Patient in my own hospital

Two stories about being a patient in my own hospital.

(1) I am really lucky to have a primary care doctor who knows how to protect me, as president of our hospital, from our well meaning doctors. Why do I need protection? Well, because the specialists are really proud of their work and want to use any malady that I have to show me their stuff. My doctor knows how dangerous this can be!

A few years ago, I signed up for an ocean kayaking trip in Patagonia. This was to entail pretty strenuous outdoor living and paddling all day long for two weeks. The program therefore required a physical exam and recommended a stress test for those over a "certain age." So I asked my PCP to order one.

She says, "No. I refuse to order a stress test for you."

"Huh?", I reply intelligently.

"Here's the deal," she says. "If I order the stress test, our especially attentive (knowing who you are) cardiologist will note some odd peculiarity about your heartbeat. He will then feel the need, because you are president of the hospital, to do a diagnostic catheterization. Then, there will be some kind of complication during the catheterization, and you will end up being harmed by the experience."

"But the reality is that whatever peculiarity he might find in your heartbeat has probably existed for decades, or your whole life. There is no history of heart disease in your family. You ride 100 miles per week on your bike and play and referee soccer for hours every week, and you have never had a symptom that would indicate a circulatory problem. Therefore, I will not authorize a stress test."

"Yes'm," I dutifully reply.

(2) A few years ago, I had a routine colonoscopy, and the GI doctor clipped off a couple of polyps and sent them to the lab for analysis. Standard practice to see if they are pre-cancerous.

Three days later, I am walking to work next to one of our pathologists down a very busy Longwood Avenue. I say, "Good morning. How are you?"

He quietly replies, "Fine, and so are you. I did your histology yesterday. No problems. Have a pleasant day."

Diagnostic skills

A friend who is a primary care doctor once told me that 85% of the symptoms that he sees in patients don't matter. They will simply go away over time. Jerry Groopman notes the same in his book How Doctors Think (on page 100): "Nearly all of the complaints patients describe to their primary care physician, such as headache, indigestion, and muscle pain, are of no serious consequence."

This makes it all the more impressive when a PCP has the diagnostic skill to notice the symptoms that do matter. This is especially the case for pediatricians, who often have to rely on noncommunicative patients and parents' descriptions of their child's symptoms. Two stories of this ilk follow.

A baby and mom go to visit the pediatrician for a "well child visit" several weeks after the child's birth. Everything seems normal, and the visit is about to end. The doctor closes with one last question: "Is there anything you have noticed about Sally that has you curious or concerned?" Mom replies, "Well, I notice that she sweats a lot while nursing." Alarms go off for the doctor, who suspects a problem and orders tests. It is found that the child has a rare heart defect that prevents proper blood flow, particularly during the somewhat strenuous nursing activity. Cardiac surgery is undertaken, and the baby is fine, avoiding major complications that might not have showed up till years later.

Another child, a two year old girl, returns to the PCP with the second urinary tract infection ("UTI") in as many months. Alarms go off for the doctor. After assuring herself that the parents are using proper sanitary practices during diaper changes, she orders a test of urinary function that indicates reflux of urine from the bladder back to the kidneys. The little girl's ureters are not properly implanted in the bladder, permitting backflow. The pediatrician notes, "I've seen too many teenage girls with kidneys damaged from years of undetected reflux and persistent UTIs." After several months of prophylactic antibiotics to see if the girl will outgrow the problem, she undergoes surgery in which the ureters are re-implanted, and the UTIs stop.

Where does that money go, anyway?

Several months ago, I related the sad story that resulted from the merger of the New England Deaconess and Beth Israel Hospitals in the mid-1990s. Fortunately, the troubled times are behind us, and BIDMC has been quite successful in providing clinical care, conducting research, and offering training to the medical professions. Along with that success has been financial progress. The millions of dollars in operating losses have been turned around to show operating surpluses. This trend is seen in Chart 3 above. (The numbers for fiscal year 2007 will be available in several weeks, after the annual audit is well under way.)

Since we are non-profit, these gains do not go to stockholders. They are plowed back into the hospital in the form of investment in buildings, facilities, and equipment to provide patient care and carry out research. Every year, we have to replace aged plant and equipment and also investment in new technology to provide the highest levels of care.

During the period of financial turn-around, we intentionally underinvested in the hospital because we needed money to meet the payroll and other operating expenses, and we knew we would not generate enough margin to cover all the capital needs. So we fell behind each year. One way of measuring this is shown in Chart 1, where I compare the amount spent on capital each year compared to annual depreciation. If you look at the bars below the line, you can see the cumulative amount we fell behind in the early years. Later, when earnings improved, we were able to increase capital investment and begin to catch up. By this year (fiscal year '07) we had caught up on the previous years' deficiencies, based on this metric.

But, as anybody in health care will tell you, if you just invest an amount equal to depreciation, you are falling behind. This is because depreciation is based on the original cost of plant and equipment, not replacement cost. If you consider the current costs of buildings and equipment, you need to invest much more than depreciation to stay even, much less get ahead. In Chart 2, I show how our cumulative capital spending during this period has compared to 130% of depreciation -- a number that is at the low end of desired investment for major facilities like ours. On this chart, you can see that we are still catching up for those bad years. It will take several more years of very good earnings to get current.

Our hope is to continue to make a healthy operating margin to renew and refresh old buildings and equipment and also invest in needed expansion both at BIDMC and our Needham affiliate. The demand for our clinical services continues to grow, and we need have adequate facilities to meet our obligations to the public. To answer the question posed in the title, that is where that money will go. But we are also very cognizant of the importance of balancing capital requirements against the very real needs of our staff -- in terms of salaries and benefits and career advancement opportunities and appropriate staffing ratios. It doesn't do you much good to invest in capital if you don't also invest in people. So, we do the operating budget first, based on staff needs and quality and safety requirements. It is the margin available after that which is available for capital investments.

Equal time

I don't want the post below to be the cause of sibling rivalry, so here is the Boston Globe announcement of my other daughter's dance concert in Cambridge, MA this weekend.

The birth of a winemaker

To share the adventures of a young winemaker, please visit this site by my daughter Syrah or Petite S'ra (formerly known as Sarah). I recommend the movie, as well as earlier postings. She sent the following message to me after I asked if it was all right to post a story on this health care blog and was granted permission:

You might even preface with a note that wine has always been tied to health and medicine. Researchers may change their minds every day about whether red wine will lower cholesterol, prevent heart disease, increase longevity, raise IQ scores or do the reverse, but the simple truth is that wine makes people happy, which is a key part of being healthy. You might further tell your readers that a case of my Zebra Wines (to be released in 2008) will make them exceedingly happy, and therefore at peak health.

Partnership for Healthcare Excellence

Speaking of consumer health care information (see below), the Partnership for Healthcare Excellence has started an ad campaign and a website designed to help create more effective and informed patients. As a new organization, they are very interested in getting feedback, so please take a look and see if their approach and information is helpful to you.

Curious about long-term drug use

A colleague of mine recently reported that, in talking with patients just after they have been prescribed a drug by their primary care doctor or specialist for a chronic condition, he found that they often do not understand the purpose of the drug and, in particular, how long they should take it. The result can be non-compliance with the regime they have been given, leading to a tapering off or discontinuation of a drug that is supposed to be taken for an extended period of time.

This perked my interest in that clearly one aspect of quality of care has to do with people's understanding of drug regimes they have been given. If a drug is really important to someone's health and poor understanding leads to non-compliance, then the result will not be good.

I am curious and would like to hear from those of you knowledgeable on this topic. Is this a common problem? Is the problem indeed a lack of effective communication between the doctor and the patient? If so, have any efforts been made by anybody to test out alternative ways of communicating this information to patients? I would guess that the drug companies out there might have studied this problem, but have doctors or insurers or Medicare?

Moral guide

Everyone I run into at the hospital wants to talk about Rose. I guess if you have been around a hospital as a nurse and volunteer for 50 years and live to be 101 years old, you have an impact on lots of people!

Today, Dr. Lachlan Forrow and I were at the front door waiting to share a cab downtown and we started talking about Rose. Lachlan has been head of our ethics program for years and also runs our palliative care service.

(More importantly, his daughter is a very good player in our town's soccer program, and I referee her games from time to time. In fact, Lachlan and I first met when I ordered him away from the goal area during a game. He was busy photographing his daughter's team from behind the goal line, and I told him he was distracting the girls and asked him to move over to the sidelines with the other parents. He complied. He had to. In contrast, as a faculty member in our hospital, he has much more freedom in choosing to comply or not with my requests. But I diverge from today's point!)

