Dutch doctors thank Helen Haskell

I was honored to participate in an extraordinary meeting tonight at Jeroen Bosch hospital.  Hendrik Brink, head of the medical staff (seen at left), wanted to hold a session for doctors from various disciplines to discuss issues surrounding medical errors.  I recommended that he use The Story of Lewis Blackman, a video produced by Transparent Learning, Inc., as a way of stimulating and focusing the discussion.  The video features Helen Haskell, the mother of this 15-year-old boy who died as a result of a series of medical errors after elective surgery.  The story is powerful, and you could have heard a pin drop as it reached its sad conclusion.

After the movie, the 50 or so staff doctors and residents broke into three discussions groups and then reconvened for a plenary session. They considered questions like the following: Was the situation in the movie recognizable?  Could it happen in our hospital?  What would you teach your residents to help avoid these kind of events?  What are the obstacles to discussing mistakes--personal obstacles, those related to the patient and the family, those coming from the colleagues in your own discipline, and those coming from colleagues in other disciplines in the hospital?

Hendrik was assisted in facilitating the discussions by medical education dean Hans Hoekstra (seen above) and JBZ patient security officer Marjo Jager.  They helped elicit comments and observations that were thoughtful and heartfelt.  It was a very good evening.

At the closing, I asked them what messages they would like me to relay to Helen if I happened to see her in the coming days and weeks.  Here they were:

Please tell her that we deeply appreciate what she has done in permitting this video to be made and in contributing personally to it with her extensive appearances on screen.

Please tell her that watching her make us feel that she understands the issues we face and that we therefore consider her to be a real partner with us in the medical community.

Please tell her that we will think about Lewis' story often and will do our best to make sure that this kind of tragic event does not occur in our hospital.

"No such thing as bad student, only bad teacher."

As we head into day two of our Lean workshop here at Jeroen Bosch Ziekenhuis (hospital) in the Netherlands, it is good to reflect on the nature of complex organizations and the messages given by an organization's leaders to the staff.  Why is it that people in hospitals engage in wasteful activities and behavior?

I posed the question in a slightly different form to our participants as a huiswerk (homework) assignment, asking them to write a short essay in response to this true-false question:  "Waste exists at JBZ because people are uncaring and lazy.  Provide evidence for your answer."  As expected, the unanimous answer was "false," and people offered the following commentaries. 

John replied with some evidence of the staff's good intentions:

Last Saturday we had an disaster exercise where a few hundred employees of the JBZ took part on their day off.  We saw a lot of enthusiasm and willingness to learn.

The employees on my unit are happy to share their knowledge with other units, in collaboration, teaching, exchanges.  They also did this for a television series about emergency care.

Anne-Marie agreed about these good intentions:

The willingness of the staff is great. They are willing to do something extra.

Monique observed, though, how people can be trained to become resigned to the way things are:

Employees are often not listened to when so they report on a problem. When people say something several times, where nothing is done, they get a resigned attitude and do things no longer. 

Hélène expanded on this thought:

 

If nothing is done by managers with signals of ineffectiveness from the staff, indifference arises and there will be more wasteful actions. 

Judith concurred, noting the inevitable presence of inertia in such situations:

A lot of things that we do we do because “we always do this like that”.

Or, noted Paul, the staff are forced to invent work-arounds:

The employees are very creative in circumventing problems that occur, causing many inefficiencies.

And then Monique offered the following underlying causes:

There are too many islands in within the hospital.  People can not or will not "watch each other's kitchen" so everyone re-invents the wheel and things are not aligned. 

If you are a long time in the same spot you will get, whether you intend to or not, a tubular vision. Someone from outside your processes can give you a whole new image and ensures that your own eyes widen.

Riny gave a similar diagnosis:

People who work in the JBZ are certainly not lazy and indifferent. It is working protocols and regulations that are not kept up to date that cause waste to occur. People in the JBZ work hard but must abide by certain old rules that are not based on the current situation. This results in noise and miscommunication, making much unnecessary work.

