Sunday, August 31, 2008

There is a reason we have elections

One more posting in honor of Labor Day.

Recently, an op-ed was published in the Boston Globe, entitled "Unions' new role in the workplace". It was written by Kris Rondeau and Janna Malamud Smith. People with good memories will remember that Rondeau was a driving force in the creation of the Harvard Union of Clerical and Technical Workers (HUCTW) twenty years ago. The slogan she and her colleagues developed -- "You can't eat prestige" -- was one of the masterstrokes of union organizing. It took several tries, but finally the union eked out a small majority in an election and became the bargaining agent for a significant number of workers at Harvard University. They were able to do so, ultimately, because they had a personal and respectful relationship with virtually every person voting in that election. Many of those employees viewed themselves as professionals who did not want or need a union. Rondeau did not attempt to bypass those people by ignoring their concerns. Instead they were treated with just as much respect as those who wanted the union. The result was that even those on the losing side of the vote felt their views had been heard and considered and did not fall into a posture of resentment and anger.

In my previous job as Administrative Dean of Harvard Medical School, I had many opportunities to work with Rondeau and her colleagues and enjoyed what we were able to accomplish together. She and her team were great negotiators, but the key to their success during this process -- like during the organizing drive -- was that they were intimately familiar with virtually every member of their union -- both learning from them and teaching them. Indeed, the HUCTW often had a better perspective on what would make the University work better than the administrators and supervisors in the University, because they had a real connection to what was happening on the "factory floor." But, instead of being confrontational with that information, they used it to educate the management, too, and worked together to enhance both the lives of workers and the underlying mission of the University.

In their op-ed Rondeau and Smith offer the opinion that this approach to union-management relations should be a guide for the future. This is a great vision, but whether or not it will be achieved is questionable. Just look at the comments under the article to see opposing views. There are clearly those who will always believe that "allying with the employer is the wrong approach and ultimately not in workers' interests; when workers' and bosses' interests occasionally coincide, it's the exception rather than the rule."

But the HUCTW history supports one point in which I believe quite firmly. If the organizing approach being advocated by the SEIU and many politicians is adopted -- i.e., the elimination of elections -- they will have created a cancer of discontent within the very union expansions they hope to achieve. Why? Because there will always be a significant number of workers in every company -- whether 30%, 40%, 50% or 60% -- who would choose to vote against unionization in a secret ballot process. By disenfranchising that group through the use of a card-check system, the unions will be sowing the seeds of resentment that will hurt them for years to come.

In America, we accept the idea that we might be on the losing side of an election, and we live with that result. But, if we are precluded from being allowed to have a say, we remain angry for a long, long time.

This was put more elegantly than I have done in comments I received from an organizer in one of the local Boston unions:

I must say I don't understand why anyone would think that to take away a person's right to an election is good idea. It's seems to me that it would create a feeling of disempowerment instead the feelings that should be created: The feelings of pride and of finding your voice, realization of the fact that you have value to add and a respectful way of sharing it.

Saturday, August 30, 2008

Don't mention the part about ending elections!

A special message in honor of Labor Day:

A little while back, I wrote of George McGovern's opinion piece advising members of the Democratic party not to support the adoption of the so-called Employee Free Choice Act, the legislation supported by the SEIU to remove the need for elections as part of a union organizing drive. My post got picked up by a website called EFCA Updates, a blog I had never heard of published by a law firm called Kilpatrick Stockton LLP, which apparently represents managements of companies with regard to labor issues. The firm also cited other blogs with points similar to mine; but this made me curious what other folks out in the blogosphere might have said in response to Senator McGovern's editorial and generally on this topic.

So, I did a blog search and discovered tons of commentary on the issue pro and con. (I will not refer you to the ones who engaged in ad hominem attacks on the former Senator. Why is it that some people feel the need to denigrate those who disagree with them? Why can't they let the strength of their arguments carry the day?)

Remarkably, while the blogosphere is full of ideas, the topic still does not make it into political debates. This blog presents the issue with a Minnesota candidate in an interesting way that you might or might not find convincing. But I think it contains an element of apt political analysis: People running for the Democratic nomination in their states have stressed their support for EFCA as part of their campaign in part to garner the SEIU's and other organized labor extensive funding of and involvement in those primary campaigns.

But then, when the candidates get to the general election and have to convince non-party regulars to vote for them, they may not be all that anxious to have this issue front and center in their campaign. After all, as Senator McGovern noted, it is really hard to explain to the general public why workers should not have the right to a secret ballot election when it is long-held American value. I note, for example, that even Barack Obama avoids this important aspect of the proposed legislation when he puts it this way:

Ensure Freedom to Unionize: Obama believes that workers should have the freedom to choose whether to join a union without harassment or intimidation from their employers. Obama cosponsored and is strong advocate for the Employee Free Choice Act, a bipartisan effort to assure that workers can exercise their right to organize. He will continue to fight for EFCA's passage and sign it into law.

I want to be quite clear that I have great respect for Senator Obama and for his persuasive powers of oratory and his ability to deliver a clear message. But something tells me that he is never going to be so direct as to say the following on the campaign trail or in a debate with Senator McCain:

I will sign legislation allowing unions to be certified as the sole bargaining representative in companies, hospitals, and other institutions without having to hold an election. Although it is vitally important under our democratic system for Senator McCain and me, every member of Congress, every Governor, and all other public officials to go through a process of secret ballot elections, unions shouldn't need to have workers do that. The idea of a secret ballot is old-hat because workers will be intimidated when they are alone in the privacy of the voting booth. In contrast, there is no danger of intimidation when union officials and fellow workers approach individuals one at a time to collect authorization cards.
It is perfectly fine in such an environment if 50.1 percent of the workers at a company sign an authorization card that binds themselves and the other 49.9 percent of the workers to be members of a union. That's why we don't need elections anymore.

Cormorants in Cape Cod Bay

This group always finds this exposed rock at low tide on which to dry their feathers.

Thursday, August 28, 2008

Welcome Blogger referrals!

Welcome to those of you who got here via Blogs of Note. I am honored to be listed. Please scroll down and you will find a wide variety of topics covered. While most postings are about issues surrounding running a hospital, medicine, and health care, you'll also find other stuff that might be entertaining or informative -- and I've recently included some lighter topics that seem appropriate for the end of summer.

Please come back often!

