Tuesday, October 31, 2006

The Week Before

The week before the drug company supplement in the NY Times Magazine, there was a glossy insert called "National Hospital Guide, a reference tool for health-conscious consumers". It portrayed itself as "designed to help you better manage your health care needs".

Of course, the major entries in the booklet were those hospitals that had shelled out the money to buy an ad in the same booklet. But then, a few others were included, too, including a few in Boston. When we inquired how the selection was made of those hospitals, the publisher told us that they had a selection process, but could not or would not tell us the criteria for selection. One group of hospitals included in that manner is a major purchaser of advertising space in the Boston Globe, which is owned by the New York Times. In the absence of public criteria for selection in the Times brochure, it is unreasonable to assume that there is some carryover influence from the Globe ad placement?

The point is this. Advertising is advertising. A selection process based on supposed clinical excellence is another. Shouldn't we expect the media to distinguish between the two when they are "guiding patients to better health"?

Monday, October 30, 2006


Like everybody else, I have gotten used to the unfortunate number of ads in which drug companies encourage consumers to push their physicians to prescribe the latest in expensive new therapies. But, the NYTimes Magazine had a supplement this weekend that, to me, was really offensive.

It was entitled "From cause to cure, a patient's guide to advances in mental health" and presented articles about Alzheimer's, bipolar disorder, epilepsy, and schizophrenia -- fully intermingled with full page ads from drug companies pushing their products which, by the way, were often featured in the articles themselves. I can't tell you how relieved I was to know that Bristol-Myers Squibb thinks that "treating bipolar disorder takes understanding"; that UCB is "the epilepsy company" that lets you have "life on your terms"; that Pfizer is "working for a healthier world"; that AstraZeneca is wants us to know that "sometimes there is another side to depression" -- and offers a postcard we can send in on which we list our diagnoses and what medications we are currently taking.

The articles and ads were illustrated by manipulative photos of people in various stages of sadness, thoughtfulness, and happiness. I believe that this kind of approach to reaching people -- especially those with mental illness -- and their family members is so cynical as to be offensive.

But, maybe I am just out of date and should learn to expect and accept this form of advertising. What do you think?

Please understand that I highly value the work these companies do: My problem lies in the way they deliver their message.

Sweet Music

A few months ago, I asked a friend of mine, Nancy Kleiman, to play her harp in several places in the hospital, just as an experiment. The reponse was so positive that a donor funded the program, and we have made it a regular thing. The comments from patients and staff have been very positive. Here is the latest note from Nancy, which tells some marvelous stories:

Dear Paul,
There has not been one day since I've begun to play the harp at the BIDMC that I haven't had a significant experience to record in my journal. But in this past week alone, the events that have occurred have been so overwhelming that I wanted to take a moment to describe for you how your vision and investment are making a difference in our community.

It began when a patient in a wheel chair, on her way to an appointment, approached me to say that she was a classically trained harpist who could no longer play her pedal harp because of her MS. During our chat, I invited her to return and try a small harp I owned that she could hold in her lap with the help of a bar that rests under her legs. This Monday when she met me in the Shapiro lobby people gathered around to watch and listen to us play a duet! A social worker looking on wept at this remarkable site. The harpist was so thrilled to be able to play the harp again that she plans to purchase a similar one. I have invited her to a harp workshop I am hosting next weekend where another of your employees, a harpist in your sleep clinic, is speaking about her work. Already, Barbara [chief of social work] and I are talking about getting this harpist involved in the hospital's support for other MS patients.

Thursday as I was playing, a social worker was about to begin a workshop to address self-care for other social workers and asked if I would come and speak about my work and be the "experiential" part of her workshop. She had the social workers close their eyes and simply relax as I played for them. She had attended another workshop where a harpist colleague of mind who started the MGH program spoke and performed this way. As we were chatting, a patient - also a musician - came over to tell me that as she entered the lobby she could tell instantly that what she was hearing was live music. She said she looked up at the harp and was no longer in a hospital.

Although I usually do not come in Friday, I checked my email and had an urgent request from a harpist at the GentleMuse program at MGH. A family of a dying patient at the Brigham and Women's had called for a harpist to do a "death vigil" for their mother who had been expected to die the day before. Of course, I called the family and they were thrilled that I could be there immediately. I simply took out my harp in the Shapiro lobby and walked it across the street. On the way, three employees at the Brigham and Women's asked for my card! One commented, "Why does the BIDMC and MGH have a harpist but not us?" I could not have been received with more welcome and warmth than by the nurses on the 12th floor and everyone else in my path. And what more wonderful example of hospital cooperation than what happened yesterday!

