Selling out to Partners

If this newspaper story by Robert Weisman at the Boston Globe is correct, the Attorney General is about to sign an agreement with Partners Healthcare System that will lock in the system's dominance for years to come.

The main provision:

Under the deal, which has yet to be formally signed, Partners’ prices would be tied to the rate of inflation, currently about 1 to 1.5 percent. That is significantly less than the recent trend of health care cost increases.

Here's why. We are talking about a system that has used its market power to build up its rates levels to be substantially above the rest of the market, say 15%.  Then our remedy is to limit its increase to inflation?

Big deal. All other hospital systems are also limited in their rate increases by recent state legislation.  Sure, they might get to go up a bit faster than Partners, but if you look at the starting point, it will be decades--if ever--before PHS rates are equivalent to the rest of the market.

Here's the accurate comment:

Boston University professor of health policy Alan Sager called the settlement a “functional compromise” by Coakley, who is a Democratic candidate for governor.

“This strikes me as more of a political deal than a health care deal,” Sager said. “If we’re relying on competition to hold down health care costs, the more competitors the better. The harm to the public will accrue more slowly under this deal, but the harm will occur.”

The agreement is simply another way of codifying what PHS already won in the most recent state legislation, when it used its political influence to obtain a figment of cost control. As I pointed out then:

The bill would allow health spending to grow no faster than the state economy overall through 2017. For the five years after that, spending would slow further, to half a percentage point below the growth of the state’s economy, although leaders would have the power under certain circumstances to soften that target.

Providers and insurers that do not meet the spending targets would have to submit “performance improvement plans’’ to a new state commission. Failure to implement their plans could lead to a fine of up to $500,000.

The problem, of course, is that a provider network like Partners with costs well above the state average will find it easier to meet the governmental targets than those with lower costs.  Why?  Because each hospital or network will be judged on its percentage increases.  If you have a higher base, you can increase the absolute number of dollars being spent to a much greater extent than those with a lower base and still meet the percentage target.  Ironically, again, the state is acting to increase the disparity in costs between the have's and the have-not's.  It is enhancing Partners' market power.

You also need to understand that virtually every hospital system in the country has set an internal rate growth target equal to the expected rate of inflation. Partners is giving up nothing by codifying that.

By the way, here's the the comment in the Globe story given by a person who makes money by selling consulting services to hospitals.  How the newspaper could include this with no indication of his client list is beyond me.

“It strikes me as a very fair approach and a very smart approach. The AG’s office is saying they want to limit the risks around cost and forming a monopoly but recognize the benefits of a very high quality hospital system bringing services to a community that could benefit from it.” 

We have to admit that none of the Democratic candidates for Governor (including one I have supported) has shown any spine with regard to taking on this behemoth.  Not one.  But this is the first of the candidates who seems to be explicit about selling out.  Let's see if any of the others are willing to take on the issue.

Failing to act as stewards of the occupation’s standards

There continue to be lots of stories about the high cost of the new drugs to combat hepatatis C.  Here's one from NPR by Melissa Block and Richard Knox.

In a previous post, I talked about the presence of  a distinguished academic on the board of Gilead, the company that makes one of these drugs.  It's time to ask the question more directly:  Where does Dr. Richard Whitley stand on this matter?

What does his silence on this issue say to the country about his duty to two masters, a federally subsidized drug research effort and a pharmaceutical company? What message does that send to the public about how they should view the relationships between academic medical centers and industry?

We don't need a Sunshine Law to see that Scott Gottlieb has it right: The profession, and academic medicine especially, is failing in its responsibility to act as the steward of the occupation’s standards.

A protracted failure of American medicine to self regulate

Scott Gottlieb, writing at Forbes, says:

The “Physician Sunshine Act” is as much a response to the past marketing excesses of the drug and device makers as a reflection of the retreating stature of the American doctor. Aspects of medical practice that were once firmly the domain of professional bodies are now subject to federal tinkering. This has profound implications for doctors and patients alike who have firmly ceded vital autonomy.

The Sunshine Act mandates that medical product companies report to the Federal government any payment or “items of value” that total $10 or more and are provided to an individual physician over the course of one year. The law also applies to “indirect transfers.” For example, when a drug company pays money to a marketing firm and then expects the group to provide something of value to doctors.

[P]rofessional medical societies should ponder how the rise of these kinds of state and federal laws represents a failing of their responsibility to act as stewards of the occupation’s standards.  This sort of federal regulation represents an enduring change in how Washington views the entire profession. Other professions (journalism, financial services) impose rules and limits on consulting work and outside payments. But perhaps no other profession is subject to federal limits and reporting requirements that are as profound as those now imposed on physicians.

One of the central tenets of professional autonomy and responsibility is the act of self-regulation. . . . Now the only professional currency that counts is what gets codified into federal regulation.

Is this part of the promised lower costs?

The Boston Globe's Robert Weisman summarizes the effect of the tax on insurers imposed by the Accountable Care Act.  Excerpts:

Insurance companies, like drug and medical device makers, were required to help fund the Affordable Care Act through annual taxes that must be booked in the first quarter for accounting purposes. But the insurers said they will try to recoup much of the added cost through the year by boosting premiums for employers and individuals buying insurance.

The taxes and fees tied to implementation of the Affordable Care Act were assessed for the first time in the most recent quarter. They will increase in each of the next four years before leveling off in 2018. Nationally, the cost to insurers has been estimated at $8 billion this year.

Access, lower cost, and choice.  Right.  I used to think it was two out of three.  Now, it appears to be only one out of the three.

We're gradually getting to understand how the Congressional Budget Office was just able to "score" the Accountable Care Act as positive for the federal budget: "That legislation includes many other provisions that, on net, will reduce budget deficits . . . over the next 10 years and in the subsequent decade." (Original version here in 2010 also did so.)