Wrong way to apply for a job

I know we all receive "cold call" letters from people looking for jobs. I do not know what kind of employment agencies advise people to send these to a CEO, in that the letters are usually not in response to open positions and generally are not attuned to the needs of the organization. And we all have websites now that list open jobs and encourage people to apply using that vehicle, which, by the way, is a major source of recruitments. But you can't fault people for trying in their own way.

But, every now and then, one comes in that is worthy of note. This one came by email today, with no personalized salutation. Something tells me that a person seeking a job in the security field is using the wrong medium if he is seeking a job through broadcast emails!

As a Director of Security Operations, I led investigative teams, uncovering fraud and real and potential threats to personnel and assets. Also, I designed and conducted training courses increasing security awareness.

My strengths include emergency planning and response, loss prevention, counter-terrorism, and I am knowledgeable of on-going issues relating to enforcement of ITAR regulations. I exposed internal corruption for one of my employers saving $300M and secured an at-risk facility in Honduras. For another employer, I identified $4M in inventory losses and implemented a preventive program.

I have posted a short version of my resume and welcome your response.

Wednesday, August 27, 2008

Laurie Edwards live!

A note from fellow blogger and author Laurie Edwards:

Dear Friends,

I hope you are enjoying the last few weeks of summer. As we look ahead to fall, I want to let you know about a joint author event I am doing at Newtonville Books on Thursday, September 18 at 7pm. My colleague Rosalind Joffe will read from her new book, Women, Work, and Autoimmune Disease. I will read excerpts from my book, Life Disrupted: Getting Real About Chronic Illness in Your Twenties and Thirties, and we will both take questions.

We are excited to be doing this together as part of Newtonville Books' Lecture Series, and hope to see many of you there. Please feel free to forward this message to any friends or family who might be interested in these books and in attending the event. Thanks so much!

Laurie Edwards

Newtonville Books
296 Walnut Street
Newtonville, MA 02460

Monday, August 25, 2008

More Than a Fan

From Michael D. Baratz, MD, Resident Physician at the BIDMC Department of Surgery:

From the time I was a 6 year-old boy, I have gotten an adrenaline rush when walking into Fenway on a summer night. Still today, at 29, the feeling remains the same. When I walked into the park on July 12th as a member of the Emergency Medical Staff, the buzz was twice as potent. I was for the first time, more than just fan. I was going to work.

The first 6 innings of the game were exciting as a fan, and nearly event-less as a doctor. I stood atop the Green Monster and saw a view of the field I had never seen. I was in earshot of the now maligned Manny Ramirez. I saw 4 home runs (3 by the home team). As the Red Sox cruised to a 10-1 lead, all I had to do was give out a few Tums and some Tylenol.

At the top of the 7th, I traded places with another resident and went down to the main First Aid stand underneath section 112. I instantly switched back to being a physician, and placed my fan-hood on hold. In addition to the usual complaints of a hot summer night: dehydration, blisters, light-headedness, and a young woman who was hit in the temple with a Kevin Youkilis foul ball (she kept the ball).

With a win in the books, and 'Sweet Caroline' on the minds of 35,000 I was expecting an uneventful end to my night. But at that moment, an EMT and a Fenway security guard knocked on the door. "Peanut allergy in the bleachers. Need a doc and an EpiPen!". The attending on staff asked me if I would go. This story would not have been interesting enough to get onto Paul Levy's blog if I had said no, right?

I grabbed an EpiPen and jogged out of the makeshift ER. I was following the EMT to our destination, when it finally hit me: we were in the first base grandstands, and she was in the bleachers. For us to get to her without playing slalom with thousands of fans, we would have to go onto the field. We did just that, and before I could even soak it in, I was jogging where J.D. Drew had been just moments before. It was a surreal moment in which I had no time to bask. The visitor's bullpen. The bleachers. My hand on the end of an EpiPen. The back of an ambulance. Over to the BI. Time finally slowed back to normal pace, and I was alone as I walked out the doors of the BIDMC ED. The events of the past few hours had just sunk in, and I felt almost like Moonlight Graham from 'The Field of Dreams'. I don’t think I can ever go back to JUST being a fan.

Sunday, August 24, 2008

Thinking of Bruce

An excerpt from a note from Bruce's wife, shortly after he passed away. It is printed with her permission. He was a very fine person whom I had a chance to get to know after I arrived at this job. I am personally gratified that we offer an environment that made possible the quality of human interaction that Wendy summarizes.

Everyone involved with his care at BIDMC was wonderful, from the volunteers and clinicians at the chemo clinic, to the MICU, to the oncology floor. With so much intelligence and compassion, they were all archetypal BIDMC folks. But I must put in a special word for Dr. Rebecca Miksad, who oversaw his chemo treatment at Shapiro (outpatient clinic), and then followed all the way through with us to the MICU and oncology. She was magnificent. I watched this young doctor sit on my husband's bed in the MICU and deliver to him what was undoubtedly the worst news of his life.

It was a meeting that I dreaded, and one that I tried with all my might to soften for him. But it was Dr. Miksad who was the key to it all, who made it bearable, if you can imagine. She explained his dreadful prognosis with such compassion and intelligence that I could hardly believe what I was witnessing. It was amazing. I don't know how she did it, but she did, and in such a way that it respected my husband -- his intelligence and his feelings -- as much as was humanly possible. I shall never forget her for the way she dealt with us. She is going to have an amazing career. I am so grateful that she was with us.

Very best, Wendy

Sunset at Highland Light

First known picture of Michael Phelps

Friday, August 22, 2008

Born to be . . .

Following up on the theme introduced last Friday, here is a pertinent animated view of the Baby Boomers.

Nick's done good!

My hospital CEO blogging colleague, Nick Jacobs, has written a book called Taking the Hell out of Healthcare. It is available here on Amazon. It is very good.

Here's a blurb I wrote about it:
"Nick Jacobs provides a clear guidebook to those of us who find ourselves in a hospital. He poses the questions that we should be asking --but often forget to -- and answers them in plain English so that we can enter the strange world of medicine with greater comfort and less anxiety-- then go home again feeling not only cured, but good."

