Tectonic forces at work

We are about to witness the clash of two tectonic plates in health care. The creation of Accountable Care Organizations, combined with a movement towards capitated and other types of bundled payments, will be forces towards integration of care across the continuum. From primary care to tertiary care to skilled nursing and rehabilitation, principles of care management will combine with financial incentives to create ever more concentration in the health care market. Proprietary electronic medical records systems and "captive" doctor organizations will work towards reducing consumer choice in this new environment.

You already see health care companies engaged in this and advertising it as an attribute. Here, for example, one company notes: [Q]uality care is not just about the care in one institution – it’s what happens between institutions. And if we don’t pay close attention to those gaps – which means measuring and acting to improve the information flow – the patient will suffer. (And, you already see health care companies engage in deceptive behavior with regard to referrals, too, like here.)

Yet, at the same time, patients and their advocates will be demanding more choice. Fully trained in consumerism in other fields, they will expect the same in health care. They will want internet-based transparency of clinical outcomes, along with tons of disease-specific information, so they can seek out and obtain the best possible care for themselves and their loved ones. They will press captive doctors to allow them to be referred to out-of-network health care companies that appear to provide better, safer, and/or more compassionate care.

How will this crash of the tectonic plates be resolved? One answer is to ignore consumer preference and rely on monopoly-like organization of care. We know from other fields, however, that this not only results in monopoly pricing, but it slows down innovation. Think of the Bell System in years past, which provided integrated service, from telephone instruments to long distance calling. Many people alive today do not know that the Bell System conspired to limit people's choice to the extent that you were not allowed to connect a non-Bell telephone in your house. The company argued that doing so would cause irreparable harm to the network and knock out telephone service for miles! You could not buy your phone. You had to rent it for a monthly fee, payable forever (see below). Actually, it was even worse than that. Your bill also included a fee for every extension outlet in your house, even outlets that did not have telephones attached.


And, if you wanted to make a long distance call, there was only one provider, AT&T Long Lines, the one affiliated with your local Bell operating company. You paid by the minute: There was no unlimited service based on a fixed monthly fee. Why? Because they could.

Eventually, the government broke up the Bell System when upstart competitors wanted to sell telephone sets and other companies wanted to offer long distance service. Standards were established that allowed anyone to use the local network and get access to dial tone. Eventually, even that monopoly was broken when other telephone companies and cable companies were permitted to string wires into the neighborhoods. And then, even those technologies faced competition from cellular networks and voice-over-internet.

Is there a lesson from all this for health care? You bet.

The heart of the problem in health care has two dimensions. First, electronic medical records are often based on proprietary systems, limiting interoperability between health care networks. Second, doctors are captive members of a provider network, often one controlled by a region's major hospital or health care company.

As computer guru John Halamka would note, the first problem is gradually going away, in a technical sense. With the advent of national data standards, it will be easier and easier to electronically connect patient records across multiple providers. There are already clear demonstrations of full integration in place, where two or more organizations have found it to be in their mutual interest. But we can expect geographically strong networks to resist this. It will take government action to enforce interoperability.

The second problem, though, requires a Bell System-like solution. As long as physician groups are owned by or otherwise financially affiliated with hospitals, the doctors in those groups will not have the freedom to refer folks to the facilities that are optimal for patients. We can make all the claims we want about the need to have a closely tied physician network to provide integrated health care delivery, but those claims are vacuous. Such systems tend to be driven by -- and serve -- the hospitals and the specialists in them rather than the community-based physicians.

Ask this question to any primary care doctor you know who is part of a hospital-based network: "Do you feel you have the freedom to send a patient to a hospital in another network? " At best, they will say, "If I really feel strongly about it, I can do so." But, if they are honest, they will say, "I don't dare do that very often, if at all. My continued participation in the contracting benefits of my network depend on sending my patients to affiliates in that network."

It is time to break this system wide open and prohibit corporate affiliations between community-based providers and hospital-based health care delivery networks. Let's free up the community doctors to make referral choices based on publicly available data about clinical outcomes, quality of service, and other items that matter to their patients. If global payments become the norm, the PCPs should "own" the payment and then apportion it among secondary and tertiary providers who best serve their patients. Let the marketplace decide which hospitals rise or fall in this environment.

Short of that, we will retain Ma Bell in health care. Then, the answer will be the one given by Lily Tomlin (aka, Ernestine, the telephone company operator):

"Next time you complain about your phone service, why don't you try using two Dixie cups with a string. We don't care. We don't have to. We're the Phone Company!"

If you cannot see the video below, click here.

Should there be a billing code for compassionate care?

Back in 2009, Dr. Amy Ship gave a moving acceptance speech when she received the annual Compassionate Caregiver Award from the Schwartz Center.

The most memorable tag line from the speech was, "There is no billing code for compassion." This resonated with so many of us -- patients and providers -- in part because it set forth the proposition that compassionate care should be an inherent aspect of medical services. The idea that some portion of a doctor's or hospital's payment should be tied to such an essential human value seemed ludicrous.

Or is it? A recent survey conducted by the Schwartz Center, entitled "The state of compassionate care in the United States," indirectly raises the issue. Those patients and doctors surveyed were overwhelmingly in favor of the idea that compassionate care was important to the successful treatment of patients. They agreed, too, that compassionate care makes a difference in how well a patient recovers from illness. Indeed, they believed that good communication and emotional support can make a difference in whether a patient lives or dies.

