Friday, April 30, 2010

Ohio mushrooms

Kristal Gartner, RN at Grant Medical Center sat next to me at lunch in Columbus and talked about morel mushroom hunting with her husband. You see them here in the wild and on the family picnic table.

Poster Session in Columbus

The Columbus conference has some great poster presentations, as well. Here is a sampling.

Hello, Columbus

I am currently in Columbus, Ohio, where I was invited to be one of two keynote speakers on quality and safety issues at the Central Ohio Patient Safety Conference. This is an annual conference organized by a number of hospitals in the area who decided years ago that "we compete on everything, but we don't compete on safety."

The other keynote speaker is one of my heroes, Robert Wachter, who is Professor and Associate Chair of the Department of Medicine at the University of California, San Francisco. Bob is a leader in patient safety. In 2004 he received the John M. Eisenberg Award, the nation’s top honor in patient safety, and his 2008 book, Understanding Patient Safety, received stellar reviews and is already in its 2nd printing. He also writes a great blog.

This is a serious conference, with about 500 doctors, nurses, and others focused on ways to reduce harm to patients. And these folks have produced results. The chart above gives just one indication, showing improvement in care to heart failure patients. At one point, the chairman asked half the people in the audience to stand up to demonstrate the number of lives saved in just the last year for this group of hospitals, just with regard to one of the metrics collected.

Here are some of the people who attended. They were wonderful hosts to this interloper from the East Coast!

Healthier Hearts? Not quite.

I recently received this data about trends in heart-related procedures. I'm sorry that I don't know the source, but I believe it to be one of the Massachusetts agencies (perhaps the DPH?)

The short summary is that procedures related to cardio-vascular health problems have dropped dramatically, with the exception of valve repairs. The explanation that I was given is that the use of drug-related therapies has risen, with equal or better efficacy than surgery. Perhaps those in the field would like to comment.

These are MA statewide volume trends between 2004 and 2008.

All open heart surgeries: Down 11% from 8762 to 7801.
Any CABG surgery: Down 21% from 5739 to 4553.
Valve surgery only: Up 15% from 2137 to 2448.
PCI only (stents): Down 24% from 16650 to 12613.
Vascular surgery: Down 10% from 19,834 to 17,823.

I hear also that fewer medical students are choosing to specialize in heart surgery. As noted here:

The educational process to become a Cardiac Surgeon is one of the longest in the medical field; after four years of college and another four years of medical school, aspiring Cardiac Surgeons spend five years in a general surgery residency and two or three more in a specialized cardio or cardiothoracic fellowship.

In the face of declining demand and this kind of personal commitment, and the likelihood of downward pressure on the rates paid for these procedures, it would appears that medical students are making rational decisions. On the other hand, if fewer enter the field and there is a shortage, maybe those who have chosen it will have the market power to drive up their reimbursement rates.

Thursday, April 29, 2010

Does market power help patients?

Rob Weisman and Liz Kowalczyk report in today's Boston Globe that the US Justice Department is investigating possible antitrust violations against Partners Healthcare System, the dominant hospital and physician provider group in Massachusetts.

The letter, obtained by the Globe, said the probe sought to determine whether the practices violated the Sherman Antitrust Act, which bars companies from using their market power to limit trade or artificially raise prices.

Since the Attorney General has already reported that rates collected by PHS are clearly higher than most others in the market, I imagine the case will rise or fall on the following proposition: Is the market power of this system necessary to produce an integration of care that brings clinical advantages to the public served by it? You could test this the following way: If you look at the actual data, is the safety and quality of care offered by PHS significantly different (in a positive way) from other academic medical centers, community hospitals, and physician groups in the state?

Note that I include all three components of the provider network. If a Partners GI doctor in the suburbs doing colonoscopies secures higher rates than his non-Partners colleague down the street -- solely because of his affiliation -- can you document that his care is better? If a patient goes to Newton Wellesley Hospital or North Shore Hospital, where the hospital and the doctors are both paid more than other community hospitals, can you document that their care is better? Ditto, of course, for the care given at the academic centers downtown.

Put it another way. Does the absence of such data -- given the paucity of transparency about clinical outcomes -- create a prima facie case that there is no demonstrable clinical benefit from Partners' market power and its resultant higher prices? Perhaps the answer depends on who has the burden of proof in anti-trust cases. Does the government have to prove that there is no demonstrable clinical advantage, or does Partners have prove that there is?

Wednesday, April 28, 2010

ACGIM recognizes Dr. Phillips

Dr. Russell Phillips was recognized this week by the Association of Chiefs of General Internal Medicine as the division chief "who most represents excellence in Division leadership." From my point of view watching Russ at work here at BIDMC, this was a superb choice. Congratulations!

A happy announcement

Ellen Feingold, who has run Jewish Community Housing for the Elderly for 28 years, is passing the reins to Amy Schectman. I can't say enough good about both people!

Amy is currently Associate Director for Public Housing & Rental Assistance for the Massachusetts Department of Housing and Community Development. In that position, she has gotten rave reviews from all parties. I'm sure they will miss her, but I bet she figured out how to ensure that her successor will continue to be successful. (Oh, did I mention that she also has a Master in City Planning from a very reputable school in Cambridge?)

Ellen is a legend in the Boston community, running and building housing and related programs at JCHE over the years. She talks of retirement, but it is hard to believe. For starts, watch her help organize an effort to defeat a referendum on this November's ballot that would kill off much of the potential to expand the state's affordable housing.

Aligning Forces for Quality

A significant announcement comes from the Greater Boston Quality Coalition, a group of over thirty hospitals, community health centers, physician groups, business groups, and nonprofits. Here are excerpts:

The Greater Boston Quality Coalition (GBQC) announced today that it has been selected by the Robert Wood Johnson Foundation to participate in Aligning Forces for Quality (AF4Q), an unprecedented effort to lift the quality of health care provided in select communities nationwide.... Greater Boston joins 16 other select regions that are coordinating efforts to improve the quality of health care at hospitals and in doctors’ offices, reduce racial and ethnic disparities in care, and provide models for implementing national reform.