And here are some other comments:

"Nick Jacobs has dedicated his life to improving the lives of others. His unique, seasoned inside look into hospitals will arm you with the information to get the best health care for you and your family."
Tony Chen, Founder of

"With twenty years in health care administration, Nick Jacobs brings directly to the patients and their families the information essential to comprehend the nuances of the complex quagmire of experiences that make up the American healthcare system. Jacobs is truly a committed patient advocate, and this book is a must read. "
Dr. Dean Ornish, Founder and President,
Preventative Medicine Research Institute

"Nick Jacobs' long experience in American healthcare pays off for patients and their loved ones who want to know the best way to advocate for themselves in today's healthcare maze. A critical read for anyone who wantsto get the most out of their healthcare journey."
Craig D. Shriver, MD FACSColonel MC, General Surgery Director
and Principal Investigator - Clinical Breast Care Project
Walter Reed Army Medical Center

"Nick Jacobs likes being Nick Jacobs, and that is a very good thing for hundreds of hospital staff and patients at Windber Medical Center. His is a special kind of ego that says he can do better by his patients and staff than just about anyone else. That's no idle boast. See for yourself. His brand of management has done very good things for all concerned. Learn for yourself."
Zane Knauss, Publicist and Writer

"Taking the Hell Out of Healthcare" provides the patient with a practical (and sometimes humorous) view on how to navigate the healthcare system. Don't leave home without it!"
Beth Bierbower,Vice President
Product Innovation
Humana Inc.

Thursday, August 21, 2008

Please join Tom's ride on September 7

Tom DesFosses is a patient of our hospital and a cancer survivor. He has started a bike-riding fundraiser for cancer research. The ride starts and ends at the Liberty Tree Mall in Danvers, MA, and you have your choice of 10, 25, or 50 mile routes. Depending on the length you choose, you go through Wenham, Hamilton, Essex, Manchester by the Sea, Gloucester, Ipswich, and Georgetown. All rides are very scenic and enjoyable rides. There are rest stops on all routes.

Here's what Tom says:

On September 7, 2008, I will be hosting a bicycle ride on the North Shore of Massachusetts to raise funds for leading-edge cancer research at Beth Israel Deaconess Medical Center. 100 % of proceeds raised through this bike ride go directly to Dr. Wong's Brain Tumor Fund and Dr. Lewis Cantley's General Cancer Research Fund. This research is very important to me and others living with cancer.

For me, this ride will be very emotional, but in another way it will give me incredible joy. It will give me time to reflect on how blessed I am to be a cancer survivor, and to think of others who are not able to join me on this quest. I hope others cyclist will join me on this ride to help raise greatly needed funds for life-saving cancer research.

This bike ride is a way I can give back to the wonderful people who have prayed for me and encouraged me along the way. Special thanks go to my wife, family and friends, who have been so supportive.

What I did this summer

Here are some excerpts from an essay by Ifedolapo Bamikole, a senior at UMass Amherst. She's from Nigeria and has been in the US for about 3 years. She is a biology and psychology double major, with interests in public health, international medicine, and health disparities. (Personal interests include piano, guitar, tenor sax, writing poems, and traveling.) She has spent two summers now shadowing people at BIDMC to learn about the workings of a major academic medical center. I think her observations are well written and insightful -- uncovering many of the issues we all face in the delivery of primary care -- and they will be helpful as she plans her career.

Another summer at Beth-Israel has come to a successful end after 12 weeks of projects, shadowing and observing at the hospital. My experience here last year encouraged me to come back, hoping to learn more. And I have definitely learned a lot more. The benevolence of some kind people has allowed me to be a summer intern here. But without the help, constant guidance, direction and knowledge of the people I worked with this summer, this whole summer internship would have been less than complete.

My mentors were Dr. Gila Kriegel and Dr. Carol Bates, same as last year. And I worked on 6 different projects: The Chlamydia screening, Pneuomax, Diabetes, narcotics, a time study project and health care proxy. These last 2 are on going right now. But for the 4 that have been completed this summer, the results and summaries were presented at QI meetings and panels of residents. These presentations were mostly for awareness purposes, to show how well HCA (our hospital-based primary care practice) is doing in taking care of specific patients, and highlighting areas of improvement. And after my work of collecting data, building a database and analyzing what I have, the intervention discussions that ensued from results presented at these meetings was always interesting to me, as I sit back, watch and listen to other people share their medical knowledge and come up with solutions to identified problems.

Before every project, I always got background information and education by one of the doctors to help me better understand what I was doing. Because of this I now know that women aged 25 and younger should be routinely screened for Chlamydia as this reduces the chances of pelvic inflammatory occurrences. In HCA 57% of women in this age group are being screened. This shows plenty of room for improvement. Among providers, there was no disparity in care given by resident or attending physicians in this area. Higher screening rates were found in Nurse Practitioners. This was a fact worthy of commendation to NPs. In order to see how well the practice was doing in the gynecological care of patients, I looked at the percentage of people who had received a Pap smear, as well as a Chlamydia screening and the result was nearly 80%, which is good.

The next project I worked on was the Pneumococcal vaccination which was quite similar to the last one in that I was to look for rates. Unlike the Chlamydia screening though, this involved looking at the older population (65 and older) who are at a high risk for pneumonia. And it was not gender specific. Here, I had a sample size of 100 patients to work with. And as I’ve learned, the bigger the sample size, the better for accurate figures people can actually work with. The results showed very good rates in general. 80% had received a pneumovax. And 83% were on Medicare which is normal and expected for this age group. There was not a big difference between English speaking and non English speaking rates of pneumovax. But when this was further broken down to male and female Non-English speakers, the difference jumps out at you as nearly 90% of male non English speakers got screened while a mere 56% of female non English speakers got screened. It was decided that this will be further looked into with an even larger population size to see if this remains true. Reasons why, along with solutions will be worked upon soon.

By the time I started on the Diabetes project and Narcotics project I had begun other things in the hospital. I took a class for observation status and then went to the West campus twice to observe a total of 4 different surgeries: Inguinal hernia repairs, a laparoscopic appendectomy and partial cecectomy, and one colectomy. The surgeon was Dr. Christopher Boyd and he happens to be a very nice man. He is a very funny man and was ready to explain things to me every step of the way, including why he was doing certain things and how he did it.

I observed, in Labor and Delivery, the arrival of a baby girl to new parents. It was their first child and my first time seeing a real delivery. The experience was nothing short of amazing. I felt like an important part of the team propping the woman up for the pushes, alongside her husband and helping her relax between contractions. The crowning of the baby’s head was just as fascinating as seeing the whole body come out so smoothly. And when the baby came out I was initially shocked at the color but watched the color slowly change as the baby took in oxygen in her lungs and steadily adjusted to life on this side of the world. The nurse I was assigned to was very kind in showing me all the procedures to make sure mother and baby stay in good shape. It took a while to wait for the placenta to come out. I was surprised at the large size of it. I never knew such big things could come out of a woman’s body. After the ‘second birth’, the woman had to have sutures to close up a very slight tear of about 2 inches. That is when I found out that obstetricians were also neat surgeons. And the invention of Epidural in medicine must be a blessing. This woman did not scream once throughout the ordeal.

