Faces from Konkan

Some people encountered during the bike ride mentioned below.

The nuisance of stray dogs and cattle

(I am taking a break from hospital-related stuff to catch up on personal activities during the Christmas-New Year break. I hope you enjoy the next several posts.)

"Be alert on the roads due to the nuisance of stray dogs and cattle especially on the turnings." Regular readers know that I often participate in charity bike rides, but I do not recall any that included this type of advice to the bikers. The occasion here was Bike4Life, a six-day 550 kilometer ride along Konkan, the western coast of India. The route led from just south of Mumbai to Goa along the narrow strip of land between the Sahyadri range and the Arabian Sea. About 70 of us participated in this fundraiser for Focus Humanitarian Assistance, an international disaster relief and prevention organization affiliated with the Aga Khan Development Network. Our group came from Canada, the US, the UK, France, and India to support this worthy cause. Beyond that purpose, we were all curious to travel through this part of India by bicycle, getting a unique perspective on these communities and the terrain.

If you want to trace the route on your own map, we started in Alibaug, a small coastal place 160km south of Mumbai, and ended on the border of Maharastra and Goa at a place called Terekhol. Intermediate stops were Diveagar, Ladghar, Gandpatipule, Madbhan, and Bhogue. Because the coast is characterized by peninsulas, we often boarded ferries (often small rickety ones) and continued our ride on the opposite shore. Sites included pristine beaches, tiny villages with varied cultures and colors, and sea forts. We had a most memorable New Year's eve at Madbhan, where local folks entertained us for two hours with a display of acrobatic dancing, as well as a musical drama based on the Hindu legend of Bhimasur, who fell just short of marrying 1600 women in his quest for immortality. I include a short video of local lads doing a sword dance, along with other scenes from the ride, yes, including one of those pesky cattle.

A fan is born!

Excerpts from a very sweet letter:

Dear Paul,

I have worked as a nurse at BIDMC for the past 4 and a half years. Due to some life circumstances (all positive and happy), I am relocating to Los Angeles just after the holidays. Although my heart is joyfully a-flutter in anticipation of my California adventure, it makes for a bittersweet departure from such a gem of an organization and the beloved city that I have called home all my life. These final weeks up have brought on a lot of reflection. And with that reflection, I realized I never thanked you personally for an interaction we had two baseball seasons ago.

I had reached out to you for help with my sister-in-law. For her birthday, I had purchased standing room tickets to a night Yankee game during a pre-season lottery. At the time of the ticket purchase, she was not pregnant. In the weeks before game time, not only was my sister-in-law six months pregnant, but she had been admitted to BIDMC for complications of her pregnancy. She was released but had restrictions. I had inquired with Fenway security if there was anyway we could get a folding chair for her at the game…the answer was uncertain. When the security representative realized I was a BIDMC employee, he suggested I send you an email. With a glimmer of hope for a sole folding chair, I sent you a message to see if you could put in a kind word on my behalf. You in turn contacted folks at the ballpark and almost instantaneously the night become one to remember – we were given complimentary roof deck seats with a food and beverage credit, and I passed the standing room tickets over to my friends at BIDMC.

We sat amongst players from the famed ’67 Red Sox, who were being honored that night. It was so above and beyond a folding chair; we were thrilled and humbled and astonished both by the generosity of the Fenway staff and how you personally acknowledged and took interest in my inquiry. Technically, that was my soon-to-be niece’s first trip to Fenway. She was born at BIDMC later that summer, and my brother and sister-in-law had nothing but positive experiences during their time here. She is now 1 ½ years old, running and laughing and getting into all sorts of mischief as one should at that age. One of her early words was “Reh-saw,” which clearly translates to Red Sox. She’s working on “Beth Israel Deaconess Medical Center,” but hasn’t quite perfected it. Attached you will find a picture of her this past Father’s Day standing on the dugout at Fenway. There is a picture of us all at the game that night…but it fell victim to a faulty digital camera.

I’ll never forget how you helped create such a lasting memory for my family to share - simply by opening an email and then sending an email. And although a late thank you is not quite the BIDMC way, I do not think it is ever too late to express heartfelt gratitude. Please know how thankful I am, and how much I appreciate how you look after and listen to your employees.

Thank you for keeping BIDMC a place that I will consider home, no matter how far away I move.

With deepest gratitude and a fond farewell,

Sharp numbers

I cut out an article last March from one of those free magazines you get while flying. This was on a flight from London in a magazine called BusinessLife, and the piece was by Tony Thorne at King's College London. The title was "Sharp Practice". (Sorry, I can't find a link.) I had meant to write about it at that time, but I just found it buried on my desk.