Jacqueline agreed, noting:

Preconditions do not always exist for employees to be efficient, and to experience the pleasure of  satisfaction. This frequently leads to demotivation and resignation.

Karin asserted that change is difficult because of the multitude of constituencies found in a hospital:

The people working there are involved and are willing to think about changes and improvements. Very often, secretaries in the clinic indicate that some things do not work. Often they already have an idea of ​​how it could be otherwise. To carry out these solutions, though, is complex. Often they must then be discussed with other stakeholders (other secretaries, nurses and medical specialists) because they would also have consequences for those people. Sometimes there is no agreement about the proposed solution.

But Jo then emphasized the importance of leadership in resolving those complicated interactions:

Leadership is crucial in achieving results and how we work on a unit.

And Hélène explained,

To prevent indifference, an equal dialogue with respect and trust is necessary, between a manager displaying serving leadership and the employee.

Izaak expanded on this, saying:

I think there are lots of initiatives that show the enthusiasm of staff to improve quality and safety. Sometimes the enthusiasm gets lost because of the lack of empowerment by the management. We forget to celebrate the success in improvements that are made on the initiative of staff members.  This gets back to them as lack of interest from the management in their efforts.

The answers are an important reminder that the introduction and dissemination of the Lean philosophy--or other any approach to improving quality, safety, and efficiency--requires leadership attention to the nature of how people learn and improve.  Our goal is to create a learning organization, to be "good at getting better" in the face of exogenous and endogenous challenges.  Leaders must have sufficient empathy to respond appropriately as the staff goes through the stages of learning--interest, distress, and pleasure.  If leaders are not attuned these stages, the staff will not learn the right lessons.  Then, we will be reminded me of Master Miyagi's statement in The Karate Kid: "No such thing as bad student, only bad teacher."

It is not the fault of well-intentioned and dedicated staff if they do not learn the aspects of process improvement that can transform a hospital: It is a failure of leadership.  As set forth by the great basketball coach, John Wooden, "You haven't taught them if they haven't learned." 

Lean lessons at Jeroen Bosch Ziekenhuis

I was so pleased to be invited back to Jeroen Bosch hospital in the Netherlands to conduct some three-day workshops on the Lean philosophy for a number of the senior managers.  Now, you can't learn everything about Lean in three days, but this set of seminars is designed to cover some of the basic principles--and especially to get participants out on the floors to see what life is like for the front-line staff.

After being greeted by hospital CEO Willy Spaan with a pertinent quote from William Glasser's Choice Theory, we started with the marvelous video Toast, produced by the GBMP.  Here, you see participants chuckling as Bruce Hamilton displays the simple inefficiencies of the toast "production" process in his home kitchen.  By viewing waste in this kind of neutral setting, people avoid getting defensive and applying preconceptions and then are better able to apply the lessons to their own workplaces.

Then it was off to gemba, to shadow various people throughout the hospital.  The point here was to identify the obstacles that people face in doing their day-to-day work and to learn better how to see waste in the organization.  Not by interviewing the staff people, but by just watching them do their work.  For example, here you see Paul van Hall, unit manager of Perinatology, as he has a chance to watch Evelyn in the central sterilization area as she organizes surgical instruments for cleaning. 

(This kind of exercise has to be done very respectfully and carefully, lest those being shadowed fear that they are being judged.  Instead, they are told, truthfully, that the point is for senior leaders to learn about how things are done in the hospital.  Most people being shadowed soon forget they are being watched, and many later express appreciation for the interest shown in their work.)

