What does "true essence" taste like?

Continuing my admittedly obsessive occasional series about the water served in hotel conference rooms, I now present this Norwegian one from a meeting today. This one had to travel 3500 miles. But unlike the decantered blueberry water or the plastic bottled water from the other side of the globe served at other hotels, this water is shipped thousands of miles in a glass bottle.

How about that bottle! We learn from the company website that the designers "utilized the depth of their experience from the cosmetic industry in understanding how to create a brand personality that differentiates itself through the entire experience, reflecting the true essence of the brand."

Cost: $2 per bottle for about 12 ounces, roughly the cost of 350 gallons of tap water in Boston.

After a taste test last year, our hospital switched from bottled water to tap water for meetings. We decided that the "true essence" of bottled water did not add to its taste.

Bravo, Dr. Ring!

Health Care on MSNBC.com reports about a recent article in the New England Journal of Medicine about a surgeon's operating room error in Boston. What makes the article unusual is that it was written by the doctor who made the mistake.

Dr. David Ring from MGH presents a clear and understandable summary of the case, what went wrong, how he handled the disclosure to the patient, and many other important details.

He says, “Just imagine the worst thing that’s ever happened to you and that’s how it feels. I don't want anybody to make the same mistake I made."

In writing this article, Dr. Ring follows in the footsteps of Dr. Ernest Amory Codman, an MGH doctor from decades ago: "Dr. Codman made public the end results of his own hospital in a privately published book, A Study in Hospital Efficiency. Of the 337 patients discharged between 1911 and 1916, Dr. Codman recorded and published 123 errors."

Congratulations to Dr. Ring and to MGH for taking this step. As we have found in our own case, wide disclosure of such errors is the best way to learn from them and help avoid them in the future. It also sends a clear message to other clinicians that reporting of errors will be handled in a just manner.

Addendum to my original post (now edited), with still more thanks to Dr. Ring:

As another interesting twist to this, the first web article about this was a case of "wrong-site journalism" which unfortunately I got caught up in as well. The first article implied that this was a wrong side surgery. But it was the wrong surgery on the correct side, not wrong side surgery. The MSNBC.com piece has a disclosure of the error on the top of the page now. Oddly enough, I wrote my original post with the wrong interpretation -- even though I read the NEJM article. Apparently I got trapped by my own bit of cognitive anchoring by reading the earlier MSNBC.com article! As Dr. Ring says in a note to me: "To err is clearly human, which only helps emphasize the points that we all believe are so important to make."

Do I hear someone kicking a can?

Robert Lowes, in Medscape Medical News (sorry, password protected) reminds us:

Physicians face a 23% cut in Medicare rates on December 1 and another on January 1 that pushes the total to roughly 25%. Both are triggered by the controversial sustainable growth rate (SGR) formula that Medicare uses to set physician pay. Put simply, the reductions represent the program's attempt to collect several hundred billion dollars that it has overpaid physicians since 2002. This debt has built up because every year Congress has postponed SGR-mandated reductions. The cost of merely freezing current Medicare rates through 2020 as opposed to cutting them as planned would amount to $276 billion, according to the Congressional Budget Office.

Kaiser Health News says:

If Congress fails to overturn the cuts this time, doctors could reconsider taking new Medicare patients* or change how they participate with the program, (AMA President) Wilson warned in an interview with Kaiser Health News. "What we're saying to them and what we want seniors to say to them is, 'You're threatening our access to care. If physicians cannot keep their doors open because Medicare now only pays about half the direct cost of running a practice, then we're going to lose access to care,'" Wilson told Kaiser.

Another article notes,

The AMA is campaigning for a 13-month extension, rather than a shorter extension until Congress reconvenes next year, taking advantage of the completely Democratic Congress. The Democrats will put the cuts on the legislative agenda this month.

Of course, the trade organizations for every physician group are also at work on the issue, from optometrists to family practice doctors to hematologists.

Most people think that Congress will just kick the can down the road a bit more with a short-term postponement. Why? Because a permanent fix would bust the federal budget rules. A reminder, too: The Congressional Budget Office analysis of the recently passed health care bill assumed that this reimbursement reduction would go ahead as planned.