Today, Lachlan said something about Rose along the lines of her being the kind of person who, when you do something in a patient setting that you feel really good about, you think that she would have been pleased. From there we went to the broader topic of how many of us have a person like that in our lives: When we are in a tense, pressured, or difficult situation and have to make the right moral choice, our actions are often influenced by how someone we admire would have hoped that we would behave.

The concept goes beyond having a mentor. It is having someone who serves as a standard against whom we judge our own behavior during a moral test. The person can be alive or long gone. But at that moment of truth, he or she is standing over your shoulder watching and judging. (This is distinct, although perhaps additive to, the kind of conscience pricking that comes from religious beliefs.)

What do you think? Do you have a private moral guide in the person of someone alive or dead whose opinion you value during those tough moments?

Congratulations, Rich!

I am proud to announce that our Dr. Richard Schwartzstein has received the prestigious Alpha Omega Alpha Robert J. Glaser Distinguished Teaching Award from the AAMC.

Rich has received an unprecedented 13 teaching awards voted by his students at Harvard Medical School (HMS). He is vice president for education at BIDMC and serves as clinical director of our Division of Pulmonary Medicine. Also, he is executive director of the Carl J. Shapiro Institute for Education and Research at HMS and BIDMC.

Rich's quote puts this in a great context, symbolizing a major attribute of academic medicine -- the integration of clinical care, research, and teaching: "For me, active work as a clinical investigator has been critical to enhancing my capabilities as a teacher, and has allowed me to provide a model for students to consider as they contemplate their own career choices."

The AAMC explains: As a medical educator, Richard Schwartzstein skillfully integrates his extensive knowledge of basic and clinical sciences to teach students about respiratory pathology. As a clinician and researcher, he carefully weighs what patients say about their breathing difficulties to better understand dyspnea. And by successfully using each experience to enrich the other, he shows students how to balance a multifaceted and rewarding career in academic medicine.

Grand Rounds is up

Terry offers a superb version of Grand Rounds this week at Counting Sheep. The topic is pain. In addition to excellent writing, her visual images are superb. Please check it out.

Farewell to Rose

Rose Finkelstein, age 101, passed away last night. She seemed to be an everlasting presence at our hospital, spending over 50 years in one capacity or another. She came here as a young nurse. After retirement, she volunteered in our obstetrics department, where she was particularly known for singing to the babies. Each year, she would win the award for most hours worked as a volunteer -- 629 hours in 2004, 650 hours in 2005. In 2004, we created an award in her name, The Rose Award, established to recognize a volunteer’s steadfast commitment to service. Rose was a sweet, kind, generous person -- with a voice to match! We join those lucky babies who had a chance to hear and know her.

Dear Board Member:

Apologies to those readers who are tired of the union topic, but there is something going on that deserves public attention. And, if you are on the board of a hospital in Massachusetts, you might want to read closely.

As I have noted elsewhere, a key component of the organizing strategy of the SEIU is to engage in a corporate campaign against a hospital and to put pressure of the board of trustees to agree to concessions during the organizing process. As the situation unfolds at BIDMC, we see the precursors of such a campaign.

Over the last few weeks the SEIU has written letters to board members of Caregroup, BIDMC, and BID~Needham regarding one or another issue -- like accounting, billing, or intellectual property transactions. In each letter, the SEIU will point out a flaw, mistake, or other circumstance that it asserts has occurred. The letter will make the point that the board members have a fiduciary responsibility with regard to the issue raised and the broader issue of supervising the hospital and encourages them to look into the matter in more detail.

Interestingly, SEIU has not sought press coverage or public disclosure of all of these items as they are filed with the boards. Instead they are simply mailed to the board members. What is going on here?

One has to predict that these issues will be raised by the union, but in what forum and in what way? One possible use could be in filings made with federal or state governmental bodies claiming that the boards of the hospital are not carrying out their fiduciary responsibilities and therefore the hospital (1) should not be permitted to issue tax-exempt bonds to support hospital capital programs and/or (2) should not be permitted to continue to receive state or federal reimbursement for patient care and/or (3) should not be permitted to continue to receive federal research funding and/or (4) should be stripped of its tax-exempt status. Another way is to simply try to embarrass the board members in the community.

Now, our boards, like most hospital boards, have all the governing structures in place that are designed to properly fulfill their fiduciary roles: Committees for compliance, audit, finance, research supervision, compensation, and the like. The board members take their responsibilities seriously and work hard at doing the job well for the community. And there are external reviews by accounting firms and audits as well by state and federal agencies, as well as bodies like the Joint Commission that review the actual delivery of patient care.

Nonetheless, in a large organization, there are be certain to be mistakes. When we find them or hear about them -- regardless of the source -- we fix them. For example, last week SEIU correctly pointed out an error from several years ago regarding BID~Needham bills to Medicare (just under two dozen patient encounters were billed incorrectly during 2004, resulting in an estimated overpayment by Medicare of approximately $569,000). Informed of the issue, we reviewed the records, notified Medicare immediately, and asked them for the best way to repay the dollars.

But sometimes we disagree with claims that have been made. A few months ago, for example, SEIU made assertions about our filings under the state's uncompensated care pool, and we readily met with the relevant state officials to explain why we felt their assertions were incorrect.

On this blog and elsewhere, you have seen the utter transparency with which BIDMC conducts its business. This transparency is fully endorsed and encouraged by our governing bodies because they understand that we are ultimately accountable to the public and that we will do a better job for our community if we admit our mistakes and try to continually improve. It would be a sad irony, indeed, if that approach were thrown back in their face in the pursuit of campaign to organize workers.

The particular issues raised by the union and any mistakes that might have been made do not indicate a lack of fiduciary controls by the boards. They indicate that in the complicated world of health care, there can be both actual mistakes and also disagreements about the interpretation of rules and regulations. I think it is fair to say that if the intensely involved and diligent BIDMC boards are accused of not carrying out their fiduciary duties on the basis of the kinds of issues raised by the SEIU, every single hospital board member in Massachusetts is vulnerable to a similar charge.

White knight for Carney Hospital

I have an idea, and I am going to offer it with all seriousness and with no sarcasm or animosity. In today's Boston Globe, Jeff Krasner writes about the sad status of Caritas Carney Hospital. Of all the hospitals in the Caritas Christi system, Carney seems to be in the most trouble, and it has been for years, notwithstanding millions of dollars of state aid, $4 million this year alone. Nonetheless, the hospital enjoys great local affection and ongoing support from the Mayor and many state legislators.

If today's story is correct, the hospital and the community and elected officials are now courting a suitor to take it over and have it separate from the Caritas Christi system. In the past, nationwide suitors for Caritas Christi actually cited Carney as one of the factors for not taking over the entire system, so it is difficult to imagine any of the hospitals in Boston as being interested. The potential financial liabilities are just too great for most of us, who have narrow operating margins to start with and are facing our own financial challenges over the coming years. And for the Partners Healthcare System, which might have the financial resources, there are already too many concerns about market power in the Boston metropolitan area.

Here's the proposal. There is one organization in town with a strong interest in hospital management and with the financial resources to take this on -- the Service Employees International Union. SEIU has millions of dollars at its disposal (reportedly over $20 million) to organize workers in Massachusetts, a local staff of some 200 people, and a desire to prove that it can improve the working conditions and quality and safety in area hospitals. I am guessing it also has a pension fund for its members, with many millions available for investment.

So why not approach SEIU with a proposal to have the union purchase, own and operate Carney Hospital? Let the union show how it can handle the full panoply of issues of running a hospital and demonstrate how it can profitably operate a neighborhood facility without the kind of state aid that has been pouring into Carney for all these years. Let the union negotiate contracts with the insurance companies, encourage access for low-income patients, maintain high regulatory standards for patient care, and do all the other things required of hospital management, while, of course, providing excellent working conditions for staff members and physicians.

What better way for the SEIU to demonstrate its potential value to the community than to take on this worthy assignment and to do a good job at it? You can read many statements by the SEIU that seem consistent with the mission of the Carney. As I say, although I may be accused of doing otherwise, I am offering this suggestion with no sarcasm or animosity. In terms of financial resources, industry experience, and stated values and mission, there is an obvious white knight in this situation, and it is 1199SEIU.