I also got to shadow doctors. Dr. Anita Vanka and Dr. Diane Brockmeyer both graciously allowed me to sit in while they saw patients at different times. One thing I must have missed out last summer was how much a lot of these patients know about their conditions. Thanks to online information and research studies, the average patient is bombarded with a plethora of ideas, and it requires a doctor to be on her toes to envisage problems that could potentially arise from such knowledge and how to correctly advise such patients. A lot of my projects made even more sense when I started to see people in clinic with the kind of conditions I was working on. And along with the observation, I got a lot of teaching from the two doctors I shadowed, who made it a point of duty to know that I was learning something new always.

The diabetes projects was very time consuming but also very high priority because of the information that it gave. For residents it was necessary to see how well patients in their panels were having their diabetes adequately controlled. Because of the high risk for a myriad of other problems, diabetes patients need to be properly monitored by PCPs and followed up in Joslin. My results showed that there was a low number of NP visits (25% as opposed to 87% of PCP visits, in the last year). 61% of these patients were seen at Joslin Diabetes Center (Note: With whom BIDMC has a clinical partnership). But for a subset of people with hemoglobin A1Cs of ≥9, 100% were being seen at Joslin which is good. Foot exams need to be either carried out more and/or documented more as it is one of the important tests in diabetics, and the rate was only 45% (n=150). Suggestions were made at the resident meetings on how to make sure patients are getting all the necessary exams done.

My second summer back at Beth Israel Deaconess was definitely worth it. I had it reinforced in me every moment that time and accuracy was of the essence in this environment for efficiency. I can’t thank you enough for the opportunity to work here again. I am more encouraged than ever to finish my final year of college successfully and one day become like all these great doctors I have worked with.

Wednesday, August 20, 2008

Art too bad to be ignored

Looking for something to do to round out your summer? I have just the thing: A visit to MOBA, the Museum of Bad Art, conveniently located in the basement of the Dedham Community Theatre, just outside the men's room. As noted by the management, the nearby flushing helps maintain a uniform humidity. The gallery is open whenever movies are showing, typically 5 to 11pm on weekdays, noon to 11 on weekends and school holidays.

The curatorial standards of the museum are rigorous and clear:

The pieces in the MOBA collection range from the work of talented artists that have gone awry to works of exuberant, although crude, execution by artists barely in control of the brush. What they all have in common is a special quality that sets them apart in one way or another from the merely incompetent.

So, who's the lady in the picture above? That's Louise Sacco, the museum's Permanent Acting Interim Executive Director. She's also one of the photographers for FanFoto for games at Fenway Park. I met her at a Red Sox game earlier this year. Louise reports that she got the job at Fenway in a tough competition with lots of, er, younger photographers. At the interviews, they all talked about their geeky love of photographic equipment, Photoshop, pixels, and the like. She said she thought it would be fun to meet lots of people in the park. She was hired on the spot.

Back to MOBA. Like any legitimate museum, MOBA depends on its gift shop to reach its financial goals. You can buy items here.

Lean is not about dieting

Following yesterday's story, here's another example of the Lean methodology in action, as presented in an email from one of our nurses to her colleagues this week. Note the involvement from others in the hospital that have had experience on their own floors. Wait, are they having fun, too!? I have heard too many reports of that. Quick, call out the seriousness brigade and put a stop to it.

From: Serrano,Marjorie I. (BIDMC - Nursing)
To: Nursing Farr 6 All

Lean Update on Farr 6 Clean Supply Room

As you could see, there was a lot of activity in the clean supply room today. The Lean team from the President’s office, Distribution plus 11R’s Marnie Pettit, RN and Martha Clinton, PCT, and Farr 7’s Beth Morrison, and Catherine McCollin worked with the Farr 6 team to redesign the clean supply room for better flow. We will be back tomorrow to continue this work.

We received training on key Lean principles which taught us that spending time searching and fetching items means less time spent on real work – time with our patients. Even when we can easily find an item, does it make sense for us to put items out of reach, i.e. too high or too low? Why not imitate the supermarkets that place frequently used items at eye level, like bread!

Lean calls these non-value added steps, “waste”. We spent the day removing as much waste out of the clean supply room process as possible. Last week, we counted the par stock right after it was fully stocked, then counted again the day after before it was restocked. This gave us the number used for one day and was used to determine the amount needed on your supply room carts (called the par number). We realized we had more stock than we needed in some cases and not enough in other cases based on this count so we removed all excess stock as well as added additional stock where needed.

Once we regained additional space, we organized the stock logically by function and for flow. For example, you will see we now will have zones for Housekeeping, ADL, GU/GI, Wound Care, Procedures and Respiratory. We then placed the most frequently used items at eye level to reduce bending and reaching. Most items are now in bins and the bin sizes indicate the amount of stock needed. The bins will have 3 labels: the “common name label” on the front of the bin – what most of you call the item, the “picture of the item label” on the bottom of the bin to tell you when that bin is empty what belongs there, and finally the “reorder label” also on the bottom of the bin that tells you the item number, cost & the ordering amount so when you are out of an item, you have the information needed when calling distribution.

Some examples of changes:

Items moved to the kitchen: Pitchers, liners, straws, cups
Items moved from Med Room to Clean supply room: Stat Lock for Piccs
Some skincare items were removed at the suggestion of the wound care specialist. These items will be reevaluated at the wound care task force tomorrow. (Keri Oil, Keri Lotion, Duoderm, Sheepskin, A+D Ointment, Antibiotic Ointment
Items that were added include: Duoderm Gel, Barrier Wipes, 5x5 Allevyn Foam, Non sterile suction tubing, Wound Cleanser, 9” armboards
Cable ties were moved to the resource drawer with the gun
Flashlights are now stored on equipment shelf in RN station.
Sustaining the gains

Lean taught us that this is a continuous improvement process so please give us your feedback and we will continue to improve. All of us own this process and keeping the Clean Supply room neat and tidy depends on all of us.

Thanks to Marnie, Pam, Bettyna, Marie, Singh, Beth, Catherine, Marnie, Martha, Bill, Jenine, Sam, Brandan


Tuesday, August 19, 2008

There's something happening here

Fellow blogger Jessica Lipnack has sent me news about an extraordinary social media experiment being led by General William B. Caldwell. General Caldwell believes that the strength and expertise of the military can be enhanced by the free flow of information offered by blogs. He has lent his considerable stature as a Three Star General to the concept, and he is in a unique position of influence in that he heads a major component of the officer training center for the US Army.