The Times learns digital

For those interested in the future of journalism in the digital age, there is likely to be no more significant document than a recent report prepared for the New York Times.  Here's a great summary from the Nieman Journalism Lab.

MIT SDM Webinar: Business System Integration

Risks and Mitigation Approaches for Business System Integration

 

MIT SDM Systems Thinking Webinar Series

Date: May 19, 2014

Time: Noon – 1 p.m. EDT

Free and open to all

Register

About the Presentation

The successful integration of new technologies is essential to continual success in today's fast-moving global economy, enabling businesses to upgrade their systems to be more effective, reliable, and scalable. Because this requires a critical alignment of business processes and technologies, organizations invest heavily in system implementation projects. Nevertheless, these projects often encounter unanticipated roadblocks to success.

 

In this webinar, Daniel Mark Adsit will discuss observed patterns in manufacturing and supply chain technology implementation projects across more than 15 countries—using examples that span diverse cultures, organizations, functions, departments, and technologies. The presentation will:

• zero in on critical focus areas for businesses contemplating a major project;
• highlight common yet unexpected obstacles;
• discuss how stakeholder factors can significantly impact system adoption; and
• outline steps to take to enhance strategies for addressing complex technology implementation dynamics.

A question-and-answer period will follow the presentation. We invite you to join us. 

 

Details/registration

Glassdoor invitation

Thanks to Glassdoor for inviting us to post this article.

Thoreau says "Keep Walden Free"

Well, no, he doesn't say that, but he would if he were around again.

The state DCR is considering proposals that would prohibit swimmers from swimming across Walden Pond (open water swimming, or OWS).  This is raising the hackles of lots of people, from triathletes to us normal swimmers, who enjoy wide open water where we can swim for a mile or more--and who value Walden for recreation and spirituality.

A 2.5 hour community meeting on the issue was held this week, and one attendee forwarded these notes: 

The DCR was soliciting user community input on what to do with the question of OWS at Walden. The concerns of DCR are multiple and sometimes conflicting. 

From the perspective of DCR, the current state of OWS at Walden is "unsustainable". Their concerns range from liability to their inability to patrol such a large body of water. Five to seven times per year they need to rescue swimmers outside the boundaries. Their life=guarding resources are not adequate to that task. They do not view triathletes as the problem, they seem to be more concerned with the untrained individuals who copy the triathletes and get in "over their head". 

DCR, from an organizational perspective, is asking itself the question "Why does this park have special swim privileges found at no other DCR park?" (Yet DCR loses more swimmers in shallow, guarded areas of its parks than anywhere else). 

DCR has a real concern with having a set of rules (swim only in designated areas) yet also having a policy to ignore their own rules. DCR feels that 2014 needs to be a "year of transition" to a more rule-driven, controlled OWS environment. DCR also stated "it does not want to do anything stupid".

DCR started the meeting by presenting two beautiful 2' by 3' color maps of Walden's 2014 designated swim areas. The designated OWS area was a 125 yard lane parallel to Red Cross beach. That's it. The other 99% of the pond was off limits. They solicited group input on these maps, which was universally hostile. DCR listened to us and withdrew this proposal fairly quickly. Other proposals were knocked about, perhaps a swim testing program to qualify to swim open water, better education about the risks, limited hours for OWS ... nothing was really hit upon as the solution. 

In sum, no resolution was reached. DCR really made an effort to listen to the concerns of the user communities, but as I state above, they have their own significant concerns as well. They are going to digest what they heard tonight and regroup. 

With Memorial Day weekend around the corner, where precisely does this leave us? I believe we will be permitted to continue to OWS, but changes are likely to be made. We must positively and firmly engage with DCR to meet their concerns, yet protect our interests.

DCR followed up with this email the next day:

I wanted to send along a quick note to again express our sincere appreciation for your contributions to last night's meeting. Our hope going into the evening was to emerge with a better understanding of the inspirations, use patterns, and concerns of the open water community and through that to identify opportunities to minimize conflicts with our regulations and policies and maximize safety for open water swimmers, the general public, our staff and other rescue personnel. We could not be more pleased with the outcome in that regard. By design or luck our group reflected the diversity of the open water community relative to time of day, style of swimmer, and the motivations that bring you to the water's edge and beyond. Among all those differences, there was universal agreement on the importance of Walden Pond in your lives and your vigorous opposition to any plan that constrained your swim to a lane along Red Cross Beach.

We at DCR gained immensely from the conversation and we look forward to an ongoing dialogue as we explore ideas you shared and your genuine willingness to adjust some preferred patterns in order to accomodate the agency's public safety and management goals.

Thank you.

My thoughts:

First, on enforceability:  Any rule that inhibits OWS will be disobeyed (yes, just like H. David Thoreau would advocate as a form of civil disobedience!)  Enforcement, given DCR's limited resources, would have to occur by issuing violation notices by park rangers when people return from their swim.  If any of those people contested the fine, DCR would have to send its staff to court to document the event and advocate for the penalty, drawing resources away from the lake.

(By the way, many people engage in OWS literally at dawn.  DCR does not have people on duty to enforce such rules during this time.  Would they use up scarce budget resources to add staff for this purpose?)

Second, on the issue.  Why now?  OWS has existed at the lake for decades.  What is prompting this proposed change that didn't exist years ago?  (I guess there were some similar thoughts in 2010.)  Those engaged in OWS are adults who understand the risks.  If the issue is the budget impact of the very occasional rescues, simply put in place the kind of rule that exists in the mountains in some jurisdictions: If you need to be rescued, you pay for it.

"That government is best which governs least."