Upon their return, we asked all the participants to tell some stories of waste they had seen and to enter the examples into the categories symbolized by the acronym UWITDMOP, standing for Unused Human Talent, Waiting, Inventory, Transportation, Defects, Motion, Overproduction and Processing. (Check Mark Wroblewski's blog for a variant, WORMPIT!)  The examples seen at Jeroen Bosch were quite similar to what I have seen in other hospitals and are common to all kinds of large, complex organizations.  Also, the experience of going to gemba opened the eyes of many of these managers, as they gained appreciation for the obstacles encountered by staff every day and for the tendency to invent work-arounds to carry out their tasks.

Social media hospital usage compared

Our friend from Nijmegen, @lucienengelen, presents an infographic prepared by one of his colleagues about the use of social media in hospitals, comparing the Netherlands, the UK, and the US.  Tom van de Belt did this by crawling through the websites of hospitals in the same way an interested patient might do so.  Here's an excerpt showing the relative use of Facebook, LinkedIn, YouTube, and Twitter:

No surprise on my part with this result.  US hospitals tend to be slower on the uptake of such tools.  Indeed, some even block the use of social media on their hospital servers!

Wachter comes to Boston

@MITSS_Support. Boston area people are in for a treat if they attend the annual dinner of MITSS (Medically Induced Trauma Support Services) on Thursday, November 29.  The keynote speaker is Bob Wachter, from USCF.

Regular readers know Bob as one of the world's experts on quality and safety in health care. (See this post about his book.)  He's also a kind and wonderful person who will certainly set just the right tone for this organization, whose goal in life is To Support Healing and Restore Hope to patients, families, and clinicians whose lives have been impacted by medical errors and adverse medical events.

Brown versus Warren: A pre-Election Day view

Back in August, I offered a pre-Labor Day view of the Scott Brown-Elizabeth Warren race for US Senate here in Massachusetts.  I suggested that Warren was in trouble on the emotional front having "failed, so far, to convey in a visceral way who she is and why we should like her."

The polls now show a close race with Warren ahead by several points. I'm hearing otherwise in my unscientific research.  My non-random sample (in Middlesex county) has been college-education, employed men and women who view themselves as being on the liberal end of the political spectrum.  I first ask them how they handicap the race and, without provocation, most then tell me how they really feel.  These are the kind of sentiments I get from men:

He's a good guy who works in a bi-partisan manner.  We need people like that in a divided Congress.

From women:

I feel like she is lecturing at me, and I am tired of it.  I don't want to have to listen to that for the next six years.

From both:

Isn't it a good idea for Massachusetts to have some Republicans in the delegation?

These reactions are in spite of an acknowledgment that they might agree more with Warren's policy prescriptions.

Interestingly, the presence of young Joe Kennedy as the apparently anointed replacement for Congressman Barney Frank may have a spill-over effect into the Senate race.  People seem to take his election as a sure thing because of the family dynasty, but they are uncomfortable with that presumption, even if they plan to vote for him.  How odd if his being on the ballot actually causes cross-overs to Brown!

Speaking of cross-overs, let's consider the impact of the elimination of polling machines--where you just run you hand down a bunch of levers and vote for one party--to the use of paper ballots--where you can't.  I voted early this week because I will be away for election day.  You have to work hard to vote a party line.  The placement of the Democrat and Republican on the ballot is different in each race (President, Senator, Representative.)  While Obama will sweep the state (after all, we really know Romney!) I expect to see a lot of cross-overs this year in the other races in Massachusetts.

Ex-external defibrillator

Is this a trend?  I noticed this excised AED in a building at MIT.  My colleague there suggested that this and others had been removed because of the difficulty in ensuring that they would be properly maintained.

Have others seen this in other buildings where they work or places they frequent?  I wonder if these kind of devices will end up like those home exercise machines, abandoned after a short time.

So what do they do for us?

A recent blog post by Sarah Kliff on Ezra Klein's Workblog sets forth the strategy and plan of the nation's insurance companies to lobby Congress after the election. The purpose:

Moving into a potential debate over deficit reduction, health insurers want to carve out a different role in Washington. Namely, they don’t want to be the bad guys anymore. To that end, they’ll soon start arming their lobbyists with data that argues that other health care sectors are actually the ones to blame.

