An opening day dawns

Above, Fenway Park at dawn this morning, courtesy of Red Sox staff.

And a new feature on Redsox.com, as announced today by BIDMC:

From hamstring pulls to back spasms – if a Red Sox player has an injury or illness, experts at BIDMC will be talking about it this season on Redsox.com.

As part of its relationship as the “Official Hospital of the Boston Red Sox and Red Sox Nation,” BIDMC is publishing a special column on the Red Sox Web site addressing some of the health concerns that commonly impact athletes. While we can't speak specifically about individual player injuries, specialists at BIDMC will give an overview of the general problem and talk about basic prevention and treatment. In an article on the back troubles of Josh Beckett and J.D. Drew, for example, Drs. Kevin McGuire and Michael Groff of the Spine Center give tips about how to prevent back pain – not just for sports enthusiasts, but for anyone.

The column is written by long-time Boston sports reporter/broadcaster Gary Gills. It will be updated at least once a week throughout the season.

To find the column, go to www.redsox.com and click on "Roster" and then on "BID Injury Report." Readers can also submit their own Red Sox-related health questions through the site.

Click through the slides (from the CDC)

Read this doc on Scribd: CDC trends in obesity 1985 2001

There is no Max Brenner

In my family, I am known for two personality disorders. First, I was born in New York. My wife and daughters forgive this, though, because they know that my mother lived there at the time I was born, and they accept that I felt it important to be near her at that moment. Also, I eventually transferred loyalty from the Yankees to the Red Sox, and so I am mainly forgiven for the original geographic sin.

The second is a more persistent problem. I really don't care much about chocolate. It's not that I don't like chocolate. It's just that it is not particularly important to me. This is beyond the comprehension of my XX-chromosome housemates. As the years have passed, I have learned to say, "Oh good", when my wife suggests we go to some other place to buy or eat chocolate. (I used to say, "Why?" and get piercing looks of the type employed by Superman when melting sheets of steel with his heat vision.)

So, after the McBurney reunion on Saturday, we wandered over to Union Square in NYC and went to a place called Max Brenner. This is kind of a chocolate emporium, based on somebody's fantasy realization of what Willy Wonka would build at retail. It is a big place, seating hundreds, and offers a sit-down area for dozens of chocolate-laced "foods" as well as a place to buy to take. It comes complete with fake chocolate pipelines reaching from one end of the store to the other, ending in large basins in which an electronic paddle mixes up 40 gallons of white or dark chocolate. As you wait, they parsimoniously offer you small samples of liquid and solid chocolate confections. Not enough to satisfy you. Just enough to whet your appetite.

After a 45-minute wait surrounded by hopeful 20- and 30-something year olds who have come down to lower Manhattan with their dates, or single-sex groups of three or four who don't have dates and used to go to Haagen Daz on the upper East Side, we get in.

Lots of choice, including the "mess" shown in the picture. We order. And instead of ecstasy spreading across the faces of Mrs. L and our friends, a vague disappointment. It turns out that the hype is better than the product. "Not very good chocolate", says one. "The granita is too grainy," says another. "Not enough brownie in the 'mess'", says the third. I extend my sympathies and graciously pick up the tab, just $37 for the four desserts.

My chocolate-free mango and yogurt drink, by the way, was excellent. But, really, there is no Max Brenner.

40th (really ?) reunion

As noted in Wikipedia, McBurney School may be best remembered as the destination of Holden Caulfield when he left all the equipment of the Pencey Prep fencing team on the subway in J.D. Salinger's book Catcher in the Rye. Salinger was briefly a student there, as were actors Henry Winkler and Richard Thomas and several other entertainment and business celebrities.

By a twist of fate, so was I. After attending public schools on Long Island, our family moved to Manhattan, and I found myself in the junior class at McBurney. My class size had shrunk from about 800 students at Oceanside High School to 72 at McBurney, and there were lots of other cultural differences, too. The school was located on West 63rd Street and was adjacent to, and shared facilities with the West Side YMCA. It has since gone out of business.

As a result of my move, I took driver's education in NYC. The first lesson was Columbus Circle at rush hour. You learn quickly.

At OHS, I had been one of the worst people on the track team. At McBurney, I was co-captain of the track team.

Well, this weekend, there was an all-class reunion for the school. It included the 40th year reunion for those of us from the class of '68. Those attending had had a variety of careers; e.g., secret service, ATF investigator, police detective, airline pilot, endocrinologist, immigration attorney, director of a judicial conduct review agency, medical equipment supplier, and director of a public service internship at a law school. Oh, and a sewer guy turned hospital CEO.

