Clustrmap

Check the very, very bottom of this blog for a new feature, recommended by my friend Glen. You stick in on your blog, and it shows where people have come from in the world, with circles proportional to the number of visitors. You can get it free at http://www.clustrmaps.com/. Click the map, and it will show you an expanded version.

(What's the revenue model? It cleverly posts ads for websites related to the topic of your blog.)

While it collects circles over the next few days, I am taking a writing break in honor of Independence Day. Please continue to submit comments, but I may be a bit slower about posting them for several days.

[Addendum on July 31. I have disconnected this link. After a while, it really doesn't show much new.]

Minor deities?

An anonymous commenter below notes:

It's interesting; there is a repeated strong undercurrent of resentment of physicians in these comments and in a lot of healthcare blogs I read.

I had already been thinking about this topic. I am reminded in some ways about how people feel about legislators. "I love my legislator, but I hate Congress." I sometimes see a similar attitude about doctors. "I love my primary care doctor, but I hate doctors in general." What's going on here?

Joke #1: What does MD stand for? Answer: Minor deity.
Joke #2: Why can't a nun be a good nurse? Answer: Because she has been taught to serve only one God.

Jokes often reflect societal stereotypes, and doctor jokes are no exception. Why do so many doctor jokes make this kind of reference? Well, in part, it is because doctors make the kind of life and death decisions that are closely related to people's view of a divine power. Doctors can quite literally bring us back from death. We admire that, but unlike our attitude towards divinity in the theological context, we also resent it.

Joke #3: A man dies and goes to heaven and is patiently waiting in line at the Pearly Gates with other recent arrivals. A man in a white coat impatiently pushes his way through to the front of the line. "Who's that?" asks the new arrival of an angel standing by. The angel replies, "Oh, that's just God. He thinks he's a doctor."

People also believe that doctors often have poor interpersonal skills, don't want to be bothered with spending time with patients, and are arrogant and impatient. This belief is compounded when the insurance reimbursement environment puts pressure on doctors to deliver service in a rushed manner. The patients attribute the brusque behavior to the MDs themselves.

Joke #4: The first Jewish president is elected and is on the podium about to be sworn in. His mother nudges the person next to her and says, "You see the man up there with his hand raised? His brother is a doctor."

And yet, almost every parent would love to see a son or daughter become a doctor. It is as highly valued a career as one could imagine, and it brings great pride to the family.

All of this suggests a tremendous ambivalence about the profession and those in it. It's really not that surprising. It is inherent in any position of power and influence and prominence and perceived wealth. We admire our political, commercial, and sports heroes but also are quick to call them bums and crooks when they don't meet the standards we have set for them. We should expect some of that reaction in the highly personal field of medicine, especially since our interaction with a doctor is likely to occur when we are most vulnerable.

When I new to health care and was being interviewed to be Administrative Dean of Harvard Medical School in 1998, I asked Dean Joseph Martin a question that reflected my own ambivalence at that time, and the resentment noted by the anonymous commenter: "Do doctors still care?" He assured me that the new crop of medical students at HMS each year was as idealistic and caring as ever, and that the people I would meet at HMS and the hospitals in Boston were likewise extremely dedicated. I have absolutely found that to be the case.

No doubt we will continue to tell doctor jokes, but I hope we can also acknowledge that the men and women who have trained for this profession and who practice it are as well intentioned as we could ever want. Sure, there will be personality quirks and occasional bad behavior, as there will be in any group of people, but there is also a level of dedication and commitment that is extraordinary.

The anonymous commenter goes further, though, and says:

And yet when I read posts in Sermo (the physicians' only website), there is a strong undercurrent of discouragement and even despair with the profession they have chosen. No one is happy on any side.

I see this, too. Much of this stems from the reimbursement environment, in which doctors feel that their professional judgments are overridden by faceless bureaucrats in insurance companies and at Medicare, or by (ahem!) ignorant hospital administrators. They fear malpractice suits, too. So they practice defensive medicine, knowing certain tests and approaches are not warranted, but feeling pressured to inoculate themselves against patient complaints and lawsuits.

And truthfully, they (particularly the older ones) may have been trained in medical school and afterwards in ways that do not reflect the social, political, and financial environment in which they practice. They have been rewarded during their professional advancement for attributes that may not be helpful for coping with the current environment. And, finally, they face an ever more knowledgeable and (perhaps entitled) public that is not so willing to be forgiving of mistakes or tolerant of ambiguity in diagnoses and treatments.

I do not pretend to have an answer to this set of problems. I would like to think that society will value doctors commensurate with their dedication, skills, experience, ability, and commitment to our well being. But this will take movement and good intentions and also understanding, empathy, and forgiveness on both sides of the relationship.

For students -- Too menial for you?

Tristan asks below:

Now that I am in college, I have been looking to obtain some medical related experience through volunteer work. I have tried the volunteer programs at some Boston hospitals, but I did not find them to be meaningful. They would generally consist of pushing patients around. I feel this is much less helpful than serving people in a soup kitchen or homeless shelter. Moreover, the volunteer sheet would often be filled months in advance, so it was as if me being there did not help anybody at all because many others were clamoring for the precious volunteer hours. The supply vastly exceeded demand. Overall, the activity seemed to be just designed to be put on a piece of paper or medical school application instead of being a program that really helped people.

Do you have any recommendations for volunteer activities which provide medical experience and help people in a meaningful way in the Boston area, and which are accessible by public transportation for us poor undergraduates?

I want to answer this is in a kind and gentle way, but here's the best I can do: Tristan, your definition of meaningful is a bit elitist. But let's just attribute it to a lack of understanding. Let me try to explain with the very example you cited.

Let's talk about "pushing people around." The people who push people around in a hospital are not only performing an important job, i.e., delivering bedridden or wheelchair-dependent patients to test, appointments, or other activities -- but the way they do the job is extremely important to the patient's experience. Their approach and demeanor can make the difference between a patient's feeling relaxed, comfortable, and welcome in a hospital and feeling like a slab of meat being delivered to the corner deli.

In our hospital, a gentleman named Chris who works as a transporter not only is friendly, polite, and helpful to his clients, but he actually sings to them while they are in transit. (He has a lovely, soft voice.) So, imagine you are tired, anxious, and upset and Chris is lovingly transporting you for an X-ray or other test. As you lie there in bed, you hear beautiful music wafting over you. You can't help but feel welcomed and comfortable and less anxious.

Tristan, there is human drama every moment in a hospital, thousands of times per day. Our job is to alleviate human suffering caused by disease. There is not one post in a hospital that is not meaningful in pursuit of that goal. You just have to look a bit deeper and find the meaning.