Bravo, Rafael

A note from our chief of General Medicine about a member of his faculty:

I write to share the wonderful news that Rafael Campo was just named the recipient of the 2009 Nicholas Davies Memorial Scholar Award by the American College of Physicians This prestigious award is given for outstanding contributions to humanism in medicine and is bestowed on individuals in recognition of their scholarly activities in history, literature, philosophy, and ethics. As the 2009 recipient of the award, Rafael will give a lecture at the Annual ACP Session in 2009. Prior recipients of the award include Rita Charon, Abraham Verghese and Edmund Pellegrino. Rafael was nominated based on his work as a physician poet, writer and essayist, who has advocated for the teaching of humanities in medical school. He has used poetry to teach humanism to medical students here at HMS and his book “The Healing Art: A Doctors Black Bag of Poetry” has served as a model curriculum for teaching humanism to medical students using poetry nationally.

I have written about Rafael previously. Check out his website.

Dear Congress, please read this

An important article by Monique Doyle Spencer.

Stretch your mind

On to much less serious topics. On a flight to Washington on Monday, I was reading the US Airways magazine and saw an article on rubber bands, entitled "Quite the Stretch," by Kostya Kennedy. Among other things, it noted, In Pittsburgh, some call rubber bands "gum bands" -- the only place in the U.S. where that slang is used.

This got me wondering, can you come up with other items that have a particular slang version in a unique part of the country? Please submit them here. (Don't tell me about a sub being a hero in some areas and a hoagie in others. Please only submit examples of a single moniker for an item that is totally different from what is used in the the rest of the country.)

Another assignment: Provide examples of words that mean their opposite. For instance, cleave means both to join together and to pull apart. Extra credit: Provide the term that describes such words. Try this without using the web to find them, ok? Honor system.

How a CEO learns

As you can tell from this blog and elsewhere, we are pursuing a very strong quality and safety agenda at BIDMC. Our progress to date has been good, but we have a long way to go. It is very satisfying and helpful for me to get to know people around the country who are doing the same, as we learn a lot from one another.

An example. Every time I hear Jim Conway from IHI give a talk, I learn something or am reminded of something important. He recently helped us during a joint retreat of the boards of BIDMC and our community hospital BID~Needham. The focus was the role of the board in governing quality and safety, a topic I have covered here earlier, but dealt with so much more effectively by Jim.

And then yesterday, he and I were making presentations at a different kind of meeting, and he repeated some of themes raised at our board retreat. He reviewed the lessons learned by the Dana Farber Cancer Institute in the ten years following the tragic death of a patient from a chemotherapy overdose. As a CEO, it helps me to hear these things again and again to really have the lessons from others' experiences sink in and to help consolidate my own thinking, and I am always grateful for the opportunity. Here are some highlights, in shorthand, without Jim's eloquence.

Key points about a culture of safety:

Based on trust, human rights, repentance, and forgiveness.
Patient and family centered.
Supports staff, enabling and motivating the highest levels of performance.
Acknowledges the high-risk and error-prone nature of health care.
Ensures individual and shared acceptance of responsibility and accountability.
Encourages and facilitates reporting and open communication about safety concerns in a fair and just environment.
Ensures that organizational structure's processes, goals and rewards are aligned with improving patient safety.
Learns from errors.
Shares stories.

And here are key points about actually implementing change. The theme is for the leadership of the place to force a kind of creative tension based on seeing what we want to the organization be -- our vision -- and telling the truth about where we are -- our current reality. That creative tension can only be resolved in two ways: (1) raising the current reality towards the vision, or (2) lowering the vision towards the current reality.* Of course, we aim for #1! (By the way, this involves particular challenges in academic medical centers, where the role of the CEO is somewhat different from other types of organizations.)

How you cultivate this creative tension over time:

Benchmark against the best practices.
Search for opportunities to be humbled.
Learn from the tragedies of others.
Keep patients and direct care staff "in the room", i.e., engaged in evaluation and decision-making.
Conduct critical risk assessments.
Story telling and learning.
Constantly look for trouble.
Be transparent.
Get information to those who need it to drive change.

I particularly like the idea of "constantly looking for trouble." Here's how you do it. Ask the staff on the floors the following questions:

What's keeping you awake at night?
What's your favorite work-around?
What kept you from giving the kind of care you want to give?

The folks in the room yesterday were slightly taken aback because an inherent characteristic of this approach is its transparency. In particular, your activities, flaws, and failures are open for the world to see. And they raised issues of the inappropriate portrayal and use of that information by those on the outside seeking commercial or political gain. Jim and I pointed out that there were some risks along those lines but that, for the most part, our ultimate constituency -- the public -- wants hospitals and doctors and other caregivers to succeed and believes in their good intentions. Transparency is consistent with maintaining that trust and indeed reinforces it because it sends a message that the organization is willing to hold itself accountable.



*This is based on the work of Peter Senge at MIT.

Grand Rounds Volume 4, Number 6

Welcome to Grand Rounds, a traveling road show of commentary from a variety of bloggers on a variety of topics. I was honored to be asked to host this week's edition.

During my relatively brief blogging experience, I have noticed that people hardly ever comment on my posts that are related to broad policy issues or scientific advances. Instead, it is the highly personal stories that seem to generate the most interest. So I asked people to submit articles with the following theme: A personal experience I (or a loved one) had at a hospital and how it caused me to change my behavior or beliefs. We got lots of submissions, and I am very pleased to share many of these with you.

As you might expect, many of these stories deal with physical or emotional pain, from the patient or the provider perspective, so be prepared to cringe from time to time as you empathize with the writer.

I'll start with Terry, just to prove I can be open-minded, in that she submitted her entry with a "Go Rockies!" closing comment! She notes: "I am a nurse anesthetist, and my blog is about my experiences delivering anesthesia care. My article is about a personal experience with anesthesia, and how it changed my life forever." I am willing to bet you cannot read it without feeling something. And here is another one from Bongi involving anaesthesia with a similar theme in a similar setting.

Barbara movingly writes about an unexpected conversation while a patient in a waiting room and how it taught her about hope.

Bruce tells us how an unnerving and awful early experience with a more senior physician when he was a nursing assistant made him into a better provider. Likewise, Tom shares how his time with a more positive mentor helped him be a better hospital administrator.

In another geat story from a current trainee, medical student Thomas Robey relays how the emotional roller coaster of witnessing a Caesarian delivery of an at-risk fetus changed his perspectives about the invasiveness of modern medicine.

Sid, who had a warm spot for the Red Sox during the World Series -- "I'm rooting for Boston in part because my wife went to Harvard and went to Fenway a few times, and in part because any team that betters the Yankees is my next favorite team" -- relates the story of what he learned while operating on another doctor. No short-cuts, no assumptions: Treat them like "regular" patients.

Susan notes: "I'm a volunteer ER chaplain who's written a post about how several visits with hospital patients have helped widen my definition of 'scripture.' And since this post prominently features Buffy the Vampire Slayer, it's also perfect for Halloween!"

Kerri Morrone, type 1 diabetic for over 21 years, finally finds a member of the medical community who actually listens. It makes all the difference. On that theme, Amy looks back on her two-year anniversary of her diabetes diagnosis, noting "the LIFE that I now appreciate as a gift worthy of celebration every single day."

Speaking of time, Laurie tells of her gratitude for providers who did a great job on a relative, but the real theme is her reflection on timing, self-care, and the fact that illness is never convenient but always illuminating. And I offer my own story about my mother that reminds us that there is no time like the present to prepare living wills and advance directives.

As usual, there are a bunch of people who submitted entries that are not related to this week's theme, but are really thoughtful or otherwise well done. Please give them a look. For this week, I have not included some very nice pieces on policy, pricing, management, transparency, and the like. As noted above, I was trying to change direction from those types of topics. Sorry to those authors.

As we consider the effects of the California fires on people's lives, check out this post by Dr. Paul Auerbach on how to survive in this fiery environment. He notes: "Given the awful situation we currently have in southern California with wildfires, every opportunity to distribute this sort of information on personal safety and what to do in an emergency situation is a big help to our firefighters, citizens, etc. Perhaps this advice will keep someone out of the hospital..." I am pleased to spread the word, Paul.

Speaking of prevention, David Williams offers advice about avoiding the norovirus. It is a really good thing to avoid.

We find amazing insights in this post by Jon Schnaars. "Amy Stern, one of our writers, had a chance to interview John Elder Robison about his new memoir that focuses on living with Asperger's."

