Students: The future is in primary care

An anonymous student asks:

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

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

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

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

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

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

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

St. Thomas Charoset

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

Panama (St. Thomas style) Charoset

From Inez Brandon Fidanque (1892-1991)

Recorded by Emma Fidanque Levy (1920-2005)

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

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

---

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

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

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

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

It's not easy being green

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

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

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

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

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

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

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

Call-in show today on transplants

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

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

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

Students, are you curious?

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

CareGroup -- Together again?!

This one takes a little explanation. Back in the 1990s, CareGroup was established to be an integrated health care delivery network comprising BIDMC, Mt. Auburn Hospital, New England Baptist Hospital, and several community hospitals. That idea failed miserably, as documented in a couple of posts below. Each hospital went its own way, clinically, although we remain tied through a bond indenture.

How ironic then, to see the Boston Herald report that the three main CareGroup hospitals have independently decided to post infection rates and other items related to patient safety. Does this mean we are an organization?! More important, can this ever be a movement?

As Arlo Guthrie said in Alice's Restaurant, in a very different context:

You know, if one person, just one person does it they may think he's really sick. . . . And if two people, two people do it, they . . . won't take either of them. And three people do it, three, can you imagine, three people . . . They may think it's an organization. And can you, can you imagine fifty people a day . . . And friends they may think it's a movement.

Birds and cowbells

With two city planning degrees from MIT, I think of myself as a well-trained observer of the urban scene and streetscapes in particular. But every now and then, I miss something so dramatic that it makes me want a partial refund on those degrees.

Driving into town the other day on Beacon Street, I saw a rather large bird perched on a street lamp fixture. "Wow," I said, "Look how calmly that large bird is hanging out in the midst of the hustle and bustle of the city." Then, it didn't move. And, as I got closer, I saw that it was a sculpture attached to the lamp post. Then, I noticed there was one on each lamp post at Audubon Circle (the junction of Beacon Street and Park Drive).

"Must be something new," I thought. WRONG! They have been there since 2005, as part of a civic art program encouraged by Mayor Menino. I have attached pictures, for those of you living out of town. For those of you in town, if you haven't seen these, take a gander (!). They are a wonderfully whimsical addition to the streetscape. And, thanks Your Honor, for brightening up our city. (And thanks to a good friend for taking these pictures yesterday. Oddly, I could not find any public images of the collection on the web.)

But cowbells, you ask? I won't give this one away just yet, but there a several cowbells hung in very strategic public places in the vicinity. Submit your nominations here.

Herding geeks deserves an award!

The Workgroup for Electronic Data Interchange (WEDI) announced that it has presented our own Dr. John Halamka with the 2007 Louis Sullivan Award, recognizing individuals who have distinguished themselves through their leadership, vision, and achievements in advancing the overall quality and efficiency of healthcare. Congratulations to John!

John chaired the ANSI-affiliated Healthcare Information Technology Standards Panel (HITSP), comprising over 200 public- and private-sector members. In January, HHS Secretary Michael Leavitt accepted the recommendations of HITSP to create 30 consensus standards that enable health care data interoperability in the United States. This sounds pretty arcane, I know, but you need these kind of standards to allow computers and disparate organizations to talk to one another electronically. This enabled an executive order that requires any new or upgraded federal health information system launched after January 1, 2008, to be compliant with standards recommended by HITSP. Agencies administering or supporting health insurance programs and government contracts for purchasing health care -- i.e., virtually everybody -- will be directly affected.

WEDI notes: "Dr. Halamka's efforts for HITSP, and his many other industry roles, demonstrate his regional and national leadership in the healthcare industry on how to use and leverage the industry's collective knowledge, expertise, and information resources to improve the quality, affordability, and availability of healthcare.

"The award is named in honor of former HHS Secretary, Louis Sullivan who in 1991 was instrumental in the creation of WEDI and initiating the healthcare industry's ongoing collective commitment to improving the quality, efficiency and cost-effectiveness of personal healthcare through the development and implementation of standards for administrative simplification. The award was first presented to Dr. Sullivan in 2001 and recognizes individuals who have distinguished themselves through their leadership vision and achievements in advancing the overall quality and efficiency of healthcare."

As I have noted elsewhere, back here at BIDMC, John is designing and implementing a marvelous clinical and administrative information system for our hospital. Check out some of his projects. Meanwhile, a prize to the real geeks out there who can name the computer shown above . . . .

Poetry in Motion

Nancy Turnbull, at the Harvard School of Public Health, has broken through the mysteries of health care reform, offering poetry where policy debates and economics have often failed. Frankly, I was hoping things would move in this direction.

Does anyone out there think this would have happened in any other state in America? I doubt it. In other countries, yes, but probably in a different medium. In New Zealand, this would have been sung in Maori. In Italy, portrayed as delicate marble sculpture in the Borghese Gallery. In India, as lapis, coral, and other precious stones inlaid in alabaster. (OK, I'll stop . . . .)

For this and your previous post, thanks for brightening our day, Nancy!

Congratulations to Ben and team!

Blue Cross Blue Shield of Massachusetts announced today that its first ever Health Care Excellence Award will be presented to BIDMC for the work done by our OB/Gyn Department in team training. I wrote about this program in a post on January 20. After a series of terrible errors, the department (along with folks from other departments), reevaluated its approach to quality, safety, and communication. Under the leadership of Chief Ben Sachs, the group learned how to apply "crew resource management" techniques to enhance their ability to carry out obstetric procedures. Ben has since become a proselytizer and instructor of these techniques to many people throughout the country.

The award will be formally presented at a BC/BS conference at the Parker House in Boston on April 2, entitled High Performance Health Care: What It Takes.

Congratulations to Ben and the whole team! And, many thanks to Blue Cross Blue Shield for this recognition and honor.

Wednesday is Student Day

In my post below, I invited students of all persuasions to write in with questions and comments and promised a weekly response. (Also, I answered some immediately.) Let's decide that Wednesday is Student Day and, I will try to have a more extensive response to one or two questions on this day each week.

Andrew Calvin asks:

I know residencies are increasingly incorporating systems improvement curricula, and it seems some academic medical centers are starting to recognize systems improvement work as a valid career path (in addition to the clinician-researcher and clinician-educator). In terms of university faculty promotion the clinician-educators have struggled to quantify and prove their worth to their departments (vs. the more easily quantifiable publication record for the clinician-scientist), and I'm wondering how the "clinician-systems improvers" (not even sure if that's the right term) can get fully recognized for their contribution and justify their academic promotion to their university department. Perhaps that's outside your area of expertise but I'm curious to your take given your unique vantage point. How do these people get recognized/promoted/etc by the hospital, whether it's an academic hospital or not?

Are you noticing an increased activity level in SI work from your clinical staff, in particular from MDs? From your perspective, do you think there is a large or growing demand in both the academic and private sector for those SI-focused clinicians? Do you see an increasingly diverse group of clinicians getting involved in this type of hospital administration (MDs, PharmDs, RNs, RTs, etc)?