Also, there is meaning in the relationships you create with employees and other volunteers. Learn what they do and how they do it; learn about their backgrounds and their families; and learn how they express the values of the institution in their work every day. Even if the actual work you are doing is a bit tedious, the relationships you establish will teach you plenty.

As to your last question, every hospital in Boston is on a transit line, so access is not a problem. And there is no surplus of volunteers, regardless of what a signup sheet on a college bulletin board might show. Call up the volunteer services office in any hospital, talk to them, and I guarantee you will find something to do.

By the way, my first volunteer job was pushing patients in beds and wheelchairs in a hospital in New York City when I was in high school!

A medical student grows and learns

Harvard medical students in training at BIDMC are asked to keep a journal about aspects of their training. This excerpt from one, who had a clerkship with our bariatric surgery group, is indicative of the type of transition that occurs as they follow a patient over an extended period of time and learn about the progression of his or her medical condition.


Before
Like most people, I think that obesity is a lifestyle issue -- it is a reflection of our society with gluttony of unhealthy food and paucity of exercise. And like most people, I feel uneasy about "fixing" obesity by reducing the size of the stomach to give the "artificial" feeling of safety and/or to curb the caloric intake by shortening the length of the digested food transit. Is this an appropriate and responsible medical approach? Is obesity a condition indicating for surgical procedure? What kind of people would allow, or even demand, to have one's body altered in such unnatural ways to escape from obesity?

After
Having spent almost one year with my patient, I am beginning to realize some answers.... Health care for obese patients has been hindered by the traditional misconception that weight is not a physiologically regulated variable, but rather determined by gluttonous food habits and hedonistic desires. Indeed, much of our US population considers morbidly obese individuals weak-willed, awkward, self-indulgent, and immoral. This prejudice cuts across age, sex, religion, and socioeconomic status, and often precipitates psychological distress in the obese. [Citing recent studies:] Of the weight loss treatment options presented, extensive research has shown that such options alone have not effectively achieved medically significant sustained weight loss in morbidly obese patients. Even combined with pharmacotherapy, results have been less than promising.....

In contrast to the disappointing results for non-operative treatments for obesity, bariatric surgery was presented as a much more effective alternative.... Surgery effectively "reset" energy equilibrium and defeated the powerful mechanisms for defense against starvation that are inappropriately overactive in obesity. Patients experienced decreased appetite, increased energy expenditure, and a decreased stress response after undergoing surgical intervention, while patients on weight loss diets experienced just the opposite.

[After many conversations with the patient:] Through rich, candid narrative, Z has taught me to relinquish assumptions, to empathize, and above all, to never forget to listen to my patients so that I can offer them what they really need.

Misplaced Priorities

"There is no more urgent issue than this for the AMA".

What could it be?

Childhood nutrition and vaccinations?

Reducing obesity in society?

Making immediate treatment of stroke accessible to all?

Improving reimbursement rates for primary care doctors, psychiatrists, and other cognitive specialties?

Working to reduce medical errors?

No. Here's the context, from the Chicago Tribune story, AMA takes on retail clinics -- Doctors groups say patients in danger:

"The American Medical Association should call for a ban on in-store clinics being opened by retail giants like Wal-Mart Stores Inc. and Walgreen Co., several doctors groups urged at the AMA's annual meeting in Chicago on Sunday."

"Faced with an onslaught of competition that is forecast to bring several thousand retail health clinics to U.S. consumers, AMA members testified that such clinics are endangering patient care, particularly for children. The doctors say the clinics, largely staffed by advanced-degree nurses and physicians' assistants, are largely unregulated and, therefore, put patients' health at risk."

" 'There is no more urgent issue than this for the AMA,' Dr. Kamran Hashemi, a family physician from South Barrington, said, urging the organization to push for more regulation of retail clinics. 'This issue speaks to what all of us do every day in practice.' If the AMA does nothing, Hashemi said, 'in five years, the chairs [at the AMA] meeting will be filled with representatives from Walgreens, Wal-Mart' and other retail outlets."

I can't tell you how reassured I am to learn that our physician groups in Massachusetts are not out of the mainstream . . . .

Uh oh, we're making it TOO nice!

Note from a friend whose spouse was in for day surgery:

This is the best waiting room. I have wireless access, a quiet table to work at with an outlet next to it, coffee shop downstairs, and a harpist just started playing. I'd work from here anytime.

Primary Source

My friend Barbra Rabson sends this note. Check it out. A nicely designed and informative website, where you can search through doctors' groups in different ways.

MA Health Quality Partners today released its most recent Quality Insights Report on Clinical Quality in Primary Care on the MHQP website. The report includes 17 clinical quality measures on the treatment of chronic diseases including asthma and diabetes, and preventive care services such as cancer screening and well child visits for approximately 150 medical groups across Massachusetts.

The technical appendix contains detail about the data included:

The clinical performance measures contained in this report are drawn from the HEDIS® Measure Set developed by the National Committee for Quality Assurance (NCQA), a private, non-profit, accrediting organization. NCQA requires that these measures must be independently audited by an NCQA-accredited auditing agency according to standard auditing specifications. All of the health plans that submitted the HEDIS® 2006 measures [My note: This is 2005 data] contained in this report had successfully completed the NCQA-mandated audits for each measurement year.

High NOTES

The June 9 edition of The Economist contains an article on NOTES -- natural-orifice translumenal endosurgery. "Rather than operating on the abdomen by making incisions in the skin, it involves passing flexible instruments through the body's orifices and reentering the abdomen from the inside" (e.g., through a hole in the stomach). The article states that the potential benefits go well beyond not leaving a scar, including reducing the risk of post-operative infection and avoiding a general anaesthetic. Also, post-operative pain would be reduced because the stomach wall has relatively few pain receptors, so shorter recovery periods are possible.

Because entry would likely be through one hole, as opposed to several holes employed in external laparoscopic surgery, new techniques and equipment will be required for NOTES. This is stimulating a lot of inventiveness and new patents.

The trick, of course, will be to develop this clever approach to surgery in a way that achieves the hoped-for medical results without incorporating yet another increase in costs for our health care system.

Maybe the big national insurance companies should volunteer to be joint-venture partners with the surgical companies to help make sure both goals are met. That would end this story on a high note indeed.

Defining Service

Now, this is customer service! Several of my staff have already volunteered to go to Bangkok for training.

More on storefront clinics

Several weeks ago, I wrote in support of the establishment of storefront clinics in the state. That post generated a lot of back-and-forth and good discussion. I recognize and respect the full set of views. It is an interesting public policy question.

Since then, the state DPH has held a hearing on the matter and also received lots of comments. Most recently, a letter was sent in from several groups outlining their list of suggested requirements for these clinics. The signers included representatives from the MA Medical Society, the MA Academy of Family Physicians, the MA Chapter of American Academy of Pediatrics, the MA League of Community Health Centers, and MA Hospital Association.