And finally, just for fun, check out this rating system for medical care proposed by the author of How to Cope with Pain.

Thanks to all for your contributions. And, of course, thanks to Nick Genes, our founder. Have a great week. And, for those whose favorite teams didn't quite make it to or successfully through the World Series, wait till next year!

Meanwhile, Grand Rounds continues next week with Terry hosting at Counting Sheep. Please tune in.

Inside Baseball

Congratulations to the Red Sox for their ALDS, ALCS, and World Series victories and to their opponents -- Anaheim, Cleveland, and Colorado -- for bringing us scrappy and well-played October baseball.

Here is the play-by-play of last night's game, as immortalized in text messages between me and one of our nurses. (Everybody at BIDMC will know which one!) Hers in plain text. Mine in italics. Simultaneous messages when on the same line.

Hate towels.
Me 2. I am w John Henry in box in Denver. Not!

U Kill me! Lets parade on Tuesday together.

(Ellsbury double in the first.)
Rookies Rule!

(First Boston run.) Woo hoo.
Mikey next. Watch him 2b or more I predict.
(He's out.)
Well nxt time.

(First Holliday out.) Happy Holliday. NOT.

(Scoops up difficult play at first.) Ortiz is red hot. Awesome Papi.

(Second Holliday out.) Not so happy Holliday.

How r those towels working?

(Strike outs.) Holey. Lester!

(Lowell double in the fifth) XO XO XO XO from me to Mikey. Told u so!

Sweet.

(Lowell slides into home.) Face first! Stunning slide.

Love him.

(Lester leaves the mound after 5 2/3 innings.)
Bravo Lester!
Tip of the hat if he was in Boston.

Canceled OR schedule 4 Tuesday . . . official holiday.

(Lowell home run in the seventh.) XO XO XO XO from me to Mikey. Mikey!

Colorado pitcher pulled after six innings.
Sad way 4 Cook 2 leave.

(DelCarmen succeeds with batter in the sixth.)
Delc snuffs him!
(Hits against DelCarmen) Pity.

Gagne warming up?!
I saw. I could cry.

(Timlin clutch strike out.) Timlin!
Love the hunter! Never want to mess with him!

I lov this.

(Kielty home run.) Kielty! Say Bobby!

Not happy Holliday.
Bad nite 4 him.

(Manny pulled to move Ellsbury to left field, Crisp to center. Scenes of Manny in the dugout.)
Manny's white doo rag a diss on white crying towels.

(Colorado home run -- Atkins in the eighth -- narrows the lead to one run.)
Poor Oki.
Big girls don't cry.

(Top of ninth.)
We could use a run or 2.
Don't worry b happy.

(Bottom of the ninth inning starts.) 1 2 3

(Ellsbury nabs Carroll ball at the wall for second out of the ninth.)
Jake!
God is a sox fan.

(Final Pabelbon strike out.)
Ahh.

Love that dirty water.
Finally back 2 full nites' sleep.

Got 2 b at work at 5:30 ugh.
To bed after trophies.

I wish I was pres [of Red Sox Nation].
Next year.

Mikey as MVP!
MVP my man.

On Sidelines Parenting

In previous posts, I have offered comments on refereeing and on coaching in the context of youth soccer. Today I wade into the delicate arena of sidelines parenting.

This is prompted by a game I refereed yesterday in which the parents of a visiting team were not only yelling instructions to their teenage daughters but were "assisting" in making calls. The first was useless, the second counterproductive. On a few occasions, they would yell out "offsides" when it was not, and their daughters would stop running towards the ball after hearing this announcement, leading to at least one goal by the opposition. My favorite parental call was a demand for a free kick when two of the opposing defensive players collided and fell in the penalty area near their player, and their girl with the ball maintained her balance, possession of the ball, and even took a shot at the goal. "Hey, ref, when are you going to call it?"

These and other parental outbursts contributed to a feeling among their girls that they were somehow aggrieved by my calls, and then the girls started focusing on that rather than playing their game. Beyond affecting their performance, this attitude led one to commit a bad foul as she was trying to get even for perceived earlier slights, providing, of course, a free kick to the opposing team near the goal.

There are a number of things I advise parents when I am coaching a team. Here are excerpts of a note sent to parents of a U-12 team a few years ago.

A now, a word on our plans and expectations. Under-12 represents a threshold year for these girls. They are developing physically and emotionally in many wonderful and challenging ways. On the soccer front, they have gotten really good at many aspects of the game, but many aspects remain to be trained before they become really competent players. But they are ready for the next step, both physically and socially. Our goal is to foster individual development as players but also social development as team members. We will do this by creating an environment in which they have lots of fun while learning.

Every girl will play every position on the field, including goalie. Every girl will have approximately equal playing time in all games. Please expect that in the fall, I plan that we will lose many games: That is because we will be working on certain skills that are important in the long run and because I will intentionally assign girls to places on the field in which they are less competent.

Your role as parents is to please make sure the girls get to all practices and games on time, ready to play. If a practice starts at 5pm, please be on the field ready to play by 4:50. If a game starts at 10:30, please be there at 9:45 for a really thorough warm-up.

We expect each player to be at all games and practices unless the player, herself, has called me to explain why she will not be there. This is important. The girls are old enough to take personal responsibility for their commitment to the team: It is not your job to call on their behalf. If your daughter must miss a practice or a game, she should call me and talk to me directly or leave a complete message as to the reasons for her absence.

Your role as parents, too, is to encourage all the players during a game. Please do not engage in sideline coaching. No instructions. Feel free to say, "Good play, Suzie", but do not say, "Kick the ball, Suzie." You will see that I barely talk to the girls who are on the field during a game. Most coaching takes place during the practice sessions or while the girls are on the sidelines during a game. Giving instructions during a game is counterproductive and confusing and robs the girls of the most important developmental tasks: learning to think and communicate for themselves during the game.

Grand Rounds coming to this blog soon

Nick Genes created the blogging version of Grand Rounds several years ago. He calls it "the weekly rotating carnival of the best of the medical blogosphere." For reference, here is the current edition on Pallimed. I am honored to be asked to host Grand Rounds Volume 4, Number 6 on October 30.

Each week there is a theme, and I have suggested the following one for this week's edition: A personal experience I (or a loved one) had at a hospital and how it caused me to change my behavior or beliefs.

As I rewrite this on Sunday, October 28, it is too late for more submittals. Looking forward to seeing you on October 30.

Senator Murray has it right

Our good friends at Health Care for All were quick to jump on remarks made by State Senate President Terry Murray at the Greater Boston Chamber of Commerce and make a pitch for a return to rate regulation of health care in the state. First, to be clear, the Senator did not advocate this policy. Indeed, she had a number of very thoughtful comments about the underlying structural problems in the health care system in Massachusetts, to which I return in a moment.

I responded to HCFA:

Sorry, but rate regulation does not control costs. As a person who was intimately involved in rate regulation for years — of electricity, gas, and telephone companies — I know from experience that rate regulation generally creates a cost-plus environment for those companies subject to such supervision. This is because the legal framework for rate regulation makes it difficult for the regulator to second-guess costs incurred by the regulated entity. So, ironically, it is the high-cost, low-efficiency organizations who benefit relative to the low-cost, high-efficiency organizations.

To expand on this, regulated companies that have the greatest core competence in accounting and legal representation before the regulatory agency do the best under rate regulation. In contrast, those who develop the managerial and organizational skills to improve quality and cost efficiency find themselves relatively unrewarded.

If rate regulation is re-introduced, it will be those entities who enter the newly regulated environment with the highest base of costs who will start out with higher revenue streams. If some type of efficiency-based regulation is put in place, those higher cost organizations will have more to gain from future efficiency improvements than the ones who start out as lower cost providers. In short, regulation produces perverse incentives.

In earlier comments, I addressed the issue of the growth of costs in this state and offered a menu of options for dealing with this. Senator Murray offers her own sensible list of actions that could be implemented or encouraged by state government action. Some of these overlap with the ones I raised. Others are additive. Between these two lists, we pretty much cover the waterfront. Here is her list:

Increase our workforce capacity of nurses and primary care physicians.

Realign payment structures so that our primary care doctors are compensated at or near the same rate as specialists. We should also boost primary care services by carving out a larger role for Nurse Practitioners.

Support the creation of limited service clinics.

Require more public information and transparency. (This would include a public process to document the need for premium increases in excess of 7% in any given year.)

