harp has captivated children mesmerized by its ethereal sound as they create a glissando of their own with sheer delight. It has distracted elderly patients waiting for rides home after seemingly endless appointments and has raised stretcher-bound patients who give a thumbs-up to acknowledge a beautiful and familiar contrast to an otherwise stressful ordeal.

The harp’s muses have been nurses stepping out of the OR for a quick respite, doctors taking the time to comment on the soothing effects of the music, staff members seeking out its tranquil space to enjoy a meal, or even deliverymen who smile with surprise to see how its simple melodies can change the sterile atmosphere they are used to stepping into as they go about their busy day. “My blood pressure goes down just walking by the harp” is a familiar refrain.

Artists have stopped to sketch; musicians, to join in. Chaplains and therapists, family and friends request the harp to travel to rooms and floors where patients would benefit from its song. Even entering the elevator, the harp inspires those who respond to its presence. People have left countless gifts of gratitude and always, waves and waves of “thank yous” to bathe the harp in heartfelt appreciation.

What this phenomenon points to is the ability of live music - and especially music from this simple, artful instrument that vibrates richly, easily and effortlessly - to support an intention to serve a community with the highest standard of compassion and care. Through the overwhelmingly positive response the harp has elicited, it has earned its place as an important and vital partner in this hospital’s mission.

Thanksgiving 2006

What Works -- Part 2 -- Clinical Pathways

The Whipple procedure is a complicated and difficult surgical procedure. It is also called a pancreaticoduodenectomy, and it generally encompasses the removal of the gallbladder, common bile duct, part of the duodenum, and the head of the pancreas.This operation was first described by Dr. Alan O. Whipple of New York Memorial Hospital (now Memorial Sloan-Kettering).

The surgeons at BIDMC have developed a "clinical pathway" to guide themselves, related physician specialists, nurses, case managers and other involved in performing Whipples and taking care of patients before, during, and after this surgery. The clinical pathway is intended to assist physicians in clinical decision making by describing a range of generally acceptable interventions and outcomes. In other fields, it might be called a "decision tree." The guidelines attempt to define practices that meet the needs of most patients under most circumstances. While the physician must remain alert to deviations from the expected, the use of the clinical pathway can bring greater predictability to the entire treatment process in many cases.

The introduction of the clinical pathway for Whipple procedures at BIDMC has had very positive results. Here is a summary of the data pre- and post-clinical pathway.

Pre-clinical pathway period: October 2001-January 2004 -- 64 patients (42% male)
Post-clinical pathway period: February 2002-October 2006 -- 121 patients (53% male)

Age distribution: Mean for both periods = 64 (comparable range of ages)

ASA class of patients (degree of disease/difficulty)
Pre-clinical pathway: I (1.6%); II (51.6%); III (46.8%); IV (0%)
Post-clinical pathway: I(0.8%); II (39.7%); III (54.5%); IV (5.0%)

Pre-clinical pathway mortality = 1 death (1.6%)
Post-clinical pathway mortality = 2 deaths (1.7%)

Pre-clinical pathway ICU admissions = 8 patients (12.5%)
Post-clinical pathway ICU admissions = 16 patients (13.2%)

Pre-clinical pathway of stay/cost = 10.8 days/$23,536
Post-clinical pathway length of stay/cost = 9.8 days/$19,999

Pre-clinical pathway readmission/reoperation = 4 (6.3%)/4 (6.3%)
Post-clinical pathway readmission/reoperation = 10 (8.3%)/7 (5.8%)
(Both readmission and reoperation are measured within 30 days.)

To put all this into English, after the introduction of the clinical pathway, nothwithstanding a greater percentage of sicker patients, cost and length of stay decreased without negatively affecting mortality, readmission, or reoperation rates.

Patients and families also like the new pathway because they receive a roadmap of what to expect and when to expect it, and they can literally follow their own progress by looking at a chart on the wall of their room.

I don't mean to suggest that we are the only place to have clinical pathways, but they remain less prevalent than you might think. This is but one example to show how effective they can be when well designed and implemented by the entire medical team.

More Links

I have added some additional links to my list (on the right side of this page). I have found these to be well written, up-to-date and thoughtful commentaries on things going on in the Boston area -- and, yes, because they have cited my blog, too. (Hey, I told you they were thoughtful!!)

I include "Massachusetts Liberal" not to be exclusionary to conservatives, but because I have not yet run across an equally well written blog with conservative views. If you know of a good one, please send in a comment with its url.