I hold no brief for the applicant -- other than joining with lots of friends and neighbors who this is a good idea for the public -- but I have to think that many requirements the opponents would seek to impose on the clinics would make them uneconomical or impractical. The letter writers would surely state that their only interest is insuring the public health. But the nature of the comments suggests more than that -- that the protectionist view I thought would come to the fore has indeed done just that.

I can't go through the whole letter here, but here is a sample comment.

"There is also large concern about the mix of patients that the MinuteClinic will take and the impact on the health care system as a whole. While the representatives indicated an intent to care for all patients regardless of their ability to pay, there is no indication that they will be established in an area with public transportation or a concentration of indigent patients. The Department should also strongly review the referral patterns and payer mix of these stores to ensure that if they have a full clinic license they will have the capacity to respond to the needs of all walk-in patients from the community and not just those that generate low risk and complexity visits."

Heads, we win. Tails, you lose. Previously, some commenters were worried about the effect of the clinics on the community health centers, which are often located in areas with public transportation and a concentration of indigent patients. Now, with the applicant avoiding those areas and focusing on the suburbs, they are essentially criticized for not competing with the health centers.

And what is a "referral pattern" for a walk-in clinic in a drug store? And how would you review such a pattern for clinics that do not yet exist? Would you look at who recommended that people buy their shampoo at this drug store? Or which doctors submitted prescription orders?

And, why should the clinics have the capacity to respond to the needs of all walk-in patients, when they are designed specifically not to do that? They made clear that they would quickly and helpfully make referrals to emergency rooms and doctors when they were presented with medical problems beyond their capability.

In summary, these clinics have worked in other states. Why are my colleagues so averse to letting Massachusetts give them a try, too?

[Disclosure: I recently was asked to join the Board of the MHA, but I was not involved in the decision of MHA to participate in this letter nor in its decision to take the position it has on this issue.]

How we manage

I often get questions as to how we manage this place. I usually jokingly reply that we don't manage, we cope. But we really do try to have a close alignment between the medical and administrative staff in support of the overall goals that are adopted each year by our Board of Directors. Those goals, in turn, are guided by our overall mission and informed by the strategic plans that have been approved by the board for clinical care, research, and education.

I thought you might like to see excerpts of this year's annual operating plan to get a sense of what it contains. Those of you who have been reading this blog for a while will not be surprised by some of the items included. There are three main categories -- improvement in clinical results and patient safety; improvement in patient satisfaction; and improvement in the organization's financial results.

Please remember that I am not presenting the complete document. Also, things arise during the year that can cause a change in plans. But this does present an example of the kinds of issues that attract managerial attention at an academic medical center like ours. The plan is based on analysis and conversations among people in all parts of the medical center. To that extent it is "bottom-up." But then it is formally adopted by the senior managerial and clinical leadership and then by the Board of Directors and becomes a "top-down" document against all are held accountable. Of course, it is widely shared with the staff by being available on the hospital's website and in meetings with people throughout the organization.

Fiscal Year ’07 Annual Operating Plan

Each year our budget and related annual operating plan offer new challenges and opportunities for success, and this is especially true of fiscal 07. While our ‘07 AOP is built around the three key areas of quality, satisfaction and financial performance as in prior years, you will note a slight shift in emphasis reflecting the challenges in this year’s budget.

This year there is an increased emphasis in implementing a more rigorous approach to improving productivity, managing clinical resources, and developing clinical pathways and in monitoring and measuring the success of these efforts. Many of you will be asked to participate in these efforts, and we appreciate your support.

We remain committed to and focused on clinical quality and patient safety and satisfaction, as they remain the primary elements defining our institution and its role in the medical community. We have achieved major progress in our quality of care and patient safety and have developed a track record of innovation in these areas. We have likewise seen continuous improvement in our satisfaction scores. In addition, we have been successful in developing programs that support the growth and career development of our employees. In ’07, our goal is to hold these gains and selectively build on the successes in these areas.

As always, this plan is supported by detailed and specific tactics and measures that will ensure our ability to be successful and measure our progress. We will periodically provide updates on these more specific actions to our Board, physicians and staff. We ask for your support and welcome suggestions on how to achieve these goals in FY’07.

Goal 1: Promote Continuous Excellence in Clinical Quality and Patient Safety

a. Achieve the goals in our annual quality and safety plan adopted by the MEC [The faculty's Medical Executive Committee] and PCAC [The Board's Patient Care Assessment Committee], including:
1. Implementing programs for patient safety, environmental safety, and emergency/disaster preparedness that ensures BIDMC’s readiness for JCAHO survey;
2. Achieving top 10% ranking in all the JCAHO/CMS quality indicators;
3. Achieving target performance in hand hygiene in 80% of critical care units and demonstrated improvement in 80% of inpatient units;
4. Achieving further improvement beyond 2006 rate in ICU central line associated bloodstream infection rate and best practice standards for VAP prevention;
5. Achieving influenza immunization rate of 60% of direct care providers.

b. Full implementation of key IS projects in patient identification, OR specimen tracking, and POE [computerized provider order entry] for ambulatory chemotherapy patients.

c. Continue to develop coverage plans and facility plans to meet patient needs and accommodate volume growth.

d. Expand the roll out of the clinical trials patient registration tool to two additional high volume departments/divisions.

e. Develop and implement patient safety initiatives in the Shapiro Simulation and Skills Center including training in the placement of central venous lines and in triggers/crisis management.

f. Achieve higher rates of donor conversion and organs/donor than the national goals for organ donation.

Goal 2: Ensure Outstanding Patient, Physician, and Employee Satisfaction and Loyalty

a. Achieve 95th percentile for patient satisfaction in inpatient, ambulatory surgery, and ambulatory visits and 90th percentile for the emergency department.

b. Complete the roll out of customer satisfaction training and job reclassification in all patient care areas.

c. Implement key recommendations from Referring Physician Survey including formal outreach to first time referrers and identifying selected enhancements to discharge fax for referring physicians.

d. Develop and implement a plan for assessment of core residency program performance in attracting and training residents.

e. Continue to foster open communication between employees and management through Town Halls, Executive Walk Rounds, and Management Roundtables.

f. Create and implement programs to recruit and retain an outstanding and diverse workforce including competitive benefits and compensation programs, career development programs, and leadership development programs to enhance the strength and capabilities of our managers.