And virtually everybody either had less hair, grayer hair, and/or a larger belt size. In short, it looked much like any other 40th reunion class in America!

Advice from the late David Newsome

Wise advice to my MIT students and others from David Newsome, a diplomat in the US foreign service, as found in his obituary written by David Stout in the New York Times this weekend:

In a 2002 appearance at the University of California, he was asked what advice he would give young people.

“Set aside some time to read about and understand the world beyond our shores,” he replied in part. “We are an insular people, and we have a tendency to dismiss foreign societies as strange and difficult to comprehend.”

Can Lord Darzi get it done?

A great article from the London Times about Lord Darzi and his attempts to reform the British Nation Health Service. Recall that I was his guest a few weeks ago and was asked to talk about quality and safety and transparency approaches here.

Here's an excerpt:

The basic structure of the NHS is not up for debate. Darzi's search is for best practice within the system. Working groups in each of the nine strategic health authorities (SHAs) in England are examining eight areas: maternity and newborn; staying healthy; children's; acute care; planned care; long-term conditions; mental health; and end-of-life care. The groups in each SHA will submit a report and Darzi will then write his report. What if different regions have completely different ideas about how to organise, say, their stroke care? His working thesis is “localise where possible, centralise where necessary”.

And, this somewhat wistful comment:

He admits that he lies awake at night thinking about how to “shift this big machine”. And he finds it hard to hear criticism. “What upsets me most is when the public are saying 'what we need is respect and dignity'. If we are not doing that, what the hell are we doing?” Perhaps wary of headlines about his surgeon's knife, he says that the only lesson for his political job that he takes from his medical career is “not to think like a surgeon”.

He is a plain-spoken, pragmatic person:

“It is all obvious stuff, but we have never done it this way,” admits Darzi. He says that the problem is that “if you look at a journey of a patient, it's fragmented. How do you integrate that care?” He cites the example of a patient with kidney pain who is referred by a GP to a consultant and then sent for an X-ray on a different day, then back to the consultant for an initial assessment. “If you are shopping in Tesco you wouldn't do that. You need to have access to competency at the time you need it.”

MIT students abroad

The students with whom I went to Florence as part of an MIT Urban Studies class have sent me a message that they expect more coverage on this blog. The class is called City to City, and involves a comparison of attributes and characteristics between Boston and another city (this year, Florence). The students actually had to do a lot of work while in Tuscany, but they also were allowed to be tourists, and as seen in the pictures here, were happy to test out the local food.

WBUR on Facebook

Our beloved and very, very good public radio station, WBUR, now has a page on Facebook and is friending people throughout the community. At this moment, they have just 139 friends, but I am predicting it will grow by a factor of ten by midnight tonight.

This is a great idea. It would be stronger still if all the reporters, hosts, and editors had Facebook pages so they could hear directly from their (usually!) admiring public.

Cross media connections continue to grow!

When an employee gets really ill

A recent case prompted me to inquire about a particular individual, and I thereby learned our policies. The issue is the degree to which a company offers employees financial support for health care insurance versus limiting the company's financial exposure after a long-term illness and absence from work. I am curious if our policies in this regard are similar to other corporations out there. Please offer comments on this matter.

The specific situation is the treatment of an employee (let's call him Sam) who is forced to miss an extended period of work because of illness. First, note that we offer long-term disability coverage, so that there is some wage support after sick time and other short-term support is exhausted. Our policy, though, is to remove Sam from the payroll for health benefit purposes after one year being out of work.

For example, let's say Sam elected the plan for receiving 60% of salary for long-term disability (LTD). He will continue to collect LTD until he is able to return to work or the age of 65.

For health insurance, Sam was on the company plan, with dual coverage. The total premium was $940.63. While on the payroll, BIDMC paid $ 725.91 (78%) and Sam paid $214.72 (22%) per month.

Upon leaving the payroll, Sam is eligible for COBRA coverage for a policy with all of the same benefits, but he loses the BIDMC contribution. The cost of COBRA will be $959.44 for dual coverage. (If he elects coverage for himself, the cost is $479.72.) He will be able to remain on COBRA for 36 months.

After 36 months, Sam would be eligible for insurance coverage offered through the Massachusetts Connector Authority.