But there was a gap between what patients said was most important to them, in terms of compassionate care, and what they actually experienced during recent hospitalizations. And, looking forward, both patients and doctors are worried that the changes being made in our health care system will make it more difficult for providers to offer compassionate care.

Now, if we remove the word "compassionate" from the above discussion and instead insert "safety," "quality," "avoiding hospital acquired infections," or the like, our immediate response would be that we need to change the system of hospital and physician payments to provide financial incentives to change things for the better. Whether we might propose a pay-for-performance approach or some kind of global payment to encourage improvement, the current environment seems very comfortable with using the payment system to nudge behavior in the right direction.

So, why not pay for compassion? Surely, we can name those aspects of care that are most closely tied to compassion, and we can likewise document whether they occur.

While I will let this debate play out in the comments below, let me start it off by saying that I believe this would be a mistake. So many discrete aspects of medical care are already monetized that is hard to imagine a payment regime that would actually focus sufficient financial attention to motivate a doctor along the spectrum of less-to-more compassion. Beyond that, the idealist in me is offended by the idea of paying someone to, in essence, be more humane. In my view, this is not a matter of remuneration. It is a matter of societal values and a training program and ongoing supervision that imbues practice with those values.

But, let's hear what you have to say. Should there be a billing code for compassionate care?

Unguarded waterfront

An important warning at Walden Pond, in case you were thinking of swimming yesterday.

Throw the snow in the Harbor!

As I was walking home last night, I saw this scene on Arlington Street in downtown Boston. I was reminded of a story I heard the other day on WBUR's Radio Boston about the problems being faced by Boston and other communities as they engage in snow removal from municipal streets. One aspect of the problem is that state environmental officials have prohibited Boston and other coastal communities from disposing of street snow in the Harbor.

Now, I don't think anyone can contest my environmental bona fide's. After all, I ran the agency that accomplished the Boston Harbor Cleanup, one of the world's largest environmental remediation projects. But this is one rule that I just don't understand.

Yes, I know that snow on city streets picks up all kinds of chemicals and pollutants from the city environment, and I know it also picks up salt and chemical de-icers during its residence time.

But, instead of dumping this snow in the harbor, it gets trucked -- using thousands of gallons of fuel which create all kinds of air emissions -- to inland locations. What happens there? It melts, and those same pollutants enter the ground water system. Or they go into city storm drains, where they end up where? Boston Harbor.

Perchance some of the melted snow goes down storm drains that empty into the city's combined system, which sends the wastewater to the Deer Island sewage treatment plant. In that case, such contaminants that are captured are concentrated in the sludge at the plant, which is eventually made into fertilizer, from which the chemicals leach out onto farmland somewhere. The contaminants that are not captured in the sludge go out through a tunnel 9.5 miles long with the plant's effluent to Massachusetts Bay, the receiving water for . . . Boston Harbor.

I just don't see the point. Why don't we save the extra expense so Boston and other coastal communities can use that money for things like environmental education in the local schools?

When snow falls from the sky, it goes directly into the Harbor. Let's follow Nature's lead.

Standard of review

A comment by an eight-year-old girl, exiting last night's tap dance performance by Savion Glover: "That was better than American Idol!"

Mystery Photo 3: Not Uluru but Kata Tjuta

     I received a couple of guesses on this place, on my Facebook account. As I warned you, you all might think it is a different place. You might think it is Uluru in the outback of Australia. Well, you are very close. It is in the outback of Australia about 16 miles east of Uluru. It is Kata Tjuta, also known as the Olgas. It is a group of large domed rock formations called bornhardts, like Uluru/Ayer's Rock). They are made of the same rock called a conglomerate which includes granite and basalt cobbles embedded in sandstone. All these cobbles are cemented together by this dramatic red sandstone. There are 36 separate domes in this formation unlike Uluru which is one megalith. The highest dome of the Olgas is 3,497 feet (1066 meters) above sea level, and about 1791 feet (546 m) above the surrounding plain. That height is 650 ft (198 m) higher than the neighboring Uluru. The tallest dome is called Mount Olga, name in 1872 by Ernest Giles in honor of Queen Olga of Wurttemberg. In 1993, a policy was adopted that allows both the traditional Aboriginal name and the English name to be used.

     Above are several views of the Olgas. There are several trails that intertwine among them. I wished we had had more time to hike among them. Below is a satellite photo of Kata Tjuta/ the Olgas showing how extensive these 36 domes are.

     Now of course I have a lot of photos of Uluru, 16 miles distant showing the effects of the various lighting on the monolith. Hit Read More below to see photos and read about Uluru, the better known of these sandstone monuments in the Australian outback near Alyce Springs.