Goal 3: Sustain Financial Strength through achievement of our inpatient and outpatient volume goals and increased focused on productivity targets

a. Achieve 3% operating margin

b. Support growth to achieve budgeted inpatient and ambulatory volumes.

c. Completing the Facility Master Plan and developing list of recommended multi-year facility actions required to ensure adequate capacity for ambulatory visits, surgical cases, and inpatient admissions.

d. Achieve significant productivity improvements required to reach the 07 budgeted cost/case and cost/visit and to prepare for FY08 budget by:
1. Implementing LEAN initiatives in 5 key areas with a focus on reducing costs and enhancing revenue;
2. Strengthening clinical resource management around high cost services in the OR and procedural areas;
3. Developing clinical pathways in partnership with physician program leaders to reduce variability in high volume/high cost DRG’s;
4. Continuing to identify and carry out projects to reduce energy utilization.

For Students -- Doing the Right Thing

A curious undergraduate asks below,

Dear Wise elders,

In trying to decide on a career path, I am always struggling with the question of "doing the right thing".

As people in leadership positions, which I think many of the readers here are.... What does it mean to be doing the right thing for your profession/industry/work? I know it's a big question... any thoughts or guidance is greatly appreciated.

I assume the question is not about what specific profession to enter. This is more a question about what ethical, moral, or leadership decisions you make in your professional life. I think the answer is pretty simple: Don't do anything you wouldn't want to explain to your mother. Or to put it more positively, do the things that would make your mother proud.

I am not being facetious or simplistic.

Errors of Misperception

OK, back to hospitals (you will be happy to know!) One of our surgeons recently gave me an article about types of errors made in surgery, with particular attention to bile duct injuries that occur during laparoscopic removal of gall bladders (cholecystectomies).

I don't think the article is generally available to the public. It is from the Annals of Surgery, Volume 237, Number 4, pages 460-469 and is entitled "Causes and Prevention of Laparoscopic Bile Duct Injuries". I quote the conclusions:

These data show that errors leading to laparoscopic bile duct injuries stem principally from misperception, not errors of skill, knowledge, or judgment. The misperception was so compelling that in most cases the surgeon did not recognize a problem. Even when irregularities were identified, corrective feedback did not occur, which is characteristic of human thinking under firmly held assumptions. These findings illustrate the complexity of human error in surgery while simultaneously providing insights. They demonstrate that automatically attributing technical complications to behavioral factors that rely on the assumption of control is likely to be wrong. Finally, this study shows that there are only a few points within laparoscopic cholecstectomy where the complication-causing errors occur, which suggest that focused training to heighten vigilance might be able to decrease the incidence of bile duct injury.

I don't know about you, but I think this is really fascinating. The article explains:

Mental procedures that solve problems by making use of uncertain, probabilistic information are called heuristic processes. Heuristics are normal, unconscious decision-making algorithms that work quickly and relatively effectively, but they do not always provide correct solutions. Visual perception is one example. The visual system implicitly makes plausible assumptions about the environment as it analyzes the imaging information being processed on its way towards the conscious mind. Because the assumptions are simplifications, visual perception provides an estimate of reality, not a replica.

...[I]nnate neurophysiological assumptions governing heuristic perception make the process vulnerable to the creation of false images. Our conscious minds are at the mercy of the subconscious heuristics. ....[P]erception of form can be faulty and beyond the individual's knowledge or control. This is central to the mechanism of bile duct injuries.

Think about this. We cannot be satisfied with avoiding only errors of skill, knowledge, and judgment -- arguably where we spend most time in surgical training. We need to understand enough about neurophysiology to devise mechanisms to avoid errors of misperception, as well. A powerful addition to the quality and safety agenda.

W(h)ither the Globe?

Another dangerous post, in that I am commenting on someone else's industry, but we all have an interest in the topic. It is no secret that the Boston Globe has been facing financial problems not atypical of many newspapers in the major markets. A steady fall in advertising revenues has resulted in a steady shrinkage in bureaus, reporters, and local coverage and more and more reliance on wire service stories. The decline of the "newspaper of record" function means that very important civic events and local stories go without sufficient coverage. Those of us involved in important local non-profit and business activities, community boards, and civic affairs fear that the participation of an informed and knowledgeable public will be diminished as the Globe itself is diminished.

The paper has responded by publishing an on-line version, but it does not generate the revenue of the old newsprint editions. They, like others, are searching mightily for the financial model that might work. There has to be substantial pressure from the owners, the New York Times, for improvement in results. This is ironic, in that the Times is a competitor, too. Indeed, as the Globe reduces its coverage of significant stories, the Times is viewed by many as the replacement paper to read.

Dan Kennedy, one of our wise media analysts, wrote an article in the Spring 2007 edition of Commonwealth magazine suggesting that a new ownership model, based on nonprofit ownership, might help ensure survival of daily newspapers like the Globe. Could be. As always, a very thoughtful analysis by Dan. But I do not see that happening soon, and even if it did, much of the underlying problem would still exist.

I certainly don't have a full answer, but let me set forth a theme: community engagement. Whether in the print or online version, the local newspaper has to be considered sufficiently relevant to people's lives that they look at it at least once a day and preferably more often. Beyond these "eyes", though, they need "clicks". Advertisers, who will continue to be the main source of revenue, have now been trained to be able to measure the precise value of their advertising investments by looking at click and purchase decisions resulting from specific ad placements.

How to do it. First, upgrade the server! As I have learned on this blog, unless people have the opportunity to comment an online forum, they will not become engaged and return to your site. It is not that they always submit a comment -- it is that they have the opportunity to do so. If the Globe's online columns and blogs do not permit comments because they do not have the technical capacity for doing so, and if you can't change the server in the next month, lease one from someone else and move your online version over there.

Second, take chances. The Wall Street Journal's blogs are self-moderating. You mean no one edits the submissions before they are posted? Right. Why? Because it means that my comments are exposed to the world immediately. The readers get immediate gratification and are stimulated to participate more. (Bad behavior is reported to the editor and then cleaned away.)

Third, work around the clock. The blogosphere does not follow a 9-to-5 Monday-to-Friday work day in Boston. Bostonians travel and live around the world and check their computers in the middle of the night and on the weekends. So, provide new content at all times to keep your sites fresh and interesting.

Integrate reader participation into your print edition. BostonNow had a concept for doing this, which is more or less successful. But it could work for the Globe like no one else. I'll explain in a minute, but first we have to recognize that it would mean reader participation in the hallowed halls of edited journalism. I am talking a significant expansion beyond letters to the editor and op-ed columns (not quite a wiki, but that is a topic for another day.)

So, let's say that one or more pages of the Globe daily edition (and of course, the online version, too) were devoted to excerpts from blogs of people who had given permission to be excerpted. Let's say that the Globe paid those people a nominal fee every time an excerpt was used. (Uh oh, I hear the reporter's union raising objections! But hold on, folks, I am trying to save your jobs.)

