Saturday, February 27, 2010

Moore's code

Although Massachusetts is a relatively small state, it has the sixth largest (by acreage) state park system in the country. One example is Moore State Park in Paxton. Here are two details from a winter walk.

Friday, February 26, 2010

It is up to us, not the US

A conversation with a reporter yesterday helped me clarify my thoughts about federal health care legislation. In my view, the most effective role of the federal government would be to provide national standards by which the health insurance companies operate (e.g., with regard to pre-existing conditions, rescission, and lifetime limits), require the existence of insurance exchanges, and establish the conditions under which universal access to insurance is made possible. Other items I would suggest for federal legislation are summarized below.

I am hoping the US government will not attempt to control the costs of health care by making legislative decisions with regard to clinical matters. Not because we should abandon cost control; but because federal efforts in this sphere are likely to be crude and not clinically appropriate. You just have to look at the process by which the USDA food pyramid is influenced by food product lobbyists to imagine how the government would attempt to regulate the design and provision of care among medical specialties, equipment and supply manufacturers, and pharmaceutical companies.

As should be evident to readers of this blog, I think it is possible for the participants in the health care system to accomplish major changes in the rate of medical cost inflation. Two articles have this theme. One is by Business Week's Catherine Arnst. The other is by Lucien Leape, Don Berwick, and others in Quality and Safety in Health Care. Both are worth reading, and they overlap in recommending several areas -- reducing infections and other preventable harm; empowering patients and families to participate in their care; and disclosing and apologizing for mistakes.

Beyond these articles, there is a remarkable consensus on these items, and yet hospitals and doctors often fail to implement them. Even hospitals that house some of the most accomplished authors in these fields often do not follow the advice of those colleagues when it comes to making improvements in the delivery of patient care.

It is not unusual for industries facing structural change to be slow to move. Why? Because the leaders of those industries were promoted based on their success in the past financial, political, and social environment. They were hired for their ability to maintain the status quo, rather than for their ability to make change. Eventually, though, societal forces make themselves felt. If an industry does not adapt, the government will step in. The medical profession has to decide whether it wants to take charge of this process or abdicate to Congress the right to act in its stead.

Thursday, February 25, 2010

More on Atrius and BIDMC

Several weeks ago, I wrote about a new clinical partnership between Atrius Health and BIDMC. Today's Boston Globe has a story by Liz Kowalcyzk that provides more context for this relationship.

The article mentions the integration of our electronic medical records. John Halamka describes this in more detail on his blog:

By working with Epic and Atrius, we enabled a "Magic Button" inside Epic that automatically matches the patient and logs into BIDMC web-based viewers, so that all Atrius clinicians have one click access to the BIDMC records of Atrius patients.

No additional password required. Nothing. The entire BIDMC medical record appears. Now, computers are just tools, but it helps to have this kind of interoperability when your goal is greater coordination of care.

Wednesday, February 24, 2010

The infrastructure chronicles -- Volume 3

Back to our occasional series on infrastructure. For this post, I will be digging back into the telecommunications portion of my career, to a period when tin cans and string dominated the industry.* Well, maybe not quite so far back, as that, but far enough that I came up empty when I did Google searches on some of the terms below. But let's get to the point.

Have you wondered how companies can offer you free teleconferencing service? Most of us are used to paying for this service, but there are a bunch of firms that offer it for no fee, and will even create customized numbers for you and offer other add-ons. How do they do it and make any money?

The answer goes back to the monopoly days of the Bell System, when AT&T and its subsidiaries dominated. But even then, there were a number of small local telephone companies, often serving rural areas. The policy at the time was to share the revenues of the Bell System with those companies to help subsidize local telephone service in otherwise isolated communities. The mechanism for doing this was called the Separations and Settlement Process.

Once a year (think "sweeps week" on television), the traffic coming into and out of these small companies was measured and provided the basis for the number of dollars that company would receive as a gift from the overall revenues of the Bell System. It worked for everybody. Ma Bell didn't care, as it was awash in revenue anyway; and it didn't want to incur the high per subscriber costs inherent in serving rural areas. The local telco's likewise welcomed the income, which enabled them to keep down the cost of basic telephone service while providing hefty profits for the owners of those companies.

The system was often manipulated. The subscribers in Smalltown were told by the local telco when the measurement period was occurring. They were urged to make as many calls as possible during that week, knowing that doing so would pay dividends for the rest of the year.

Fast forward now to the end of the AT&T monopoly, the introduction of long distance competitors like MCI and Sprint, cellular service, cable TV, and other technological advances. Consider the Telecommunications Act of 1996, which served to open up the very switches owned by the big regional telephone companies (like Verizon) and the little ones, too, to anybody who wanted access to those computer racks.

Through this all, Congress preserved the policy goal of subsidizing local exchange service, especially for rural areas. Over time, new versions of the Settlements process emerged. It still pays for those local telco's (now called local exchange companies, or LECs) to have traffic, in that they are paid extra money from the national pool of telecommunications revenues based on minutes of use emerging from and ending in their central offices.

Now, you are starting to get the idea. A teleconference company mounts its switch on the rack of a carefully chosen LEC, maybe somewhere in the middle of Iowa. The teleconference company's very existence provides extra traffic for that LEC, generating extra Settlements revenue, part of which is shared with the teleconference company. The company does not need to charge you a fee for a teleconference, because the entire United States is already paying for it.

What is the difference between the service and technology behind the free teleconferencing service and the one you pay for? Nada.

Why would you ever want to pay for this service? Beats me. You and everyone else already are, in your regular local and long distance telephone rates.

How long will this deal last? When was the last time Congress took away a subsidy?

Now you can understand why I love health care. Having been weaned off the world of telecommunications subsidies, I craved a field in which the subsidies are even more rampant and impossible to untangle.

* I worked as a telecommunications regulatory consultant for a while, and I was also Chairman of the MA Department of Public Utilities, which regulates common carriers in the state.

A back-handed way to make policy

One of the arcane steps in government regulation of health care is the Physician Payment Rule. This is the manner in which CMS, the Medicare agency, annually allocates payment dollars among the various specialty services. The PPR effectively makes policy.

The construct for all of this is a zero-sum game. When CMS wants to raise fees for some specialties (e.g., primary care doctors), it is required to reduce the fees for others.

The American College of Cardiology notes that the most recent version of the PPR contains such a drastic reduction in payment rates for office-based cardiology diagnostic tests that many community cardiologists are considering joining a cardiology service in a hospital.* So what's wrong with that? Well, once those MDs start providing the same services in a hospital, it means fewer services will be available close to people's homes in the community. Further, the rate the hospitals can charge for exactly those same diagnostic tests is higher than the private doctors could charge.

So the overall cost to society of health care actually goes up, notwithstanding what is supposed to be a zero-sum impact. Patients are inconvenienced, too.

As you know, I have advocated for an increase in payments to PCPs, so they can spend more time with patients and get out of their triage role. But it is short-sighted to require that, in the short-run, the sum of physician payments from Medicare not change. Perhaps the President and Congress can add this item to their health care summit discussions.

*ACC also charges that the CMS data and methodology are flawed. I don't comment on that.

Tuesday, February 23, 2010

Dr. Cocchi goes to Haiti

This is a story about and by Michael N. Cocchi, MD, a fellow in Critical Care Medicine in our Department of Emergency Medicine. He joined a group of doctors and nurses recently in a medical relief mission to Haiti. It was his first time on such a mission. When I heard some of his stories, I asked if he would be willing to share them with us.

The photo of his patient Yvonne and the circumstances surrounding it are described in the video.

If you can't see the video, click here.

Easier than voting for tax increases

Just a thought as federal and state policymakers make speeches about putting a lid on the rates charged by private insurers. One of the best kept secrets of health care reimbursement rates is that the federal and state payers, Medicare and Medicaid, do not pay rates that are fully compensatory. This means that private insurers pick up the subsidy for the public plans and include those costs in their rates so that hospitals and doctors can be kept whole.

So . . . the fastest way to hold down insurance rate increases would be for the federal and state governments to pay their fair share. Of course, then someone would have to increase taxes. This takes political courage and a commitment not to hide the full costs of government programs. How much better to use the insurance companies as tax collectors instead.