     There is an interesting touristy tradition at Uluru which involves parking in one of the bays along the Ring Road around Uluru, and having champagne and canapes, or in some cases even a buffet supper while watching the sunset over the monolith. I tried to find where this custom came from but it no doubt came from a group of tourists that happened along, parked for sunset and decided to tip a few glasses. It certainly didn't come from the Aboriginal peoples. They have many restricted areas around Uluru and actually along with the Australian government put a ban on all alcohol products in the park in 2007. There was concern that many young girls had been sexually molested in some of the small Aboriginal villages around the base of Uluru. The blame was placed on tourists bringing alcohol into the area. For a while you could only drink alcohol if you were a member of a tour bus group in the special parking lot for buses. But apparently the Aboriginals backed down and attributed the sexual cases to a local who had since moved on and the government had to lighten up because tourism was being affected. At any rate, this custom is back in full swing. The only limitations now are that you are not allowed to just park along the road; you must pull into one of the 4 parking areas provided for this. And you are not allowed to walk off into the sand dunes or areas off the road. We did enjoy the sunset very much there. It must be one of the most rewarding views at that time of day in the world. The naturally red sandstone becomes unbelievable hues as the light changes. The following photos just give a hint of those vivid tones.

     The local tribe of Aboriginal people is called the Anangu. For them, Uluru and Kata Tjuta are very sacred places. There are many folk tales and creation stories that are told about especially Uluru. The shamans of the Anangu do not allow these stories to be told to outsiders. But sometimes they do get out. Since Australia has made an effort to allow the Anangu to decide what is allowed and what is not allowed these restrictions are usually abided by. Some areas are not to be photographed because they are exclusively for either women or men of the tribe and photos would allow the opposite sex to see the restricted area of the other sex. The Anangu who do not climb the sacred monolith,  have reluctantly allowed outsiders to climb Uluru, but only in this one area. The base of this trail is shown below.

Below are two photos that demonstrate how the color tones can change as the sun sets.

     There are many small canyons and caves along the periphery of Uluru. We tourists are allowed to enter this particular cave. It shows a good example of the cave painting that is present in many of these places. You will see examples in the next two photos. A sign at this site says: "A Home Becomes a Gallery. You are standing where parents have taught their children for 1000s of years. These abstract symbols illustrate stories in every day lives of each genereation of the Anangu. Every symbol has many different levels of meaning and can help illustrate different stories. However, the original purpose of a symbol was only known to the artist who painted it."

     The Anangu tribe and their ancestors have been living in this area for at least 5000 years, and some knowledgeable in study of the origins of peoples think they lived here almost as they do now 10,000 years ago. Many Western tourists visiting this cave ask from when the paintings date. The Anangu do not have the same relationship with time that we do. There are no doubt marks here that were made many hundreds and maybe thousands of years ago, but there are also marks that were made very recently. The Anangu just write on top of previously made marks. They do not feel the need to preserve the old marks without alteration that we feel.

     Our guide told us a story about the Aboriginal people that demonstrates the difference between their and our culture. An Australian farmer of European descent was out hand plowing his field one day. He was walking back and forth behind the plow and sweating and suffering the whole day. All of this time, an Aboriginal man was sitting under a tree at the edge of the field and just watching the farmer. The farmer came over the man and said, "If you come with me, I will teach you how to do this plowing. Then if you stick with it and plow this whole field, I will pay you some money that we agree on and you will be earning some money for your family. If you do a good job, you can come back to me tomorrow and all through the planting season and help me. You will earn a lot of money and you will be able to send you children to a better school. And you will be able to put aside money for later in your life. Then you can retire and just sit around doing nothing then."

     The Aboriginal man looked strangely at the farmer and said, "But that last is what I have already been doing all today. Didn't you see me? And I didn't have to work at all."
     This culture usually does not look to the future. They do what they can to get their food for that day, such as hunting and gathering, or perhaps working at an odd job for money for that day. Then when they have accomplished that they stop working and sit down to rest. Just as this story indicates, there is no thought to working for the future or to putting away money or even food for the future. That is one reason that the Western culture and the Aboriginal culture have such a hard time mixing.

      Above is a photo of the other side of Uluru. If looked at from the top, it is actually sort of a trigular shape. There seem to be fewer canyons and indentations on this side of the Rock.

      Below is another resident of this area. He posed very nicely for us. After searching on the Internet, I have decided this is one of the species of sand monitor or goanna lizards that are very common in the Australian outback. They are preditors, have sharp teeth and claws, and eat small mammals and bugs. They burrow to look for food, and to nest. They also frequently stand on their hind feet and even sometimes are seen to run only on their hind feet. They readily get used to people; hence this one posing calmly for us in this area of many tourists.

     Below is the Anangu Culture Center with some representations of their art, which is of distinctive style. It is often a very large pointillism which tells stories about daily life of the people here. For example the large circles of dots would each represent people. So this is likely the story of a trip with multiple people. The one below actually shows the footprints of the journeys of the people being represented. 

      Below is an Anangu artist displaying her work near the Visitor Center. We purchased the piece that the lady is holding with me along side. After taking her picture with the piece, we learned that she was just selling these; the artist was an Anangu man who was seen elsewhere among the displays but we did not get his photo. The piece that this lady is holding up tells the story of two women as evidenced by the boomerang and circle shapes. These women would be sitting on their haunches and these are roughly the indentations in the sand that their bodies would make. One long oblong is a knife and the other is a plate like recepticle. These two women have gone hunting for desert bananas as they are called. The central circle represents the banana vine and its branches. We now have this piece framed in our home representing to us and our visitors the art of this very interesting people and our visit to Kata Tjuta and Uluru.

Cleaning for a Reason

From a friend:

If you know any woman currently undergoing chemotherapy, please pass the word to here that there is a cleaning service that provides free housekeeping -- once per month for four months while she is in treatment. All she has to do is sign up and have her doctor fax a note confirming the treatment.

