My son's story -- Part 1

From a friend of a friend, a compelling story.

My son is sleeping right now...had a rough weekend - his blood pressure dropped, his blood count was decreasing, and he had chest and neck pain. The clinical team adjusted his meds, gave him a unit of blood, and are now trying to figure out what to do next. He is scared and worried and wants so desperately to be "normal" again. He is scheduled for leg surgery this afternoon and then we wait to see what the next steps will be.

While I have a few quiet moments, I thought I'd document the story of how he made it this far....it is a story of extraordinary luck and a fair amount of clinical heroism.

My son was born 17 years ago with transposition of the great arteries (his heart had over-rotated and was pumping in a way that didn't allow oxygenated blood to move from the lungs to the body and back again) so he had a 9 hour operation at a week old to reconstruct his heart. Luckily, we lived in a city where the Children's Hospital happened to have the pediatric cardiac surgeon who had trained with the surgeon who had developed the arterial switch, the new and better corrective surgery indicated for TGA. He obviously made it out of that surgery fine and he grew up to be an active, curious, intelligent, athletic, musically gifted young man. His older brothers cherished him but didn't coddle him....he was just one of three rambunctious, rollicking boys who all played sports and games with abandon.

He was cleared every year for athletics by pediatric cardiologists...the anatomy of his reconstructed heart was "unusual" and his EKG was abnormal but he had no activity restrictions. Once he got to high school, he ran cross country, dove, and played lacrosse. My only three sport athlete, to be honest.

Saturday, August 1st was the time trial for the cross country season....a chance for the boys to set their initial times for the year and to show the coaches their level of fitness. My son had trained hard this summer and had experienced a bit of a growth spurt, so he was pretty excited about posting a great time. He was laughing and joking during warm-ups. I stood in my typical spot, removed from other parents so I could watch him circle the open part of the course 3 times during the race. He looked over at me and gave me his million-watt smile and a thumbs up.

My son is not a top runner....in fact, he usually finishes in the bottom third of the team during races...but the team wins State nearly every year and the coach is a remarkable, inspirational man who had encouraged his older brothers to also run CC in the fall to stay in shape for their main sports, so my son had decided to join and stay with the team despite his poor finishes. That all meant that I would be one of the last parents on the course waiting for him to round the bend, run up the last hill, and then turn and sprint into the stadium and cross the finish line.

My son stayed with the middle of the pack for the first 2 laps but faded somewhere in the woods during the final lap....so he ran up and down the hill past me with only 2 runners behind him, neither of whom were in sight...so he was, in essence, running the last lap alone. I told him he was doing great and that he only had about a mile left, back thru the woods and out again. He was struggling, but he always struggled at this part of the race. I watched him run between the baseball field and the football stadium and into the woods along the creek for his final mile. I saw him run across the opening of the woods as he circled back to finish the race, but he disappeared into the trees and I waited for him to pop out the other side.

I noticed some commotion a moment later as some of the front runners who had already finished sprinted into the woods...then a few parents ran in...but I was on the other side on the hill so I focused my attention on the other side of the woods to see him emerge so I could cheer him as he sprinted into the stadium. Then I heard someone yell "Runner down!" and saw the trainers flying toward the woods in their golf cart. The odds were pretty high that my son could be the runner who had fallen - I figured he might have sprained his ankle or hurt his leg, so I started to run the 150 yards to the woods.

I reached the path and saw a group of runners kneeling in the dirt in a circle, praying, and a clump of adults hunched over a prone body on the path...I walked up and saw my youngest and most precious son lying in the mud, blue and not breathing, as the trainers and a parent and his coach worked on him...the trainers were hooking up the portable AED to his chest, with its strangely robotic voice telling them what to do with each step....the parent giving him chest compressions and directing everyone in a calm but authoritative tone....his coach on all fours over him, yelling in his distinctive voice that this was his race and all he needed to do was breathe no matter how hard it seemed for him - just finish the race and take a breath, over and over again.

I watched them try to revive him as I called his mother, who was working, to tell her he had collapsed....I narrated the action to her on the phone as they fired the AED, gave him CPR, yelled at him to breathe, and finally, finally watched him take a few deep, ragged breaths on his own. The parent found his pulse - it was weak but there, and he checked my son's pupils to make sure they were reactive...he was still unconscious but back with us.

The ambulance arrived, they got him on the stretcher and starting bagging him as his breathing had stopped again....they asked what hospital we wanted him to go to....the local children’s hospital where he received all his cardiac care or the closest hospital....I thought for a second and said "please just take him to the closest one".

I raced out of the woods and up the hill to my car so I could get to the hospital to meet his mom and prepare for whatever came next.

Continued below.

My son's story -- Part 2

Continuing from above:

Here is what I have been able to piece together from various people who had been at the school during the race....the stuff I didn't see happen.

The team was supposed to run a new, different course that would have sent them on a big loop of the campus with only a single opportunity to see the runners after the start before they returned for the finish... the rains before the race caused the coaches to decide to use the "old" course which keeps them fairly close to the parents and coaches. This would prove to be the first link in my son's incredible luck chain...had they run the "new" course, he would not have been seen or had the chance for as quick of a response from the trainers, etc.

A part-time landscaper came in on his off day to make sure the path in the woods was clear of debris and to groom any part of the trail that had been impacted by the recent rains - no one asked him to do it but he didn't want any of the boys to get hurt on "his" trail so he came in on Saturday just to make sure....this landscaper, having finished his work for the morning, was in his cart ready to drive back to the Physical Plant building and wash up to go home...his normal route back was blocked by the parents and some of the runners who had already finished the race, so he decided not to disturb them and he turned the other way to go into the woods to take the much longer route on the path.

He saw a runner ahead of him as he turned into the woods and he called out that he was passing on the left...the runner moved over a little and the landscaper passed him....this runner was obviously my son...after he passed my son, he turned in his seat to look back over his shoulder....he didn't hear a sound....he didn't sense any danger or distress...he simply turned back to look at the runner he had passed - at that very moment, my son had his heart attack and fell sideways to the right, down the steep bank of the creek, headfirst between two large chunks of ragged concrete and a big tree into a pile of brush right above the creek.

The landscaper turned his cart around, yelled for help, got to my son to try and pull him up but he was down too far and wedged in, so the landscaper called 911 and ran out of the woods still yelling for help. This was clearly the second link in the chain....had he not come in that morning, had he not decided to be a nice man and not disturb the parents by the normal exit...had he not entered the woods when he did...had he not turned to watch my son fall...no one would have known what had happened until it was too late.

His calls for help were heard by 3 boys, two current members of the team and a third who had graduated but was there to watch....they sprinted into the woods and saw my son in his precarious position and tried to pull him up....a fourth boy ran in and called 911 as well and then ran back out to get help from the coach, who then yelled for the trainers and they all went into the woods.....the boys couldn't get him up because the bank was muddy and very steep, and he was about 6-7 feet below them.

Another person, a parent, had heard the calls and entered the woods about 20 seconds behind the boys....as luck would have it, this parent was a renowned general surgeon (whose son was the senior captain and one of the boys trying to pull my son up the bank) who, without hesitation, leaped from the bank all the way down into the pile of brush below my son and started carrying him by the shoulders up the bank, with the runners lifting his legs. They were able to extricate him from his awkward position and lay him on the trail. The parent/doctor then began to do chest compressions and direct the just-arrived trainers to get the AED up and running. This was the third link.....had he not been there or close enough to hear the cries for help, my son would have most likely died in the ravine.

We learned much later that the problem that caused the heart attack was due to his reconstructive surgery when he was a baby...as he grew and became more active, one of the reimplanted coronary arteries became pinched between the rebuilt pulmonary artery and the aorta....this was an inevitable result of the surgery that saved his life 17 years ago and would have happened at some point - while swimming, riding his bike, walking in the neighborhood, playing lacrosse, or running by himself in the neighborhood as he trained for cross country....so the fourth link - he happened to have his attack while at a school with trainers equipped with an AED, with coaches and parents and teammates right there ready and able to help him. He wasn't alone....and he was in the best possible place to have his attack (even though he complicated things a bit by having it in the woods and falling down a steep bank)

Continued below.

