Friday, December 29, 2006

Happy New Year

Best wishes to all for a Happy New Year. My New Year's resolution is to take another week off from writing this blog. After five months of writing, several times per week, I realize that my addictive behavior extends beyond Blackberries! I am going to see if I can refrain for a few more days.

But I promise that I will be back . . . .

Friday, December 22, 2006

Merry Christmas

A note from Linda Myers, who runs Windows of Hope, our oncology support shop:

Windows of Hope just received a wonderful donation of handmade scarves for us to give away to cancer patients along with a lovely monetary donation. The scarves were made by the staff of Deaconess 4-inpatient psychiatry and the psych consult nurses as a way to support cancer patients.

A staff member wrote to Linda:

We have all had our lives touched by this illness either through personal experience or by the experience of loved ones or colleagues, and it was decided that the "pink scarf project" would be a nice way to be supportive, serve as a rememberance, and as a tribute to the survivors in our lives. It was great fun. Some of us perfected our knitting skills -- there was a healthy competition for the " most knit" by two nurses -- some of us learned to knit, with a few tears and dropped stitches, others had their mothers or their daughters do the project. A few contracted the job out and some who couldn't knit perfected their shopping skills or bought the scarves so a donation to Windows of Hope could be made. All in all, it was a rewarding experience. WE WISH YOU WARMTH AND PEACE AS THE PINK SCARF KEEPS YOU WARM.


This is such a nice sentiment that I think it deserves top billing on this blog for a few days. So, for that reason and as part of my continuing personal effort to avoid addictive behavior, I am going to take off a week or so off writing entries for this blog. I will still moderate comments, though, so please feel free to send them in.

Thursday, December 21, 2006

First, kill as few patients as possible

That was the name of a humorous book by Oscar London, but there is a serious side to the concept:

For years, Don Berwick and his colleagues at the Institute for Healthcare Improvement have been proselytizing and working to improve care in the nations' hospitals. They conduct important research and offer training programs for all types of hospitals, medical staff, and administrators. Recently, they have offered a metric that is the grandaddy of all metrics, the
hospital standardized mortality ratio. This is a disease and procedure based, risk-adjusted single number that tells you how you are doing in term of deaths compared to the average and compared to other hospitals. According to IHI, "the HSMR, appropriately adjusted for multiple variables such as population characteristics and diagnoses, provides an essential starting point in improving care and reducing mortality. "

In shorthand, for us lay people, the metric gives a sense of your likelihood to die at a specific hospital compared to other hospitals. If your hospital has a value of 1.0, it is average. If you have below 1.0, it is better than average. If you have above 1.0, it is worse than average. [Note: See correction to this statement in my comment below.] As with all metrics, you can quibble with the components and argue with the calculations, but it is as powerful a tool as I have seen. It is rapidly becoming the touchstone for many hospitals as they review their safety and quality programs.

IHI offers this tool to help people do better. It is not meant for advertising purposes or punitive purposes. As they note: "Many hospital deaths could be prevented if all the factors that contribute to them were better understood. Each hospital death provides an opportunity for learning -- by understanding and addressing local conditions that contribute to mortality."

We recently asked a group of outside experts from places with the strongest national programs to review BIDMC's progress in patient safety and quality. We received a good grade, but we also received a number of thoughtful and helpful suggestions for improvement. We have high aspirations. Our goal is to set audacious targets for improvement in overuse, underuse, misuse, and waste in the care of patients -- to set plans and milestones for doing so -- and to manage towards those targets.

Academic medical centers have a special responsibility in this regard, to create within the safety and quality program an academically rigorous examination of what works and what does not in various health care settings. I have given you a few examples in the postings below, entitled "What Works". But no single hospital has a monopoly on ideas when it comes to this field, and the first step is for all of us to disclose publicly how we are doing.

This HSMR number is not published anywhere unmasked by name, but if you contact IHI they will give you your own data, which is what we did. To relieve your suspense, 0urs is 0.71, which just puts us in the top ten percent in the nation. (Frankly, if a Harvard-affiliated academic medical center were not better than average, everyone would have a reason to wonder why.)