Cleaning for a Reason will have a participating maid service in her zip code area arrange for the service. The organization serves the entire USA and currently has 547 partners to help these women.

Be a blessing to someone and pass this information along.

Website for parents

I'm taking a step away from health care for a moment to offer something that might be of interest to parents. One of my former soccer players, Dr. Alexis Lauricella, sends the following note.

But first this question: How can someone who in my mind is 14 be a Ph.D? Of course, as was always the case, I am really proud of her.

Here's the note:

I just wanted to let you all know that I started a website for parents about child development. I have always felt particularly frustrated by the fact that there are very few services and very little information available to help parents become the best parents they can be. This is only the beginning, but I wanted to create a website/resource where parents can learn about basic child development and parenting information. If you know anyone who is a parent, who may become a parent, or in anyway may benefit from basic child development resources (e.g., teachers, nurses, pediatricians, etc) please feel free to pass along this website and the Facebook page (See below for links) and please feel free to sign up yourselves! The website has resources and a few blog posts and I tend to post articles and interesting resources daily on the Facebook page.

PlayLearnParent Website
PlayLearnParent Facebook Page
PlayLearnParent Email: playlearnparent [at] gmail [dot] com
PlayLearnParent on Twitter: ARL@playlearnparent

I would really appreciate help getting this out to people, so please feel free to pass this along to anyone. And thanks to everyone who has already "liked" PlayLearnParent on Facebook or has taken a look at the website!

Global warming in the extreme?

Hmm, perhaps the headline writer on Boston.com needs a chemistry lesson.

At least it feels that way!

Actual image of commuters in Boston this morning after the recent series of snowstorms.

Mystery Photo 3

     Here is Mystery Photo 3. I have decided to offer two photos of this place to try to help you out. Also I will tell you that it is not in the United States. But be careful. It may not be what you think it is.

Residency Work Hours on WIHI

New Models for Residency Work Hours
Thursday, January 27, 2011, 2:00 PM – 3:00 PM Eastern Time

Guests:
Christopher P. Landrigan, MD, MPH, Director, Sleep and Patient Safety Program, Brigham and Women’s Hospital

David B. Sweet, MD, FACP, Program Director, Internal Medicine Residency, Summa Health System

James F. Whiting, MD, Surgical Director, Maine Transplant Program and Surgical Residency Program Director, Maine Medical Center

Donald Goldmann, MD, Senior Vice President, Institute for Healthcare Improvement

If you survey the American public on efforts to restrict the number of hours medical residents can work without sleep or time off, there’s overwhelming support for new rules and regulations. The relationship between lack of sleep and the increased likelihood of impaired judgment and medical errors seems like a no-brainer to most patients. The bigger challenge is to convince residents themselves – and, perhaps even more, those who teach new physicians – that work hour limits make sense...and can be implemented without compromising continuity of care or interfering with education and training. Still, a growing number of residency program leaders are discovering that the only way to move this debate forward is to dig in and start innovating and doing things differently.

David Sweet and James Whiting are two such program directors who will be joining WIHI host Madge Kaplan on January 27 to describe what residency training can look like in systems grounded in patient safety, greater teamwork, better handoffs, increased supervision, and educational redesign. The changes at Summa Health System (16-hour limits are the norm for all residents) and Maine Medical Center are noteworthy; they join a growing number of residency programs not just doing the bare minimum to comply with Accreditation Council for Graduate Medical Education (ACGME) rules, but seeking to create new and better models of care.

Christopher Landrigan’s research on sleep deprivation and patient safety, along with Don Goldmann’s knowledge of hospital improvement and the goals of residency training, will deepen the conversation and round out what is sure to be a rich discussion. Both Drs. Landrigan and Goldmann appreciate the challenges residency programs now face to institute critical changes, but reform also opens up all sorts of possibilities. We hope you’ll join us on the next WIHI.

To enroll, please click here.

Reminders of Art Buchwald

I cannot locate the article, but I think it was Art Buchwald who once wrote a humorous piece about competition between the two airlines who ran shuttle services between New York and Washington, DC. It went something like this:

The piece opens with a phone call to the US Airways agent. "I see you just raised your fares to New York."

"Yes, we did that to compete against Pan Am. They just raised their fares."

"Wait, I thought the idea of competition was to lower prices."

"Why would we do that? If we lowered our fares, and they followed suit, it would be a race to the bottom. We would both lose money."

Recently, Tufts Health Plan (730,000 members) and Harvard Pilgrim Health Care (1 million members) announced a plan to merge here in Massachusetts. This would leave two major insurers in the state, along with Blue Cross Blue Shield (3 million members).

Not surprisingly, the leaders of the two suitors have said that the merger would cut health costs in the state. Rob Weisman and Kay Lazar at the Boston Globe summarize that view in this article, but in this one, Lazar raises an opposing view:

The bargaining clout of a larger company could help it negotiate better prices from hospitals, but one less major insurer might also mean consumers would have less choice and end up paying more, said officials of leading consumer and business groups.

“Like a town with two gas stations versus four gas stations,’’ said Jon Hurst, president of the 3,000-member Retailers Association of Massachusetts. “Two can copy each other with gas prices, but if you have four, someone is always going to be looking for the edge.’’

Has Mr. Hurst landed on an important distinction? It is one thing to assert that the merger will reduce health costs. That is certainly likely if providers have only two insurers with whom to negotiate payment rates. It is another thing altogether to argue that a merger will reduce premiums. Why?