How does an SI project work between a hospital administration and a university department that staffs it - who typically is in charge? What sorts of backgrounds/training/experience have you seen that seems to help these individuals?

It is my impression that the academic promotion system is lagging behind the needs of the profession on this front. As you have seen from several posts on this blog, there is a real and extensive need for people to be engaged in system improvement study, planning, and implementation. The techniques of service and industrial process improvement that have been used for years in other service and production industries have not yet been fully incorporated or appropriately modified in a great number of hospitals.

I believe there are serious structural and/or sociological reasons for that in medical communities. First among those is that medical students, residents, and junior faculty generally do not get professional recognition for having strong interpersonal skills or engaging in teamwork. In academic medicine in particular, you are trained to be decisive and act as an individual in the clinical setting, and you receive professional recognition in the research arena for the work you do as an individual. Systems improvement activities, in contrast, require an ability to interact well with others at a personal level and to create teams to accomplish mutually agreed upon goals.

Second, in many hospitals, there is a divide between the administrative people and the medical staff. They come from different backgrounds, have different training, and find personal satisfaction in different ways. In some sad places, the relationship between the two groups is downright toxic, with MD considering administrators as intelligence-deficient and administrators considering MDs as stuck-up egotists. Even when the relationship is exceptionally good, the difference in perspectives and approach to problem solving can get in the way. (A friend of mine once said that doctors use inductive reasoning and administrators use deductive reasoning -- dunno, maybe she was right.)

But what does that have to do with academic promotion? Well, if your department or division chief does not see the value of your time spent in system improvement research, planning, or implementation, you are rowing upstream with regard to academic promotion if you have made that a cornerstone of your time on the faculty. If he or she does see the value, then you will have mentoring and support to use that aspect of your time towards either the research or teaching professional advancement path.

What's the strategy then? In choosing a hospital, find a place where these activities are strongly encouraged by the academic leaders. Then, design a career path that enables you to design and publish academically sound research studies in the field. Our Triggers group, for example, designed their program from the get-go as an academically sound experiment, and they fully intend to produce peer-reviewed journal papers on the subject. So did our Team Training group.


I cannot speak for how quickly academic medicine more broadly will endorse system improvement as a field. Perhaps you would more wise to term your activities the "science of care," but even then I see somewhat slow acceptance in some quarters. But rest assured, these activities are crucial to the future of the health care field. This is being driven by cost pressures on the industry and by a public that is ever more knowledgeable of the outcomes delivered in a hospital, as contrasted with its reputation. You will not go wrong by studying, experimenting, and implementing programs in this arena.

On your final question, who is in charge of a given system improvement activity in a hospital? The best administrators know that a program will not work unless there is a medical champion. The smartest doctors know they need a strong administrator to help. So, the most effective programs occur when a medical champion teams up with an administrative leader to garner the best of their respective learning and teaching styles and to tap the experience and skills of both disciplines. (Usually, the MD is deemed to be in charge, but it is actually a co-chairmanship.)

In saying this, I do not mean to leave out others. The Lean program described below is based on a multi-disciplinary team -- MDs, administrators, front-desk staff, medical and technical techs, respiratory and physical therapists -- as inclusive a group as possible to study, design, and implement change. Whether as part of a Lean process or more generally, everyone has something to contribute, and your job as MD leader is to be extremely respectful to people who, frankly, you often wouldn't talk with (and -- admit this now -- sadly, not even notice!) in the course of your daily activities. My best ideas often come from the clerical staff, housekeepers, transporters, food service people, surg techs, and lab techs -- those hard-working and extremely devoted people "on the ground", closest to patients, who are excellent observers of the human condition, and who are watching what is really happening.

So, by all means, pursue this arena. Look for a hospital where you will get strong support from your academic chief of service. Then, look for allies on the administrative side. Show respect to all those who work with and around you. Trust me, you will get noticed, and you will find yourself busier and more engaged than you would have ever thought possible!

A Lean machine

Virginia Mason Medical Center in Seattle has become famous as the hospital in America that has most dramatically endorsed the Toyota Lean Production System. The senior administrative and medical team, led by CEO Dr. Gary Kaplan, started the process with a visit to Japan and then designed a hospital-wide program to bring greater efficiency to many aspects of the institution's operations. They entitled their program the Virginia Mason Production System and made significant improvements in many aspects of health care delivery.

At BIDMC, we were not prepared to go quite so far as VM, but we did create a small office to test out the heart of the Lean process, Rapid Process Improvement Workshops. In these short-term intense exercises, a team of people from a variety of jobs categories in a given service or production area get together to map out every step in a customer service or production process. Each step is labeled as "value added" on "non-value added", i.e., with regard to accomplishing the objectives of the area, and then the group decides on strategies to eliminate NVA steps. Then, they actually put them into practice to test their efficacy towards meeting goals of service quality and/or efficiency. Other, longer terms plans and objectives are also decided upon and put in place.

One target area for us was our orthopaedic clinic. Like most clinics, there would be check-in, delays waiting to see a doctor, delays waiting for an X-ray, delays waiting to see the doctor again after the X-ray, and so on. In sum, the average time for a clinic visit was about three hours. Is there any doubt as to why there were disgruntled patients, cranky front-desk staff, frustrated X-ray technicians, and angry doctors?

With great support from our Chief of Orthopaedics, a team was assembled, and they went to work, aided by our Lean coordinator and other helpers. The top chart above shows how many NVA steps (the ones with red dots) were in the "before" process, i.e, the "current state". (Observers often find that over 90% of steps in any service or production process are NVA.) The "final state" chart underneath shows the change in relative NVA and VA steps after the Lean review.

The third chart shows the overall improvement in the amount of time a patient has to spend getting that X-ray and physician consult: Down from three hours to about an hour! Let's repeat that. Previous time for a visit -- 187 minutes. Hoped for target by the Lean team after its analysis -- 84 minutes. Actual results -- 6o minutes or less.

Of course, patients were happy. The staff was very pleased, too. Fewer cranky patients at the front desk complaining about long waits. Efficient use of X-ray equipment and Rad Techs' time. And, doctors being able to stay on schedule all day long. And then being able to add additional appointment slots because they knew they could stay on schedule.

The biggest problem: Patients finished their appointments so quickly that their spouses were nowhere to be found. They were still downstairs at the cafe having a cup of coffee, without enough time to read the whole newspaper!

Forbidden Pleasures

I lied. This is really about forbidden abbreviations. But I will do anything for more readers. (No, not really anything....)

One safety improvement I have learned about during the past several of years was the effort to prohibit certain medical abbreviations. This is a Joint Commission requirement, and it is a really, really good one.