There are so many other stories I could share. A day does not go by that someone doesn't ask me to teach the harp. At least five of your staff - including a physician - have seriously asked me to do so! And even the Starbucks manager is begging me to play in the mornings when her lines are out the door! Since I have already been asked to provide harp music by chaplains to play for a dying patient and by the nurses in Farr 9 and the psychiatric unit, I am envisioning a time when your harpist is available to respond to such requests. I have retired from teaching to make myself available on a volunteer basis to do just that because I believe that this service is a vital and compassionate role to be filled. Paul, that I could do so to serve your community is my ultimate dream!


Thursday, October 26, 2006

CareGroup -- Part 2

Shortly after arriving as Administrative Dean at Harvard Medical School in the fall of 1998, I was invited to attend a three-day strategic planning retreat for the senior managers and clinical leadership and lay leaders of CareGroup. They were kind enough to invite me, as someone new to the medical field, to get an intensive briefing on the inner workings of part of the Harvard hospital system. It was a fascinating experience, and I learned a lot.

I was struck by the sense of unity and purpose of all those attending to create a vibrant and strong CareGroup integrated health care delivery network. Nonetheless, within a short time, I noticed that it wasn't working.

First of all, the merger of the BI and the Deaconess was well into several years of bad results. What had been portrayed as a merger of equals was actually a takeover of the Deaconess by the BI. A look at the clinical and administrative leadership of the BIDMC made it clear that the BI folks had the overwhelming role in running the place. This, along with other misteps, left the Deaconess people feeling left out and alienated and undervalued. Doctors left, nurses were disgruntled, referring physicians changed loyalty, and lay leaders from both the BI and the Deaconess in the community became disenfranchised. Operating losses grew year after year, into the tens of millions of dollars.

The CareGroup holding company, meanwhile, made clinical judgments that further weakened the BIDMC -- most noticeably a commitment to moving the preponderance of orthopaedics to New England Baptist. For a general hospital like BIDMC to lose this specialty meant a significant hit and loss of potential growth to its bottom line.

As BIDMC weakened, both the Baptist and Mt. Auburn, the two other major hospitals in the system, feared for their financial future -- because the debt issued under the CareGroup name was a joint and several obligation of all of the hospitals. How could the two hospitals raise philanthropic donations, for example, if donors thought that funds would be used to bail out the Medical Center?

Meanwhile, the system's three small community hospitals in Needham, Waltham, and Ayer were suffering from the usual woes of community hospitals in Massachusetts, and the Baptist and Mt. Auburn also fretted about the financial impact of those hospitals. The CareGroup board ultimately voted to close the Waltham hospital, but it had to remove the local board to do so, because that local board refused to accede to this action. This use of reserve powers by the holding company board sent a shock wave throughout the system: While everybody knew that the CareGroup board had this authority, it had never been used so dramatically.

You can imagine why this series of events led to a lack of cooperation and collaboration among the Caregroup hospitals. All hope for an integrated health care delivery system was shattered. Eventually, at the behest of the hospitals, the CareGroup board voted to reduce its authority over the member institutions, removing itself from clinical matters and focusing instead on its fiduciary responsibility to the bond holders.

Wednesday, October 25, 2006

Are there any doctors out there?

If so, I can't imagine that you don't have an opinion about my comments on Transplants, below. In that posting, I am suggesting that not all hospitals should be permitted to do all kinds of clinical procedures. Are you going to let a non-MD like me make a clinical judgment like that -- unchallenged? (I got more comments on the cookies!!)

Tuesday, October 24, 2006

How magic happens

The magic of academic medical centers occurs at the intersection of clinical care, basic science research, and clinical research. The excerpt below is from an article written by Dr. Jerome Groopman and printed in The New Yorker this past July. If you have chance to read the whole thing, you will find a wonderful story of how a young scientist, working in collaboration with others in the hospital, developed a theory that might end a disease.