My son's story -- Part 3

Continuing from above:

I arrived at the hospital about 3-4 minutes before the ambulance....it is amazing how fast you can drive when you just don't care if you get a ticket. I met his mom at the entrance to the ER and waited. The ambulance pulled in and they unloaded my son, still bagging him. The parent/doctor had ridden in the ambulance and he had already called the hospital to alert the cardiologists and the trauma team (they didn't really know if he had also received a brain injury when he fell down the ravine).

They packed him with ice to lower his body temp to help protect the brain function and reduce the damage from the heart attack and put him on a ventilator to allow them to stop bagging him
They took him to the Cath Lab to take a look at his heart and determine what might have caused the attack - his arteries were wide open so it wasn't from a blockage in an artery.

They took him to Radiology to get a CT scan of his head to see if there was any swelling or trauma from the fall - luckily there was no evidence of trauma, but he was still unconscious
They then rushed him to ICU where the cardiologists and Critical Care Team tried to get him stabilized, assessed, and cleaned up.

Finally we were allowed back to see him in ICU after about an hour.....he was connected to all kinds of machines, pumps, and IVs....and he was completely non responsive. The cardiologist walked us out and told us what was going to happen next - they were going to do an EKG and an Echo-cardiogram to figure out what his heart function was and to assess the damage to the heart muscle. She told us he was "very sick" (a term she used with us over the next 36 hours) but that they were going to do all they could to fix him. I signed a bunch of non-specific releases and went back to the waiting area to, well, wait.

Four hours later she came back out with a cardiac surgeon....and with the parent/doctor who had been with my son since the event. They pulled us aside and told us his heart function was drastically reduced (an ejection fraction of 20%), his lungs were filling up with fluid despite the diuretics they had him on, and his vital signs were dropping....they wanted to discuss options with us....they also told us they had put him on a unique cooling machine called Arctic Sun (which sounded like a juice box flavor) that would keep him at a constant lowered temperature for the next 20 hours and that they had called in an interventional cardiologist in on his off day to help them decide what kinds of things they could do to prevent him from failing completely. I signed a few more release forms and we went back to wait.

By now the waiting room at the hospital had about 60 people in it all for my son....teammates, classmates, teachers, coaches, family, friends, neighbors, random people, etc. I was on point to come out and give the crowd updates as we had them....

A few hours after the last conversation with the trio of doctors, the cardiologist came back out and told us that they were going to have to do an aggressive and fairly unique combination of interventions - a TandemHeart centrifugal pump to take the load off of his laboring heart and ECMO to essentially provide a lung/heart bypass to take the load off of his lungs and to oxygenate his blood for him. It was the only hope to keep him alive long enough to give his heart and lungs a chance to recover. The major complication from the intervention was the likelihood he would lose blood flow to his right leg as they were bypassing his circulatory system via a large catheter in his femoral artery. They would try a percutaneous bypass from his left leg to his right leg to give it some blood flow but clots could still form in his right leg that would require a vascular surgeon to remove....so they had called in the top vascular surgeon in the area to come in on his off day to be at the ready – he gladly agreed to help as was the father of a former classmate of one of my other sons.

They performed the emergency interventions at his bedside in ICU and we waited... a few hours later we were told that the pump and the ECMO were doing their jobs and the leg bypass was giving his leg some blood, but it had become apparent his lower leg was getting no circulation....a clot or clots had formed but he was too unstable to move from ICU to the OR....at 2am, the interventional cardiologist told us he was most likely going to lose his leg but he wouldn't survive the amputation even if they could get him to the OR, so we just had to wait and see through the night.

The next morning the crowd grew as more and more people heard the news....I gave the room the latest discouraging update and we all settled in to wait for the next communication from the clinical team. Sometime that morning the cardiac surgeon and the vascular surgeon came out and told me they thought his heart and lungs were sufficiently strong enough now to do the frantic sprint to the OR to perform a fasciotomy to remove the clots and try and save as much of his leg as they could. Seven hours later, the vascular surgeon came out to tell us he had opened up his leg and cleaned out dozens of clots, large and small, and the blood flow had returned to his leg to about mid-foot...it looked like his leg would not be lost, but that he would most likely lose the forefoot. They had also started to warm him up and to take him off of the drugs that had kept him in an induced coma....we would be finding out soon enough whether or not he had any brain function impact from being without oxygen on the trail.

He stayed in ICU that night and the next morning we were told his heart function was stable and his lungs greatly improved, so they were going to take him off the pump and the ECMO and the ventilator to see if he could do it all by himself...he did....later that day, the parent/doctor came back to tell us, with tears in his eyes, that my son had responded to some yes/no questions he had posed with a squeeze of his hand! We waited and watched him the rest of that day but he was still mostly unconscious.

Early the next morning, the cardiologist came out and told us to follow her into the ICU....she walked up to his bed and told him to open his eyes....he did....she asked him his name and he responded with a coarse whisper and then asked what had happened. The cardiologist started crying at this point. We were able to bring more and more people back to see him in the ICU and he started joking with his brothers and friends and talking more and more.

Continued below.

My son's story -- Part 4

The final chapter, continuing from above:

The next few days were a blur of more tests, more proof that he was back (he still couldn't remember the day of the race but remembering all kinds of things), and a move to the CIU step-down unit and then to a private telemetry room. He was stable and recovering but a bit sad and scared as the reality of his situation settled in.

His leg is still open from the fasciotomy with a wound pump affixed, and he will require surgeries to debride the dead muscle and to put a skin graft over the two openings....he doesn't have much feeling in the lower leg and can't really move his toes yet, but the blood flow has improved so much he won't even lose a part of a toe, let alone his forefoot.

After an MRI, a CT scan, and a contrast angiogram, they discovered without a doubt that the attack was caused by the pinching of his anterior descending coronary artery...the fix is most likely a single bypass that should remove all risk of a recurrence going forward (pending reviews by a few other cardiologists at other renowned hospitals), but that surgery will have to wait until the leg heals a bit and he is done with rehab. He is on the road to improvement and I am so thankful he is here to hang out with me still.

So here are the last few links in his luck chain...the clinical ones:

There are 6,000 hospitals in the country....only 300 or so have the Arctic Sun technology to lower a patients temp accurately and in a monitored way...and the hospital he was brought to is the only hospital in our area with the machine...that 24 hours of cooling helped protect his brain function, but as importantly they believe, helped keep his leg healthy enough to survive the surgery and let the blood flow return almost to normal.

There are 6,000 hospitals in the country....only 100 or so have the TandemHeart and ECMO combo technology and the experience to use it...the hospital he was brought to is the only hospital in our area with the technology and a doctor who can use it - the interventional cardiologist they pulled in that first weekend is the only one at the hospital who has used it...in fact, he is the one that brought the technology with him when he came to this hospital a year ago...there is no question the time and support the combo intervention provided allowed my son to live through that first night critical night....

The parent/doctor who stayed with my son for the first 72 hours is one of the top surgeons in this city, and he was so emotionally invested in my son's care that he called in a bunch of favors to get the right vascular and plastic surgeons to be put on his case, and he called the head of the renowned rehab centers in the area to "encourage" them to take him on for inpatient rehab on his leg…his constant attention and compassion pulled us and my son and the other doctors and nurses through the first tough few days.

My son is receiving absolute top-notch care from the only place in the area that could have saved him, but was by luck, not by any “consumerism” on our part - we didn't Google "teenage arterial switch survivor with heart attack" or pull up HealthGrades to find the best hospital or doctors to treat him....we have benefited from the kindness and skill of a community of health care providers affiliated with a hospital that was uniquely situated to help him, but the only choice we had in this was what hospital to drive him to.

I don't know how often this kind of story happens in the U.S....or how much our connections the parent/doctor helped us get to the right place at the right time for the right care from the right providers...I want to believe we experienced a normal level of care or attention, but I don't know if another 17 year old would have been swarmed by a whole hospital of care givers and given a chance to have the best people available help him purely by luck...it scares me a bit to think how different this would have turned out if we hadn't landed at this hospital...if he hadn't collapsed at a meet at his well-prepared and wonderfully staffed school....if all the random and independent coincidences and factors hadn't lined up perfectly, in the right order, to create the chain that kept him alive and now thriving.....it is amazing and scary all at the same time.