Monday, February 22, 2010

The Bucket Brigade

These are pictures from the founding meeting of The Bucket Brigade on January 9. This new charitable organization is the brainchild of Monique Doyle Spencer (seen above) after meeting Samuel Kuacliet (below). It is further described in a Boston Globe story today by Adrian Walker.

Samuel's village in southern Sudan was attacked in 1987 when he was tending the cows, and at age 6 he and his family walked 1000 miles to Ethiopia to escape. A number of the refugees were eaten by lions along the way, or starved, or otherwise perished. After the war between Eritrea and Ethiopa erupted, they returned to Sudan. During this rainy season walk, a number of refugees were eaten by crocodiles, or starved, or otherwise perished. They were forced to leave Sudan again in 1992, this time to Kenya.

In 2001, Samuel managed to immigrate to the USA. Seventeen years later, he returned to his village in Sudan and saw his mother again. During that intervening period, he did not know whether she was alive or dead.

He brought back money and goods for his community. When Monique heard this story, she decided to start a charity to provide direct assistance to this village, called Yirol. As noted on the website:

We’ve adopted one village. We’re a group of volunteers, so the overhead will be minimal. Each year, our volunteer will go home and, working with the villagers, assess the highest needs.

That’s when we spring into action, wiring funds directly to merchants and our volunteer. We monitor every penny and encourage new ideas to help the people of the village develop self-reliant ways to survive.

I was honored to be asked to serve as a founding member of this board. I hope you will find the story compelling and contribute funds to serve this small corner of the world.

Not facing the odds

My friend Sam Mygatt died last Tuesday. I am posting, with her permission, remarks that Sam's daughter Jen offered at his memorial service. Sam and Jen provide us with important lessons. The first is about the value, or lack of value, associated with statistics. The second one shows how a family can interact with a receptive medical team to make a real difference in the treatment of a patient.

Dad told me on Monday that he figured there was a “Better than 50% chance,” that he would die either that day or the next. 50%: it strikes me that these have been some of the best odds Dad has had in the past years.

He and I made a deal on Monday afternoon, that at his memorial service, I would tell you all about the role I played in his cancer treatments over the past several years. He thought it might be useful to some of you in the future. So here goes.

First, statistics. They work on a population level; they don’t mean much when you’re talking about one person. I remember reading, in 2006, that 92% of patients who have synovial sarcoma will also have metastatic synovial sarcoma at some point. Pretty nasty. But look, you either have metastatic disease or you don’t: you never have almost-metastatic-but-not-quite disease. Dad knew there were unpleasant statistics, probabilities, and time frames to be found should he look, but he intentionally did not. In not knowing them, he wasn’t bound by them, he wasn’t limited by them, and he refused to be governed by them. “Come and get me,” was how he approached it, and on he went.

In 2006, we moved into the realm of clinical trials: high risks, possible yield, but no real expectations. The 20-page consent forms stated, among other things, that Treatment X was not expected to help us; hopefully it could help others in the future. Before Dad embarked on each clinical trial, I read up on the drug, to get a sense of what might be in store for us. We fell into an agreement that I’d sift out unpleasant statistics and unnecessary information, tell him what I thought might be most useful to him, and make sure to offer whatever strands of hope that I found. Certainly, some people want to know all that they can about the disease they have, but not Dad. In the way he and I split the work, he was able to focus all of his energy on healing and strength and priorities, and I was able to anticipate pitfalls and dig around for back-up possibilities should the current treatment fail him.

Over the next several years, I read up on synovial sarcoma, following any lead back to reliable sources, before bringing select findings to Dad. An online sarcoma forum provided some of my best ideas, and a research database called PubMed was an amazing resource to ground these ideas in science and credible possibility. Dad has had a remarkable oncology team in Boston, and everything I did was ancillary to that. Dad’s oncologists and nurse practitioner both welcomed and came to expect Dad’s enthusiastic participation in his own care, and so I was able to participate.

Because clinical trials are on such shaky ground, it seemed remotely possible I could find something to actually help him, that he wouldn’t already get from his oncology team. Amazingly, I did. Two examples for you.

In December, 2006, one of Dad’s meds quite suddenly rendered him unable to walk or use his hands for a week. We didn’t know that the cause was peripheral neuropathy, a semi-preventable side effect. But you can’t prevent it unless you anticipate it; we hadn’t, because it was not emphasized in earlier visits. On Christmas morning, after his doctor had told him to stop the drug until next week's appointment, I easily found information about the drug’s side effects and how to manage them. I watched the fear in Dad's eyes dissipate as he read the three printed pages, describing exactly what he was experiencing, and he made quick changes to his daily routine to calm the problem. It was a tiny thing that anyone in this church could have found with a quick Google search, but the impact was profound. This was the beginning of my role as a trusted member of his treatment team.

On to our biggest triumph. This was really pretty amazing… One of the drugs I researched actually turned out to be the most successful treatment regimen he had during his fight with metastatic cancer. He flat out would not have started to take the drug without the background research I compiled, which he then proposed as one option of several to his oncology team. The oncologist didn’t think it would amount to much, but we gave it a try anyway, in combination with another drug. Over two months, Dad’s tumor burden shrank by 50%, and we stayed with the drug for a year before discontinuing it. He credits this year of his life to the research I did, mind you, as a 25-year-old with no formal medical education.

I tell you this second story for several reasons. One, he got an extra year of life out of it, maybe more. I helped give that hope and time to Dad, and I can think of nothing more valuable in this survival quest. Two, he asked me to share it with you, and I have always had a habit of doing pretty much anything he requested. And perhaps most importantly, he thought you might be able to borrow the idea should you be faced with a similar situation.

This story is about more than figuring out and fighting this disease. It’s about a guy who believed so much in his daughters, and expected so much from them, that he trusted one of them to play a very special role in the last years of his life. He taught all three of us to learn independently and to back up our ideas enough to present them respectfully to the experts. There’s a lesson here in advocacy, in deciding what is most important and pouring our energy into it, and in believing that we can indeed make a difference.

Dad lived 11 amazing years after being diagnosed with cancer, and plowed through 12 rugged drugs in 10 combinations. I can name them all if you ask; they sound like poetry. For years, I have laughed with family and friends in amazement at his resiliency, courage, and grace. Dad had every intention of living as long as his glass was half full, and his story is a triumphant one. For sure, he faced poor odds, but in never acknowledging them, perhaps he never actually faced them after all?

Saturday, February 20, 2010

Illusions on Duxbury Beach

Remember the old science fiction movies, where they took a 2-inch lizard or tarantula and superimposed it into the scene of frightened people and cities being crushed? You just knew that Godzilla really was forty feet tall!

Check out this tree-like structure from today's walk on Duxbury Beach, south of Boston. In another setting, you might be persuaded that the photo above is of a large tree knocked over by a storm. But, no, it is just an interestingly shaped sponge, and, as you see here, merely a few inches tall.

Meanwhile, watch the video below. It is a little unclear, but if you watch closely, you will see a flock of birds just to the right of the SUV, turning and swooping as a group. As they do so, they show us bottom, side, and top views; and they go from nearly invisible to dark to shimmering white. (Stick with me here. You may have to watch it 2 or 3 times to see the birds.)

If you cannot see the video, click here.

Friday, February 19, 2010

Before the Earthquake

With all the coverage of recent relief in Haiti, we sometimes forget that US caregivers often went before the earthquake and gave their time, energy and money for medical services for children there. Ruth Adomunes and Marianne Mcauliffe are exceptional PACU nurses here at BIDMC. This is a YouTube video with moving images of the work they have done through the Haitian Health Foundation.

Thursday, February 18, 2010

The Year of the Tiger

The BIDMC Employee Involvement Committee decided that we should have a Lunar New Year celebration in honor of the Year of the Tiger. Our staff came together for a great event, featuring Lion Dances and Ethereal Dancers from the Massachusetts Vietnamese Scouts Association, and Chinese dulcimer players and dancers from Boston's Kwong Kow Chinese School. You've seen and heard the older dulcimer players before, but here is a video of some younger ones and the other performers.

If you cannot see the video, click here.

Here's what's happening in the Bay State

As the federal government and the various states consider what to do about health care costs, Massachusetts is proceeding along its own path. I thought my readers would be interested in a summary of those events.