The work will be grounded on the core principle that in order to transform the health care system, everyone who gives care, gets care and pays for care must work together. The Greater Boston Quality Coalition’s AF4Q initiative will focus on four key areas:
-- Performance measurement and public reporting: using common standards to measure the quality of care that doctors and hospitals deliver to patients and making that information available to the public.
-- Consumer engagement: encouraging patients to be active managers of their health care, and make informed choices about their doctors and hospitals.
-- Quality improvement: implementing techniques and protocols that doctors, nurses and staff in hospitals and clinics can follow to raise the level of care they deliver to patients.
-- Health Equity: reducing disparities in care for patients of different races and ethnicities.

Specifically, the Coalition’s AF4Q initiative will initially center its work on reducing preventable emergency department visits and associated admissions. This indicator of primary care access, primary care effectiveness, appropriate treatment in community settings, and system integration has been overwhelmingly supported by GBQC stakeholders.

Airspace Rebooted

My pilot friend who had sent along previous no-fly zones sends this fascinating clip on the restoration of air traffic in Europe as ash levels from the Iceland volcano diminish. He notes: "Due to varying ash density across Europe, the first flights can be seen in some areas on the 18th and by the 20th everywhere is open."

If you cannot see the video, click here.

Airspace Rebooted from ItoWorld on Vimeo.

Tuesday, April 27, 2010

Healthy Work/Healthy Home

BIDMC celebrated its 12th annual Healthy Work/Healthy Home Enivironmental Action day today. Awards were presented to environmental champions in the hospital, and especially people for whom their specific efforts were not part of their job description.

Jim Hunt, Mayor's Menino's chief of environmental and energy services, was the guest speaker. He talked about the City of Boston's engagement in sound environmental and energy practices, which has been recognized in the City's 6th place ranking by SustainLane.

Following the breakfast session, people congregated at a set of exhibits and were offered these nice water bottles as a remembrance of the day.

Monday, April 26, 2010

Update on MA Health Reform

Sarah Iselin, President of the MA Blue Cross Blue Shield Foundation, sent along a copy of a new report entitled, "Enrollment and Disenrollment in MassHealth and Commonwealth Care." It was prepared for the Massachusetts Medicaid Policy Institute by Robert Seifert, Garrett Kirk, and Margaret Oakes. Neither an indictment nor a congratulatory document, it is a thoughtful and useful report on a particular aspect of the MA health reform experiment.

Here's the link.

From the Executive summary:

Massachusetts has made great strides in making health insurance attainable for nearly all of its residents, and the state’s main public coverage programs — MassHealth and Commonwealth Care — have been a significant component of this achievement. Beyond getting coverage, though, it is necessary to maintain coverage, because continuity of coverage is an important element of access to care, particularly among those with frequent medical needs.

Evidence from MassHealth and CommCare, and from Medicaid and CHIP programs in other states, suggests that a sizable number of people are unable to maintain their coverage over a period of time, despite remaining eligible for the program. There are a number of reasons for this enrollment volatility, including:

--an enrollee’s income has increased or they have gained access to employer-sponsored insurance;
--an enrollee does not want to or is unable to pay required premium contributions; or
--an enrollee fails to return paperwork or provide other necessary documentation of their eligibility, in some cases because MassHealth does not have a current address for them.

Of those who are disenrolled, some will come back to the program at a future date and requalify for benefits, while others will transition to another public program, private coverage or uninsured status. If an individual returns to the program after a short time, it is often because the initial disenrollment was due to a failure to return paperwork, provide adequate documentation of income or employment status, or some other reason unrelated to conditions of financial eligibility. These administrative closings followed by swift reopenings — sometimes called “churning” — can disrupt people’s access to health care.

Not all movement on and off of programs is churning: some enrollment and disenrollment is a natural and legitimate consequence of a program where eligibility is based on income and employment circumstances that are subject to frequent change.....

Sunday, April 25, 2010

Non-zero sum

Let's face it. Health care is an odd field. Costs are unknown or indecipherable. Prices for the services offered are hidden from consumers. Likewise, the value (efficacy, quality, safety) of the services received is hidden from consumers. In no sense does it represent other markets, in which transparency of these elements reigns and which therefore have a better chance of reaching the "efficient market" described by economists.

In such an environment, growth in market share by one participant is usually solely at the expense of another: a zero sum game. But even in the dysfunctional world of hospitals and physician marketplaces, such transactions can add value to society. In that case, the result is a non-zero sum game. But only if the "winners" actually do add value.

The business strategy of our hospital is remarkably straightforward. We hope to be the high quality, low cost provider among academic medical centers in our region. We look for community-based partners -- hospitals and physician practices -- for whom we can respectfully help to deliver coordinated care. You have read numerous examples on this blog about how we are trying to do this.

But this is more than a business strategy. It is a matter of values and mission. You won't find this mission statement written in our formal documents or in any strategic plan. Its strength lies in the fact that it is a deeply held belief.

I never told you this story, but when Gloria Martinez, one of our transporters, won our first caller-outer-of-the-month award, she first graciously accepted the award on behalf of herself and the other transporters. Then, with no coaching or prompting whatsoever, she said that she and her colleagues viewed their job as "trying to provide the kind of care we would want members of our own family to receive."

I know I do not violate confidences when I tell you that this simple statement from Gloria left tears in the eyes of our Board members. That a person who pushes beds and wheelchairs and delivers specimens -- who in another institution might be anonymous and ignored -- could simply and elegantly express the community purpose of our hospital was a very moving moment.