Here is the introductory paragraph from his product:

The US Army Combined Arms Center Blog Library is intended to inform and educate readers while providing a medium for intellectual discussion and debate about important issues involving the US military in today's environment. The blogs contained in this library are intended to elicit comment. Our blog rules provide a wide degree of freedom. They are intended to allow individuals to express opinion and ideas in the interest of intellectual discourse and increased mutual understanding. We strongly encourage intellectual comments and debate.

Recently, members of Congress offered guest postings on this blog. I am sure that having these champions for our soldiers do so provides still another level of institutional support for this concept.

But this is not just a forum for general policy discussions. For example, look at this post: Campaign Planning in Counterinsurgency. This and other topics traditionally would have been quietly discussed in classroom settings. Here, though, General Caldwell and his colleagues have created an open forum to stimulate debate and creative thinking. The blogs permit this to go on asynchronously, enabling individual reflection on the principles taught in the classroom and allowing people's thoughts to evolve over time, while connecting back in a helpful way to their colleagues. The asynchronicity is logistically important, too, when you consider that our soldiers are stationed in many time zones across the world. I am guessing that our military men and women will gain new insights from this type of learning and sharing.

It is impressive, too, that General Caldwell has not been held back by the traditional view that public disclosure of military topics represents a breach of security. As we all know, many of these topics are in the public gristmill anyway, and many claims of a need for secrecy are overstated. While I am sure that some areas will always have to remain off-limits for national security reasons, it is good practice for military officers and others to express their ideas in a public forum and experience the nonhierarchical give-and-take of social media.

In short, this is a really impressive venture. Jessica first wrote about this several months ago here. One of the comments on that post, however, is indicative of the objections that could arise:

I think the military is one of the few places where Web 2.0 / Enterprise 2.0 / social media paradigm is not appropriate.

The military relies on the chain of command and respect for the hierarchy to operate effectively, especially when lives of the soldiers and civilians is on the line. The web 2.0 paradigm flattens the structure and effectively allows anyone to say anything. That breaks down the chain of command.

The other issue is possibility of soldiers inadvertently revealing operational matters, operational history or location information that could expose information to combatants.

These are interesting points, but I, for one, am confident that people of General Caldwell's intellect and thoughtfulness will work through those issues in a way that is consistent with the core values of military strategy and execution. He and his colleagues deserve our enthusiastic support and appreciation.

Bullish on the Container Store

Quick, buy stock in the Container Store. As we continue with our expanded use of Lean process improvement techniques at BIDMC -- often originating from a BIDMC SPIRIT call-out -- a big part of each project seems to be reorganizing stuff. Here's an example from a recent exercise in our food service area.

The "before" picture shows you what things were like for the folks who organize and retrieve kitchen and serving supplies. Notice the mish-mosh of boxes, and look to see how hard it is for the staff member to reach the high shelf. Also, consider how dangerous it is for her to do so, with the chance of boxes falling on her head. The supplies themselves are kept in the original packing boxes, requiring someone to open a box each time something is needed. Only after opening the box, too, can they see if the inventory is running low.

The "after" picture shows you the change. Notice that the top shelf is now off-limits. Meanwhile, supplies have been organized in see-through containers, each with a clear label showing what is packed therein. The bins are easily pulled to permit removal of the supplies. And, because the original delivery boxes have been emptied, inventories are clear on a continuous basis.

As we say in the hospital world, this is not brain surgery, but it does require a thoughtful view of the work situation. That view, by the way, is constructed by the people who work in this area, not by some high ranking administrator. They get guidance from our Lean project team in the basic principles, but they are the ones who own the solution.

Monday, August 18, 2008

From my former life

An op-ed in yesterday's Boston Globe about management of large public works projects, based on my experience running the metropolitan area water and sewer agency. (You know, it is hard to squeeze things into the 700 word limit they give you!) I am hoping it will be helpful, not only in the specific advice offered, but in reminding people that it is possible for the state to build high quality large public works projects. We are going to need the public's support for those over the coming decades as we plan and implement other major infrastructure improvements.

Sunday, August 17, 2008

Henna, Xeloda, Roche, Europe, August

Monique Doyle Spencer's Op-Ed about the use of henna as an antidote for a known side-effect of Roche Pharmaceutical's important cancer drug, Xeloda, has been picked up and published by the International Herald Tribune. Roche is based in Europe, so maybe the article will get more attention there. On the other hand, it is August, and people in Europe often take off the whole month. That probably would explain why I have received no reply to my note to the CEO of Roche on the same topic.

Meanwhile, even though it is August, Monique did receive an apologetic note from a staff person at Roche, particularly for the part about inquiring about her long-dead mother, but the person missed the point again. With her permission, I include excerpts from a follow-on note from Monique:

I appreciate the kind letter you sent. I understand how mistakes like this happen and I'm sure everyone felt chagrined....

I have exactly one issue. I am deeply frustrated that no one has answered my question: Does anybody at Roche seek remedies for side effects due to Roche's products? Is that anybody's job?

To be honest, I have no interest in becoming a henna poster child. Yet ... when henna came my way, it made a great difference in my ability to tolerate Xeloda. The Xeloda will extend my life and the henna is the ONLY reason I can tolerate the Xeloda....

In New England, the Boston Globe and WBZ radio reach a broad audience, so I am receiving phone calls and letters asking for my help. I've created a
web page to send people to, giving them full instructions about henna. Elderly people often do not have internet access, so in some cases I've given people henna or sent them printed instructions.... I expect word to continue spreading. I've already noticed the story appearing on cancer bulletin boards, and I've posted on a few to pass information along.

My point is that people really suffer from HFS. For some it keeps them out of their favorite sports, for others it is crippling pain. I just want somebody with the means to help them! I hope that Roche will look into it, or fund a study to prove or disprove henna's efficacy.

Can you help?

Thanks again for your kind letter.


Monique Doyle Spencer

Sunrise over Pamet Harbor

Saturday, August 16, 2008

Exercise equipment secondary market?

Pictures from a recent visit to the Town of Truro solid waste transfer station. Note, in this pile of stuff, the disproportionate representation of exercise equipment, whether stationary bicycles, stair steppers, or other varieties. I don't know if these are thrown out by year-round residents or by the summer "wash-ashores" in this Cape Cod community. I wonder if all those people who have been laid off this year by those secondary market mortgage investment companies would want to think about creating a secondary market in this equipment.