Friday, May 16, at 5:00pm: Breaking news from Universal Hub!

The state Department of Conservation and Recreation said today "open-water swimming" will continue to be allowed at the historic Concord pond, but that people really shouldn't try it until they know what they're doing:

Over the last three years, there have been 28 saves by lifeguards at DCR's Walden Pond, 13 of these saves came from outside of the designated swimming areas. Water rescues in depths of more than 20 feet put swimmers, lifeguards, and emergency response personnel at a greater risk. In recent years there has been a marked increase in the number of inexperienced swimmers attempting to cross the pond creating a new and more urgent public safety challenge for the agency.

Walden Pond is a kettle pond that has a depth greater than 100 feet (108’) at its deepest point. In an effort to ensure the public’s safety at Walden Pond, while attempting to accommodate the growing popularity of long-distance swimming, DCR recently shared a draft proposal with The Walden Pond Advisory Board and other community stakeholders that would create an unobstructed, 125 yard swim lane for distance swimming in a designated unguarded swimming area. This proposal has been met with some skepticism by community advocates. As a result of ongoing conversations with advocates and emergency responders, this proposal is no longer being considered.

Please explain this drug pricing

I don't understand this, do you?

Here's a full page ad from Pfizer in the New York Times that, it seems to me, makes a prima facie case that the company is engaged in price discrimination against (1) the federal government through Medicare and ACA Exchange plans and (2) uninsured people.  If you are in those categories, you pay $30.  On the other hand, if you are with a commercial insurance company with one kind of policy you pay $4, and with another kind of policy, $30.

I guess this is legal, but it sure makes you wonder how it can be, or whether it should be.

Thanks for the donation, doc?

I guess we would call this a success, but it doesn't feel like it to me.  Indeed, it feels like someone is taking advantage of the good will of doctors.

Here's the story, reported by Adam Ragesua at Marketplace.  Excerpts:

Across the country, a few hospitals have come up with a counterintuitive way to save themselves money: offer minor surgery for free.

The doctors work on Sundays for free, while the facilities and diagnostics are donated by the Medical Center of Central Georgia.

 “This is a way that we can support this program, with patients that we would likely see anyway, that would be in our system because they have a need that hasn’t been taken care of,” said Roz McMillan, one of the hospital’s vice presidents.

In other words, Lammon Green’s lemon-sized cyst was probably going to land him in the emergency room eventually, and since he’s uninsured, the hospital would’ve ended up eating much of the cost.
Cutting the thing off before it gets that bad is a much simpler procedure.

By donating their services instead, the hospital is saving themselves thousands of dollars in the long run, said Laura Ebert, who runs a program called “Surgery on Sunday” in Lexington, Kentucky that started in 2005.

Is this sensible or simply a perverse result in states that have chosen not to expand Medicaid?  But it goes further than that, as Adam reports:

Low income people in many states are getting insurance through an expanded Medicaid, but their deductible for an elective surgery could be as high as $10,000.

“Hernias and gallbladders and things that we do on a regular basis are considered elective surgery, not life-threatening, so therefore they’ll have to pay their deductible,” Ebert said.

That means people are likely to put off their surgery. The problem gets worse, they end up in the E.R., and Medicaid reimbursements are low -- so again the hospital gets stuck eating some cost.

As long as a hospital has a doctor willing to donate her time, it might be cheaper to take out that gallbladder for free.

Sorry folks, but this is sick.  Now, Adam adds in a comment:

Maybe this is the thing I didn't communicate effectively: all of the free surgery programs I'm talking about here were started by surgeons as their own volunteer enterprises. They then got the hospitals on board to donate facilities, materials, and liability coverage, and I wanted to explain one of the hospitals' motivations for doing so. I didn't include a skeptical doc because I simply didn't encounter one -- it was their idea to donate their own time on Sundays.

That is lovely, for sure, but in my mind it still remains wrong that this should be necessary as a solution to this problem created by state governments.

Walking the walk

If you ever, ever wanted validation as to the importance of transparency with regard to clinical outcomes, please read this comment on the post I wrote about how we introduced it at BIDMC:

For me, a trainee at the time, the most important effect was that it underlined a shared sense of mission and purpose around quality improvement. The reporting didn't have a big direct effect on my practice--I just tried to learn how to put in central lines the right way, while my elders had already defined what the "right way" was. The indirect effect was as part of a sense of purpose, though. The absence of a sense of purpose of this kind is toxic. For instance, if you have an advertising campaign that emphasizes our kindness or humanity, but we have no policies or practices that distinguish our kindness or goodness from anyone else's, it may be persuasive to our market as a branding tactic, but it's actively alienating to those of us who work within this system. Conversely, if we walk the walk more than talk the talk, it's inspiring. Posting the data probably influenced very few patients one way or another--but it definitely made many of us feel like we were walking the walk. 

Oh good, now they're after hernias

A report from LEERINK, a stock market analyst, relates a conversation with a general surgeon who does 150 daVinci robot surgical cases per year.  (Sorry, no link available.)  An excerpt:

The surgeon has noticed a significant recent effort from ISRG to push robotic use in hernia as a way to target general surgeons. For him, the case for adoption is stronger in more complex ventral cases vs. inguinal hernias, but he still thinks the economic/clinical rationale is tenuous for both. In his view, robotics' penetration in hernia is unlikely to go above 5% (up from <1% today), and he has yet to find a hernia procedure that is "ideal for da Vinci."

Well, economic and clinical rational has never mattered before.  Will the profession ever put a stop to this supply-push form of medical equipment sales?

Report from the field

Warning:  This is the kind of story that will leave you fuming.