I look for the experience from others of you out there. I notice, for example, that the Federal Government uses a similar one-year rule. In the Office of Personnel Management benefits handbook, it says, "Your enrollment will terminate at the end of the pay period which includes the 365th day in consecutive leave without pay status." In contrast, if I am reading things correctly (and it is easy to interpret things wrong in the state jargon!), the Commonwealth of Massachusetts appears to have a rule that "an employee is not entitled to more that 26 weeks of ... medical leave [for the employee's own serious health condition] in a 12-month period." During that leave, the state continues to pay its share of health care insurance costs. After that, the COBRA policy kicks in and the employee pays the full amount of coverage.

More from Brent James

Another part of the Silverman Institute's inaugural event was a grand rounds presentation by Brent James for our medical staff. When I saw the title of yesterday's talk -- Quality health care for the 21st century: A new outlook for humanity -- I said, "Wow, that's pretty expansive!" As it turned out, it was an accurate description of the talk. Let me try to provide some highlights.

First, we were grounded by the fact that the main determinants of health (in terms of how long we will live) are:
-- 40% Behavior (tobacco, alcohol, and obesity)
-- 30% Genetics
-- 20% Environment and Public Health
-- and only 10% Health Care Delivery (hospitals and clinics).

In 2006, the US spent $7100 per person, or 16% of GNP, on the last category. The trend in this cost is dramatically upward. What do we get for all that money?

Much of the US system is based on the rapid response aspects of health care. In contrast to other countries, where the emphasis is on primary care, we spend a lot on treating those problems. We provide better access to specialists and to technology, and we do not ration these services as they do elsewhere. Accordingly, the US mortality rate for heart attack and trauma, for example, is well below Europe. But the impact on overall mortality of our progress in these secondary care arenas is overwhelmed by the impact of a strong primary care emphasis in other countries.

James cites "the rule of rescue" as a reason for this. This is defined as "the imperative people feel to rescue identifiable individuals facing suffering or death." (Jonson, 1986 -- Sorry, I don't have the full cite and can't find it.) Our health care delivery system is skewed in this direction.

Ironically, other countries are now finding an increased demand for rescue care and so are seeing large financial pressures emerge in that segment of their own systems. (See my post below on Tuscany's desire to expand emergency services.)

After this overview, James turned to the problems in our system. As he notes, these actually emerged as a result of the design of the medical system through the 1900's, and he quoted Albert Einstein as saying, "Today's problems are often yesterday's solutions." Here are the problems:

-- Well-documented massive variation in practice based on local medical myths.
-- High rates of inappropriate care.
-- Unacceptable rates of preventable care-associated patient injury and death. (Hospitals are actually the #4 or #5 major public health problem in this regard!)
-- A striking inability to "do what we know works".
-- Huge amounts of waster and spiraling prices that limit access.

Why have these problems emerged? We continue to rely on the "craft of medicine", in which each physician practices as an independent expert -- in the face of huge clinical uncertainty (lack of clinical knowledge; rapidly increasing amount of medical knowledge; continued reliance on subjective judgment; and limitations of the expert mind when making complex decisions.).

We can begin to overcome these problems by practicing medicine with a "Shared Baseline" approach (a form of LEAN production) in which you measure, learn from, and (over time) eliminate variation arising from the professionals -- while retaining the variation that arises from the patients. He terms this "mass customization." This will assisted by full use of electronic medical record capability, and it will need to be done to make full use of EMRs. Finally, care needs to be organized around the team of caregivers, and not the individual practitioners.

¡Qué le vaya bien, Ralph!

One of the great pleasures of being a CEO occurs when one of your clinical or administrative team gets tapped for a position of responsibility and importance at another institution. The latest was announced today, in that Dr. Ralph de la Torre is heading over to Caritas Christi to be their new CEO. We all wish him well and look forward to a continued and growing relationship between our two organizations in service to our patients.

Reporter's question about Facebook

On Boston.com, the following Reporter's Question:

Facebook friends with your boss?
Has your boss or superior coworker asked you to be their friend on Facebook and you felt uncomfortable about it? What did you do and why? Email jodiaz@globe.com to share your story.

I'll answer this from the other side. My view is that anything put on Facebook is something the writer feels comfortable being made public, including the fact that the writer has a page. Once you have a page, you are open to invitations from virtually anybody in the world. But, you are always free to say "no thank you" by not accepting an invitation. Also, if a person does accept and later decides to remove the link, it is easy to do so.

I have invited people from BIDMC to be friends on Facebook to create another line of communication with those who like that medium. Some people prefer it to email. But, I certainly understand if they choose not to accept my invitation. Not only would there be no hard feelings on my part, but I am extremely unlikely to even remember who did not respond.

Now for something really important

A Facebook message I received at 9:10 am yesterday. I like how it shows that everyone is involved in improving the patient experience. Notice the quick turn-around on this issue of superb local importance.