Friday, August 15, 2008

Facebook for my generation

Can't wait to add some friends, but I keep forgetting my password.

(Click on the image to enlarge so you can read the entries.)

Thursday, August 14, 2008

Summer term is over

A picture from a farewell luncheon for our Summer Health Corps high school volunteers who have spent the last six weeks working at our hospital. They found themselves in a variety of settings, from the GI unit to the post-op area to radiology. We were happy to have them here, and we hope that the experience promotes a longer term interest in hospital and health care for at least some of them.

Which people?

"There are many people who would prefer to see this site never get off the ground, and as participants in the system, there are dozens of ways to delay and roadblock development and implementation."

Wow. This is a pretty important statement by Charlie Baker, CEO of Harvard Pilgrim Health Care. He was talking on his blog about continuing delays in the public posting of payment information by the MA Health Care Quality and Cost Council. The information would indicate how much individual hospitals get paid for particular services by the state's insurance companies. Charlie is a member of the Council and has been working for months in trying to move this along.

Let's think this through. Which people could possibly have an interest in slowing down the publication of this information? You can post your answers below.

(Disclosure: Charlie is a member of the BIDMC Board of Trustees, an advisory body to our hospital, not the fiduciary governing body.)

Wednesday, August 13, 2008

3v3 Soccer Tournament to benefit AIDS programs

Finally, I get to combine my soccer and work interests! A note from Nadia Ouhib, on our Neurology staff, but also a student at Boston University. We are happy to help sponsor this event, and I encourage you to join in for this worthwhile cause:

I am responsible for a tournament that I have been organizing with the BU Soccer Club, called the "Lose the Shoes" tournament on September 27th. It will be a series of 3 v. 3 matches where students from schools all over the Boston area will compete, enjoy live music, and free food with their $5 registration fee at BU.

This tournament, however, is no ordinary event. It is being held in cooperation with Grassroots Soccer, an organization committed to fostering AIDS awareness and prevention in Africa. A charity event, all proceeds will go to Grassroots Soccer and their beneficial efforts to help those less fortunate. The theme of the tournament, "Lose the Shoes," requires students to play barefoot (or with socks) on our brand new turf field, similar to games played in the streets of Africa. We anticipate a fun and successful event.

Check out details on the tournament and other events! Our BU Soccer Club event website.

Lusaka Sunrise: Watch this YouTube video to learn about the program in ways words can not describe.

Tuesday, August 12, 2008

Surprising use of Lean

A note from one of our rehabilitation staff, who had gone through an exercise in learning and applying Lean principles in the occupational therapy clinic:

The Lean organizational concepts have been helpful for me with patient care and in one case recently in particular!

Recently I treated a young patient with early Alzheimer's who needs to organize home etc. to help him with memory impairments. It was very helpful to show him some of the ways we have organized our department to improve our efficiency, particularly with the labeling. I feel that those same concepts will be helpful for him to organize in his home environment as it needs to be extremely organized to help him with memory impairments.

I don't know if people elsewhere have used this approach in a therapeutic way and put this story out there to see if so and to welcome comments if you have. (Mark Graban or others, do you have examples of this from your extensive experience?)

More on henna

Monique Doyle Spencer shared with me a letter she received after writing her recent op-ed about the potential value of henna in ameliorating side effects of an important cancer drug. I reprint it with permission of the author:

I was very interested in "Anybody Want a Zillion-Dollar Cure Idea" (Globe Op Ed 8/1/08). My twin brother was diagnosed with colon cancer and was also put on chemotherapy using Xeloda. He suffered mightily with the same side effects as Ms. Spencer. We constantly asked "Can't something be done to relieve this torture?" After four years of suffering, he died last May. It is sad to know that the drug company could have conducted a study of this simple antidote or noted on their website the relief that some people had received. Shame on Roche Pharmaceuticals and the industry.

When I wrote about this below, at least one commenter suggested that it would be difficult for Roche or a similarly situated pharmaceutical company to make recommendations about this or another antidote, citing legal and regulatory issues. I don't know enough of the law to address that. I also have to assume that the response Monique received to her queries never made it up the full chain of command in the company and so might not have been reflective of the view of senior management. So to be fair about all of this, I am going to do my best in the next few days to contact my CEO counterpart at the company and make him aware of all this and see if he is interested having some of his folks brainstorm with our people and others like Monique about how to get the word out or do more research on this matter.

Monday, August 11, 2008

Don't blame me. I'm from Massachusetts.*

I recently wrote about the large sums of money being spent by the SEIU to influence current elections and raised the question about when and if the topic of the so-called Employee Free Choice Act would enter the candidates' debates.

Around Boston, these kind of comments have been used by some to portray me as out of touch with the traditionally liberal bent of Massachusetts politics. Now, to my rescue comes none other than -- tah dah! -- George McGovern. In an August 8 op-ed in the Wall Street Journal, he raises exactly the same issues.

Here are the final two paragraphs in his article:

I worry that there has been too little discussion about EFCA's true ramifications, and I think much of the congressional support is based on a desire to give our friends among union leaders what they want. But part of being a good steward of democracy means telling our friends "no" when they press for a course that in the long run may weaken labor and disrupt a tried and trusted method for conducting honest elections.

While it is never pleasant to stand against one's party or one's friends, there are times when such actions are necessary -- as with my early and lonely opposition to the Vietnam War. I hope some of my friends in Congress will re-evaluate their support for this legislation. Because as Americans, we should strive to ensure that all of us enjoy the freedom of expression and freedom from fear that is our ideal and our right.

*To assist those readers under a certain age, this was a popular bumper sticker in 1973 and 1974, after the 1972 Richard Nixon Presidential election victory. McGovern only won one state's electoral votes, Massachusetts. Nixon resigned the presidency this week 34 years ago after it became clear that he had authorized or condoned illegal activities against his opponents during that election.

Sunday, August 10, 2008

Seals in Motion

A video of some of those seals I mentioned several days ago on a sand bar just off of Head of the Meadow Beach in Truro. The cows are quick to head to the water when approached. The bulls stand firm!

Saturday, August 09, 2008

Real baseball

Player and crowd scenes from a playoff game between Orleans and Harwich at the Cape Cod Baseball League tonight. This is real community baseball, where college kids are given local housing and part-time summer jobs so they can play for several weeks at fields where the fans can sit close and meet the players and the mascot. After each game, a local restaurant, business, or family treats the players to dinner. One in 7 of all Major League Baseball players played in the Cape Cod league!