We fully engage clinical transparency because we view openness in such matters as the best way to hold ourselves accountable to the standard of care we -- the Board, the clinical leaders, and the administrative leaders -- have set for ourselves. We do not do this for competitive purposes, but if the health care marketplace recognizes our progress and rewards us with a growing market share, we are happy to contribute to a non-zero sum result for society.

Saturday, April 24, 2010

Sunday in Chinatown

While some people wait patiently for a dim sum table on Sunday morning, others play an intense game of Chinese chess. (Taken a couple of weeks ago.)

Friday, April 23, 2010

Geoff delivers for the interpreters

More from our interpreter service group. A really nice note from Stephanie Baumeister, the group's coordinator, about Geoff O'Hara, one of our systems specialists. Translation of some terms: CCC is our electronic medical records and scheduling system. "Non-staff languages" means foreign languages where we rely on per diem help for interpreters because there is not enough demand to have people on payroll. Shari is our head of interpreter services.

Good morning, Paul!

I just wanted to let you know about the great work that Geoff O’Hara did for us. Because non-staff languages do not have their own CCC schedule where appointments for patients who need an interpreter can automatically be booked with their healthcare provider (which is the case for staff language interpreters), we used to have to rely on schedulers to notify me in order for me to arrange for an interpreter to be present. There had to be a better way. Shari and Geoff talked, and Geoff came up with a brilliant program. He worked very hard for an entire week until we were all happy with the results. Now, whenever a non-staff language appointment is booked, rescheduled or cancelled, CCC sends me an automated email to notify me. Not only that, but it is sent in the scheduler’s name, so that I can just “reply” to sender to easily communicate with the scheduler. Since the new system was implemented in September, we have caught, on average, another 100 appointments a month (projecting about a 1500 appointment increase for FY2010) that without this enhancement might have slipped past us. It has also helped us to educate the staff about the Medical Center’s policy of having a professional interpreter present for appointments instead of family and friends, which was the cause of some of the lack of notification. My mailbox is stuffed now, but the patients and providers are getting the help they need.

Here is what the emails look like. See how Geoff added location for my benefit? My interpreters appreciate that!

An appointment for a patient requiring interpreter services has been scheduled.

Patient: XXX,XXX (MR # XXXXXXX) Language: *BULGARIAN

10/15/10 | 9:00 AM | GERONTOLOGY LMOB (SB) | GERONTOLOGY,GANGAVATI LM Lowry Bldg (110 Francis St) | 1st Floor


An appointment for a patient requiring interpreter services has been changed.

Patient: XXX,XXX (MR # XXXXXXX) Language: *ARMENIAN








An appointment for a patient requiring interpreter services has been cancelled.

Patient: XXX,XXX (MR # XXXXXXX) Language: *ARMENIAN

04/16/10 | 1:45 PM | PHYSICAL THERAPY -SHAPIRO CC2 | HARRIER,DARLENE SC Shapiro Clinical Ctr | 2nd Floor

What vacation?

It is April and school vacation week here, but some students choose to use their vacation time for non-recreational purposes. Here, Brookline High School senior Kate Spencer is spending the day shadowing our Spanish interpreters to get an idea of how they do their jobs. You see her with Teresa Barbosa, the lead for our Spanish group, who is outlining the plan for the day.

Thursday, April 22, 2010

Keep 'em coming , Claire!

I'm always getting ideas from the staff. Sometimes these are in person, sometimes on Facebook. Here's one that came by email from a loyal Red Sox fan:


Sorry to bother you but I had a thought, why are our patient's sox blue and green ? They should be red, for the Red Sox. I think this would be a great idea. Imagine all of our patients with red sox on !!!!!!!

Thanks for your time.

Me to Joe, head of purchasing:

Cute question -- answer, Joe?

Paul, please see the answer provided by Jeff, one of our managers and the individual who handles this portfolio.

Hope that helps and please let us know if you need any additional information.

Thanks for your note,


We receive this suggestion every year. Although it would be a very trendy idea, we have sound reasons why we do not.

The most important reason why we do not is for slip and fall prevention of our patients. Our current double tread slipper socks are currently color coded to size: Medium Green, Large Blue, X-Large Beige and Bariatric Gray. With separate coloring, this quick visual helps nursing obtain the correct size they are looking for and that the patient is fitted correctly. A one-size-fits-all slipper in red or any other color does have a tendency to slip, bunch or turn and possibly increase the chance of a fall. If we were to have the same color (Red) in all the sizes, nursing would spend too much time looking for the correct size and improper sizing could occur.

This suggestion has been before the Product Standards Committee several times in the past and has been rejected.


Claire --

I found out the answer! Sorry...


Thanks for your help, I had my hopes up. I had visions of patients in red sox in my head!!! I have other ideas I would love to share with you. I'll be in touch. I really, really appreciate your attention. Thank you.


El aspecto humano

I received this warm and moving letter of appreciation from the South American friend of a patient here. I present it in the original Spanish to be true to its sentiment. Ana Marin is our patient navigator, part of a joint effort with the American Cancer Society. Annie Banks is one of our social workers and part of our palliative care consult service.

[BIDMC] que fue para él y mí, nuestra segunda casa, mientras él recibia tratamiento de un tumor canceroso en el cerebro, ésta lucha duro 1 ano y 1 mes hasta que falleció. Deseo agradecer el mas importante aporte - "El aspecto humano" de todos las personas que intervinieron en su atención. Fue maravilloso, ver su sonrisa, consideración, campasión y profesionalismo.

Cabe mencionar el personal del departamento de Neurologia, las trabajadores sociales y la Navigadora de pacientes con cancer, Ana C. Marin, ACS/BIDMC, quien también me puso en contacto con Annie Banks, LICSW, a quienes profeso enorme gratitud y aprecio.