His story isn't over....but the trajectory of his recovery and the continued excellent care he is receiving gives me a significant amount of hope that this will all have a very happy ending....

Explain the tangible benefits

A last thought for today on the health care legislation, this from Dan Balz in the Washington Post. I found it very interesting and perceptive. I don't generally mean this blog to be so focused on politics, but this issue is just too big and fascinating to let go.

But then I saw this comment under the article and thought I would share it with you, as also being a really interesting view. I don't know the author. I shared the post with friends who join me in really wanting a health care bill and really wanting the President to be successful, and they thought that AOS1 had nailed at least part of the problem.

Dan Balz-

I like this column, but I'd go one step further to say that what we are seeing on the health care debate is the inevitable extension of a character trait of President Obama's -- one that has served him well before, but isn't serving him well now.

"Barry" Obama, Candidate Obama, Senator Obama and President Obama have all been particularly effective active listeners. By facial expression, body language, and in his responses, he comes across as someone who is genuinely (and I don't doubt his sincerity) listening to what you have to say. In responding, though, the active listener is usually trying to convey that he/she has heard and understood what you said -- not necessarily what his/her own position is.

As a result, Obama has always struck me as something of a Rorshach test -- love him or hate him, you could see in him what you wanted to see. That's great for getting votes, not so great when you are leader of the Free World. On healthcare, that means left wing Democrats could see the avatar who'd bring about single payor (or darn close), and right wing Republicans could see a big-government loving socialist.

The truth is somewhere in between, as is the bill that President Obama would ultimately like to sign. To get to that bill he needs to develop a short list of items that explains the tangible benefits -- I agree with your column. But he also can't continue to allow people to believe what they want to believe about his position. He needs to affirmatively state what his position, and correct those (on both sides of the debate) who continue to see what they want to see.

The health care bill can't be a thousand page ink blot.

-AOS1

How to deal with the public option

Richard Thaler, in Sunday's New York Times business section, offers a cogent description of the issues surrounding the public option for health insurance. Read the article here.

His conclusion:

ALL of this leads me to conclude that if we impose sensible rules on the public option, it will neither save nor destroy the health care system because it will simply not get much market share. And if we do not impose those rules, the public option will hurt rather than help.

So here’s some free advice to members of Congress: While you are enjoying your August recess and town hall meetings, instead of arguing about whether to have a public option, argue about the ground rules.

To the Republicans, I say this: If you can get real assurances that the public option has to break even, and that it will get no special deals from suppliers, let the Democrats have it but ask for concessions on tort reform in return. (That could actually save some money.) The resulting public plan will be too small to notice.

To the Democrats, I say this: If you want competition in health care, you won’t get it if the public option can make deals its competitors can’t. So either give the Republicans hard assurances that the public option would have to break even and not get special treatment, or, better yet, just give it up to ensure that some useful health care reform is passed. A public option is neither necessary nor sufficient for achieving the real goals of reform, and those goals are too important to risk losing the war.

In memoriam: A. Stone Freedberg

Last April, A. Stone Freedberg, the former chairman of Cardiology at the Beth Israel Hospital, celebrated his 100th birthday with a special concert at Symphony Hall. I sadly report that he passed away yesterday at 101.

Warren Manning, one of our cardiologists, notes that Dr. Freedberg did extensive research in cardiac physiology, especially with regards to thyroid disease (working with George Kurland and others) with a long bibliography. Read, too, this fascinating story about him from the New York Times. After he retired from the BI, he served as the Harvard Medical School student physician for nearly 2 decades. Warren notes that "his mind was razor sharp" until the very end. He will be missed by many.

Deadlock in Congress

The Onion, as usual, has a serious message hidden in a funny story.

Insurance Protections

I was sent a copy of a letter from David Axelrod, Senior Adviser to the President, with a list of things that the Administration hopes to include in the health care reform legislation to deal with nasty practices of some insurance companies. While some of these protections exist in some states to some extent, it would be great, as I have mentioned earlier, if these regulatory requirements could be extended nationwide. I haven't heard much objection to them, even from people in the insurance industry, so I am hopeful they will survive the legislative process.

The one thing I do not see here and have not seen elsewhere is a prohibition against balance billing, e.g., when a doctor charges you the difference between what an insurer covers and what he or she wants to charge. This is not legal in Massachusetts, but is common practice in states like New York. Has anyone out there heard of interest in changing this on the national level?

Here's the list:

1. Ends Discrimination for Pre-Existing Conditions: Insurance companies will be prohibited from refusing you coverage because of your medical history.
2. Ends Exorbitant Out-of-Pocket Expenses, Deductibles or Co-Pays: Insurance companies will have to abide by yearly caps on how much they can charge for out-of-pocket expenses.
3. Ends Cost-Sharing for Preventive Care: Insurance companies must fully cover, without charge, regular checkups and tests that help you prevent illness, such as mammograms or eye and foot exams for diabetics.
4. Ends Dropping of Coverage for Seriously Ill: Insurance companies will be prohibited from dropping or watering down insurance coverage for those who become seriously ill.
5. Ends Gender Discrimination: Insurance companies will be prohibited from charging you more because of your gender.
6. Ends Annual or Lifetime Caps on Coverage: Insurance companies will be prevented from placing annual or lifetime caps on the coverage you receive.
7. Extends Coverage for Young Adults: Children would continue to be eligible for family coverage through the age of 26.
8. Guarantees Insurance Renewal: Insurance companies will be required to renew any policy as long as the policyholder pays their premium in full. Insurance companies won't be allowed to refuse renewal because someone became sick.

Learn more and get details: http://www.WhiteHouse.gov/health-insurance-consumer-protections/.

Request from Health Care for All

I am posting this at the request of our friends at Health Care for All:

Have you ever had a bad experience in a hospital or other health care setting?

Has someone in your family received poor health care in Massachusetts?

Have you been an advocate for someone or helped them navigate the complex health care system?

If you answered yes to any of these questions, please consider joining the Consumer Health Quality Council, a coalition of consumers who advocate for improving the delivery of health care in Massachusetts. The Consumer Council was founded by Health Care For All close to three years ago to respond to growing concerns about the quality of health care nationally and in Massachusetts.

The Consumer Council’s mission is to empower those impacted by health care quality issues to have a voice in our health care system, to engage fellow consumers to be active partners in their health care, and to advocate for high quality, safe, and accessible health care for all Massachusetts residents.

Here are two examples of how Consumer Council members share their stories to advocate for change in how health care is delivered:

Robena Reid’s mother, Marie, entered a Boston area hospital in December of 2006. Her mother was diagnosed with a rare type of cancer affecting the pleural membrane surrounding her lungs.

While in the hospital, her mother contracted an intestinal infection caused by clostridium difficile. Because of this hospital-acquired infection, her mother was unable to receive treatment for the cancer and passed away. Robena has become an advocate for improving care and testified at the Massachusetts State House, with the help of Health Care For All, to encourage public reporting of hospital-acquired infections.

Lucilia and Joe Prates’ father, Antonio, went into a hospital to have kidney stones removed in January of 2005. As a result of the procedure, Antonio became a victim of a hospital-acquired infection and an adverse medical event, which ultimately led to his death in August of 2005. Lucilia and Joe share their father’s story in hopes of improving the quality of care that others receive.

You can view additional videos of Consumer Council members’ stories at www.hcfama.org/quality/stories . Since its inception, the Consumer Council has been successful in advocating for state laws that aim to improve the delivery of health care and make it safer for patients and families. Massachusetts leads the nation in many measure of health care quality, but there is a lot of room for improvement. We can, and should, always strive to do better.

The Consumer Council and Health Care For All urge those of you who have received poor quality care to start speaking up and sharing your stories and to work with us toward the common goal of providing high quality care to all residents of Massachusetts. For more information about the Consumer Health Quality Council and how to become a member, please contact Kuong Ly at Health Care For All: kly [at] hcfama [dot] org or 617-275-2940.