For those of you non-medical folks out there, let me provide some examples relating to medication dosages. Now, you have to imagine these things being written in a doctor's handwriting to get the whole point. (Admittedly, this is corrected with computerized order entry, but that still does not exist everywhere.)

Trailing zeros. If you write a dosage that is supposed to be in whole units like this -- 1.0 mg -- it will often be read as "10 mg". That is a big difference, an entire order of magnitude. So the rule is "don't use terminal zeros for doses expressed in whole units." So it is properly done like this -- 1 mg.

Missing leading zeros. In contrast, when a dosage is a fractional amount, it is unacceptable to leave off the zero, like this -- .5 mg -- because it is easy for the decimal not to be seen and the dosage read as "5 mg", another order of magnitude problem. So the rule is to always use a preceding zero when the dose is less than a whole unit -- 0.5 mg.

You have to use some imagination for these next two, but remember, some people have really bad handwriting! An international unit was often called an IU. With bad handwriting, this could be read as "IV" (intravenous) or "10" (ten). The solution: Write out "international unit." Ditto for unit, or U, which could be mistaken for 0 (zero); 4 (four); or cc (cubic centimeter). So, it is now written out as "unit".

For frequency of medication, the old QOD, every other day, is gone. The "O" can be confused with a period, as in Q.D (once per day). What's the new terminology? -- "every other day."

When these requirements were first introduced, there was substantial resistance from some in the profession. That is pretty much past now, as people have become retrained, but there is occasional backsliding. I hope the medical schools are teaching the new rules so we don't have to retrain all those interns!

Welcome World!

One of the pleasures of this blog is to check each morning on StatCounter.com and see where people have come from to view it during the night. (StatCounter does this by viewing incoming ISPs, so it is not entirely accurate. It also just keeps a running total of the last 100 visitors -- unless you buy a larger log size.)

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

Regardless of where you are, welcome! Come back often. Tell your friends. And, please, especially those from outside of the US, feel free to submit comments. Also, wherever you come from, please read the extraordinary writing in the post below.

Comes the Peace

I just met a remarkable man who has written a remarkable book. His name is Daja Wangchuk Meston, and the book is called Comes the Peace, My Journey to Forgiveness (Free Press, 2007). Here is the excerpt that he read at a gathering tonight. I dare you to read this and then tell me you don't want to read the rest.

Chapter Four -- Ordination

Disillusioned about her own unhappy childhood, my mother was determined that I would not grow up as she or anyone in her family had, seduced by wealth and fame, drugs and booze. The surest way was to physically remove me from her childhood home. Temptations that haunted her in Beverly Hills would never be a part of my life in one of the poorest countries of the world.

She could think of nothing better for me that memorizing scriptures, sitting at the feet of the lamas, and one day, after having mastered English in classes, traveling around the world with them as their able translator. In her eyes, I could be a Buddhist teacher, greatly appreciated and respected. Wearing maroon robes and going barefoot, I wouldn't be troubled with appearances. My days would be deliciously spent in spiritual texts, exploring questions that really mattered -- like "What is compassion?" -- and engaging in lively debates with wise men. As a monk, I would learn morality, empathy, suffering, and the nature of impermanence, things she says she never learned in school. Protecting me from evil was her was of showing love for me.

And so, after consulting with her lama, my mother arranged to have me sent to the monastery at the age of six to spend the rest of my life as a Buddhist monk. In the Tibetan culture, it's not unusual for young boys to go into the monastery. She thought I would learn not to need her, as she had learned not to need her own mother.

I can't help but feel there was the matter of convenience. She being a nun, I being a monk, we would both be consumed with spiritual studies, and she wouldn't have to worry about being a mother to me in the traditional sense. We could grow blissfully spiritual, but independently, without me needing her guidance or affirmation, she assumed. Our lives could follow parallel paths and never have to intersect and intertwine. I would get what I needed from the monastery and the teachers there and not have to bother her. Moreover, I would be so isolated I wouldn't even realize I was missing something.

There was only one problem: I shared none of my mother's aspirations for myself and she never supported mine. We were pursuing the exact opposites.

Best of health care jokes

STOP: Skip this posting and read the one above it! This is like cotton candy compared to real nourishing food above.

Another high risk posting, this of health care-related jokes I have received over the years. This is problematic in that I have discovered that most medicine-related jokes are offensive or demeaning in some way. I do not repeat those -- or even admit whether I find them funny or not! -- and so you have to help me to decide if the remaining ones make the grade.

---

Hospital regulations require a wheelchair for patients being discharged. However, while working as a student nurse, I found one elderly gentleman -- already dressed and sitting on the bed with a suitcase at his feet -- who insisted he didn't need my help to leave the hospital.

After a chat about rules being rules, he reluctantly let me wheel him to the elevator. On the way down I asked him if his wife was meeting him.

"I don't know," he said. "She's still upstairs in the bathroom changing out of her hospital gown."

---

A mechanic was removing a cylinder-head from the motor of a Harley motorcycle when he spotted a well-known cardiologist in his shop. The cardiologist was there waiting for the service manager to come take a look at his bike when the mechanic shouted across the garage, "Hey Doc, want to take a look at this?"

The cardiologist, a bit surprised, walked over to where the mechanic was working on the motorcycle. The mechanic straightened up, wiped his hands on a rag and asked, "So Doc, look at this engine. I open its heart, take the valves out, repair any damage, and then put them back in, and when I finish, it works just like new. So how come I make $39,675 a year and you get the really big bucks ($1,695,759) when you and I are doing basically the same work?"

The cardiologist paused, smiled and leaned over, then whispered to the mechanic...''Try doing it with the engine running."

---

For those of you in a quandary when considering your health insurance options, I offer the following Q and A:

Q. What does HMO stand for?
A. This is actually a variation of the phrase, "HEY MOE." Its roots go back to a concept pioneered by Moe of the Three Stooges, who discovered that a patient could be made to forget the pain in his foot if he was poked hard enough in the eye.

Q. I just joined an HMO. How difficult will it be to choose the doctor I want?
A. Just slightly more difficult than choosing your parents. Your insurer will provide you with a book listing all the doctors in the plan. The doctors basically fall into two categories: those who are no longer accepting new patients, and those who will see you but are no longer participating in the plan. But don't worry, the remaining doctor who is still in the plan and accepting new patients has an office just a half-day's drive away.

Q. Do all diagnostic procedures require pre-certification?
A. No. Only those you need.

Q. Can I get coverage for my preexisting conditions?
A. Certainly, as long as they don't require any treatment.

Q. What happens if I want to try alternative forms of medicine?
A. You'll need to find alternative forms of payment.

Q. My pharmacy plan only covers generic drugs, but I need the name brand. I tried the generic medication, but it gave me a stomach ache. What should I do?
A. Poke yourself in the eye.