I don't know what long-term fix will be used for this problem. Thoughtful observers like BU's Austin Frakt have come up with proposals, but such plans are unlikely to be adopted during a lame-duck session.

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* I do not believe this option is open to private practice doctors in Massachusetts. Can someone validate that for me? In any event, though, hospitals and doctors working in hospitals cannot exercise this option.

Extra security

Being a security guard at a hospital brings with it unexpected situations and challenges that call on one's training, skills, and composure. Here's a note from last Friday to our chief of security from a nurse who happened to be near our front entrance at the right time:

Hi,

I am a nurse on 5/6 Feldberg who was in the Feldberg Lobby yesterday afternoon when a Code Blue* was called -- Location Feldberg circle outside the front door on the sidewalk. I ran out the door and found a man in a wheel chair being helped out of a car by two Public Safety Officers, Marianne Hughes and Platini Pontes. They both said "He is not breathing."

Immediately the three of us jumped into action. We put the patient onto the sidewalk from the wheelchair. Marianne started doing chest compressions immediately. I was trying to get the man's clothing off to be able to do better compressions. Platini was trying to manage the crowd and initial surge of people rushing towards the patient. Marianne did compressions for a while, and then I relieved her.

The patient did get a heart beat back and was transferred to the ER. When the code was over I went looking for the two of them, as I wanted to tell them what a great job they had both done. I was only able to locate Marianne. She was a little upset as this was the first Code Blue she had ever participated in. I told her that she performed outstandingly, as did Platini.

One of the most important things in a cardiac arrest is prompt CPR, which we initiated immediately. Quick thinking on the officers' parts contributed to this man coming back to life. I can not praise their actions enough. I hope you can acknowledge their performance in a special way as they definitely deserve a commendation.

Pam McBurnie, RN

The chief replies:

Pamela:

I appreciate your taking the time to provide such positive feedback on Marianne Hughes and Platini Pontes.

I am very proud of them. Marianne said that you were terrific and so supportive.........so thank you too.

Chris

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* Code Blue = A message announced over a hospital's public address system, indicating that a cardiac arrest requiring CPR is in progress.

I'm sorry, Doctor Famous is busy

What happens when a referring doctor insists that "Doctor Famous" see his or her patient, even when other physicians on the staff can do the job just as well? In Lean terms, waste is introduced into the system. As diagnosed below: The minute an additional seemingly unnecessary step is added to the flow it adds a huge delay. Here's an example:

A patient needed a certain kind of ultrasound. The hospital-based surgeon helpfully made the appointment call for the patient, telling the scheduling attendant that the procedure had to be done by one of two specific radiologists. Those radiologists only schedule those particular scans for a few hours a week, so the attendant quite properly replied that the next available times would be a few weeks hence.

The patient later wrote me to complain: Why would this all take so long to get scheduled?

I passed along the complaint to our chief of service, Jonathan Kruskal, who wrote:

I just wanted to get back to you about the patient complaint about scheduling an anal fistulogram. You may be interested to know that we have reviewed the actual telephone discussions that took place during the scheduling. (I am enclosing the tapes - How's that for an analytical tool!)

We developed this technique here at BIDMC and are the recognized authorities in the US. All of our ultrasound faculty can do this procedure, which takes less than 5 minutes to complete. The process issue here is that this physician only wanted Bob Kane or me to do this.

Obviously, Bob and I are not scheduled to work in ultrasound every day. To rectify this I trained all our staff to do this so that the studies can be scheduled every day. If the doc had simply scheduled the study it could have been done on any day the patient chose, and Bob or I would happily have reviewed the study even if we had not actually done it. As we all know from work flow analyses, the minute an additional seemingly unnecessary step is added to the flow it adds a huge delay, which is what happened here. We have spoken to [the surgeon] about this, but s/he still prefers to have Bob or me do these.

We do these studies from 1-2:30pm because they can only be done on a single machine (no other local hospitals have these dedicated anal imaging machines) that requires time for setup and probe cleansing. It is this same ultrasound unit that we use for guiding liver biospies (by hepatologists) in day care each morning and for intraoperative ultrasound, so we need to keep it available during mornings when these typically take place.