Meanwhile, back here in Boston

Let's shift attention briefly from from the national arena discussed below to the local scene.

I am always inspired when I read articles by Don Berwick and Atul Gawande. In addition to substantive wisdom, they have a fluid and persuasive style. Such is the case in an August 12 op-ed authored by the two of them and Elliott Fisher and Mark McClellen in the New York Times. They rightfully point out that, if medical systems across the country adopted reasonable steps in the use of evidence-based medicine, quality and safety, collaboration and efficiency, the current national debate about how to afford universal coverage would disappear.

This is not a new message for these authors, but there is little evidence to date that it has been internalized by doctors and administrators throughout the country, especially here in Boston. To put it in medical terms, we know what medication needs to be taken, but the patient is not being compliant with the prescription.

My friends at Blue Cross Blue Shield of MA believe that a change in the payment system, from fee-for-service payments to a capitated system, is a primary way to help solve this problem, and they are supported in this view by the recently convened Payment Reform Commission. They may be correct that it would be helpful, but only if there is sufficient state regulation of rates to counterbalance the market power of the state's dominant health care system and to get its disproportionate reimbursement rates under control.

But I think the advocates for capitation would be among the first to admit that the other opportunities mentioned by Berwick et al are not dependent on changes in reimbursement rates. In fact, the op-ed makes that point, noting that lower-than-average costs have been achieved even in some communities that do not have a capitated form of reimbursement.

Here in Boston, competition among hospitals has driven costs up, not down. The hospitals' drive for market share combined with doctors' desire for the latest prestigious machine, lab, or building leads to a medical arms race in this city. Efforts at collaboration or rationalization of services among the academic medical centers -- even those in the same system -- routinely fail. Closure or consolidation of ailing hospitals is very difficult and unusual, in that financial rescue is often offered by a state Legislature concerned with constituency issues. And, as noted above, contrary to other parts of the country where there is a dominant provider concerned with lowering costs, the one in Massachusetts has used its market power to raise costs in a manner that has not been effectively challenged by the insurers or their subscribers.

So, for the next article, I'd like to see these authors or someone else address the on-the-ground problems of the Boston metropolitan service area. Is it possible to take the broad themes from the op-ed and bring them back home and advise this group of patients how to take their medicine? Or is there something about this organism that suggests a different diagnosis and treatment plan?

Iced Coffee

Cool down from politics for a minute and read this story by Jessica Lipnack. You will be glad you did.

Backdoor single payer will not happen, but something good will

On Friday, Jack Beatty, appearing on Tom Ashbrook's WBUR program On Point, honestly revealed all about the President's hope for a public insurance plan. Listen here starting at minute 23:50 for the introduction, and at minute 25:00 for Jack's own comments after President Obama's remarks in New Hampshire:

"It is disingenuous of the President."

"The fact is that the public plan opens to the door over time to Medicare for all."

"But the Democrats can't say that, and yet that is the fact."

"A robust public plan ... over time, is going to take more and more business from private insurers."

"This is backdoor single payer."

I made some of these points several weeks ago.

Whether you, dear reader, want a single payer or not, the issue now is Presidential credibility. Put aside the recent craziness about end-of-life care and other manipulated public outcry at town meetings. As I noted in July, real people have real concerns about the legislation and the legislative process. This showed up recently, too, in a recent New York Times poll. The President and his folks have wanted to hurry through a bill that affects one-sixth of the national economy, and when they hide their underlying philosophical intent, it undermines their chances. It deserves more time and consideration and honesty than that.

We will, however, get legislation. It will include new requirements for insurers to abandon nasty practices like denying coverage for pre-existing conditions and the like; it will create a national exchange like the Massachusetts Connector to allow individuals and small groups to shop around for better insurance products; and it will include subsidies for some low income people. It will not include the public plan, although there will be permission to establish local co-ops, like those that provide electricity to rural areas.

The House of Representatives will wait for the Senate to act first, because they want to be sure that a bill can pass the Senate. The need to get at least 60 votes in the Senate is critical. Why? Actually, not so much to avoid a filibuster, as to bring in conservative Democrats and moderate Republicans to get 50 votes. Yes, 50. For as things stand now, the Democrats can't even get a simple majority, much less a filibuster-proof majority.

The points to be worked out are the significant details:

How many people will get a subsidized plan? The numbers seen in the House are unreachable if the cost is borne solely by the wealthy. And since a broad-based tax increase is unlikely, the Senate will compromise with a lower number of families included.

How will the national exchange work? Will it be regulated by the states subject to national guidelines? Likely, given the prerogatives of the Governors. But this will mean a lack of uniform standards and plan designs. Will private insurers be allowed to participate in all 50 states? Will they have to?

Will there be a body that rules on efficacy and cost-effectiveness of new diagnoses, treatments, and medical equipment and supplies? Probably not, as manufacturers fear discouragement of new products and services.

The result will look a bit like Massachusetts: New rules for insurers to protect consumers; substantially greater, but not universal coverage; and some public subsidies paid for by progressive tax increases. I'd say this isn't too bad. It is not everything everybody would want, including myself, but the President will be able to sign a bill and claim victory. Given the amount of effort and political capital expended, though, it will be the last step for many years to come.

Our prom night

This will seem silly to some of you, but those of a certain generation might understand and enjoy this. A group of my high school classmates (McBurney School in New York City '68) were trying to remember why we chose not to have a senior prom. This email sequence all started when our class president recently sent out some notes trying to find a common date for an informal reunion, and he expressed some frustration in pinning it down. As you see, it is an amusing mix of adolescent memories and serious times, which oddly brings our small group close again. (There were only 72 in the class, 28 of whom were sharing this email thread). Here's the flow of email (with most names omitted):

Sounds like we are trying to plan a prom all over again.

Er, we never did have a prom, as I recall!

We did not have a prom, but I got asked to Dalton's prom by Linda G and we more than made up for the lack of McB's prom. It's funny, I can't remember her name, but sure remember what she did!

(From me) I went to the Franklin prom with Sally B. Dinner at the Waldorf; carriage ride in Central Park; Chuck Berry at the Village Gate; Middle Eastern folk music at Cafe Feenjon in the Village; walk up Fifth Avenue past St. Patrick's where they were setting up the TV lights for Bobby Kennedy's funeral; then breakfast up on the West Side somewhere. Great memories.

I went to the Marymount prom at the Plaza with Carol B. She lived on 55th and 5th. I was visiting her on a June evening. The motorcade came down Fifth Avenue to bring Senator Kennedy's body to St. Patrick's.

I don’t remember going to a prom. I don’t know which is sadder, that I didn’t go to a prom or that I can’t remember if I did. Paul, however, I do remember Sally B, too.

Well the number of us who went/did not go to a prom would certainly be an interesting trivia question to get answered by all of us. I remember: I did not go to one, but what I did that night is lost in time.

My recollection is that we voted as a class to forgo having a prom, but now I wonder if that was merely my own vote, followed by indifference as to whether the rest of the class did or did not decide to have prom. At any rate, I went, as did Mike B, to Franklin's prom, which I will allow was at the Waldorf, because Paul Levy says it was, but I don't remember running into him there, and all I remember of the night was (1) Mike and I and our dates and two other Franklin couples went to hear Martha and the Vandellas at the Copa afterward, and (2) I and my date, Joan F. later wound up in Atlantic Beach, where her folks had a summer house, and that in the morning we drove back to the city and met up later with some of the folks from the prom at some East 70's burger place to round out a 48 hour day. Also remember I didn't get lucky that night, and that very soon after that night Joan broke my heart.

(From Tom) The Class of 1968 created a Prom Committee, on which I served. My old class book shows that Nathan A and Jimmy K were also on that committee. The Committee voted that in 1968 because of the Viet Nam War there would be no prom. It was specifically considered and rejected. The discussion centered around the desire to take a position that rejected the status quo, and that in so doing, reject the war. It was determined that the prom represented the status quo, and in that light, it was determined that our class would forego having a prom. It was also said that having a prom while the war was underway was inappropriate. I don't remember that the position was ever put to a class vote. It just seemed to have tacit acceptance; and soon thereafter, school came to an end. No prom.

