Dave did good. We are all happy.

My friend Dave deBronkart, aka e-Patient Dave, called me early in 2007 to let me know that he had been diagnosed with late-stage renal cancer and that he could be expected to die within just a couple of months. I told him that this was unacceptable, in that we were scheduled to have our 35th college reunion that June, and that he needed to be there. Well, things turned out quite well. He not only showed up at the reunion, but at many other important events.

Here's a note sent today from Dave to his BIDMC doctors and NPs (David McDermott, Andrew Wagner, Mee Young Lee, Gretchen Chambers, and Megan Anderson), reprinted with his permission:

Medicos,

This week marks two years since my last bit of treatment from any of you. I continue to be well, sleeping well and loving life. I'm so well that, as some of you know, my weight has returned to "entirely too normal." :-) But I'm countering that: for the first time since high school I've become a regular bike rider. (Not getting up at 5 a.m. to do it, like SOME executives, but you gotta start somewhere.)

I tell people about you everywhere I go, which these days includes conferences and policy meetings. I've begun (unskillfully) doing recorded interviews with Dr. McD and Dr. Wagner to make the world aware of what you offer that's not available everywhere; I hope to do more, when you docs say there's more news to share. (Next time around I'll let YOU talk more...)

Ginny and I are having a fabulous summer, making the most of life. Yesterday we decided that next summer we'll celebrate our tenth wedding anniversary with a trip to Switzerland and Germany, where she went many years ago. Gonna get us some Alps! And on May 31 I got to walk my daughter down the aisle, and next weekend is Mom's 80th birthday party. Needless to say, it is a JOY to be present for these events.

Thanks for making all this possible. You're wonderful. (Pass the word to anyone else who worked on my case - too numerous to recall. And all of Stoneman 7.)

Dave

How much we could change

My colleague Gene Lindsey, CEO of Atrius Health, appeared twice in the Boston Globe in the past few days, once as the author of an op-ed, and once as the subject of an interview in the business section. As always, Gene offers thoughtful observations on current matters, and he comes to these issues with a wealth of personal and institutional experience.

I'd like to focus on a few of his points and explore the implications for an academic medical center like BIDMC. With regard to the movement towards capitated (er, now, "global") payment schemes, Gene perceptively notes that:

There needs to be a way to connect patients to primary-care physicians so that payment is made to the organization providing the care. Optimal Accountable Care Organizations will need to have a scale large enough to accept the risk of providing care on a fixed budget and the expertise and infrastructure to manage risk.

This is consistent with the message I sent to our staff a few weeks ago, where I noted:

We need to enhance and expand our clinical relationships with community hospitals and multi-specialty groups to provide a specific focus on quality and safety, to ensure that patients get the right type of care in the right place, but also to provide a dramatic improvement in the communication about patients' needs and the status of their care.

If Gene is right about primary care doctors having an ever-increasing role in managing the continuum of care in the future, the structure of the institutional relationship between primary care organizations like those in Atrius Health and the tertiary care organizations exemplified by BIDMC matters a lot. One model, which could be functional but not very interesting, is that the tertiary center would serve as a vendor to the primary care practice. In essence, this is mainly a commercial role, with a focus on the rates charged by the hospital for the services it "sells" to the PCPs.

A more vital role, though, is a true partnership, in which the medical and administrative staff in both organizations constantly seek ways to improve the patient experience. While there will always be the business aspect of who gets what percentage of the global payment, the real time and effort would be spent on improving communication of patients' clinical information, on enhancing modes of treatment based on the latest evidence, on taking steps to reduce the possibility of harm to patients at all stages of their treatment, and on helping staff in both settings redesign their day-to-day work to make it more rewarding and efficient .

In Gene's words, the latter approach reflects a commitment not to focus on "how little we need to change [but] rather [on] how much we could change." That sounds just right, but it is fair to ask tertiary hospitals how good they are at change and how well they have endorsed change in the past. Our place has learned a lot about change during the past few years -- first out of necessity when we had the near-death experience of the post-merger debacle -- later out of choice when we established audacious goals for patient quality and safety and satisfaction, when we committed ourselves to unprecedented levels of transparency of clinical outcomes to hold ourselves accountable, and when we adopted a staff-driven approach to process improvement.

The main thing we have learned about change is to be modest about what you know and what you don't know. We look forward to the opportunity to learn from Gene's group and others in the state as we pursue the creation of accountable care organizations that are truly accountable, truly care, and truly are organized.