What Works -- Part 1 -- PatientSite

The first in a series of innovations that work (!) and make a difference in patients' lives:

A recent story on MSNBC called "Tired of waiting for the doctor?" made reference to PatientSite, our user-friendly, personalized electronic communications link between patients and their doctors, using a secure website:

Most patients have experienced playing phone-tag to get test results. That’s at least partly because of the traditional paper-based method of relaying information. Test results are transcribed onto paper, then given to the doctor, who then phones or snail-mails them to patients.

At Boston’s Beth Israel Deaconess Medical Center, patients can get test results electronically the same time as the doctor through a private online account called PatientSite. “There is no waiting for paper printouts to arrive by mail,” said Dr. John Halamka. All test results show up on the site, except those involving diagnosing cancer or HIV, “assuming that this news should be delivered in person,” he said.

PatientSite has been up and running for many years, well ahead of most of the industry. Patients like the fact that they can use it for a variety of routine functions -- from requesting prescription renewals, to making appointments and getting referrals, to viewing their own electronic medical records, including medications, allergies and test results, radiology reports and electrocardiograms. Doctors like it, too, because it frees them up to spend person-to-person time with patients on more important matters.

The long-term success of PatientSite also means that it can be used to study other new ways to improve care. Here is an example funded by the Robert Wood Johnson Foundation.

Try out the demo!

Priorities

Even though Joan Vennochi pokes at me a little in today's column, I am glad to take the medicine for the cause she espouses. She sharply criticizes Governor Romney's recent budget cuts and issues a challenge to the new Administration, saying:

A lame-duck Romney is showing a willingness to exploit society's most vulnerable in order to look fiscally tough to a national audience.

But the future belongs to Governor-elect Deval Patrick and the Legislature. What will it be?

As always, Joan is a voice of conscience and political reality. Equally important, people on Beacon Hill read what she says, and she can often have an impact on the course of events. Let's hope so in this case in particular.

----

For those who did not read the piece to which she refers, here is the beginning of the op-ed co-authored by Dr. Jim Mandell, CEO of Children's Hospital, and me back in December 2005.

MORE THAN SOX AT STAKE IN TRANSPORTATION DEBATE

In 2005, the defending world champion Boston Red Sox squeezed a record 2,847,888 faithful through the turnstiles of its "lyric little bandbox of a ballpark." An average of 35,159 fans cheered their hometown heroes for each of 81 regular-season games.

In contrast, just down Brookline Avenue from Fenway Park, each year more than 14 million (more than 60,000 on any given day) patients and visitors, physicians and nurses, students and professors, medical researchers, administrators and others cram into the one-half mile radius of another jewel of Boston the Longwood Medical Area. Comprising 21 medical, academic, cultural, and religious organizations including Harvard Medical School and many of its affiliated teaching hospitals, as well as six colleges the area is one of the richest centers of health care, research, and education in the world and a major engine of economic growth in Massachusetts.

Greetings, Huntsville!

A note to our director of Emergency Services. No further comment necessary from me!

To: Mccool,Michelle (BIDMC - Director of Ambulatory/Emergency)
Subject: You Made Our Day

Greetings from the Emergency Department Staff at Huntsville Hospital in Huntsville, Alabama!

Ms. McCool.
The school bus accident involving several High School students made National news. Our Emergency Department treated most of the victims. Your ED nursing staff heard about the accident and performed the most honorable gesture; they treated our nursing staff to lunch. Today, Nov. 21, 2006, around noon, we received several pizzas with a note attached from the ED Nursing staff at Beth Israel Deaconess Hospital saying we are with you keep up the good work! It was an honor to receive this token of recognition. The President of the United States can bestow a token of appreciation upon an individual for a job well-done, but when colleagues bestow a gesture of recognition the meaning is far more substantial. We would like to say thank you, and, your staff made our day.

Attached is a picture of a few staff members who were on duty and treated the victims. I hope you receive it. The person holding the "N" is from Boston. This really touched her.

--
James Noland RN,MSN,CEN
Clinical Education Specialist
Huntsville Hospital Emergency Department

Albert Schweitzer Fellowship

Two years ago, BIDMC’s board of directors voted to enter into a sister hospital relationship with the Albert Schweitzer Hospital in Gabon, Africa. The new relationship recognized the shared values among BIDMC, Schweitzer and those who have carried out his legacy. BIDMC is honored to be home to the Albert Schweitzer Fellowship Program, which trains physicians to help unserved people throughout America and the world. Here are some details from their website:

In 1940, the Albert Schweitzer Fellowship was founded in the United States to support Dr. Schweitzer’s medical work in Africa during World War II. Since Dr. Schweitzer's death in 1965, the Fellowship has continued to provide direct assistance to the Schweitzer Hospital in Lambaréné and, and more recently, to underserved communities within the United States.

