I'm taking a blogging break for several days and leave you with some poems written by doctors and nurses here that were presented at one of our Schwartz Center Rounds several weeks ago. They appear with the permission of the authors, and I will present others in the future. (Apologies to the poets if I made formatting errors.)
With all the talk on this blog and elsewhere about the business aspects of running a hospital, these poems and poets provide a fine reminder of the intensely personal aspects of health care. I hope you appreciate them and the sentiments presented.
---
ENCOUNTER ON THE STAIRS
By Warner V. Slack, MD
Next to Children’s Hospital, in a hurry
Down the stairs, two at a time
Slowed down by a family, moving slowly
Blocking the stairway, I’m in a hurry
I stop, annoyed, I’m in a hurry
Seeing me, they move to the side
A woman says softly, “sorry” in Spanish
I look down in passing, there’s a little boy
Unsteady in gait, holding onto an arm
Head shaved, stitches in scalp
Patch over eye, thin and pale
He catches my eye and gives me a smile
My walk is slower for the rest of the day
---
Silent Burial
By Janet Greene, RN
Loving in secret takes its toll.
Afraid to discover my twisted soul
which loves things without beauty,
I close the door hoping to find shelter.
Feeling the chill from the wind of people’s voices,
I wrap my sweater to me,
And tuck my hands carefully in the cuffs.
Quietly I cherish someone others loathed to touch.
Her mind grew like a crooked branch,
And her laugh had a silly shrill.
Restless eyes betrayed her childish spirit
That earned no wisdom over time.
Distance keeps my secret even in death.
May the earth
Gently bury my untidy companion,
And let me mourn in peace.
In Memory of Bertha Ann, 1984
---
EVENING OF LIFE
By Anupama Gangavati, MD
Inside the nursing home
In a small corner
There…I saw her
Eyes dark and dried of tears
Wrinkled face
Reflecting fatigue
Her gray hair in a total mess
Like the evening of her life.
“I lost my best friend…of eighty years”
She said
“I hope my time will come soon”
Overwhelmed, I got confused
Didn’t know how to react
I even lost my own smile
And now,
In my solitude,
The silence of the night
Seems to be telling me something
That I hate to believe
Perhaps a sheer reality
And now,
Those dark eyes haunt me
As I close my eyes
And ask myself
“Does old age bring miseries?”
And now,
The silence of the night
Leaves me wondering
And just wondering….
---
The Baby Killer
Susan Lane, RN, MSN, MBA
Pain… searing
Belly… throbbing
There is no baby.
There will be no baby.
Endometriosis.
---
Finding meaning while on call in early daily light savings time…..
By Booker T. Bush, MD
I remember teaching some of you
How to be on call
‘Not an architect, but a fireman be’.
Round early
Before the family
Who will
Express their need and wanting
Their time usually after noon
You must grant, but can avoid
By,
Rounding early
And the white cloud
Granted’on Friday an easy evening
With no calls,
So much so that you tested your beeper,
And Saturday evening and night,
Shortened
By an act of a cowardly congress,
Made you arise early, to meet
A woman
Admitted with delirium
Perhaps due to too much medication for pain
Who said
While tearing at her hair,
(there is a witness, an intern enthralled)
I am in pain and you withhold it from me,
isn’t there an imbetween place with the medications…?
Something between pain and confusion
And we stood barriered,
For she had this before done.
But while tearing at her hair
(straightened though
Black but now returned to not)
said I have my lung cancer,
And my breast disfigured
But one of my daughters, has just been told
She also, has a breast that must be removed,
And another, who has been told,
That both breasts must
Be removed
And another who also must
Sacrifice her uterus…
And perhaps her breasts also
Finding meaning…
I raised them
As best I could
I gave them
My all, and now there is this
Only tears
And pain,
And no imbetween
Daughters with
No breasts,
No uterus
And you withhold
My pain medication
And we can only listen
And listen
And she becomes more calm
And she apologizes
And she becomes calm
And we listen.
And she begins to heal
And because of the white cloud, and
Because of the easy evening,
And because of a cowardly congress.
I go to church to sing
Corelli
And I have time to think,
Before seeing more patients.
This is what we do,
We listen, we take the time
And the Corelli.
So I won’t write of the call
About the cats, biting toes
That 2 Percoset
Every 4 hours
Can’t heal
It is the time,
Un imbursed that the architect, nor the Fireman
Wishes to offer.
Thank God,
For the time
For the Corelli
---
Emotions
By Nagma KC, RN
With an inspiration to heal
Eyes open up without much sleep
Rushing, off I go towards my journey
Heart full of love and care
hands full of devine touch
less load, alas! no
much work there is,
and so is hope
I try my best to heal
Lessen the sorrow and erase
the inner soul with pain
Easy work it ain't,
Emotionally drenching it is,
My heart is filled with pain
Seeing the moans, and the groans
helplessness and shrill cries
Oh Lord! I whisper
Please Help Him/ Help Her
Dear God, I say
take away their sorrow,
Oh Please! take away their pain
Doctors are called, medicines are given
Eyes become teary and my heart heavy
Why is there so much pain, I ask
Everyday, every hour, every second
Hazy my view becomes
I quit! I say
A hand on my shoulder
A smiling face, it's my colleague
It's the Nurse
It's okay she says,
You can do it
With a new vision, off I go
Helping again, the sick
8 hours are gone, now is the time
Mercy Lord, I survived I say
And, I healed and spread love
Tired, sad, happy
I leave for home
Will be back tomorrow, I say
Will do a better job, I dream
Help us all, I pray
Dear God! Dear Lord
take away all sorrow and pain!
Tuesday, August 28, 2007
Monday, August 27, 2007
Observations from Iceland
As noted below, I had a chance last week to attend a very informative conference in Iceland with representatives from the major hospitals and medical schools of the Nordic countries (Iceland, Sweden, Denmark, Norway, and Finland). The health systems in these countries are owned and financed by the government and are often appropriately cited for the quality of care offered to the public. Indeed, in debates here in the US, they are often called out as examples of what we might strive for in terms of universal coverage and a greater emphasis on primary care than we have.