Genders' discrimination

An email recently arrived from Europe, with two descriptions of the same three weeks of travel. The contrast would make Deborah Tannen's mouth water.

Her's:

Paris: croissants
Marseille: bouillabaisse
Nice: pan bagnats
Cinque Terre: pesto, anchovies, focaccia
Venice: marinated octopus
Florence: gelato, gelato, gelato, gelato, gelato

Oh yeah, saw some cool stuff, too.

Sending lots of love.
Ciao,

His:

Paris: Bike Velib: 20,000 bikes for public use. A shame American credit cards don't work in the system...
Marseille: Chateau D'If, and hidden beach on the next island
Nice: Tour De France!
Cinque Terre: 4 towns hiked in 3 hours.
Venice: Watching the kayakers make a stand against a city dominated by motorboats.
Florence: Da Vinci Museum with full scale replicas of his work.

Wowza.

Mind the Gapminder

A friend sent a link to an application called "Gapminder." It provides an amazing display of comparative quantitative information. Go play with it.

Blog from Children's Hospital Boston

My friend Jim Mandell, CEO of Children's Hospital Boston, sends me notice of a new blog:

Last week, Children's Hospital Boston launched the first health and science blog from a pediatric hospital in the country. Called Thrive, it will cover breaking pediatric news at Children’s, as well as commentary about issues or new treatments in pediatric care that would benefit from our expert opinion.

Blog entries include a link to an interview with Children’s pediatrician Judy Palfrey, MD, the president-elect of the American Academy of Pediatrics, about how health reform might impact children. Last week, there were entries on our autism research and the NIH’s new stem cell guidelines, a wonderful posting from a parent whose child benefited from treatment for a rare disorder and a commentary from David Ludwig, MD, PhD, director of Children's Optimal Weight for Life Program, about how federal stimulus funding could be used to improve the health of all Americans.

Gratitude is good for you

Emergency Departments are busy places, and, even in the best organized ones, people have to pull together in unexpected ways to make things work well. As you can see above, our folks decided to create an opportunity for staff to say "thank you" to one another to recognize those small and large moments when people made an extra effort for their colleagues and patients. Here is a sample of some of the messages, including one from a patient who noticed the form and submitted it:

Sue J. (RN): What a Gal, the most gentle, courteous, pleasant nurse in the ER. Thank you for giving me Sue as my Nurse. Patient John Smith [name changed]. Keep up the good work.

Julie & Janice (Tech): Thank you for your help on Tuesday 6/30. Dynamic Duo!!!

Kim & Catherine (Reg): Thank you Ladies for holding down the Core Desk when I needed a break on Wednesday.

Lisa C. (RN): I want to thank you for the encouraging words that you gave me the other day. It made me look at my role here in a whole new light. Your advice also made my week goes a lot smoother and I was able to smile. Thank you!

Mary Jane (OBS): Thank you for your astute observation while sitting for a patient in yellow yesterday. You kept him safe before he was admitted. I informed the nurses upstairs. Thanks again.

Jill M. (RN): Thank you Jill for starting my patients IV Tuesday and getting his blood. You are so sweet!

Ana G (Tech): Thank you so much for all your help over the years, and for sharing all your goodies especially the artichoke–spinach dip. Also you are great!

Maggie (RN): You are a gift! You give a whole new energy when you are here. You seem to have endless supply of energy. It is a pleasure to work with you!

Claire (RN): Thanks for helping me with that IV today. Sometimes I feel funny asking for help when I know how busy everyone is. I appreciated your ready willingness to help my patient. Thanks again.

Canadian Lean is bakin'

My virtual and occasionally in-person friend, Farhan Merali, (Harvard Medical School MD 2011 and Harvard Business School MBA 2011), sent along this link to an excellent introductory article from Healthcare Quarterly about application of Lean principles in the Canadian health care environment. It was prepared by Dr. Dante Morra and associates from the University of Toronto and Toronto General Hospital. As you will see, Lean principles and philosophy are independent of geographic setting.

MITSS HOPE award nominations are open

I'm posting this at the request of Winnie Tobin at Medically Induced Trauma Support Services:

Nominations are now being accepted for the Second Annual MITSS HOPE Award. The MITSS HOPE Award was established in 2008 to recognize people -- patients, families, healthcare providers, hospitals (or teams or departments therein), academic institutions, community health centers, grass roots organizations, EAP programs, etc. -- who exemplify the mission of MITSS: Supporting Healing and Restoring Hope to patients, families, and clinicians impacted by adverse medical events. The winner will receive a $5,000 cash prize to continue their work.