Well, in a duopoly, as noted by Mr. Buchwald, there is a tendency for the two market participants to fix prices. That is especially the case if one participant is much larger than the other. The dominant player sets the price ceiling and enjoys what economists call "monopoly rents." The secondary player needs only to use that ceiling to establish its prices, at a level just below that of the dominant firm, but also at a level that is higher than would be possible in a truly competitive market, a contestable one that would be characterized by free entry.

Let's think about it this way. If you are on the Board of Tufts or HPHC, why would you merge? The first reason, and the one that I think motivates this decision, is survival. Most observers think an insurance company needs about 2 million subscribers to compete. You need this many to have sufficient economies of scale to drive down transaction costs. You also need that scale to have sufficient access to capital. And, you also need that scale to participate in the national insurance market that now characterizes the needs of large business customers.

Beyond survival, the Board members have to believe that the financial results for the combined entity would be greater than for each one standing alone. Some improvement in that regard can come from eliminating redundant positions and otherwise reducing administrative costs, and some can come from economies of scale in electronic processing of claims and payments. Some would likely come from increased leverage over providers, who will no longer be able to play off one firm against the other.

But what is to prevent some improvement from being derived by the market power of a duopoly, an improvement that would be solely based on extracting more from consumers than would otherwise be the case?

The answer here, as in other industries, must be state regulation. As a former regulator, I will tell you that state regulation is a crude alternative to competition. It is inherently ex post in nature, and it is extremely difficult to get the facts and data you need to do a thorough job.

Nonetheless, with diligent, expert staff, a regulatory agency can do a pretty good job. In this situation, however, the ability of regulators to do well will be dramatically enhanced if the public is let into the process by having total transparency of the accounts of the insurance companies, the premiums they are setting, and the payments being made to the providers.

In essence, the insurance companies in the state have now positioned themselves as public utilities. The secrecy of rates, charges, premiums, actuarial methodology, and the like that have characterized the system have no place in a duopoly environment. To extent current law does not permit this kind of openness, the state should act to make it a condition for the future.

Defining a defect

From Charles Kenney's book Transforming Health Care, about Virginia Mason Medical Center's journey:

Implementing the program was not a simple matter. Defining a defect in a medical setting presented a challenge.... [D]octors pushed back. The argued that many instances of harm -- ventilator-acquired pneumonia, for example -- should not be considered an error because these things happened in medicine. Complications, they argued, were inevitable.

This is a typical assertion, based on a belief that there is a statistically irreducible amount of harm that must occur in medical settings. There may be such a statistically irreducible amount, but most hospitals are not close to the potential minimum. As Gary Kaplan and his team showed, and as shown at BIDMC, setting an audacious target of zero defects and organizing work to reach that target can enable the people in a organization to reach or get mighty close to that target.

Joseph Gavin strived for such a goal in space flight. Others are doing so in medicine.

Real transparency is a concomitant of success in such a transformation. You cannot improve what you do not acknowledge to be flaws. That is why I pound away below as to its importance and as to why misuse of transparency is unethical.

In her humorous way, Ethel Merman tried to show us the way when she decried the view that "these things happen." But this is deadly serious. Those who stand in the way are causing death and injury as clearly and directly as those who wield weapons.

If you cannot see the video, click here.

Transparency is not marketing

When is transparency not transparency? Answer: When it is marketing.

A recent ad campaign by a well known hospital system suggests that you are better off going to one of its hospitals if you have a stroke because they have a speedy rate of administration of an anti-clotting agent. It is true that rapid administration of this drug is very important.

But the data offered by this hospital system are old, based on the period 2006-2008. According to the Boston Globe, "State officials said that when data for 2009 and 2010 are released next year, they expect the gap between hospitals will have narrowed because of improved care."

Look, no one will argue that you don't get excellent care at this hospital system. Quite the contrary. But to suggest that you will get better care, based on old data, just isn't right. It might even raise unnecessary concern among patients or their families. Imagine, for example, that a loved one is having a stroke and you ask the ambulance to go to a hospital that is farther away because you think that the patient will get faster treatment. The extra time spent in the ambulance might add danger itself.

Also, selective use of clinical outcomes for marketing purposes is a slippery slope. Let's review the issue, for example, of "door-to-balloon" time. The Joint Commission has set a standard for opening blocked arteries with catheterization (percutaneous coronary intervention) within 90 minutes of presentation at an emergency room in a hospital. The hope is to achieve this goal at least 90% of the time.

But one member of this same hospital system only accomplished this standard about 60% of the time for part of 2009. I don't recall a marketing campaign back then that referred to this result.

You cannot be selective about transparency. You have to post the good and the bad. See the VA story below. If you use it for marketing purposes when the numbers are good, you rightfully open yourself up to attack for selective use of statistics.

Let's just accept that transparency is about holding ourselves accountable to a high standard of care and learning from one another, rather than attempting to use it as a marketing tool.

Jobs -- A personal history.