Check out the charts.  You will be pleased to know that the rate of growth in insurance premiums lovingly tracks the rate of growth in medical costs in the country.  In the 2010s, for example, medical costs rose 54.61% and premiums rose 56.09%.  What that is supposed to tell us, I don't know.

Is it meant to tell us that insurance costs as a percentage of overall health care costs have stayed roughly constant?  I guess so, as seen in this chart:

So, let's think this through.  As health care costs have soared over the decades, the insurance companies' share of the costs have stayed about the same.  That means that they have been unable to implement the kind of technological and operational efficiencies of other sectors in the financial services industries.  Such is certainly the case in Massachusetts, something I noted a couple of years ago:

Golly, we see an average annual increase in the administrative costs of Massachusetts insurers of 9.3%. How can this be the case? In other financial services industries, unit costs of transactions have gone down, not up. What is it about health care that suggests the opposite should be the case? 

But let's go further. The lobbyists plan to use a chart showing the overall growth in US health care expenditures.  Here it is:

I don't know the purpose of this.  I think it shows that those in the industry are tacitly admitting their failure to contain prices--if one accepts that is part of their function.  But is it?  Actually--as I have just noted--if their share of the health care budget has stayed constant, they have had an interest in watching the total number of dollars go up.

What's the next phase?  Well, if the Massachusetts experience is prologue, the insurance companies will next want to shift risk as much as possible from them to the providers, doctors and hospitals.  As I have noted about Blue Cross Blue Shield of MA:

Think of it.  The firm, in the face of little or no empirical proof, has persuaded an entire state to adopt a rate-making approach whose main value is to shift risk from it, the dominant insurance company.  Now, risk does not disappear.  Usually in society, we pay people to assume more risk.  Also, people from whom risk is shifted usually expect a lower return.  Here, the risk is shifted, but the insurance company gives up nothing.  Indeed, it is secure in pricing its product because it knows exactly how much money it will pay out in medical claims.  Meanwhile, the percent of premiums it collects to cover administrative costs remains remarkably constant, even as revenue grows.  The capital reserves that it has accumulated over the years to cover actuarial risk remain untouched, even though the degree of risk assigned to it has fallen.

There may be an odd result from this lobbying campaign:  Insurance companies will have destroyed every argument for them to exist.  They will have demonstrated that they have had no impact on overall health costs.  They will have demonstrated that they are a constant tax on the growing health care budget.  Meanwhile, they will no longer be insurers, having shifted risk away from them and on to other parts of the sector.

In short, they will have done everything possible to justify a single payer health system.

With undergrads at Northeastern University

It was back to Northeastern University today, this time to address Professor David Boyd's undergraduate leadership class.  You see him here with Caroline, one of the students who made a very good observation.  Pictures of two others are also included here.

Today's topic was the paradox of hospitals in America (and elsewhere).  Well-intentioned, intelligent, and well-trained doctors somehow participate in making hospitals extremely dangerous places to be.  (Listen to this story on Marketplace for more particulars on that topic.)

We spent a lot of time talking about the nature of medical errors. In particular we discussed the concept of normalization of deviance, explained nicely in this blog post by Steve Whitehead:

Each time a behavior or standard doesn’t lead to a catastrophic result, we are more tolerant of that standard.

It makes for an interesting contradiction. A history of success and positive outcomes does far more to erode our standards than a single negative outcome. The longer our success, the more normalization of deviance comes in to play.

Get away with doing something unsafe or substandard enough times and the unsafe and substandard become your standard.

Cognitive errors of this kind are rampant in organizations where work-arounds become the norm.  Each time some well intentioned, task-oriented person designs a work-around to overcome some obstacle in the workplace, it creates the potential for an unsafe or wasteful process.  Quality and safety in hospitals therefore requires a knowledge of cognitive errors and of the science of process improvement.  The leaders of such institutions need to create an environment in which mistakes and near-misses are cherished as opportunities to be "hard on the problem and soft on the person," rather than opportunities for blame and criticism.