Expand our use of new technology that will streamline administrative functions and reduce the duplication of services.

Readjust the financial incentives that are the foundation of the current system and make smarter use of the money we are already spending.

Redesign the “determination of need” process that is supposed to provide statewide and regional planning for significant health care services.

Stranger in a strange land

A note from Dr. Tom Delbanco, the founder of our Division of General Medicine and Primary Care. I received it late last night, but I held for posting until just this moment for reasons that will be obvious.

Cross fingers for my survival. Visiting professor right now at U. Colorado. Grand Rounds tomorrow (Wednesday) at noon. Have decided to lead of with pix of Ortiz and Ramirez. May be shot. Still, it’s important….

Whew, I thought this was us

I received this email, and I first thought it was a complaint about us. But no, it was about another hospital in town, and the writer was drawing a contrast with our place! We continue to do our mystery shopper program to learn directly about these kinds of service glitches. I am not claiming perfection at our place, but we keep trying to do better and better.

In September, we were very pleased to hold a teleconference explaining our mystery shopper methodology as part of helping 14 hospitals around the country who had requested information after reading the June Boston Globe story. None were from Boston.

Upon driving up to the ambulatory clinic area we encountered heavy traffic, which required 4 Boston PD officers to direct traffic. On pulling into the ambulatory entrance valet parking area, we were told by the valet attendant to move on as the valet parking was full. He did not volunteer an alternative, but when I asked him I was directed to go to the parking structure [a short drive away]. So, I dropped my family member patient off (as she had been instructed to arrive 15 minutes prior to her appointment time, and it was exactly that time) and proceeded to the garage. However, when I reached there, the entrance to the garage was blocked off with a barrier and a sign saying that the lot was full. There was no mention of where patients should go. Had I been a patient from out of the area, I have no idea where I would have parked.

Once I did park and get into the hospital, I had trouble finding the right clinic, and a clinic front desk staff member who I asked had no idea either, offering only the explanation "I just started working here 3 days ago and so don't know these things yet."

On finally reaching the right clinic, I found my family member patient still in the waiting room. She had not been told by the front desk that the doctor was running behind. However, we learned from other patients who had been waiting for up to an hour and a half that she was running behind and that it is possible to give the front desk staff a cell phone number and to leave to get some lunch. We were not offered this option, but when we went to the front desk to ask, we were allowed to do this. On coming back, we still had to wait, and were finally called in at 1PM (for an appointment time that was for 11:00AM!)

Way to go, BID~Needham!

Here's a note sent to Jeff Liebman, CEO of our affiliated community hospital in Needham -- a very small hospital with a great ED and a big heart. We currently have plans to expand the emergency room because of the growth in demand we have seen and are projecting in Needham and the surrounding towns. (By the way, use of the ED in this hospital helps relieve pressure on crowded ED's downtown.)

Dear Jeff:
Unfortunately, I had the opportunity to spend another evening in the Emergency Department. Fortunately, it was at Beth Israel Deaconess - Needham!!!

At about 8:30 P.M. on Monday evening, my mother (85 years old & living alone in her home in Newton) tried to avoid/swat a bee in her kitchen, lost her balance, fell backwards against the wall, and thought she had broken her wrist. I was at a business meeting in Hartford, CT with my brother when she called.

What does one do in a situation like that?

I called my sister-in-law and suggested that she bring my mother directly to BID~Needham.

Meanwhile, my brother and and I headed home immediately to help out in any way we could.

Jeff, by the time I arrived at the ED, there was nothing for me to do except watch Dr. U put a splint on my mom's broken wrist, listen to his clear instructions, suggestions and follow-up plan, hear some closing and encouraging remarks from both the doctor and the nurses, and take my mom home.

All of that in under two hours - unbelievable!!! My mother's comfort level was such that she was even counseling one of the nurses on her social life.

The ease, the smoothness, the speed, the attention to detail, the understanding, the clarity, and most of all the care - all were outstanding.

The team who treated my mother were all exceptional regarding not only her care but also their warm, informative approach to my mom, her situation and her condition.

Jeff, I do not want to spend any time in an ED, but if I must, the ED at BID~Needham is the place for me and my family. The entire staff could not have been more kind, compassionate and understanding.

I am sure you hear this often, but I wanted you to know what a great team you have and what a fine hospital you oversee.

Best personal regards,

Wanna help write my speech?

I have been invited to give the Brunel Lecture at MIT tomorrow (Tuesday) afternoon. This is a nice honor, but I am not so impressed with myself to miss this chance to ask you for help. I told them I would address the issue of process improvement in academic medical centers. If you have any stories about successes or failures in that environment, please post them, and I will try to wend them into my story. It would be even better if they could be somewhat humorous. But be forewarned: I will have a computer with projector tied into the Internet during my talk, so you might find your comment displayed for all to see.

Geekdoctor arrives!

I'd like to recommend a new blog, started by our indefatigable CIO, John Halamka. I am absolutely confident that people in the health care world -- and beyond -- will find it full of extremely useful ideas and thoughtful approaches to the information world of health care . . . and beyond.

Quick teamwork for one baby

A year ago, I wrote about the really tiny babies in our neonatal intensive care unit. The NICU is a wonderful place, full of optimism.

The other day, I was curious. I received a copy of this email from one of our neonatologists to several nurses and people from several other departments.

I just wanted to say thank you for your hard work and help with this situation. You potentially helped save the life of one our smallest and most vulnerable infants. The teamwork that was displayed and the constant support with this urgent matter was phenomenal. I would just like to say thank you. It is a pleasure to be working with all of you. It is people like you that make BIDMC a special place to work.

I has no idea what it was about, so I asked for an explanation. Here it is:

We had a patient exposed to chicken pox. Since all of my preemies are considered immunocompromised, chicken pox is a potential life-threatening disease. There used to be an immunoglobulin that we could give to patients. It is no longer available. Our only option was to get emergency compassionate use of an experimental immunoglobulin. The hitch was it had to be given in a very short amount of time after the exposure to be effective. That meant we had to get emergency IRB* approval, pharmacy on board, and the company to ship us the immunoglobulin. It all happened within about 24 hours. It was really amazing.

Amazing indeed. That little baby will probably never, ever hear the story of how a group of adults banded together to help make sure that s/he would grow up!

* The IRB is the internal supervisory body of medical staff and outside reviewers that approves protocols for human subject experiments.

I could have told them that

Our Dr. John Halmaka was just named CIO of the Year by the Massachusetts Technology Leadership Council in their review of all companies and industries in the state. From their website, the MTLC "is dedicated to fostering entrepreneurship and promoting the success of companies that develop and deploy technology across industry sectors."

Information in a Heartbeat

Back in April, I announced the formation of a new service at Beth Israel Deaconess Medical Center, the Cardiovascular Institute ("CVI") . This unique new patient care program encompasses all of BIDMC’s cardiology, cardiac surgery and vascular clinical services. Perhaps a bit boastfully, but I believe accurately, I stated that "The CVI will provide patients with the highest quality care – delivered by some of the best physicians in the world – in an integrated fashion unparalleled anywhere in the country."

I explained to our staff: "This group will build an integrated program from the bottom up. It will reflect advanced technology and clinical practice, the skills and drive of our clinicians, and the underlying needs of our patients and families. By aligning the goals and daily activities of physicians, nurses, allied health staff, administrators and the medical center, the CVI will create new opportunities to promote quality and safety, improve efficiencies, serve a larger number of patients, and put into action the best practices in cardiovascular medicine."

The CVI has already made great progress towards these goals, but that is not why I am writing this post. I am writing to tell you about a thoughtful -- and patient-centered -- idea that has been implemented by Dr. Ralph de la Torre, MD, the CVI's president and CEO. You see it pictured above.

If you are a patient in the CVI, you will receive the red heart shown above when you are discharged. When you open it, you will find a memory stick with your own patient record recorded for your personal use. Let's say you leave to spend time at your winter home in Florida or go on vacation to Arizona -- or England --- and you need to see a doctor there, either in an office or in an emergency room. Rather than engaging in a cumbersome exchange of medical records between incompatible information systems, you simply hand over your heart memory stick, and the local doctor or hospital can view the relevant information about your recent treatment at our hospital.

The memory stick will work on any computer with Microsoft software. There is no HIPAA issue. You own and control your medical record and only you can authorize someone to view it.

So, indeed, any doctor you trust can have your information in a heartbeat. A reassuring thing to have in your pocket after you have been treated for cardiovascular problems.