The Preeclampsia Puzzle (The New Yorker)
In June, 2000, Ananth Karumanchi, a thirty-one-year-old kidney specialist at Beth Israel Deaconess Medical Center, in Boston, read an article in Nature about preeclampsia, a poorly understood disorder that affects about five per cent of pregnant women. In the developing world, preeclampsia is one of the leading causes of maternal death; it is thought to kill more than seventy-five thousand women each year. In the United States, where treatment is more readily available, few women die of the disease, but complications -- including rupture of the liver, kidney failure, hemorrhage, and stroke --can cause lasting health problems. (In rare cases, patients with preeclampsia develop seizures or lapse into a coma; this is called eclampsia.) The only cure is delivery. "If a woman develops preeclampsia near term, then she is induced to have a delivery or undergoes a Cesarean section," Benjamin Sachs, the chief of obstetrics and gynecology at Beth Israel Deaconess, told me. "In most cases, as soon as she is delivered we know she will get better. But, if preeclampsia develops early in the pregnancy, then we have a huge challenge, because we have two patients: the mother and the baby. If you deliver the baby early to spare the mother, then you put the baby at risk for the complications of prematurity; if you wait, then the mother can have severe complications and go on to eclampsia."

What is CareGroup?

One of the persistent questions I receive from people at BIDMC and outside is, "What is Caregroup?" Here is the answer.

In the mid-1990s, the Partners HealthCare System was established with a merger of MA General Hospital, Brigham and Women's Hospital, several community hospitals, and many physicians. The business concept behind this merger was to establish a new corporate entity that reflected the changed health care marketpace. The new corporation would have better access to capital, garner economies of scale by larger scope, and have more leverage with insurance companies because of its extensive reach and integration of care delivery.

Beth Israel Hospital, the third largest of the adult care Harvard teaching hospitals, was not part of that merger and began to search for its own partner. It joined up with the New England Deaconess Hospital, and added affiliations with New England Baptist and Mt. Auburn, along with three small community hospitals and a number of community physicians. The goal was to establish another integrated health care delivery system -- CareGroup -- to be the bookend to Partners in Eastern Massachusetts.

But many problems soon ensued (which I will describe in future postings), and CareGroup failed as an integrated health care delivery system. A few years ago, therefore, the board of CareGroup, under urging from its member hospitals, redefined its scope. Its main purpose today is to satisfy the fiduciary obligations of the system with regard to previously issued bonds, which are a joint and several obligation of the three hospitals. CareGroup no longer has any clinical responsibilities.

Throughout the country, there are stories of mergers and corporate reallignments gone awry in the hospital world. This is no surprise. I used to be involved in other industries in which competitive market frameworks replaced regulated, cost-plus businesses (electricity, natural gas, telephone -- to mention a few). The first refuge of management in the face of such change was often to look for merger partners, but such mergers often failed. In future postings, I will provide more details about the BIDMC and CareGroup experience, but in the meantime, I would love to receive comments from you about interesting successes or failures from other parts of the country.

Monday, October 23, 2006

More from Monique

Monique Spencer, the author of The Courage Muscle, A Chicken's Guide to Living with Breat Cancer -- see our posting below -- has an op-ed in the Boston Globe today.

Like Captain Louis Renault (Claude Raines) from Casablanca, we are shocked that our demure, shy, and withdrawn friend might have strong opinion about the current political scene . . . .

Saturday, October 21, 2006

Heart Stents

Read this story in the New York Times. I think it is really well written and takes a complicated medical issue and fairly and clearly presents the various aspects of it.

I post it to give a sense of the complexity of advanced medical treatment. A new technology emerges that appears to hold great promise of treating disease -- in this case, drug-coated stents vs. non-coated stents vs. cardiac surgery. As time passes, doubts emerge as to the relative efficacy of the three.

The solution for the doctor is to stay up-to-date on the latest literature and studies and try to do what is best for the patient who shows up today. Unfortunately, the evidence is not always conclusive. I think this is a significant emotional burden for both patients and doctors. You can't ask someone who is having a heart attack to wait until this is resolved. You also can't ask a doctor who is treating the patient to wait until this is resolved.

I am certainly not wise enough to offer a solution to this particular or general problem, and so I welcome your thoughts.

Really little babies

I just attended a reunion of NICU babies at our hospital. The NICU is the neonatal intensive care unit, where premature or other medically distressed babies go to get bigger and stronger. Over the last 15-20 years, there have been major advances in the treatment of these babies that allow even very small ones (1.5 pounds) to survive. Surfactants allow their lungs to be opened, and new types of ventilation permit them to breathe without damage to delicate repiratory tissues. Previously, many would die. Ordinarily, they stay in the NICU until their normally expected birthdate, which could be days, weeks, or months.