In 1978, the Fellowship began sending senior medical students from the United States to work at the Schweitzer Hospital in Lambaréné. Fellows work together with an international staff of Gabonese and expatriate professionals, providing skilled care through over 35,000 outpatient visits and more than 6,000 hospitalizations annually for patients from all parts of Gabon.

In 1991, the Fellowship launched its U.S. Schweitzer Fellows Programs, through which students in health professions and related fields carry out direct service projects in underserved communities in the United States. To date, more than 1,000 Fellows have contributed over 200,000 hours of service at hundreds of domestic community agencies.

Today, the mission of The Albert Schweitzer Fellowship is to reduce disparities in health and healthcare by developing “leaders in service” - individuals who are dedicated and skilled in helping underserved communities, and whose example influences and inspires others.

Please join us in supporting this wonderful program. Here is an easy link to tell you how.

Door-to-door salespeople

A short while ago, one of the commenters on a November 6 posting on union organizing said:

"Your argument that your meetings are evened out by home visits is likewise unconvincing. In case you haven't noticed, the door-to-door salesman is extinct. Why? Because Americans dislike having somebody knock on their door to talk to us about just about anything. Nor do we like getting calls at home. (Did you notice how popular the "do not call" registry is?)"

Today, we received a report that two of our nurses (at least) had SEIU representatives come to their doors this weekend. The representatives had long lists of addresses for our employees.

Oh, and as I noted on August 25, previously they had conducted a telephone survey.

So, I guess this commenter is out of touch with current organizing tactics. :)

By the way, we had heard rumors that the SEIU and the Mass Nurses Association had reached an agreement that the SEIU would not engage in organizing nurses. I guess that rumor was incorrect.

Awful news in mental health

I just read this notice from the Massachusetts Hospital Association:

"Department of Mental Health Commissioner Beth Childs has just informed MHA that, effective Wednesday, November 22, 2006, DMH will no longer accept inpatient admissions to any state DMH hospital or unit. In addition, DMH will restrict access to its residential programs. The Commissioner indicated that this action is being taken due to Governor Romney's recent 9C cuts to the DMH budget. This action will have a far-reaching negative impact across the entire health care system."

This is deeply troubling. Please understand that the state's funding for mental health programs was in no way overly generous before these cuts. We and others had already seen an overflow of violently disturbed patients from state facilities into our own hospitals, patients who were putting themselves, other patients, and caregivers in physical danger.

In the posting below, I termed the Governor's words on another topic to be "nasty." As I read the items in italics below, I realize that my focus on his speeches was misplaced and distracting from something far more important. Here, we are not discussing rhetoric: We are facing executed deeds. It makes me incredibly sad to be in a state where these actions would be taken. Read the items below and tell me if you agree.

Here is a detailed description of the cuts made by the Governor, sent to me by our chief of pyschiatry:

5011-0100 Administration 9C Cut $454,289
Elimination of 17 DMH staff positions, effective January 28th. Identified personnel positions include Central Office and Area program managers, licensors, housing coordinators, quality assurance staff, and managers who oversee services. As a result of significant staff reductions in previous fiscal years, these staff reductions will severely impact DMH’s ability to manage and operate ongoing client care functions.

5042-5000 Child/Adolescent 9C Cut $844,668
Elimination of 40 DMH positions comprising 37% of the DMH employees who provide direct care to children and adolescents in the community. 880 seriously emotionally disturbed children, adolescents, and their families will no longer receive case management services. Children/adolescents who are clinically screened for DMH continuing care inpatient/community services will wait longer in acute psychiatric settings, and there will be an increase in out of home placements. The affected employees are the linchpins of the child-adolescent system. They play a critical role in assuring that services from multiple providers are coordinated such that the child/adolescent’s mental health needs and all related issues, such as substance abuse, medical problems and educational problems are addressed.