I wonder if my academic medical center colleagues in Boston and around the country would similarly be willing to post their HSMR number publicly on their own and to authorize IHI to maintain a publicly available list on their website. With a national debate swirling about the cost of care and value of academic medical centers, what would be more powerful than a grand display of openness about our progress in trying to kill fewer people?

Wednesday, December 20, 2006

The SEC is on the phone

Report today on one of those Blackberry sites:

Slide for RIM stock

Here's yesterday's numbers for BlackBerry-maker Research In Motion's stock price.
Nasdaq (RIMM)- $132.24 a share, a decline of $3.27 cents (-2.41%) from Monday's $135.51 a share close. Tuesday's volume of 8.823 million shares was a little higher than RIM's three-month 8.310 million share daily average traffic.

For the record, I did not sell short before posting the item below!

But maybe the person on The FASTForward Blog did . . .


Monday, December 18, 2006

Blackberry Cold Turkey

The most important attribute of email is the asynchronicity of the medium: The sender and the receiver do not have to be in contact at the same moment. This enables efficient communication. You can integrate emails into the fabric of your life. You originate a message when you want, and you reply to another's when you want.

Until the "revenge effect" occurs! How does this work? Email was invented. Then Blackberries were invented so we could be sure, when we are away from our computer, to receive emails as soon as they are sent and reply to them immediately. In fact, we feel compelled to read and respond in real time. Asynchronicity disappears.

Worse, manners disappear. We sit in meetings and, at best, try to look at our handheld screen without appearing to be distracted from the conversation. You have seen the maneuvers -- a casual glance towards the crotch where fingers are quickly at work -- a sudden excuse to go to the restroom -- a coughing fit so the person can turn away from the table and check the Blackberry. At worst, we just put the device on the conference table in front of our face and divest from the conference.

Worse still, relationships disappear. A couple sits side by side at an airport, each reading and writing email on their two machines. A child impatiently waits to talk to a parent while the driver hurriedly answers an email while stopped at a red light.

I write from experience. I was a "Crackberry" addict. As I look back and see how often I was rude or inattentive, I am embarrassed. As I look back and see how often I responded in haste to an email in the midst of other activities, I am appalled.

But, I have given it up. The impetus was when Cingular wrote in November to tell me that my bare bones Wireless Mobitex data service was going to be discontinued, but that I could "upgrade" to one with a higher price with more functionality, if I also bought a new Blackberry or Treo. I had until December 31 to make the switch: "All Mobitex devices on your account will be unable to send or receive messages after that date."

I read that sentence and had quite a different reaction from that hoped for by the Cingular marketing department. Gee, if service will end on December 31, why wait? Let's end it sooner. So, I did. I called that 800-number and shut 'er down that very day. Blackberry cold turkey.

I have since discovered marvelous things. The sun rises in the morning and sets at night. Airport lounges are great places to visit with friends or read a book. Red lights are an excellent excuse to stop driving, look around, and see what's happening on the streetscape. People in meetings pay more attention to you if you pay more attention to them. The email that arrived three hours ago is still relevant -- or better yet, no longer matters!

Sunday, December 17, 2006

What Works -- Part 4 -- Central Line Infections

Central line-related bloodstream infections are a serious problem in hospitals. A central line is a port installed directly into a major blood vessel to permit a catheter to be used for the quick delivery of medication for patients in ICUs and in other settings. Because of the direct connection to major blood flow, an infection associated with the installation will flow quickly into the blood stream and to major organs. This article from the Centers for Disease Control attributes a mortality rate of 12 to 25 percent (!) for each infection -- not to mention increasing costs by about $25,000.

The Institute for Healthcare Improvement likewise notes that "up to 4,000 catheterized ICU patients die each year in the US from avoidable infections and organ failure (sepsis) related to central venous catheters (CVCs). . . . Forty-eight percent of ICU patients in the US have central venous catheters, accounting for 15 million central-venous-catheter-days per year in ICUs. . . . Within this population, studies indicate an estimated 4% to 20% (500-4,000) of patients will die from catheter-related bloodstream infections."

Like others in the country, the medical leadership at BIDMC decided that our current rate of central-line infections was too high and set about to change it. When we started, our average rate of central line infections per thousand patient days in the ICUs was about 3. This was better than what we often see nationally, but our doctors were impatient to improve it. After all, each case has a high potential for serious patient injury or death. So the goal is to get to zero.