We've been doing this for over 15 years. Patients are usually thrilled that we offer this unique high quality service. I've never had anybody complain about access before, especially since these are never urgent studies.

Protons killing cancer and our budget

Proton beam therapy is an effective modality for killing certain types of cancer cells. New England and the Northeast are fortunate to have a proton beam machine at Massachusetts General Hospital, where it has been in use for some time effectively treating patients. This is a valuable resource, serving the entire region and beyond.

But what happens when everyone wants one? Well, we see the medical arms race at work again.

These are huge (see graphic below) and very expensive machines, costing upwards of $150 million dollars. At that price, there should only be a very few in the entire country. Yet, as noted in a recent paper by Anthony Zietman, Michael Goitein, and Joel E. Tepper in the Journal of Clinical Oncology, "In the United States alone, seven centers are in operation and at least 10 more are likely to come into operation in the next decade." J Clin Oncol 28:4275-4279

Here's the map of existing facilities and others currently under development or construction, as posted on the web site of the National Association for Proton Therapy (NAPT). What will this look like in a few years?

There is no way this makes sense. As noted, the main value of these machines is in treating certain distinct forms of cancer. The problem occurs when one is purchased as a prestige item. Since there is not enough demand for its use for the appropriate cases, it starts to be used for other types of cancer that would ordinarily be treated with traditional forms of radiotherapy. The article notes:

Protons were used historically to treat relatively rare tumors that were located close to radiation-sensitive normal tissues. Recently, however, much more common cancers are also being treated with protons, notably prostate cancer and non–small-cell lung cancer. The published clinical data on proton therapy have been reviewed in several recent publications. These reviews have underlined the lack of level I evidence for a superiority of proton therapy.

In short, the purchasing hospital needs to figure out a way to amortize the cost, and so it starts using the machine for cancers that were more cost-effectively treated in other ways. The authors explain:

Because of the high capital cost of a proton therapy facility, when a hospital invests in a proton therapy center (or any other expensive new technology), it takes a very substantial financial risk. It has likely elected to reduce its investment in other important areas of health care, it needs to amortize its costs rapidly, and it needs ultimately to generate a profit. Thus, the use of protons becomes as much a business decision as a clinical one; creditors and investors may drive the utilization and potentially the patient mix.

Because of its prevalence, and because of the simplicity and hence economy of its treatments, prostate cancer has become the economic driver for many new proton facilities. Aggressive marketing and high rates of reimbursement mean that the treatment of prostate cancer with protons can be highly profitable. The pressure to undertake such profitable treatments is exacerbated when the success of the business model requires a high throughput of patients.

Who provides the money for these investments? Some is from philanthropists, but the major source is noted in this Forbes article by David Whelan and Robert Langreth:

Most of the $1.5 billion that has been sunk into or committed to building proton centers has come from investors hoping to make a profit. Even the proton center at the august M.D. Anderson Cancer Center in Houston is mostly owned by various investors.

And it appears that the reimbursement system may aggravate the situation, as Forbes notes:

Medicare pays twice as much for a round of protons as for X-rays: $34,000 for eight weeks of therapy versus $16,000.

And then elected officials get involved, too:

The centers have become magnets for politics. In Michigan the Beaumont hospital chain struck a deal with ProCure in 2007 and applied to the state for a license. Other hospital systems, including the University of Michigan and Henry Ford, protested, arguing instead for a consortium-run center. State regulators agreed. But Beaumont and ProCure refused to join and lobbied Michigan Governor Jennifer Granholm, who overruled the regulators last year.

President Eisenhower warned us about the military-industrial complex. We are have now entered the era of the health care-finance industry complex.


(Graphic is from the Forbes article cited above.)

Playing for Change

A grateful patient of ours has created a benefit featuring Playing for Change live in concert on November 17th at Symphony Hall. All proceeds will support lung cancer research here at Beth Israel Deaconess Medical Center.

The patient writes:

I am Judy Roberts, a BAC lung cancer survivor and grateful patient of BIDMC. Lung cancer survivorship comprises a small group, and in an effort to change this, we are “orchestrating” a music event at Symphony Hall on Wednesday, Nov. 17, at 8 p.m.