Following the creation of the Massachusetts universal health care legislation in 2006, the state expanded its focus from providing access to the issues of quality and cost. The Legislature passed Chapter 305 of the Acts of 2008 in August of that year. A provision of that law requires the Division of Health Care Finance & Policy, in collaboration with the Attorney General’s Office, to hold annual public hearings concerning health care provider and insurer costs trends.

In preparation for those hearings, the Division prepared three preliminary reports, found here, on health insurance trends and the structure of the industry. Also, the Attorney General issued her own report on related topics.

In its letter of invitation to the hearing, the Division has set forth its agenda:

"The Division seeks to understand to what extent - if any - your organization’s experience varies from the agency’s findings, to solicit additional information that explains the premium and cost increases, to gather your perspective on the dynamics driving the trends observed, and to obtain your recommendations for short and long term solutions to such dynamics."

"With your assistance and active participation, the Division seeks to develop tangible policy recommendations to mitigate health care cost growth and to develop an integrated health care delivery system in a final report to the Legislature. "

I thought you would find it interesting to read some of the questions that hospitals have been asked to answer in advance of the hearing.

After reviewing the preliminary reports located at please provide commentary on any data, or finding that differs from your organization’s experience and the potential reasons therefore.

Do you see trends in your revenues, from 2006 to 2008 or more recently, that differ materially from these aggregate trends with respect to:

--The rate of change in outpatient facility prices and faster revenue growth compared with inpatient revenues;

--The growth of revenues for outpatient imaging services;

--Price changes versus other sources of growth in revenues, for inpatient and outpatient services.

What are the one or two most important underlying causes of your experience, as described above? Provide any information you have that will support your assertions.

What accounts for the growth in inpatient facility prices? What accounts for the growth of hospital outpatient facility price per service?

What accounts for the growth in utilization of outpatient hospital facility services? Do you foresee the same factors continuing to drive the growth in total facility revenues in future years?

How does your relative market position or market share affect your cost or revenue trends?

The concentration of teaching hospitals in Boston means that tertiary hospitals effectively serve as the “community hospital” for many patients. If your hospital is located in Boston, what reasonable solutions could your organization develop to provide routine care in less expensive – but appropriate - settings? If your hospital competes for patients with a teaching hospital outpatient facility, how has this impacted your revenues, costs and service mix?

Overall, we found an increase in the proportion of services being provided in more expensive settings. Is this trend occurring in your market area? What is driving this trend and what solutions would moderate this trend without impacting quality?

From 2006-2008, what was your average annual increase in labor costs compared with your average annual increase in patient revenue? What are the major factors driving change in labor costs? What are the major factors driving change in patient revenues?

Are the costs of acquiring medical equipment and technologies increasing, decreasing, or staying the same? Why and how do you think this is the case? What contribution is this having on your overall costs?

The following questions relate specifically to your experience in service prices and mix of services provided:

What factors do you consider when negotiating payment rates for inpatient care and outpatient services?

Do you generally negotiate contracts with carriers as part of a larger system or as an individual facility? Is there a material difference in how you approach contracts when you are contracting as part of a system vs. as an individual facility?

If applicable, do the services provided in your outpatient facilities in suburban areas differ from those in Boston? If so, how? For those services offered in both locations, do you charge the same or similar rates for all locations? If not, how do the rates – or price paid per person - differ and based on what factors? Are these facilities competing with community physicians or hospitals, or both for the same patients?

How has the expansion of outpatient facilities impacted the composition of surgical and medical admissions to your institution? How has the expansion of outpatient facilities impacted the price or cost paid per person of your institution?

How does the variation in prices among different providers in your peer group (e.g., teaching/community hospitals, providers in your geographic area, your key competitors) affect the payment rate increase you seek in negotiations with health plans? Please provide an explanation of how you define your “peer group”.

What specific actions has your organization taken already to address these trends in the short term or long term? What current factors limit the ability of your organization to execute these strategies effectively?

What types of systemic changes would be most helpful in reducing cost trends without sacrificing quality and consumer access? What other systemic or policy changes do you think would encourage or help health care providers to operate more efficiently? What changes would you suggest to encourage treatment of routine care at less expensive, but appropriate settings?

Could enhanced competition or government intervention or a combination of both mitigate the cost trends found in the Division's report? Please describe the nature of the changes you would recommend.

What would be the impact on your organization of making data public regarding quality and the reimbursement rates paid by each carrier to each hospital or system in a manner that identifies all relevant organizations? What is the advantage or disadvantage to your organization of the current confidential system?

Please identify any additional cost drivers that you believe should be examined in subsequent years and explain your reasoning.

Please provide any additional comments or observations you believe will help to inform our hearing and our final recommendations.

Wednesday, February 17, 2010

As Brent James has taught us . . .

Several months ago, the New York Times Magazine featured an article about Brent James, from Intermountain Health. I have written about him here, too, as one of the experts in improving quality and safety and other processes in hospitals.

Today, one of our doctors was giving a report about the activities of one of our clinical care committees. I perked up when he started a sentence with, "As Brent James has taught us . . ." The rest of the sentence had to do with the idea of not responding to a single clinical event, but rather focusing on a pattern of such events to find underlying systemic issues worthy of investigation and improvement.

I think Brent would be happy to know that his lessons have taken root at this Harvard teaching hospital. I, too, am pleased that we have provided opportunities for our staff to learn from people like him. Academic medical centers have done fine studying disease, diagnoses, and cures, but they lag in understanding the science of process improvement. We aim to change that here.


Dan Balz writes this column in today's Washington Post about whether Evan Bayh was overstating the degree of partisanship in Congress and whether, notwithstanding that, he should have stuck around to deal with the problem.

I don't think any of us have been alive long enough to know whether the first is true. Politics always seems at its worst when you are in the middle of it. It may be, though, that the existence of social media has made it more combative, for the old-style behind-the-scenes sausage making is no longer possible. Also, clever users of these media can create a "movement" in just a few hours, pushing positions to the extreme. Though politicians have become experts in using social media to run election campaigns, they have not yet figured out how to use these tools to help build bipartisan coalitions to govern.

And, on the second, we have no right to judge this gentleman on his personal decision. If he no longer wants to try to stay in Washington to work on the problem, there will be plenty of other candidates. No one is indispensable.

But I was struck by this quote, ""If I could create one job in the private sector by helping to grow a business, that would be one more than Congress has created in the last six months." Senator Bayh's statement is emblematic of an underlying philosophy of government that might be at the heart of the current partisanship. In this country, many people feel that it is really not the job of the government to be the job creator.

I think lots of people intuitively understand the Keynesian imperative to use federal fiscal policy during a recession in a counter-cyclical manner to boot-strap the economy. But there comes a point where the cost of doing so, and the burden it puts on future generations of taxpayers, becomes a political argument against further expansion along those lines. In my view, that is the tectonic fault line currently in Congress.

I don't dispute that nasty tactics are in use, by both parties. But I am suggesting that there is a legitimate public policy debate behind the discord.

Thus far, President Obama has not figured out how to bridge this gap. Bill Clinton did, after he lost the Congress to the Republicans. He moved their way politically and was able to build a bipartisan coalition on several issues. The first George Bush did likewise with the Democrats.

Obama does not model the behavior he asks Congress to employ. He calls for civility, but then he demonizes or rails against industries and people (banks, bankers, insurance companies, even Cambridge police officers.) Parts of his speeches are brilliant; but parts make him sound like a partisan legislator. He has never really run anything, and he is still getting his leadership legs. He has not figured out how to make his voice count for something in the Senate. There is thus no role model to provide coverage for moderate people in both parties who might be able to build the winning coalition.

A basic rule of negotiation is to give the other side something they can take home to their constituency. That is also an inherent characteristic of the republican form of government that comprises our Congress. Someone has to model that behavior. In these times, it has to be the President.

Tuesday, February 16, 2010


A note from nurse Judi:

Sometimes we get so bogged down with every day life we forget about the little things that we do which can mean so much to our patients. Yesterday, I had such an experience. Several months ago I got a panicked call from a lovely gentleman who had emigrated from Russia and was living and working in Massachusetts. He was calling about his wife who was recently diagnosed with breast cancer.