An advantage of actually meeting with people who run such systems is that you get to hear some of the details that do not make it into the public discussions here. I thought I would share just one aspect with you. In so doing, please recognize that I make no apologies for or denials about the inadequacies of our own approach. I am just trying to relate aspects of theirs that might be overlooked.
So, the simple question I asked was this: When the parliament sets the national budget for health care, how does it decide how to much to allot? Here in the US, the "budget" that we set for health care is partially set by Congress (for Medicare) and by state legislatures (for Medicaid), but well over half of our health care budget is not set centrally, but results from thousands of decisions and transactions by multiple players in the system. I was curious to learn, in contrast, how a welfare state decides on the appropriate amount.
I did not get answers about each country, but a pattern began to emerge. Using Iceland as an example, the answer seems to be that the parliament uses, as a rough guide, a desire to maintain overall health care costs at a certain percentage -- 10 or 11% -- of GNP. The US, at 15% is viewed as too high. Other European countries, at under 10%, are viewed as too low.
I pursued the question further. Is this percentage based on a quantified assessment of the actual health care needs of the public, i.e., is it driven by public demand (e.g., a growing aging population)? No. Does it take into account the government's expectation for certain quantifiable levels of service quality, medical quality, or operational efficiency of hospitals and other parts of the system? No.
In essence, this appropriation by the parliament is a politically derived decision, just as it would be for any appropriation for a program of important national priority, and it therefore competes with other worthy national programs for resources.
I offer this not in criticism, but just as a useful reminder to those of us in the US. The managers of the Nordic hospital systems, once their single annual appropriation is handed down, make important decisions about what services to offer to the public and what services not to offer. They also respond to appropriation levels by determining service quality levels. In the face of inevitable limitations on the ability of the nation hospital system to offer all services demanded by the public, a growing parallel system is emerging, in which private practitioners offer elective therapies and procedures outside of those supported by the national system.
Of course, we make similar managerial choices here when we run hospitals. The difference is that we do so in response to a variety of price signals set forth by a meld of public and private payers. Also, we have the advantage of one factor not really present in Europe, philanthropy from generous donors who help us provide advanced diagnoses and treatments that would not otherwise be available to the public.
As I note above, I am not saying one is better than the other. Just different. I predict, though, that the systems will start to look more and more alike over time. Pressure in the US for a more nationally-determined approach. Pressure in Europe for more of a private market approach. It shouldn't surprise us to see this convergence. After all, the countries are dealing with the same organisms, both biologically and politically.
An advantage of actually meeting with people who run such systems is that you get to hear some of the details that do not make it into the public discussions here. I thought I would share just one aspect with you. In so doing, please recognize that I make no apologies for or denials about the inadequacies of our own approach. I am just trying to relate aspects of theirs that might be overlooked.
So, the simple question I asked was this: When the parliament sets the national budget for health care, how does it decide how to much to allot? Here in the US, the "budget" that we set for health care is partially set by Congress (for Medicare) and by state legislatures (for Medicaid), but well over half of our health care budget is not set centrally, but results from thousands of decisions and transactions by multiple players in the system. I was curious to learn, in contrast, how a welfare state decides on the appropriate amount.
I did not get answers about each country, but a pattern began to emerge. Using Iceland as an example, the answer seems to be that the parliament uses, as a rough guide, a desire to maintain overall health care costs at a certain percentage -- 10 or 11% -- of GNP. The US, at 15% is viewed as too high. Other European countries, at under 10%, are viewed as too low.
I pursued the question further. Is this percentage based on a quantified assessment of the actual health care needs of the public, i.e., is it driven by public demand (e.g., a growing aging population)? No. Does it take into account the government's expectation for certain quantifiable levels of service quality, medical quality, or operational efficiency of hospitals and other parts of the system? No.
In essence, this appropriation by the parliament is a politically derived decision, just as it would be for any appropriation for a program of important national priority, and it therefore competes with other worthy national programs for resources.
I offer this not in criticism, but just as a useful reminder to those of us in the US. The managers of the Nordic hospital systems, once their single annual appropriation is handed down, make important decisions about what services to offer to the public and what services not to offer. They also respond to appropriation levels by determining service quality levels. In the face of inevitable limitations on the ability of the nation hospital system to offer all services demanded by the public, a growing parallel system is emerging, in which private practitioners offer elective therapies and procedures outside of those supported by the national system.
Of course, we make similar managerial choices here when we run hospitals. The difference is that we do so in response to a variety of price signals set forth by a meld of public and private payers. Also, we have the advantage of one factor not really present in Europe, philanthropy from generous donors who help us provide advanced diagnoses and treatments that would not otherwise be available to the public.
As I note above, I am not saying one is better than the other. Just different. I predict, though, that the systems will start to look more and more alike over time. Pressure in the US for a more nationally-determined approach. Pressure in Europe for more of a private market approach. It shouldn't surprise us to see this convergence. After all, the countries are dealing with the same organisms, both biologically and politically.
The Shock Doc
It is always heartening when one of our trainees moves along to a higher calling. Several years ago, Dr. Jeremy Weiss was a fellow in interventional radiology at BIDMC. He now has a highly regarded practice on the West Coast, but he also has a sidelight as a magician. Check out his site here, and watch some of the videos in the "gallery" section in particular. Also, read the provocative posting on his blog about the late Dr. Ofey.
Friday, August 24, 2007
Iceland scenes
A few pictures for those of you who are unlikely to get here.--One of many outdoor sculptures in Reykjavik, this one by Ásmundur Sveinsson.
--Evidence of the direction of lava flow, seen on rocks throughout the country.
--A grave marker from years ago: To this date, each Icelander has a first name and then a last name based on his or her father´s first name. There are no last names. Phone books list people alphabetically by their first names.
--The side of a glacial valley, cut through volcanic rock. (All the rock here is volcanic.)
--Road and pipe leading from the geothermal energy plant that serves the capital city. Bore holes produce steam and hot water. The steam drives a turbine to produce electricity. The leftover steam and hot water then pass through a heat exchanger to heat cool water taken from a lake, which is then transported about 30 kilometers to Reykjavik, losing only 2 degrees Celsius en route. Geothermal energy is a key asset in Iceland´s economy.