This turned out to be a multi-faceted problem. Central lines are often inserted by residents who have been trained how to do the insertion by other residents. (Dr. Atul Gawande provides a vivid description of this learning process in his book Complications: A Surgeon's Notes on an Imperfect Science.) Beyond the insertion process, decisions must be made about how long the line should stay in, and how often it should be maintained. Very often, there are only informal rules of thumb in a hospital for these determinations -- and there is often wide variation even within a single hospital.

Our folks set about to make this process more rigorous, analytical, and controlled. Sessions were held among surgeons, medical doctors, anaesthesiologists, nurses, and residents to reach a consensus on the proper method for inserting a central line. A specific kit was designed, so that anyone inserting a line had the full complement of supplies at hand. Detailed rules were established for the protocols surrounding maintenance of the line and its withdrawal. And, a system was set up so that every single infection that occurred would be analyzed to determine its cause -- so corrective measures would be taken going forward.

Here are the month-to-month results for the first year of the program:

Month ----- Infection Rate
Oct 05 ----- 1.67
Nov 05 ----- 1.28
Dec 05 ----- 2.43
Jan 06 ----- 3.07
Feb 06 ----- 1.40
Mar 06 ----- 1.07
Apr 06 ----- 0.00
May 06 ----- 0.59
Jun 06 ----- 1.15
Jul 06 ----- 0.57
Aug 06 ----- 3.03
Sep 06 ----- 2.50
Oct 06 ----- 0.00

As you can see, the figure goes up and down, although progress is good. The key thing is that every single case of infection is analyzed thoroughly, with the results shared across the broad range of hospital staff in the ICUs. What goes wrong? As many things as there are people. For example, one day, our chief of medicine happened to go by as another member of the staff was not following the protocol. When he pointed it out -- and none too gently! -- the person was embarrassed and really had no excuse for doing it wrong. So human nature often comes to play. Sometimes more technical factors arise. Regardless of the cause, each case is used to reinforce the program.

With about 1600 ICU patient days per month at BIDMC, the difference between an infection rate of 0.0 and one of, say, 2.5 is 4 actual people. Over the course of a year, that same difference amounts to 48 people who either get or do not get an infection. Applying the CDC's cited mortality rate of 12 to 25 percent, the difference amounts to saving the lives of 5 to 12 people -- just at our hospital.

When you look at numbers like those, you can see why our medical staff -- and people around the country -- are rabid about making this improvement real and permanent. Doctors and nurses devote their lives to alleviating human suffering caused by disease. They are heartbroken by the thought that their own well-intentioned actions might lead to death, and they are driven to get better and better at what they do.

Thursday, December 14, 2006

A holiday gift

I am posting an email sent by one of our doctors to his colleagues in our Ob/Gyn department this past week. (He said it would be all right.) I think it is beautifully written. 'nuf said:

Subject: Holiday Greeting

As we get closer to the beginning of the December holidays, I want to wish everyone a wonderful holiday season. I also want to take the opportunity to relay to everyone a personal experience that I recently had and how it helped me have a new perspective on my role as an Ob/Gyn. I hope not to offend anyone by what they may see as an inappropriate use of this e-mail forum, or may see this as a bit self indulgent. If you do, I take no offense, and feel free to click the delete button and move to your next e-mail. If you wish to read, continue on.

Some of you know that I attended a wedding this past weekend. Now, we have all been to weddings, some of us can even remember our own wedding. This one had the usual trimmings of outlandish outfits and outlandish behavior. And of course, it had the usual consumption of various types and quantities of libations. However, the wedding stands out as something special because of the emotional issues that the bride and groom brought together under the wedding canopy. The bride was widowed on 9/11. Her husband had been a passenger on one of the flights that was crashed into the Twin Towers. At the time, she was pregnant with her third child, and delivered that child the following spring here at BIDMC. Every time I have been in the presence of this women I have been truly amazed at how she has dealt with this incomprehensible tragic loss, and how since 9/11 she has created a warm and loving environment for her children. What she has done with her life since this loss goes beyond inspirational (see, but what she did this weekend is the ultimate goal a person can have when dealt with such a loss as hers. She and her new husband have brought love, happiness, and the thirst to enjoy life into her soul once again. I would imagine this would be my most difficult accomplishment if faced with a tragedy such as hers. At the wedding she talked openly about her loss, as well as her rediscovered love, and I feel blessed that I was able to be a witness to such a beautiful moment.