The story goes like this. His wife was visiting Russia and caring for her sick 90 year old father, when she felt a lump in her breast. Frightened, she went to the local hospital in Russia for a biopsy and was told by the physician that it was cancer. She wanted to come to BIDMC for her care and left Russia immediately. The only medical information that she brought with her was the pathology report, in Russian, and a breast ultrasound. Nothing else. She tried for several days to obtain the pathology tissue but was not able to get anyone to agree to send the samples to the US. So, we started from scratch. She had to undergo the biopsy all over again so that we could indeed confirm if this was cancer and plan treatment accordingly.

The patient is now on the other side of her treatment and doing well, and yesterday they stopped by the breastcare center to visit and bring me beautiful roses, but what really grabbed my heart is the following. She told me with tears in her eyes that she wanted to show me something…when I looked it was a pair of hospital socks, you know the kind we give to patients to wear so they don't walk barefoot through our hallways. She asked, "Do you know what these are," and I replied, "Of course, they are hospital socks," and she said "No, they are caring."

I looked at her sort of skeptically because at first I didn't get it. She went on to explain: "This simple act of giving out socks to keep ones feet warm exemplifies caring, that we would care so much about our patient and keep them comfortable and safe and warm." Her plan was to take these simple socks back to Russia on her next visit. She wanted the people at home to see how much the doctors and nurses and health care workers here "care" about their patients. Enough to make sure that their total being is cared for, including even making sure their feet are warm!

Monday, February 15, 2010

In the dunes

Amongst the dunes near High Head on Cape Cod, you find microclimates and evidence of fauna and flora at various stages in their lives and deaths -- cranberries, lichen, rodents, bayberries, and birds.

Beach sponges

The common sponges found along the ocean have a texture and structure worth noting.

Saturday, February 13, 2010

A New England character

New England is home to many interesting people who have contributed in their own ways to the vibrancy of its economy and culture. I am going to try to capture, in a few word and pictures, one such person, a friend, Ira Molay, who died over ten years ago.

I am prompted to do this because I joined his daughter yesterday in trying to clean out his basement workbench and was stunned to see how much of his presence persisted there. (You will soon understand why the clean-up has taken this long.)

As this obituary suggests, Ira was an an inventor, silversmith, and industrial design engineer. He was the closest thing to Thomas Edison that I have ever seen. He had infinite curiosity. He would always be scribbling on the napkin when you went to a restaurant, either practicing Japanese or designing a new electronic circuit or sketching an idea for jewelry. He held several patents, one in 1976 for a portable sound system, but he mainly designed things for sale to electronics component companies or for pleasure.

If I may stereotype a bit, Ira was unlike most Jewish boys who grew up in Brooklyn in that he joined the Marines and loved to hunt for wild boar.

And then he would used the boar's tusks for jewelry, first performing the equivalent of a root canal to clean out the insides and then filling them with resin so they wouldn't crack.

The workbench was not really a workbench. It was an explosion throughout the entire basement. Of course, there were electronics of all kinds, and fasteners, and tools.

But there were also music box and clock parts and exotic woods to make cases for those music boxes and clocks. Ira would collect burls while in the forests for his boar hunts to use for the same types of items. An abalone shell provided mother-of-pearl for jewelry or to inlay into a wooden belt buckle.

A Shopsmith was the centerpiece, providing a versatile tool that performed lots of functions. There was an acetylene torch, an industrial sized oxygen tank, and hazardous chemicals too numerous to mention. There were illegally acquired syringes for squirting substances into small spaces.

The assortment of containers to hold all this stuff ranged from high-end cabinets to coffee cans.

Of course, there was a fully stocked darkroom. Then there was the fishing gear, too.

The curiosity extended to horticulture. Ira would take a seed or pit from a fruit or vegetable he had eaten and try to grow the plant. An avocado was easy. How about a naval orange? These are supposedly sterile, but he found one with a pit and nurtured it into a small tree. On the one-year anniversary of his death, it produced a tiny orange, and it lives on to this day.

Friday, February 12, 2010

To disclose or not disclose

Fellow blogger Dan Kennedy, over at Media Nation, raises a thoughtful question. I'll pose it to you for your advice.

Dan says that in a post like the one I wrote yesterday, which criticizes a proposal by the Governor, I should disclose that I am supporting another candidate (Charlie Baker) in the next gubernatorial race. You can see how I and other people responded. What's your view?

To help you get started, one friend later wrote me the following note:

I don't see that you have any obligation to state your political position on your own blog. No one ever expected you to declare who you supported for president when you commented on national health reform and other issues over the years.

Another pair of friends replied:

We agree that you are well within your rights to not disclose. Having said that, given that you are so well-positioned as an advocate for transparency, disclosure, as Dan points out, is not necessary a bad thing. We don’t think that it’s necessary to disclose every single time – once on your blog would be sufficient. You may want to consider that all of the people who read your blog may not have seen anything in the Globe about the Charlie issue, and would probably welcome the additional information.

If we think back to the early days of social media, the first question people wanted to know was how to separate the wheat from the chaff. One of the ways we learned that blogs build status is through authenticity and allowing readers to better get to know the author. Disclosing only adds to the authenticity of your blog; we’re not sure it detracts at all.

Even accepting the wisdom of these latter two friends, I have to ask the question, "What constitutes a level of support for a candidate that would warrant disclosure?" Is it that I have donated money? (This fact will be published by the state.) Is it that I have said publicly that I support the candidate? Is it that I have said privately that I support a candidate? Is it that I support a candidate in my head but haven't yet told anybody? And what if I change my mind during the course of a campaign?

By the way, while I am at it, should I disclose my electoral choices even when reporters, editorial writers, and op-ed writers in the newspapers do not do so? Should a blogger try to meet higher journalistic standards than the traditional media?

Thursday, February 11, 2010

View from a Grain of Sand

Director/producer Meena Nanji was at MIT this week to moderate a showing of her documentary, View from a Grain of Sand. Here's a summary of the movie, which is very moving:

Shot in refugee camps of Pakistan and the war-torn city of Kabul, three remarkable Afghan women lead us through the maze of Afghanistan's complex history, informing this examination of how international interventions, war and the rise of political Islam have stripped Afghan women of their freedom over the last thirty years.

Combining verité footage, interviews and rare archival material, this evocative film is a harrowing, thought-provoking and movingly intimate portrait of a still divided and brutalized nation. Addressing timely issues of women, Islam, and US foreign policy, the film is a compelling and vital addition to the global dialogue of our times.

Here is a link to the trailer. Below is a clip of Meena talking before and after the showing.

If you can't see the video, click here.

Pi is not equal to 3

Our Governor has made proposals to limit the increase in insurance rates, especially those paid by small businesses. Here's the story in the Boston Globe. A quick summary:

A 40-page bill filed by the governor yesterday proposes to give the insurance commissioner the power to essentially cap health care price increases.

Rates hospitals and other health providers charge insurers would be “presumptively disapproved as excessive’’ if they increased faster than the level of medical inflation, and they could be rejected after a public hearing.

Similarly, for health insurance plans sold to employers with 50 or fewer workers, premium increases that exceed one and a half times the level of medical inflation would be considered excessive and could be turned down.

Just a few weeks ago, the Attorney General issued a report, after months of study, that explained that insurance price increases in the state were the result of two factors, the underlying increase in health care costs and a disparity of reimbursement rates that paid some providers substantially more than other providers.

What is the connection between the two actions? None that I can see. The Governor's ideas fail to take account of the Attorney General's findings. Further, they fail to understand the structure of the industry.

The editorial writers at the Boston Herald have grasped the issue, here. You cannot, by administrative fiat, impose the kind of price controls proposed by the Governor without undesirable consequences.

What happens if we force the insurance rate increase to certain subscribers to be less than a certain percent per year? Either insurance companies modify their plan designs to include less extensive benefits or to require higher copays by those subscribers. Or, they meet the pricing target for that customer group by raising insurance premiums for other subscribers to cover this subsidy.

What does it mean to limit the amounts that providers charge insurance companies? This suggests that providers determine the rates that insurance companies pay them. Check the returns earned by Massachusetts hospitals. In a typical year, half have negative margins, and most earn returns that are not sufficient to renew and replace plant and equipment. For the majority of hospitals and doctors, the rates are set by the insurers, not "charged" by the providers. (Of course, as noted by the AG, there are some providers with the market clout to do better.)

The Governor's proposals remind me of the apocryphal state legislature that decided that the value of pi was inconvenient, mandating it to be 3.0 instead of 3.1415. You can't change irrationality by wishing it to be rational.