Outpatient clinic of innovation
An interesting idea from Ulleval University Hospital in Oslo. (There are some similar concepts that I know of from the US, like MIT´s Center for Biomedical Innovation and Entrepreneurship Center, but this one has its own unique features.) Here´s a summary from Andreas Moan, Director of Research and Education:
The Clinic of Innovation is run like any traditional out-patient clinic with one major difference: The purpose of this Clinic is to facilitate the conversion of ideas from research and medical practice into new services or products to the benefit of both patients and society. We also want to offer the same kind of service to ideas generated outside the hospital, offering our medical and research expertise. The Clinic of Innovation is organized as any other out-patient clinic, offering diagnostic work-ups, treatment and follow-up.
It is a joint venture between the Ulleval University Hospital and Medinnova, a Technology Transfer Office with 20 years of experience in innovation. The Clinic has two main customers: First, people working within the health system with new ideas on how services, treatment, organization or products can be improved or developed. Secondly, the Clinic acts as a bridge into the health system for people, commercial parties, biotech and other research-intensive businesses who may be looking for an initial point of contact to the public health sector.
Culture and language is quite different in the public health system and in private enterprise, and our goal is that the Clinic of Innovation may serve as a meeting point and as translators. Our employees have experience from both the private and public sectors.
Although this Clinic is organized as any other out-patient clinic, there is one major difference: To this Clinic you can refer yourself – please see below.
The Clinic of Innovation offers:
Diagnostic work-ups entailing evaluating your idea’s potential in both research and commercial context, or calling external competence as needed to do so. Depending on the diagnosis, the idea (and its owner) will be offered treatment that may entail
- direct problem solving
- development as a joint venture/active project
- establishment of contact with new networks that we believe will help develop the idea
- referral to group therapy with other innovators facing similar problems
Follow-up means seeing you and your idea back for follow-up and additional referral or problems solving as the idea evolves.
The Clinic of Innovation is also a tool to inform about the importance, possible economical impact and sheer pleasure of innovation. The tools for this activity include media coverage, advertising and visiting relevant people and communities inside and outside of the hospital.
How do you find the Clinic of Innovation?
Physically located at the Ulleval University Hospital in Oslo, Norway.
On the Internet: at www.ulleval.no “Idépoliklinikken” in our rather remote language and at www.medinnova.no
E-mail: idepoliklinkken@uus.noPhone: +47 23 02 70 23
Point of contact: Eli Margrethe Walseth
What can you expect?
New ideas are best submitted by a webform located here Medinnova or by email or phone.
The Clinic of Innovations has weekly intake meetings, so you can expect an answer within no more than two weeks. We may want to contact you ahead of the intake meeting to better understand your concept. Your referral is guaranteed full confidentiality, confirmed on the return receipt you get on our referral form. We will also sign a confidentiality agreement at the first appointment.
The Clinic of Innovation is run like any traditional out-patient clinic with one major difference: The purpose of this Clinic is to facilitate the conversion of ideas from research and medical practice into new services or products to the benefit of both patients and society. We also want to offer the same kind of service to ideas generated outside the hospital, offering our medical and research expertise. The Clinic of Innovation is organized as any other out-patient clinic, offering diagnostic work-ups, treatment and follow-up.
It is a joint venture between the Ulleval University Hospital and Medinnova, a Technology Transfer Office with 20 years of experience in innovation. The Clinic has two main customers: First, people working within the health system with new ideas on how services, treatment, organization or products can be improved or developed. Secondly, the Clinic acts as a bridge into the health system for people, commercial parties, biotech and other research-intensive businesses who may be looking for an initial point of contact to the public health sector.
Culture and language is quite different in the public health system and in private enterprise, and our goal is that the Clinic of Innovation may serve as a meeting point and as translators. Our employees have experience from both the private and public sectors.
Although this Clinic is organized as any other out-patient clinic, there is one major difference: To this Clinic you can refer yourself – please see below.
The Clinic of Innovation offers:
Diagnostic work-ups entailing evaluating your idea’s potential in both research and commercial context, or calling external competence as needed to do so. Depending on the diagnosis, the idea (and its owner) will be offered treatment that may entail
- direct problem solving
- development as a joint venture/active project
- establishment of contact with new networks that we believe will help develop the idea
- referral to group therapy with other innovators facing similar problems
Follow-up means seeing you and your idea back for follow-up and additional referral or problems solving as the idea evolves.
The Clinic of Innovation is also a tool to inform about the importance, possible economical impact and sheer pleasure of innovation. The tools for this activity include media coverage, advertising and visiting relevant people and communities inside and outside of the hospital.
How do you find the Clinic of Innovation?
Physically located at the Ulleval University Hospital in Oslo, Norway.
On the Internet: at www.ulleval.no “Idépoliklinikken” in our rather remote language and at www.medinnova.no
E-mail: idepoliklinkken@uus.noPhone: +47 23 02 70 23
Point of contact: Eli Margrethe Walseth
What can you expect?
New ideas are best submitted by a webform located here Medinnova or by email or phone.
The Clinic of Innovations has weekly intake meetings, so you can expect an answer within no more than two weeks. We may want to contact you ahead of the intake meeting to better understand your concept. Your referral is guaranteed full confidentiality, confirmed on the return receipt you get on our referral form. We will also sign a confidentiality agreement at the first appointment.
Thursday, August 23, 2007
Nokia power
A quick progress note about the local scene. More on the conference later.In Iceland, when you go to the pool for your morning swim and bath in "hot pots", you can rent a small locker, in which you can securely charge up your cell phone during your swim. You can pay for it with a coin or by text messaging to a certain number, after which the rental and charging fee will be deducted from your bank account. The locker has built into it three power cords with different connector attachments for the most popular cell phones, especially Nokia´s.
(Cell phones can also be used to pay for parking in municipal lots by text messaging.)
By the way, the pools are public and are considered an essential public service, right after schools, so every municipality has a least one. The water is heated geothermally, and people swim outdoors all year long, and it is a regular routine for many. The pool was comfortably warmer than the air on a cool 50 degree Farenheit morning. The hot tubs are ranked by temperature, starting at 38 degrees Celsius and rising in two degree increments from there. I felt a bit like the proverbial frog in a slowly heated pot of water as I went from one to the next. At 42 degrees, you really are fully cooked.