With the Northeastern MBA's

I always enjoy giving guest lectures at Professor David Boyd's leadership classes at Northeastern University. Last night's session with his MBA students was no exception.  As is my custom, I include pictures of a few who made particularly insightful observations.  Names are included so you can hire them!

I started out by asking the students to set forth likely characteristics of the high performing anomalous company in a given business sector.  Mark, here, pretty quickly keyed in on the importance of empowering front-line staff.

But, what, I asked, did we hope those front-line staff would do?  Someone replied, "To suggest solutions to problems in the workplace."  We probed this a bit and concluded that--while suggested solutions were always welcome--the more important value brought by front-line staff is to point out problems in the workplace.  What conditions might lead to poor production quality, to a poor production process, to waste, or to an unsafe condition?  The responsibility then falls to the supervisor to be responsive to those concerns and to bring in people from throughout the company to explore the problem in real time, invent possible solutions, and experiment with those.

I had them recall the work of Steve Spear, who has diagnosed companies that do well.  Here's a summary from a previous post:

As Steve has written in his studies of Toyota and reviews of other high performance organizations, the common characteristic of these organizations is not in their ability to design perfect and complex production or service delivery systems. Rather, it is their ability to discover great systems. They do this by managing their work flow to encourage people at all levels to call out problems; to "swarm" together to solve those problems; to share this process of discovery with others in the organization so that the solutions are diffused widely; and to cultivate the skills of people throughout the organization to be involved in this kind of constant improvement.

Who are they going to blame?

Once the dust settles, or the flood water recedes (in this case), someone will conduct a root cause analysis to figure out why the emergency generator at NYU Langone Medical Center failed to operate during Hurricane Sandy when the Con Edison power supply was disrupted.  Given that this investigation will involve two sectors of society (politics and health care) most characterized by a need to find someone to blame, some poor person at the hospital will be deemed to be the culprit.  It will not be a person too low in the organization, as that would generate sympathy and make it look like a cover-up of higher wrongdoing.  Nor will it be the CEO.  I am guessing it will be the vice president for facilities.  It has to be high enough in the organization to make it look a person of certain authority failed at his or her job.  Being a good soldier, he will gracefully fall on his sword and issue apologies. That will do the trick to produce a fine newspaper story.

The real story will likely be more complicated.  It will involve the difficult choices that have to be made by hospitals regarding how to allocate scarce resources in the operating and capital budgets.  It will involve the matrix used in these decisions, weighing the need for upgrades of clinical equipment and that of infrastructure.  Or, of adding staff on the clinical floors versus staff in the infrastructure areas.  The problem will reside in the priorities established by the administration and the hospital's board of trustees.  It will have been aggravated by insufficient state funding for Medicaid patients and concerns about future federal cuts in Medicare.

And, it will not be that the administrative and board judgments were necessarily wrong or suffered from a lack of rigorous analysis. It will just be that they turned out to be unlucky.  There but for the grace of God goes almost any hospital in the country, starved for resources to maintain basic infrastructure.

That, though, won't be in the newspaper story.  The personal tragedy of the guy who falls on his sword will result from the hospital's need to blame somebody to expiate its perceived sin in the public arena.

Evacuation practice can help

A friend on Facebook posted this picture of her niece, a resident in Pediatrics at NYU hospital. A few months ago the niece had lightheartedly posted the picture with the caption "In case of emergency, stuff a baby in each pocket and run like hell!"

And, guess what they had to do at NYU hospital this week? For real. They had to evacuate 20 babies from their NICU. (Here's one report, with this picture excerpted from the ABC News video.)