In this case, I would urge the Governor to use his existing authority or seek new authority to mandate total transparency of insurer-provider reimbursement rates to shine sunshine on the current payment system; to do likewise for measures of clinical performance; and to increase payments to primary care doctors to move them out of their triage mode and reduce the use of higher paid specialists. Those actions would help alleviate the concerns noted by the Attorney General, the ones based on the actual market conditions in the state.

Wednesday, February 10, 2010

Or whatever . . .

A young friend says:

Going to contest a speeding ticket this evening. Any advice is greatly appreciated...I mean I was speeding but I know...I don't want to like, pay for it or whatever. That should work, right??

The ultimate social medium

For your amusement on a soon-to-be-snowy day here in Boston. Original post is here.

Introducing the Hot New Social Network, PhoneBook

Allows User to Call Friends, Speak to Them

SILICON VALLEY (The Borowitz Report) – A new social network is about to alter the playing field of the social media world, and it’s called PhoneBook.

According to its creators, who invented the network in their dorm room at Berkeley, PhoneBook is the game-changer that will leave Facebook, Twitter and even the much anticipated Google Buzz in a cloud of dust.

“With PhoneBook, you have a book that has a list of all your friends in the city, plus everyone else who lives there,” says Danny Fruber, one of PhoneBook’s creators.

“When you want to chat with a friend, you look them up in PhoneBook, and find their unique PhoneBook number,” Fruber explains. “Then you enter that number into your phone and it connects you directly to them.”

Another breakout utility of PhoneBook allows the user to arrange face-to-face meetings with his or her friends at restaurants, bars, and other “places,” as Fruber calls them.

“You will be sitting right across from your friend and seeing them in 3-D,” he said. “It’s like Skype, only without the headset.”

PhoneBook will enable friends to play many games as well, such as charades, cards, and a game Fruber believes will be a breakout: Farm.

“In Farm, you have an actual farm where you raise real crops and livestock,” he says. “It’s hard work, but it’s more fun than Mafia, where you actually get killed.”

In memoriam: Victor Alpert

Back in my college days, I was the volunteer manager of the Tanglewood Festival Chorus, the chorus of the Boston Symphony Orchestra. I also managed to wrangle a part-time office gopher job at the BSO. Between the two positions, I spent a lot of time hanging around Symphony Hall and got to know Victor Alpert, the orchestra's librarian.

Victor died recently, and his obituary was published today by the Boston Globe. Writer Walter Dawkins captures him perfectly, and I have little to add.

Just this. I was a nobody in the BSO organization, and Mr. Alpert always treated me like a respected colleague. I would drop by the library, and he would tell me stories and joke around, and we had a great time together. Whether at Symphony Hall or in the Tanglewood shed, he would give me a warm welcome. Walking out onto the stage to place the conductor's score on the podium, he would look up to the back row of the chorus and give me a wink and a wave.

I will miss this fixture of Boston cultural life.


America is a great country, and I love its entrepreneurial spirit. But sometimes people go a little too far. Here's an example. (By the way, I never left a voice mail message.)

Dear Mr. Levy:

Thank you for your voice mail. My fee for a one day visit at your office in Boston is $9,800. I believe you to be a man of integrity, so if don't (sic) get any value from my one hour presentation then you owe me nothing.

I would like to share a few observations and propose a hypothesis on the topic of business continuity and disaster recovery. Discontinuity can provide a rare opportunity for sustained competitive advantage to be gained quickly.
  • Decades of profits in one year
  • Double digit market share gain
  • Enhanced brand name and goodwill
I have faith that your company and our country will emerge even stronger after any potential crises. This is because we value the rule-of-law, meritocracy and a market based economic system.

The last 10 years of my professional experience has been in sales for independent software vendors. I attended the PhD program in Economics and Applied Statistics at the University of California at Santa Barbara.

Thank you for your consideration. If you have further interest please feel free to call my cell phone at (415) 238-****.

Tuesday, February 09, 2010

Doctor's orders

Sad ironies occur every now and then. Why do they feel ineluctable in health care settings?

Michael Howell is one of the BIDMC physicians who has been greatly involved in the enhancement of patient care in our ICUs. I sent him an email asking if he would review an article that IHI's Maureen Bisognano and I had written about this process. He received the note while accompanying his terminally ill grandfather to another hospital.

Here is his reply:

I am happy to review the article in the next day two. It is ironically appropriate: I am sitting in an ICU waiting room right now, excluded from visiting because it is not yet 10am. My 95 year old grandfather, who had an existing DNR/DNI order, was (presumably inadvertently) intubated and I am down in a small town in northern Alabama. It's my fourth or fifth time on this side of the ICU door. Terrifically challenging, since my dad had already gone through the difficult process of moving to comfort-focused care, and now we find my grandfather on life support against prior directives.

See the photo for the way visiting hour policies are conveyed here.

Mercifully, the funeral was recently held. We offer condolences to Michael and his family.

Sunday, February 07, 2010

How to get enough votes in the Senate

When Hillary Clinton was running for President, she set forth a more modest agenda for health care reform than her competitor, Barack Obama. Maybe she understood better, based on her experience, how difficult it is to get a comprehensive bill through Congress in this field.

What is possible now that the President has lost the 60-vote majority in the Senate? I think the thing to remember is that he was having trouble even holding together the 60 votes he used to have. He had to agree to an assortment of give-aways -- to Nebraska, to Louisiana, to the labor unions -- to get the votes he needed. In part, that proved to be the undoing, as Massachusetts voters watched this sausage being made and sent a message through the election of Scott Brown that they didn't like what they had been seeing.

Now, it may be that the Republicans will act to kill anything that might come along. I don't think so. I think they are willing to be part of a bill, but it has to be a bill for which they can claim credit among their constituencies. What might it be?

Insurance reform: People, irrespective of party and political leanings, despise the practices of insurance companies that limit or take away coverage. The use of pre-existing conditions to deny coverage, lifetime limits of coverage, and rescission of policies are nasty and unfair. These practices remain as sources of insecurity among Americans, even those with insurance. There should be near-universal support to change them.

Tort reform: I think that most people feel that, while people should have a right to sue for medical malpractice, the process that exists today is inefficient and arbitrary for both plaintiffs and defendants. Any doctor will tell you that fear of such suits also leads to the practice of defensive medicine, driving up costs for all of society. Tort reform does not require limitations on payments. It could be accomplished with the establishment of specialized courts and procedures that would add greater certainty to outcomes and reduce the tensions and abuses associated with the system. This should not be a partisan issue.

Payment reform: Nobody likes the results of a system that systematically underpays primary care doctors and leads them to a life of 18-minute appointments and a role as triage doctors, a way station to referrals to higher paid specialists. If Congress were to order Medicare and state Medicaid plans to take the lead in establishing reimbursement rates for PCPs that reflected their value to families and patients, we would be on the way to a more rational system of care. Likewise, if physicians were paid for care delivered by telephone and electronically, millions of unnecessary and time-consuming office visits could be eliminated. If these steps were taken for Medicare and Medicaid, private insurers would follow.

Transparency: A national mandate for public disclosure of the rates paid by insurers to providers would help drive greater rationality in payment methodologies in the states. Disclosure of clinical outcomes in clinically important arenas would provide impetus to improvement in patient safety and quality. How can this be a partisan issue?

Now what about access? I fear that expansion of insurance coverage is the third rail in this debate. Why? Because it requires revenue to support the subsidies that would be required, and tax increases are really hard to achieve. The President made this issue more radioactive than necessary by proclaiming at the start that you could get access, choice, and lower costs all in one neatly wrapped package. Everybody in the field knew that you could not. This then resulted in sleight-of-hand revenue measures that became the undoing of the bill as Christmas tree ornaments were added to undo the effect on particular states or interest groups.

As I have stated here, a fair approach to generate the revenues for expanded access is to eliminate or reduce the pre-tax treatment of insurance premiums. Doing so would use the progressive income tax system in a way that would apply a larger percentage of these costs to more wealthy people. Could this approach gain a bi-partisan consensus? It could not gain support even among the Democratic majority, so I am guessing not. And the Republicans seem to express no interest at all in mandates for greater access. Maybe we have to accept as a reality the idea that expanded access is a casualty in this debate. I hope not, but I don't yet see an answer to this that can get 50 votes, much less 60.