At a major academic medical center, a friend was recently scheduled for a tricky off-label injection into her leg to deal with a long-term disability.  The previous injection had proved to be helpful. Knowing that the placement of the injection was critical, my friend specifically requested that the attending physician, rather than a trainee, administer it.  When the time came for the injection, the attending left the room, and the trainee delivered it--into the wrong place.  My friend immediately knew something was wrong but decided to wait a few days to see if there was any long-term effect.  There was, and her physical condition reverted to a much earlier period, setting her back over a year in treatment progress.

She reported this to the attending and also talked to the site manager at this hospital.  Neither was responsive.  Indeed, the site manager said that my friend should have expected a trainee to handle the case because it is a teaching hospital and because it was an elective procedure.  No one admitted that a mistake had been made or apologized in any way.

She asked to get a second opinion as to the cause of the problem and the next steps. The doctor chosen for the second opinion was rude to her, yelled at her, and refused to discuss the data my friend brought in for the meeting.

The president of the hospital likewise was rude and unresponsive.

Meanwhile, from a third party, my friend learned that the original attending knew that things were awry in the clinic that day, that she was in error by not being present for the procedure, and that the trainee indeed caused the damage.  The doctor did not tell the patient any of this, but panicked and hid all of these facts.  My friend also learned that the other people at the hospital from whom she had tried to receive satisfaction were protecting the attending.

But this hospital is at the top of the list in US News and World Report.

Playing both sides

“We have to break people away from the choice habit that everyone has,” said Marcus Merz, the chief executive of PreferredOne, an insurer in Golden Valley, Minn., that is owned by two health systems and a physician group. “We’re all trying to break away from this fixation on open access and broad networks.” New York Times, May 13, 2014.

Whew, that doesn't sound a lot like the promises made during the debate on the Affordable Care Act:

No matter how we reform health care, we will keep this promise to the American people: If you like your doctor, you will be able to keep your doctor, period. If you like your health care plan, you'll be able to keep your health care plan, period. No one will take it away, no matter what."

Let's put aside politics, though, and focus on what's happening.

Look at the corporate structure behind the statement above.  The insurance plan is owned by providers. One way to make money in a changing marketplace is to be both the buyer and the seller, no?  Look at some of the "success stories" often discussed in the media, like Kaiser Permanente and Geisinger. These and others control both sides of the transaction for a substantial segment of the population in their catchment area.

What will happen in markets like Boston where there is a dominant health care provider with dramatically higher costs than the rest of the market?  Is it possible for insurance companies to create commercially viable limited networks comprising the lower costs doctors and hospitals? They may try, but the day may also come when that provider group, to save its position, will create the insurance entity that will be focus business towards itself.  Once it does, it will be able to manipulate internal transfer pricing to optimize profitability.  Here's the advertising pitch, hyperbole included:

"Now, the same health care system that has brought you the latest in medical advances brings you the latest medical advance, an insurance plan that guarantees access to the best hospitals and doctors in the world."

Transparency is not about competition

Cheryl Clark at HealthLeaders Media has an excellent story about how making hospital clinical outcome data public affects providers. It speaks positively about the efforts of my former hospital in this regard and quotes the hospital's chief quality officer:

"But transparent reporting's strongest impact has been internal. There's the overall message that we're confident enough in our performance to share information publicly, and the accountability that it signals. It's generated a series of conversations about what we want to make sure we're doing well at, that we're tracking it."

This point echoes a theme I stated back in 2008, based in great measure on something I learned from Jim Conway, which he picked up from the work of Peter Senge in The Fifth Discipline:

There are often misconceptions as people talk about "transparency" in the health-care field. They say the main societal value is to provide information so patients can make decisions about which hospital to visit for a given diagnosis or treatment. As for hospitals, people believe the main strategic value of transparency is to create a competitive advantage vis-à-vis other hospitals in the same city or region. Both these impressions are misguided.

Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

I do have to correct some misstatements in the article, though.  It suggested that our early forays into transparency of clinical outcomes began in 2003, and that the impetus was the following:

Commercial reputation seemed to suggest BIDMC's competitors were better hospitals, "but when we looked at the data, it didn't look that way to us; it looked like we were the same or better. So we felt there was nothing to lose by creating a more level playing field, by making the data available."

Not at all the case.  First of all, the year was 2006, and not 2003, when I began posting real-time central line infection rates on this blog, followed by other metrics, based on great work by our clinical leaders.  And this had nothing to do with competition.  I wrote these pieces because I was really proud of our progress on these clinical issues.  Also, consistent with the points made above, our Chief of Medicine, VP for Healthcare Quality, and I felt that transparency would lead our staff to hold themselves accountable to a higher standard of care.  Our staff had few or no objections, as they felt comfortable that the data were accurate and were not being used to blame anyone for lapses in performance.  The mantra became, "Let's be hard on the problem and soft on the people."

Our Board of Directors, again with advice from Jim Conway but also from Lee Carter, then chair of the board of Cincinnati Children's Hospital, and MIT's Steven Spear, soon got on board and made a huge commitment to the elimination of preventable harm and to the publication of quarterly figures summarizing harm on the corporate website.

That's how it happened.  It required no governmental mandate, just a commitment from the administrative and clinical leadership, supported by the governing body of the hospital.

Well done at Community Hospital

When we talk about standard work in clinical settings, it can refer to lots of things, but adherence to safety protocols tops the list.  Here's a great story from the Washington Post about Community Hospital in Munster, Indiana, describing what happened "when MERS showed up at its emergency room."  Excerpt:

MERS might not have been the first thing on the minds of doctors and nurses when a still-unnamed patient came into the emergency department with symptoms of what looked like a bad case of the flu.