At this reunion, we revealed photographic portraits of 11 of these babies, who now range in age from 3 to 14. There are pictures of their baby days and from now, along with a written summary of their stay in the NICU and their current activities. They kids play lacrosse, compose music, excel at school, and engage in a multitude of normal activities. Some have neurological or other problems resulting from their premature days, but all are happy, functioning children.

The portrait gallery is called the "Hall of Hope" and is designed to give current NICU parents encouragement as they walk by to visit their really little babies. We are not the first place to do this, but I am pleased that we have done so.

If you had or knew a NICU baby (or were one!) and want to relate your story, please submit a comment.

Friday, October 20, 2006

How am I doing?

Former New York Mayor Ed Koch used to wander through the city yelling out to people, "How am I doing?" I am writing to ask the same question.

I know that hundreds of people view this blog every day, but most do not submit comments, and it is hard to know if people actually read the postings, much less find them enjoyable or interesting. Sometimes, writing this feels a little bit like being lost at sea and sending out messages in bottles, with the hope someone will pick up a bottle and respond.

So, here's your chance! Is this a good use of my time? Yours? Even if you have not commented before, please send feedback, ideas, and suggestions. I promise to post everything you send in (subject to normal rules of politeness and nice language). Thanks.

Thursday, October 19, 2006

The "other" Beth Israel

Dr. David Shulkin, CEO of Beth Israel Hospital in New York, has started a blog. I have listed his link on this page for those who want to check in with him. It looks like it is mainly designed as an internal communications tool, but perhaps we can all offer him some ideas.

Errors, Improvement, and Discipline

This posting is long, but I think the final point is very important, so please bear with me. Last year, one of our doctors violated one of our safety regulations, and although there was no harm to the patient, we disciplined him with a temporary suspension of privileges. The fact that we took this action ended up in the newspapers. Now, this doctor is one of the experts in his field and very well regarded in the region and often takes on cases that are so difficult that others will refuse to take them. A number of people in the hospital and from other hospitals contacted me about the case, wondering how we could treat such an exemplary doctor in such a manner. It occurred to me that the case would be an opportunity to remind everyone in our hospital about our standards and procedures, and I did so in the email that follows.

But after you quickly read my email, take the time to slowly read the one that I received from a nurse a day later. That's the message that really hits home.

Here's mine:

Dear Colleagues, I received a number of comments following last week's press report regarding disciplinary action against one of our physicians. Many of you were proud that you work in an organization that engages fully in the internal and external processes designed to improve care and ensure safety. However, some of you expressed surprise and concern and asked "Why couldn't this be limited to an internal process?" I thought it would be worthwhile to explain. We know that we all have the best of intentions in treating patients at BIDMC. In the vast majority of our hundreds of thousands of patient encounters each year, things go well. Every now and then, though, there is an unexpected adverse patient event or a near miss. This could result from a series of unexpected events that may be the fault of no one. Sometimes, though, it results from potentially avoidable medical error, a care process that does not work effectively enough to prevent errors, or from poor judgment of a member of our medical staff.

Our Medical Executive Committee, comprising all of the departmental Chiefs and several other members of the physician staff, establishes rules of procedure and conduct that apply to medical care professionals here at the hospital. Those rules call for review of major adverse events and near misses whenever they occur. (Given industry experience, we can expect about four to six such episodes each month.) We conduct confidential peer reviews of these cases in the following manner: First, appropriate cases are identified at departmental conferences. These are then reported to our Department of Health Care Quality, where they are investigated to determine the root cause. We look for ways to learn from them and make improvements so we can better serve our patients. The vast majority of those reviews do not result in punitive action against a doctor. Indeed, we depend on healthcare professionals to disclose fully all facts so that the process can be accurate and helpful to future patients.