In 2006, my life hit “black ice” when I received a cancer diagnosis whereby the force of terror was palpable. Further, as a lifelong non-smoker, being called “an enigma” did not serve to quell my fears. Soon after, surgery stimulated me to boldly attempt to mold the face of lung cancer, create awareness/disturbance through illustrating the stunning contrast between lung cancer statistics versus all other cancers, hoping to contribute in changing its trajectory.

The concert is “Playing for Change," based on Grammy Award winner Mark Johnson’s music documentary where street musicians from around the world not only are playing for change$$, but playing TO change their community, the world. The symmetry of this world music and its mission aligns with the towering research that lies ahead for Dr. Costa [my doctor] and others. It all starts with change.

It’s not what we have, but what we give that defines us in life.

For tickets, click here.

SOS: Morse code does not predict well

Expanding on last week's post on falls, Marsha Maurer, our chief nursing officer, reports:

We've achieved fall rates at BIDMC on par with those noted in the JAMA article by using an algorithm, fine tuned over the past few years based on root cause analysis of each fall. The algorithm guides nurses to an individualized safety plan for each patient identified as "at risk" on the Morse falls tool. Of note, delirium has its own leg on the tool. It was a series of root cause analyses which identified the upstream impact of delirium on a subsequent fall that led both to this leg in the tool and the GRACE work.

We have found, however, that the Morse is a blunt tool. It over-predicts who will fall, and entirely misses some people at fall risk; for example otherwise alert, oriented and ambulatory oncology patients who become weakened over the course of chemotherapy and who overestimate their own strength. Given this, our departments of Nursing and Health Care Quality are working with the Institute for Healthcare Improvement on the next frontier of assessment and intervention -- a falls bundle. It is in pilot use now. The bundle dictates three interventions for all patients regardless of fall risk status: 1) Bed in low position -- with a clear visual cue that this is so; 2) the infusion pump on the side of the bed where the patient will exit; and 3) the call light in reach.

Concurrent with this is the use of a more clinician-friendly simple risk question: "Is this patient willing and able to RELIABLY use the call light to get help?" If the answer is "no" this puts the patient in a high risk category for falls, and additional falls prevention strategies will be implemented.

We are hopeful that this will provide a more specific and meaningful risk identification process and ultimately a reduction in the overall fall rate.

Epilogue

This work at BIDMC and the work cited in the previous post from Brigham and Women's Hospital are exemplary and clearly complimentary. But what is striking is the lack of coordination between the two efforts. Two Harvard teaching hospitals, separated by only a few blocks (see map), both concerned about patient safety, have had virtually no contact on this topic.

I hope I am misinterpreting, but I am concerned that this may be one of those instances in which the competitiveness among the Boston hospitals has spilt over into the safety arena. For sure, there are other areas in which information about quality of care is shared and protocols are examined together. But wherever there is a lack of discourse, opportunities for collaboration are lost. In contrast, remember our colleagues in Ohio, where the rule is, "We compete on everything, but we don't compete on safety." We owe it to our patients to adopt the same approach.

Really patient-centered!

Check out this story.

An issue, guaranteed

I don't mean this in a partisan way, but it is really distressing to read this New York Times article about Republican plans to dismantle parts of the recent health care bill by using the appropriation powers of the House of Representatives. I say this because of the unintended consequences that will result if they are successful in this approach. Let me give an example.

I think one of the most important aspects of the law is "guaranteed issue" of health insurance: Insurance companies will no longer be permitted to use pre-existing medical conditions as a bar to coverage. A concomitant of guaranteed issue is the individual mandate, the requirement that all people purchase health insurance. Why?

Left to their own, insurers will impose pre-exisiting conditions types of restrictions because they understand the moral hazard aspect of insurance. Healthy people provide an actuarial balance to sick people. If people only buy insurance when they need care, the risk profile of the insured population rapidly swings, upsetting the actuarial calculations used to establish premiums. So, if these restrictions are outlawed, everybody needs to be in the risk pool. Accordingly, you have to ban optional insurance.