August self-portrait

Eat your heart out, Rembrandt!

Wednesday, August 06, 2008

Budget Time

It's budget-making time in the hospital world, as many of us prepare for the fiscal year starting October 1. I suppose there was an era when this was easy, but those days are long gone. To put it simply, the cost curve is going up faster than the revenue curve. Other types of business deal with this by adding new product lines, enhancing the value of those products already offered, increasing marketing to gain market share, and garnering efficiencies in the production process. Most of those options are not so available in the hospital sector, and particularly for academic medical centers.

Like other hospitals, we at BIDMC have five revenue sources, in size order, clinical services, research, current use philanthropy, investment returns on our cash assets, and royalty or equity payments from the sale or licensing of intellectual property. Of our $1.2 billion in revenues, though, the first two predominate by far. About $1 billion comes from delivery of inpatient and outpatient care, and $200 million comes from research grants. The remaining three items are measured in the $10's of millions, all together.

The business model for academic medical centers has been to enhance clinical revenues by building sufficient bed and clinic capacity to increase both the volume and acuity of patient visits. On the research side, the business model had been to take a loss-leader for several years by providing laboratory space and salary support for the best scientists, with the expectation that they will be sufficiently productive over time to cover both their direct costs and also contribute to overall corporate revenues through indirect cost recovery.

Thus, hospitals faced a clear growth imperative. As long as your incremental revenues from treating more patients exceeded the incremental costs of treating those patients, each year could show improvement over the last. Likewise, as long as you could count on those new researchers to get off the dole and eventually cover their space and personnel expenses with ever-increasing grant revenues, all would be fine. Indeed, the expanding research enterprise would contribute enhanced indirect revenues to help offset the hospital's fixed overhead costs.

For years, all was well on the clinical side of the house. While government payers (Medicare and, especially, Medicaid) did not cover their full cost of service, payments from private insurers would make up the difference. Now, though, we can project a declining rate of payment increase from both the federal and state governments, increasing the needed subsidy for those elderly and poor patients -- but precisely at the time private insurers are recoiling from doing so because of pressure they feel from their business and individual subscribers. Private insurers are making clear that they don't want their rates to increase faster than their estimate of overall (not health care) inflation, and, also, they feel less obligation to make up the shortfall in government payments.

The private payers are also more and more interested in move towards some kind of capitated rate system (i.e., paying $x per year for the full spectrum of medical care) for those patients covered by their insurance products. In the past, if their rate was a bit too low, selling more units of care to an ever more service-demanding population could make up the difference. Now, though, they are looking to control the product (rate X units) and therefore want to move to a more global fee per patient per year.

On the research front, a dramatically slower growth rate in NIH funding for biomedical research means that many more of those bright researchers you recruited or were just about to recruit into the research labs you just constructed will find themselves unfunded for longer periods of time. You either have to cover their salaries, lab expenses, and space costs from general hospital revenues, or lay off scientists and just cover their now empty space costs -- all the while explaining to your highly skeptical faculty that you remain fully committed to a strong research program.

What, then, is a business plan that is most likely to produce overall positive net income for a hospital over the coming years, income that is essential for capital investment for renewal, replacement, and enhancement of clinical and research functions? (For the accountants out there, think about a target of funding 130% to 140% of depreciation each year -- requiring an operating margin of at least 4%. Please note that I am talking about a hospital in good standing, not one that is engaged in a financial turnaround.)

1) Focus on growth in clinical services that are most suitable for a high level tertiary facility, those that coincidentally produce the best margins. Meanwhile, stabilize, reduce, decant, or eliminate those that do not. But decisions here must reflect the interdependencies of low-margin and high-margin specialties. For example, you cannot eliminate the low-margin nephrology division if you intend to expand your high-margin kidney transplant program. And, you can't eliminate money-losing psychiatry at all, given the pervasive co-morbidity of mental illness with many physical illnesses, especially among the elderly.

2) Optimize use of space. To the extent you can avoid expensive new construction (currently priced at over $1000 per square foot for construction costs alone) by reconfiguring space use, you avoid new fixed costs and are able to expand volume at lower incremental cost.

3) Achieve operational efficiencies. No, not by an administrative fiat that reduces staffing, but by application of LEAN methods or other improvement programs that tap the know-how and creativity of your front line staff. But, you need to aim for double-digit improvement, not just 1 or 2 percent per year.

4) Work to eliminate preventable harm. When hospital acquired infections, for example, are avoided, the extra costs of extended lengths of stay are also avoided. Even under most current insurance payment methodologies, the business case for harm-avoidance is compelling.

5) To the extent insurance rates move toward capitation, learn to coordinate and manage care across the spectrum of services. This is really hard when you don't control, say, that nursing home that receives your discharged patients. But get ready for the day, by enhancing interoperability of medical record systems and building cooperative relationships among the physicians along the spectrum of care.

6) Meanwhile, research must also be managed, not just to produce higher revenue per square foot, but also to ensure that the research agenda is consistent with the hospital's clinical priorities. There is probably, too, an optimum range in the overall size of the research program for a given overall hospital size. Analyze this, and head towards that target over time.

7) Understand that philanthropy is the fourth line of business -- along with clinical care, research, and teaching -- if an academic medical center is to thrive in doing those functions society expects of it. Whether enhancing the income statement with current-use unrestricted donations or relieving capital budgets with restricted-use investment gifts, philanthropy is an essential component of hospitals' futures given other economic trends. Generally, investments in philanthropy yield about 16 times their annual cost and therefore represent one of the highest and best uses of operating funds.

I don't think that anything I have said here is new or controversial among hospital administrators or their Boards. However, it has become clear to me that many of these concepts are outside of the realm of experience of many hospital doctors, scientists, and other staff. If you are reading this and it is new or strange to you, please comment. If you are reading this and are involved in hospital management or governance and have something to add or subtract, please comment, too.

Tuesday, August 05, 2008

Henna, ha, hai na*?

Monique Doyle Spencer offers a damning op-ed about the unresponsiveness of Roche Pharmaceuticals to an off-the-shelf remedy (henna) for a widely known side effect (hand-and-foot syndrome) of its cancer drug Xeloda (capecitabine). The fact that she does so with her usual dry humor should not disguise that fact that she has a very serious and important case to make.