Wednesday, April 21, 2010

Hope and Monique visit with Emily

I have written before about this wonderful new book for young women. It has received a nice review from the Washington Post. An excerpt:

Gynecologist Hope Ricciotti and health writer Monique Doyle Spencer have produced this guide for women in their late teens, 20s and 30s to steer them away from what they call the "Favorite Four" sources of health (mis)information: best friends, Mom, magazines and the Internet.

Now you get to hear and see the authors discuss it on Emily Rooney's Greater Boston Show on WGBH-TV.

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

Reputation versus quality: U.S. News Hospital Ranking

Each year, US News and World Report publishes its list of the top 50 hospitals in various specialties (example here). Now, an article has been published suggesting that one aspect of the methodology used by the magazine is flawed.

"The Role of Reputation in U.S. News & World Report’s Rankings of the Top 50 American Hospitals," by Ashwini R. Sehgal, MD is in the current edition of the Annals of Internal Medicine. (You can find an abstract here, and you can obtain a single copy for review from Dr. Sehgal by sending an email to axs81 [at] cwru [dot] edu.)

Dr. Sehgal finds that the portion of the U.S. News ranking based on reputation is problematic because reputation does not correlate with established indicators of quality:

The relative standings of the top 50 hospitals largely reflect the subjective reputations of those hospitals. Moreover, little relationship exists between subjective reputation and objective measures of hospital quality among the top 50 hospitals.

More detail is provided in the article:

The predominant role of reputation is caused by an extremely high variation in reputation score compared with objective quality measures among the 50 top-ranked hospitals in each specialty. As a result, reputation score contributes disproportionately to variation in total U.S. News score and therefore to the relative standings of the top 50 hospitals.

Because reputation score is determined by asking approximately 250 specialists to identify the 5 best hospitals in their specialty, only nationally recognized hospitals are likely to be named frequently. High rankings also may enhance reputation, which in turn sustains or enhances rankings in subsequent years.

Given the importance attributed to the U.S. News ranking, this article is bound to raise concerns. I know that the folks at the magazine have worked hard over the years to make their rankings as objective as possible, and it will be interesting to see their response to Dr. Sehgal's critique.

Tuesday, April 20, 2010

Dr. Yang explains the Lean approach in 7 minutes

Following up on the post below about the use of Lean process improvement in the hospital setting, I am pleased to present this video. It shows Dr. Julius Yang explaining the difference in a traditional workplace setting from one in which Lean principles are in effect.

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

Lean update -- Readmissions

Several of you have asked for updates on our Lean process improvement efforts. There is lots of stuff going on at the hospital in this regard, and it is not possible to put it all in this blog. But here is a summary of the work on an important set of clinical projects related to transitions of care. It is in the form of an email from Doctor Julius Yang, who is coordinating the effort.

I offer these as works in progress, with a full admission of current flaws in our processes. I know folks in other hospitals will find the subject matter familiar, as the issue of readmissions is one we all face. Perhaps our approach will provide you with useful suggestions. We also welcome yours.

Notice below the involvement of residents. This is very important in an academic setting, as they are key participants in the delivery of care. It also provides these young doctors with a chance to learn process improvement methods, something that is usually not taught in medical schools.

Notice, too, the beginning of more outreach to patients after they leave the tertiary setting.
This is likely to be a growing trend nationwide. We are certainly not the first place to do this, but it remains relatively unusual for hospitals, which have tended to focus only on the acute care setting.

Hello all,

I wanted to take this opportunity, now five weeks after the close of our Multidisciplinary Quality Improvement Retreat, to once again thank all of you for your participation and important contributions towards improving the transition from hospital to home, and then to clinic, for our patients. Our rate of readmissions to the hospital within 30 days of discharge from the Medicine service remains high, hovering at about the 20% range. We've run more detailed analyses of these cases, and continue to find a wide variety of "root causes" for these readmissions, including medical decision-making at discharge, poor coordination of care plan with extended care facilities, lack of outpatient visit prior to readmission, ambiguous contingency planning when symptoms recur, among others. Based on this analysis, we continue to pursue multiple avenues for improvement simultaneously.

In terms of the two specific project streams generated from the QI Retreat (telephone follow-up with patients within 24hrs of discharge to home, and an electronic discharge checklist), over the past month a number of workgroups have made progress towards implementation of these initiatives. A brief update:

1. Post-discharge Telephone Follow-up
With strong support from our Nursing Directors in medicine, cardiology, and our Director of Patient Safety, we have received approval to conduct a pilot intervention for a "Nurse Discharge Specialist" whose role will include post-discharge telephone follow-up with patients at high risk of readmission. The target population for the pilot will be those patients who have been admitted to the hospital with heart failure, and especially those who have had prior readmissions. The intervention will consist of a dedicated nursing role to visit with these patients prior to discharge for both education and assessment of factors that may lead to readmission. Once discharged, this nurse will then follow-up with the patient by telephone the following day, to reinforce education and to ensure continuity in the discharge plan. The telephone "scripts" that were developed in the retreat will help to inform how this encounter is designed. During the pilot, there will be one nurse each weekday to serve in this role, to be shared across Farr 3, CC7, and Farr 2, with the intention of capturing 6-8 patients per day. The goal of the pilot will be to refine the logistics of this position, assess feasibility and generalizability, and assess impact on readmission rate for those patients seen by the Nurse Discharge Specialist. We anticipate the pilot will begin in May.

2. Electronic Discharge Checklist
Although we do not yet have a "live" electronic checklist, there has been some important progress over the last month. First of all, our Case Management leadership have embraced the concept of a "discharge checklist" to ensure that all requisite factors have been addressed prior to discharge of our patients at high risk of readmission (for now, we are defining "high risk" to include patients with heart failure, or patients who have been readmitted previously). We are therefore planning a pilot intervention in which our case managers will be in charge of a "checklist" (resembling the concept explored in our retreat) that will be used to guide care planning at daily case management rounds. The goal of the pilot will be to refine the checklist tool and its use, assess feasibility and generalizability, and assess impact on readmission rates. We anticipate this pilot to begin in the next two weeks.