Wednesday, August 22, 2007
Shrimp Cocktail
I am in Iceland (yes, Iceland) for a couple of days to give a talk at a conference -- more on that in a moment -- and I was reading an article about Icelandic shrimp in Atlantica, the Icelandic Air airplane magazine. I ripped it out at the time because I thought it was interesting but didn´t think about it again until tonight when I was eating some of those exact shrimp at a reception.It appears that there is a carbohydrate -- chitosan -- derived from the exoskeletons of Icelandic shrimp that is applied to bandages that have a high success rate in external hemorrhage control in combat operations. According to this article, the company that makes them is based in Oregon and is called HemCon and has apparently sold more than 400,000 bandages to the US Army.
The good news is that the bandages help. The bad news, of course, is that they are needed by our armed forces and by civilians in war zones. (Before anyone asks, I do not know if BIDMC or any of our faculty ever have had any financial relationship with this company -- and I have not had a chance to check with our folks in Boston, so I can´t find out right now -- but I doubt it. There is a very large trauma service in Seattle, and I would bet that clinical trials would have taken place there.)
By the way, the local shrimp are delicious and are served peeled (maybe to send the exoskeletons to work as bandages.)
The conference I am attending is called the Nordic Conference for University Hospitals and Faculty Deans, with attendees from Iceland, Denmark, Sweden, Norway, and Finland, and three of us guest speakers from Calgary, Manchester (UK) and Boston. I always worry a bit when I am invited to speak at these things because I have so little knowledge of the field compared to others, but I liked the topic I was assigned. It is "Never let the practice of medicine be replaced by the business of medicine." Of course I agree with that, but I also think part of the topic has to be "Never forget that the business of medicine can affect the practice of medicine."
What´s really interesting is that these countries, which have national health insurance systems, are feeling the pinch more and more from their legislative bodies. Members of parliament are upset with the rising costs of health care and want to see more efficiency and higher quality. The underlying system is not likely to change, but hospital CEOs are expected to deliver more for less, and they look towards our US experience for ideas and suggestions.
I can´t wait to see what I am going to say during my talk tomorrow. If I come back wearing lots of shrimp-laced bandages, you will know that it didn´t go very well.
P.S. I took this picture of a waterfall east of Reykjavik at a World Heritage Site called Þingvellir National Park.
Tuesday, August 21, 2007
Roll-back of insurer rating systems?
On my favorite topic, reporting of clinical results, Theo Francis at the Wall Street Journal talks about ranking of physicians by insurance companies:
Doctors and regulators are pushing back against rating systems that some health insurers have developed to guide consumers in choosing physicians. New York Attorney General Andrew Cuomo demanded last week a "full justification" of the rankings that Aetna Inc. and Cigna Corp. have rolled out in the state. He warned the companies that the ratings are confusing and potentially deceptive, in part because insurers don't disclose how prone to error their rankings are. The move follows rankings lawsuits by doctors accusing insurers of libel, unfair business practices and breach of contract in other states.
A number of insurance company people here in Massachusetts had raised similar concerns with me, stating that any ratings they produced would be viewed as self-serving by members of the public. So, I guess this throws the ball back into the court of the public agencies. (Or, of course, providers could self-report on an insurance company website that was open to all.)
Doctors and regulators are pushing back against rating systems that some health insurers have developed to guide consumers in choosing physicians. New York Attorney General Andrew Cuomo demanded last week a "full justification" of the rankings that Aetna Inc. and Cigna Corp. have rolled out in the state. He warned the companies that the ratings are confusing and potentially deceptive, in part because insurers don't disclose how prone to error their rankings are. The move follows rankings lawsuits by doctors accusing insurers of libel, unfair business practices and breach of contract in other states.
A number of insurance company people here in Massachusetts had raised similar concerns with me, stating that any ratings they produced would be viewed as self-serving by members of the public. So, I guess this throws the ball back into the court of the public agencies. (Or, of course, providers could self-report on an insurance company website that was open to all.)
Odd survey
I picked up the telephone last night at home to find one of those electronic surveys on the line. Once I heard the introduction, I stuck with it all the way through just to see what it was about. I´ll describe it, and then people can respond if they know why it was done and whether it is what it says it is.
It started by saying that it was a survey for the state Department of Public Health. There were about two minutes worth of questions, all answerable by pushing a button. It seemed to be about health insurance, and whether I had insurance through my employer or through the new Connector Authority (set up under the new MA health insurance/access law). But then it asked a weird question: Did either of my parents smoke? If so, which, the male and/or the female? It also asked the usual question about my level of education and my age. And then it concluded by saying again that it was a survey for the state DPH.
Of course, I realize that all these surveys, supposedly anonymous, really are not likely to be. After all, they know your phone number, and from that they know your name and address. But that is not what had me wondering.
If it really was the DPH, why are they doing a survey about health insurance? The responsibility for that lies with the Connector Authority, a completely different state agency. And the Connector Authority is already collecting data on how many people in different categories have insurance through their employer or through the plans made available by the Connector. And why ask about smoking in my family history? And, finally, the way the survey announced it was being done for the DPH was just a little off-kilter: It just did not sound like a state agency. Finally, in all the articles about the state budget this year, I never read any coverage about a DPH appropriation for this kind of survey.
So, I wonder if this was really a survey for some company trying to sell insurance or some broker trying to broker insurance sales? As a result of these calls, they could easily segment respondents by age, address (and therefore likely income), family health history -- just what you would want if you were selling health insurance.
Am I too cynical? Maybe someone out there from the DPH will read this and comment. If you are doing the survey, what is it for? If you are not, perhaps you could notify some law enforcement officials that someone is appropriating your name for other purposes.
It started by saying that it was a survey for the state Department of Public Health. There were about two minutes worth of questions, all answerable by pushing a button. It seemed to be about health insurance, and whether I had insurance through my employer or through the new Connector Authority (set up under the new MA health insurance/access law). But then it asked a weird question: Did either of my parents smoke? If so, which, the male and/or the female? It also asked the usual question about my level of education and my age. And then it concluded by saying again that it was a survey for the state DPH.
Of course, I realize that all these surveys, supposedly anonymous, really are not likely to be. After all, they know your phone number, and from that they know your name and address. But that is not what had me wondering.