This is about precision heuristics. One application is in the pricing of goods and services.

More generally, we tend to think that "claims expressed in numbers ('78.6 per cent effective') appear to be objective -- based on empirical data -- while claims expressed in words ('finished to the highest technical standards') tend to be judged as subjective. The same distinction operates between round figures or round numbers, often suspected of being guesstimates, and sharp numbers, assumed to show verifiability."

I can already hear some of my colleagues in health care saying, "I told you that transparency of clinical outcomes is misleading! You give the impression of precision when the measurement of the quality of medical care is inherently subjective."

Sorry, guys, don't even try it. I have addressed that before, saying:

We have learned from studying other industries that have engaged in and achieved process improvement that such improvement requires an approach to the organization of work that is very different from that seen in most hospitals. But it also requires measurement and transparency. While even the best calculations and data don't tell all, they do tell a lot, and they are the only way we have for an organization to hold itself accountable.

But those in the medical profession sometimes fall into the trap of believing that because measurement is an inherently reductionist and mechanistic act, it can never be sufficiently accurate to reflect the overall realities of patient care. The paradox is that without it, we can inadvertently fall into the trap of self-congratulatory statements about our good intentions. Only with it can we demonstrate that we actually have a "relentless determination to do best by each patient."

So, sure, let's watch out for the traps of precision heuristics, but let's also watch out for the traps of imprecision, unsupported generalization, and unsubstantiated reputation.

Freedom to Move

My friend Brian Hughes is one of those creative entrepreneurs. His current project is to sell modification kits to Segways that make them useful for handicapped people. The idea is to mount a comfortable seat on the machine, from which the person can easily reach the controls and transport himself or herself around. This would be an alternative to hand-powered wheelchairs or even electric wheelchairs.

This is still in early development, but here's his website. You can watch a video and see some test runs. If you have ideas for how Brian might be able to move this concept along, or of particular groups of people who might benefit from this kind of product, please get in touch at brian (at) segsaddle (dot) com. Or if you live in San Antonio, go visit and give it a try.

Just checking in on your Rx

An idea I heard somewhere:

A week after a prescription is ordered, an automatic email goes from the doctor to the patient saying:

"It has been a week since I ordered a prescription for you. Please call me if you have had any problem filing the prescription, or if you have had any unexpected reactions to it, or if you have any questions whatsoever."

Is this a good idea? Is anyone out there doing it? Do you have any results you would like to share?

Better than buying ads

I meant to cite this article about the use of social media in health care settings several weeks ago. It's main focus is marketing, but I think the ramifications extend beyond that topic.

On the marketing front, a friend (Lisa Pollack at Denterlein Worldwide) suggests:

Mr Maruggi talks about guidance and professional information as two key uses of social media in the health care industry, and I would add to that the power of trust in a social network. Facebook/MySpace/LinkedIn et al are made up of networks of people pre-selected to trust each others’ opinions. Tapping in to that trust network could be a remarkable step forward to a hospital wishing to build its brand.

I remember talking about hospital advertising about a year ago. I know that many people are put off at the idea of a hospital spending lots of money on media buys to enhance its image. Maybe social media offers a more cost-effective and socially acceptable way to do that, plus a forum to offer material that has a clinically educational content.

Merry Christmas & Happy New Year

Taking a blogging break through New Year's, plus a little more. You are welcome to submit comments, but there may be a delay in moderating them.

See you on the other side . . .

What if?

Just thinking, along the lines of a New Year's resolution. What if all of the hospitals in the Boston metropolitan area -- academic medical centers and community hospitals -- decided as a group to eliminate certain kinds of hospital-acquired infections and other kinds of preventable harm? And what if they all committed to share their best practices with one another and to engage in joint training and case reviews in these arena? And what if they all agreed to publicly post their progress on a single website for the world to see?

Let's start simply. My candidates:

1 -- Eliminating central line infections (Metric: The number of CLIs, as defined by the CDC. Goal = 0)
2 -- Adopting the IHI bundle to help avoid ventilator associated pneumonia (Metric: Percent compliance with the bundle. Goal = 100%)
3 -- Adopting the WHO protocol developed by Brigham and Women's Hospital's Atul Gawande for surgical procedures (Metric: Percent of surgical cases in which the pre-op, time-out, post-op checklist has been followed. Goal = 100%)

The medical community in Boston likes to boast about the medical care here, but we don't do a very good job holding ourselves accountable. This would be a terrific way to prove that we are serious about reducing harm to patients and that we can cooperate across hospital lines for the greater good.

"Shehekeyanu" meets "Woo pig sooie!"

We bought this menorah many years ago from the artist, Katya Apekina, who had just arrived from Russia. She was still pretty unknown. Since then, she has become quite famous, with works in many places. Here's her website.