Reduction in case management revenue in Fiscal Year 2007 of $600,000.
5046-0000 Adult Mental Health Services 9C Cut $1,900,000
Elimination of DMH research funding currently provided through contracted services with university medical schools. The DMH funding leverages over $10 million in external funding to support these programs. The direct service impact will be:
150 individuals with early signs of major mental illness who received treatment currently supported in research protocols will be terminated from the treatment protocols; elimination of training in crisis management; 90 families will lose supports and interventions for dealing with parental mental illness; and service system evaluations capacity will be eliminated.
Termination of 96 individuals from residential supported housing services providing essential in home supervision and supports. These supports include medication management, maintaining activities of daily living, maintenance of employment and housing. The residential services and supports currently enable these adults to effectively manage their symptoms and enhance their functioning, so they can live independently. Without residential supports many clients run a substantial risk of becoming homeless. This cut will lead to a shift toward more expensive interventions such as emergency rooms, acute inpatient care and homeless shelters.
This reduction will result in a loss of rehab option revenue in Fiscal Year 2007 of $390,000.

5046-2000 Homeless Services 9C Cut $ 260,098
5047-0001 Emergency Services and Community 9C Cut $ 369,812
5047-0002 Retained Revenue 9C Cut $ 787,427
The reduction in the three accounts listed above amounts to $1,417,337 in reduced funding. This will result in 243 individuals being terminated immediately from residential supported housing services. These individuals will lose essential in home supervision and supports. These supports include medication management, maintaining activities of daily living, maintenance of employment and housing. The residential services and supports currently enable these adults to effectively manage their symptoms and enhance their functioning, so they can live independently. Without residential supports many clients run a substantial risk of becoming homeless. This cut will lead to a shift toward more expensive interventions such as emergency rooms, acute inpatient care and homeless shelters.
This reduction will result in a loss of rehab option revenue in Fiscal Year 2007 of $552,762

5055-0000 Forensic Mental Health 9C Cut $500,000
Elimination of 9 FTE clinicians in Adult Court Clinics and 6.1 FTE clinicians in the Juvenile Court Clinics. Loss in will result in inability to provide needed evaluations and consultations to 6,942 adults in the District and Superior Courts and 366 children, adolescents and families in the Juvenile Court. Additional expected impact includes increased inpatient hospitalizations for statutory evaluations; increased reliance on DYS detention and adult bail incarceration, and increased utilization of adult detox services (particularly MASAC and Framingham State Prison)

5095-0015 Adult Inpatient Facilities 9C Cut $1,909,961
Reduction in DMH inpatient staffing in two critical areas: 57 direct care staff (nurses, and mental health workers) will be eliminated at the DMH operated continuing care inpatient facilities; and a reduction of 16 psychiatrists funded through Comprehensive Psychiatric Services contracts.
Direct Care and Psychiatrist staffing cuts at this level would jeopardize DMH’s JCAHO Certification and our ability to meet the Medicare/Medicaid Conditions of Participation. A cut of 16 psychiatrists will result in the lack of required attending physician capacity for 267 beds. DMH will therefore be forced to freeze all civil admissions to DMH inpatient facilities while it attempts to reduce its inpatient census. The simultaneous reduction in community services required by these 9C cuts grossly impairs DMH’s ability to discharge individuals safely.

Bravo, Derrick!

Derrick Jackson's column in today's Boston Globe, entitled "The antigay obsession", prompts me to write on a related topic. I have not used this page to comment on current political and social issues, preferring to focus on hospital topics, but I think this is important. And it does relate to medicine and the BIDMC, too.

Beth Israel Hospital was established in 1916 because of discrimination against Jewish doctors and Jewish patients. Open access was therefore a deeply held belief at that hospital, and it is a belief that persists with the new BIDMC. We welcome all ethnic, racial, religious, and cultural groups, and we do our best to treat everyone the same, i.e, as though they were members of our own family. This includes people of all sexual orientations: heterosexual, homosexual, bisexual, and transgender.

This is not only a matter of social justice. It is a matter of life and death. To discriminate on any basis whatsoever is to say that some people are entitled to better care than others. We just do not accept this.

Mr. Jackson's article cites people from religious organizations who say negative things about gay people and about gay marriage. I understand that homosexuality makes some people uncomfortable, and I also understand that gay marriage makes some people uncomfortable. What I don't understand is why they can't ease off and just leave people alone to live their lives.

Unfortunately, our own Governor Romney is in this camp. Fortunately, his term ends soon, and we will be rid of his distressing and nasty speeches on this issue in Massachusetts. Unfortunately, he feels that taking this position will help him in a run for national office, and so now he will express it in a bigger forum. I hope that the vast majority of people in the country agree with Derrick's column and with the people he quotes from South Africa, a country that truly understands discrimination: "This country cannot afford to be a prison of timeworn prejudices which have no basis in modern society."