As required by state law, the most serious of the adverse events are reported to the state Board of Registration in Medicine ("BORIM"). Some types of cases must be filed with the state Department of Public Health ("DPH"). The law states that the entire process at the BORIM is protected by the rules of confidentiality as a peer review event, but cases filed with the DPH are not confidential. There are other occasions, however, where a member of the medical staff may have willingly or knowingly violated one of the rules set forth by the Medical Executive Committee ("MEC"). Here, too, a confidential investigation is undertaken, whether that doctor is a full-time faculty member or any physician with privileges at our hospital. If there is a violation, the Chief of that service imposes a penalty that he or she deems appropriate. That case is then reviewed in its entirety by the Medical Executive Committee. Assisted by an internal peer review panel, the MEC can accept or modify the Chief's determination. The record of that case is then forwarded to the BORIM. The Board conducts it own review and takes it own action, which may be similar, more severe, or less severe than that taken by the Medical Executive Committee. It can assess a range of penalties, the ultimate one being a revocation of a license to practice. Unlike the adverse events reports, under state law, disciplinary actions are made public by the Board. We do not seek press coverage of these events, but actions by the state can generate media inquiries. When they do, we provide clear, open, and honest comments to reporters to help put the case in proper context.

This series of processes is governed by the laws of the Commonwealth of Massachusetts. In the case of adverse events, those laws are designed to encourage disclosure by doctors by shielding them from unfair criticism and publicity during a substantive review of a case. The hope is to learn from our mistakes in a helpful and constructive environment. These reviews can often lead to resolving system problems, too. For example, the computerized physician order entry system was largely a response to illegible and incorrect written orders that resulted in medical errors. In the case of disciplinary actions, though, the laws are designed to publicize misbehavior -- to inform the public about the record of a doctor and to deter others from acting in the same manner.

No one takes pleasure from a process in which a highly trained physician who has devoted his or her life to healing patients is put through the agony of this kind of publicity. On the other hand, the public has a right to know if a caregiver has acted in a manner inconsistent with the professional standards established by his or her peers. Men and women who choose to become doctors do so out of a great sense of service to their fellow human beings. The fact that we engage in intense review processes of our own colleagues is a sign of this quest for excellence. On those few occasions when a member of the medical staff is hurt or embarassed by this process, it is because his or her colleagues have acted to prevent patients from potential harm in the future. It is a sign of the strength and commitment of our Medical Center. It is also the law of the land, and we will abide by it.

Sincerely, Paul

Now, here is the nurse's note to me:

I feel inclined to respond to your email with an experience I had today on the floor. Your email proved to be helpful in my circumstance. I am a new nurse at the hospital, and I am currently orienting. On my way to work early this morning I was thinking about the hospital and the recent publicity via this incident with the doctor. I actually felt a huge sense of pride coming into work. Taking the higher road is not always easy but lends it self to a freedom and power that all great institutions must embody. I believe that Beth Isreal's commitment to excellence is a model for both myself and other hospitals to emmulate.

At work today I made a mistake, a medication error. My stomach turned, I felt faint . . . however I recalled my focus earlier in the day: on the integrity of the hospital and the type of light that it shined on my paradigm as I entered my day. I felt an immediate sense of freedom and put my attention on what I needed to do to correct the error. Although embarrassment and fear visited me, I wasn't overwhelmed by the emotions. I contacted the right people, and helped maintain the safety of my patient. It was a very challenging day . . . and I grew. I will go to sleep with integrity; knowing I was honest, feeling I had done all I could.

I know healthcare presents these types of moral dilemas to all of us who choose this challenging field to work in. Beth Isreal is a safe place to honestly confront these dilemnas and strive to achieve the excellence that I know can exist.

** RN

Wednesday, October 18, 2006

Best of Boston Cookies: The Secret is Out!

The chocolate chip cookies served at Beth Israel Hospital were listed as Best of Boston in 1995 or so. People used to come in off the street to buy them at the hospital cafeteria! For those of you who always wanted the recipe, here it is. You might want to reduce the quantities for household use . . . :)

Yield: 600

Preheat oven 300 degrees
Baking time: 12-15 minutes

7 ½ lbs of granulated sugar
7 ½ lbs of brown sugar
10 lbs butter
1 ½ cups vanilla
28 eggs
15 lbs flour
1/3 cup and 1 tablespoon salt
1/3 cup and 1 tablespoon baking powder
1/3 cup and 1 tablespoon baking soda
12 ½ lbs chocolate chips
1½ lbs walnuts (optional)

Soften butter and whip with both sugars
Beat eggs and mix in salt, baking powder, and baking soda
Gradually mix in flour
Add chocolate chips and walnuts

Tuesday, October 17, 2006

A Statistically Valid Sample?