That would make sense. I would have to bet there was no vote.

Even if this were not the true story, I would embrace it! Thanks.

That was the choice? Geez I was on student council kind of, and I cannot recall a vote vis-a-vis Vietnam and/or a Prom. What the f..., I still ended up in Phu Bai. . . and I went to a prom.

I don't remember that either, and being the rarest of birds (an Upper West Side conservative) I know I would have. And thanks for your service, Jack!

I, too, remember a summer prom night in Jersey with a redhead, 64 Oldsmobile and later the soft sands and surf of Belmar by the sea near Asbury Park, then a Doors concert.

If memory serves me right, I do remember a vote on the prom. It is my recollection that it was the entire class voting. In fact, I am positive that there were class members who were really pissed about the fact that we were not going to host a dance, although I don't remember any of our near term predecessor classes having a prom either. As far as the reason we voted "no", Tom's memory makes a great legend. Its a whole lot better than the thought that we were either too lazy to organize the event, or too cheap to gather dates, flowers, etc.

A surgeon's story

Our chief of surgery, Jim Hurst, recently went through an extensive medical experience, and he said I could share his story with you. I have edited it a little but have tried to preserve Jim's folksy Southern style. In it, you get a feeling for the mixture of nervousness and affection felt by members of our staff while treating him. But you also see a surgeon learning new things about himself, those same staff people, and the medical system. Many thanks to Jim for allowing me to share this with a broad audience. (I have embedded links to several of the technical terms.)

Each day when we wake up, most of us think about juggling administrative and clinical duties. Hardly do we think about becoming consumers of our own art and craft. The following is a summary of just that: I became a consumer of the best BIDMC has to offer. Much of which follows has been recounted to me by either my wife or the nursing staff from the TSICU (Trauma-Surgical Intensive Care Unit). You see, either the severity of the illness or the drugs or perhaps both have rendered the time between April 2, 2009 and the first week in May 2009 a total blank, save for brief snippets.

I have had a number of major surgical procedures in the past. On many occasions, I have told trainees that I am convinced that every surgeon should have a major surgical procedure early in their career. It has clearly made me better able to relate to my patients over the years. The critical nature of this illness, however, has not only put a sharper focus on my own mortality, but on other aspects of our health care delivery system as well. From this, I am steadfastly convinced that, although we as health care providers may not be able to cure every disease process, two things we can provide; freedom from pain and freedom from the fear that many times surrounds the delivery of health care.

The day began, not unlike many others. My wife and I had been in Cincinnati to visit our family and to pick up a vehicle which we planned to drive back to Boston the following day. The first stop was to one of my favorite restaurants where we dined on a Southern boy’s delight of sausage gravy and biscuits. While some say it will stick to your ribs, more likely it would stick to one’s coronaries, or any other endothelial surface for that matter. Once all tanks had been filled; both ours and the vehicle’s, off we went on the 863 mile trip. Having made this drive previously, we planned to stop in Buffalo, which is exactly half way between Cincinnati and Boston, for the evening. The choice of locations provided two things I enjoy most: Famous Dave’s Bar-B-Q and Starbucks. You see, it takes little to keep a Southern boy happy.

When we arrived in Buffalo, it was only 2:00 p.m. Not wanting to waste five hours of daylight, off we went. We arrived in Boston around 9:00 p.m., tired but home. The following morning, my back was stiff. Having had back surgery previously, a stiff back is no stranger, given an occasional error in judgment, such as sitting in a car for 14 hours. Being the TSICU attending for the upcoming week, I figured it would work its way out. Monday was not terribly comfortable. Tuesday, being on call for trauma as well, most of the day was spent either in the emergency room or lying on the floor in my office. By the end of Wednesday, my administrative assistant made the remark that I was limping. Of course, this was steadfastly denied.

Then came Thursday morning April 2. Around 4:30 a.m., I awoke with one of the worst pains I can recall having. Back pain was not so much an issue as the radicular pain down the right leg. Not wishing to bother my colleagues, I waited until 6:30 a.m. to call Alan Lisbon (vice chairman of anesthesiology for critical care) to ask that he cover for me in the TSICU. He and I both agreed that a call to Mike Groff (one one of our neurosurgeons) was in order. Waiting for some time to pass, the call was placed. Mike was his usual cordial self. Pain medications were called into the local pharmacy with the directions to plan to come to his office is three days if the pain did not resolve. Prior experience told me this was likely.

Shortly thereafter, I began having crushing, substernal chest pain. With a family history of cardiac disease, I clearly thought the worst and agreed with my wife to call 911. This is where my memory begins to fade. There are faint recollections of the paramedics responding and placing me on a “scoop” stretcher. I recall what appeared to be an eight foot tall police officer standing over me as the paramedics loaded me into the squad. My wife later told me that the initial transport was to be to (a local hospital). After some heated exchange, and an initial normal EKG, they agreed to transport me to BIDMC. Suzanne was told by the officer that she should go on ahead, but do not panic when the squad passed her on the road. I have no recollection of the ride to BIDMC, but only that the paramedic said that we were pulling into the ambulance dock. After being taken someplace in the ED, I faintly remember vomiting all over myself and those taking care of me. I remember apologizing profusely. That brings an end to any other personal memory.

Suzanne said that the initial efforts centered around pain control and efforts to further define the nature of the problem. After growing four out of four bottles of blood culture positive for Staph. aureus, coupled with a deteriorating neurologic exam, it was off to the OR for an 11.5 hour procedure. This included pedicle fixation at three levels and posterior interbody fusion of L4-L5 and L5-S1. Findings included a diskitis at L5-L5 and an epidural abscess at L5-S1. This ultimately grew out Staph. aureus, fortunately methicillin sensitive.

Suzanne said that returning to the TSICU looking like Biff the Michelin man, I remained intubated overnight. The following morning, I was ready for extubation. Protocol calls for determining a RSBI or rapid spontaneous breathing index. The post-op course was complicated by both hepatic and renal failure. Thankfully, both were rather mild and resolved spontaneously over time. I have no recollection of either being intubated or being awakened in preparation for extubation. The next 7-10 days is a blur with only a few moments of clarity. Red Sox Nation would be pleased to know that one of those moments was recalling the delivery of a Red Sox home jersey -- #31 Jon Lester’s. I recall making demands that it be hung on the wall by the bedside for all to see.

The next setback came on April 14. Pam McColl removed my sutures and uttered that word no one likes to hear, "Hmmm." I hate that word. This time, it meant another trip to the OR for debridment. The second procedure lasted 5.5 hours. This time Dr. Kevin McGuire (an orthopaedist) joined Dr. Groff. The debridment again grew Staph. aureus. A PICC line was placed for administration of twelve weeks of intravenous antibiotics. After three days, I was discharged home with pain control being the major issue at this point.

Suzanne said, although I was seemingly coherent, in the final analysis, I had little orientation to time, place or person. She said the most telling of the moments was when I asked how to operate the TV remote. Being someone who will likely be buried with a remote in hand, this was highly uncharacteristic. Looking back on this one event, she said this should have been a warning sign of events to come. Only snippets of visits by friends linger during this first discharge.

After a time, pain control became a bigger problem. Around 9:00 p.m., a Saturday night mind you, I reluctantly allowed Suzanne to phone Mike Groff. Not only was pain out of control, but now I was in acute urinary retention. Instead of telling wife to go to the ED or call 911, he came over to our home, helped my wife carry me down the stairs and assisted her to the ED. He had called ahead to give the ED staff a heads up. Intake, MRI and disposition was done in less than one hour. At intake, the nurse asked if I would like a male attendant to put in a Foley catheter. At that time, I could have cared less, but the offer was touching. I would bet few neurosurgeons have taken the measures he took that evening.