And that’s the point, Alan Kumar, the hospital’s chief information officer, told me Monday: Staff are drilled on proper procedures for handling infectious diseases regardless of what they might be, so if they ever face a situation like this one, the danger can be contained.

“If they all know the protocols and standards, [and follow them],” he said, “when something like this comes in, the exposure is minimized.”

A friend at a major academic medical center wrote me:

Think about what this community hospital did.  I can't even imagine seeing the kind of general process they exhibited in my place, or others for that matter.  Protocol, protocol, and the staff did well.  They had no suspicion of what they had in their midst until ex post.

How you use "influence" matters

These stories are always a bit silly, but sometimes they deserve comment.

Modern Healthcare published its annual "50 Most Influential Physicians and Leaders."

First, some advice.  If you have to go look at the article to see if you are in it, you are not.

Second, as we look at this, we need to understand that some people are in it because of what they have done and what they are doing.  Just to name two of many in that category, we can see Richard Gilfillan, CEO of CHE Trinity Health, and USCF's Bob Wachter. 

Others, on the other hand, are on the list solely because of the positions they hold, even if they have not contributed very much to the advancement of safe and effective clinical care, improvement in medical education, or the like.  These are folks who, frankly, are the dinosaurs of the profession, who have moved up to the "top" over the years but who are holding back the kind of disruption needed in the health care industry.

I guess, in that sense, they are "influential," but not in a way that we would like to see.  They have not used their influence in hospitals, lobbying organizations, and other institutions to make a noticeable or lasting difference.

No, I will not name them, but I do hope they have an opportunity for early retirement so some fresh blood can take their place.

Patient Voice Institute raises patient voices

A special announcement is coming this week at the HXRefactored Conference, the launch of a new non-profit called Patient Voice Institute.  I'm hoping this can be the group that finally gives patient advocates a chance to work together to amplify their voices and influence the healthcare system.

From the website:

The Patient Voice Institute (PVI) is dedicated to the support, advancement and inclusion of the Patient Voice in Health Care. What are “Patient Voices”? Experienced, passionate, informative speakers, presenters, educators and collaborators who provide compelling cases for what patients need from the system, and how to achieve it.

What PVI Does:

• PVI works with patient organizations and individuals to amplify the patient voice in ways that are comprehensive, consistent and true; developed by, with and for people who are patients, family members and consumers.
• PVI creates connections across patient groups, patients and families, and health care organizations, associations and others to support all sides in developing true partnerships.
• PVI provides evidence-based principles that reflect what patients want and need, training and matchmaking for patients and organizations who want to work together, and online promotion programs to encourage patient engagement in the policy direction, operations, and daily interactions of health care.

Led by a terrific team, this could be just what the movement needs.

Brookline Booksmith offers graduation table

Hey Bostonians, Brookline Booksmith has included How to Negotiate Your First Job at a special table for college graduates and their parents.  Please drop by a get a copy.  For a sneak preview click here.

Of course, worldwide you can find a paper or e-book copy here.

Extremist Buddhists? Impossible!

I've seen this now a few times, watching friends titter (with some embarrassment, because they know it's inappropriate) when they hear or read news reports about "extremist Buddhists" in Myanmar.  Why do they laugh?  Because the image of radical Buddhists engaged in genocidal-like behavior is inconsistent with my friends' stereotype of Buddhists as calm and meditative, focusing on the nature of the mind, on clarity and awareness.

This disconnect between our stereotype of how people of a certain religion should be viewed and how some of them behave can be disconcerting.  It happens when the aggressive or hostile political acts of a subset of people of a religion conflict with the underlying premises of the faith, as practiced by the majority.

Our perceptions sometimes then rebound in a dangerous way.  We extrapolate the bad behavior of a religion's extremest members to all members of that faith.

The Aga Khan made this point with regard to Muslims in his recent address to the Canadian Parliament:

"What is highly abnormal in the Islamic world gets mistaken for what is normal."

But it is not only about Muslims.  The same has occurred with regard to extreme actions taken by Christians and Jews in other settings. Think of violent actions by some Catholics and Protestants in North Ireland during "the troubles."  Were the acts representative of the religious beliefs of most people of those faiths?  Of course not.  Ditto for some awful things that some extremist Jews have done to their neighbors in Israel. 

Extremist actions of this sort reflect the appropriation of the name of a religion in support of a political goal.  We observers often fall into the trap of equating those extremist actions with the tenets of the religion.

But, in the US, we do one thing more.  If other members of a faith do not decry the actions of the extremists, we say, "You see, they won't keep their own people from doing harm," or, "They must be the same at heart."

I've seen a lot of my American brethren do this when a Muslim commits a terrorist act.  If the Muslim community does not rise in "sufficient" public outrage, they are assumed to be somehow complicit.

When terrorism or other extreme behavior occurs, is it the special responsibility of those of the religious faith of the criminal to denounce it?

I don't think so.

Each of us chooses to respond in our own way to these terrible events.  Let's not take someone's decision to respond privately, rather than publicly, as a sign of support for extremism.  Indeed, it is likely the case that they are grieving more than we can know because their faith has been improperly used to justify a heinous act.

Or perhaps they have chosen an approach based on forgiveness--a theme set forth over the years by Ghandi, King, and Mandela.  Here's an example, from the family of a person who was recently killed by extremist Muslims in Kabul.  They wrote:

We mourn those who plan and commit these atrocities (who) have never known the beauty of our faith, Islam, or of any other faith in the path of God.

My personal bit of intolerance

I am pretty easy-going guy when I referee youth soccer games, especially when the boys and girls are 9 or 10 years old . . . except when they jump up and hang on the net, like this fellow in the picture to the left.

While it doesn't happen often, nets have been known to fall over and severely injure kids who do this.  Yes, the nets are supposed to be anchored, but sometimes they are not, and sometimes the anchors are insufficient to withstand the torque of a person hanging on the top post.