Every year, US News and World Report lists the top hospitals in the country. Everyone in the health care field knows that the methodology used in this survey has no statistical or scientific validity, but everyone wants to be at the top of the list!

Here's a story on efforts by the University of Pittsburgh Medical Center to try to score well in this annual survey. We wish them well, especially because their former Chief of Medicine is now Chief of Medicine here at BIDMC. So if they get highly ranked, based on his many years of fine work there, we will share in their pleasure.

Site Feed

At the suggestion of several people, I have created a link on the side of this website to a site feed for those who want to use it for automatic delivery of new postings.

Having said that, I have no idea how this works and don't really want to know . . . . :))

Monday, October 16, 2006

Not Transparency

Several months ago, the state of Massachusetts started a website (click on the box in the lower right of the home page that says Health Care Quality and Cost Information, and then click "physicians") with data on the volume of certain procedures done by individual surgeons at hospitals in the state. There are several problems with this website.

First, the state is using administrative datasets (i.e., billing information) to generate the numbers. Those datasets only allow for a certain number of "operators" to be listed as part of an admission. So, for a person who has multiple operations during the same hospital admission, not all of the procedures will be captured.

Second, the coding logic that the state uses has some oversights. Mass General Hospital and Boston Medical Center, for example, note that the category of abdominal aortic aneurysms (AAA) does not include endovascular repairs, which represent a significant portion of those types of surgeries. MGH points out, "The conventional surgery involves a major incision and the AAA is repaired by the surgeon sewing in an artificial aorta. The stent graft (or minimally invasive operation) achieves the same goal (eradication of the AA) by working up through the arteries in the groin. In the past year the percentage of AAA repaired with the minimally invasive approach has grown to 70% at the MGH." BMC states, "The ... definition allows us to report only on the volume of direct aortic aneurysm repairs. At Boston Medical Center, we do both endovascular aortic aneurysm repairs as well as direct repairs; adding the endovascular cases would more than double the volume reported for FY04."

Third, the numbers are out of date and do not represent the latest volume of surgeries carried out by doctors. I have suggested to people in the state and to insurance companies that it would be very, very easy to have real-time information on these topics: The state could set up a website and give password access to each hospital, and we could update the website from our own databases virtually every day of the year. We all keep track of our doctors' clinical volumes.

To keep us from "cheating" -- as if we would! -- the data submitted by us could be printed in italics and listed as unaudited until the state actually caught up with the figures in its own reports. At that point, the font could switch over to plain type.

And, finally, to persist with one of my favorite topics (see below), why doesn't the website include solid organ transplant surgical volumes? These are easily counted and reported. Wouldn't you want to know these figures if you needed a new liver or kidney?

We all appreciate the steps the state is taking, but if we are going to be serious about transparency, let's improve what is posted so consumers have up-to-date and accurate information.

Sunday, October 15, 2006

TV Remote Controls

From time to time, I will post a comment on the little things that work well or poorly in our hospital. I hope this will give you an insight into the unusual aspects of running a hospital that are not present in other organizations. If you want to send me other examples, I will try to address them, too.

How many of you have been a patient in a hospital bed and have faced the problem of the TV remote control that requires you to cycle through the entire set of channels to get back to an earlier channel or to turn off the television? How incredibly frustrating, right? You lie there in bed and say, "What dodo thought of this?" Here is the explanation, from our person in charge of facilities, in response to a patient's complaint:

"We researched it and found that the remote is the one that is connected into our nurse call system, and the company did not have alternatives that would be more convenient. We checked with other hospitals in town and they all had the same limitations. Having these systems integrated reduces the number of separate handheld items hooked to the bed and allows the speaker to be at the bed, particularly important in a double room.

"We looked into the possibility of making available commercially available universal remotes and programming them to work on our TVs, but they would not meet the infection control and electronic system standards required in a hospital (e.g., the infrared used could interfere with the monitoring system). We went back to the nurse call system company, and they are now going to offer remotes that let you turn the TV off without cycling through the stations and allow you to cycle backwards (so if you are on Channel 5 and want Channel 4, you do not have to go ALL around). We don't know if they figured out this new technology based on our call or not. They claimed nobody had ever inquired about this before, but regardless, we are thrilled. As we replace our older remotes, we will use these alternative products and continue to push the company to do even better by more closely mimicking the remotes we all have at home."