But look at this quote from the article cited above:

Republican lawmakers said, for example, that they would propose limiting the money and personnel available to the Internal Revenue Service, so the agency could not aggressively enforce provisions that require people to obtain health insurance and employers to help pay for it.

I think the Republicans know that guaranteed issue is popular with Americans, and so they do not directly want to repeal that provision of the new law. But what will happen if healthy people start to opt out of getting insurance, only to return when they get sick? The system will quickly get out of balance. Ironically, this will only cause premiums to rise. I don't understand why the Republicans would want that to happen, and I fail to see a strategic political advantage arising from that result.

This makes me wonder if they have thought this through completely and whether they understand the unintended consequences of their proposed actions.

Turn left, then jet ski across the ocean

You can count on Google maps to give you the best possible route between two places. See, this, for example, to go from Japan to China. Found on Flickr, here.

Good "advice" here

A friend sends a link to this site, The "blog" of "unnecessary" quotation marks. He notes that it is for when italics, underscore, uppercase, or larger point size just won’t “do.”

Can you hear me now?

A discussion on Medscape Physican Connect begins as follows:

My patient's cell phone rang in the middle of his medical visit yesterday. I was fully expecting him to react as I would in such a situation: apologize and turn his phone off. Instead, he jumped up off the exam table, flipped open his phone and proceeded to talk to his wife for several minutes while I waited to resume the exam. This is a patient I have a good rapport with and have known for a long time. I asked him to please turn his phone off during our appointments from now on. However, I can't help but think: isn't that just common sense? I know patients talk on their cell phones in the waiting room, but am I crazy to think that cell phones have no place during a medical exam? I am tempted to post a sign in my office room saying "All cells phones and guns must be checked in at the door". Has anyone had any similar experiences? If so, what has helped you to curb this rude behavior among your patients?

The best comment:

I had a family come in all texting on their own phones during the visit. The girl continued texting during the exam, even on her back during the abdominal exam. The mother finally told her this was rude. I really think they were texting each other.

There is no free lunch in genetics, either

Martin Pollak, our chief of nephrology, sends along a link to a recent podcast in which he is interviewed. He summarizes:

Basically, we have sorted out why African Americans get so much more kidney disease than other groups. It is related to the development of genetic resistance to sleeping sickness in Africans about 5000 years ago. Specific genetic differences that protect against sleeping sickness increase the risk of kidney disease.

Check Science Magazine Vol 329, 13 August 2010, at page 841 for the full printed version, and for a commentary article, in Vol 329, 16 July 2010, at page 263.

Trying to make falls always out of season

Patricia Dykes of Brigham and Women's Hospital and and her colleagues published an interesting article in JAMA about preventing falls. Falls are a tough problem to solve, and these folks experimented with using a computer-assisted algorithm to design individualized fall protocols. The results were promising.

Most places use the Morse Fall Scale (MFS) to assess each patient's risk for falling. However, the linking of an individual patient's risk profile to a fall prevention plan is not usually standardized.

In contrast, this group used a "Fall TIPS" toolkit that automatically tailors each patient's fall risk profile (as calculated using the MFS) to a fall prevention plan that is based on the patient-specific determinants of risk.

I was curious to learn more, and Patti kindly explained to me in a note:

The interventions that we programmed into the toolkit are based on what we learned from our focus groups with professionals/paraprofessionals/patients/family members are both effective and feasible in acute, short stay hospitals. The Fall TIPS toolkit places this tailored plan within the work flow of all team members, including patients and family members.

This is really nice work. Recall that we are experimenting with a different set of ideas in our GRACE protocol. Eventually, as we all share results, the number of falls everywhere will diminish.

love shrinks tumor and other miracles

This is a beautiful entry by Marilyn Kass on The Momo Blog.

CHCs + BIDMC = Healthier communities

Our hospital is honored to be affiliated with a number of community health centers in the neighborhoods of Boston and surrounding communities (and also one on Cape Cod). Our folks recently produced the following video to provide a representation of how we jointly offer services to people in those communities. I think you will enjoy getting to know the people involved as you watch the video.

If you can't view the view, click here.