Secondly, two of our QI retreat alumni, Elena and Andrea, have worked with another one of our residents, John Greenland, to develop a highly-detailed mock-up of an electronic discharge checklist, viewed through the POE alternate dashboard. It looks fantastic, and appears quite feasible to execute from existing data resources. We are now planning to present this model to I.S. for their review, with the goal of collecting their assessment of feasibility and timing for further development and implementation of such a tool.

As we continue to further develop these two project streams, I see that a major challenge still lies in establishing "stability" for change and continuous improvement at the front-line, "unit staff" level. Because of competing schedule demands, it has been difficult to coordinate routine meetings for front-line staff on each unit, in order to help teach and develop "kaizen mindset". I would like to try to gather us, as QI retreat alumni, perhaps in the next two weeks to further explore the best model by which to pursue this goal, and welcome any input or thoughts you may have in the interim.

Again, thanks to all for your work last month - the improvement continues.

Monday, April 19, 2010

2010 Boston Marathon

It was a sparkling spring day for this year's Boston Marathon, a 26.2 mile run from Hopkinton to Boston. Before the race these people had prepared a welcoming sign in chalk for Tina, who is clearly a Canadian. The first runner to step on Tina's artwork was Teyba Erkesso, from Ethiopia, who won the women's race. You see her whizzing by in this picture at mile 19, where she was far ahead of the pack. She finished in 2:26:11, edging out the next person by a mere three seconds.

The men came next, clumped together bit more at mile 19. But by the end, Robert Cheruivot from Kenya pulled away, finishing in 2:05:52. He beat the next runner by almost two minutes.

I was looking for, but missed, my colleague Scott Kashman, CEO of St. Joseph Medical Center in Kansas City. He ran a very respectable 3:10:30.

As was the case last year, BIDMC's Dr. Doug Horst was part of a large group of runners who were raising money for the American Liver Foundation. You see him here, near the 24-mile mark, still in good spirits.

Some friends, including a couple of soccer buddies, invited me to play in their band at mile 23 or so. Instruments included African drums, a piccolo, gongs, sticks, and, of course, a sousaphone. The ensemble was well appreciated, especially by the "less elite" runners who were still coming by late in the afternoon.

Volcanic ash moves east

My pilot friend sent this update last night:

The volcanic ash has just about reached North America. Some flights tomorrow are canceled in Newfoundland! I doubt it will spread significantly in North America since the prevailing winds blow from west to east, but it is still amazing.

Here's a story from CBC News.

Sunday, April 18, 2010

Rock and Roll Jihad at Harvard

Professor Ali Asani, a friend on the faculty of Harvard, hosted a wonderful conference this weekend entitled, "Contemporary Muslim Voices in the Arts and Literatures." You can see the program here. Asani, who is Professor of Indo-Muslim and Islamic Religion and Cultures, organized a marvelous mixture of music, poetry, film and other art forms. The two days demonstrated how the arts can be integrated into the traditional view of the academy to bring greater depth of understanding of political, cultural, and religious issues.

After the formal conference, there was a special treat. Salman Ahmad, the world famous Pakistani Sufi Muslim musician, visited one of the Harvard dormitories and gave an impromptu concert and talked with a small group of people about his experiences. Ahmad explained a bit about his new autobiography, Rock and Roll Jihad, which explains how he became a musician notwithstanding tremendous cultural and religious objections.

Ahmad also related an interesting story about cultural misunderstanding. He had been invited to perform at New York City's upcoming Earth Day celebration, but he was uninvited when someone decided that a performer who talked about jihad would not be appropriate. In Ahmad's view, though, jihad means striving in the way of Allah, "not the meaning that has been kidnapped by terrorists."* After this was made clear to the Mayor's office, he was re-invited to perform in the concert.

As he notes on his Twitter page, @sufisal: "Jihad means to strive, struggle, overcome the ego, and to find your purpose NOT commit violence and/or spread terror."

My speech to the hospitalists

Several of my readers have asked me to post this link to the speech I gave a few days ago at the Society of Hospital Medicine. I listened to it and think it is ok. Please let me know what you think.

Discount to FELA!

The Migraine Research Foundation offers discount tickets to the hit Broadway musical FELA! The show tells the true story of Fela Kuti, the legendary Nigerian musician, whose stirring Afrobeat rhythms ignited a generation.

Whether you live in New York City or plan to visit, this is a great way to see a terrific show and also help the Foundation's work. Twenty percent of the ticket costs goes to the Foundation. Click here for tickets.

Saturday, April 17, 2010

Fallout from Iceland volcanic eruption

A pilot friend writes:

This is the map of the flight restrictions due to the volcanic ash. Unprecedented. Solid red=low level (surface-20000 ft), dashed red=high level (20000 ft - 35000 ft).

More from the Washington Post here.

Friday, April 16, 2010

Feed me!

There is a fascinating article by Justin Sonnenburg from Stanford in the April 8 edition of Nature (Volume 464, 837-838) entitled "Genetic pot luck." I'm sorry that you need to pay to get full access, but here is the major point.

It turns out that humans are not designed to digest the kind of seaweed that is used to make sushi. However, if you eat enough of it, you ingest enough of the marine microorganisms that live on seaweed that they serve to help you digest seaweed. But it is not just colonization by these microorganisms: It comes about when the microbiota in your gut acquire genetic material from these other organisms through a process called lateral gene transfer.