Friday, October 13, 2006

More on Transplants

See my posting below on the waste involved in having more transplant programs in New England that are necessary. Now see this article on the creation of yet another liver program, this one at Dartmouth Hitchcock Medical Center. The article notes: "When DHMC first begins performing liver transplants, only private-payer insurance carriers will be covered for the procedure, Berk said. The hope, however, is that publicly funded insurance programs will approve it shortly thereafter and begin referring patients. "

I have nothing against DHMC or the very fine doctors there, but why should society support this program when there is already surplus liver transplant capacity in New England? Another quote: "Of the 4 million people in (New Hampshire, Vermont and Maine), about 40 are succumbing to liver problems every year," Berk said."

The article notes that some potential recipients lack transportation to get to another center in New England. Can this really be true? It is not that far, and people travel throughout the region all the time. If transportation costs are the issue, let's raise money to pay for it rather than hundreds of thousands of dollars for a new liver transplant program that will not do enough procedures to justify its existence.

Wednesday, October 11, 2006

Concierge Practices

Is it right and good for primary care doctors to change their regular practices into "concierge" or "boutique" practices? Most of the doctors associated with BIDMC have the traditional kind of arrangements with their patients, but a few have adopted this other model. Here is a portion of an essay written by my friend and colleague Dr. Harold Solomon on this topic. Please let us know how you feel about his approach and his point of view:

"Four years ago, in frustration, and after a 38-year career in internal medicine and nephrology, I closed my Beth Israel Deaconess Hospital-affiliated practice, reopened as a "concierge" physician. As an alternative to quitting medicine altogether, I joined MDVIP, a national association of physicians. I wanted to make a loud statement about the error of undervaluing primary care.

"MDVIP charges a $1500 annual fee, covering a prevention-oriented physical and wellness plan, other services- newsletter, personal health information CD, website, and internet services. I limit my practice to 600 patients. I participate in all insurance, HMO, and Medicare. Fewer patients means quick access, same day visits for acute problems, a personal touch. I rarely sign out to coverage. Unless I am in a plane, or abroad, I am the first contact for my patients’ after hours needs.

"I was moved to preserve the quality of my work, and was willing, for the first time in my career, to be a bit controversial. . . . 475 patients signed up, and to my surprise, I had overestimated signups by the rich by a third, underestimated the middle class patients by a third. The demographics of my practice did not change. This was not an "elite" patient group. Why did more rich patients leave that I expected? I did not understand then, but I do now. The upper class patients already know how to get special care. They become hospital donors, are connected socially. Many hospitals have development offices which promise better access in exchange for donations. At Boston's most famous hospital, there is a "concierge" floor. Donors of $1000 get a unique color hospital ID card which alerts employees of your importance. You get a free flu shot, ahead of the line!

"Most doctors defer to patients with stature -- politicians, celebrities, physicians, the wealthy. A former cabinet secretary left me angrily, and was seen within three days by a colleague whose practice is "closed", and who is a public figure in the movement for universal access in Massachusetts! I wondered who pried his closed door open!

"The argument against "boutique" medicine is that it creates a two-tiered system. I would argue that the US has had a multi-tiered system for many years, as does Great Britain, Germany, New Zealand, Denmark -- countries I have visited recently. Whenever the government, or insurors, limit care, a segment of society looks finds more. Instead of forcing mediocre primary care from the bottom up, why not force quality care from the top down?"

Tuesday, October 10, 2006

Community Health Centers

With all the focus on hospitals, it is easy to forget the important role of community health centers in the delivery of care, particularly in otherwise underserved urban and rural areas. BIDMC is affiliated with several community health centers in Eastern Massachusetts. Those centers provide primary care to their patients and refer them to our place if they need more advanced diagnoses or treatment. They are Bowdoin Street Health Center in Dorchester, Fenway Community Health, South Cove Community Health Center in Boston's Chinatown and in Quincy, Dimock Community Health Center in Roxbury, Joseph Smith Community Health Center in Brighton and Waltham, Sidney Borum Community Health Center in Boston, and Outer Cape Health Services in Provincetown and Welfleet.

Here is a wonderful story about UMMA Community Clinic in the poorest section of Los Angeles. They have a video at http://youtube.com/watch?v=kLiagBbSryY that is pretty inspirational.