Nominations are due by September 14, 2009, and the award will be presented at the MITSS 8th Annual Dinner to be held at the Boston Marriott Copley Place on Thursday, November 12th, 2009, from 5:30 to 9:30 pm.

For more information about the award, or to nominate someone, visit us on the web; call Winnie Tobin at (617) 232-0090 or e-mail wtobin [at] mitss [dot] org; or, mail us at MITSS, 830 Boylston Street, Suite 206, Boston, MA, 02467.

Costs are not the same as rates

Many "old" media outlets do not identify the authors of their editorials. Thus, when an opinion is offered, you have no way of knowing who wrote it or what their qualifications are. Your only recourse when there is something unsupported or absurd used to be to send a letter to the editor, where you have about a 0.5% chance of being chosen for publication. And they would edit what you sent in. Then, blogs were invented.

This thought was prompted last week when I read a New York Times editorial entitled, "Financing Health Care Reform." Here's the quote in question:

Meanwhile, it will be important to get some guaranteed fast savings from the health care industries by cutting and reallocating hundreds of billions of dollars from projected spending on Medicare and Medicaid, as the Obama administration has proposed and Congress is considering. Just to be sure, Congress ought to establish a fail-safe mechanism that could impose additional cuts after a few years if savings are less than projected.

Since I don't know the author(s) or whether he/she/they actually know anything about Medicare and Medicaid, I am uncertain how to respond to this suggestion. Except to say: "Are you out of your mind?" Medicare rates just barely cover costs today, and Medicaid rates have not covered their costs in years.

This is all part of a general confusion about cost savings versus appropriation savings, a point I made back in March:

On the cost front, the president for now seems to be confusing underlying costs with how much the government chooses to pay. His budget proposal apparently would reduce Medicare payments to doctors and hospitals as a way of building a savings account for greater access. Reductions in appropriations might reduce costs to the federal government, but they do not reduce the underlying costs of care. With 50% of American hospitals operating at a deficit right now, it is hard to imagine how a reduction in federal payments for Medicare patients deals with the cost problem.

If we have a desire, which I support, to provide greater access to health care, let's consider it a national priority and pay for it directly. But a fear of using the dreaded "T" word -- taxes -- is causing the executive and legislative branches to force cuts in services. And meanwhile, the President doesn't want to us to use the word rationing because he knows the negative political ramifications of that (even though we certainly ration care today, mainly by family income). But what do you think will happen if you cut revenue to health care institutions and doctors?

Readers here know that I strongly support improvements in the quality and safety of patient care and the reduction of inefficiencies in the provision of care. Washington seems to think you are more likely get those improvements by underpaying hospitals and doctors for the care they deliver. You will not.

How you get there is not simple, but it involves transparency of clinical outcomes and rate structures so employers and workers can see the actual value offered by different health care providers. This would stimulate competition, too, in that insurance companies could then offer plans and products that reflect providers' relative value propositions to their subscribers. Meanwhile, let's pay primary care doctors and other cognitive specialists rates commensurate with their real importance in the health system. Then, they could take the time needed to care for patients appropriately and not just act as a triage way station to higher cost specialties and invasive procedures.

Isn't it revealing that Medicare and Medicaid could today set an example for all by requiring this kind of transparency and these payment changes, but there has not been the will to do so?

So, instead, we take a political shortcut, one that will have adverse consequences for years to come.

Cape Cod seals return

The seals are back, at low tide on a sand bar about 1/2 mile northwest of Head of the Meadow Beach.

Nessie arrives on Cape Cod?

No, it's not the Loch Ness monster. It is a sturgeon that washed up ashore from Cape Cod Bay earlier this week at Great Hollow Beach in Truro, MA . The locals suggest that this fish from the ocean found itself entrapped in the bay, whence it ran aground. Length = 22 feet, as you can see from the tape measure. The video gives you a sense of the whole animal. It's no longer there: The Town hauled it away before it fully decayed.

You can imagine where these came from

A weekend return to our lighter summer theme: I present excerpts from a cookbook prepared by our daughter as a gift to her mother. A key section is called "Tools and Tips: Lessons learned along the way." Some have particular relevance to this season, while others have universal applicability -- notwithstanding their autobiographical origin.