If it really was the DPH, why are they doing a survey about health insurance? The responsibility for that lies with the Connector Authority, a completely different state agency. And the Connector Authority is already collecting data on how many people in different categories have insurance through their employer or through the plans made available by the Connector. And why ask about smoking in my family history? And, finally, the way the survey announced it was being done for the DPH was just a little off-kilter: It just did not sound like a state agency. Finally, in all the articles about the state budget this year, I never read any coverage about a DPH appropriation for this kind of survey.
So, I wonder if this was really a survey for some company trying to sell insurance or some broker trying to broker insurance sales? As a result of these calls, they could easily segment respondents by age, address (and therefore likely income), family health history -- just what you would want if you were selling health insurance.
Am I too cynical? Maybe someone out there from the DPH will read this and comment. If you are doing the survey, what is it for? If you are not, perhaps you could notify some law enforcement officials that someone is appropriating your name for other purposes.
Monday, August 20, 2007
Way to go, Stacey
A recent email, from Stacey, one of our great ICU nurses, about a doctor with visiting privileges from an affiliated institution:
Paul,
I have been encouraging and supporting the hospital’s policy regarding hand hygiene. My understanding is that all personnel are to use Calstat when entering or exiting a patient’s room, even if they are not going to give direct patient care. I happened to notice Dr. X entering a room without using the Calstat. I went and politely reminded Dr. X to use the Calstat. Dr. X appeared quite annoyed that I requested him to do so as he said he had already examined the patient and was just looking at the monitor. This is not the first time I have had such encounters. How would you like this type of situation handled in the future?
My reply:
Thank you, Stacey,
You did EXACTLY the right thing, and I appreciate how uncomfortable that can be.
We have indeed asked everybody to remind everybody else about the importance of this matter. As you know, it is very easy to pick up germs from equipment and material near the patients and then pass those along to other patients and staff, even when the doctor or nurse has not actually touched the patient.
I am copying Dr. Sands, our SVP of Health Care Quality, who will now follow up with Dr. X.
Sincerely,
Paul
Paul,
I have been encouraging and supporting the hospital’s policy regarding hand hygiene. My understanding is that all personnel are to use Calstat when entering or exiting a patient’s room, even if they are not going to give direct patient care. I happened to notice Dr. X entering a room without using the Calstat. I went and politely reminded Dr. X to use the Calstat. Dr. X appeared quite annoyed that I requested him to do so as he said he had already examined the patient and was just looking at the monitor. This is not the first time I have had such encounters. How would you like this type of situation handled in the future?
My reply:
Thank you, Stacey,
You did EXACTLY the right thing, and I appreciate how uncomfortable that can be.
We have indeed asked everybody to remind everybody else about the importance of this matter. As you know, it is very easy to pick up germs from equipment and material near the patients and then pass those along to other patients and staff, even when the doctor or nurse has not actually touched the patient.
I am copying Dr. Sands, our SVP of Health Care Quality, who will now follow up with Dr. X.
Sincerely,
Paul
Sunday, August 19, 2007
It's official: Infections are bad
Emily DeVoto has a nice summary of the issues (and the link to the New York Times article) surrounding a possible Medicare rule that would withhold payments to hospitals when hospital-acquired infections occur. Zagreus Ammon also pitches in on the topic, as does John McDonough at Health Care for All.
Drive Calmly
Turning now to the infrastructure crisis, please read this hilarious -- and totally accurate -- column written by Monique Spencer. She writes about the "traffic calming" measures installed on Beacon Street in her home town of Brookline, MA. An excerpt:You put a red light on every block. You get rid of parking in order to kill the retailers. You make new pedestrian crossings appear overnight, in between the red lights. Special bike lanes appear on one block, then disappear, with nanny signs that say "Share the Road." Meander the side streets and you'll find giant mounds in the road that are supposed to make you slow down. The traffic engineers call these "vertical deflections." Their real function is to eject the newcomer. At night, he does not see the mound, because it is not lit. He hits the takeoff ramp at 30 miles per hour, and by the time his car touches ground again he is in the next town.
I do not feel calmed.
In a more serious vein, part of the reconfiguration was to remove one lane of traffic to create a protected area for on-street parkers along the median island of Beacon Street -- accompanied by a "bulb-out" or "neckdown" at each intersection (see picture above). Let's please recall that the Brookline section of Beacon Street is one of the evacuation routes from downtown Boston in the event of civil emergency or natural disaster. Now that three outgoing lanes have been transformed into two, it seems that we have a 50% reduction in traffic capacity. Were the emergency preparedness people from Boston notified before this happened?
Saturday, August 18, 2007
Now it's the ADL of New England board's turn
The next chapter in the ADL story is splayed on the front page of the Boston Globe today. Keith O'Brien reports: "The national Anti-Defamation League fired its New England regional director yesterday, one day after he broke ranks with national ADL leadership and said the human rights organization should acknowledge the Armenian genocide that began in 1915."
Andy Tarsy, the regional director who did the right thing, has now taught the public an additional lesson: Sometimes doing the right thing costs you personally, at least in the short run. But I predict and hope that Andy will not have to worry for long.
The action by the national ADL organization now turns the focus on the board members of the local ADL affiliate. Presumably Andy had the support of his local board in taking the action he did. A former board member commented to the Globe: "I predict that [these] actions will precipitate wholesale resignations from the regional board, a meaningful reduction in ADL's regional fund-raising, and will further exacerbate the [national] ADL's relationship with the non-Jewish community coming out of this crisis around the Armenian genocide."
Local board members really have no choice but to resign over the firing of their hand-picked executive director. But these are highly committed volunteers and community leaders who strongly believe in the mission of the ADL. What's for them do to in support of that mission?
The clear answer is to resign, rescind any philanthropic commitments they have made to the national ADL, immediately create a new regional organization with precisely the same mission, hire Andy back, and go to work rebuilding support throughout New England for the important programs they have been running.
[Disclosure: Andy's father is a member of the faculty at BIDMC, but I have not consulted with him on any of these blog postings.]