Training rounds

Sorry, I can't resist posting this old corny British joke sent by a good friend:

While making rounds, a doctor points out an X-ray to a group of medical students.

"As you can see," she says, "the patient limps because his left fibula and tibia are radically arched. Michael, what would you do in a case like this?"

"Well," ponders the student, "I suppose I'd limp too."

Generosity in Guatemala

A group of our nurses spent time this summer donating time in a rural mobile clinic taking care of, well, anybody who needed help. Here is a picture of them setting up the clinic in one Guatemala village. This is part of a program called Jungle Medic Missions run by a couple named Bryan and Riechelle Buchanan. Here is the journal entry from this particular group of nurses.

When I hear reports from one of our Emergency Department nurses, Nicole, about this program, I am incredibly impressed (again!) by the generosity of our staff in donating their time for this kind of cause. They spend all their professional time here in Boston taking care of sick people, and then they use their vacation time to do the same for those less fortunate. We should also be reminded that, whatever our health care access problems here, there are parts of the world that go for months and longer without having access to medical professionals.

I hope you will join our family in sending financial support to this worthwhile cause.

Reminder about hand hygiene

I have a cameo appearance on an NPR report tonight by Richard Knox on hospital acquired infections and again discussed the issue of hand hygiene. You can listen here.

We have made some, but not satisfactory, progress on the hand hygiene issue at our hospital. In keeping with our emphasis on transparency, you can look here and use the pull down menu of "alphabetical listing of topics" to view the "hand hygiene" figures through the spring, about which I commented in April.

We keep adding ideas and programs in this arena, for visitors as well as providers, using virtually every idea we can scour from other hospitals in the country. But no one has discovered the silver bullet on this yet. If you hear of any good ideas, please submit them. Meanwhile, I am anxiously awaiting the next period's figures to see if we have improved.

Good work by the MHA

The MA Hospital Association has organized its members into producing a website presenting data on falls and bed sores in the state's hospitals. Here's a summary of the program and a link to the website.

The MA Nurses Association quickly said that this was "just another public relations gimmick by the hospital industry to avoid doing what they should be doing, which is to prevent these complications from occurring in the first place." (Sorry, I don't have a link to this quote. The press release was emailed to me.)

I understand that the MNA is pursuing a certain agenda that the MHA has opposed, i.e., legislation to mandate nurse staffing ratios, but it is a shame that it could not find a way to compliment the MHA for doing something worthwhile. As I have discussed elsewhere, publication of clinical results is a highly effective way of holding organizations accountable and helping to drive quality improvement.

Is it just a sign of the times that discourse on such items has to be the victim of polarization on other issues?

Do you respect me more or less?

Eliot writes a comment on one of my postings below:

Mr. Levy,
Your consistently anti-union bias makes me respect you less. You may think you are being reasoned and dispassionate; simply responding to unfair attacks upon your integrity by SEIU, but I think you are ignoring the inherent tilt in your opinions which comes through with every blog post you write on this subject.
October 13, 2007 10:37 PM

Thank you, Eliot. I understand that one of the possibilities from expressing my opinions publicly is that some people will respect me less. Another is that some will respect me more.

But, I don't believe that you should respect someone more or less for opinions stated. I believe you should respect or not respect people for the actions they take and the deeds they do.

On the specific point you raise. I do like to think I am being reasoned, but several of you have pointed out what you believe to be inconsistencies in my logic. I created this blog to give people a chance to comment in whatever way they like, so it is perfectly fine to disagree.

I do not claim to be dispassionate. In the last six years, I have come to have great affection for this hospital and the people who work here. When I see that hospital and those people coming under attack, I respond. Once again, you are free to point out flaws in that response.

And, finally, you should be careful of the term "anti-union". I think if you talk to people who worked with me in other organizations in which unions were present or wanted to have representation, you would be hard-pressed to find folks who would use that description of me. With regard to union organizing at BIDMC, I have been very clear about my opinion, starting months ago with a note to our staff. Here's the pertinent excerpt:

"For me the underlying question is whether a union at BIDMC would enhance your ability to deliver the kind of patient care that is so important to all of us, to strengthen our research program, to improve our education programs, to strengthen our ability to serve the community, and to improve our employees' chances for personal and professional development and advancement. I do not believe that it would, and so I intend to advise you against creating a union here. Ultimately, though, the choice will be yours, and we will respect your judgment on that matter if and when the time comes for a fair and free vote on this issue."

I also said:

"We believe in free elections in which each employee, unencumbered by peer pressure or other outside forces, gets to vote "yes" or "no" in the sanctity of a private voting place. Thus, we cannot agree to a "neutrality" agreement nor to a system that bypasses the federal NLRB election process. In other parts of the country, hospitals that have taken similar positions to ours have found themselves subject to massive public relations attack by unions. The object of these attacks seems to be to denigrate the reputation of the hospitals and to put pressure on volunteer boards of trustees and management to agree to the unions' organizing terms."

I don't see any of this or my other comments as anti-union or unreasonable, but anyone is free to disagree. To me, what is more striking is the silence on the part of my colleagues from other hospitals, the insurance companies, and the business leaders in the state. Civic leadership demands that corporate and institutional leaders be clear where they stand on major issues of the day. And this is one. The SEIU has made it clear that it is targeting all of the Boston hospitals for organizing efforts. Dear colleagues, if you support what it is doing, please say so publicly. If you do not, now would be a good time to be heard. I know what you are saying privately, in the confines of those business meetings and board rooms . . . but it doesn't mean squat if you are not saying it to your elected representatives, the media, and the public. The SEIU is counting on your intimidated silence as a form of complicity. So far, you are squarely in the union's camp.

Tolerance as a religious imperative

As Ramadan winds down, I'd like to take a moment to wish my Muslim friends, associates, and readers "Eid Mubarak!" and to use this moment to refer all of my readers to some very elegant and wise words from His Highness the Aga Khan, the Imam of the Ismaili community.

A Dorchester story

Our community health center on Bowdoin Street in Dorchester is a neighborhood gem, providing clinical care to the neighborhood and also offering a source of comfort and support to families in troubled times. Our staff there are totally dedicated to their mission of public service, but sometimes they have to act in ways that go well beyond their job descriptions. Here's an email on which I was copied that was sent to the center's director by one of its doctors:

This past week was a heart wrenching experience for the community center with the violence of gun shots ringing out just down the street. I would like to acknowledge the act of courage of one of our staff during this event. She [name omitted] was having lunch in the local takeout restaurant across from the shooting incident. When two shooters appeared across the street from the restaurant and shot at their intended victim, without regard for her own safety she gathered up three young girls who were drawn to looking out the front window, as the action unfolded. She ushered and shielded them into a protected area.

Although later she confessed how dangerous and frightened she was, she thought only at the time of the young fragile lives needing protection.

I hope, by writing this memo, that others will read this and feel a same sense of pride that I have for the Bowdoin Street Community Center staff.

Afterwards a number of us wrote to this staff member and offered our thoughts and support, and, in characteristic fashion, she thoughtfully responded:

Thank you very much for your kind thoughts and support. It truly means a great deal to me that colleagues from the medical center take time to understand and acknowledge the challenges we face in providing care in this neighborhood. These kind of dramatic incidents do draw our attention, but the reality is that our staff deals with the impact of violence every day while caring for patients. I find that the cumulative secondary trauma has a greater impact than the single dramatic incidents. Your continued support and presence over the past several month means a great deal, thank you.

When I asked her if I could use this material on the blog, she further responded modestly, as I would have expected:

Good Morning Paul-
Well, my first thought is that I'm a little uncomfortable with the attention, although I'd like you to use the excerpts if you feel that placing this on your blog will increase awareness about the work we do and the challenges that are faced at the health center. Perhaps you could reference a social worker at BSHC and not include my name.

I do appreciate your support in helping us facilitate the changes that are within our control. Your commitment means a lot.

And then she added,

Although what would really help me get over this traumatic event would be to sit behind home plate at Friday's [Red Sox-Indians] game....just joking.

Well, here's the problem. I already allocated our tickets to an employee raffle -- the proceeds of which, by coincidence, will go to purchase a new passenger van to transport patients to and from this very health center -- but I tried to make up for that by buying her a bunch of raffle tickets. It will be super if she wins!

Now that's CPR!