Putting aside the bureaucratically ham-handed response from the company to her suggestions, there is a real substantive issue here. Why isn't the company helping to tell the story of a low-cost, easily available antidote to that side effect? The drug they sell is an important and good one. The uncomfortable, and sometimes painful, side effect is openly acknowledged. The antidote works in at least some cases and clearly has no adverse impact on patients. (If henna has a major side effect, millions of Indian brides are at risk!) Why not tell them about it, or at least encourage others to do so?

Meanwhile, Monique herself has begun a small campaign to spread the word about this particular remedy. Check out this new blog she has set up, where she notes:

"I want to spread the word about this treatment. It's simple and cheap. By the way, I don't own any henna companies or websites of any kind. I'm a cancer patient trying to help anyone with this syndrome. If you have it, you understand why."

Pharma companies have all kinds of ways to get their message out when it comes to selling their products. Surely a clever person at this firm could figure out a way to do so here that would enhance their public image and not put them at legal risk. Maybe, as a start, Roche should link their website to Monique's blog.

Disclosure: I have not contacted anyone in our hospital to determine if we have any financial dealings with this company. We are often engaged in clinical trials with pharmaceutical companies, and we may or may not be with this company. As should be evident from what I have just written, any such relationship that might exist has had no influence on the content of this blog posting.

* = Hindi slang for "Yes, is it not?" Sorry, couldn't resist.

Sunday, August 03, 2008

Next stage of transparency

Several months ago, we announced some audacious goals for BIDMC that were established by our Board, including elimination of preventable harm by 2012. We also promised that we would publish our progress towards that goal. We have now set this up on our website here. You can watch to see our data each quarter in each of the several categories listed.

When we were getting ready to publish these numbers, some of our trustees asked if we could put the numbers in terms of the percentage of cases in which there was preventable harm. By that measure, the number would be very, very small, about 40 cases out of over 200,000 in a calendar quarter, about 2/100's of a percent.

We said, "No, the point is to emphasize that each of the case involved an actual human being." Describing them as a percentage would dehumanize the physical impact on a real person, someone's mother, father, sister, or brother.

Last week, I was invited to give a lecture on this topic at the Harvard School of Public Health, and a different question was posed by a doctor in the class. "How can you set a target of zero," he asked, "when we know that zero is impossible?" I replied, "Putting aside the question of whether zero is impossible, the most motivational target is zero. If you say that we are trying to reduce, say, infections by 20 percent per year, people will feel satisfied if they meet that target. The idea is to establish creative tension for the organization by adopting an audacious goal. And, by the way, in certain areas, other hospitals have shown that zero is attainable for extended periods of time for certain types of error-avoidance."

At the other end of the spectrum, we are taking criticism from some people who see an inconsistency between these efforts at transparency and our lack of discussion or disclosure about particular cases. But we need to do that for reasons of patient privacy or for other legal reasons. For example, when a malpractice case is filed, we cannot and will not discuss that case publicly. For one thing, any comment we make can be construed as a violation of the patient's privacy. For another, as any lawyer will tell you, it is simply bad policy to discuss issues of this kind of litigation in a public forum. The plaintiff's attorney faces no such constraints, of course, and might perceive some benefit in holding a press conference to discuss the case. While we understand a reporter's desire to write a balanced story, our reply usually has to be, "No comment."

But outside of a particular lawsuit story, what are we going to say and disclose about all these cases of harm that are summarized on our website? The answer is that it depends. You can see from the chart that there are currently over 100 cases of preventable harm per year spread over several categories. As we have recently, when we think a specific case warrants wide public disclosure to help our staff be alert to a major challenge or teaching opportunity, we will give it wide circulation. Other specific cases will be given more limited distribution among our staff, consistent with their value in teaching about the need and means for quality improvement in a given sector of our hospital. And, in other situations, a pattern of several cases of a certain type might be presented to particular segments of our staff as a warning of a problem area.

We understand that our inclination towards transparency will garner criticism from some who think we are not being transparent enough when they have an issue or curiosity about a particular case. That is a by-product of what we have chosen to do, and we accept that.

Another by-product is that publication of these numbers may give the impression that we harm patients more than other hospitals. After all, we publish our numbers, and they do not. And many cases we publicize to our staff will inevitably be considered newsworthy by the local media. This, in fact, is why doctors and hospitals often don't like to talk about this stuff. Fundamentally, they don't want to be judged by the general public and the media, whom they deem to be unqualified observers of the medical scene.

Anyway, I want to assure you that there is no indication whatsoever that we harm patients more than other hospitals. (In fact, we know that our figures for certain types of hospital acquired infections are well below average.) But please remember that every study or analysis ever done indicates that hospitals rank highly among the country's public health hazards. Don't think that you are more safe in a place just because they don't talk about their errors. We believe that the only way to improve in this arena is to be open and honest about your mistakes and thereby enable people to learn from them.

Saturday, August 02, 2008

Cape Cod Seals

Seals (300 of them!) on a sand bar near Head of the Meadow Beach in Truro. Click on the picture to get a close-up view. Below, boy approaches carefully to get a good shot.

Friday, August 01, 2008

Where's Wally?

I know people from outside New England will believe that I am absurd in saying this, but the resident of this bedroom is one of the luckiest and happiest children in the region. This mural was produced by Emergency Department X-Ray staff member Amanda Martin (seen above). I am pleased to note that she even included the BIDMC logo on the jumbotron, once again reiterating our presence as the Official Hospital of the Boston Red Sox and of Red Sox Nation.

A REAL premier gold card

How many of those credit card offers do you get in the mail each week? I can't keep count anymore. You might never believe there is a crisis in the capital markets associated with inadequate due diligence before offering people credit.

But every now and then one comes through that you are tempted to sign. This one wended its way to my office, having first been mailed to me at our division of otolaryngology. That alone should have given me a hint. (Not being an MD, I am not anything close to an otolaryngologist and have always had trouble pronouncing the word.)

It was a premier gold card from Capital Network Leasing Corporation, aka CAPNET. It offered me $100,000 in available credit -- 0.0% interest or no payments for 90 days; no activation or annual fees; and seasonal promotions for preferred customers. In small print, it said "We will not require financial statements or tax returns for any transaction under $100,000, but do reserve the right to request and verify your financial statements and tax returns for all transactions over $100,000.

I'll keep my transactions under $100,000 so I don't have to provide proof of creditworthiness. I hear that you can get good deals on HumVees right now. Maybe I can squeeze in two under the limit.

But, boy, if you get $100 grand with a gold card, imagine what platinum would bring!