Just bragging

In a posting below, I mentioned a story about bad service at our hospital. But, sometimes I hear stories about our folks that make me really proud to work here. So, here are three. I know I am just bragging -- so if you don't want to feel like you are reading a press release, skip this one! But, if you just want to feel good, read on.

My mother has been a patient in your gerontology department for the past year or so. I am completely blown away by the marvelous, compassionate care taking place there. Dr. B, one of the gerontology fellows, has been simply amazing, going over and above the call of duty. Even though she was working at the Brigham today, she stopped in to see my mother at her appointment--which was followed by hospitalization. Then Dr. M, who saw my mother today, pushed the wheelchair herself from her office to the ER. You should be so proud to have such dedicated professionals working for you.

From a trauma surgeon to the chief of pathology:

I just wanted to thank the Blood Bank personnel for their admirable work on behalf of [x]. If there is some way for you to share this message with them, I would appreciate it. It occurred to me afterwards that in the melee of such a bad operative trauma episode [patient crushed by heavy machinery], we lose track of the fact that there are dedicated folks buried deep in the hospital who feverishly are working with us to provide life-saving blood products, without which this patient certainly would have died.

A letter to one of our trustees:

I thought that I would write you a note to tell you about my experience as a new breast cancer patient.

From the moment that my doctor found the lump, I have been on a journey, one that is scary and emotional. Starting with the biopsy today I have had to see numerous doctors and have been taken care of by a group of compassionate, caring, professional nurses.

Dr. K was the first doctor that I saw. He talked to me for an hour listening to my concerns and answered all my questions. The surgery went very well, due in part to his outstanding skills, I am sure. Then I was off to Dr. R and Dr. L with my husband in tow. He wanted to get another opinion at Dana Farber, but after speaking to them, he didn't feel that it was necesary. They also spent a great deal of time with me going over my diagnosis and treatment opitions.

I am very lucky. I will need radiation for six weeks starting on the 29th of November and will need to take a Taxmofin like pill, then off to the rest of my life and great grandchildren.

It is important for me to let you know that your work for the BIDMC is paying off. If I have to go through the breast cancer then I know that I am at the right place.

AT&T and The Bell System (remember them?)

Steve Bailey, a Boston Globe columnist, offers an interesting column in today's paper about the market power and the behavior of the largest hospital and physician group in the state, Partners HealthCare System. The head of that group makes a cogent and thoughtful comment (as he often does) about the ambiguity in today's society about its desire for greater cooperation among health care providers and its wish for a competitive marketplace.

With respect, though, the comment misses the point that Partners could be more cooperative, still maintain its dominance, continue to be financially healthy, and could also enhance the efficiency of the overall system. Instead, it rationalizes aggressive stances in the marketplace with a supposed need to ensure quality.

What I have learned in my short time in this field, though, is that no single hospital or system has a monopoly on good ideas to enhance quality and efficiency. When one group puts up barriers to cooperation, everyone loses an opportunity to improve.

As a student of other industries, I also humbly suggest that protectionist behavior by a dominant provider also removes a key stimulus -- within its own system -- to encourage behavior that enhances quality and innovation and customer service. Remember Ernestine, Lily Tomlin's telephone operator?

Customer service?

We try really, really hard to be good at customer service. (This is in addition to offering very good medical care!) By customer service, I mean what the patient's experience is like when he or she calls on the phone or comes to the front desk. How well do we help each person navigate the unwieldy system in a big hospital? Often we do well, but sometimes we blow it! Here is an example of the latter:

I want to share a less than optimal experience, just so you know.

I have an appointment Thursday at Dermatology. I've been well reminded: a paper letter with map, two email reminders, and (tonight) a voicemail on the home phone. This is all fine. Clearly taking responsibility for making sure the patient doesn't forget, and doing it all automated, cost-effective.

However, I want to *change* the appointment, and that's not going so well.

Over the weekend I tried using PatientSite. No option to change apptmt.

Today during office hours I didn't get to it. Oops. So on the way home I called in. No menu option to change an appointment, but there's one to cancel. I selected that, to see what I'd get, and I got:

"The cancellation voice mailbox is full. Please call back during normal business hours."

No catastrophe - I'll deal with it, obviously - but not a particularly good customer experience.

Thanks!

So . . . we will keep trying to improve! We do learn from these comments, and we make changes in how we do things. For those of you out there who experience this or any kind of problem, please do not hesitate to write me.