Addendum on August 19. In writing this, I didn't mean to suggest that local board members who choose to stay on the board and try to work changes in the national ADL should be faulted at all. That is an alternative approach that deserves a lot of credit. It is, however, a long row to hoe -- and until it all gets worked out, I am guessing it will be hard to find a person willing to be a successor for Andy at the New England regional branch.
Andy Tarsy, the regional director who did the right thing, has now taught the public an additional lesson: Sometimes doing the right thing costs you personally, at least in the short run. But I predict and hope that Andy will not have to worry for long.
The action by the national ADL organization now turns the focus on the board members of the local ADL affiliate. Presumably Andy had the support of his local board in taking the action he did. A former board member commented to the Globe: "I predict that [these] actions will precipitate wholesale resignations from the regional board, a meaningful reduction in ADL's regional fund-raising, and will further exacerbate the [national] ADL's relationship with the non-Jewish community coming out of this crisis around the Armenian genocide."
Local board members really have no choice but to resign over the firing of their hand-picked executive director. But these are highly committed volunteers and community leaders who strongly believe in the mission of the ADL. What's for them do to in support of that mission?
The clear answer is to resign, rescind any philanthropic commitments they have made to the national ADL, immediately create a new regional organization with precisely the same mission, hire Andy back, and go to work rebuilding support throughout New England for the important programs they have been running.
[Disclosure: Andy's father is a member of the faculty at BIDMC, but I have not consulted with him on any of these blog postings.]
Addendum on August 19. In writing this, I didn't mean to suggest that local board members who choose to stay on the board and try to work changes in the national ADL should be faulted at all. That is an alternative approach that deserves a lot of credit. It is, however, a long row to hoe -- and until it all gets worked out, I am guessing it will be hard to find a person willing to be a successor for Andy at the New England regional branch.
Friday, August 17, 2007
In sickness and in health
My friend Dave sent me notice of a new blog, called In Sickness and In Health, "a place for couples going though an illness experience - to share stories, advice, resources, and to learn from each other." It's by Barbara Kivowitz. Dave says, "She writes well, has a lot to talk about, and ought to attract an audience, I think." Let's help her along.
Thursday, August 16, 2007
Stand firm and clear, ADL
I am prompted to write on this issue after being awakened to it by a stirring talk I recently heard by Rabbi Ronne Friedman at Boston's Temple Israel.
Back in May, I wrote a post congratulating the Anti-Defamation League on their World of Difference program. This is a thoughtful and well-intentioned program to teach schoolchildren ways of avoiding prejudice.
Recently, the ADL has been involved in a major controversy about the genocide of Armenians by the Ottoman Empire in the early part of the last century. There is a good description of the dispute on Blue Mass Group.
I fear that ADL has lost its way on this issue, refusing to support a Congressional resolution that calls the massacre what it was, genocide. Now they try to rationalize their failure. See these words of their local civil rights counsel:
The Jewish community in Turkey has clearly expressed to us and other major American Jewish organizations its concerns about the impact of Congressional action on them, and we cannot ignore those concerns. We are also keenly aware that Turkey is a key strategic ally and friend of the United States and a staunch friend of Israel, and that in the struggle between Islamic extremists and moderate Islam, Turkey is the most critical country in the world.
Compare that to the pledge students are asked to take at the end of the ADL's World of Difference Program:
I pledge from this day onward to do my best to be aware of my own biases against people who are different from me. I will ask questions about cultures, religions, and races and other individual differences that I don't understand. I will interrupt prejudice and speak out against those who initiate it. I will reach out to support those who are targets of harassment. I will identify specific ways that my peers, my school, and my community can promote greater respect for people and create a prejudice-fee zone. I firmly believe that one person can make a world of difference and that no person can be an "innocent bystander" when it comes to opposing hate.
I know this pledge is not exactly on the point of the current dispute, but its message is close enough. The pledge does not say that I will stand up against prejudice only when it is politically convenient to do so or only when it is risk-free to do so. Or that I will shy away from controversy for fear of offending an important constituency.
Rabbi Friedman reminded me that Adolf Hitler used the genocide of the Armenians as part of his rationale for destroying other groups. Here's the quote he read.
Our strength consists in our speed and in our brutality. Genghis Khan led millions of women and children to slaughter — with premeditation and a happy heart. History sees in him solely the founder of a state. It's a matter of indifference to me what a weak western European civilization will say about me.
I have issued the command — and I'll have anybody who utters but one word of criticism executed by a firing squad — that our war aim does not consist in reaching certain lines, but in the physical destruction of the enemy. Accordingly, I have placed my death-head formations in readiness — for the present only in the East — with orders to them to send to death mercilessly and without compassion, men, women, and children of Polish derivation and language. Only thus shall we gain the living space (Lebensraum) which we need. Who, after all, speaks today of the annihilation of the Armenians?
In simple language "annihilation" of a particular ethnic, religious, or social group is "genocide." Hitler knew exactly what he was saying.
Nothing can bring back those who died. The government that was in power at the time is long gone, too. But the surviving people of Armenian descent -- along with every other group that could possibly be the target of genocide -- deserve the support of the ADL in validating what really happened in 1915.
If the national office of the ADL remains recalcitrant on this issue, the New England Region should break ranks and make an alternate position clear.
(By the way, here's the text of the disputed Congressional resolution: Calling upon the President to ensure that the foreign policy of the United States reflects appropriate understanding and sensitivity concerning issues related to human rights, ethnic cleansing, and genocide documented in the United States record relating to the Armenian Genocide, and for other purposes.)
Addendum. Breaking news on August 17: The New England chapter did indeed break ranks. Bravo to them!
Back in May, I wrote a post congratulating the Anti-Defamation League on their World of Difference program. This is a thoughtful and well-intentioned program to teach schoolchildren ways of avoiding prejudice.
Recently, the ADL has been involved in a major controversy about the genocide of Armenians by the Ottoman Empire in the early part of the last century. There is a good description of the dispute on Blue Mass Group.
I fear that ADL has lost its way on this issue, refusing to support a Congressional resolution that calls the massacre what it was, genocide. Now they try to rationalize their failure. See these words of their local civil rights counsel:
The Jewish community in Turkey has clearly expressed to us and other major American Jewish organizations its concerns about the impact of Congressional action on them, and we cannot ignore those concerns. We are also keenly aware that Turkey is a key strategic ally and friend of the United States and a staunch friend of Israel, and that in the struggle between Islamic extremists and moderate Islam, Turkey is the most critical country in the world.