     All of the talk recently is about jobs -- that is the lack of them, and the political pressures to produce more jobs to turn our economy around. Unfortunately a lot of people have probably recently received the infamous "pink" slip lately. Social Science research has shown that "'Tis Worse to Give Than to Receive." Emplyers have a 100 percent increased risk of heart attack in the week after firing an employee. I am not sure if that applies when 10 or 20% of a workforce is let go. Still it has to hurt the administrators somewhat because it means there is no money coming in and no economic growth, if for no other reson. And yet 20% of Americans would like to fire their boss. Only 20%, sounds very low, doesn't it?
      Now that I am in retirement, I began thinking about my past jobs over the years. I read somewhere that the average American holds 9 different jobs by the time he/she is 32 years old. This of course reflects all those summer jobs as a teenager and college student. I began to review my past jobs. I decided to list my previous jobs just to demonstrate to myself and perhaps future descendents how a life can evolve through work. Read on about my work history and its implications. Hit Read More.  
      My first job was lawn mowing for my mom and dad and for my grandmother at her farm. That is how I earned my very first cash. I recall counting those few dollars and hoarding them away. I did help teach at Summer Bible School but that was unpaid volunteer work.  Many young girls at that time earned money by babysitting. But I only recall one such job. I was hired to keep the three children of the local high school math teacher and basketball coach. I was to show up at 9 in the morning and keep the children all day until about 5 pm when I was due at practice for a high school play. I had to feed the kids lunch and get a dinner ready for them before I left and would be replaced by a grade school girl in a pass off of responsibility. There were two boys probably about 6 and 8 years old and then there was a toddler in diapers. Well shortly after I fed the kids their lunch, the two boys asked if they could go outside and play. It seems too strange but in those days this was common; kids would disappear into the backyards of neighbors  and roamed the neighborhood with other children, playing kickball and softball. Well as I cared for the toddler I realized that I had lost track of the two boys; they were not in their home's yard nor in immediate neighbor's yards. Even then as the responsible party, I felt some discomfort with this. So I packed up the baby into the stroller and took off worriedly looking. It took me quite a while to find them about 2 blocks over playing baseball. I suggested they come home but they balked and I didn't know how to exert any power to get them to come home. So I nervously took the baby home and put him down for a nap and every now and then snuck down the street a little to see if the boys were still down there. When it came time for my mother to pick me up and take me to play practice I noticed the toddler climbing the stairs with poop dripping out of her diaper. Well, I couldn't run away and leave that cleanup to the grade school student so I began working to clean up the mess. My mother even stepped in to help me so that it would get done a little quicker. As a result I arrived about 30 minutes late to play practice. When the drama teacher who was also a very strict social studies teacher found out I was late because I was babysitting for the basketball coach, he had a fit and I knew he was going to make trouble for me and for the coach. I don't think I ever babysat again after that. It was not a job for me.
     Summers later in high school and into my college years as well, I worked as a carhop at a local drive-in. The drive-in opened at 4:30 every day and stayed open until all the cars were gone and none were entering the parking lot, usually somewhere around 11 PM. My only night off was Monday night when the drive in was closed. I remember feeling sorry for myself because I missed the late afternoon and evening and its cooling activities -- a time of day that I convinced myself was my favorite. I think it only became my favorite when I started working at the drive-in. It was kind of an interesting job -- you got to see all the local people, and you got to serve some kids you knew from high school. That could be fun or it could be miserable depending on the kids. The owner's son also worked inside as the soda jerk ( and he was one -- a jerk, I mean). I had kind of a crush on him so I tried to be real cool when dealing with him. Of course, like any food job, your pay was mostly tips, though I did get a small hourly payment.
     My town had the county fair every August, and for a few summers I worked doing some bookkeeping, and writing checks for services for the county fair during its run. Those were short jobs, only about 3 weeks long. But it was fun working with responsible adults as a new experience. Of course, the work was basicly just clerical but I didn't know any better so I felt very important. I was working in the office there in the main building of the fair. Wow! Bigshot!
     One summer during college as I began to think about going to medical school, I decided I should take a job as a nurse's aid at a nursing home. I felt I should do some sort of medical work and get my hands dirty, so to speak to see if I could take that kind of work and to make sure I wouldn't be too squeamish. I found a nurse's aid job in Rockford with just those characteristics. I did fine with the caretaking and the bathing of patients and the cleaning up of their incontinence. What I had the most trouble with was dealing with the behavior of the other nurse's aides. Many of them worked harder at avoiding work than they did at the job. And if another aid sherked her job, that meant I had more work to do by having to process more patients because she would only finish getting two patients ready for bed.  I was too responsible to sherk my responsibilities toward the patients assigned to me. I guess that was a good sign about my character, but I had trouble dealing with these situations. The work was otherwise not hard. One summer I worked the nurse's aid job during the day starting at 7 am, and the car hop job in the evenings. I always came home kind of wound up from the drive-in and couldn't always get right to sleep, so mornings came pretty quickly. I must have become quite sleep deprived because one night near the end of summer, I fell alseep driving the 25 minute drive home, and rolled the used car my father had bought me earlier that summer, totalling it and lacerating my scalp and my arm in the process. But I was enormously lucky in that accident; we just lost the car, but no other major injuries. That would seem to indicate that I shouldn't work two jobs and deprive myself of sleep in the process, but what did I end up doing? Going to medical school and becoming a doctor, a profession which probably produces the most sleep deprivation of all.