My Congressman

I happened to listen on the radio last night to Congressman Barney Frank's speech last week to the Great Boston Chamber of Commerce. If I heard correctly, one of his points was that the new Congress should make it easier for unions to organize service employees, unlike industrial workers, because creating more unions in service establishments would not result in any competitive disadvantage to the US because those businesses can not move to other countries.

Do any of you out there have a reaction to this?

Isabel's story

Those of you living in eastern Massachusetts may have seen a recent television ad from Blue Cross Blue Shield of MA about a young woman named Isabel and her discovery of and treatment for breast cancer. The whole story is on the BCBS website and is really worth viewing.

Can I confess something? When I first saw the ad, I was a bit annoyed that BCBS was taking credit for this person's treatment, when in fact it was carried out by doctors and nurses at a hospital in the Boston area. (No, I don't know which one.) After all, what right does an insurance company have in owning this story?

But watching the full video convinced me otherwise. BCBS really did make a difference in Isabel's experience by providing an additional level of comfort and support beyond what was given by her caregivers and her family. That is terrific, and the people in the company deserve credit for reaching beyond the traditional role of an insurance company and displaying that extra degree of humanity.

And Isabel, too, deserves a lot of credit for telling her story. I am sure it will be an inspiration to thousands of people. Bien hecho, Isabel!

$8.60

That's the average annual investment per American in cancer research, in federal funding through the National Institutes of Health. The total federal investment per American in cancer research over the last 30 years is about $260.

What has this produced? Thirty years ago, when people were afraid to even mention "the Big C", we were only able to detect large, advanced tumors. There was virtually no early detection. Survival times were short. Only one child in 10 survived cancer. Treatment was highly uncertain and painful and required long hospital stays.

Today, for the first time, annual cancer deaths in the United States have fallen. There are ten million cancer survivors. Early detection and screening are more effective. New targeted, minimally invasive treatments have multiplied. New discoveries make it possible for the first time to "personalize" cancer treatment.

These facts and figures were contained in a recent presentation by Dr. Elias Zerhouni, Director of the NIH.

I don't know about you, but I think that is a pretty great return on investment!

A really good cause

As you can imagine, I am expected to attend fundraisers for many worthwhile causes. One of my favorites, from which I am just returning, is an annual breakfast in support of Health Law Advocates. HLA provides legal assistance to people who are having trouble gaining access or services in the health care system. I urge you to check out their website to learn more about the organization and see if you want to get involved.

In addition to the worthiness of the cause, the HLA breakfast is always a pleasure because of the quality of program (great speakers, music, humor) . . . and because it always ends on time!

Look for the union label

The gubernatorial election will be over tomorrow, so look for an increase in organizing activities here in Boston. The SEIU was an active participant in the elections, supporting some candidates with money, time, and effort.

On the issue we have covered in a posting below, both Deval Patrick and Kerry Healy are on record in favor of elections and said they would not support efforts to substitute a "card check" form of union certification. So, it is unlikely that this tactic will be pursued. But watch closely, and let's see if the union changes the debate slightly. Perhaps now it will be in favor of elections, but not the form of election carried out under the auspices of the National Labor Relations Board. Here is an example of arguments being used in an organizing campaign in Chicago.

Look for the union, too, to cite papers and articles from selected academic think tanks, which may point to successful management-labor partnerships at other hospitals. Of course, that is not the issue, is it? There are both successful and unsuccessful management-labor partnerships in both union and non-union environments. The issue here is the process by which workers get to choose whether they want a union or not.

Finally, if all else fails, look for aggressive tactics to discredit the management and the boards of hospitals who don't give in. All of sudden, the hospitals you have trusted to provide high quality care to all people will be pictured as having low standards, not caring about poor people or minorities, abusive of their workers, wasting federal research dollars, or worse. Trustees -- those generous unpaid volunteer lay leaders -- will find themselves publicly characterized as unworthy of supervising non-profit hospitals.

I can understand why a union might want to change the rules of the game to improve its odds of success. Will hospitals in the state accede to this, in response to pressure from the union and several of their friends in elected positions?