Now, let's say that people would be paid in scrip -- let's call it "GlobeCash" -- that could be used for on-line purchasers with advertisers who had either advertised on the online or paper version of the newspaper. Or, let's say people could donate their payment to a charity of their choice. Or maybe advertisers announce that a portion of the proceeds received through GlobeCash will be donated to the Boys and Girls club or -- better yet, to the charity of your choice in your neighborhood. Maybe they announce, too, that any purchase made through their link on the Globe site will likewise produce a donation to the charity of your choice. Maybe we keep running totals of the thousands of dollars generated for local causes by traffic on the Globe's site. Maybe the Globe Foundation announces that, each calendar quarter, it will match the contributions made by its readers to the favorite causes as compiled through this mechanism.

As we all acknowledge, bloggers are narcissistic. Imagine the flow of bloggers who would vie to be seen by several hundred thousand viewers every day. Only the Globe has the potential to offer this exposure. Imagine the buzz when you pick my blog excerpt today. What do I do? I immediately post the fact that I have been excerpted, and I direct even more traffic to the Globe. Other bloggers try to write more and more interesting stuff so they can be chosen. An intensely powerful set of positive feedback loops is created. As a blogger, I'm happy. Readers are happy because they are getting the latest news and commentary from a variety of sources. Advertisers are happy because they are getting eyes, clicks, and feel-good PR because of their charitable contributions.

The managing editor is now getting nervous. "How do I ensure the quality and accuracy of the blog excerpts I have chosen?" "What if we get sued for libel?" So, yes, you need to assign an editor to this feature, just as you do for your letters and op-eds. Yes, that person would use judgment. Yes, you would post a disclaimer saying that these excerpts are not the product of trained reporters etc, etc. Please, just get over it. (If you let the lawyers run the newspaper, it will look like Lawyers Weekly. How many readers do they have?)

But what is really happening here? All of sudden, regardless of actual ownership, this is now our newspaper. You have given me a reason to check in, to participate, to feel pride, and to feel a sense that you are relevant to our community in a variety of ways.

This is just one set of ideas from a person on the street. I am not saying these are the be-all and end-all. There are certainly people with more expertise and better ideas out there. I am just saying that the Globe needs to give people a reason to be read -- so that advertisers believe that they can't afford not to be there. If people believe it is their paper they will read it. Use the forces and opportunities of technology to make it happen so your excellent reporters and columnists can earn a salary and work on the really important functions envisioned in the Constitution.

New links

I included some new links over there on the right. Please check them out.

Not on health care, but with interesting observations about organizations, networks, and the world, Endless Knots, by Jessica Lipnack and Jeff Stamps.

BLOG Medicine, with wide-ranging news and commentary on health care issues.

Health Management Rx, with Jen offering commentary on "the road ahead."

HISTalk, full of news and opinion from the domain of health care information technology.

Best one-liner from a patient

Here it is, the best one-liner I have heard of from a patient, a terminally ill person fully aware of the prognosis, but with an inexhaustible zest for life and marvelous sense of humor:

BIDMC Nurse: Let me get you into this recliner and make you comfortable. Put your feet up, relax. Would you like me to get a sheet to cover you?

Patient: Actually, I'm trying to avoid that.

Online with real clinical results

Here's an email I sent to our staff today. Also picked up by the Globe. Please check out the site and let us know what you think. Now I can stop posting infection rates on this blog . . . .

Today we start a new experiment, a web site directed to the public called "The facts at BIDMC: We're putting ourselves under a microscope." You can find it on the external BIDMC web site at www.bidmc.harvard.edu/thefacts .

What's this all about? It is our belief that the public deserves timely and accurate information about the quality of care at hospitals. There are other web sites that provide some information; however, most of what is available is not current and is often based on administrative data like insurance claims, rather than on clinical data.

So, we decided to create our own. On this web site, you can see how we rate on certain "process metrics" – for example, how closely BIDMC is following recommended guidelines for treatment of heart attack and heart failure. You can also see how well we are doing in reducing harm to patients – such as our progress in eliminating central line infections. We also show how many times we have done certain kinds of procedures, like bariatric surgery, heart bypass surgery and others.

We show the latest numbers we have for all these metrics. Where national comparisons or benchmarks exist, we compare ourselves to them. Where national standards do not exist or where we think they are not adequate, we show our own goals and how we are reaching them. Where we are not doing as well as we would like (such as with hand hygiene), we show that too.

For each item we post, we try to explain how to interpret and use the numbers. Over time, we plan to add more categories of medical services.

As I noted, this is an experiment, so we also provide a page for reviews and comments. I recognize that this is a new experience for all of us – to have our work so starkly laid out and measured for all to see. I hope you all see this as a valuable tool that helps each of us do our jobs better every day. So please take a look and send us your thoughts.

In memoriam: Mr. Wizard

Don Herbert, the man called "Mr. Wizard" on his television show in the 1950's and 1960's, died yesterday. Here is the obituary, including this quote that says it all:

"Over the years, Don has been personally responsible for more people going into the sciences than any other single person in this country," George Tressel, a National Science Foundation official, said in 1989. "I fully realize the number is virtually endless when I talk to scientists. They all say that Mr. Wizard taught them to think."

Mr. Wizard would hook you at the beginning of the show with something that looked magical, and then he would teach you the science behind it. I can still visualize particular programs, and I am talking about things from 40 years ago. (There's the one where he dropped a rock into a pail of water, and it caught on fire. Quick, name the element!) I never became a scientist, but he provoked my interest in and study of science as a boy and to this day.

For Students -- Go to college reunions

No new questions from students today. I think I may drop this series for the summer unless there is more interest.

In the meantime, some unsolicited advice for former students. Go to your class reunions at your undergraduate and graduate school. Beyond the obvious networking opportunities, you will reinvigorate old friendships and, surprisingly, make new ones. You will also have fun.

At our MIT reunion this past weekend (Class of '72), we had a number of nerdy events, as you would expect for our beloved school. One was a poetry contest, based on themes like blogs, Smoots, and "An Inconvenient Truth". Here are three of the notable haiku's that emerged.

---

My boyfriend left me.
Everyone knows how I feel
Including my boss.

---

I say it is true.
Everyone is an expert
When they have a blog.

---

One gas guzzler, please.
Would you like it supersized?
Yes, I love the heat.

More on mystery shoppers

Several months ago, I wrote a post on our use of mystery shoppers to evaluate and improve customer service. Today Liz Kowalczyk at the Boston Globe covers the story in more depth (and with better writing!) I also find it really interesting to see the different perspective on this technique across the city's hospitals.