Compare that to the pledge students are asked to take at the end of the ADL's World of Difference Program:
I pledge from this day onward to do my best to be aware of my own biases against people who are different from me. I will ask questions about cultures, religions, and races and other individual differences that I don't understand. I will interrupt prejudice and speak out against those who initiate it. I will reach out to support those who are targets of harassment. I will identify specific ways that my peers, my school, and my community can promote greater respect for people and create a prejudice-fee zone. I firmly believe that one person can make a world of difference and that no person can be an "innocent bystander" when it comes to opposing hate.
I know this pledge is not exactly on the point of the current dispute, but its message is close enough. The pledge does not say that I will stand up against prejudice only when it is politically convenient to do so or only when it is risk-free to do so. Or that I will shy away from controversy for fear of offending an important constituency.
Rabbi Friedman reminded me that Adolf Hitler used the genocide of the Armenians as part of his rationale for destroying other groups. Here's the quote he read.
Our strength consists in our speed and in our brutality. Genghis Khan led millions of women and children to slaughter — with premeditation and a happy heart. History sees in him solely the founder of a state. It's a matter of indifference to me what a weak western European civilization will say about me.
I have issued the command — and I'll have anybody who utters but one word of criticism executed by a firing squad — that our war aim does not consist in reaching certain lines, but in the physical destruction of the enemy. Accordingly, I have placed my death-head formations in readiness — for the present only in the East — with orders to them to send to death mercilessly and without compassion, men, women, and children of Polish derivation and language. Only thus shall we gain the living space (Lebensraum) which we need. Who, after all, speaks today of the annihilation of the Armenians?
In simple language "annihilation" of a particular ethnic, religious, or social group is "genocide." Hitler knew exactly what he was saying.
Nothing can bring back those who died. The government that was in power at the time is long gone, too. But the surviving people of Armenian descent -- along with every other group that could possibly be the target of genocide -- deserve the support of the ADL in validating what really happened in 1915.
If the national office of the ADL remains recalcitrant on this issue, the New England Region should break ranks and make an alternate position clear.
(By the way, here's the text of the disputed Congressional resolution: Calling upon the President to ensure that the foreign policy of the United States reflects appropriate understanding and sensitivity concerning issues related to human rights, ethnic cleansing, and genocide documented in the United States record relating to the Armenian Genocide, and for other purposes.)
Addendum. Breaking news on August 17: The New England chapter did indeed break ranks. Bravo to them!
Blood Test
I discussed below the results of the unannounced survey by our accreditation body, the Joint Commission. We are also subject to inspections by other regulatory agencies. One is conducted by the Food and Drug Administration, to ensure that our handling of blood products (i.e., blood banking and transfusion) is carried out in accordance with federal standards. The inspections are completely unannounced. There are no black-out dates, so we are not given blocks of time for which we can expect an inspection.The standard enforced by the FDA is called "current Good Manufacturing Practice" (cGMP). The rules of cGMP cover areas such as organization and personnel, facilities, equipment, supplies and reagents, standard operating procedures, labeling, compatibility testing, records, adverse reaction files, and deviation reporting. The goal, of course, is to ensure that the blood products we collect from donors, process, crossmatch, and transfuse to our patients high certain standards for safety, purity, potency, and labeling.
Our unannounced inspection started on August 7. The inspector spent 5 full days touring our facilities, interviewing staff in our Pathology Department and on the floors, observing operations, and reviewing documents and records. By touring the blood banks and the Infusion & Pheresis Unit, the inspector checked to see that our facilities were clean and orderly. During this inspection, the inspector observed an autologous whole blood donation in the Infusion & Pheresis Unit. In the blood bank, she observed our processes for receipt of blood from our outside blood suppliers as well as our processes for management of our inventory, including confirmation of the blood component ABO and Rh type. Additionally, she reviewed the functionality of our blood bank computer system related to product testing, patient testing and product distribution for transfusion.
The inspector also checked for proper storage and handling of blood products. Blood storage refrigerators and freezers were audited for proper temperature and proper labeling and segregation by ABO and Rh type. Records of temperature monitoring and alarm conditions were reviewed to ensure that products were maintained at the proper temperature at all times. Disposition records were reviewed to ensure that products not suitable for transfusion were destroyed.
Written standard operating procedures were also checked for evidence of timely reviews. Training records of new employees were reviewed, as were quality control records of equipment, such as the blood irradiator, and also for reagents used in blood typing and compatibility testing.
I am pleased to report that the FDA inspector found no reportable issues or recommendations. We are quite pleased with this result. We always want to be able to assure our patients that blood products they receive at this hospital have been prepared following good manufacturing practice in order to ensure the products’ safety, purity, and effectiveness.
Wednesday, August 15, 2007
Brand identity
A recent informal survey we conducted indicates that more people know BIDMC is a teaching hospital of Harvard Medical School (52%) than know we are the Official Hospital of the Boston Red Sox (36%). However, we have been the former since the 1920's and the latter only for five years. This suggests to me that there is a relative lack of staying power in the Harvard name. I've put in a call to the administration at Harvard with some suggestions as to how they could enhance their brand identity. I left three options on President Faust's voicemail:
1) Merge with and leverage off the reputation of another university. My suggestion was MIT.
2) Purchase the Red Sox and move the main administrative office of the university to the snack bar on the Green Monster at Fenway Park, where it will be seen every time Mike Lowell or Manny Ramirez hits a home run.
3) Become the official university of the Boston Red Sox.
Thus far, no one has returned my call.
1) Merge with and leverage off the reputation of another university. My suggestion was MIT.
2) Purchase the Red Sox and move the main administrative office of the university to the snack bar on the Green Monster at Fenway Park, where it will be seen every time Mike Lowell or Manny Ramirez hits a home run.
3) Become the official university of the Boston Red Sox.
Thus far, no one has returned my call.
Dr. Sachs discusses New Orleans
Please listen to this excellent interview on WBUR with our departing chief of OB/Gyn who is heading off to New Orleans. Doctors and nurses in particular might want to listen to his offer.