Q. What if I'm away from home and I get sick?
A. You really shouldn't do that.

Q. I think I need to see a specialist, but my doctor insists he can handle my problem. Can a general practitioner really perform a heart transplant right in his/her office?
A. Hard to say, but considering that all you're risking is the $20 co-payment, there's no harm in giving it a shot.

Q. Will health care be different in the next century?
A. No, but if you call right now, you might get an appointment by then.

---

The Board of BIDMC, feeling it was time for a shakeup, hired Paul Levy to be the new CEO. This new boss is determined to rid the institution of all slackers and bring real fiscal discipline.

On a tour of the facilities, Paul notices a guy leaning on a wall near the staff lounge. The room is full of doctors, nurses and aides and he wants to let them know he means business!

The CEO walks up to the guy and asks, "And how much money do you make a week?" A little surprised, the young fellow looks at him and replies, "I make $300.00 a week. Why?"

Paul, towering over the guy, then hands him $1,200 in cash and screams, "Here's four weeks pay, now GET OUT and don't come back!"

Feeling pretty good about his first firing, a slightly taller Paul looks around the room and asks, "Does anyone want to tell me what that goof-off did here?"

With a sheepish grin, one of the radiologists, mouth full of pepperoni, mutters, "He is the pizza delivery guy from Dominos...."

---

True menu listing from our cafeteria:

Whole Wheat Pasta w/ Summer Vegetables Deglazed w/ Marsala Whine

What Works -- Part 6 -- Triggers

If you are a patient in an academic medical center, who is watching over you in the middle of the night? Chances are it is a young nurse or intern, among the least experienced people in the hospital. Do these folks have the judgment and experience to respond to potential patient instability?

So imagine, on a regular late night visit to the room, a nurse notices that a patient has developed a fast respiratory rate, a drop in blood pressure, a drop in blood oxygen saturation, or a drop in urine production. S/he needs to make a decision about whether to call the intern. When the doctor returns the call, s/he needs to decide whether or not to actually come to see the patient -- or to just make treatment recommendations over the phone. Then, the intern needs to decide whether or not to wake up a more senior resident or the attending doctor in charge of the patient -- or to make the decisions around changing the plan of care autonomously.

The next morning, after rounds, the attending or another senior physician arrives and decides that there is a need to change the patient's treatment regime or even move the patient to the ICU because of a severely deteriorated condition. Hours of proper attention have been delayed, and the treatment plan now has to make up for lost time.

Or worse, before the attending arrives, the patient suffers cardiac arrest and a "code blue" is called to resuscitate the person.

Extreme example, maybe. Exaggeration of the usual mode of care, no.

When a patient on a medical or surgical unit becomes unstable, early intervention can be very important. Knowing this, the Institute for Healthcare Improvement has recommended that hospitals deploy a response team at the first signs of a patient's decline. But, how do you make sure this happens in the middle of the night? Standardizing a response makes a lot of sense when you think about the complex communication systems that exist in most hospitals.

In 2004, a series of events led us to recognize the need to change. First, a journal entitled Critical Care Medicine published an article in April on rapid response teams that caught the attention of our ICU doctors. Next, we had two very serious adverse events in which well-meaning, very involved junior providers did not recognize the tempo of patients' deteriorating condition. Our folks analyzed those cases and concluded that the care patterns for "acutely decompensating inpatients were complicated, sometimes disorganized, and had multiple single-point failure modes." Among other things, we conducted a survey of our house staff (i.e, the interns and residents) and found that they would contact attending physicians for many acute patient events only about 25 percent of the time. This suggested an area for major improvement.

(But first, an aside. Why wouldn't an intern or resident call the attending physician? Part of the mentality of medical training is an overstated belief that you don't really learn unless you do it yourself. Young doctors often believe that it will be viewed as a sign of weakness to call for help. Their senior residents reinforce that belief, based on their own training.

Another factor is the outright fear of calling an attending physician at 2:30 in the morning and getting the following response: "You woke me up for THAT?! What did they teach you in medical school anyway???")

Here is how things are today at BIDMC. The nurse notices that the patient has developed a certain condition, based on a standardized set of criteria (Triggers). The nurse is required to call the doctor, the senior nurse in charge and the respiratory therapist -- and they all come to see the patient. They collaborate on a plan of care for the patient going forward. Regardless of the time of day or night, the intern/resident then calls the attending doctor in charge of the patient to let him/her know that the patient has "triggered".

The standard set of Triggers we use are based on changes in heart rate, blood pressure, oxygen saturation, urine output, an acute change in the patient's conscious state, or marked nursing concern. Wait, what is this one called "marked nursing concern"? This means that if the nurse has any concern whatsoever about the patient, based on observation or instinct, s/he is authorized to call a Trigger. It turns out that this last criterion is just as valid an indicator of patient distress as the more quantitative measures. (This will come as no surprise to nurses or to those of us who highly respect their judgment!)

So how much of a difference has this made? Over the course of the past year we have have observed significant reductions in "code blue" cardiac arrest events and a significant reduction in relative risk (a 47% decrease) of non-ICU death for our patients. We are also learning a lot about teamwork, communication and systems of care as a result of closely reviewing our responses to Triggers that are called.

One side effect of this improved coordination of care and the decrease in frequency of "code blue" events is that we now need to use our simulation center to train more of our interns, residents and nurses so they can get enough experience resuscitating patients! What a lovely problem to have . . . .

Students, it is your turn

A comment from CK on a blog called Marketing Profs: Daily Fix,

I'd love to see a CEO run a blog that solicits questions from students (college or MBA) and then he/she answers one a week.

Let's try it out, but expand it to all schools. Students out there, do you have a question you would like me to answer? It is OK to be anonymous if you want, but please indicate what school you attend, your degree program, and your year.

Navroz Mubarak!

Happy new year to our friends from Hike4Life! (Madagascar pictures courtesy of Rabiyyah. Thanks!) BTW, the flower shown is the Madagascar periwinkle, Catharanthus roseus, from which a derivative comes that is used to make a medicine that reportedly decreases mortality among leukemia patients.

Thank you, social workers

I sometimes say that our doctors and nurses cure the patients, but the social workers heal the families. The Social Work Department has a pervasive presence in the hospital by assisting patients and families with a huge range of problems. Social workers are the unsung heroes in many regards, helping patients and families through extremely stressful situations.

But beyond patient consultations, the department also is involved in many special programs that are highly regarded: Celebration of Life; DriveWise; more than fifteen support groups for patients and families; the Room Away from Home program, annually providing housing for hundreds of needy out-of-town patients and families; Cancer Navigator, a program designed to assist patients of color to access and utilize cancer services; the patient special needs fund; and the Patient-to-Patient, Heart-to-Heart volunteer program for cancer patients.

Several years ago, our hospital was in financial meltdown, and the social work department was a target because so many of its services were not reimbursed by insurance companies. In fiscal year 2000, the department had about 43 FTEs. By 2002, it had been cut to 28, a reduction of 15 FTEs or 35%.