If any of you have had great experiences at these community health centers or others, please post them. The staff at these places are extremely dedicated. Let's provide them some positive feedback and encouragement!

Monday, October 09, 2006

Electronic Medical Records

Partners Healthcare System had an ad in the Globe yesterday talking about the development of their Electronic Medical Records (EMR) System. They deserve credit for their progress on this important project. We have a similar effort underway in our hospital. As of this week, we have the same adoption of EMRs as Partners - 85% of our faculty are using electronic records in their practices. In addition, all of these doctors will be using ePrescribing (electronic delivery of accurate prescriptions to pharmacies) by the end of the year. Several dozen of our physicians have this available to them now.

But along with this good news comes a problem:

Twenty-seven percent (27%) of the patients who are seen at either BIDMC and Brigham and Women's Hospital are also seen at the other hospital. But if you have a blood test at BWH, and doctors at BIDMC want to view the results at your next visit at our place, the information is not available on their computers. Why is that? It is because our EMR system and the one run by Partners Health Care are not interoperable. Likewise, if you need to go to an emergency room in Worcester, but your primary care doctor is part of Partners primary care network or is one of our primary care affiliates, the ER there cannot get instantaneous electronic access to your medical history.

As we each make progress with our own systems, it would be great if we could also learn how to share data across systems. Interoperability is at an early state in the country because of the need for standards, privacy concerns, and lack of a consistent architecture. We look forward to working with our colleagues across the state to solve these problems.

Saturday, October 07, 2006

Religion and Union Organizing

Now, here is a very, very delicate issue, on which I would welcome comments. I apologize if it makes you uncomfortable, but it was an important moment, and I think it deserves exposure and debate.

Recently, a person affiliated with unions in Massachusetts (not the SEIU) said to me, "As one Jew to another, I would hate to think that you would be publicly taking the kind of position you have been taking on this SEIU matter." I was really stunned by this -- to think that this issue would be couched as a matter of religion, rather than being addressed on the merits. My response to him was, "As one Jew to another, I would like to think that you would be ashamed of me if I did not stand up to an undemocratic approach that undercut the rights of a group of people."

See the posting below on union activities for background on this issue, and then answer the question: What do you think? Was he out of line? Am I?

Friday, October 06, 2006

Have you read the Globe today?

Christopher Rowland, a reporter at the Boston Globe, has a story about my blog in today's paper. We had a nice talk about it a few days ago. Mr. Rowland, while an excellent reporter, left out a key quote as to why I started the blog: "It was to have a dialog with people about issues of importance without the interference of reporters and editors." :)

Seriously, I like the story . . . and, more importantly, I really do appreciate the difficulty for reporters and editors in making sense of complicated issues in health care. Isn't it interesting, though, that this blogging topic is newsworthy enough to be put in the newspaper? For hundreds of thousands of people, a blog is just a blog and no big deal, but as noted when I started this experiment, among CEOs it remains rare. Thanks to the Globe for printing the story. Maybe some of my colleagues will join in with their own blog, or at least reply to some of my postings: Hey guys and gals, you can do that anonymously, so you can say all those things you REALLY want to say, but where you don't want attribution . . . . :)

If you are just joining this site as a result of Mr. Rowland's story, please read on and write back.

Tuesday, October 03, 2006

Monique's book

October is breast cancer awareness month, designed to help people understand this disease, seek early diagnosis, and inform folks of advances in treatment. In recognition of that, I want to tell you about something that can be very helpful to you, a friend, or a loved one.

A couple of years ago, we published a wonderful book on the subject by Monique Doyle Spencer, which is designed to help people who have the disease understand and cope with many aspects of the treatment process. We published the book because it is funny, and commercial publishers felt that it was inappropriate to have a humorous book dealing with cancer. We thought it deserved public exposure. It is called, "The Courage Muscle, a chicken's guide to living with breast cancer." After my mother-in-law read it, she said, "I wish I had had this book to read during my treatment." Many others have said the same thing, and the book's reputation has spread by word of mouth and occasional newspaper columns and Monique's interviews on television and radio.

You can buy it from Amazon, but if you buy it from the hospital instead, the proceeds go to support Windows of Hope, our non-profit oncology shop that sells wigs, scarves, and other supplies for cancer patients. Just send a check for $16.95 to Windows of Hope, 330 Brookline Avenue, Boston, MA 02115, and we will mail you a copy. Or call 617-667-1899.