An excerpt from a book (Icelanders, by Sigurgeir Sigurjonsson and Unnur Jokulsdottir, Forlagio, ISBN 9979-53-469-9) given to me after my talk in Iceland in August. I have been slowly reading it and came upon this story about a man named Stefan Stefanson, who lives in a very isolated area called Fagridalur.

I had a heart attack the year before last. Since then I haven't been up to the mountains as much. You don't have the same stamina for walking. I'd experienced it before. I thought I was getting asthma or some such nuisance, felt as if I was suffocating, then it got better. But it came back later. I was on my way home ... and found a Norwegian family on the road who had a puncture and needed a spanner, so I gave them a hand. I felt a touch of it then but it passed. So I drove home. I had a second attack by the gate here. There wasn't any pain but I felt as though I was suffocating. I drove through anyway and shut the gate. Then drove up the hill here beside the stream. That's the last thing I remember and in fact I died there. But I drove on home. Drove into the tree here in the garden, was flung against the steering wheel and gave myself a heart massage, jolting myself back to life. I drove a hundred metres as dead as a doornail. So you could say I was unlawfully alive.

Intended or unintended consequence?

On September 27, 2007, Governor Patrick signed a bill allowing the card-check form of organizing for public employees in Massachusetts. As reported by the State House News Service:

Gov. Deval Patrick thrilled a roomful of labor activists this morning, signing a new law that allows unions to organize without holding elections, but instead circulating cards. Patrick later waved off questions about the bill robbing anti-union workers of their rights, saying, “I think . . . the time for debating this bill is over. It’s been passed, it’s been signed. It is about making it more straightforward for people to organize in the workplace, and that was its intention, and we intend to see that that intention is carried out.”

Now, it appears that the law would apply to the organizing of teachers in the state's charter schools. Was this its intention, or an unintended consequence?

Way to go, Tufts!

Congratulations to Tufts University president Larry Bacow for offering student loan support plans for graduates who become teachers, social workers, or work for nonprofits. This is not surprising given Larry's personal commitment to public service. I think this is a great example and wonder why more heavily endowed universities on both sides of the Charles River don't also do this.

Kudos to Globe photographers

I was struck today, as I have been many times, by the excellence of the Boston Globe photographers. A particularly beautiful photo today, by David L. Ryan, is of sailboats and is on the front page of the Metro section. (Sorry, I couldn't find it on the electronic version of the paper. I wonder why it wasn't included.) David is one of several terrific photographers with the newspaper, and we are lucky to have them locally and also fortunate that the Globe editors are able to allocate sufficient space to properly present their work.

Things that come by email

How did we survive without some of the things that come by email? Perhaps, previously, they would never have existed. Here's the latest example, some correspondence between two friends on which I was copied.

This is weird, but interesting!

fi yuo cna raed tihs, yuo hvae a sgtrane mnid too Cna yuo raed tihs? Olny 55 plepoe out of 100 can. i cdnuolt blveiee taht I cluod aulaclty uesdnatnrd waht I was rdanieg. The phaonmneal pweor of the hmuan mnid, aoccdrnig to a rscheearch at Cmabrigde Uinervtisy, it dseno't mtaetr in waht oerdr the ltteres in a wrod are, the olny iproamtnt tihng is taht the frsit and lsat ltteer be in the rghit pclae. The rset can be a taotl mses and you can sitll raed it whotuit a pboerlm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe. Azanmig huh? yaeh and I awlyas tghuhot slpeling was ipmorantt! if you can raed tihs forwrad it.

And the response:

It even works in our friend's new tongue, Icelandic:

Svmkmaæt rnsanókn vi? Cmabrigde hkóásla ?á stkpiir ekki mlái í h?vaa rö? stfiar í o?ri eru, ?a? enia sem stikipr mlái er a? frtsyi og stías?i stinaurfn séu á rtéutm sat?. Aillr hniir sfitarnir gtea vire? í aöljrgu rlgui en ?ú gtuer smat lsei? ?a? a?vuledlgea. Áæ?satn fiyrr ?sesu er a? mnnashgrniuun les ekki hevrn satf friyr sig hleudr oir?? sem hiled.

And the explanation:

Here's a link to the science, dating back several years. Whew, close call. I almost did a spell check on this posting!

When good teams go wrong

Several years ago, I published an article in the Harvard Business Review entitled, The Nut Island Effect, When Good Teams Go Wrong. Here is a link to a preview of the article.

Here's the opening:

They were every manager’s dream team. They performed difficult, dirty, dangerous work without complaint, they put in thousands of hours of unpaid overtime, and they even dipped into their own pockets to buy spare parts. They needed virtually no supervision, handled their own staffing decisions, cross-trained each other, and ingeniously improvised their way around operational difficulties and budgetary constraints. They had tremendous esprit de corps and a deep commitment to the organization’s mission.

There was just one problem: their hard work helped lead to that mission’s catastrophic failure.

The team that traced this arc of futility were the 80 or so men and women who operated the Nut Island sewage treatment plant in Quincy, Massachusetts, from the late 1960s until it was decommissioned in 1997. During that period, these exemplary workers were determined to protect Boston Harbor from pollution. Yet in one six-month period in 1982, in the ordinary course of business, they released 3.7 billion gallons of raw sewage into the harbor. Other routine procedures they performed to keep the harbor clean, such as dumping massive amounts of chlorine into otherwise untreated sewage, actually worsened the harbor’s already dreadful water quality.

How could such a good team go so wrong? And why were the people of the Nut Island plant—not to mention their supervisors in Boston—unable to recognize that they were sabotaging themselves and their mission? These questions go to the heart of what I call the Nut Island effect, a destructive organizational dynamic I came to understand after serving four and a half years as the executive director of the public authority responsible for the metropolitan Boston sewer system.

As I note in the article, "Since leaving that job, I have shared the Nut Island story with managers from a wide range of organizations. Quite a few of them—hospital administrators, research librarians, senior corporate officers—react with a shock of recognition. They, too, have seen the Nut Island effect in action where they work."

Not that I am selling HBR, but here's where you can order the article. I would be really surprised if you do not have examples in your own organization.

Firing doctors

Several years ago, before taking this job, I was asked to turn around a relatively small clinical trials data processing company. I had to lay off a number of people who were not critical to the company's success, and one of these included a doctor who had been hired to expand the business into a certain area that we determined was no longer appropriate. This was not a case of incompetence or lack of energy or enthusiasm. He was great guy with terrific credentials, but we just could not afford his particular expertise in that troubled little company.

Recently, we had a chance to meet, and he confessed to me that my decision to lay him off had caused him to have a real crisis of confidence. He had never been fired before and, as he put it, his view of himself as a person and the job he did was one and inseparable. Here, I had torn them apart, and it took him a while to remember and feel that he was still as adept and valuable a physician as he had been before he was fired. Indeed, he was able to thank me, years later, for teaching him the important lesson that a particular job does not define who he is.

I replied to him that I thought that his initial reaction explained to me why doctor-managers often find it difficult to fire other doctors. They too quickly internalize how it would feel to themselves to be fired, and they project this onto others. They conclude that they cannot devalue the professional abilities of a fellow physician by terminating his or her employment. They have difficulty separating the business imperative from the degradation of one's self esteem.

(When I talk about safety and quality improvement in public forums, I often refer to an aspect of this problem. If you are a doctor, you have to assume that you are a good doctor and that you are taking good care of your patients. How could you live with yourself otherwise? You have devoted your life to this calling, and you have spent years and years in training, and you often live a lifestyle that is very demanding in service to your patients. And yet, we need doctors to understand that they are often part of systemic flaws in patient treatment that leads to death or injury. Admitting that makes them no less able as physicians. Quite the contrary.)

In the business world, personnel decisions have to be made for the greater good of the organization -- sometimes to save the jobs of hundreds of other workers. Good managers do their best to help employees who are not working out in a particular position by mentoring, training, or offering other support. But every now and then someone has to be fired. Notwithstanding that business imperative, doctor-managers are often overly influenced by physicians' view of themselves. I have seen dozens of cases in which this leads to leaving physicians in positions when the good of the organization demands otherwise.

Oddly enough, many of us in other professions seem more comfortable at being fired. In fact, we sometimes too easily tend to blame the boss for our own flaws. In any event, we often move right on to the next job, scarcely looking back. Maybe, too, that is why we are more adept at firing people. We understand that a termination notice is not necessarily a statement about a person's inherent worth. More often that not, it is just business.