Saturday, February 06, 2010

The end of Moby Dick

It was somehow appropriate to find this distressed edition of Moby Dick on Horseneck Beach, just down the road from New Bedford. Are those remains of the great whale in the post below?

Bones on the beach

On a cold and windy day at Horseneck Beach in southeastern Massachusetts, bleached out remnants of sea creatures provoke thoughts of what they might have been.

Friday, February 05, 2010

A scene from Ballinvalley

In a post below, I mentioned Thomas Rice's new book, Far from the Land. I want to present you with an excerpt and hope you agree how compelling it is. This takes place when he is a small boy living on a farm with his sisters and mother, abandoned by his father.

Tinkers were Ireland's "untouchables" in the forties, marginalized and despised, especially in the farming community. . . .

The first time I saw Bridget Cash at the gate, I nearly died of fright. She was more than six feet tall with long, jet-black curls that sprung out from under her black shawl like live, corkscrew creatures. She had piercing black eyes, glistening like coals and flashing with passion when she spoke. She visited Ballinvalley about twice a year in her regular nomadic cycle.

We never saw her without at least six children -- and infant or two in a dilapidated baby carriage and others trailing along. The children were always in tatters, often barefoot -- even in winter. . . . [I]t was clear to me -- even then -- that these children were suffering from hunger.

Mother and Bridget were friends, sort of. They always greeted each other on a first name basis.

"Good morning, Bridget. Glad to see you again. Seems like only yesterday."

"Hello, Margaret. How have you and the family been?"

Bridget and the children were then usually invited in to warm by the fire and have some tea and fresh bread. . . . This might seem like normal hospitality if Bridget was a regular visitor or relative who came by once in a while. But she was not; she was a tinker. . . .

If you spent any time around Mother, this you knew: she did not seek approval for what she knew was the right thing to do. . . . Nobody, particularly the needy, was ever going to come to Ballinvalley and go away hungry as long as there was food in the house.

This morning was different. . . . I heard Mother say in a tense, apologetic voice, "Bridget, I'm sorry to tell you this, but I don't have anything for you or the children today."

I turned back and stared at Bridget Cash. I saw her draw herself up to full height, black eyes flashing in disappointment and suspicion. . . . Bridget suddenly assumed a new persona. She launched into her pitiful, whining, begging ritual. . . . "If you have any heart, you won't turn away innocent childer."

Mother sighed, looked down, nervously wiped her hands in the apron, and tried again. "Bridget, rest assured that if I had anything in the house, I'd share it with you. You know I would. I always have."

Reaching for the latch, [Bridget] wheeled back on Mother, filling the farmyard with flashing, black-eyed vengeance. Her voice now a low, ominous growl, she fired her last desperate shot, "Margaret, you'd better not be lying to me. If y'are, I'll put a curse on you and yours that you'll live to regret."

Mother, her voice calm and steady, clasped her hands as if in prayer, looked straight at Bridget and replied, "Oh, Bridget, you can trust me. I'd never lie to you about something like that."

For a long, tense moment, the two women looked at each other across the rain-swept yard, water dripping down their worn faces. Not a tinker, not a farmer, just two mothers searching for the common humanity that was all they had to share.

Then, slowly, Bridget's eyes softened, her shoulders slumped, and she walked towards Mother, arms out, and they clung to each other in anguished silence.

Thursday, February 04, 2010

WIHI Program on Second Victims

I just saw this note. This should be very good. Please tune in if you can.

Adverse Events and Their Aftermath: SOS from Clinicians

Thursday, February 4, 2010
2:00PM - 3:00PM Eastern Time

Albert Wu, MD, MPH, Professor, Johns Hopkins Bloomberg School of Public Health
Linda Kenney, President and Executive Director, MITSS
Susan D. Scott, RN, MS(N), CLNC, Coordinator, Patient Safety, University of Missouri Health Care

Whenever there's an adverse event or medical error in health care, clinicians are affected, too. As organizations develop more accountable and transparent ways to interact with families and patients who've been harmed, the emotional and professional needs of doctors, nurses, and staff – whether directly or indirectly involved in an incident – also need to be addressed. In a 2000 essay in the BMJ, Dr. Albert Wu coined the phrase “the second victim” to put a face to the health care personnel facing loss of confidence and isolation in the aftermath of a tragic event. Now, a decade later, Dr. Wu's courage in naming a problem and his willingness to openly discuss the “private hell” that can beset even the most talented caregivers have helped many hospitals and health care organizations acknowledge the needs of their staff and create systems to support them.

There's not nearly enough in place...yet...but Dr. Albert Wu, along with Linda Kenney of MITSS (Medically Induced Trauma Support Services, Inc.) and Susan Scott from University of Missouri Health Care, are among those leading the way with experience and solid recommendations that can benefit all health care organizations. WIHI welcomes the trio to the program and welcomes your participation and energy as we work to prevent adverse events by, in part, building reliable “aftermath safety nets” for clinicians and staff when adverse events occur.

There is no fee for participating in a WIHI program, but enrollment is required. Visit

Wednesday, February 03, 2010

First-hand accounts from Haiti

In case you missed this segment on Emily Rooney's show on WGBH-TV on Tuesday, here's a link featuring Dr. David Walton of Brigham and Women's Hospital; Shannon Manzi, a pharmacist at Children's Hospital; and Keith Lindsay, commander of the National Disaster Medical Assistance Team.

I also include a picture taken by our Dr. Richard Wolfe of supplies being unloaded at Buen Samaritano hospital, on the outskirts of the border town of Jimani. Unfortunately, there will be many takers for these walkers and crutches.

With gratitude to our kind and generous staff

For those of you following our budget shortfalls last year, the sacrifices people made to save the jobs of their fellow workers, and the updates over the last few months, here is the final chapter, an email sent on this past Monday:

As promised, I am getting back to you with our financial results through January, and the plans with regard to restoration of raises. The short story is that we are meeting our budget plans, and so I feel comfortable committing to you that we will restore raises soon. The easiest and fairest way to do this is to start effective April 1, since that is the date we stopped giving raises last year.
I want to thank all of you for the sacrifices you have made in support of your fellow workers. We were able to avoid hundreds of layoffs last year because everyone stepped up to the plate and helped out. This is a marvelous reflection on people working here and the sense of community we share.
Lisa Zankman, our SVP for Human Resources, will publish an email with the details in the next few days. Stay tuned.

Two new books

I have two new books to recommend.

First, Thomas Rice has written Far from the Land: An Irish Memoir, set in rural Ireland in the 1950s. It is wonderful and evocative. A reviewer notes: "We come away with a renewed respect—and pride if you have any Irish bloodlines or identity—for rural Irish culture and the people who carry it forward with quiet dignity against the tide of their colonial history."

Thomas is donating the next six months of royalties to Partners in Health, in support of its relief efforts in Haiti. It is available on Amazon, here.

Second, Wendy Chapin Ford's book is called To Get Back Home: A Mysterious Disease: A Fight for Life. Here's a summary: Her life seemed perfect until she was stricken with Acute Demyelinating Encephalomyelitis and rendered comatose within days, and then, after a tense weeks-long battle for survival, quadriplegic. She was treated at BIDMC, and her doctors found themselves confounded, and she slipped further and further away. Initially, she was not expected to live, or, ultimately, to walk again or recover her prior intellectual abilities. Doctors have referred to hers as a miracle case, and the mysteries persist to this day.

You can order Wendy's book here.

Tuesday, February 02, 2010

Red Sox Nation + 1

The NBC Today show was here this morning to film the delivery of a baby. Here's the video clip.

Within minutes, we received this note from the South:

Good morning!

I was watching the Today show and saw the newborn wearing the hospital's baby hat with the BoSox logo. Is there any way I can get a couple of those hats? Someday I will be a grandmother, although according to my sons, it's going to be a while, but hey, you never know, eh?



Manlius, NY 13104

Faina's story

Details from Dr. Richard Wolfe, our Chief of Emergency Services, about the young lady mentioned below.

Shortly after we came to Jimani we found Faina. She was a 7 week old baby girl survivor. The earthquake had collapsed a house on her family and she was found under her mother who had protected her from the falling debris. The baby had a crushed leg and a wound on her buttock. Her mother did not make it. So it was up to a surviving aunt to find help.