     In college, I took on a job working serving food in the dorm cafeteria. I had to wear a uniform, and worked either serving food on the line, or managing the beverages, pouring milk into glasses, and keeping the juices and water pitchers filled. I also typed people's termpapers and other writing for other students who didn't know how to type. I had audited a typing class in high school so I was quite a good typist.
     I also worked in an unpaid capacity to man the college radio station for some hours, spinning some music and just filling in with various raconteur sometimes by myself and sometimes with another college gal. That was kind of fun, but you really didn't get much feedback. I never knew how many listeners we had. In some ways it was like doing this blog; you really didn't know what kind of effect you were having. As far as I knew then I could have been just talking to the air waves, and right now I might be just writing to that great wireless network somewhere between the cosmic plasma and reality without any intelligent beings intercepting my words ever.
     During one summer in college, I got a job at a factory that made batteries of all shapes and forms. My mother had worked at this factory in Freeport, IL when she graduated from high school. She sort of pushed me to apply there for the summer. I could stay in Freeport with my aunt and uncle during the week and them she would come to pick me up and bring me home for the weekend. I usually worked the 2 PM to 10 PM shift so I never saw my aunt and uncle. They were in bed asleep by the time I walked home from the job. It was a very lonely job. That job was working on an assembly line. The factory had set up a summer line using temporary summer help. It was kind of difficult to make friends with the others on the line. First we were all trying to work fast doing one thing to move the line fast, so you couldn't always converse. And if you did converse, the topics were uninteresting. I had little in common with these folks; they spent Monday through Wednesday talking about hanging one on the last weekend, and Thursday and Friday talking about how they were going to party the coming weekend.  It was hot, and messy and boring. I complained to my mother about these concerns and she said, "It's good for you. You are seeing how the other half lives." I didn't exactly know what she meant by 'the other half,' but I probably made some sort of unconscious decision that I was not going to be in that 'other half.'
     After I graduated from college in microbiology form University of Iowa, and was set up to start medical school in the fall at the University of Wisconsin, the UW found me a job for that interim summer, working as the microbiologist in an entemology lab on campus. My work was to try to find out if certain pesticides would be broken down by microorganisms in the soil. Basicly I was crushing up apple maggots and culturing the result out to identify the fungi and bacteria from the guts of these little creatures. Strangely enough, that was a very fun summer. The other lab workers there were great fun. And our lab was one block away from famous Babcock Hall in the Dairy department, with its famous ice cream productions each day. We always took an afternoon break and went and got an ice cream cone. My college roommate had come to Madison with me since she had the summer free before starting teaching in CA in the fall. She found a job selling encyclopedias door to door (a job that is obviously totally obsolete now). But this meant that she worked evenings and I worked 8 to 5 Pm in the entymology lab. We had come to Madison to keep each other company and we never saw each other. I got into the habit of walking over to the UW Student Union and sitting on the Terrace writing letters to college friends. Low and behold, that is where I met the man that would become my husband a year later. So, yes, it was a very fun summer!
     During the summers of the first 3 years of medical school, I got a job in the State Lab of Bacteriology. Mostly I streaked out stool samples looking for Salmonella or Shigella, stool pathogens. Then we had to do recultures and chemical analyses to identify and type the pathogens. It sounds like a rotten job, but it really wasn't a bad job either. It was 2 blocks away from Babcock hall in the other direction. Also the ice cream cone breaks.
     Then came internship and residency at Mount Sinai in Milwaukee. Those years occurred during the years that I had my children. That is another story that there may be a chance to tell on another occasion. After residency and the birth of my second child, I began my internal medicine practice at Milwaukee Medical Clinic where I practice for 34 years, retiring 2 years ago.
     If I count up all these little and very huge jobs, I arrive at 12 different jobs from about age 16 to 30. Of course, in my case I was working through about 10 years of schooling at the same time. That changes the picture a little bit. Once I settled into my medical practice I stayed put for 34 years before retiring.
     It is interesting to look back at such an long productive work life and recall the people that I had contact with as fellow workers, as bosses, and later as patients. Though I enjoyed the science of many of my later summer jobs and the science involved in being a physician, I think that the most rewarding part of any and all of these jobs was the personal interrelationships that they created -- some temporary but many lasting a lifetime. I really would not have lived my life any other way. It was terrific!  