Muddy Buddy

Now, for a change of pace. In case you haven't noticed, I love competitive sports -- like baseball, soccer and running hospitals. Here's one that meets some kind of definition for something, but I don't know what. It's called Muddy Buddy. In relay-like fashion, a pair of teammates take alternate phases of the race on foot and bicycle, ending up in a slog (together) through a muddy pit. The pair above just finished the San Jose race. I'll let you guess which picture is "before" and which is "after."

Time to call HBS?

This post is about strategic planning in the Boston health care market. I hope you will respond with your reactions and thoughts. As a friend of mine likes to say, "there is no monopoly on brains" when it comes to these matters, and I welcome your judgment -- and that way I won't have to pay money to strategic planning experts from Harvard Business School!

Here's the scene. BIDMC is a very fine hospital in a city with lots of very fine hospitals. (We are blessed in Boston to have really wonderful clinical care in so many places.) Our two largest competitors are part of a network (Partners HealthCare System) that has beautifully executed its business plan and therefore has substantial leverage over the three main insurance companies in the state, which has resulted in higher rates for the hospitals and physicians in that network. BIDMC and the other hospitals and affiliated physician groups get rates that are under the price umbrella negotiated by the dominant system.

As "Avis" to this "Hertz", we have adopted a plan to position ourselves as a low-cost and high-quality provider in this region. We have done so because we believe that demands from the public and financial pressures on insurers will over time put substantial pressure on the academic medical centers, and that we will best situated for the future if we are known for both high quality and low cost. As you have seen on this blog, we aim to be quite transparent with regard to our clinical outcomes. Also, we hope to achieve operating efficiencies to lower our unit costs. (Note to unions: We do not intend to do that by squeezing our workforce. Quite the contrary, we intend to be the preferred place for people to work because of an environment that provides respect and opportunities for them.)

And, consistent with that strategic visions, on this blog and elsewhere, I have argued that insurance companies should pay us all based on the quality of our clinical results and not based on market power.

A recent posting by Charlie Baker on his blog makes me wonder if this makes sense. (I do not think he intended this result.) He said the following:

One can argue that Partners sets the table for everyone else - and that all providers benefit from their negotiations. If Partners gets “X” out of their negotiations with TAHP, HPHC, BC/BS of MA, etc., then everyone else gets some percent of “X,” which might be, in fact, higher than it would have been if Partners didn’t set the bar so high to begin with. When Partners decided some seven or eight years ago that they were going to demand huge rate increases year after year after year out of the private employers and health plans to “re-balance” the health care system in MA, most other providers benefited from that. They didn’t get the increases that Partners got, but they shadowed the increases Partners got, which was still substantial.

Beyond Charlie's point, there is also little or no indication from corporate purchasers of health insurance in this state that they are interested in insurance products that are based on quality of care. If there were interest in that, the insurers would have developed products along those lines by now. Further the state has been maddeningly slow in posting comparative figures on outcomes that are useful and meaningful to consumers.

So, here is the question. Since BIDMC has and will continue to have an excellent clinical reputation and very good relationships with community hospitals, multi-specialty groups, and other referring physicians, should we abandon our call for structural changes in the payment system? Would we be better off just living with the current arrangement, i.e., receiving rates that are just below those provided to the dominant provider network? Sure, we would never catch up with them in terms of earnings potential, but we would do better than most hospitals in the region. As consolidation and closures continued in the state, we would inherit a share of the clinical volume that will be passed along.

Of course, we would continue to make progress with regard to improving the quality and safety of patient care because that is our mission, but we would not choose to bear disproportionate costs of being innovative compared to other hospitals, and we would discourage talk of such extra innovation in our negotiations with insurers.

Before you comment on all of this, please remember that health care is not like other industries, in which companies are rewarded in the marketplace for being the high-quality, low-cost provider. That situation does not yet exist in the health care system. So, am I better off being a industry leader with regard to that approach, or am I better off biding my time and continuing to follow the traditional path until there is a real sign of change in the marketplace?

Marine buddies

Here is a touching story from WCVB-TV Channel 5 about a Marine at an unusual graduation ceremony.

Return of the robots

Several months ago, I wrote a post on the use of surgical robots to do radical prostatectomies and suggested that the main impetus for using robots was marketing, that the incremental medical value of such instruments had not yet been demonstrated.

In the May 2007 issue of Nature Clinical Practice - Urology, the journal's editor-in-chief, Peter Scardino, makes the same points, but offers substantial more scientific support that I could ever muster and certainly brings more credibility to the issue than I offer. Here are some excerpts:

Patients . . . are . . . seduced by the notion that the machine eliminates human error.

The fundamental measures of quality for any medical treatment are its safety and efficacy, which require meticulous documentation in well-designed clinical trials. Where are the trials that show superior outcomes with [robots]?

Studies that report better outcomes with [robots] that with open prostatectomy are limited to single-institution or single-surgeon experiences . . . that claim superior results compared with their own previous experience.

In spite of the evidence to date, enthusiasts are convinced that [robots are] superior to both laparoscopic and open prostatectomy techniques.

Technological advancements, no matter how compelling, are only as good as our ability to use them prudently and wisely.

Dance and poetry, music, and a poetry slam?

Yesterday's Pride Award ceremony at BIDMC recognized two individuals who have made outstanding contributions within the gay and lesbian community. What made this day different from past events is that both awardees are involved in the arts (among many other things.)

They are Liz Nania, the Director of Out to Dance! and Rafael Campo, MD, an internist at our hospital, and an accomplished writer and poet. You can find a sample on his website.

Speaking of the arts, I also want to take a moment to acknowledge the fine work of the Longwood Symphony. This is a talented group of medical professionals who offer concerts to the community, but who conduct their concerts as benefits for charitable causes. This season's concert series is over, but you can sign up for next year's tickets, volunteer to help, or make a donation at their website.

Now to the poetry slam. Rafael reminded me that there are lots of amateur poets in the medical community, some of whom are inspired by their experiences in patient care and some who write for other reasons. If any of you -- or any non-medical folks out there -- would like to reply with a comment that contains a poem you would like to share, please do so.

For Students -- Hospital Business Planning

Rocky asks below, "Do you ever find that the decisions you make may be great for the hospital but not the best option for patients? This comes up repeatedly in the pharmaceutical industry, where often the products being developed are directed toward the business market and not the greater burden of illness. Hospitals generally generate surpluses from providing cardiac and cancer care but lose money providing mental health and pediatric care. Are you ever forced to put a higher priority on the well being of the hospital than on providing the best health care services for the well being of patients, and how do you grapple with that?"