Way to go, Mary Jo!

Congratulations to Captain Mary Jo Majors, US Naval Reserve, who today is receiving the Outstanding Woman Veteran Award at the Massachusetts State House. Mary Jo is Director of Clinical Operations at South Cove Community Health Center. Well, she is more than that at South Cove! She is also Director of Nursing, the Emergency Preparedness Coordinator, and the Quality Assurance and Quality Improvement Coordinator. (South Cove CHC has 3 clinics and serves the health care needs of a population of almost 25,000 primarily Asian patients with limited income and resources.)

The award is presented by the Massachusetts Women Veterans’ Network. Previous award recipients are listed here. Mary Jo joins a very distinguished group!

Here is the summary of her own accomplishments:

Captain Majors has been selected for this award because she is a woman veteran who has chosen to continue to serve with honor in the Navy and give back to her country for over 41 years.

Captain Majors made a commitment to join the Navy as an officer candidate while in college to take advantage of the scholarship program to complete school and serve her country following the sudden death of her father, a WWII Army veteran. She was the first in the family of five to serve on active duty and began serving her country during the Vietnam War. She has continued to serve in the Navy since then and to provide leadership, education, mentorship, and care to service members and their families in both the active duty and reserve components during her many duties and assignments over the years.

She puts “service to others” first and has demonstrated this throughout her career whether it was providing direct nursing care to the many returning wounded Vietnam War veterans at the Naval Hospital in Tennessee, or on special reserve orders to assist with the deployment of active duty staff for assignment to the Hospital Ship Comfort and the arrival of medical reservists to Bethesda Naval Hospital during Operation Desert Shield and Storm, or serving in the Pentagon to help improve the medical and dental programs and benefits offered to members in the reserve or those already retired. She continued this personal commitment to help others in the reserve force during OIF/OEF with support to the reserve command in Quincy.

She also spends many hours every month working with young women who are in various stages of a military career, whether it be as an applicant to become an officer in the Navy or a Midshipman at the Naval Academy; a NROTC Nurse Corps Midshipman attending a local Boston college; a newly commissioned NC officer; or those currently serving their country by providing guidance and letters of recommendation to enlisted hospitalmen to attend nursing school or obtain a NC candidate scholarship, or preparing junior nurse corps officers for career planning and selection boards. She utilizes her skills as a senior woman officer to mentor, educate, and be a role model to guide these women and encourage them to further develop as leaders and outstanding members of the Navy.

She has the reputation of performing her duties with total enthusiasm, engagement, exceptional ability, personal initiative, and dedication to duty and has received recognition of such with additional requests for her service, such as with future involvement with the Yellow Ribbon Family Service Support Center and the Naval Reserve Returning Warrior Weekend programs.

We are aware of the beauty of life

From the ridiculous below to the sublime, please watch this incredible video about Alice Herz-Sommer, a 107-year old Holocaust survivor/musician. I hope you are able to watch it all the way through and see the context for these very moving final comments:

I never hate. Hatred brings only hatred.

I was born with a very, very good optimism. And it helps you when you are optimistic, when you are not complaining. When you look at the good side of our life, everybody loves you.

Only when we are so old -- only -- we are aware of the beauty of life.

If you cannot see the video, click here.

Fresh. Slow. Too Close. Not Yummy.

Let me start by saying that I enjoy the Longwood Galleria and its restaurants and am a regular patron and encourage others to go there. But what did they have in mind by hiring this billboard truck to drive through the Longwood area to advertise?

Why would anyone elect to send a truck through the intersection of Longwood and Brookline Avenues, one of the most congested intersections in the City of Boston?

Traffic congestion is measured by Level of Service, as reflected in the chart below.As you travel down Brookline Avenue on the route taken by this truck, you approach the intersection of Longwood Avenue. It is rated as Level F in the morning and level D in the evening. Here's what the Level F ranking looks like.

It shows an average delay of over 80 seconds (often over 5 minutes), a volume/capacity ratio greater than 1.0, and a queue of almost 400 feet of vehicles waiting to get through the intersection.

There has to be a better way to generate business for these excellent restaurants than by contributing to the congestion.