The tray under the menorah has a different provenance. It was one of many hog-themes gifts we received from friends when we moved from Little Rock, Arkansas in 1981.

Is it kosher to put pigs under a menorah?

Regardless: Happy Chanukah!

Thanks again, Grant

Lots of milestones today. Here's one about soccer. Each year, registered soccer referees have to take a recertification class. At the session this morning, we had a nice surprise. Those of us who have been officiating for 5, 10, 15, and 20 years were given tokens of appreciation from the MA State Referees Committee. The gold whistle was for serving for 10 years, and the pin was for reaching 15 years.

Of course, being the compulsive sort, I have a record of every game I have officiated, going back to that first Under-10 girls game on April 23, 1994, and listing the other 514 since then.

I have written here about the differences between officiating girls and boys games, the relationship between referees and spectators and coaches, and the evolution of confidence in soccer referees. What I have not mentioned so much is the camaraderie that develops among those of us who are referees. It is independent of age or gender, and it is a great part of the game.

Our girls soccer league created a scholarship award that is awarded each year to the girl referee who "has achieved high standards of maturity, sensitivity, good humor, and sound judgment in managing play to promote the great game of soccer." It is named in memory of Grant Balkema (shown in photo), one of our friends and fellow referees, who died suddenly about four years ago.

Here is a portion of the eulogy I delivered at his funeral:

"I have an image imprinted in my mind, one that has popped up dozens of times in the last few days: I am greeting Grant as he is walking off a soccer field after having refereed a game. He is always smiling. He loved to referee. He never took himself too seriously, and he always did what he could to help make the game fun for the children or young adults playing the game. He was the perfect ref, in that he understood that the best game was the one in which people forgot that there was a referee on the field."

Grant received his referee certification a few years after me, and so I think he would have received recognition today for having passed the 10-year mark. So, on behalf of all of us who knew him and officiated with him, I am taking this moment to offer that recognition in a different way.

Post #1001

Hard to believe, but since starting this blog in August of 2006, I have written 1000 posts, making this #1001. For those who have been there from the start, thanks for your loyalty. For new arrivals, I hope you will visit often. For those who have arrived somewhere in between, or who have come and gone, or left and come back, thanks for gracing me with your time and attention.

Now, to the point of this post. Please meet Garry Dunster, night nurse in our Emergency Department, arriving yesterday to BIDMC in record time despite the snow and a few minor mishaps. Gary rides to work every day. (He reports: "My commute is 32 miles one way from Upton, if I'm on one night I'll ride both ways. If I'm on a couple of nights together, I'll make my big cycle in, then sleep at my mother-in-law's in Belmont before cycling home again on the last morning. I hope I can be an inspiration to a few others to give up the car and look for a greener alternative for the commute to work. Although the summer is perhaps the time to start!!!)

Regular readers know that I like to bike ride, too, but I have a firm belief in the importance of friction (between the wheels and the road), something sorely lacking in this weather. Maybe Gary has those special snow tires with embedded studs . . . .

"someone may just end up dead"

A blogger named Bongi from South Africa gives a sense of what it feels like to be a surgeon. For those of us who are not, this is an important insight. It must be considered if we are interested in process improvement and better teams in the ORs:

i try to refer away whatever i feel is not in my scope but once the knife goes through the skin you become suddenly very alone. it is too late to think there is someone else who can do the job better than you. you must be the best for that patient at that moment. this becomes more acutely true when something goes wrong and you have to dig yourself out of a difficult situation. the thing about difficult situations in my line of work is if you handle them not too well someone may just end up dead. somehow to believe you are the best does seem to give just that little more of an edge.

i am not justifying surgeon's arrogance and i hope never to be arrogant. but i can't imagine being able to do what i do without just a little more than the normal amount of self confidence.

Medgadget Best Blogs

Many thanks to those who have nominated this blog for "best" categories of medical blogs at Medgadget, best medical weblog and best health policies/ethics weblog. I was honored to win in these two categories last year. With so many regular writers of excellent blogs, I think this friendly competition will be even greater this year.

If you have favorites in these categories, please make nominations. It is okay to renominate some who are already nominated, as the folks at Medgadget will narrow down the list in each category to a few finalists based on several criteria -- and I am guessing that repeat nominations count in their calculations.

The categories for this year's awards are below. I also list the blogs I have nominated so far, but I welcome other suggestions. In particular, I don't recall who might have started up his or her blog during 2008, for the second category.