I might word the question slightly differently, but essentially the answer is a sad and simple "Yes." The current reimbursement environment is such that we cannot afford to expand or maintain certain services that we know are of value to society. For example, we have one inpatient psychiatric floor and could probably have two or three, in terms of need. We used to have a transitional care unit, which was closed because of poor reimbursement. I would love to have a long term acute care facility and a hospice facility, but I cannot because they would lose money, under the rules that apply if they are part of a hospital. We are not the only ones facing this, and so you see similar trends throughout Boston and the country. Even in the surgical field, one of our neighboring hospitals shut down their ophthalmic program because there were "higher value" surgical services that would otherwise use that space. And while we have a superb obstetrics department, with 5000 births per year, I have had to limit expansion because of the relative profitability compared to other types of care.

The current reimbursement environment is a relic of the past. With regard to mental health, I believe it embodies long-standing societal prejudices against people with mental illness. Other aspects of the system reflect other societal decisions. As a hospital executive, I have to balance the need for the hospital to stay solvent with our desire to be as helpful as possible to people with different types of medical problems. While we do all kinds of cross-subsidizing within the hospital, some services, inevitably, are not affordable.

In memoriam: Clete Boyer

A confession that might end my career in Boston (although my family already knows and they have chosen to stay with me): I not only grew up in New York but was a Yankees fan during my formative years as a boy. Our heroes in the 1960's included the spectacular infield quartet of Moose Skowran at first, Bobby Richardson at second, Tony Kubek at short, and Clete Boyer at third. (By the way, the outfield was all right, too!)

Boyer just died at age 70. We remember him as making spinning, diving stops, and then connecting with superb throws -- sometimes on his knees. Bobby Richardson is quoted in the obituary today, "When I made the double play, I could just about close my eyes, put my glove up, and the ball would be there."

On a summer night in Boston, I can still feel the boyhood thrill of watching an awesome double play. Now I root for Mike Lowell at third, but Cletus Leroy Boyer is embedded in my memory.

Neck manipulation and strokes?

A few years ago, a very good friend of mine suffered a stroke from a dissected carotid artery. Once they had an image of her neck and saw the damaged blood vessel, one of the first questions the attending neurologist asked was, "Has she been to a chiropractor recently?" In fact, every single neurologist who saw her in subsequent weeks asked the same question.

These questions reflect a belief among some doctors that neck manipulation by chiropractors can cause damage to the arteries in the neck, leading to the creation of clots that can then enter the brain and cause an ischemic stroke. Here is an example of an article on the subject.

As you know, I am not a doctor, and I do not pretend to be an expert on such things. I also know that chiropractors do miracles for many people and alleviate lots of pain. So this is not a diatribe against that profession. Far from it.

Obviously, this is an area in which clinical trials and randomized studies are difficult. But, I now always warn my friends to be alert to this potential danger and seek gentle approaches to neck pain.

Death close up

I know I am not the first to comment on this, but for me it is a relatively new experience to see death close up. In these past five years working at the hospital, I have visited patients who were close to death and have spent some of their final hours with them. Before working here, I would have imagined that such an experience would have made me feel, at a minimum, awkward, but more likely extremely uncomfortable. I am sure I would have been afraid of doing or saying something "wrong". In short, I had a very self-centered view -- thinking mainly of my own discomfort -- and I avoided those circumstances.

Once taking this job, I considered it part of my responsibility to visit patients at all stage of their treatments, including the final stages. Instead of the expected discomfort, I have found these moments to be stunningly freeing and beautiful, notwithstanding the tragedy of the situation. The people who have given me the privilege of their company during such times have been open, honest, warm, funny, and even cheerful. Maybe it is still very self-centered on my part to say so, but they have confided in me in a way that leaves me both honored and humbled.

I write this in thanks to them and their families for the chance to be part of this very, very intimate human experience.

Advice to referees -- and managers?

Speaking of sports, let's now turn away from cheese racing and back to the beautiful game, where I want to present a different twist on the girls soccer topic.

Several years ago, my friend and fellow referee Grant led me to the following email, written by Dr. Cindy Moore at the University of Washington. She has graciously allowed me to reprint it here. Sure, it is about soccer, but I would ask you to consider any ramifications for management of teams in an organization.

Here's Grant's introduction from January 2003:

What follows is a long but very interesting email describing the results of a survey done by Cindy Moore describing how women vs. men respond to game situations, mainly soccer. VERY interesting read, most of it rings true. There are lots of things that I have observed over the years, but not really been able to process as clearly as Dr. Moore.

Not all human behavior falls into neat columns and works every time for everybody. I polled a statistically large number of males and females as coaches, players, and officials (female officials not so large a number here) on a survey that I entitled "Perceptions of the Female Game" a few years ago for my Ph.D. thesis. I hold various psychology/anthropology degrees and work at a large university. I researched many psych/educational studies, plus interviews, survey, and observed games both live/taped to see if I could draw comparisons between the two genders in a soccer game from a behavior statistical difference point of view.

(Males/female respondents were for the most part, white, and recreational/district older players or youth players at all competitive levels. Officials whom responded were a from very diverse population both age/regionally/experience level.)

Some points to ponder: Females will delay their retaliation for a number of reasons:

1) They are socially oriented. Most retaliation will NOT be done by the one involved in the cheap shot but rather by a team-mate who will take out the offending player. Why? Females are socially, not individually, organized as males usually are. Having a team-mate retaliate for you strengthens the bond of the team/group. When you commit a cheap foul against one, it is against all.


But ALWAYS be aware of the social clique on any female team you officiate. You should be able to identify the main clique, who is on the "outs", who is new. You may have a player always in the open -- never will anybody pass her the ball -- it won't be happening because more than likely on a female team they haven't bonded (trust) or she has offended somebody and the possible win won't override the social organization of the group. Winning isn't the first priority of the team (lot of variables here depending on age, etc) but the socialization, bonding of the team is always an overriding factor on any female team. The best player, if she has does something to offend a higher female in the group, won't see the ball passed her way.

2) Females choose their time for retaliation because they do not want to be caught doing so for the most part. If they can execute the perfect "payback" without getting caught, so much the better. They do not like public criticism. (Anybody ever yelled at their wife/partner in public or tried to correct them publicly in some manner?) School studies show that teachers correct and call upon males at a much much higher percentage rate than females. From a very early age males are used to speaking out, being corrected, trying for any attention either positive or negative interaction. Males will raise their hand to respond for the interaction/attention -- never mind the "right" answer -- to be respected as intelligent. Females usually only raise their hands when they are very positive about being correct, looking good in front of their peers and the authority figure-teacher.

As a referee: what does this mean?

1) Identify the social leaders of the team.