Again, I found myself a patient in the TSICU. The usual smattering of studies were ordered, and the acute pain service was again involved. On Saturday, after the second procedure, the infectious disease consultants ordered a an Indium-111, tagged white cell scan to search for other sources of infection. That was, of course, after trans-thoracic as well as trans-esophageal 2D-echo looking for cardiac sources. This required a central venous line. Alan Lisbon drew the short straw and was responsible for starting the central line. I, to this day, do no know who suffered the most, him or me. I truly felt sorry for him; however, his spirits were lifted when he proudly proclaimed, after reviewing the chest X-ray, that the line was in good position and that there was no pneumothorax. I must admit, there was more than a little relief on my part as well. I would liken this test to be about as pleasant as sliding down a forty-foot cheese grater into a vat of alcohol. The pain service became engaged and found a combination of medications that seemed to do the trick. During this time, my memory was again fuzzy, no doubt, secondary to the multitude of drugs on board.

Amidst all this, a few comical stories are in order. First, let us call her nurse S asked if I liked strawberry shortcake. Of course, who doesn’t? She brought in what looked like a piece of strawberry shortcake, adorned with whipped cream, that looked at least a foot tall. Magically, it disappeared.

Ah, yes, hospital cuisine. Coming to the rescue was Joe Rizzo from the department of surgery finance office. Seems he is a wonderful cook. With a last name ending in a vowel, you guessed it, Italian food. Well, the chocolate cake didn’t hurt either. So much for the food stories.

Not wishing to bother the nursing staff when I wanted to ambulate, I would simply unhook myself from the monitors and attempt to stroll around the TSICU. Of course, I forgot that unhooking the monitor set off alarms all over the place. This proved to be an unpopular idea.

Then one evening, after 10:00 p.m. meds, I dreamed (must have been) that someone was calling me to come to room #17 (frequently used as the emergency OR during off hours). Convinced I was dreaming, I ignored the call. Who knows how much time had passed when I thought I heard the same call punctuated by a tap on the shoulder. Not to be thoughtless, I began unhooking all monitoring devices once again. Remembering the gentle reminder to stay “connected,” a call to my nurse to tell her where I was going was in order. Nurse B entered the room, but my explanation and sortie were short lived. She pointed her finger and sternly said, “Now listen. It is not about you, it is about us. You fall and our licenses are gone.” Needless to say, that convinced me that the red nurse call button was at the bedside for a reason.

Ah yes, now came physical therapy. While we hurriedly enter a “PT” order in POE (computerized provider order entry system), rarely do we give a second thought to what actually goes into a PT consult. Mary Beth and her staff, all of whom I am convinced deserve to be saints or knights of the realm, may be the unsung heroes of our patients’ recovery. When pain gives one little motivation to get out of bed, much less exercise, they face a real challenge. Learning to walk with a cane and assistance is a real blow on so many fronts. Nonetheless, given goals that were necessary to meet in order to be discharged, the game was on. Climbing stairs, a normal process during rounds, became like climbing a mountain. Then there is the infamous yellow elastic band, used as a resistance trainer. Being quite proud that I had mastered the art of the yellow ribbon, I managed to let the band slip off my foot and smack me squarely in the face. Once the pain had subsided, we all had a real laugh. This was perhaps the first time I had actually laughed in over a month.

Physical therapists have the uncanny ability to push you to the brink of determination rather to the edge of frustration. They are truly a remarkable component to our health care delivery system.

I left the TSICU for home on May 4. There were many valuable lessons learned during this time. The first is how one feels with an hematocrit of 23. We push our patients to get out of bed, be mobile and “get with the program.” However, with an hematocrit of 23, a walk around the bed is an all-hands evolution. Brushing one’s teeth is a task which requires a total expenditure of energy. A shower and shave is about a 1.5 hour evolution. Most importantly, I got to know the night staff well. Unless we admit patients in the evening, we sometimes have little contact with the night staff. This was a wonderful thing: to talk about families, learn likes and dislikes, and to realize what a wonderful staff with which we are lucky to have. One afternoon, a nurse with whom I worked as an intern was in Boston. She paid a visit. The outflow of emotion was overwhelming. I was an intern 37 years ago.

Finally two sobering events occurred during the hospitalization. A psychiatrist may have a field day with these two, but again they may have a field day with me at any rate. One afternoon according to my wife, she arrived to visit finding me sobbing uncontrollably. She asked why? I told her that I had seen all the patients who had died on my operating table. They were coming to welcome me. They were not angry or hostile, but expressed understanding and understood it could happen to anyone. Lastly, I have seen “the light.” It was perhaps the brightest light I have seen. Though bright, it was not harsh, but soothing. I know it was not the OR lights, for I have operated under them for many years. I offer no explanation to either event, but rather the observations. You are free to draw your own conclusions.

My goals were simple. Walk up the stairs without a cane. Walk to the end of the block. And finally, shower and shave without assistance. The dedication and compassion of the team involved in helping me reach these goals is overwhelming. It is difficult to express gratitude to those who have saved your life, preserved your ability to alleviate suffering and alter the course of disease. Thanks is simply not enough.

Later, when discussing the whole experience with one of the TSICU nurses, she asked whether I minded being admitted to a unit in which I work every day. The answer is quite simple: Why would I want to be admitted elsewhere when I know the knowledge, dedication and character of those with whom I work daily? When I see the length to which they go for my patients, the answer is a no-brainer. I am now back to work, full-time, thanks to a wonderful supporting health care delivery team. They are simply the best.

Do we have to worry about this, too?

Here's something that never would have occurred to me. A colleague today suggested that if the President and Congress are successful in eliminating or dramatically reducing the number of uninsured Americans, some in Congress would argue that the tax exemption enjoyed by non-profit hospitals should be the next target. The logic would be that if we were no longer providing free care, there would be no public service rationale for the tax exemption.

This thought left me surprised, but anything is possible. In my view, of course, this is not sound logic. First of all, there are other functions carried out for the public good in academic medical centers and other hospitals, like education and training of future doctors and nurses, and scientific research. And, even if everyone does end up with government-sponsored insurance in the future, there would remain a substantial deficit in those government payments. For example, the states pay Medicaid rates that are substantially below the actual costs of caring for Medicaid patients. These patients are subsidized by hospitals all across the country.

Beyond this, if the tax exemption were revoked, it would just raise the cost of care delivered in hospitals, adding sales tax to the purchase of goods and services; property tax on the value of plant and equipment; taxable interest on bond issues to finance new buildings and equipment; and state and federal income taxes for those hospitals lucky enough to earn a margin at the end of the year. Those costs, in turn, would be built into the rates, undercutting the goal of controlling cost increases in this sector.

If my colleague is right and this kind of sentiment is indeed likely, perhaps those currently deliberating on the health reform bill should put in some safeguard to protect the nation's non-profit hospitals and consumers from this unintended consequence.

Worth reading

Please check out the August 3 post called Political Correctness and Health Care Reform on Richard Wittrup's Health Care Anew.

Answers for Savina

I used to have a regular feature on this blog called "Wednesday is Student Day", to respond to questions raised by students of all ages. That faded away after a while, but I still get occasional questions from students, and some of them are of general interest. When they pop up, I will post them here. The latest arrived last week. Here it is, with my answers in italics.

Hi Mr. Levy!

My name is Savina Mehta and I'm a sophomore finance major at Michigan State University, in East Lansing, Michigan.

Although I am a business major, I have always had this passion for medicine. A few months ago, I was even toying with idea of changing majors , and transferring into a pre-med program. However, after researching the healthcare industry, I realized that I could combine my two greatest academic interests: business and medicine. And that's when I decided that I wanted to hold an executive position at a hospital, specifically holding the position of CEO.

Mr. Levy, I've read your blog and I'm really interested in what you do. I just had a few questions about how you got started in this industry.

When you were in school, what did you study?
At the time, I had no plans whatsoever to be involved in health care. I was interested in regional planning and infrastructure issues. At MIT, after the required math, science, and humanities courses, I took a composite of engineering, city planning, economics and econometrics, statistics and probability (to keep up my math skills!), operations research, and decision analysis. (And then there was one really great course in art history when I cross-registered at Wellesley College, which might have had something to do with an interest in art history and might have had something more to do with the relative gender mix at Wellesley versus MIT at the time.)