This reminded me of a post I put up two years ago showing an evacuation drill of our neonatal intensive care unit, which included this video.  It has since become one of my most-viewed blog posts, and I include it again.  You can never do too much emergency planning.  (If you cannot see the video, click here.)

Capital flows to private equity

An MD friend and colleague is intrigued by the financial machinations beyond private equity investment in hospitals.  At heart, I think he agrees with this columnist on Kevin, MD, who wonders whether there is a place for this kind of investment.  But in the meantime, he mulls this quote from a New York Times story about the growing popularity of junk bonds:

Then there are the bonds issued to pay dividends to a company’s private equity owners. The hospital company HCA borrowed $2.5 billion on Oct. 16, in part to make payments to its three private equity owners — Kohlberg Kravis Roberts, Bain Capital and Merrill Lynch Global Private Equity. Mr. Penniman said that deals like this, in isolation, increase a company’s debt and make it harder to fulfill its obligations to bondholders. A spokesman for HCA, Ed Fishbough, said: “We’re pleased with the response to our offering” from investors, and also with the company’s debt levels. 

I explain that this growing popularity is a reaction to the low-yield environment in the marketplace, where there is a tremendous amount of cash looking for a home.

He replies:

As I am learning about private equity, I am puzzled by what passes as "normal."  I am not saying ethical.  Does HCA sell bonds to pay its private equity owners because they have to, or is there something else going on that story does not discuss?

I answer:

They have capital commitments to their owners.  It is part of the deal, extracting $ along the way for the PE investors.  Of course, it is by no means arm's length.  So it is just a way of giving the investors an early reward for taking the "risk."  But, in truth, it is a low risk because the cash extraction is part of the pro forma in the first place.

It is all legal?  Yes.  Is it normal? Yes.  Is it all ethical?  As they define the word, yes.

Playing wii while the winds swirl and tide rises

Read the last line from today's New York Times live hurricane updates:

Monday-Morning Non-Evacuators

 

The police have been going door to door in the evacuation zone. No one is going to drag you out of your house if you refuse to leave.

But the National Weather Service issued a rather blunt warning on Sunday to those considering defying an evacuation order:

THINK ABOUT YOUR LOVED ONES, THINK ABOUT THE EMERGENCY RESPONDERS WHO WILL BE UNABLE TO REACH YOU WHEN YOU MAKE THE PANICKED PHONE CALL TO BE RESCUED, THINK ABOUT THE RESCUE/RECOVERY TEAMS WHO WILL RESCUE YOU IF YOU ARE INJURED OR RECOVER YOUR REMAINS IF YOU DO NOT SURVIVE.

Those in New York City who refuse to evacuate will also earn the wrath of Mayor Michael R. Bloomberg, as well as the wrath of Hurricane Sandy herself, as Cara Buckley reported Sunday night.

But in the Rockaways, where rain has begun to fall, there were plenty of people around. “Don’t leave the castle,” a father of four told WINS-1010 radio. “I don’t think my safety’s at risk. We’re gonna tough it out and play Wii all day until the power goes out.”

Please help Fred

@Fredtrotter, health hacktivist extraordinaire, has posted a fascinating project on MedStartr.  Read it and then, if you are moved, please commit some money.  He explains:

This data set, which we got from a carefully formed FOIA request against the Medicare claims database, shows how hospitals, doctors and other organizations work together.  This conglomeration of data set shows everything — from the connections between doctors who refer their patients to each other to any other data collected by state and national databases. It displays real names and and will eventually show every city.

This data set could be the best source of public information about the quality of doctors ever. More importantly, it should help doctors to encourage other doctors to improve their skills — for example, by seeking board certification. This data set will allow patients and administrators to evaluate the health system on both micro and macro scales and give them the tools to take steps towards addressing inefficiencies.

How could it be used?