With regard to the particular problem of digesting the nori used to wrap sushi,

The analysis revealed that these [genetic] sequences are abundant in the intestinal microbiomes of Japanese individuals, but not in the microbiomes of residents of the United States. The authors conclude that seaweed, which is prevalent in the Japanese diet . . . was probably the source of the microorganisms that introduced the useful genes. Although it is not clear when in human history the transfer, or transfers, of these genes occurred, continuous consumption of seaweed is the likely selective force that drove the retention of this "polymorphism" in Japanese

Wow. How about that!

Now, for me, this raises the reverse question. Once we have evolved to be able to metabolize seaweed, do these bugs in our gut notice when we don't eat it for some period of time and cause us to have a craving for maki? In other words, do they send a message to the brain that somehow says, "Feed me sushi?"

(Thanks to former HMS Dean Joe Martin for telling me about the article.)

The sleaze factor

Here's the down side of the Internet, which otherwise has produced such good for the world. As reported by the Washington Post, a media-owned blog published a report about a public official's personal life, based on an unsupported comment by someone who has an interest in hurting the Administration. Although ultimately withdrawn, you can bet that the story has its own life now and is spreading to other sites.

Tax Day message

A friend forwarded this link to me. It is an article posted yesterday by James Tracy, Headmaster of Cushing Academy, entitled "The Joy of Tax." I think it is a nice reminder that part of the price of a strong society is our commitment to funding the government -- to provide essential services and to help those in need -- both of which functions our economic system is not designed to deliver. An excerpt:

Well, today is That Day, April 15th, and I seem to be the only person smiling. Leaving the post office after dropping off my tax payments, I have the same warm feeling I get when I leave WalMart after finding a good bargain. It is all the rage these days to rail against taxes and vilify government. Why doesn't this get through to me? My idea of a Tea Party is to pay my taxes gratefully then enjoy a cup of Earl Grey.

....Any human organization on such a scale is going to have corruption and inefficiencies, but, compared to the rest of the world, the American civil servants, overall, do a stellar job keeping us all safe, well, and provided with opportunities to better our lot. So I pay my taxes with a sense of patriotic pride, knowing that I am helping others as I have been helped and also that I continue to benefit.

Thursday, April 15, 2010

Jon leaves. Glen takes over.

The State House News Service reports:

Jon Kingsdale, a former insurance industry executive who worked as the first executive director of the state's Connector Authority, will step down in June and be replaced by Glen Shor, a senior member of Gov. Deval Patrick's fiscal team. The changes at the top of the authority comes four years after Kingsdale was selected to help launch the new authority, which has focused on running a subsidized insurance program called Commonwealth Care and launching a Commonwealth Choice program aimed at delivering health insurance options to families and individuals. Shor has worked for the past three years as assistant secretary for health care policy and deputy general counsel within the Executive Office of Administration and Finance.... Before joining the Connector, Kingsdale, who was appointed by former Gov. Mitt Romney, worked as senior vice president of policy development at Tufts Associated Health Plans. In a press release, Kingsdale said Massachusetts had "built the model for national reform." About half of the estimated 400,000 individuals in Massachusetts who have obtained insurance since the 2006 law passed have enrolled in plans through the Connector.

Many thanks to Jon for doing a superb job, one which he essentially had to invent from scratch. He did it all with excellent judgment and thoughtfulness and respect for the wide variety of constituent groups in the state. Congratulations, too, to Glen, who brings his own wisdom and experience to the position.

Senator Murray offers her plan

For my out-of-town readers who are following this: Liz Kowalczyk and Rob Weisman report in the Boston Globe on the next stage in the Massachusetts story about insurance rates. Our Senate President, to her credit, has become the de facto policy leader on this very tough issue.

Wednesday, April 14, 2010

How much would you bid for a $10 bill?

I have taught many negotiation classes over the years, and I continue to do so at my hospital. The attendees include students, doctors, and administrative people. It is a very interactive session, with several simulation exercises used to demonstrate some of the principles of the field.

I often present one game that is an auction. I offer to sell a $10 bill to the highest bidder. Here are the rules: Bids start at $1 and must go up in $1 increments. The winning bidder wins the $10 bill and pays me the amount of his/her bid. The second place bidder wins nothing but must also pay me the amount of his/her bid.

What do you think happens? Well, usually there are two bidders who have trouble stopping. The person in second place offers a new bid in the hope of being the higher bidder and getting the $10. Then, the other person, not wanting to pay money for no return, feels the same way. I think the highest price I have received over the years for the $10 was $24 (and $23), which netted me $37.

This game is illustrative of what happens during wars and lawsuits and other fruitless types of negotiations, where the parties lose track of their underlying interests and the value of the matter in question.

We only reached $14 (and $13) this week. Later, the "winner," one of our fine neurologists (and one of my soccer buddies), sent me this note:


As a scientist, after the class yesterday, I immediately searched for explanations of what happened during the “Ten Dollar Auction” game. I had a particular interest in my behavior and the others’ reactions. I made significant revelations. The paradox of irrational decisions on rational choices worked perfectly.

I have found the following very interesting aspects and facts:

  1. In the overwhelming majority of games, both the highest and second highest bidders will pay in excess of the amount the group is auctioning.
  1. There are four major components of the players’ behavior:
  • prospect of winning for a small upfront investment
  • trapped near the $10 level by not wanting to lose the bid
  • remaining consistent with the earlier commitment to avoid being judged foolish to enter the bidding war
  • ego, competition, rivalry
  1. Yesterday I think the limbic emotional part of my brain overruled my higher level cortical thinking driven by my academic high ego and soccer player-coach competitiveness.

The general lesson I learned from this game and from my search is the following:

  1. Ego and competitiveness in a competitive and adversarial environment leads to irrational escalation of commitment, which beyond the “Ten Dollar Auction Game” lessons has very important implications for organizational behavior.
  1. According to Gregory P. Smith, international business consultant, this auction game is very effective for demonstrating the benefits of internal competition and the possible downsides of an adversarial environment.
  1. While internal competition can generate enthusiasm and energy, cooperation can prevent the irrational escalation of commitments (bidding war). Maybe this is why high ego academic professors can not and should not run academic medical centers?