Somehow the aunt managed to get on a bus with the baby. It was filled with injured patients headed to the Dominican border. It’s a 40 mile trip on a road clogged with starving traumatized refugees. Entry into the Dominican Republic is limited to injured victims and a single family member. So unlike many, the pair was allowed entry into a place where security, food and shelter were available. When she arrived at Buen Samraritano, our field hospital, Burt was on duty. He is a pediatrician from Central Massachusetts who was always calm with a soft reassuring smile despite the horror stories and chaos. He had arrived a few days before when an old medical school classmate had asked him to come and help with the kids. He immediately saw that the baby was in critical condition.

Besides the devastating wounds, Faina was dehydrated and hyponatremic. Burt had to rely on his clinical skills as the i-stat machine and x-ray hadn’t yet arrived. He went to work, did his best, and saved her life. When we met her, a day later, she was feeding vigorously, making good eye contact, and charming every provider in the camp. However, the wound was contaminated and very close to the gluteal artery. We all knew it was only a matter of time before it became infected leading to sepsis and death. With the resources we had in camp, the debridement she needed was extremely dangerous because of a high risk of injuring the artery and causing an exsanguinating hemorrhage.

We had over 30 patients who needed a level of care the exceeded the resources of our field hospital. The USS Comfort was saturated and there was no easy way to get her transferred to the hospitals in the United States. We knew that the Order of Malta had developed Sacre Coeur hospital in the north of Haiti, staffing it with world class experts and equipment. Importantly for Faina, they had pediatric intensivists and plastic surgeons who could provide the care that was needed. However this meant flying from the Dominican Republic to Haiti and that apparently required special authorization. We could not simply take an ambulance as it was a 10 hour drive over two mountain ranges through a devastated country.

The US military and Dominicans were both willing to help, but we could not get the authorization to fly because of red tape somewhere within the UN. Countless calls to everyone we knew were made to find help, but for days the authorization kept being denied. Her aunt allowed us to shoot this picture to better communicate why transport was so badly needed. Finally, someone got through to somebody and yesterday, on Sunday morning, a fleet of US military helicopters descended on the camp and carried off 36 of the sickest patients. The last I heard, Faina was safely away, still charming everyone and still resistant to infection.

Bearing witness to Haiti

My friend Jeff Swartz, the CEO of Timberland, recently took his company plane to Haiti to help deliver relief supplies and personnel. What he saw left a searing impression. I share excerpts of his note to his staff. (To supplement Jeff's letter, I present this picture of Faina. Hers was one of several lives saved by BIDMC and other doctors last week. Story here.)

Last week, I visited Haiti, in the company of Bill Shore, the founder and executive director of Share Our Strength, and a Timberland Board member, and chair of the Board's Corporate Social Responsibility Committee, and in the company of Wyclef Jean, a 12 time Grammy award winner, a Haitian musician and activist, Timberland’s partner in an effort to plant trees and reforest Haiti, as part of our global Earthkeeper efforts. The visit was in response to the earthquake that struck Haiti 3 weeks ago; our visit was an attempt to focus Timberland’s Earthkeeper resources temporarily on disaster relief. The trip was emotional and powerful; I left Saturday night and was back in the office Tuesday.

So, what’s so hard about a brief note that describes the heroism of the many doctors we saw, the heartbreak of the destruction we saw, the inspiration I felt with Bill and Wyclef, and the indignation I felt at the world’s well intended but inept efforts to cope with this disaster?

Maybe it is the scale of the disaster, in the context of a country already ravaged by history. Maybe it is the raw, emotional experience of being amidst death and destruction, and in the presence of the dying. Maybe it is the feeling of futility that waited for me at each stop we made in Haiti. Yes, we made a difference, but we did not even scratch the surface of the pain and agony.

For all these reasons and more, I have not done my job by you; I have not been able to bear witness to you from Haiti. So, below, I have tried to right that wrong. Call this note, “bearing witness” -- but “bear with me” also works -- it is a very long note. Long for the reasons I cite above, and long because it is hard even now for me to say simply why a bootmaker flew to Hell and how the experience of that Hell affirmed my belief in the mission of commerce and justice. So, here goes:

1.30am Saturday night in Manchester, NH. One backpack, with no change of clothes, just a camera, a notebook, malaria pills, and my Bible. Drove to Manchester with Billy Shore; not a lot of chit chat.

On the plane, Wyclef Jean was waiting, exhausted before the trip began. He was going back to Haiti for the 2nd time since the quake — many of you saw him on CNN two nights after the disaster, with his wife, telling stories about transporting 10s of dead bodies to temporary morgues. Wyclef is a man of many faces — we know him as a musician and a celebrity, for sure, but if I jump ahead and tell you about Wyclef by the end of this voyage, I would speak of an immensely gentle, noble, powerful man — one part dreamer, one part prophet, one part revolutionary.

And on the plane, strangers -- physicians from Partners in Health. When the earth shakes and the flimsy medical infrastructure disappears — PIH calls on physicians and nurses and medical students — and they drop what they are doing, like the doc from San Francisco on our plane, like the med student from New York…they pack their backpacks, grab whatever medical supplies they can round up…and we meet them, 1.30am, bound for Hispaniola.

(After arrival, a helicopter trip to Haiti.)

From the air, in a little over an hour or so, you flit across beautiful inspiring mountains and along magnificent beaches, from the Dominican Republic to Haiti. There is a large lake that demarcates between the two countries, on the route we flew, but you don’t need a map to know where one world ends and another begins. The lush agriculture on one side of the lake leads to a more hardscrabble agriculture on the other; the big (ok, functional) highway on the DR side leads to one lane each way winding on the other. We can see the aid trucks crawling along on the Haiti side. And in minutes, Port au Prince looms ahead, dense, destroyed, honestly not to be believed, from the air. A densely packed city, an up and down city of folded hills, and everywhere you can see…cataclysm. You have a city that started with basically no functioning infrastructure – and then the whole darn thing falls down. So what’s left? A world of pain, and human spirit.

First stop, Cite Soleil – the City of the Sun – which is the worst slum in Port au Prince. Clef says, not a lot of blanche (white people) in Cite Soleil ever; should be interesting. Just what I’m looking for — interesting. Because as the convoy weaves through the city, I am reduced to holding the video camera in my lap and filming my knee. I can’t believe the physical destruction. Nor the swarm of humans walking. People walking in the streets — this is one of the overwhelming images of this voyage. Where are they going? What are they seeking? Walking, everywhere. Streets choked with dust and detritus and despair, and folks out walking. Whole blocks just leveled.

Our convoy pulls to the curb under the bluest sky and with the blazing sun as witness. Within 30 seconds of Clef’s appearance on the sidewalk, there are ten thousand young people around us. On a retaining wall in front of us, clogging the wide street, everywhere the eye can see. Beatles en route to Shea Stadium; I’ve never seen a crowd like this, form this fast, be this close.

We are in the Cite to feed the hungry. We’ve already seen a UN convoy heading from the airport to distribute food and water—white armored personnel carriers, soldiers in body armor and combat gear, turret gunners manning loaded weapons, sirens blaring, trucks roaring through the clogged streets—to hand out 50 lb bags of rice. Clef reminds me that good intentions don’t feed people. 50 lbs of rice not all that helpful, when there is no pot, no cooking fire, and no clean water anywhere with which to cook the rice. The Yele model is a little different—we brought food from the DR, food that Yele purchased, and somehow, in this destroyed city, Clef’s team cooked 8,000 hot meals of Haitian cuisines (goat stew). Someone “found” 8,000 styrofoam take-out trays, from one of the destroyed restaurants somewhere in town. And found a truck. Here’s the truck, here’s the meals, here’s Clef with a bullhorn shouting in Creole, and here is a mighty river of the hungry, lining up to be fed. With sweat pouring off of everyone, we began to hand out the meals.

We are working hard in the sunny version of hell, but despite everyone’s best efforts, of a sudden, it starts to get tense. The Yele volunteers are shouting at the folks in line in Creole, "Don’t push, don’t push," but you could see in the eyes of the mothers and the fathers and the children, everyone watching the pile of cooked meals in the back of the truck get smaller and smaller and a sense of despair and maybe even panic begin — will I get a meal for my child before they run out? And so all of a sudden, the business of Sunday lunch heads in the wrong direction — the river of hungry humans becomes a raging river, pressing forward, starting to crush each other and us. And so the security guys – with good intentions – shove themselves in front of us, and everyone started taking out their weapons and I heard safeties being taken off and I knew we were not far from a really bad situation.