Even though we were in dire financial straits, I decided that we needed to enhance our social work staff and program. We needed more people, and we needed to put more money into professional development programs to maintain the expertise of our staff.

In our 2003 Strategic Plan, I challenged our Board to expand this program and other programs that had shrunk over the years but that were important to help maintain our reputation for warmth, caring, and compassion, and to prove our commitment to the neighborhoods of Boston. As I look back at it now, I made what was a rather pushy request:

The cost of [expanding these programs] rises from approximately $500,000 in fiscal year 2004 to $1.3 million in fiscal year 2007. Our strategic recommendation is that the Board of Directors commit itself and the other governing bodies to cover these costs on an annual basis from unrestricted donations. . . . Just as the Board of Directors is expecting every doctor, nurse, and administrator to make a full-fledged commitment to the success of BIDMC, so too should it be willing to make as strong a pledge of behalf of the lay members of the community who are given governance privileges for this institution.

The response from our lay leaders was immediate and unequivocal. I had asked them to increase their annual gifts by 15% in the first year to cover the new program costs. Instead, they responded with a fifty percent increase in donations!

This was a moving and incredible statement of support from our lay leaders. I believe their response emanated from a desire to express their appreciation to the staff and to say in part, "Thank you, social workers."

Data, data, everywhere

A good and thoughtful follow-up on the Jayco issue this morning by the Globe editorial staff. The final line:

Patients need a reliable source to tell them which institutions do the most to minimize errors and correct those that occur, and have the best outcomes at treating disease.

Who can disagree? But, here is the upshot. There are already tons of public reports about hospital performance on a variety of metrics. Two problems: (1) They are based on administrative (i.e., claims data) rather than more accurate clinical data; and (2) they are way out of date. These numbers might as well not be published at all -- in terms of the useful information they provide to referring doctors and to patients. Think about it, are you going to make a decision about treatment based on numbers that are two years old? The numbers remind me of the accurate, but useless, answer given by the apocryphal student in the exam question displayed above.

The writer says that my proposal for self-reporting is "is no substitute for comparative data from an unbiased source". It is not a substitute, but it is available in real time and it is based on exactly the same data each hospital uses to make decisions about clinical improvement.

I have now heard a lot about the lack of comparability across hospitals. For example, I am told that each place measures central line infections differently. A simple solution: Normalize the results. Let's set June 2006 as the base period for all hospitals, with a value of "1". Each month, show whether the chosen metric has risen or fallen relative to "1". That way, the public can see whether things are getting better or worse in that hospital.

You know, what is striking about this "debate" is the lack of criticism I have received on this blog about this kind of proposal. Indeed, most comments have been quite favorable. If you folks out there who think it is stupid, useless, or otherwise bad would just submit comments (even anonymously), all of our readers would have a chance to judge for themselves. Are you that reluctant to engage here on the issue for fear of giving credibility to this medium (i.e, a blog)? Please: I won't be offended by disagreement. We work in academic medical centers, where open discourse is to be encouraged and treasured. (See the marvelous comments below on an even more controversial subject to understand how vibrant the conversation can be.)

All right, call the MSPCA: I am beating this horse past death!

And a note to the interns, mentioned below: Please read through the various postings and comments on this topic. It will be the major issue facing hospitals during your residency and after. Perhaps your arrival in our institutions will help us all come up with better solutions!

Welcome to our "matchless" interns!

The famous and infamous "match" process for assignment of graduating medical students to hospitals for their medicine internships was completed last week. This is the end of a stressful process for the students and will determine where they spend most of their time in residency training programs for the next several years. (Read paging dr jess at the link to the right to get a first-hand feel for the process.)

We are very pleased with the people coming to join us at BIDMC. The 62 interns come from 43 different medical schools all across the country -- Florida, Duke, Miami, Oregon, Cornell, Vanderbilt, NYU, Temple, GW, Yale, Penn, Dartmouth, Rochester, Emory, to name a few -- and even that small medical school on Longwood Avenue. (What was the name of that one again?) Our faculty reviewed 1500 US applications and 1000 international ones as part of this process and had the pleasure of interviewing lots of interesting, thoughtful, and dedicated students.

By the way, women outnumber men by ten among the entering class.

If you are an entering intern reading this, we are already starting to get acquainted, but I look forward to getting to know you better this summer. In the meantime, set up a feed for this blog to stay tuned in, and please feel free to post comments.

This Doctor Really Thinks

One of our national treasures is a gentleman named Jerome Groopman. An accomplished clinician, researcher, and teacher, Jerry is also a great writer. (And he is Chief of Experimental Medicine at BIDMC.) He has a new book, called How Doctors Think (published by Houghton Mifflin.)

Check out this interview from the CBS Evening News with Katie Couric from Friday night. Here is a small part:

"One of my misdiagnoses was a woman who I found irritating," Groopman says. "And we all have people that irritate us. She was complaining of discomfort under the center of her chest. And I basically closed my mind. I gave her antacids and stopped thinking. And it turned out that she had a tear in the aorta; the major vessel that leaves the heart."

Groopman admits that patient died.

Then read the excerpt from the book on the same website.

On this blog, I have made a number of postings and responded to a lot of comments about how to improve health care in hospitals. I do it from the perspective a non-doctor, with just a short time running a hospital. Jerry brings a whole different dimension to the discussion. This is an incredibly valuable book.

Also, get a chance to view the guy in action on the Colbert Report tomorrow and Tuesday. Oh my gawd, did I just say the Colbert Report? Jerry, quick, call me!!!

There is no mystery in Mystery Shoppers

Nobody wants to be thought of like Ernestine, Lili Tomlin's rude telephone operator! We have been trying to improve customer service in our hospital. Academic medical centers are often not great at helping patients navigate their way through their clinics, and we are hoping to set a higher standard at our place.

We have borrowed the concept of "mystery shoppers" from other service industries. We train people to pretend they are patients or patients' family members, and then we send them into a clinic to make observations and take notes. We also do this with our call centers, so we can see how our people serve the public on the telephone.

We then share the results with the chiefs, the clinic managers, and, of course, the front-line staff. As in the case of clinical improvements, we do not engage in the "blame game", but rather we use the shoppers' reports to offer helpful suggestions to people. Often, too, the problem is not with the front-line person, but there is some systemic problem behind the scenes that needs to be fixed.

Curious? OK, here are samples from two of our clinics. In the first, the Emergency Department after a very busy day, you can see areas for improvement. In the second, the more sedate Infectious Disease clinic, things look pretty good. (Excuse the stream-of-consciousness feel of the reports. We ask our shoppers to maintain a running commentary of what they see and hear.)

Remember, these take place in the waiting rooms -- not the patient care areas. These particular surveys are designed to review service quality, not the quality of the medical care offered in the exam rooms.