Man of Patients

Please read this lovely story from today's Boston Globe about George Geary, former CEO of Milton Hospital (for 18 years), who recently completed nursing school. George and I overlapped for a while as CEO's, and I was always impressed with his integrity, thoughtfulness, and caring. I am sure he is a great nurse! I wonder if we can recruit him away to join BIDMC . . . :)

More on Cookies

A few weeks ago (on October 18), I published the recipe for the world famous Beth Israel cookies. I received a number of oral comments and emails from people in the Boston area about this. Here is an exchange with one of our doctors, which tells you a lot about the culture of our hospital: (1) Everyone feels comfortable writing me with suggestions and comments; and (2) I take every suggestion seriously; (3) members of the administrative staff are undefensive and honest about steps being taken to improve the place; (4) running a hospital food service is like running a restaurant, with thousands of customers with a variety of taste and preferences; and (5) even doctors and nurses sometimes need a little treat to do the right thing, i.e, get their flu shot!

Dear Paul,
I was reading your blog last week with the old recipe for the much missed and wonderful BI cookies.

Today, I got my flu shot and a reward voucher for a cafeteria cookie, which I decided not to get because I try to avoid trans fats and suspect that the current hospital cookies (and other foods) are made with partially hydrogenated fats.

Is my concern correct? If so, as a health institution should we be asking our cafeteria to avoid using partially hydrogenated fats in the foods they prepare and sell?

Here is the reply from our director of hotel services:

Your message concerning trans-fat foods was forwarded to me; the food service is one of the departments I oversee.

We share your concern and we are taking steps to address it. First of all, the cookie you were offered for getting your flu shot is a trans-fat free product. We are converting to trans-fat fee items whenever possible, but some of our very popular items are not currently offered as such. For example, the jumbo cookies we sell in the cafeteria are not trans-fat free; as soon as they become available we will make the conversion. Earlier this year we began using trans-fat free fryer oil in both our patient and cafeteria programs. We are now offering more trans-fat free cakes, pies and crackers.

Our goal, like many food service establishments is to become totally trans-fat free, it will just take a little time. We will continue to look for and offer healthy options to our cafeteria customers.

Good government?

Now that all of you have teached me how to use this blog, I decided to try another one in a different arena. I was recently asked by the mayor of my city to chair a citizen's commission on municipal budget and finance issues.

I suggested to my fellow volunteers that it might be useful to the commission members and the public to have a blog in which people could exchange views and stay up to date on the activities of the commission. They agreed and have already used the blog for a healthy exchange of views on several issues. So far, we have not heard much from the public, but I am confident that will pick up steam.

So, if you are interested, take a look and see if this kind of site might be useful to you in similar activities.

Choices (for men only)

You learn you have prostate cancer, and you have been told that you need to have a radical prostatectomy to remove the diseased gland. You have a choice of an "open" procedure or a laparoscopic procedure. (By the way, we offer both at BIDMC.) How do you choose? What are the pro's and con's?

I attended a recent seminar of this topic -- yes, you get to do this kind of thing when you run a hospital -- and I was surpised to learn from our Chief of Urology that the case is not at all clear cut. I had thought that the laparoscopic procedure would be a clear winner on many counts, but there are arguments to be made on both sides.

I am giving my layperson's interpetation of what I learned, so please don't rely on this. Check with your doctor or the literature for a more accurate reading on the matter. Medicine being an inexact science, there are bound to be lots of opinions.

Since men only are reading this posting -- hold on, maybe some women readers joined us and are interested in this question, too -- I know that your first question will be about potency rates after the surgery. The answer: Similar results.

OK, what about effectiveness in removing the cancerous tissues? Similar results.

What about returning to regular life activities? With open surgery, doesn't the open incision mean a longer recovery time? No, postoperative pain is comparable in the two cases, and men can return to activities just as quickly despite an incision.

And so on, and so on. Are you surprised like I was?

Here's my pitch, instead

If Alice (below) can sell useless plaques, let me instead try again to sell something more practical. For those of you arriving recently, I repeat my posting from several weeks ago. (If enough of you buy this, I won't have to clog up my blog with repeated advertising!)

"A couple of years ago, we published a wonderful book on the subject by Monique Doyle Spencer, which is designed to help people who have the disease understand and cope with many aspects of the treatment process. We published the book because it is funny, and commercial publishers felt that it was inappropriate to have a humorous book dealing with cancer. We thought it deserved public exposure. It is called, 'The Courage Muscle, a chicken's guide to living with breast cancer.' After my mother-in-law read it, she said, 'I wish I had had this book to read during my treatment.' Many others have said the same thing, and the book's reputation has spread by word of mouth and occasional newspaper columns and Monique's interviews on television and radio.