Are there particular subjects that would best prepared me for a position such as yours?
Beyond the particular topics, look for classes that have interesting and involved professors, where written and oral communication skills are emphasized, and where quantitative reasoning and rigorous analytical problem solving are expected.

How did you get the position of President and CEO at your hospital? Did you start off as a consultant or an adviser?
My path to this job was unusual in that I had virtually no background in the field. I was hired mainly because of my managerial experience in other settings.

Is it common to find business people holding executive positions at hospitals? Or are many of them M.D's?
I think, nowadays, there is about a 50:50 split at the CEO level.

What do you like about your job? What do you dislike?
I love, not like, the people who choose to work in hospitals. They are the most well-intentioned people you will ever meet, devoted to alleviating human suffering caused by disease. I dislike the fact that those of us in hospitals are not yet fulfilling our ability to reduce harm to patients. It is a sad paradox that well-meaning and committed people inadvertently end up hurting the very people they seek to serve.

What advice can you give a student who wants to hold a position like yours, one day?
Don't even think about planning a career. It will follow its own course. (This is my ninth job in 35 years.) Take jobs that do good for the world, where you can learn something new, and where you can have fun (i.e., where you can enjoy the people with whom you work.) Follow your instincts and your inclinations. Be alert to opportunities as they arise. Take risks: Ask for difficult assignments and do your best to carry them out. Learn to trust the people with whom you work, give others the credit when things go well, take responsibility when things go awry, and be generous with positive reinforcement with your peers and with those you supervise. Follow the golden rule, which is the same in all the world's religions.

I know that you are probably very busy, Mr. Levy and I am so sorry to bother you with questions. But I would really appreciate any help you can offer me.

Thank you so much!

Best Regards,
Savina Mehta

The infrastructure chronicles -- Volume 2

Second in our our occasional series.

One of my most memorable moments in public service occurred in the Town of Weymouth, just south of Boston. I was running the local water and sewer authority, and we were making massive (multi-billion dollar) improvements to the region's wastewater treatment system. With little or no state or federal financial assistance, most of the cost of those investments was being borne by the ratepayers in the communities we served. We therefore had to increase water and sewer fees by double-digit rates every year. This was very unpopular, but very necessary to meet federal water quality standards in Boston Harbor, the depository of the wastewater from 43 eastern Massachusetts communities. The MWRA had been created by the state government to take on the politically unpleasant task of siting sewage treatment facilities and raising the rates to pay for them, after decades of neglect by the state government itself.

At a community meeting in Weymouth, a resident said, "Don't raise my water and sewer bills. Let the government pay for this."

There, in two sentences, portrays the problem faced by elected officials in financing and maintaining essential public infrastructure. We are seeing this played out here in Massachusetts, where costs have been laid by the state government on the local transit authority, but where the political pressure against fare increases is severe. Indeed, the Governor finds himself in a lose-lose situation, one that has resulted in the untimely firing of the previous MBTA general manager and may now serve to unseat the Secretary of Transportation and also may jeopardize the Governor's reelection chances.

It is for this reason that single-purpose public authorities have been created: To take the politically unpopular steps necessary to finance essential public services. Legislatures and governors have realized that they need some political distance, or cover, from siting decisions and rate increases. While there is always the danger of authorities becoming too removed and unaccountable, safeguards can be built in to protect against that.

An alternative danger, though, occurs when a Governor steps into the work of a public authority and starts to put his or her hands on the levers. It is very hard to pull back after doing so, and it is likely to turn out poorly for the state's chief executive.

Commentary along those lines was filed yesterday by Robert Ciolek, an experienced public administrator, on Blue Mass Group, our local political blog:

What is it about the political and managerial abilities of the Governor and his team in terms of dealing with independent public authorities?

The legislative essence of such entities is their very real "independence". They were specifically created to remove them from the clutter and infighting of state government in order to focus on their mission. Yes, the Governor generally appoints the Board of Directors and over a period of time effectively takes indirect control over their strategic mission, but Deval Patrick and his team seem to want to continually muddle in the day to day operations....

Fighting these unnecessary battles is counterproductive and meaningless.... It is perfectly appropriate to suggest broad goals for independent public authorities, and having a key senior staffer coordinate the relationship of the state administration with various independent entities makes sense. Further, placing knowledgeable and dedicated individuals on governing Boards will, over several years, give sitting Governors effective control. But these blatant back room coups d'etats and resultant coverups is not fooling the public and will come back to haunt the Governor in 2010.

Sept 11 Blood Drive

We held a press conference today to bring attention to the 7th annual September 11th Day of Remembrance blood drive, to be held at Fenway Park and City Hall Plaza. This is a joint effort of the American Red Cross, the Red Sox, BIDMC, Legal Seafoods, Mayor Menino and the City's Police, Fire and EMS departments, and others. The event has also expanded to other states in new England.

Shown here at the press conference are Caroline Ogonowski, daughter of John, who piloted AA Flight 11; Dr. Deborah Nagle, a surgeon at BIDMC; and Donna Morrisey, with ARC Blood Services.

You can make appointments to give blood by calling 1-800 GIVE LIFE or going to this website.

How we spend our time

The New York Times posted this terrific interactive graphic on how Americans spend their day. Click on the different categories to explore groups within the population. I think the "computer use" category is probably understated, in that a lot of it is within other categories (like "work") or more and more simultaneous with others (like "TV" or "socializing"). Of course, there are those who also insist on texting while driving. I don't know how that is accounted for, but I wish they would stop.

Please call me next time

After years of being a somewhat public figure, I have gotten used to being misinterpreted and misquoted in the popular press, even when a reporter has interviewed me. But this is the first time someone in academia has done so, and it was compounded by a failure of a respected business magazine to conduct proper fact-checking.

Here's the story. I recently received a "teaser" saying,

"Recently, people have been asking us what they can do to respond to the current economic crisis and the major leadership challenges they face today. We have also received numerous requests for success stories of organizations investing in their capacity for adaptive change.

"Here are some new resources that we think you will find helpful:

"...Our article in the July-August issue of the Harvard Business Review, "Leadership in a (Permanent) Crisis," identifies three case studies that illuminate recommended practices, tools and tactics from the Adaptive Leadership framework. A quick taste:

"...Embrace disequilibrium – When Paul Levy became the CEO of Beth Israel Deaconess Medical Center, there was a high level of disequilibrium in the hospital. The organization had both financial challenges as well as difficult internal tensions. After working through the financial issues, Levy kept up the state of discomfort in order to induce change and resist the temptation for the organization to fall back on status quo."

There are two problems here. The first is that the authors misrepresent my management approach. The second is that neither they nor the publishers of the magazine contacted me in preparing their publication or the publicity surrounding the publication.

Beyond the break in protocol, this public characterization of how I manage an organization is troubling. The authors make it sound manipulative and disrespectful of the people in the organization, as opposed to a role more akin to coaching. They make no mention of how I frame issues in the context of the underlying values of the organization and the people working here, nor encourage a shared governance approach to problem-solving, both aided by being very transparent about the state of the institution. This draws strength and involvement from the staff: That, not embracing disequilibrium, is the key message.

Indeed, it feels like the authors squeezed what I actually did into their pre-existing analytic framework rather than fully exploring what it was.

Imagine how a nurse or doctor reading this would respond. I think they would feel that they had been used, versus how they really felt during that time -- engaged and energized. That is the ultimate problem with the materials presented by the authors and publisher.

I hesitated to write this, but I know of no other way to correct the record in a manner reasonably contemporaneous with publication of the teaser and the article.

Problem must be visible!

Well, back to work after some weekend diversions!

We recently hosted Mr. Hideshi Yokoi, president of the Toyota Production System Support Center in Erlanger, Kentucky, and Mark Reich, a general manager at TPSSC. This is part of our own orientation to Lean process improvement. Together, we visited gemba and observed several hospital processes in action, looking for ways to reduce waste and reorganize work. It was fascinating to have such experts here and see things through their eyes. Mr. Yokoi's thoughts and observations are very, very clear, notwithstanding a command of English that is still a work in progress.

