Transplants

Speaking of transparency (see below), the Los Angeles Times reported in June that 20 percent of U.S. transplant centers were found to be substandard, in part because of a failure to perform enough operations to ensure competency. Here is the link to that story.

In New England, only BIDMC and MGH perform over 100 kidney, liver, and pancreas transplants per year, based on data collected by the United Network for Organ Sharing, UNOS, the national organization that monitors such matters. Several other hospitals perform only two or three dozen.

If you needed a liver transplant, would you be willing to travel an hour or two to go to a transplant center that was more experienced? If insurance companies care about clinical results, shouldn't they be directing patients to those centers with more experience and better results?

Transparency

In the health care world, it has become fashionable to be in favor of "transparency," which roughly means public access to how well providers deliver care and what they charge for it. I agree with this. Health care is one of the few industries in which consumers do not see this information, and it is time to change that.

There are two ways to provide information on how well providers deliver care. One is based on processes, e.g., what percentage of emergency room patients with chest pain are advised to stop smoking (yes, that is one that is commonly collected.) The other is based on results, e.g., what percentage of cardiac surgery patients survive. Both can be important, but is obviously the latter that most consumers will care about. I am in favor of publication of both of these kinds of data, but especially the latter.


The price issue is more problematic. Hospitals and doctors don't get to set their own prices. These are negotiated with insurance companies. Recently, two CEOs of insurance companies in Massachusetts, Charlie Baker of Harvard Pilgrim Health Care and Jim Roosevelt of Tufts Health Plan, were heard to say or were quoted in the newspaper as being in favor of posting the prices that hospitals and doctors charge. Did they really mean that? This would mean that HPHC and Tufts would have to disclose to the world the rates that they have negotiated with BIDMC, Mass General Hospital, New England Medical Center, and the like -- in addition to the rates they pay different groups of physicians. In the past, sharing and publication of these rates was not permitted and was actually a violation of anti-trust laws.


Let me make it clear. We would LOVE to have those prices made public because we believe it would make clear that the largest player in our market, Partners Healthcare System (the owner of MGH, Brigham and Women's Hospital, and several others), gets higher rates because of its market dominance. We would rather have rates based on the quality of patient outcomes -- where the providers that achieve better results would be paid better. Maybe that is what Jim and Charlie are hoping for, too, so they can get out from under the market power of Partners and so consumers could make more rational choices about where to get their care. Maybe they believe that the best way to achieve it is for the state to order them to post their prices. Whatever their motivation, they deserve our support.

Too sad to think about

A note from one of our staff members. Most of us never have to think about such things. I hope it does not get you too upset:

"A small group of providers here performs above-and-beyond assistance to families that is little-known but beyond value. When a pregnancy fails and a baby dies in utero or is delivered stillborn here, clinical providers (MD's, nurses, social workers) strive to recognize the loss with the family, and to help them create mementoes of their baby. Almost always, the mementos that are most cherished by parents and famililes are photos of their infant. Our Media Services department staff go to Labor and Delivery and to the morgue to take professional quality black and white photos of these infants. Their skill, caring and attention to detail result in images that are often beautiful, despite the loss of life and occasional disfigurement, and are treasured by the bereaved families.

"When a family requests to see an infant after he or she has been transferred to the morgue, Pathology staff members locate and prepare the baby for viewing by the family. This is not a task listed in their job descriptions, and making this available to families means putting aside other pressing work, but they understand the importance of this last good-bye to some family members.

"Even for those providers whose clinical duties include exposure to neonatal death with some regularity, work with bereaved parents of infants is wrenching. Preparing the babies means handling them, and an inevitable confrontation with the tragedy of their deaths. These special efforts of the Media Services and Pathology staff are an extraordinary example of BIDMC employees giving of themselves for the benefit of our patients. "

How to add a comment

A lot of people have written to say they don't really know how to use a blog. It's simple; you just need to know where to click.

A blog is basically someone's online diary, except that others can add their comments. I start a topic by posting an initial message; others (you) add comments.

There are many different types of blogs on the Internet. I use a popular one called Blogspot. Here's how it works.

Underneath each of my initial posts is a note "3 COMMENTS," "12 COMMENTS," etc. Click that note to read the comments or add one of your own. A new window will open up, where you can read the comments and add one.

To add a comment you'll need to register, which takes a couple of minutes. You don't need to show your name publicly (you can post as Anonymous or any nickname), but the registration info (behind the scenes) is a way of having people be responsible for their posts. (It avoids spam-like posts or "hit-and-run" flaming messages.)

I very much hope you'll contribute. Dialog is the whole reason I started this blog. I want to share my thoughts and I want to know yours.

If you want to know more about blogs, a good (though long) description is at http://en.wikipedia.org/wiki/Blog. Detailed Blogspot help is at http://help.blogger.com/. But if you only want to read and post, the above is all you need to know.