I thought about my own little meaningless personal battles that I have every day, and the battles we all face both in our professional and personal lives. The struggle to balance family and career, and trying to find ways to pay the bills. In our professional and personal lives, we all deal with loss on a daily basis- infertility, miscarriage, recurrent miscarriage, still births, birth defects, cancer, and the list goes on. We face many obstacles in our goal to keep a positive attitude -- angry patients, ungrateful patients, emotionally unstable patients, anxious patients, pissed off colleagues, depressed colleagues. It becomes too easy for us to become a scientist to our patients and not health care providers, keeping us emotional detached from ourselves as well as the needs of our patients.

But for some reason, we have chosen this profession, or maybe let the profession chose us. And this profession gives us a tremendous gift. The gift to give something of ourselves to other people. Each day we are given at least one moment to realize how lucky this gift is. Sometimes it is obvious such as when we get a good baby after a month in the hospital on bedrest, or sometimes small such as when a colleague or patient says a simple thank you. We have been given the gift of being able to help people through some of their most difficult, frightening, and tragic moments. We help them with our skills, our insight, and our kindness. And then we are given the bonus gift of being able to witness one their most joyous moments, the birth of their children. I have an opportunity each day to recognize the value I add to other peoples lives, and if I can recognize that value it can help me get through the rest of the crap I face on a daily basis. I can fill part of my soul with the joy people feel when I help them, and then incorporate that joy into my interactions with the world around me.

And so this is the gift I give to myself this holiday season. The gift to continue to enjoy the profession I have chosen for my life, and how valuable it is to those around me as well as to myself.

Tuesday, December 12, 2006

Western style sex and humor?

Here is a story from MSNBC about a restaurant in Arizona with waitresses dressed up as scantily clad nurses. One of our nurses mentioned it to me and expressed her feeling that this was not only demeaning to the women in the restaurant but also to nurses and the nursing profession.

The owner says, “If anything, I think it glorifies nurses to be thought of as a physically attractive and desirable individual. There’s a Faye Dunaway, Florence Nightingale hipness to it. Nobody wants to think of themselves as some old battle ax who changes bedpans for a living.”

It goes without saying that this kind of place would never survive in Boston or indeed anyplace east of Minneapolis. (I hope! Tell me if you think I am wrong.) Even accounting for the free spirit of the wild West, I am having trouble with this one. Beyond the obvious pornographic aspects, it is demeaning to the profession and the people in it. The guy's comments just add to the insult.

You don't buy that? Think about it this way. Some guy habituates this place and gets used to seeing "nurses" in this outfit and flirting with them. Later, he is in a hospital for real. Does anyone out there think that he will not look at and regard the hospital nurses in the same way?

Monday, December 11, 2006

Hip Fractures

This past weekend, the Boston Globe began running a three-part series examining the impact of hip fractures on the lives of elderly patients. The articles focus on the life-altering experience that this injury often proves to be, demonstrating its impact on patients and their families as well as on the health care system.

Over the course of the past 18 months, Globe reporter Alice Dembner and photographer Bill Greene followed a number of hip-fracture patients beginning with their admission to BIDMC, through their surgeries and hospitalization to their post-operative recovery in rehabilitation and nursing home settings, and finally, in their homes. (Of course, the patients and families gave permission to be followed in this way, and then written about.) Among the current BIDMC physicians participating in this long-range project were orthopedic surgeons Doug Ayres and Edward Rodriguez and gerontologists Suzanne Salamon and Katy Agarwal.

The series began on Sunday, Dec. 10 and appeared both in print and on the Globe’s website, (where extra features are available.) As part of the project, Dr. Salamon will also participate in an online "web chat" Tuesday, Dec. 12 from noon to 1 p.m. This web session is expected to kick off a new Globe/ weekly feature entitled "Ask the Doc." Here are the links to Part I and Part II and the sidebar features associated with the main stories.