1) Do not use the microwave to make chocolate cake or hard boiled eggs.

2) While picking blueberries in Truro, do not crouch in poison ivy.

3) Never make mashed potatoes in the food processor.

4) Avoid eating ice cream cones while driving in convertibles on hot days.

Global Music-Medicine Project

A note from my virtual friend Mohan Sundararaj about a new project called The Global Music-Medicine Project, whose goal is "to globalize evidence-based music therapy," especially in developing countries.

While music is not the cure, we do believe that it barely takes its rightful role within humanity, global policy or medicine beyond candid and superficial discussions.

Sox show their heart again

A note from Lissa Kapust, one of our social workers who helps out patients with ALS ("Lou Gehrig's Disease"). On July 4, the Red Sox joined with other Major League Baseball teams to commemorate the 70th anniversary of Lou Gehrig's farewell speech. The team's management offered us one of their corporate suites for ALS patients and family members.

I wanted to let you know that the day at Fenway was magical. We filled the Red Sox Executive Box with 25 smiling patients, family members and ALS staff. The day went flawlessly; even sunny skies. The Sox loss was unfortunate, but put no damper on a fabulous day.

Some of our patients made it down to the field as Shilling read the Lou Gehrig "luckiest man alive speech". One patient was given a signed bat from a Sox player (Lugo) which he clung to throughout the game, sitting in his wheelchair, grinning from ear to ear. We had a visit from Sox management, including staff coming by with World Series trophies for our gang to pose with for Kodak moments. Wally [the team mascot] came by for photo ops and hugs. Kait Desmarais [the suite manager] and the food manager came by (and stayed for some time) to take it all in and to be sure there were no problems. The food selections were perfect with special help from the chef who prepared food that would be appropriate for the chewing/swallowing problems for some of the patients.

At the end of the game came a surprise. I went to pay for the food and was told that the Red Sox had picked up the entire tab. I tried to tip the Box attendant, and he refused.

Then the hugs and goodbyes to patients who talked about that we might be able to come back to Fenway again. Pretty hopeful for patients living with ALS.

What the CEO cannot do

This is what leadership looks like. It comes in the form of an email from Michael D. Howell, MD, MPH, our Director of Critical Care Quality and Associate Director of Medical Critical Care, to the ICU nurses, house staff, fellows, pharmacists, respiratory therapists, and attending physicians. Without these kind of champions throughout the hospital, the CEO's job is impossible.

All –

Fifty days. No splashes in any of the nine adult ICUs.

For those I haven’t met (welcome, new interns and fellows!), I’m the Director of Critical Care Quality and one of the ICU docs. In the past, I’ve written about our work to improve patient safety (90% reduction in central line infections, etc), speed delivery of critical medications to our patients (70% reduction in time-to-first-dose antibiotics), and more recently about work we’re doing to improve the experience for patients and families in critical care. Today, though, I’m writing about your safety.

Most of you will have noticed the box in the upper right corner of the Portal [note: our intranet home page] that lists the number of days since an employee injury. You’ve probably noticed that it’s always zero, meaning that one of our colleagues is hurt every day. I’ve been sort of agitated by that, and a few months ago we set it as one of the major improvement priorities for critical care.

As our first target for improvement, we sought the elimination of exposure to bloodborne pathogens by splashes. If you or a friend has ever gotten blood in your eye, you know it’s unpleasant, shocking, and scary. Some of our colleagues have, in fact, even been exposed to HIV and hepatitis this way. We know that nearly all exposures from splashes should be preventable by using personal protective equipment. And yet, before we started our work, someone got splashed about every week or two in our ICUs.

Many of you have participated as we began to try to figure out how to prevent these. Here are a few things we learned:

· ABGs and accessing arterial lines are especially risky procedures. In January alone we had *five* splashes from this mechanism.

· Glasses don’t offer adequate protection. Many people have gotten blood in their eyes (or mouth) while wearing their own eyeglasses.

· Splashes happen at unexpected times: disconnecting a Foley, flushing a PICC line, suctioning an ET tube, and being in the room while someone else was doing as ABG – people have been splashed in all of these ways.

Yesterday, though, we crossed an important threshold -- it has been fifty days since our last splash exposure in any of our nine adult ICUs. That’s definite, meaningful progress. Distribution tells us we’ve more than doubled our mask usage, and in some cases they have even had trouble keeping up with demand. That’s because of your work.