So, today as I was checking in the little 10 year old boys, I saw one of them jump up and hang from the goal.  I directly, and within hearing of the others, told him to get down and to never do that again.  Three minutes later, one of his teammates did the same thing, a clear demonstration of the sound-brain barrier that exists in little boys.  I decided it was time to make sure none of them would ever forget the lesson:  In very strong and loud language, I stood just a few feet away from the second boy and looked him in the eye and told him that he should never, ever do that again.  He was cowed, as were his teammates.  And then I said to them all that if they ever saw anyone doing that, they should tell him to get down. 

Then, gently, I said, "Now go and have a great game and have fun."  And they did.

Schwitzer offers a guide to reading health care news stories

Gary Schwitzer, writing in JAMA Internal Medicine -- in an article that has been moved out in front of the paywall --- freely accessible for 6 months -- summarizes the work of a team of reviewers from HealthNewsReview.org who evaluated the reporting by US news organizations on new medical treatments, tests, products, and procedures between 2006 and 2013.  The results:

After reviewing 1889 stories (approximately 43% newspaper articles, 30% wire or news services stories, 15% online pieces [including those by broadcast and magazine companies], and 12% network television stories), the reviewers graded most stories unsatisfactory on 5 of 10 review criteria: costs, benefits, harms, quality of the evidence, and comparison of the new approach with alternatives. Drugs, medical devices, and other interventions were usually portrayed positively; potential harms were minimized, and costs were ignored. 

Here were the standards applied during this seven-year period:

Ten review criteria were used to assess each news story reviewed. The review criteria addressed whether the story (1) adequately discussed the costs of the intervention; (2) adequately quantified the benefits of the intervention; (3) adequately quantified the harms of the intervention; (4) evaluated the quality of the evidence; (5) widened the diagnostic boundaries of illness and promoted public awareness of these widened boundaries, which may expand the market for treatments, a practice that has been termed disease mongering; (6) quoted independent sources and identified the conflicts of interest of sources; (7) compared the new approach with existing alternatives; (8) established the availability of the intervention; (9) established whether the approach was truly novel; and (10) appeared to rely solely or largely on a news release as the source of information.

The one type of mistake that I have seen all too often is described in the article as "the tyranny of the anecdote."  Gary explains: 

Stories may include positive patient anecdotes but omit trial dropouts, adherence problems, patient dissatisfaction, or treatment alternatives. In one example, 4 major US news sources used the same “breakthrough” patient anecdote of one man’s reported improvement from a heart failure stem cell experiment. This example illustrates another common problem: patient anecdotes provided by public relations representatives for medical centers or industry that put an overly positive spin on an intervention. 

How perfectly these stories coincide with the anecdotes used by firms and hospitals in promoting their products or services.  How much more so when the reporter works in a small or medium size community whose hospital has decided to buy into a firm's technology. It becomes quite evident that the journalist is often taken in by the jingoism of the hospital and "finds" the anecdotes that support the joint marketing campaign of the suppplier and the hospital.   Gary suggests that "fawning coverage of new technologies" is the result:

Journalists often do not question the proliferation of expensive technologies, such as proton beam radiation machines and robotic surgical systems. The use of new technologies can increase the costs of medical care but may not improve care.

Gary suggests:

Our findings can help journalists improve their news stories and help physicians and the public better understand the strengths and weaknesses of news media coverage of medical and health topics. 

I hope so. These reporters, often younger men and women on the staff of newspapers, need to understand that their reports can have a substantial impact on the public perception of new medical devices, therapies, and hospitals.  They owe it to the public to be diligent and rigorous in their coverage. Are they up to the task?

A reprise: Is this the free part, or the fair part?

Back in 2009, I wrote a story about an agreement between the Service Employees International Union and a major health care chain in Massachusetts which pretended to offer workers "free and fair elections."  It was nothing of the sort, of course.  In fact, it was a gag agreement that precluded an open debate about the merits of organizing those hospitals.

Five years later, we read this article in Modern Healthcare about a deal between the SEIU and the California Hospital Association.

The partners hailed the accord as a potential model for labor-management relations.

Boy, this must be good and really important.  We read further that the deal creates an organizing “code of conduct.”

The new deal, which was signed Monday night, includes facilities that operate a majority of the state's hospital beds. The hospital association declined to name the hospitals that signed the agreement, which will end Dec. 31, 2017. 

The code of conduct, which will govern organizers' communication with hospital employees, would seek to transform historically tense and negative conduct by unions and employers into more constructive and positive relationships... The partners declined to publicly release the code of conduct.

Wait, so unnamed hospitals signed a code of conduct that is being held confidential.

What a breakthrough for workers and managers! They don't know if their hospital signed the agreement.

What a victory for transparency! A code of conduct that is supposed to govern union-management relations is being kept secret from workers and managers.  Further, nothing was said as to how the code would be adopted or enforced.

So we have to assume that either the whole agreement is a nullity or that it contains elements that would be so abhorrent to workers or managers that the partners are afraid to announce what it says.  We can be confident, though, that it will offer workers "free and fair elections."  Whatever that means.

Partnering with patients on WIHI

Madge Kaplan writes:

The next WIHI broadcast — Partnering with Patients for Safety: The Next Phase of Work and Commitment — will take place on Thursday, May 8, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:

• Tejal K. Gandhi, MD, MPH, CPPS, President, National Patient Safety Foundation and Lucian Leape Institute
• Susan Edgman-Levitan, PA, Executive Director, John D. Stoeckle Center for Primary Care Innovation, Massachusetts General Hospital
• Maureen Bisognano, President and CEO, Institute for Healthcare Improvement (IHI)
• Linda K. Kenney, Executive Director and President of MITSS (Medically Induced Trauma Support Services, Inc.)