I think you will agree that this is a powerful set of stories, laying raw human emotions in front of all us to see. Congratulations to the Globe for allocating the resources to this project and to the reporter and photographer for presenting it in an incredibly thoughtful and sensitive way.

The Real Beth Israel

Please be sure to read the second comment under my posting "All are above average," below.

Saturday, December 09, 2006

More Links

I have added links to two other health care blogs (on the right), one called Kevin M.D. and the other called Med Chatter. There are a gazillion blogs in this field, and I am trying to be selective about those I suggest to you. I have included those that I have found to be thoughtfullly written, up-to-date, and helpful. Please visit and see if you agree -- but please don't forget to come back. :)

I heard a presentation yesterday where someone mentioned how many blogs per day are being created. The number apparently doubles every six months or so, several thousand each hour. It is impossible to keep up with the 50 million+ sites.

Those more expert than I could offer perspectives on all of this. When you get to 50 million blogs, is this just a lot of noise out there? Is this just an ephemeral posting and scanning of news items and observations? Or is it really the thoughtful engagement of millions of people per day? Television stations now design their news stories to catch the attention of viewers within the first seven seconds. Do blogs do any better? Does it matter?

Are we all better informed, or do we just have the feeling that we are? Is it more democratic? Certainly so on its face -- but don't wealthy and powerful corporations, unions, interest groups, and politicians have more resources to devote to this medium than individuals? Can't they cleverly boost the "ratings" of their blogs while giving the impression of just being like the rest of us? We know that they all create not just one blog to push their agenda, but many different ones to appeal to different population segments. We know, too, that they use "fronts" in which their names and agendas are not immediately evident. We know, too, that they have staff and money to enhance designs and messaging and post supportive comments and create momentum for their causes.

Over the centuries, those with power have always figured out how to maintain it, and those temporarily out of power have always figured out how to get it back. Are political and economic cycles essentially immutable, or do we think the blogosphere has changed that?

Friday, December 08, 2006

All are above average

BIDMC doctors and nurses help women deliver 5000 babies per year. I like to joke with parents that all of our babies are above average and that we offer an SAT guarantee: If the kid's college entrance exam score is below average, the parents should find me for a complete refund.

The Globe reported, though, on a particular case that made even us take notice. I have total confidence that this girl will be at the top of her class!

Welcome to the Club, John

The Massachusetts Eye and Ear Infirmary, one of the nation's preeminent research and clinical centers in that field, has designated a new CEO. His name is John Fernandez, and he comes to MEEI after a distinguished administrative record at Brigham and Women's Hospital and elsewhere. Here's more about him from a story in today's Boston Globe.

Welcome to the Harvard-affiliated-academic-medical-center CEO club, John! We all wish you well.

(I've sent John instructions on how to set up a blog, but he says he might be too busy for a while . . . .)

Thursday, December 07, 2006

What Works -- Part 3 -- New GI Therapy

A number of people suffer from GERD (gastroesophageal reflux disease), aka acid reflux from the stomach that rises into the esophagus and creates heartburn. We all see lots of ads on television for purple pills and other medications that are designed to help with this problem. Those work for some people, but for others the problem is not alleviated through medication.

Some of our doctors have been using an alternative technique, called endoluminal therapy. The technique is to reach down into the esophagus with a device that pulls up some of the tissue at the boundary of the stomach and the esophagus and clips those tissues together to strengthen the sphincter. The procedure takes 10 to 15 minutes.

The results have been very good. A large percentage of patients have been able to get off medication or reduce their dosages considerably, and the holding power of the therapy also looks positive, with consistent results many months after the procedure.

I think this is an interesting example of how clinicians in academic medical centers often look beyond current therapies and conduct research and try out new ideas that hold promise for patients.

In making this post, I also want to disclose that one or more of the BIDMC doctors have been involved in the development of some of the technology that is used for this procedure and hold equity positions in one or another company than produces them. That, too, is a practice in academic medical centers that is authorized under various federal regulations as a way of moving conceptual ideas into the marketplace. Doctors in the Harvard system have a strict conflict of interest policy to which they must adhere when engaged in these kinds of activities.