VA stands for "very accountable"

A mutual friend recently introduced me to Scott Gould, Deputy Secretary of the Department of Veterans Affairs, who informed me that VA has recently posted the performance data for all 153 medical centers at Veteran's Health Administration on the web. Here's the introduction from the website:

Welcome to the VA Hospital Compare web site. This site is for Veterans, family members and their caregivers to compare the performance of their VA hospitals to other VA hospitals. Using this tool, Veterans, family members, and caregivers can compare the hospital care provided to patients.

Imagine that. They are actually inviting people to make comparisons of clinical quality in their hospitals. I am guessing that this kind of transparency gives people in the individual hospitals an extra incentive to do well. As I have often said about transparency, its main value is in holding ourselves accountable to the standard of care we say we believe in.

This is clearly exemplified by the VA. See below for more from the website. I say bravo and congratulations!

The Secretary of Veterans Affairs (VA) and the VA’s Under Secretary for Health are committed to transparency − giving Americans the facts. The Veterans Health Administration (VHA) releases the quality goals and measured performance of VA health care in order to ensure public accountability and to spur constant improvements in health care delivery. The success of this approach is reflected in our receipt of the Annual Leadership Award from the American College of Medical Quality.

Raising the bar for the 21st century healthcare
Much of the data in LinKS and ASPIRE are simply not measured in other health systems – VA is raising the bar. When available, VA uses outside benchmarks but often sets VA standards or goals at a higher level. VA scores hospitals more than 30% different from the goal as underperforming or red and those only 10% different from the goal are shown in green in ASPIRE. But a red site within the VA might be a good performer compared to outside counterparts. The scoring system is designed to move VA forward. ASPIRE is not about finding fault but about helping VA to target opportunities for improving performance.

Post volcano

Many of you expressed interest in my earlier two posts about the impact of the Iceland volcano on air traffic in Europe. There is a follow-up article on aerospace-technology.com about this period of time and lessons learned.

Here's an interesting excerpt:

In response to claims that operators should have allowed airlines to fly, Haines states: "It would have been unthinkable to abandon the current international guidance without the necessary evidence - when you are dealing with peoples' lives it is not enough to just make up a less restrictive standard. You have to agree on a new standard based on robust evidence and data."

New standards and new procedures have been researched and developed since April 2010 - including ash measurement, ash location, charting and operational planning.

I'll leave you to read the rest of the article on your own, but I will observe that the airline industry and its regulators seem much more adept than the health care industry in systematically studying adverse and unexpected events, rigorously drawing lessons from them, sharing safety lessons even among competitors, and applying industry-wide solutions quickly.

Plum Island scenes

An aerial view of a river system? Not quite. It is just a pattern on a winter beach at Plum Island, north of Boston.

Even the walkway to the beach has a special presence on a crisp and cold winter day earlier this week.

Talinn, Estonia. More photos and information.

     MYSTERY PHOTO: Talinn, Estonia, the capital. Several years ago after a tour to Moscow, Russia; a river cruise up the Volga, through various lakes etc, to St Petersburg, Russia, we then took a bus trip to Talinn, Estonia. I loved Talinn. It is a walled medieval city that is well preserved, having been spared much of the damage to Western Europe during World War II. It has become a tourist destination and therefore has many businesses, restaurants and pubs that cater to tourists. Particularly people from Helsinki, Finland take the 3 hour ferry over to spend a weekend in Talinn. We learned much of the history while we were there and viewed several of the historic churches. I have posted several photos of the city and its charm.

      This is the Town Hall, the only surviving Gothic Town Hall in Europe. The present structure was completed in 1402. Talinn was  a member of the Hanseatic League. This was an alliance of cities and their guilds along the Baltic Sea and North Sea that cooperated economically in the 13th-17th centuries, also called the Hansa. The Hansa merchants from each city elected the governing council and it met in this building. This Town Hall was used until the 1970s for city meetings. It is now only used for special events. Below is a map showing the extent of the Hanseatic League.

     Below are two photos of the largest town square in the Old City, although there are several smaller squares.

    Below are two pictures which show some of the architecture of the Old City; first just an interesting building, and then an interesting door. 

    

The city streets are very narrow and winding and demonstrate very nicely what life was like in this city in medieval times. 

      There is a restaurant in the Old Town that we went to twice. This is where we found many of those Finns visiting for a day or the weekend to be eating, imbibing and having a general good time. The food was very hearty and served  in old looking pottery by waiters and waitresses in medieval dress. The restaurant was busy both on the street and inside the old building. You could definitely imagine yourself backwards in time here at this establishment.

      Below is a photo of the Old City to refresh your memory, taken from the waterfront of the Baltic Sea.  In the middle picture below, you can see the beautiful church in the center which stands higher than the rest of the buildings. That is the Alexander Nevsky Cathedral, a Russian Orthodox church, which is located in what is called the Upper Town. The rest of the Old City photoed sites here are located in the Lower Old Town. The photo below that shows that there is a modern city of Talinn which is where our hotel was located. This area is within walking distance of the Old City Wall.

     Below is a photo of the radio/tv tower which is located outside the main city, across a bay from the Old City. We went up into this radio tower to see the view. Apparently it is now obsolete and regarded as becoming unsafe, so it would be closing after the summer season that we were there. Also nearby is a botanical garden which is quite pretty. It was worth driving out to this place, but it may not be open any more.

         Below are photos of the Old City Wall, some portions dating to the 17th century. There are 26 cone roofed towers guarding the corners of the City Wall. They are in quite good repair. It was important to make these towers round, because cannon balls were deflected by the round shape if the city should come under attack, especially from the sea.  



     Mostly this city was very well maintained and was very clean and fresh looking even though many of the structures are very old. But here was some evidence of the age of the infrastructure here. We were walking from our hotel to the Old City and were just about to pass through a pedestrian gate in the wall. We were passing a very large flower market when we heard a pop and then a hiss and then some sound of tumbling bricks just 10 feet behind us. We turned around and the brick sidewalk that we had just walked over, had exploded as shown here. We concluded that there must have been a gas leak that got ignited and basicly blew up the sidewalk. Scary! If we had been on top of this spot, we would have been knocked down I am sure; not killed, but certainly injured in some way. We went on and saw the Old City. When we returned this was a hole filled up to street level with sand. The city works had been active. We regarded ourselves as very lucky and just went on with our travel.

          All in all, with the exception of the exploding sidewalk, our visit to Talinn was very much enjoyed. Do try to include it in any plans you have for a Baltic Sea cruise, or Eastern European tour.