Tuesday, August 14, 2007
Service Wards
Being new to hospitals -- and being pretty oblivious to what they were like 10 years ago, much less 30 -- I recently learned something amazing. This will not be new to many readers who are above a certain age and spent time in hospitals, but for me it was a stunning revelation.
As late as the 1970's, the Boston hospitals -- including BIDMC -- had service wards. These were full floors of beds dedicated to those members of the public from lower income groups without insurance. Then, there might be different parts of the hospital with two or three patients to a room for the slightly better off. Finally, there would be private rooms for the well-heeled.
Corresponding to the bed layout, the service wards were staffed entirely by residents. Attendings, i.e., full-fledged doctors, would only serve the well-to-do patients. (By the way, emergency rooms were also totally under the authority of residents.) Nursing ratios, too, varied by income level. Our current Board Chair, Lois Silverman, told me of being a young nurse with total responsibility for 30 patients on a service ward!
Here is a marvelous description of this at Massachusetts General Hospital, written by Dr. Jerry Groopman, who was an intern there in 1976. (I include this as representative of the general situation because it is so nicely written, and not at all to reflect solely on MGH.)
There were three clinical services, Bulfinch, Baker, and Phillips, and over the ensuing twelve months we would rotate through all of them. Each clinical service was located in a separate building, and together the three buildings mirrored the class structure of America. The open wards in Bulfinch served people who had no private physician, mainly indigent Italians from the North End and Irish from Charlestown and Chelsea. Interns and residents took a fierce pride in caring for those on the Bulfinch wards, who were "their own" patients. The Baker Building housed the "semi-private" patients, two or three to a room, working- and middle-class people with insurance. The "private" service was in the Phillips House, a handsome edifice rising some eleven stories with views of the Charles River; each room was either a single or a suite, and the suites were rumored to have accommodated valets and maids in times past. The very wealthy were admitted to the Phillips House by a select group of personal physicians, many of whom had offices at the foot of Beacon Hill and were themselves Boston Brahmins.
Who would have thought that, only 30 years ago, equal access meant separate and not at all equal? Today, we when talk about equal access to health care, we actually mean equal. At BIDMC, care is truly delivered without regard to income. A Stoneman or Feldberg descendant from Back Bay or the western suburbs might be in single or double room in the Stoneman or Feldberg building named after their parents or grandparents -- but so might a Smith or Jones from Dorchester, Mattapan, or Roxbury. The staffing ratios -- residents and attendings and highly trained nurses -- are the same, the housekeeping is the same, the food is the same (room service!), and all the televisions show the Red Sox on channel 26, and have those cumbersome TV remote controls.
Full disclosure: The only physical amenity that is left to those who choose to pay extra is to acquire a single room when there is not the medical necessity for a single room. This is only permitted when such rooms are available. Otherwise, they are allocated first to those cases requiring isolation, and then generally assigned to other patients.
As late as the 1970's, the Boston hospitals -- including BIDMC -- had service wards. These were full floors of beds dedicated to those members of the public from lower income groups without insurance. Then, there might be different parts of the hospital with two or three patients to a room for the slightly better off. Finally, there would be private rooms for the well-heeled.
Corresponding to the bed layout, the service wards were staffed entirely by residents. Attendings, i.e., full-fledged doctors, would only serve the well-to-do patients. (By the way, emergency rooms were also totally under the authority of residents.) Nursing ratios, too, varied by income level. Our current Board Chair, Lois Silverman, told me of being a young nurse with total responsibility for 30 patients on a service ward!
Here is a marvelous description of this at Massachusetts General Hospital, written by Dr. Jerry Groopman, who was an intern there in 1976. (I include this as representative of the general situation because it is so nicely written, and not at all to reflect solely on MGH.)
There were three clinical services, Bulfinch, Baker, and Phillips, and over the ensuing twelve months we would rotate through all of them. Each clinical service was located in a separate building, and together the three buildings mirrored the class structure of America. The open wards in Bulfinch served people who had no private physician, mainly indigent Italians from the North End and Irish from Charlestown and Chelsea. Interns and residents took a fierce pride in caring for those on the Bulfinch wards, who were "their own" patients. The Baker Building housed the "semi-private" patients, two or three to a room, working- and middle-class people with insurance. The "private" service was in the Phillips House, a handsome edifice rising some eleven stories with views of the Charles River; each room was either a single or a suite, and the suites were rumored to have accommodated valets and maids in times past. The very wealthy were admitted to the Phillips House by a select group of personal physicians, many of whom had offices at the foot of Beacon Hill and were themselves Boston Brahmins.
Who would have thought that, only 30 years ago, equal access meant separate and not at all equal? Today, we when talk about equal access to health care, we actually mean equal. At BIDMC, care is truly delivered without regard to income. A Stoneman or Feldberg descendant from Back Bay or the western suburbs might be in single or double room in the Stoneman or Feldberg building named after their parents or grandparents -- but so might a Smith or Jones from Dorchester, Mattapan, or Roxbury. The staffing ratios -- residents and attendings and highly trained nurses -- are the same, the housekeeping is the same, the food is the same (room service!), and all the televisions show the Red Sox on channel 26, and have those cumbersome TV remote controls.
Full disclosure: The only physical amenity that is left to those who choose to pay extra is to acquire a single room when there is not the medical necessity for a single room. This is only permitted when such rooms are available. Otherwise, they are allocated first to those cases requiring isolation, and then generally assigned to other patients.
Top HMOs
Liz Cooney reports on White Coat Notes that Tufts Health Plan, Harvard Pilgrim Health Care, and Blue Cross Blue Shield of MA all received excellent ratings in a Consumer Reports reader survey. She notes, "The health plans were judged on how satisfied respondents were with the choice of doctors, care from doctors, access to doctors, primary-care doctors and billing."
Congratulations to all three companies, all of whom provide excellent service to their customers. Not to take anything away from their accomplishments, but since none of them actually provide medical care, perhaps the doctors and hospitals in Massachusetts also deserve some of the underlying credit for their successful survey results.
Congratulations to all three companies, all of whom provide excellent service to their customers. Not to take anything away from their accomplishments, but since none of them actually provide medical care, perhaps the doctors and hospitals in Massachusetts also deserve some of the underlying credit for their successful survey results.
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