It is very difficult to fairly evaluate the quality of doctors in this country. Our State Medical Boards only go after the most outrageous doctors. The doctor review websites are generally popularity contests. Doctors with a good bedside manner do well. Doctors without strong social skills can do poorly, even if they are good doctors. It is difficult to evaluate doctors fairly. Using this data set, it should be possible to build software that evaluates doctors by viewing referrals as “votes” for each other.

Our goal is to empower the patient, make the system transparent and accountable, and release this data to the people who can use it to revitalize our health system.

Why does he need some money?

This data set can be made substantially more valuable by merging it with other “openish” data sources on the performance of doctors and hospitals. We want to turn this into the ultimate source for open doctor and hospital data.

Almost every State Medical Board in the US releases a report about the doctors in that state. This usually includes information on the doctors medical school, information about board certification and information on disciplinary actions against the doctor.

All of these state-level data sources believe that it is a appropriate to charge $50 to $1000 for copies of this data. Frequently, the states release data that is not yet linked to the NPI data. Sometimes some data is only available in PDFs etc etc. In short this data is currently available, but it is either messy, confusing and disconnected… or it is organized but expensive.

As a result it is not possible to get a full profile for a particular doctor, as they potentially move between states, without paying for expensive data aggregation services. These services charge as much as $150 to data on a single doctor. At those kinds of prices, there is simply no way that a data scientist can afford to really do any significant work on doctor data.

This crowd funded project will enable us to purchase all of this data from the various public sources that sell it, and then to perform the conversion required to merge this data with the core NPI database. Our calculations indicate that for $15k we can comfortably get the state medical board data from every state in the union.

At the Aquarium of the Pacific

I'm giving a book talk at the Aquarium of the Pacific in Long Beach, CA, on Monday night, so I went over today for a look around.  What a great place!  Some samples here.  That's a grunt sculpin, above.  Check out jellyfish below:

The Waiting Room comes to Boston

The Waiting Room, @petenicks compelling documentary about an Oakland hospital, is coming to Boston as part of its nationwide roll-out.  December 1 at Kendall Square Cinema.  Tickets here.  There will be a discussion with the producer/director after the 6:45 show.

The spider that is eating Oakland

A dangerous neighborhood for Halloween!  Best to keep an eye on small, tasty children....

How to stop a future cancer epidemic

The theory of preventative care, including inoculations, is that we spend a little money now to offset big expenses later in life.  But sometimes behavioral friction keeps this from happening, even when the technologies and approaches are proven.  We are witnessing such a failure right now with regard to Human Papilloma Virus (HPV).

Here's the story, from MGH's James Michaelson, PH.D., arguably one of the most thoughtful, trustworthy, and sensible researchers in the field of analysis of cancer survival.  Jim and his team develop sophisticated mathematical methods for predicting the risk of local, regional, and distant recurrence.  He says:

There are a couple of good papers about Human Papilloma Virus (HPV), and the coming epidemic (yes, an overused term, but truly applicable here) of head and neck cancer. As Chaturvedi et al say in a recent paper: "If recent incidence trends continue, the annual number of HPV-positive oropharyngeal cancers is expected to surpass the annual number of cervical cancers by the year 2020."

I get to see this problem from two angles: From my work as the the manager of the MGH/MEEI Head and Neck Cancer Database, and  from my experiments in using computer telephone messages to get patients in for preventive health services, such as the fabulous HPV Vaccines: Cervarix (from GlaxoSmithKline) and Gardasil (from Merck). The vaccines are incredibly underutilized. Only about 1% of eligible boys and only 50% of eligible girls get one shot.  Only about 25% of girls get all three shots.

Beyond the misplaced reluctance of parents to have their children inoculated--or the lack of understanding of the importance of this for boys as well as girls--I wonder if part of the problem here is that insurance companies see no real payback in helping to promote this.  After all, what is the chance that a child I am covering today with insurance is likely to be my subscriber by the time he or she gets cancer?  Unlike polio, measles, and mumps, which show up during childhood, the head and neck cancers are not likely to show up until adulthood.  While the cost per delivered dosage would be remarkably small, especially measured against the societal savings, there is currently no way to internalize that cost-benefit equation into insurance practice.