You can buy it from Amazon, but if you buy it from the hospital instead, the proceeds go to support Windows of Hope, our non-profit oncology shop that sells wigs, scarves, and other supplies for cancer patients. Just send a check for $16.95 to Windows of Hope, 330 Brookline Avenue, Boston, MA 02115, and we will mail you a copy. Or call 617-667-1899."

I thought I had seen it all

We have a very good email system that intercepts a lot of the spam being sent out, but sometimes things slip through. As you can imagine, companies are trying to sell us all kinds of this. This morning, one arrived that I never could have imagined.

Here's the text:

Congratulations Paul on being recognized by The Chronicle of Philanthropy as one of The Philanthropy 400!

We prepared an online preview of your handcrafted special edition plaque for your review. Click here to personalize, customize and preview your plaque. Only 3 business days left to SAVE $30 on your order (order by Nov 6th, 2006).

If clicking on the link doesn't work, please copy and paste the entire address into your web browser or follow these simple instructions:
Click to the following website: www.amreg.comEnter Preview Code: 3262340

Now, with just a few clicks of your mouse you can prepare your plaque exactly the way you want it:
* PERSONALIZE the wording, font size or style.
* CUSTOMIZE your favorite wood finish and choose gold or silver for the wood trim.
* PREVIEW the plaque exactly as it will be delivered.

Please do not hesitate to call or email me with any questions. I would be happy to walk you through the simple steps of customizing your plaque.
Alice Sydney
1-866-964-0866 x8330
asydney@amreg.com

Here would be my response to Alice Sydney:

Dear Ms. Sydney,
America is a great country, full of entrepreneurial ideas. I guess your company figures there are people out there who would actually buy a plaque to commemorate the fact that their hospital raised a lot of money. Personally, I am extremely grateful to generous people in our community for their contributions to our clinical programs, our teaching, and our research. We could not survive and thrive without their help. But I am hard-pressed to figure out why anyone would buy this and where one would hang such a plaque. I guess some CEOs find comfort or excitement in this kind of self-congratulatory pat-on-the-back that could be placed in their offices; but if I had the spare cash to buy your plaque, I would instead donate it to the hospital.
Sincerely,
Paul Levy

And, by the way, did you notice that the sales pitch has the wrong name of our hospital . . .

:)

Clean Hands

The disk on the left shows bacteria colonies that grew from my hand before it was washed with a disinfectant. The disk on the right shows the number of colonies that grew from my hand after it was cleaned with the waterless, alcohol-based antiseptic that is in dispensers outside every patient room in our hospital.

It has been well documented that many infections in hospitals occur because of bacteria transferred from one patient to another when nurses or doctors do not wash their hands between seeing patients.

The New England Journal of Medicine published an article on this topic in July, 2006, entitled "System Failure Versus Personal Accountability -- The Case for Clean Hands," by Doctor Donald Goldmann at the Institute for Healthcare Improvement. His conclusion: "Each caregiver has the duty to perform hand hygiene -- pefectly and every time." "Yet, compliance with hand hygiene remains poor in most institutions -- often in the range of 40 to 50 percent."

It is inconceivable to those of us who are not doctors or nurses that caregivers would not follow simple standards for hand hygiene. We wonder why it does not occur. The article provides good background information on this topic.

Our clinical chiefs and senior adminstrators know that our hospital needs to have high performance in this arena, and we are strengthening our encouragement for this behavior through both positive reinforcement and penalties. As an example, our Chief of Medicine recently wrote the following to his staff:

Appropriate patient care requires that immediately prior to and following each patient encounter anyone having contact with the patient will cleanse the hands thoroughly, using either hand washing or the alcohol-based hand cleansers that are available everywhere in our environment. Anything less than perfect compliance with this standard (except in the case of a patient emergency requiring immediate intervention) represents substandard care which we will not tolerate.

To make this more clear: Everyone (including students, trainees, and faculty who may not expect to touch the patient when they approach) who enters a patient room or an exam room must clean their hands immediately before and immediately after the encounter. In addition, we are all responsible for ensuring that everyone on the healthcare team -- from attending physicians to environmental services personnel --practices scrupulous hand hygiene. Our task is to lead by example through good practice, to notify other healthcare workers if they forget to perform hand hygiene, and to respond respectfully when others do the same.

Please help us to ensure the finest care for our patients by adhering to and insisting upon proper hand hygiene.

Again, we lay people might wonder why it is necessary to provide such advice and reminders to people who have been trained in medical school; but since it is apparently necessary, my colleagues at BIDMC and other hospitals will continue to do so.