Wednesday, December 06, 2006

A modest proposal

Yesterday, I learned of a program being run by Aetna that prompted me to think differently about the medical records issue. While there is a general belief that interoperability of electronic medical records among health care providers would be of great value to society, there are obstacles to that process that keep arising. Some of these are technical, some are based on privacy concerns, and some are based on corporate decisions to protect information to maintain market share. Here, from Aetna, is an approach that might suffice to skirt many of these issues and enable consumers to send information to whatever providers they would like.

Aetna has created a personal health record -- using the claims information it receives from providers -- that is placed on a secure website and is made available to its subscribers. So, for example, it will show your test results, inoculations, allergies, surgical procedures, hospital stays, chronic illness treatment patterns, and the like. Not only can a subscriber review information about his or her medical histories, but he or she can also authorize any provider to look at it as well.

Think about this. An Aetna subscriber does not need Hospital A to share its medical records with Hospital B: The subscriber can authorize this without an intermediary. Whether the patient has shown up at an out-of-town emergency room or just wants to visit a doctor or hospital in another provider network, the feature is instantaneously available.

I know this is not a complete medical record, but it contains enough information to be helpful in many cases.

Why can't we do this in Massachusetts? It could start with Blue Cross/Blue Shield, the largest insurer in the state, acting alone. Or imagine the power if BCBS, Harvard Pilgrim, and Tufts were all to create this program as a shared venture, but with a firewall between their systems so that data stayed with the subscriber's current insurer. If the underlying platform were the same, the subscriber's data could easily be transferred if an employer or the individual subscriber changed insurers.

I think this is an elegant solution that could help cut the Gordian knot of the interoperability problem. If we can solve 80% of the problem with a quick fix like this, it might be more valuable than waiting a decade to solve 100% of the problem. Maybe those of you out there who are more expert can tell me why I am wrong.

(By the way, Aetna also uses this information to conduct an evidence-based medicine review for patients with chronic problems to help reduce underuse and overuse of medical services. For example, if a diabetic patient is not keeping up with a treatment regime, the patient's primary care doctor is notified by Aetna's medical consultants to contact the patient. Sharing of this data is authorized by the patient when he or she becomes an Aetna subscriber.)

Cardiac Results

The state of Massachusetts announced yesterday that it is going to publish mortality rates, by individual heart surgeons, on a public webiste. Here is the story in today's Boston Globe on the topic.

This is good, but I wonder again (as I have below), why the data can't be more current. Here's what I said on October 16, 2006:

... [T]he 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.

Also, to persist with one of my favorite topics, why doesn't the website include results from solid organ transplants? These are easily counted and reported. Wouldn't you want to know these figures if you needed a new liver or kidney?

By the way, I have a feeling that Bill Clinton -- after he reads the MA cardiac surgery mortality rates -- will wonder if he should have had his heart surgery in this state rather than in NYC!

Sunday, December 03, 2006

When is death?

A story in today's Globe about a current case at our hospital provides a thoughtful and balanced description of the legal, moral, and social dilemma that can be faced by hospitals, nursing homes, and other providers at the end of life. I'll let the reporter's accounting stand for itself, and I would welcome comments from those of you out there who have opinions on the issue.

Saturday, December 02, 2006

Doctors, researchers, med students: Check this site

Here's a relatively new site called Healtheva, which is a kind of Myspace for physicians, researchers, residents, interns, and medical students. If you are one of those, I recommend you take a look.

Friday, December 01, 2006

December 1 and Prepping for the PMC!

I just returned from a 20-mile bike ride starting at 4am in balmy 63 degree (!!) New England weather. Who would have thought that I could be training for the Pan Mass Challenge at this time of year?

The PMC is the world's largest athletic fundraising event. This year 4300 cyclists raised $26 million for cancer research and treatment at the Dana Farber Cancer Institute. (You see a small portion of them in this picture.)

A group of us from BIDMC participate in the ride. One of our nurses, Marybeth, has ridden for 24 years of the 27 years of the ride's existence. We do this even though we compete in some arenas against DFCI -- because there is enough work to be done in cancer research that it will take lots of people working together to solve this problem. Indeed, BIDMC is part of the Dana Farber/Harvard Cancer Center, which comprises 7 Harvard institutions and over 900 scientists working on this disease.

Something (the calendar) tells me, though, that my chances for lots more early morning training sessions are about to disappear!