The Emergency Dept wait area is comfortable, well designed area with corner views of the Medical Center area. It is well lit with natural Department and fluorescent lighting. Area is modern but messy and dirty. On today’s visit, which occurred late in the day after the ED had been on diversion, there was litter strewn about, empty soda bottles on side tables and food crumbs all over the floor. Entryway is free of obstruction to passage. The first group of seating is reserved for patient triage. Security greeted me as soon as I entered and told me where to wait. The guard would not allow me close to the desk area unless I required nursing assistance. I wasn't sure how patients were actually checked-in, since the security guard primarily interacted with the patients who arrived and he asked them to have a seat. There is a large C shaped desk that seemed to be shared by security and nursing that was part of the wait area. Once I took a seat further back in the area I was not acknowledged again. Co-payment and referral signage were not posted. Patient Rights and Health Care Proxy information were available in various languages on a nice turnstile rack that needed restocking. There was no PRC information. Infection control information was posted throughout the area. One box of tissue was on a side table; no Calstat bottles. There is a vending machine in the back along with restrooms. Restrooms needed cleaning. General appearance of the waiting area was messy. At the check-in desk there were soda bottles and a coffee cup. Area was lacking in entertainment reading; there were a couple of old, torn magazines scattered around. Addresses were visible and there were no instructions for coping. Several informative brochures were neatly arranged on a long side table. Area had a plasma screen television which was on, tuned to nightly news. RN triage area is further along the large C shaped desk area and provides for privacy. Ten patients arrived within fifteen minutes of one another and overall the staff managed the patients efficiently through the triage area. Information regarding waits was not provided once in rear wait area. Staff was pleasant and courteous. Name tags were visible. Nursing personnel wore lab coats. At times personal conversations occurred between security and nursing but were not overheard. The security guard was chewing gum. I asked security (my only option) for directions to the cafeteria. He instructed me on how to proceed to the Farr Building then said -- "you’ll find it". My assessment of customer satisfaction in this clinic would be 3.0 -- good patient flow system but lacking in friendliness.


The Infectious Disease Clinic shares a good size waiting area with the Travel Clinic. Area is up to date, warming, inviting and comfortable. When first entering the French doors you see the water cooler and excess bottles. It does not pose an obstruction to passage. The reception assistants made eye contact with me immediately. I chose a seat in the corner as she inquired how they could be of assistance. There was no posted signage on the walls or framed on desks. Kleenex was on all side/reception tables. One Calstat dispenser was on the wall by the entrance area; no others visible in the area. Appearance of the waiting area was more than satisfactory -- clean, neat and orderly. Plenty of updated reading material for entertainment and infectious disease related. None of the magazines had stickers with copying instructions. Names were blacked out. Most of the magazines were addressed to MDs in the Lowry Building. There was no television in the waiting area, more than adequate seating and no clutter on the reception desk. A small bouquet of fresh flowers was in the room along with several healthy appearing plants. One of the staff members was caring for the plants and making pleasant small talk with those waiting. I would rate the area a strong 5 in the customer satisfaction area. There were 3-4 attendants behind the desk at all times. They spoke quietly, discreetly and professionally. None wore lab coats but were dressed in professional work attire. All had their name tags visible but I was unable to obtain names without further calling attention to myself. Twice 2 different attendants approached me in the corner and asked how they could be of assistance. Therefore, I was addressed/approached a total of 3 times in 22 minutes. One gentleman was seated several chairs next to me the entire time who was never approached. But he seemed content. One patient was identified by their first name but it was clear they had an established relationship. Physicians in the area wore lab coats, walked in the wait area to greet their patient, shook hands and lead them to the exam area. A physician approached one gentleman to offer an explanation of the wait after I was there approximately 15 minutes. As I was exiting the area I asked directions to the bathroom -- interrupting a work related phone conversation. The attendant was extremely pleasant, giving specific directions. As I was exiting the area a physician who heard my request offered additional instructions.

If Jayco didn't exist, we would want to invent it

The Joint Commission (previously known as the Joint Commission on Accreditation of Healthcare Organizations, and still informally called "JCAHO" or "Jayco") has for years assessed quality and safety in hospitals. Previously conducting a somewhat bureaucratic review of files and written rules, Jayco recently enhanced its survey procedures to complete much more thorough investigations of actual clinical procedures and the medical staff's understanding of patient care guidelines.

Also, the Joint Commission now does unannounced surveys, in contrast to the previously scheduled visits. So, a team shows up on a Monday morning and spends the week in your hospital conducting an extensive and intensive review. If they find things wrong, they issue "requirements for improvement", and the hospital must show a detailed plan for making the improvements in a set period of time. If they find enough things wrong, the ultimate sanction is a loss of accreditation, which is bad in many respects, not limited to losing the right to be paid by Medicare.

This is all to the good. Notwithstanding great intentions by well-meaning medical staff and effective supervision by a board of trustees, independent external reviews are helpful in many respects. Our slogan is, "If Jayco didn't exist, we would want to invent it." That is not to say that a visit doesn't make us sweat, and that the prospect of their unannounced arrival doesn't keep people awake each Sunday night. It does.

One of the medical standards currently being enforced by the Joint Commission is something called "medicine reconciliation". Part of this standard means that we are supposed to to discuss with all patients the medications they were taking before entering the hospital, and review their medications again upon discharge. This is supposed to apply to both inpatients and outpatients.

This makes tremendous sense, of course. How can you give thorough and proper care to patients without knowing what medicines they are already taking? But, frankly, it is not always carried out to the full extent. Things happen: A busy clinic, a confused patient, a missing note from the referring physician. But clearly, the goal is full compliance.

This is just one example. It would be the truly extraordinary hospital that gets a perfect score from a Jayco surprise visit on the wide range of patient care standards. But that's just the point, isn't it? Even the finest institutions can improve, and sometimes we all need an objective outside observer to tell us where we should focus our efforts.

The job of hospital management is to use those findings as positive challenges for the institution and help it achieve ever better results for the public. Having talked with my colleagues in the other Harvard hospitals and in the other Boston-based hospitals, I know they share that view. The public should feel good about that shared perspective -- while still holding us accountable for better and better performance.

New links

I have posted some links to other sites on the right. They are really well written, with interesting points of view. Some are brand new and need visitors! Try them out. From their profiles:

Apollo, MD: Apollo is a physician-in-training in an allopathic medical school in the U.S. Drawing from historical perspectives, recent news, and personal experiences during medical training, he hopes to provide perspectives on medicine and health care on the middle ground between patients, physicians, and other forces influencing the delivery of medical care.

Paging Dr. Jess: I'm a fourth year medical student starting internal medicine residency this summer.

Boston lab coat review: Working hard every day at one of Boston's major teaching hospitals. Help and healing do not come when we pretend and mask our pain, but rather when we are honest and admit our need.

ER RN: Expanding my horizons, gaining knowledge, having way too much fun along the way.