2) Try quiet words to the player and make them specific words. Females key off of specific feedback. "Number 11, hands off her shirt," "Watch the hip check," etc. Females process intrinsic information; males are extrinsic. You can yell across the field to the males to knock it off, and they will grin and get the picture. If you do that with a female, she will elaborately look around, like whom is he addressing, it can't me, or begin a discussion of what are you talking about -- "What am I doing?" -- and then engage you all game long in what did you call, why, what did you see, that wasn't right, it was this, etc. Females have a very fine sense of justice and what is "fair." Be consistent and apply laws/calls/fouls consistently throughout the game. Or be prepared to hear/discuss your games and perceived unfairness as you call 34 to 1 foul ratio, catch that hip check but not this one -- "Are you blind?"

3) Next step in player management is to talk just a bit louder to include her immediate peer group of teammates.

4) Use the team leader (not always the captain -- watch for the social structure) or her best friend on the team -- notice who helps her up -- her friend will cross the field to help her up or check her well-being. (Guys it will be the nearest one handy on their way for positions.) Make your discipline as quiet as possible as long as the person allows it to happen this way. Once you have made it public, forget about putting that player into your pocket anytime soon in the near future. Once a problem now, always a problem. She won't let it go until she has spent some deep processing time on it. Do not waste any more effort on recapturing friendly relations -- stay professional and just know no warm and fuzzy feelings are likely.

Ever fight with a girlfriend, wife, partner? Where do most of you resolve these issues? Females pick their battleground carefully. Most of these "discussions" will take place in one of three places: 1) bedroom; 2) car; 3) kitchen -- when territory has been declared and likely interruption free. Females like a captive audience with their undivided attention. In the above areas, most males will not easily escape the discussion, and the females will pick the time of discussion to have the fewest interruptions.

There are chemical reactions in the fear/flight response (higher blood pressure, increased respiratory, acute sensory perceptions, etc). To decrease these reactions, males require one of two things -- action or time. So if you see a potential harmful retaliation coming, put on the speed and get there ASAP and provide a distraction to buy some time to let things chill out. Know either you are going to be effective in first few seconds or you will have lost it, but the results will be quickly known and usually the equalizer will be done within 10-15 minutes.

Females require one of two things -- time or verbalization! Ever had a female partner talk, go over and over and over the same upsetting scenario time/again? Recognize this increases coping ability, decreases the response syndrome. Expect words to be flying or voice used in some mannerism in a tense situation -- the females will talk, mutter, talk, mutter, talk to others all game long about the situation and into the locker room afterwards. This forms the oral history and why 10 years later two females will remember, recognize, and have a score to settle up. In a female game, OFTEN the game you think you see before you will have hidden agendas. Females will carry the baggage looking for exactly the right moment to execute retaliation so pay-back won't be forgotten, maximize effect and allow them to avoid go-to-jail card. I have had lots of stories about females games -- you know -- not a darn thing was happening, play was going well, when strike, bam, boom, etc. Ref didn't see it coming . . . and couldn't from the play on the field before him. What he missed was the female body language signs of impending war -- whispers on the wind, cold shoulders, stiffening body movements passing the enemy and the 'look'.

With males, in contrast, retaliation is upfront, personal and usually involves "in your face" immediately or within next 10-15 minutes retaliation. More than likely, once given, the score is evened, payback given, accepted, then the game can proceed. They may even pat each other on the butt, arm, give a thumbs or help each other up, later in the game. Watch for the pairing.

Males when tense usually clench jaw, make fists, scowl, lengthen stride, puff up and they do NOT communicate well. They STOP talking and are poised for action. They may storm into a tense situation and that intimidates females players to where they feel personally threatened. So make a point when you are upset in the female game to communicate verbally (quietly, directly, and specific language to the player) and watch your body language -- especially the fists as you run, jaws clenched, etc. Learn to smile wide, and it doesn't hurt to indulge in some light social chitchat. Females seem to appreciate more also that a referee checks when they are injured and how they are doing after a hard foul or tackle.

An interesting side note to my survey that I'd like to share. Female players are very perceptive about male officials. They noted smell (!), hair combed, uniform professionalism. Body language drew a huge response when asked their perceptions of male officials. I was expecting mechanics, whistle, etc, but what I received was very critical body/dress/socialization skills/interaction comments!

Obviously I have a lot more material and again, please, not all of it will apply across the board to every male/female. These are statistical averages and not all the time does it happen this way. Also, the comparisons do not necessarily hold true anymore in the competitive upper division female games. Times are changing, and both female and males are drawing closer in some types of behavior. For example, the red and yellow card count here has led me to think that females are becoming more outspoken about language, and certain kinds of violent conduct are on an increase in the female game.

Is it sponsored by the NHS?

Apropos of the post below on the National Health Service in the UK, I have found one of the ways they ensure a hefty census of patients. Here is the website that describes it all, entitled, Daredevils face danger in cheese chase race. Yes, a cheese race.

Highlights of the article:

Dozens of madcap competitors risked their necks on Monday for a shot at glory in one of Britain's most barmy annual events -- chasing a rolling cheese down a steep hill.

Jason Crowther from Pembrokeshire, west Wales, won the first of the five bone-crunching races to complete a hat-trick of victories over the last three years. "There's no training you can do for this," said the battered 25-year-old, proudly clutching the seven-to-eight pound (3-3.5 kilogramme) cheese.

Oddball Japanese television personality Daisuki Miyazaw, 34, claimed second place in one race. Seemingly dazed, he said: "We are strong, but it hurts so much," before hobbling off for medical treatment.

For students -- I lost Wednesday!

Dear students,

I completely missed Wednesday this week, probably because of the holiday. My apologies. I'll continue our student series next week. In the meantime, please submit questions.

A view of the NHS, and Switzerland

For several months, I have been reading a terrific blog by Steve Pashley about political, customer service, and management issues in the UK's National Health Service. As people in the US consider what changes might be appropriate for our health care system, Steve's comments offer a helpful insight into another country's experience.

On a related topic, there will be a program about the Swiss health care system on June 22 in the State House, Boston. Here are the details. It is sponsored by the Brandeis' Massachusetts Health Policy Forum and Health Care For All.

To Indians

This is specifically for my readers from India, or people who have friends there.

I have been playing a game to see if we can have readers from all the states of India. So far, I have noticed people from Andhra Pradesh, Gujarat, National Capital Territory of Delhi, Himachal Pradesh, Jammu and Kashmir, Karnataka, Kerala, Maharashtra, Orissa, Punjab, Tamil Nadu, Uttar Pradesh, and West Bengal. (In italics, if added after the initial post.)

I am particularly interested in expanding my audience in your country because I know there is intense interest in hospitals and medical issues there -- and also because you have a very high rate of computer literacy and Internet activity. I would love to get your perspectives on these issues.

So, please pass the word and encourage your friends to tune in and to let me know where they are from. Thanks very much.