Advice from friends

I sent an email to a bunch of friends to let them know about this site. Here are some of their reactions, which include a lot of advice about what to include, how to write it, and so on. (Lots of them didn't know how to reply to the blog itself, so I have copied their comments from emails they sent me.)

Doctors and Nurses Have Families, Too

Our doctors and nurses are so dedicated to taking care of patients that I sometimes have to remind them to spend time with their own families, ironically, particularly during times of medical crisis. Recently, a relative of one of our medical staff was diagnosed with a terminal illness, and the staff member was torn between a desire to be with the relative and a sense of obligation to patients at BIDMC. I advised this person that colleagues at the hospital would cover and that s/he should spend every available moment with the family member. I recently received the following bittersweet note just after the family member died. (I have removed details which might identify the people involved.) It has lessons for us all.

Dear Paul,
I want to thank you for your words of encouragement and admonition to forget about work for a while. My [relative] died on Thursday afternoon, only a month after s/he was diagnosed. I spent most of the month here with a couple of quick trips back to Boston and I have no regrets. My [relative] was the best friend I could ever have asked for. We had a lot of quality time together during the past month. S/he saw all the grandkids, brothers and sisters, close friends, and had time to get all affairs in order to his/her satisfaction. We got some video telling some of his/her best stories and many pictures with family and friends that will be special memories forever. We had a lot of time to talk about the past and future, joke and laugh about any number of fun experiences too. We were truly blessed by the local hospice; their service and compassion was nothing short of incredible. My [relative] died a peaceful death with dignity and with my sister and me at the bedside holding hands and telling him/her how much we loved him/her. S/he was comfortable and ready. I must also say that I am truly blessed to have friends and colleagues that I can depend on to carry on at work without me having to worry, check in, solve problems, etc. Everyone at BIDMC has been supportive, and they have made this time one in which I could really focus on what was important.

Union Issues

One of the issues facing many hospitals is the desire of the Service Employees International Union to organize members of our workforce. The SEIU last year announced its intent to do this in the Boston teaching hospitals.

In October, 2005, I wrote to the following message to our staff as part of a fall update on a variety of topics:

"The other major change in the local environment is the announcement by a national union that it intends to organize the workers in the academic medical centers in Boston. I want to make our position clear with regard to this effort and union organizing efforts in general. We intend to follow the law with regard to labor relations, a law that is designed to give a fair opportunity both to employees who favor unionization and those who oppose it. Congress has been very clear that employers have to give workers a fair choice in these matters. Accordingly, we will vigorously oppose any efforts to short-circuit the legitimate process by which employees of this hospital can consider, debate, and vote on this issue. For me the underlying question is whether a union at BIDMC would enhance your ability to deliver the kind of patient care that is so important to all of us, to strengthen our research program, to improve our education programs, to strengthen our ability to serve the community, and to improve our employees' chances for personal and professional development and advancement. I do not believe that it would, and so I intend to advise you against creating a union here. Ultimately, though, the choice will be yours, and we will respect your judgment on that matter if and when the time comes for a fair and free vote on this issue."


Here is a more recent (early August, 2006) email I sent to my staff on the topic:

"On the union front, you may recall that I wrote last fall to inform you that the Service Employees International Union had announced plans to organize workers in the Boston hospitals. They appear to be interested in BIDMC. During the last months and weeks, the SEIU has submitted Freedom of Information Act requests about several of our researchers and research projects funded by the NIH; has submitted an FOIA request at Mass HEFA, the state agency that issues our bonds; and most recently has been conducting telephone surveys of our some of our employees. Some of you may have received these calls. These activities are entirely legal, although you might wonder, as we do, what relevance our peer-reviewed research has to a union organizing process.
In other situations, the SEIU has attempted to get hospitals to agree to bypass or modify the normal union organizing procedure envisioned under the National Labor Relations Act. A normal unionization process consists of getting authorization cards from 30% of the members of a future bargaining unit, followed by a secret ballot election of that group of workers, under federal rules and monitored by the National Labor Relations Board. Each employee, unencumbered by peer pressure or other outside forces, gets to vote "yes" or "no" in the sanctity of a private voting place.
Instead, in some cases the SEIU has pushed for a "card check" system, in which the election process is bypassed once 50% of the workers sign authorization cards, and the management of the hospital agrees to not talk about unionization - a process called "neutrality". In some other instances, the union has agreed to an election, but with the same one-sided "neutrality" terms during collection of signatures and the voting.
My belief is that a topic as important as unionization deserves a free exchange of views. If the management of the hospital agrees to a "neutrality" agreement that limits our ability to discuss the pro's and con's of the issue, that would be at variance with the history and culture of this academic medical center, a tradition steeped in open dialogue and exchange of views.
Let me say again: We believe in free elections in which each employee, unencumbered by peer pressure or other outside forces, gets to vote "yes" or "no" in the sanctity of a private voting place. Thus, we cannot agree to a "neutrality" agreement nor to a system that bypasses the federal NLRB election processs.
In other parts of the country, hospitals that have taken similar positions to ours have found themselves subject to massive public relations attack by unions. The object of these attacks seems to be to denigrate the reputation of the hospitals and to put pressure on volunteer boards of trustees and management to agree to the unions' organizing terms.
We hope and trust that the SEIU will not use these tactics in Boston. It is hard for us to imagine that a union that says that it is dedicated to improving the healthcare system would intentionally undermine public confidence in one of the world's best hospitals. But this has happened elsewhere, so we must be prepared for that eventuality. We will hold fast to our principles and would participate in a union organizing process based on the rules and regulations set forth in federal law, a process designed to protect the rights of all parties. We have too much respect for our employees to bargain away your rights to a free and fair election. We trust the people who work here, and we would respect your judgment should an election be authorized. You earn that trust every day by the way you take care of patients, participate in research, train medical professionals and one another, and support a wide variety of community activities.
In closing, if any of you have concerns or questions about any of these matters, please contact me directly, or your Human Resources representative, or your supervisor."