It was fun to learn so much.

Thank you.

Tuesday, April 13, 2010

VAT on the horizon

Several months ago, a friend met with a high government official and expressed concern that the new health care bill would be more expensive than people were saying. "Oh yes," said the official, "In several years, the United States will pass a value-added tax to cover the cost."

After the bill passed, Charles Krauthammer wrote this column in the National Review saying the same thing:

American liberals have long complained that ours is the only advanced industrial country without universal health care. Well, now we shall have it. And as we approach European levels of entitlements, we will need European levels of taxation.

I believe that a VAT is a move in the right direction. (I distinguish for the moment between amounts of taxation and the form of taxation.) Current tax policy in the United States discourages saving and investment and rewards consumption. Think of the double taxation on what you earn as salary and then what you earn as interest on your savings; think of income taxes on corporate profits and then again on the dividends you collect. A VAT avoids those problems.

The problem with a VAT is that it is regressive in nature, affecting lower income people more than wealthier people because lower income people spend a bigger percentage of their income on consumables. But you can adjust for that with income-based rebates or exemptions.

But, there is the danger that this tax will be able to be increased with little public scrutiny. It will not necessarily be visible because it is added at each stage of production, and so Congress could just jack it up whenever it wants. Also, you don't hear talk of reducing other taxes as this new one is introduced. That is why some people are nervous, like the gentleman quoted here:

Jon Hurst, president of the Retailers Association of Massachusetts, said he fears a value-added tax would simply be used to fund new programs....

The costs of health care reform were intentionally designed not show up in a big way until well into the next Presidential term. It is thus likely that it will be a few years before the debate begins in earnest, but it is on the horizon.

Dr. Aroesty goes the distance

We had our annual service awards reception last night for people who have worked here for a long time. The "winner" was cardiologist Julian Aroesty. Michael Keating wrote the following story:

Of the many highlights Julian Aroesty, MD, Cardiology, has had during his stellar 45-year career at BIDMC, there is one that overshadows all others – “Getting a job here in the first place!”

Aroesty’s eyes light up with a bright smile as he recalls the day he came to Boston to interview for a Senior Resident position. He met with Hermann Blumgart, MD, George Kurland, MD, and A. Stone Freedberg, MD, who told him there were three things they expected of every physician who worked at Beth Israel Hospital.

“First, they said that everyone has to be a good physician and take care of patients; even those who worked in the labs had to rotate on the medical service for two months so they’d never forget this job is about taking care of patients,” he said. “Second, they said you have to love to teach because our job is to teach the next generation. Third, they said we all have to advance medicine and basic science. Well, after the interview I said to myself, ‘This is the place for me.’”

But it wasn’t as easy a choice as he makes it sound. Aroesty is a first generation American who comes from a small community of Spanish-speaking Jews in Rochester, NY. The community traces its lineage back to those who were expelled from Spain in 1492 and went to Turkey where they continued to speak Spanish for 500 years despite being in a non-Hispanic country.

“I thought about staying in Rochester and being the first physician to the community, but the offer to come here was so good I decided to take it,” he said. “My mentors were men like Drs. Blumgart, Kurland, Freedberg and Paul Zoll – millions of patients the world over have been saved by Zoll’s research (heart monitors, pacemakers and defibrillators). Working with people who love to teach is such a huge thrill.”

New Beginnings

The cardiac catheterization lab had only recently opened when Aroesty accepted an attending position. “My job was to make it busy, make it high quality,” he said. “I went out and spoke at all the neighboring hospitals. I was half-time person, half-time in the lab and half-time in my private practice. My wife said this was actually double-time. She was right, of course, because most days I would leave at 7 in the morning at get home around 9 at night. But it’s been a wonderful, thrilling career.”

Aroesty met his wife, Elaine, a nurse practitioner, when she was a nurse at BI. “She’s gorgeous and wonderful,” he said with a smile. “I met her, wooed her and married her. Everyone was chasing her, but I caught her – I still don’t know how, but I did.”

Now, at age 78 and-a-half, Aroesty says he’s starting to slow down so he can spend more time with his grandchildren. “My wife calls this retirement on training wheels,” he joked. In fact, that’s why he wasn’t able to attend this year’s Service Awards event – he was visiting his grandchildren in San Francisco.

Among the other highlights Aroesty recalled was the day in the mid’80s when Mike Lipman, then Director of Admissions, called him into his office and said, “I want you to know you’re the number one admitter to the hospital. What’s more is that you admit 50 percent more patients than the number two admitter.’ I did that by establishing relationships with doctors in the community who knew I never turned off my beeper and I never had an unlisted phone number – and my patients knew that too. I never took off Wednesdays, never joined a country club. I just devoted myself to the job -- and I loved it!”

He also loved the people he worked with. “This is a wonderful hospital because of all the people who work here,” he said “The nurses are truly dedicated and absolutely wonderful, and so are all the people who work on the floors. They’re the reason this is such a special place.”

Changes in the Lab

There have been many changes in the lab over the years, but one of the most important is in imaging. “The big difference is that going from film to digital gives us a much lower radiation exposure - to the patent and to us,” he said. “My first experience with cardiac catheratization, in the early-‘60s, I actually had to look into the X-ray tube to guide what we were doing. It wasn’t on a separate monitor. So the X-ray beam was coming up through a florescent screen into my eyes. I was reasonably protected, but this is what we had to do at the beginning.”

Over his career, Aroesty has performed more than 20,000 cardiac catheterizations and more than 2,000 angioplasties. “I was always very cautious and not afraid to send a patient to surgery if I felt it posed a better outcome,” he said. “I always said to myself, ‘If this was my father, or if this were me, what would I want?’”