The highlight? At one point, we pointed out a new information system that we were thinking of putting into place to monitor and control the flow of certain inventory. Mr. Yokoi's wise response, suggesting otherwise, was:

"When you put problem in computer, box hide answer. Problem must be visible!"

Too many zucchinis?

And, in case you missed this year's Zucchini Festival in West Stockbridge, MA, check out pictures here.

Art in the Park in Worcester

A great exhibit in Elm Park in Worcester, MA, through October 1. About 20 sculptures by various artists sprinkled throughout the park. Many are whimsical, like those shown here. It is worth a visit if you are in the area. See more pictures on my Facebook page here.

Beach umbrellas, from two sides

Nice sentiment

Great artwork on a Truro beach, composed in eel grass and sand.

Hey seals, look up and smile

Here's another view of those Cape Cod seals near Head of the Meadow Beach, this one from above, thanks to a friend who took us up for a scenic view in his Piper Cub.

Learning from success

A fascinating article about research being done by some folks at MIT. Apparently we learn better from success than failure.

When I asked Clif Saper, our Chief of Neurology to comment, he said the following. I think the last point has something to do with how I am supposed to treat Chiefs of Service!

The thing that is most salient in this work is the role of reward. Emilio Bizzi at MIT began studying prefrontal neurons and their role in directing eye movements in the 1960’s, and found that they had no real relationship to the eye movements when the monkeys randomly scanned the room. But later it was found that if you reward the monkeys for looking in a certain direction, they respond briskly. Primate prefrontal cortex is a machine for shaping behavior based on reward. There is a lesson in there...

Seeing through to quality

Jonathan Kruskal, our Chief of Radiology, points out out a useful website of the Radiology Society of North America, on which he has been working with the RSNA's Quality Committee. He notes:

This is a very useful site which includes resources for radiologists who want to get started with QI projects (very helpful for all of our residents now undertaking the QA elective); tools to help identify areas for improvement and tools for designing interventions, educational QA offerings (including the vertical daylong QI course at RSNA that Scott Gazelle from MGH and I am organizing this year); clinical guidelines and performance measures; and QA self assessment modules (SAM's).

I, too, note with some pride that the site links to four recent quality-related papers from Jonny's department (including those from Alex Bankier, Jacob Sosna and Bettina Siewert).

Edgar Schein helps out

Because of a gift from Twitter friend Ralf Lippold who I met (in person!) while he was attending a conference on Cape Cod, I just read a wonderful book by Edgar H. Schein entitled Helping, How to offer, give, and receive help. It is a great exposition of the importance of helping in a society. Beyond the general discussion, there are good lessons for people in business about the manner in which help is offered and received.

Here's is a short paragraph that I found compelling, headed, "Accepting help as a leadership function."

Many people in senior management positions have the power and the potential to be effective change managers through learning how to help, but their formal position and actual power often lead them into premature fixing. Those at the top of the ladder, in particular, are drawn to the expert and doctor role, whereas effective change management really requires the process consultant role. The dilemma of the organizational consultant is how to get across to clients that they need to learn how to be process consultants and accept the role as a legitimate and necessary part of being an effective leader.

You are so right, Joe!

A note from Joe Castro, manager in our trauma program:

I wanted to share several pictures with you that capture the beautiful gardens that surround the West Campus. The one above is of Michael Trzcinski and James Robblee – two of the many maintenance crew members responsible for keeping the medical center looking great! I see them often about the campus – always busy in the discharge of their duties. I told them what a great job they have consistently done to keep BIDMC looking good throughout the calendar year.

What you don’t see in these pictures are the MANY patients and visitors who take notice of the flowers. I walk between the Lowry building and the west campus buildings several times during the day. On countless occasions I see people react to colorful plantings either by taking pictures, stopping to smell the flowers, or simply sitting amongst them as a form of respite while taking a break from visiting a family member admitted to the ER or inpatient wards.

Michael and James spoke highly of the support given to them by their department heads, further mentioning the commitment of the medical center to maintain the quality and variety of the flower beds and their aesthetic value. Theirs is a job well done and I wanted to take this moment to ensure that these gentlemen, as well as others within their department, get the credit that they truly deserve!

Can you taste the difference?

If your place is like ours, you will find that lots of people purchase bottled water rather than using tap water. As someone who used to run the local water system, I can assure you that any municipal tap water delivered in America, and indeed throughout most of Europe, has to meet higher standards for purity and quality than water sold in bottles. Tap water also is delivered through pipes, often by gravity, with very little energy required, whereas bottled water uses petroleum for the bottles and for transport. (Indeed, some brands are transported thousands of miles.) Finally, bottled water is many, many times more expensive than tap water.

Here you see summer interns Joey Bazinet and Kimberly Chun offering taste tests to staff and visitors at BIDMC. Our facilities department is trying to persuade people to make the switch to tap water. Because inside pipes sometimes add their own flavors and particulates to the municipal water, our facilities folks will install and maintain a filter in anybody's lab or office area. Installation cost = $500-$600. Annual cost to maintain = $50 ($25 filter two times per year). Compare to the annual cost of Poland Spring water of over $700.

Another CEO enters the blogosphere

Welcome to Scott Kashman, CEO of St. Joseph Medical Center in Kansas City, who has started a blog. You can see it here.

Now that the numbers are growing, I have added a new category of links over there on the right side of the page, devoted to health care CEOs who have blogs. Please let me know if you know of others.

Primary Causes

The following sentence from the report of the Massachusetts Payment Reform Commission caught my eye: "It is widely recognized that the current fee-for-service health care payment system is a primary contributor to the problem of escalating costs and pervasive problems of uneven quality." As mentioned below, I admire the work of this Commission, and I have no quarrel with the principles adopted by it, but I believe this particular conclusion is overstated. The characterization is risky in that it gives no relative weighting to other causes and may serve to take those other causes of the hook in terms of policy development. Some reading the report may think that if you change payment methodologies, it will make a sufficiently significant dent in the rate of health care cost inflation. I'm not so sure.

I recently had a chance to view the average annual medical cost inflation rate of a health system's capitated patient group over the last five years. It was ten percent. This was ever so slightly below the health system's fee-for-service patient group, and I am willing to concede that the payment system made a difference. But the point is that is was not a major difference. What might be the other "primary contributors" to the problems we are trying to solve?

Here's my list, produced with the benefit of no data, but just observation of what actually goes on in the four walls of our hospital:

1) Demographics. The huge cohort of baby boomers have now entered the age at which they are seeking hospital care. Meanwhile, their parents are living longer than ever and are coming to the hospital for both acute and chronic care.

2) Entitlement. The first cohort named above expects and demands everything for themselves, and of the insurance products they expect their employer to purchase. For their parents, they often expect extraordinary end-of-life care interventions, paid for by Medicare.

3) New stuff. See #2 above. A knee that previously would have remained sore in the past or be treated by physical therapy becomes a target for arthroscopic surgery.

4) The medical arms race. Physicians and hospitals feel compelled to buy the latest technology, even without proof of enhanced clinical efficacy.

5) Defensive medicine. Yes, the threat of malpractice law suits leads to over-testing and other extra costs.

6) Regional medical mythology. Thanks to Brent James for this insight. Local practice patterns often are just that, with no evidentiary basis.

7) Preventable harm in clinical settings leading to extended hospitalization and bodily injuries.

8) Lack of access itself. If people don't have health insurance and can't get proper early diagnostic and preventative care, they are a more expensive burden on society when they get sick.

9) The cottage industry problem. The medical profession, both in physician practices and hospitals, has failed to adopt process improvement approaches that are common in other industries, that result in redesign of work flow and systems to derive efficiency, quality, and standardization.

10) A sedentary and malnourished lifestyle for all age groups, leading to obesity and other associated physiological problems that are the precursors to major health issues.

In a post below, I outlined the things I would like to see in federal health care reform legislation. Those don't address all of the causes mentioned above, but we should not expect a new law to do so. We can fix some of our inadequacies through legislation, but many components of our problems lie deeper in society.

P.S. While there are pro's and con's of each country's health care systems, similar cost pressures have become evident in much of the rest of the world. Perhaps this suggests that a common organism underlies our problems, homo sapiens and its curious ability to live longer and expect more.