Health care is at a tipping point with respect to patient engagement — from something that’s “nice to do” (or even “the right thing to do”) to something that’s absolutely necessary. Research and experience are making it clear that no health care organization can operate in a reliably safe way without the involvement of patients and families. And without their involvement, any organization’s safety agenda is bound to encounter diminishing returns. Patients and family members offer extra eyes and ears to events unfolding around them, and have crucial knowledge about and perspectives on what kinds of changes will help them the most.

To frame what a vision of patient engagement needs to encompass, and what an across-the-board implementation of that vision needs to embrace, The National Patient Safety Foundation’s Lucian Leape Institute (LLI) has just published a comprehensive report that lays it all out: Safety Is Personal: Partnering with Patients and Families for the Safest Care. The contents of the report and how to make it actionable are our focus on the May 8 WIHI: Partnering with Patients for Safety — The Next Phase of Work and Commitment.

NPSF’s Dr. Tejal Gandhi, IHI’s Maureen Bisognano, Susan Edgman-Levitan, and Linda Kenney will walk us through the report’s recommendations, anchored by some of the latest research on the link between patient engagement and health outcomes; identify barriers that must be overcome; and describe a clear set of responsibilities that need to be owned and shared by health care leaders, clinicians and staff, and policy makers. Patients and families cannot be held responsible for safety, but they can assist at every level with redesigning care and shaping an organization’s safety agenda. WIHI host Madge Kaplan welcomes you to this discussion. Please tune in! ​

I hope you'll join us! You can enroll for the broadcast here.

The medium that delivers the next message

Passing through the airport the other day, I bought a New York Times and the clerk kindly put the newspaper in this plastic bag.  I was appalled later when I saw this advertisement on the bag.

Irony arrived when I took out the newspaper and found this article by Matt Richtel.  The lede:

Electronic cigarettes appear to be safer than ordinary cigarettes for one simple — and simply obvious — reason: people don’t light up and smoke them.

With the e-cigarettes, there is no burning tobacco to produce myriad new chemicals, including some 60 carcinogens.

But new research suggests that, even without a match, some popular e-cigarettes get so hot that they, too, can produce a handful of the carcinogens found in cigarettes and at similar levels.

And later in the article:

[N]ew research suggests how potential health risks are emerging as the multibillion-dollar e-cigarette business rapidly evolves, and how regulators are already struggling to keep pace.

Which sends a stronger message to the young audience targeted by these e-cigarette companies, a sex-laden graphic with a subtext about rebellious behavior, or a thoughtful newspaper story.  Not even close, no?

Goal Play: Closing in on 10,000

I'm extremely pleased to note that cumulative sales of my book Goal Play! Leadership Lessons from the Soccer Field are close to reaching the 10,000 mark.

According to BK Publishers:

The average U.S. nonfiction book is now selling less than 250 copies per year and less than 3,000 copies over its lifetime.  Only 62 of 1,000 business books released in 2009 sold more than 5,000 copies, according to an analysis by the Codex Group (New York Times, March 31, 2010).

One of the great moments in my writing life was when Edgar Schein, author of Helping and many other leadership and management books, offered to write a foreword for Goal Play!

I am delighted that people around the world have found the leadership lessons of Goal Play! to be valuable to them.  If you have not yet had a chance to enjoy the stories from the girls soccer teams I have coached and the adult leadership lessons that emerge from them, I invite you try a copy (paper, ebook, and even audiobook.)  Also, if you know graduating college students or young professionals who might benefit from the book, I'd be honored if you considered it as a gift for them.

I've also been invited to address corporations and institutions around the world on the ideas contained in the book.  You can see this website for some examples.  If I can be part of your company's leadership training program or the like, please contact me at goalplayleadership [at] gmail [dot] com.  Thanks!

Letter from Barro Colorado Island and STRI

For a change of pace, I'm happy to present a short summary of a tour today to Barro Colorado Island, on Panama's Gatun Lake, home of a portion of the Smithsonian Tropical Research Institute (STRI.)  Our guide was Dr. Helene Miller-Landau, a staff scientist with research interests in ecology and evolution.

Under an arrangement with the Panamanian government, STRI manages the island and oversees the research taking place there.  It has been preserved in a natural state for many decades and offers an excellent laboratory to study flora and fauna.  A 50 hectare plot of land has been set aside to permit the complete mapping of virtually all the plants, providing a baseline against which to compare changes during the coming decade.  (Indeed, based on this precedent, several such plots have been established in other countries, and an effort is ongoing to coordinate research programs across these widely divergent sites.)

Beyond spending time with Helene, we had a chance to meet the panoply of scientists on the island.  They included Don Feener, from the University of Utah, who was a long-time resident years ago and stops by now for occasional visits.  His field is social insects, and particularly army ants, and he has been focusing on the variety of parasites that feed on this species.  But what gins up Don as much as the ants is the chance to meet with the young researchers on the island, graduate students and post-docs, who have come to carry out their own portion of the world's extensive study of tropical forest wildlife and plants.

We had a chance to spend time with several of these folks, and their enthusaism and desire to share what they have learned and to learn from one another is infectious.  I pointed out that such a spirit of collaboration and sharing is often missing from the world of medical research in the esteemed halls of academic medical centers and university biology departments.  Helene and others pointed out that the small likelihood of another researcher being able to "steal" a research finding, given the need to be "on the ground," might be one reasons people are more open about their progress and frustrations.  Also, there is more uncertainty in this field as to what direction of research is likely to be successful, so there is not a race to a certain conclusion, as there might be in more established biomedical research.  Whatever the reasons, it was a refreshing change from some places I have frequented.