Good morning Paul. I work 3rd shift maintenance and the other day I was in a patient's room and they started complaining that we don't have NESN anymore. I don't know if this is true or not but I would think being the official Red Sox hospital we would carry the channel that the Red Sox are on. Well, if you could look into that it would be great. I'm sure it is hard enough for the patients to have to be away from the family due to sickness but it makes it worse when they can't watch their beloved Red Sox. Thanks again.

My reply at 9:39 am:

We do have it. I think it is ch. 26, but I will check.

And the response from our media services director before 10:00 am:

Yes, we have NESN. It is currently on Channel 25. When we finish reprogramming TVs -- hopefully by the end of the week-- it will move to Channel 31.

On a more serious note to managers out there, please note the validation of Facebook as an internal corporate communications tool. Many people of a certain generation prefer it to regular email.

Silverman Institute inaugural event

I just returned from celebrating the inaugural event of BIDMC's Silverman Institute for Health Care Quality and Safety. The Institute was created by a generous donation from our Board Chair Lois Silverman and her late husband Norman, and is the focal point for our quality and safety programs, as well as academic programs in that field. The event was also the inauguration of a new lecture series, entitled the Michael F. Epstein, MD Lectureship on Clinical Quality and Patient Safety, generously funded by numerous donors in honor of the hospital's previous chief operating officer.

Our speaker was Dr. Brent James, from InterMountain Health Care. He had a lot of useful things to say about the quality improvements in his system, but the focus of the talk was "Doing Well by Doing Good: The Business Case for Quality."

My main take-away: Within a very few years, we will face a hockey stick pattern of unfunded shortfalls in medical costs paid by the federal government. At that point, there will be four main options: (1) raise taxes; (2) decrease Medicare benefits; (3) shift funds from other programs, like education and national defense; and (4) reduce payments to providers. Which of the four do you think is most likely to be preferred by elected politicians? Number (4), of course. "The money is not going to be there. The business strategy of providers has to be based on managing the cost structure of clinical care." Improving the quality and safety of care is the most efficacious way of doing that.

So, quality improvement has to be a core business strategy for hospitals. Now is a good time to start and learn how to do this. As Brent notes, "It was not raining when Noah built the ark."

Dear hospital colleagues: Do we really need this reason, also, to reduce harm in our hospitals? Well, it can't hurt to be reminded that there is a financial case to be made, in parallel to the humanitarian aspects. Early adopters will do better when the rain starts to fall.

Healthy Mouth, Healthy Sex

This is not a topic I ever expected to cover. I was led to it by Diana Huff, a Facebook friend (and mutual admirer of David Meerman Scott). Her client Helaine Smith has written an ebook on the topic. Here's the link to the book. It is short and informative and worth a look -- and, yes, actually goes beyond sex to discuss several areas of oral health.

I mention it also because this is a great example of social media viral marketing, of the type often discussed by David. And, here I am, both telling you about it and participating in it by promoting not only the book, but also linking several types of social media in the course of doing so.

(Disclosure: I have no financial relationship with any of the people mentioned and make no warranties about the material contained in the ebook. I do hope, however, that some of my colleagues with chronic bad breath will read that section of the book.)

Not your average CVS

Pictures of drugs and other substances from an old, old pharmacy in Villa La Quiete near Florence. Note the opium precursor, papaveri.

Trauma in Tuscany

I thought I would expand a bit on the reason that I was asked to address senior hospital officials during my recent visit to Florence. This comes from the fact that people at our hospital and others have been engaged in a program to help the hospitals in Tuscany develop an emergency medicine program. As outlined in an article last year in the Annals of Emergency Medicine (Volume 50, Number 6, Pages 726-732. December 2007):

Italy lacks standardized specialty training in emergency medicine. There is no system of national or regional accreditation of the knowledge base or skill set of physicians working in regional emergency departments, which results in variability of emergency medical care delivery not only between hospital EDs but also within individual EDs. To address this need, the Tuscan Minister of Health chose to develop a partnership with emergency medicine specialists from the United States to help expedite the growth of the specialty in Tuscany. The collaboration called the Tuscan Emergency Medicine Initiative consists of the regional health care service, the Tuscan university system, Harvard Medical International, and the Beth Israel Deaconess Medical Center Department of Emergency Medicine.

The program leaders plan to train more than 625 physicians by June 2008.

A new step in the planning stage is to create a pediatric trauma program. To date, no such program exists. Our doctors are working in cooperation with others from Children's Hospital Boston, as well as the Meyer Pediatric Hospital/University of Florence School of Medicine to create one and to enable major pediatric trauma to be consolidated in this new center by creating a regional pediatric trauma referral system.