I don't want you to read this and think that I am a person who enjoys firing people. Those who have worked with me know otherwise. They also know, however, that when the time comes to terminate someone's employment -- whether a physician or otherwise -- for the good of the majority in the organization, I do not hesitate.

On Coaching

Having coached for 20 years and having just witnessed, as a referee, many soccer games at our town's Columbus Day tournament, I again reaffirm my long-standing unscientific survey of games by noting that the teams that do the best are the one with the quietest coaches. Why is this?

Soccer is a thinking person's game, and it is hard for a player to think if an authority figure is yelling at you as the ball comes your way. Kids who are trained to think learn how to make the right decisions in the split-second action of a game. Kids who are trained to listen to their coaches learn to wait to be told what to do.

Here's what I was taught by a great coach, Dean Conway, in coaching school and try to pass along to my fellow coaches. You coach during practices or quietly on the sidelines to the players who are waiting to be substituted in. You do not yell instructions to players on the field -- especially ones near the ball -- because (1) by the time you yell something, the play has developed and your instruction is too late; (2) chances are that your instruction was wrong in the first instance, anyway; and (3) if the player is listening to you, she is not able to think for herself or does not hear a teammate calling for the pass or otherwise saying something important.

Coaches who are reading this and don't believe me should hear what the kids say to each other and to me (as referee) on the field when their coaches persist in yelling instructions. Trust me, their comments about you are not pretty.

As a coach in a tournament, I love it when the opposing coach yells instructions. Two things happen. First, I see the other team's players get all tense, make mistakes, and lose their sense of teamwork. Second, my kids turn to me and say, "Can you believe that guy?" Then they (not I) win the game.

Now I see

And while we are on quotes, one of my favorites is by Pasteur on the nature of scientific discovery: "Chance favors the prepared mind." See this article, too, on "Aha!" moments.

For music lovers

Maybe you have heard this line by Mark Twain, but I had not till yesterday: "I'm told that Wagner's music is not as bad as it sounds."

Kettles are hot stuff

A few weeks ago, a friend was climbing Mt. Wachusett in central Massachusetts and witnessed a portion of the annual hawk migration, in which hundreds of hawks join together in circular updrafts on their way south. It sounded really special, and then on September 20 I saw a small version just off the MA Turnpike in Ludlow -- about 30-40 birds in an upwardly rising vortex. I mentioned this to a colleague at a meeting yesterday after she pointed out the grackles out the window on their migration, and she told me of stories of kettles of 65,000 hawks en route to Mexico. Hard to imagine until you look at this site, which also gives instructions on how you count the number of birds. My colleague also recommended Living on the Wind by Scott Weidensaul as an authoritative source on these matters, and I am pleased to pass along the suggestion to you.

Nice work, CGH

Congratulations to Tom Quinn, president and CEO of Community General Hospital in Syracuse, NY, for posting the results of their Joint Commission survey on September 28 -- and for the very respectable survey results!

Epilepsy Treatment

A relative of mine in California is about to have a vagus nerve stimulation (VNS) implant installed for treatment of epileptic seizures. Her quote: "My new neurologist, who is an epileptologist, suggested I consider VNS to control my seizures since they are considered intractable if not controlled by taking two medications (and I take three). I know there are no guarantees, and there are (generally) minor side effects. My doctor gave me names of other patients to talk to, and Cyberonics' representative met with us to answer questions in advance. It's an outpatient procedure at Kaiser."

Anyone out there want to offer comments on their personal experience with this therapy to help her in anticipation of her surgery next week, and the device being turned on a couple of weeks after?

Artistry everywhere!

As you have seen, I like using this blog to post information about local artists and craftspeople, performers, and, of course, my favorite author and other writers, too. I hope you don't mind, but it is a nice break from the serious business of health care, about which it is too easy to get too serious. And after all, why are we trying to keep people healthy anyway, if not to enjoy the finer things in life, like music, art, dance, and other culture?

Here's another local artist, Laura Davidson, who was referred by a friend, who says: "This wonderful artist makes Victorian style tunnel books -- beautiful little trifles that are kind of accordions folded." One timely one is pictured above, in honor of the season.

And, speaking of dance, check out this forthcoming performance in Cambridge in November. Watch out, nepotism involved in this one!

Hester's Blog Posting

A note I received today from Hester Hill Schnipper, a wonderful social worker at our hospital:

I am sending this to alert you to a new venture that I have undertaken. Revolution Health is a new website, founded by Steve Case, the man who began AOL. I have agreed to serve as the Breast Cancer Advocate -- which translates to writing a weekly blog, being available for questions and comments, monitoring the online support groups that we hope will flourish.

I am very excited about this opportunity to help create the kind of wonderful support that we have at BIDMC online, making our special brand of help available to women all over the world.

Don't worry: I am not leaving my day job!

Please check it out. I am sure Hester is eager to hear your thoughts. (And, I am really glad she is not leaving her day job.)

Chewbaca? Not!

Another timely piece in the Boston Globe by Monique Spencer.

Zipper bling!

Stepping way, way away from health care: For the person who has everything, see the pictures above for ZipBling necklaces. Yup, these are really made from zipper pulls. I think they are really neat and surprisingly attractive, and I like that they are often made from surplus materials. My friend Louise makes them in various colors, sizes, and styles. They close with a magnetic clasp. You can contact her at lloewenstein@comcast.net.

Future States, but not including Massachusetts

I was invited to speak at a National Academy of Engineering symposium today entitled "Health care as an adaptive enterprise, an engineering challenge." My fellow panelists were Christopher Meyer, Chief Executive of Monitor Networks; William B. Rouse, Executive Director of the Tennenbaum Institute at Georgia Tech; W. Mark Saltzman, Chair of the Department of Biomedical Engineering at Yale University; and Jerome H. Grossman, Director of the Harvard Health Care Delivery Project. The proceedings will be published by the NAE in a few months.

It is always helpful to leave the confines of Massachusetts to catch up on innovations in health care. Yes, I did mean to say it that way. You have to cross the state line to get a sense of what is happening or at least being considered in other jurisdictions.

To give Massachusetts credit, it did pass major legislation to help expand access to health insurance to its citizens. But there things stopped, without addressing a lot of underlying questions or preparing for structural changes in the industry. We create a Quality and Cost Council as part of the access reform bill, but treat it as an afterthought, with little authority and budget. We let protectionist groups stifle innovative, low-cost ways of delivering health care. We bumble away on the relatively simple issue of transparency of clinical results.

Oh, there is always a stated reason. We can't have minute clinics here because their patient records will not be electronically connected to doctors' offices (as if most doctors offices are connected to hospital information systems.) We can't enforce transparency because there are no single definitions of the rate of central line infections or hospital mortality (although, really folks, they are close enough.) And we don't have a strong quality and cost council because . . . gee, why? (Who could have an interest in slowing down government review of these items?)

Meanwhile, in the rest of the country, people are exploring interesting paths to disrupt the high cost-low efficiency-low quality health care delivery system in an effort to move from a cottage industry to something more worthy of the 21st Century. I'll leave the descriptions of these to the papers. Some will work. Some will not. What's interesting is that the people behind them are not targeting Massachusetts as a state to explore. The reason is clear. The entrenchment of our providers, insurers, and others makes it exceptionally difficult to introduce new service delivery models here.

Instead, the scenario for Massachusetts is surely one of further industry concentration, certainly on the provider side and perhaps on the payer side as well. The weaker hospitals and physician groups will continue to seek affiliation with the prospective winners (and, yes, of course I'd like BIDMC to be in that latter category) in order to get better reimbursements. The disruptive forces that would otherwise force all participants -- but especially the market leaders -- to think hard about quality, safety, and cost efficiency will be missing.

At some point, because of ongoing cost increases, there will be a public call for a return to rate-setting by the state, but it will come too late. The people of the state will already be paying a hidden tax for the reluctance of its officials and the silence of the business community to encourage a more vibrant market. With the return of price regulation, the rates set in this quasi-utility environment will ensure full cost recovery for the inefficiencies that will have been built into the system. As a former regulator, I am quite confident of this point: Price regulation is a highly ineffective mechanism for promoting innovation and efficiency.

Instead of preserving market power and then counting on price regulation as the final safeguard, why not allow lots of ideas to enter this state and see where they take us? Yes, take some risks. As Mr. Meyer pointed out at the NAE, and as you will read in his paper, history proves that the future belongs to the risk-takers. If you stand by and adopt a strategy whose main aim is to mitigate risk, you will be left behind.

In which state do we want to find ourselves ten years from now?