Tales from the ER and Beyond: To get into medical school, you have to be well-rounded. It's pretty much an admission requirement. Ironically, it doesn't take much time for medical school to beat the well-roundedness out of you.

Everything Health: Dr. Toni Brayer has practiced Internal Medicine in San Francisco for over 20 years.

Diabetes Mine: Inquisitive, perhaps-just-a-tad overly analytical new diabetic based in San Francisco, CA. Diagnosed with Type 1 in May 2003.

Transplant Headquarters: Had a kidney transplant in 2000, watched the field of transplantation swirl around me before and after, decided to start a blog about it.

Better grades on VAP

Good progress on implementing steps to reduce ventilator-associated pneumonia. Recall my story in January on this topic.

Our goal is to make sure we are carrying out the five-part Institute for Healthcare Improvement "bundle" to reduce the incidence of this disease. As I noted back then, if you want to reduce VAP, you institute this bundle of steps. But, like your toughest sixth grade teacher would say, "There is no partial credit!" Unless you carry out all five steps, you do not get a perfect score. Here are the monthly stats:

April 06: 83%
May 06: 74%
June 06: 82%
July 06: 80%
August 06: 76%
September 06: 86%
October 06: 92%
November 06: 85%
December 06: 87%
January 07: 93%
February 07: 98%
March 07: 100% (to date)

In addition, our folks are working on instituting improved oral hygiene for these patients, another aspect of reducing the VAP problem. There we have gone from 58% (in April 06) to 91% (in March 07).

But, I want to make clear that these are process metrics. This differs from the central line infection story I have mentioned elsewhere, where we measure the actual number of cases. My folks tell me that actual VAP rates themselves may not be accurate because it is the most subjective of all nosocomial infections and the most difficult to track. We are currently engaged in refining our methodology for actual VAP surveillance.

Finally, I want to point out that this effort requires a variety of specialties to work together -- several types of doctors, nurses, respiratory therapists, and pharmacists. In this case, 14 people serve in the VAP Working Group. They develop protocols, data monitoring, and training programs and then have to persuade dozens of other people to engage in the program on a sustained basis. As I have noted below, the unique environment of academic medical centers creates interesting challenges in process improvement. These folks deserve a lot of credit for what they have accomplished, but the real test will be to see if they can keep it going. Knowing the people involved, I am optimistic.

This new media stuff is getting me dizzy!

How circular is this?

I run a hospital blog.

The Wall Street Journal runs a heath care blog (link to the right).

They do a story about my blog on their blog -- complete with video:
http://blogs.wsj.com/health/2007/03/16/paul-levy-online-ceo/ .

Now, I do a story about their story about my blog on their blog.

Somebody . . . protect us from ourselves!!!

Play Ball!

You haven't had a chance recently to really criticize my managerial judgment and priorities, so it is time to offer that opportunity. It is after all, Spring Training. Let's talk inside baseball.

Several years ago, a number of hospitals in Boston were vying to become the Official Hospital of the Boston Red Sox. This is a sponsorship arrangement. In return for paying an annual fee, the designated hospital has exclusive naming rights to be associated with the team, both for purposes of outside advertising and for signage in Fenway Park. You also provide first aid to fans in Fenway Park for the 81 (or hopefully more!) home games each season. (Provision of medical service to the players is not necessarily included, as Major League Baseball quite appropriately does not want to require players' treatment decisions to be tied to sponsorship contracts.)

Those of you from other cities and countries are probably already wondering about this. What is the possible advantage to a hospital that chooses to do this? Those people who are citizens of Red Sox Nation (anywhere in the world) already understand the value.

In our case, finding ourselves engaged in a successful turnaround after almost going out of business because of a botched merger between 1996 and 2001, we were looking to remind people in Boston that we were alive and well. We wanted to portray a sense of permanence for our hospital, which had been badly beaten up in news reports and in community perception for several years.

Also, I had had a chance to meet the owners and top management people at the team, and I discovered that we had virtually identical philosophies of community involvement and stewardship of our respective "franchises."

So, we made a proposal that, yes, included a payment and first aid, but that equally focused on programs we could do together for the community. As an example, one of the showcase programs we proposed to sponsor was the Red Sox Scholars. Each year, 25 economically disadvantaged but academically excellent fifth graders from Boston neighborhoods would be inducted into the program, $5000 put into an interest bearing account towards their college education, assigned a "medical mentor" from BIDMC, and presented with programs designed to enhance their teenage years and encourage them to stay in school and go to college.

Another program combined the resources of BIDMC, the American Red Cross, and the Red Sox to encourage blood donations. By publicizing the "blood donor of the game" and by co-sponsoring a September 11 anniversary blood drive, we have encouraged hundreds of people to give blood that is used by hospitals throughout the city. Likewise, we have sponsored a skin cancer awareness day and an organ transplant awareness day at Fenway Park.

I have received criticism from some for entering into this partnership, but I would do it again in a heartbeat. I will not even try to make a case that spending money in this way brings in more patients to our hospital and ultimately improves our financial ability to conduct research and teach medical students. I will, however, unashamedly make the case that two championship institutions from different lines of business can jointly make wonderful contributions to the life of our city.

Oh, I almost forgot to mention something else. Over the decades, our hospital has been known for success in treating all kinds of diseases. But this was the first time ever that we cured a curse . . . .

My Mom's wishes

In the story below, there is an important sentence: We discussed possible actions with Dr. X and decided to halt all invasive treatments, a course that my family has long agreed to.

I know from personal experience what this simple bit of family planning can mean for the terminally ill patient and for his or her relatives. My Mom's living will had this directive, among others:

That no extraordinary measures be used to prolong my life if in the sole judgment of my daughter and my physician such measures will not restore me to a level of life that is commensurate with the mental and, to a lesser degree, physical standards by which I have been fortunate enough to live. Without limitation, such extraordinary measures include cardiac and/or pulmonary resuscitation, mechanical respiration, tube (intravenous and/or nesogastric) feeding and antibiotics.

She wrote and signed this in the early 1990's, when she was in her early 70's and therefore likely well before it would be likely to be applied. The application of her directive occurred two years ago after an accident left her with a severe head injury and internal bleeding in her brain. When it became clear that, in her words, "the application of life-sustaining procedures would serve only to artificially prolong the moment of my death", my sisters and I were empowered to have a short and decisive conversation to remove the respirator and other measures that were keeping her alive. With no regrets on our part, she died just a few hours later.

Afterwards, the ICU nurse kindly reaffirmed our decision, saying to me: "You, of all people, know that we can keep people alive forever. You did the right thing. She would have spent the rest of her life on her back in a nursing home, unable to talk or move. Surely, she would not have wanted that."

A living will with this kind of advance directive is one of the greatest gifts a parent can give to his or her children. If you don't have one, or your parents don't, please have one prepared and discuss it with your relative while you are both still able to do so.