Both of these programs are examples of the kinds of capability US academic medical centers can bring to other parts of the world. But this is certainly a two-way street, as our doctors also learn a tremendous amount during their time abroad. And, of course, marvelous relationships are created that bring lasting value to all participants.

(The picture above is the view of Florence from Fiesole.)

Sign of the times

When I lasted visited Siena twenty years ago, this was one of the busiest shop fronts in the city, the public telephone center. Now, with ubiquitous cell phones, you can see how it looks on a day when the streets are full of tourists.

Another advance for transparency

I'm sorry if this has been around for some time and I missed it earlier, but Massachusetts General Hospital has posted an excellent site on its quality and safety programs and results. I think it has a very nice graphic design, and it is clear and understandable in terms of the explanations and numbers. I am not surprised, in that I know that CEO Peter Slavin and his colleagues are highly committed to excellence in this arena. Please take a look.

I welcome your thoughts about the relative ways MGH and BIDMC present this information. As I have often mentioned, these kind of sites are not about competition between and among hospitals: They are most important as a way to hold ourselves accountable to ourselves and to the public. I welcome your help in telling us if our presentation can be improved to achieve those goals.

Florentine Stakes

I had a chance to talk with the head of the Tuscany health service, who informed me that the province spends about 1400 Euros per year per person to cover the full range of health care services -- from cradle to grave -- from childhood vaccinations to nursing homes -- for its population. This struck me as an extraordinarily low amount, but he assured me it was the full bill.

Recall that a similar figure for the Netherlands was 2800 Euros per year (and I am not sure it was as all-inclusive as the Tuscany figure.) And the number for the United States is just under $7000. For these purposes, I am assuming comparability in value between Euros and dollars. While exchange rates between countries vary (sometimes inaccurately) and affect the relative price of imports and exports, the local currency represents a reasonably close approximation of purchasing power for domestically produced and consumed services.

We have talked before about some of the explanations for the disparity between the US and other European countries, for example in Iceland. A single payment system that simplifies transactions could be part of it. A strong primary care network that probably helps prevent some diseases and certainly treats many people at the lower end of the acuity and specialty spectrum and thereby reduces the cost of care is probably part of the reason, too. A parallel private system to the public system that provides services that are rationed by the public system -- but is not counted in the public financial figures -- can also be part of it. But what might account for the very low number in Tuscany, even relative to other parts of Europe?

From observation, you can see that there is less obesity and a more foot-dependent lifestyle than in the US -- although I am not sure those characteristics are very different from the rest of Europe. Certainly, too, the food is more healthy, with an emphasis on olive oil, fresh vegetables, less processed food (and consistent consumption of very good Chianti!) (But assuming away the effects of bistecca a la Fiorentina!) Perhaps, too, there is a genetic component attributable to the phenotype of people living in this part of Italy, a population that has been quite homogeneous for centuries.

But there is something else. The doctors in Tuscany get paid very little. An attending physician in a hospital will earn 2500 to 3000 Euros per month. A chief, 4000 to 5000 Euros per month. How can this be? There is a history, but basically it results from government policies years ago that made it relatively easy and financially attractive for people to go to medical school and become doctors. Indeed, the course of study was tuition-free. There are now so many doctors that they actually staff ambulances, rather than the EMTs we would have in the United States.

So, we could hypothesize that this surplus has bid down the wages of the medical profession. (Nurses are paid still less.) And, if you don't have to pay off your debt from school, you can accept lower wages. (In the US, the average amount of medical school debt is about $100,000, but that includes people who have no debt, and it also does not include carry-over debt from undergraduate college. It is not unusual for doctors to have accumulated debt of $300,000 or more by the time they finish residency training.) So, we have to assume that a significant share of the cost of medical school shows up as a underlying component of our overall health care costs, as a necessary component of doctors' salaries.

Also, after undergraduate medical education is over, the cost of residency training in the United States is covered mainly by the federal government as part of the Medicare program, so it is counted in our overall $7000 figure. I am guessing that this portion of the cost of physician training also does not show up in the health ministry book of accounts, so it is not in the 1400 Euros.

I am not suggesting here that the disparity in salaries and other such matters accounts for the entire difference, but this point is emblematic of discussions about national differences in health care costs. As you dig down into the issue, you often find that people are not counting the same things in the same ways.

But, based on recent experience, I will suggest that having a glass or two of Chianti while discussing the topic makes one care less about getting the numbers exactly right . . . .