I would welcome your thoughts about what I have said in both of these notes.

Sad and beautiful story

This is a note I received. (I have removed the patient's name and other identifiers, as well as the name of the nurse.) I can't begin to tell you what a privilege it is to be part of a team that can do this kind of thing. The underlying values of our staff often come through, especially during these incredibly important moments.

Dear Mr. Levy,
A great hospital is measured not only by its ability to save lives, but in its skill and sensitivity in aiding and comforting terminally ill patients who can't be cured and their families. My 93-year old mother was admitted to the BID on Thursday for what was initially thought to be pneumonia. Further tests revealed a massive and inoperable massive tumor in her lung that had invaded her rib cage and was strangling vessels to her heart.
My mother had made it clear she wanted no heroic measures. The staff made every reasonable effort to stabilize her prior to moving her home for hospice care. The oncologist who called us late on Friday night to discuss her condition did not sugarcoat the diagnosis or prognosis, nor was he cruelly blunt. Instead,with great skill and wisdom in his choice of words, he clearly helped us understand the grim reality. It helped prepare us for the call that came at 5:30 AM Saturday alerting us to her rapidly deteriorating condition. Twenty-eight years ago, the B.I. did not make it easy to stay with my father during his last hours, and we were not called until well after his death. This time, we could be at her bedside and shepherd her through the process.
During her last hours, my mother was fortunate to be under the care of S.K. We could not have asked for a better nurse or human being.
S. was acutely sensitive to my mother’s discomfort and our monitoring of her changing condition. She explained options clearly and carefully. She cleaned her, adjusted her bedding and took steps to move her from side to side to alleviate other problems. She helped to block undesired intrusions to provide the family with much desired privacy. And in a loving gesture that will forever be remembered by those of us at her bedside, she fluffed my mother’s hair to make it more presentable. In one of our last conversations my mother had said that she wanted to go out "like a lady."
With S’s help, she did. There are many others who helped contribute to my mother's care.
My husband and my sister join me in thanking them and you for the caring kindness and professional expertise of the Beth Israel Deaconess staff.

Single Payer

Many people think that a single payer system would improve the cost and quality of medical care in America. I disagree. This topic was recently covered very well in a new book by Michael Porter and Elizabeth Teisberg, called Redefining Health Care, published by the Harvard University Press. (By the way, here is a review I recently wrote about the book. You have to register to read the review, but there is no fee to register.)

I think they make a persuasive argument that a government-controlled single payer system would inevitably face budgetary pressures and would shift costs to providers, suppliers, and patients, and would ultimately lead to rationing of services and a slowing down of innovation.I'm not saying the current US system is ideal, but at least it offers the possibility of competition among insurance companies and gives my hospital a chance to negotiate better reimbursement rates in return for offering higher quality and better value to consumers than my competitors provide.

What do you think?

Running a hospital

Hi,

The other day, I was reading a NY Times article that menitoned that only 1 CEO of a Fortune 500 company had a blog. I don't run a Fortune 500 company, but I do run Beth Israel Deaconess Medical Center, a large academic medical center in Boston. I thought it would be fun to share thoughts with people about my experience here and their experiences in the hospital world. This is my first blogging experience, so please excuse if I mess things up . . .

A few rules: I cannot comment on individual and legally confidential patient care issues in this forum -- although I can refer patients of our hospital to the appropriate people if they have problems or complaints. I also cannot comment on individual and legally confidential personnel matters of our employees -- although I can refer people to the appropriate folks in the hospital to help them.

So, that's it. Feel free to open this up with questions about what it is like to run a 600-bed hospital; or to offer your thoughts about the state of medical care in general; or to comment about how wonderful (!) our hospital was during a recent visit; or what it is like to work at our hospital or whereever you work.

My first comment is this: I am new to health care, and I have never worked in a place where people are so consistently caring and devoted to alleviating human suffering caused by disease. It is, in many ways, a beautiful place to work. But many of the forces facing hospitals, doctors, nurses, and others make it really hard to do the job well.