From my own practice, I know that it can be irritating and sometimes challenging to put on a mask and visor every time you’re doing something with a patient. But look at it this way: If we’d done things like we used to, we would have expected three to five more of our colleagues to have gotten blood splashed in their eyes during this time period. Instead, no one did.

I want to make a special request of those of you who are more senior, with lots of ICU experience: Please watch out for your junior colleagues, and if they are forgetting to wear a mask with visor, please remind them. Remember also that you set an extraordinarily powerful example with your own practice. By not wearing a mask, you may unconsciously be training your more junior colleagues to put themselves at risk.

Finally, I want to say ‘thanks’ to everyone who is helping with this, and particularly to Sabrina Cannistraro who is helping to lead the project, analyze the data, and coordinate the work. We will keep focused on splashes for the next several months, and once we’ve convincingly eliminated them we’ll begin to focus on needlesticks, lift injuries, and other challenges to our own safety.

As always, feel free to send comments, questions, and rebuttals directly to me, and please forward to anyone I’ve omitted.

Thanks,

- michael

Real competition? Really?

Paul Krugman's desire for advocacy has become so strong that he apparently has let his economist's training slip. Look at these two excerpts from yesterday's column in the New York Times.

Referring to a Senate committee's action, he notes that its plan for health reform:

achieves near-universal coverage through a combination of regulation and subsidies. Insurance companies would be required to offer the same coverage to everyone, regardless of medical history; on the other side, everyone except the poor and near-poor would be obliged to buy insurance, with the aid of subsidies that would limit premiums as a share of income.

This is good and sensible. But then, he slips off the wagon.

And those who prefer not to buy insurance from the private sector would be able to choose a public plan instead. This would, among other things, bring some real competition to the health insurance market, which is currently a collection of local monopolies and cartels.

"Real competition" is when all participants play by similar rules. As I have noted, that could not and would not be the case with regard to a public plan.

It's working!

Still exercising. Check back tomorrow.

New exercise regime

As I take a Fourth of July blogging break, I am pleased to note that Gretchen Reynolds in the New York Times reports on research showing that short, hard bursts of exercise may do as much for you as regular lengthy routines: "Can you get fit in six minutes per week?" Good news. I am canceling the morning bike rides and the soccer games. This will leave lots more time this summer for eating and naps. I'm sure to end up healthier.

See you on the beach, but only under the umbrella: No more swimming. I don't want to undo all the good effects of those very special six minutes. And the latest research shows the beneficial effects of sleeping. Probably more so when a light, warm breeze is blowing.

Gin and tonics are part of the new plan, too. My research shows that limes are an essential food group in the summer.

A real power bar

It's lunch time and time to report that BIDMC has recreated the famous chocolate chip cookie recipe. It is now available for sale in our cafeterias. Click on the image to enlarge and read closely to find the special ingredient.

ENFP or ENTP?

As we move towards a holiday weekend (here in the US), we'll shift to a couple of days of less hefty topics to help you start relaxing. Blogs are pretty narcissistic by nature, but this post is as self-centered as they come. Skip it right now if you are concerned.

I thought it would be fun to take a Myers-Briggs personality test. It has been many years since I did so, and I forgot what I am like, so I asked one of our HR people to set it up for me.

The results are back and are presented above. I appear to be an ENFP, which stands for extraversion, intuition, feeling, and perceiving. But, the third category was a close call, and I might actually be an ENTP, i.e., extraversion, intuition, thinking, and perceiving.

The characteristics associated with ENFP people are: "Warmly enthusiastic and imaginative; see life as full of possibilities; make connections between events and information very quickly, and confidently proceed based on the patterns they see; want a lot of affirmation from others, and readily give appreciation and support; spontaneous and flexible, often rely on their ability to improvise and their verbal fluency."

In slight contrast, the characteristics associated with ENTP people are: "Quick, ingenious, stimulating, alert, and outspoken; resourceful in solving new and challenging problems; adept at generating conceptual possibilities and then analyzing them strategically; good at reading people; bored by routine, will seldom do the same thing the same way, apt to turn to one new interest after another."

I fear that the instrument is flawed. That it reached no conclusions about my suitability for being a CEO is fine. After all, I'd rather not know. But, the diagnosis made no reference at all to my soccer coaching ability. That is an inexcusable omission.