-- Best Medical Weblog

-- Best New Medical Weblog (established in 2008)

-- Best Literary Medical Weblog: Look me in the Eye; Notes of an Anethesioboist

-- Best Clinical Sciences Weblog: Scan Man's Notes; Pallimed

-- Best Health Policies/Ethics Weblog

-- Best Medical Technologies/Informatics Weblog: Life as Healthcare CIO

-- Best Patient's Blog: Pregnant Stephanie; Beating Social Anxiety; The new Life of e-patient Dave; Look me in the Eye

"Carefully tend to those kinds of moments"

There is a weekly segment on NPR called “Story Corps”. Today’s recording made me think of what great people work in hospitals.

Load 'em up! Move 'em out!

As promised below, more pictures and narrative from Bruce Wahl showing the truck loading for our Holiday Lights gift program: "Here are some photos from today's Holiday Lights activities. At around 3 pm Jacquaetta Hester-Walker started taking the 12 + carts down to the Loading Dock 1 at a time.... They were fairly heavy being that they were overflowing with gifts. We called upon the Service Ambassadors and a few of my Media colleagues. Many hands make light work. We loaded the 25 foot box truck to capacity and sent it on its way. When I returned upstairs to the staging area gifts had continued to arrive. There will be at least one more "smaller" trip out tomorrow AM. I was truly overwhelmed with the amount of gifts and the efficiency with which they are being handled."

Day 7

Update from my stormed-in brother-in-law in Worcester:

Home again and fridge is clean. See there are some benefits to no elec for a week. Friends and neighbors Jeff & Judy have moved in as their house is one of the 7000 in Worc still w/o elec. No cable so we listened to Celtics win 16th straight; then sang songs and went to bed, our own bed, early. Tried to get rebroadcast of Paul's interview on NPR yesterday but need an Internet connection which has not yet arrived. 12 inches of snow due tomorrow and 6 trees hanging over new wires. Seemed like a time for prayer or, better yet, a climber w a chain saw. Have good one.

Sent from my iPhone

A Spear right on target

Steven Spear writes in response to an op-ed article in the New York Times. Simple and clear and clearly correct. Excerpts:

Jonathan Gruber (Medicine for the Job Market Dec. 4 08) may be right that healthcare reform will be economically good, but his assertion that we need to spend more to get more is based on the assumption that the care we currently receive is limited by the investments we make. This premise is wrong. The problem is not too few resources available to meet overwhelming needs. Rather, it is that those resources are managed in such an antiquated fashion that 1/3 to 1/2 are regularly squandered at great human and financial cost.

We do not need to spend more. Rather, we need to reward those who are getting better and provide incentive to others to do the same so what we invest is better spent. First, the federal government is uniquely able insist that performance be measured: both of treatments for various conditions and also on how well those treatments are carried out. This will be a huge benefit to payers and patients who, right now, are severely compromised in determining where they should look for care and if they are being treated as well as possible. Second, the federal government should make choices of where to access care based on those measurements, setting a powerful example for states and the private sector to do the same. The resultant shift in resources from those who use them badly to those who use them well will mean far better care for many more people–meaning poor access and poor care won’t be drains on society, and care will be provided at less cost—meaning that wealth will be available for other important uses.

Caller-outer award of the month

A key part of BIDMC SPIRIT is the idea that everybody in the organization is encouraged to call out problems they see in the workplace, problems of safety, efficiency, or anything else.

A few weeks ago, when holding their retreat, our Board decided to create new monthly award. Instead of honoring someone who had solved a problem, they would honor someone who had called out a problem. The idea was to provide further encouragement through the organization to those who notice and mention problems.

The first award has now been presented, to Gloria Martinez (in picture), who called out the problem with the delivery of specimens from the GI department to the pathology laboratory. This led to a complete revision of that delivery process, which later spread to other areas as well, as noted below.

Gloria received a congratulatory letter, plus two super tickets to a Red Sox game of her choice next spring.

Spreading the story of discovery

Several weeks ago, I told you the story of how we had improved the process for getting GI specimens to the laboratory for analysis. But part of BIDMC SPIRIT is to transfer the lessons learned in one setting to another.

I received a report last month that the process that was developed to improve specimen pick-up and transport in the GI department was successfully implemented in all other interventional procedural areas in the medical center. Our folks note, "This process was designed to provide a timely and safe transport of specimens bound for the departments of Pathology and Cytology. (These types of specimens are especially sensitive in nature due to the fact that they are often un-recollectable.)"

"This new process, developed by a multi-disciplinary team of staff from all levels, ensures that specimens are signed out in a timely manner while also providing full reconciliation at the point of intake. It improves the process for employees preparing the specimens for transport, those providing transport and those receiving the specimens in pathology, while minimizing the chance that any specimens will be misplaced or misassigned."