Two remedies come to mind:

1) As being explored by Jim, use voice-recognition telephone calls and other media to spread the word to parents.  Funding for this could logically come from the pharma companies producing the drugs, or from chains like CVS or Walgreen's. Maybe, also, some multi-specialty practices will choose out of a sense of responsibility to take it on as part of their regular family medicine practices. 

2)  Less likely, especially given the sensitive politics, make this inoculation a legal requirement like polio and other vaccines.  As an economist would say, this would internalize the externalities by government fiat.

Merge. Be happy. Go under.

How many times have we seen this: An industry goes through a structural transformation, often as a result of disruptive technologies that cause it to lose its prior economic prominence.  The next stage is that two large players in the sector decide to merge, convinced that they will somehow obtain economies of scale that will enable their future well-being.  Government regulators, applying old standards of market dominance, fret but then allow the merger to proceed, for fear that the incumbents might go out of business otherwise.  The merger takes place.  It is only then that the world of finance discovers that the newly created company is composed of two leaky lifeboats strapped together, with no greater chance of success than the two antecedent firms.

Health care.  Well, maybe.  But right now I am talking about the proposed merger of Random House and Penguin.  As reported in the New York Times:

A merger of Random House and Penguin could help the publishing houses cut costs by combining resources, and it would give them more heft in negotiations with Amazon and Apple as readers increasingly abandon print for cheaper e-books.

But for authors and their representatives, news of the merger discussions . . . came as another potential blow in an already challenging profession.

Several literary agents said a merger would lead to a consolidation of publishing imprints, thus reducing the number of bidders vying for titles. They also said that combining editing and marketing resources would likely lead to layoffs and potentially put added pressure on authors, especially those who do not churn out mass-market hits.

All this folderol justifying a merger and expressing concern about it overlooks what is happening in this field.  Putting aside the really big authors and their agents, no one needs publishers any more.  To use the technical term, publishers have now been disintermediated.  Any author can self-publish a book.  There are several user-friendly platforms that not only walk you through the process of publishing but also handle distribution and get you in the marketplace within hours or days of completing your book.  For example, I wrote my book Goal Play! and self-published it on Createspace, an Amazon subsidiary.  I had no need for an agent to find me a publisher, but I did hire an editor to help me with the book, a designer to craft the cover, and an experienced typesetter to deal with formatting issues. 

But what about marketing and publicity? Again, you don't need publishers for that (not that they really help the majority of authors anyway.)  Once published, I started marketing the book using my various social media platforms:  This widely read blog, Facebook, Twitter, LinkedIn.  Friends and contacts using those media helped me “go viral” by re-tweeting or sharing.  Several bloggers kindly published their own reviews.  Other readers posted reviews on Amazon.  Several print and electronic newspapers published reviews.  I began a tour with speaking engagements across the country and in Canada and Europe.  Within a few weeks, I had documented well over 3 million “eyes” who had the potential to read about my book, and thousands of people who had heard about it directly from me.

About two months after I published my book, a business book publishing company contacted me to offer to republish it under its name.  They had read it and liked it a lot.  They asked how many I had sold.  I said that things went a bit slowly at first but were picking up, with almost 4000 copies sold.  They were stunned.  I learned that business books, on average, sell fewer than 3000 copies over their lifetimes.

Here's the funny part.  Notwithstanding my success to that date, the publisher immediately made it clear that they would want to change the emphasis of the book, employ a new title, redesign the cover, and re-set the interior.  In return for that, they would offer me royalties that were more than 80% lower than those I could receive on my own.  Also, they said that I would still have to do the bulk of marketing and publicity.  I demurred.

Any author today can do what I did.  The idea that publishers add value to the process is simply untrue for the vast majority of authors.  Let this merger go ahead.  It means nothing.