Dear Mr. Levy, My husband was a patient in your hospital...

When I receive a letter like this, I never know from the salutation if it will be a complaint or something else. This one is clearly something else, and I want to share it with you. Those of you who work in hospitals have doubtless heard similar stories; but for those of you who do not, it provides an insight into the dedication and thoughtfulness of the kind of people who work here and in other places in Boston and throughout the country. It also implicitly provides several pieces of advice to all of us who will go through the experience of terminal illness with a loved one.

Dear Mr. Levy,

My husband was a patient in your hospital in late January through early February 2007. He arrived at BIDMC via a MedFlight from Florida. We, myself, my two sons and their wives, and our BIDMC primary care physician felt that the small community hospital there was not able to deal with the complex issues that my husband seemed to have.

Dr. V continues to be our primary care doctor even though we moved to Florida. We communicate to him via PatientSite and have our annual visits with him each summer and he was constantly aware of my husband's condition while in Florida. He arranged for a hospital-to-hospital admission. We arrived very late on Wednesday January 24th. My husband underwent many tests on Thursday and Friday. We were given a diagnosis on Friday evening.

The diagnosis was not one we wanted to hear; lung, liver and bone cancer, but a course of action was set in place. My husband was to have radiation therapy starting on Monday January 29 to reduce his back pain. The nurses who took care of him were all professional and kind to him and kept me continually informed. They made sure that he was heavily medicated before the transport through the hospital and in radiation treatment, which sounds like a trivial compliment but was actually of utmost importance to minimize the suffering caused by the bone cancer and exacerbated by movement. The nurses in radiation oncology were wonderful and did whatever they could to reduce his pain and make him as comfortable as possible.

On Friday, February 2nd, it became apparent to myself and my sons that my husband was not doing very well, and a CAT scan was scheduled to determine if he had pancreatitis. We asked for a meeting with Dr. X, the hospitalist, to tell us what his condition was at that point. I am sure this type of situation is never easy for a doctor, but Dr. X very clearly and compassionately indicated to us that my husband only had a few days or weeks left to live due to the cancer in the liver being so aggressive. We discussed possible actions with Dr. X and decided to halt all invasive treatments, a course that my family has long agreed to. Dr. X also set up a meeting between us and the palliative care team for later that afternoon. Seemingly within minutes Dr. X had the wheels in motion. All scheduled tests and treatments were cancelled, IVs were stopped and, most importantly to us, had us moved to a private room. Her action was stunning, and we cannot say enough about how fortunate we were to have her during this most difficult time.

We met with RN L that same day. The palliative care folks seem to be a special breed of people doing an incredibly difficult job with kindness and compassion. L promised us that pain relief strategies could be altered such that my husband was not in a drug-induced stupor yet still be relatively pain free. She also stated that we should use the window of opportunity to have friends and family visit as much as possible while he was clear headed because it was all going to be a façade and the cancer would be working just as aggressively though it would not appear so. She was eventually proven correct on all counts.

When my husband woke up Saturday morning he was quite clear-headed for the first time since we arrived back in Boston. We all got to talk with him, and he got to enjoy his children and most importantly, his grandchildren. The private room was wonderful, as we could just close the door and have fun with the grandchildren. He seemed so well that we all expected to see him get up and walk home, giving us pause to our decision to stop treatment. L and Dr. X reminded us, however, that this was just a fleeting condition and that we were doing the right thing. We just cannot write enough times in this letter how great these folks were to us.

L had delivered what she said she would, some very quality time with my husband. Also, I want to stress that because he was able to be on palliative care, his last week at BIDMC was less stressful for both of us. This is an incredible service that makes a very difficult time as humane as possible. These people deserve all possible accolades for their incredible efforts. In general, everyone from the cleaning staff, dietary staff, transporters, medical assistants and nursing staff, were kind and wonderful. So much for the thought of the impersonal big city hospital.

My husband was moved to a nursing home on Friday February 9th. He passed away on Sunday February 11th. Thanks to the efforts of the team, we were at least able to enjoy our final week with our husband and father and he was clear-headed and joking until the day he left BIDMC. We will forever be grateful for that.

Paying it forward

A note from Alabama, from James Noland RN, MSN, CEN, Clinical Education Specialist, Huntsville Hospital Emergency Department Office.

"On November 20, 2006, a tragic school bus crash occurred in Huntsville, Alabama. More than thirty students were brought to Huntsville Hospital. Among the injured were four young women who sustained major head injuries and later died. This tragedy made national news.

"In Boston, MA, at Beth Israel Deaconess Hospital Emergency Department, nurses heard about the tragic event and performed the most honorable gesture. The nurses from Beth Israel Deaconess Emergency Department bought the staff of Huntsville Hospital Emergency Department lunch the next day. Yes, on November 21, 2006, around 11:30am several pizzas arrived with a note attached that read to: all emergency room nurses from: your Emergency nursing colleagues at Beth Israel Deaconess Hospital in Boston, we are there with you, keep up the good work. This was such an honorable gesture.

"So, when the tornado swept across Enterprise, Alabama, and the bus crash occurred in Atlanta, Georgia, the ED nurses from Huntsville Hospital collected money and bought pizza for the staff at Medical Center Enterprise in Enterprise, Alabama, and the ED staff at Grady Memorial Hospital in Atlanta; we decided to pay-it-forward.

"There is a spotlight section on the Beth Israel Deaconess Medical Center website that says 'BIDMC is making a difference in Boston and around the world...' and they certainly are. Thank you BIDMC for what you did and the difference you are making."

And thank you, Huntsville, for paying it forward!

Soliciting organ donations

Our chief of transplantation, Dr. Doug Hanto, has strong opinions about the ethical issues surrounding solicitation of organs for transplant. He recently set those forth in an article in the New England Journal of Medicine. Here is a summary from the Boston Globe's White Coat Notes.

Dr. Hanto has built a very successful solid organ transplantation program at BIDMC. We are proud of the work he and his colleagues have done. I am also proud that he has chosen to engage directly in these very controversial subjects. I also agree with him. Check it out and see if you do, too.

A story from our harpist

Sent by our harpist:

I want to share a short and poignant story from yesterday in the lobby (names are changed).

As I was playing, two distraught-looking women were drawn into the harp's music. I asked if everything was okay and Nancy told me her husband was upstairs actively dying.

I asked if she would like me to play for Paul and she was simply thrilled. I said it was my job here and my pleasure. Nancy told me her daughter, who was in the room, is a music therapist.

As I began to play, everyone started to cry. Nancy got onto the bed with Paul and everyone actually sang along to any familiar music I played. When I finished with Danny Boy, the daughter followed me out to thank me and hug me saying that everything I played had meaning for the family. She was so grateful and appreciative.

I told her the music was a gift from the hospital and that the greatest gift was surrounding her father with such love and peace at his final hour.