This is truly a special place, in terms of flora and fauna, as you see from several pictures I've included.  But it is also a special place for the expansion of human knowledge, and it is a tribute to parties in both Panama and the US that it has been allowed to flourish.

Celebration of Women in Healthcare

12th Annual Celebration of Women in Healthcare

Thursday, May 8, 2014

5:00 - 7:30pm

Tufts Health Plan

705 Mount Auburn Street, Watertown

 

Featuring award-winning journalist Robin Young, co-host of Here & Now on WBUR/NPR, who will emcee a “story slam” about compassionate healthcare. Storytellers, who will share their own personal experiences, will include:

• Dianne Anderson, President and CEO, Lawrence General Hospital
• Consuelo Donohue, long-time nursing supervisor at Tufts Medical Center and interim nursing manager of the NICU, and mother of Richard Donohue, Jr., the MBTA officer who was injured in the aftermath of the Boston Marathon bombings
• Sharon McNally, Chief of Staff, Dovetail Health, and Co-Chair, Schwartz Center Leadership Council
• Joyce Murphy, Executive Vice Chancellor, UMass Medical School, and Member, Schwartz Center Leadership Council
• Charlotte Yeh, Chief Medical Officer, AARP Services, Inc

We’ll also be asking one or two audience members to share their stories of compassionate care, so please come prepared!

Ticket Price: $125 per person. Please RSVP by May 5
Corporate and Individual Sponsorship opportunites are available.
Click here to register!

In memoriam: Frank Scarcella

Wicked Local photo by Matthew Healey

Francesco “Frank” Scarsella died this week.  He was a fellow soccer referee in our region.  Here's a good sense of him from the local newspaper a couple of years ago:

If you’ve been to a youth, high school, college or semi-pro soccer game in New England in the last 40 or so years, you’ve probably seen Francesco “Frank” Scarsella out on the pitch.

Although he loves to play, Scarsella is best known among New England soccer fans as the preeminent referee in the state

At 68, Scarsella said he’s not only refereed thousands of games, but he’s probably trained tens of thousands of referees since 1978.

“Sometimes I’ll be out on the field and someone will come up to me and tell me that I was the one who trained him,” he said.

Scarsella emigrated from Italy at age 13 and he says that his love of the game is in his blood.

A friend writes:

Frank was one of those people who impacts other people’s lives in subtle ways.  He worked with my teenage daughter during a tournament as she took her first steps beyond the little cocoon of our town league.  He was supportive and kind, in his own way, to a young referee.  And he always, always retained his sense of humor.  We need more like him.

Another colleague noted:

We can see Frank’s true grit. There is something to be said about living life the way he wanted to. He told me at the time, he was given a five year window, when diagnosed. He exceeded that through fearless force of his will.

Frank trained all of us, regardless of our age.  We'll miss him.

It's working!

We're so excited to be getting feedback on our job negotiation book.  Please consider buying copies for your own college graduate or others you know.  Here are two recent reviews.  The first deals with the gender issues we cover in the book.  The second suggests that the advice we offer is helpful not only to first-timers in the job market, but other young professionals, too:

Take note, Females!
I went to a talk that Paul and Farzana gave at Tufts University School of Medicine a couple of weeks back. I was concerned because as a young student about to graduate grad school, I expressed to them that I was worried about negotiating because I'm young and don't have much experience. They assured me that once I've been offered a job, the company has already decided that they want me. Furthermore, they explained (and the book does too) that as a woman, I must go about the negotiation differently. I won't spoil the book, but I'll just say that I used the methods that the book suggests for women. Long story short, I was able to get my employer up $14k!!! I would recommend this book to anyone, but especially females. Sadly, our world can still be quite sexist. After accepting this sad truth, Paul and Farzana do a great job of describing how to deal with the hand that we, as women, are dealt.

Amazing book!
This book seriously increased my pay significantly, changed my job description to reflect a more senior role, AND enabled me to maintain a respectful and positive relationship with my future employer! This book was a helpful, fast read, and provided several examples and useful language that I was able to incorporate in my negotiations. This is by no means by first job - this book is helpful to anyone and everyone who is looking to create a mutually beneficial relationship with their future employer!

I highly recommend this to any graduating student or working professional.

The book is available on Amazon in paper and ebook form and is also on every other ebook platform.

POTUS is the topic for TT

Here my nomination for today's Throwback Thursday, a post from 2009 on medGadget.  Perhaps it strikes my fancy because of the uptick in health care expenses for the country:

During Barack Obama’s healthcare reform tour, while touting cheaper clinical and technological approaches for medicine, the President got a hands-on experience with the Da Vinci robotic surgical system from Intuitive Surgical. The Cleveland Clinic, perhaps having an odd sense of humor, touted to the President one of the most expensive pieces of equipment used in the OR.

Spring cleaning over at the blogroll

I spent some time cleaning up my blogroll (the list of blogs on the right side of this page.)  I deleted the ones that no longer link to a working website, that have been transformed into commercial enterprises, and that have gone dormant (defined as no posts since January.)  If you see that yours has been taken down in error, please let me know and I'll restore it.

The exception to my rule about inactivity is that I've retained two sites in remembrance of two wonderful women who died from cancer. It makes me happy to go back and read them.

One disturbing trend:  I used to have links to 24 sites that deal with transparency and Lean process improvement.  That has now shrunk to 14, a pretty sizable reduction.  I hope that doesn't reflect the status of either transparency or Lean in the health care world, but maybe it does.

And on a lighter note, check out this post by Freida McFadden on A Cartoon Guide to Becoming a Doctor and see if you can come up with the right answer!  Post it over there, not here!