That’s a guiding principle he strives to teach his students.

“Sometimes you’ll see something that we could easily fix with a stent, say a proximal LAD lesion in a young guy,” he said. “And the fellow standing next to me says, ‘Let’s go for it.’ I say, ‘No, we’re going to send this guy to surgery for a LIMA.’ He says, ‘Why, we can fix it.’ I say, ‘I know we can fix it. The risks of both procedures are about the same, but he’s 50 years old. The LIMA lasts forever. The stent doesn’t. If this were you, which one would you want?’ He says, ‘Well, I guess I’d take the LIMA.’”

It’s these lessons (being thoughtful about what modality is best for each patient) that returning students say they appreciate most from their time as fellows.

“When they come to talk to me the thing that really pleases me is that they tell me the most important thing I taught them was judgment,” he said. “They say, ‘You taught me to really think about what I was doing rather than just going forward with the lesion-fix. Knowing that there are many ways to fix a lesion and that we have to choose the best one.’”

Aroesty also jokes that his lessons don’t always have their intended effect. “I once heard that a fellow who was on duty when I came in at 3 a.m. to help a patient decided to switch from cardiology to anesthesiology,” he said. “This fellow said that if this is what Aroesty is doing at 3 a.m. when he’s in his 60s, then I want to be doing something else. I laughed when I heard that, but honestly, it’s energizing to get up in the middle of the night and save a life. How many people have a job where you can do that?”

Monday, April 12, 2010

Imani Winds with Stefon Harris -- Special price

There is a very special performance occurring at Boston's Jordan Hall this Friday night, April 16.

Imani Winds with Stefon Harris
Friday, April 16, 8pm
NEC's Jordan Hall

The Grammy-nominated wind quintet Imani Winds' innovative programming and ground-breaking collaborations have been enriching and diversifying traditional wind quintet repertoire since the group was founded. For this performance, Imani Winds teams up with the enormously gifted jazz vibraphonist and composer Stefon Harris. The program will feature the Boston premiere of a new work written by Harris, and co-commissioned by the Celebrity Series of Boston.

Here's the deal. There are still some tickets left for this show. Because I am on the Board of the Celebrity Series, I have been authorized to make a special offer to my readers here. If you contact the Celebrity Series and tell them that you heard about this performance on my blog, they will give you a 50% discount off the ticket prices -- making them $20, $22 & $25. You can do it by phone at 617.482.6661 (Monday-Friday from 10am-4pm) and save the $5 per ticket fee, or you can order on-line here and use the following code, PLIMAN (in all caps). The offer ends Friday 4/16 at noon.

I look forward to seeing you there.

Sunday, April 11, 2010

Will a lava lamp work on Jupiter?

Let's start out the new week on a lighter note. I came in on the end of an email conversation among several of my MIT classmates. (We have exchanges like this. It might come from taking physics and calculus together. It might be indicative of some other problem. I'm not sure.)

Dave to Bill and Doug:

OMG. Look at this:

Lava Lamp Centrifuge

Would a Lava Lamp work in a high-gravity environment such as Jupiter? Would the wax still rise to the surface? Would the blobs be smaller and faster? With broad disagreement on the answers, I built a large centrifuge to find out.

Aside from being highly dangerous (the builder describes several scenarios), he did get the answer.

Bill to Dave and Doug:

Well, inquiring minds want to know

Doug to Bill and Dave:

This falls under the heading of what I call "rabid research", wherein some nut job decides to answer a seemingly unimportant question with a proper scientific experiment. Correctly done, it should involve serious overkill & inventiveness.

Nicely done!


Mr. Fraser's video is below. If you can't see it, click here:

As he notes:

The centrifuge is a genuinely terrifying device. The lights dim when it is switched on. A strong wind is produced as the centrifuge induces a cyclone in the room. The smell of boiling insulation emanates from the overloaded 25 amp cables. If not perfectly adjusted and lubricated, it will shred the teeth off solid brass gears in under a second. Runs were conducted from the relative safety of the next room while peeking through a crack in the door.


One of the treasures of the Boston area park system is the Blue Hills Reservation. It is managed by the state's Department of Conservation and Recreation, and the agency does a marvelous job with its upkeep and maintenance.

But what is this sign about? The context is seen in the photo to the right: A tree next to the path. Maybe someone from the agency can reply with a comment.

In the meantime, for fun, you can offer your own thoughts.

Friday, April 09, 2010

Hospitable hospitalists

I was invited to give the keynote address at the national meeting of the Society of Hospital Medicine in Washington, DC. SHM is committed to enhancing the practice of hospital medicine by promoting education, research and advocacy and has more than 10,000 hospitalist members. They asked me to speak on "The hospitalist's role in the hospital of the future." (Here's a story they wrote afterward.)

Who should I run into but our own Chief of Medicine, Mark Zeidel, who had been invited to be the featured visiting professor for the conference, providing mentoring and insight to those in attendance. You see Mark here with Scott Flanders, Director of the Hospitalist Program at the University of Michigan Health System and President of the SHM.

Hospitalists are now the largest specialty group in medicine in the country, with approximately 28,000 in the profession overall. As noted by panelist Ronald Greeno (on the right), they have a key role to play in improving quality and reducing waste in the hospital environment. He was joined in those sentiments by Patrick Conway and Leslie Norwalk, who further expanded on the implications of the recently passed health care reform act.

About 2,500 people attended this session, including strong representation from BIDMC and several alumni of our program who currently work at other hospitals in the country. Joe Li, one of the first hospitalists in Boston, was voted to be President-elect of the Society and will serve as President next year. Joe has had leadership roles regionally and has also served as the Treasurer of SHM. Congratulations for this well deserved honor!