At this point I was crushed behind a wall of security people, up against the open back of the truck. In front of me, not 3 humans deep away, there was a little girl. And someone must have stepped on her or something – she started to cry. In the raging ocean of human suffering—her tears and her fear was too much for me. So I reached between 2 security guys and put my hand on her and shouted in French,”Its ok, I’m gonna get you.” I couldn’t lift her up; I was wedged too tightly -- but now I was back in CEO mode and so I said to the security guy in front of me, “Get me that little girl.” And he did -- lifted her up and passed her back to me and I held her tight, in my arms, and she was sobbing and so was I. I held onto her, maybe 8 years old, talking to her in French, and after about 30 seconds she stopped crying. Because the crushing that was hurting her — that’s gone now. I’m holding her and we’re behind a security guy and so she’s not going to get crushed. So she stopped crying.

My view of the world says, she should have still been crying. But her view of the world is, no. I may not have a home, I may be hungry, I may be living in hell – but that’s normal. That isn’t worth crying over. If someone is hurting me on top of all that, then I’ll cry. I handed her a meal and off she went – as if to say, I’m going back to the normal despair of my day and I can handle that, don’t need your help, thanks a million and have a good day.

We went back to handing out the food. The crush didn’t go away, but the fear of a bad scene did. I’m still kinda pinned against the truck; from under the truck, a little brown hand reaches out and grabs my cargo calf. I look down, and there is a little hand clutching my leg. Can’t see the child — he or she has crawled through the densest crush of people I’ve ever seen, wriggled under the truck, and grabbed me — signaling, "I beat the line, now give me a meal." I slipped one down to the hand; the hand grabbed it and vanished. My heart still has not come back — a child, figuring out how to get a meal.

From Cite Soleil we drove through destruction towards Bel Air, our next destination. Nothing belle about Bel Air; the sun is starting to wane in the sky, birds are chirping, but this neighborhood is destroyed, concrete smashed like you cannot imagine.

When we get there, Wyclef disappeared to talk to some of Bel Air’s residents and I was left standing there with Billy, and feeling the smell. One of the security guys said to me, “You know what that smell is, right?” And I’m thinking no, but I bet you’re gonna tell me and he said, “That’s dead people.”

When Clef came back he said, “Smells bad,” and I am quick to agree, but he says, “No – it smells really bad. No rescue teams have come here. No rescue teams will ever come here.” If there was some way someone was still alive amidst the rubble in this corner of this sad city, they were left to die. Clef led us here because he had work to do to try and negotiate with angry young men, no more violence. And while he worked at that, I kept an unwilling vigil with the dead.

We left Bel Air, but in my heart, I can still see it and hear it and smell it. Leaving them there, men, women and children entombed in rubble – it’s just not right.

Our convoy headed up into the hills. Billy asked me, "Where are we gonna sleep?" One of the guys who has been driving us around says, "Come to my house, you can sleep there." He has an undamaged house? He does, higher up in the hills. And so, Haitian rhythm — I got a little girl’s bed, with teenage movie stars taped to the wall, and Barney the purple dinosaur on little girl sheets, and Billy got the room that belonged to the older daughter. Security guys sleeping on the dining room table and living room chairs.

I sent my kids one last note, opened my Bible and studied for 15 minutes, and was asleep in my clothes with my boots on without even realizing it for 4 precious hours — no dreams, no thoughts, dark and silent and asleep.

Dawn was signaled by the roosters and a rosy sunrise. We headed downtown to University Hospital, the biggest hospital in Port au Prince.

We found a mixture of desperation and dignity like I’ve never encountered. In the sweltering sun, big strong young men and women from the 82nd Airborne, taking care of business — securing the hospital, and helping the PIH doctors. We watched a big blond trooper from somewhere shoulder his M4, and bend down to pick up an old woman who was too sick to walk any further, and carry her with dignity and caring to the triage station in the bright heat — a grey file cabinet resting on its side. We watched the medics triage the sick, and then we walked into the hospital itself.

How shall I tell you what we saw? Civil War technology, 21st century doctors, pain and suffering, grace and dignity. Post operative “wards,” nothing more than cots stacked in the open air, every single patient having experienced at least one amputation from the crush injuries that could not be treated otherwise. David Walton, a young PIH physician told me as we walked through, we have saved their lives to this point by amputation — but 100% of the patients you see are real mortality risks. When they are “discharged,” which they have to be — we have many many more behind them waiting for these cots — where will they go? How will they be kept free of infection?

A surgeon from New York showed us the “operating theater,” a medium sized storage room that hadn’t fallen down in the quake. Four army cots, propped up on blocks, so the surgeons wouldn’t have to bend un-naturally. IV’s hanging from the what looked like repurposed coat racks. Most of what they were still doing was amputations. Because after enough time has passed and wounds haven’t been treated, there’s just nothing else you can do.

They told us, when children came in hurt, they cast them as quickly as they can in order to immobilize the victim -- because in some of the crush injuries, if you move it you could take out blood vessels and someone could bleed out. So they immobilize with casts, but then when it comes time to deal with the actual injury, the cast needs to come off again. Do you know what you can’t take a fiberglass cast off with? Scissors. Scissors don’t cut through fiberglass — and so the docs can’t get to the wounds. Because you need a cast saw, and guess what? They didn’t have one at University Hospital.

Dr Dave said, “We’ve really got to find a cast saw,” and I said, what do you mean, find? And he said, “Well, we know they have cast saws at the airport, we’ve been sending SOS messages for 4 days and we can’t get them here.” Not 5 miles away. So now I’m all ready to go storm the airport and thankfully Billy Shore said he had a better idea … whipped out his iPhone – can you see the irony of standing in this place and Billy’s on his iPhone? And he sent a note on Twitter that said, “Anybody got a surgical cast saw I could use?” and the network goes whacko and an hour later there are 3 of them being Fed Exed to Yele Haiti people because they’ll do whatever they have to to get aid to those who need it.

Before I left for this hastily-planned trip, people – many of them rightfully disgruntled family members – demanded to know what I hoped to accomplish with my visit. I always replied, honestly, that I didn’t know and wouldn’t know until it happened ... but that I had faith that we would find a way to share strength. A week later, and plenty of tears later, I am still not sure.

Yele would have served the meals without me. University Hospital would have gotten a cast saw, eventually. Somehow, nothing I did would have gone undone. So CEO as disaster volunteer, not a good model. But, CEO as witness — that is a different story.

What my eyes have seen, my heart has felt. And so this voyage is just beginning.

The good that comes from this journey lies rather in what happens next.

It lies in the limitless kindness of Bill Shore — who worked his cell phone to reach Senator Bob Kerrey, the Congressional Medal of Honor winner from Nebraska, who lost his leg in combat in Vietnam, and who spent more than the last decade building a prosthetic “industry” in Vietnam, so his former enemies could have prosthetic care for their wounds. Billy used to work for Kerrey, and moved by what he saw — 70% of Haiti is young people, and so 70% of the amputees face a life long challenge of prosthesis — Billy persuaded Kerrey to begin to set up a prosthetic network in Haiti. Lives will be saved and destinies altered by this kindness.

We are working with Yele, to ensure that the pipeline from the DR to Haiti is open and working, so aid can go not to a UN depot, but to the people who need it so desperately.

And, Yele and Timberland are continuing to work together, more intimately than either imagined, to set up an operationally sound approach to helping our brothers and sisters in Haiti. I’ll be back in touch with more information as our partnership continues to evolve, and to share with you the ways in which we’re hoping to bring our vision of commerce and justice to bear for Haiti’s citizens and survivors.

Thank you for bearing witness to my experience by reading this far. I wish I could leave some of this out; I wish most of it hadn’t happened. Thank you for kind words you’ve shared; I needed your strength and I still do. Most of all, thank you for building a community at Timberland whose values give me license for such a journey -– not in an indulge-the-crazy-CEO way, but in a “of course you should go, why are you still standing here?” way.

No clever conclusion to write — because this voyage is hardly begun. Home from hell, changed and different, but unrelenting in my view that the path to heaven lies true north by commerce and justice.

Yours in service,