A painful story

This is a painful story to write.

A close friend of mine, in his 40's, had a persistent light cough for many months. Finally, when he had an X-ray taken, it showed a large tumor on his lungs. He was diagnosed with stage 4 lung cancer. As a non-smoker and strapping, physically fit man, he was shocked, as you can imagine.

He went to his non-Boston-based medical practice, and he was told the prognosis was 12 to 18 months before he would die. They offered him, though, the chance to enroll in a clinical trial, based on a cocktail of chemotherapy agents.

Meanwhile, he wrote to me and another hospital-based friend in Boston, and our cancer experts in both places pointed out that there is a particular genotype of tumor that is susceptible to an oral chemotherapy drug. This type of tumor is present, in the case of non-smokers, about 17% of the time. Folks here recommended that he have a biopsy to see if he was "lucky."

When he went back to his local medical practice and relayed this information from two of the world's greatest oncologists, the local doctor discouraged him from getting the biopsy. He said that recovery from the biopsy operation would delay the start of the clinical trial by a month. The doctor intimated that there were very few slots left in the trial and that my friend might be excluded if he waited.

My friend chose to ignore the local doctor's recommendation, relying on the advice of the Boston doctors. He came here and had the biopsy. It was a match. He started the chemotherapy regime, and it shrunk the tumor by 90%. This enabled it to be surgically removed, with good pathology results in the surrounding tissues. After surgery, he returned home in good shape and has started a maintenance chemotherapy program.

Upon returning home, too, he discovered that the local clinical trial actually was not at all fully subscribed, that they have been having trouble getting enough subjects.

The conclusions I draw from this are very distasteful. Perhaps I am too close to this because it involved a friend, and perhaps others of you see this differently; but I see a medical practice that intentionally put one its patients at risk to support the professional advancement of one of its doctors, and perhaps the financial advancement of that person or the practice, too.

Am I being unfair in my characterization?

Success at the Right Speed: Learning from Toyota

WIHI continues its series of useful webcasts. This one will be on Thursday, May 6, 2010, from 4:00 PM – 5:00 PM Eastern time.

Three of the world's experts on implementation of the Toyota Production System, or Lean, in the hospital setting will be on the air:

Steven J. Spear, Senior Lecturer, Massachusetts Institute of Technology; Senior Fellow, IHI;
John Toussaint, Founder and President, ThedaCare Center for Healthcare Value; and
Gary Kaplan, MD, Chairman and CEO, Virginia Mason Health System.

Here's the description from host Madge Kaplan:

It’s hard to imagine a discussion about improving health care without mentioning “lean thinking” or “doing more with less”; how about striving for “zero defects” or “eliminating Muda” or waste? The principles that fuel the Toyota Production System (TPS) are so embedded in the way we think about health care quality, it’s no wonder the car manufacturer’s recent safety problems have been troubling and cause for concern far beyond the world of auto makers alone.

But, as with everything else Toyota, this detour from its own core values and the U-turn now taking place to get back to them are providing new learning for health care. Who better to tease this out for us than Steve Spear, John Toussaint, and Gary Kaplan, three individuals whose careers have been profoundly shaped by adapting the best of TPS thinking to health care delivery.

Bring your ears and your wisdom to WIHI on May 6 -- and note that we’re starting a bit later in the afternoon so John Toussaint can join us from Australia. To enroll, please click here.

Not enough, AHA

The American Hospital Association does excellent work in representing the views and interests of hospitals across America, and it genuinely seeks to help frame medical and hospital issues in a way that serves the public interest.

But because it is a membership-based organization, it can be hard to be as aggressive on some issues as the times call for. One such discussion is going on right now. The Association is considering a number of strategic performance commitments, one of which is to "advance a health care delivery system that improves health and health care."

I can't argue against that goal, but the manner in which it would be pursued and quantified is weak. See the slide above. It is the draft of what is being discussed by hospital associations across the country.

The first two items are certainly worthy, but the manner in which they are measured is problematic. The metric is a three-year running average produced by CMS and published a year after the year is over. Accordingly, no one will know if the 2012 target is met until 2014.

Why rely on administrative data collected by CMS when every hospital has its own data in real time? Why use a three-year rolling average when we are trying to demonstrate progress over the coming year or two?

The third goal, to achieve improvements in central line infection rates, is simply inadequate on its face. The idea of taking three years to move from the 2009 baseline of 5 cases per thousand patient days to a new target of 1 in 2012 does not reflect the deadliness of hospital acquired infections nor the progress that any hospital can make to reduce them in just in a few months.

The target for central line infections should be zero. That is the only intellectually compelling goal. The time period for doing this should be much, much shorter.

CPOE saves lives. Well, sure, but more than that.

When I first read this article*, "Electronic medical orders may save lives," I thought it was a hold-over from five years ago. But, no, it is current. It suggests that this is the first time someone has been able to document that a computerized provider order entry (CPOE) system has saved lives in a pediatric setting.

I believe in evidence-based medicine and scientific studies, but this looks like a study with an overly limited outlook that may cause some people to question the value of CPOE. Sure it is great to save lives, but most medication errors don't kill people. Most of them result in increased morbidity, extended length of stay, or other things short of death.

In light of these facts, a quote like this in the article leaves me bewildered:

The debate over whether CPOE is working as intended is hardly over, said Menachemi: "I think it would be foolish to believe that any one study can end the discussion."

Let's go back to the basics. Hand-written drug orders are subject to transcription errors at both ends, the person writing them and the person reading them. Each time you add an intermediary in the drug ordering process, you add an opportunity for error. Also, unless there is real-time and accurate checking for drug-drug interactions, allergies, assessment of doses based on body weight and the like, there will be some percentage of preventable medication errors.

Maybe I live in a rarefied world of early CPOE adopters, but does anyone out there think this is still subject to debate? Instead, let's focus on enhancing the implementation process for CPOE, as well as maintaining the functionality of the systems that are installed. Check John Halamka's blog for commonly made mistakes on these fronts.

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*with thanks to e-Patient Dave.

I was wrong. I am sorry.

The Board of Directors of BIDMC today issued the following statement, which has been distributed to the media and to the entire hospital community.

The Board of Directors of Beth Israel Deaconess Medical Center, with the assistance of outside counsel, has completed its review of allegations made involving President and CEO Paul Levy. The review focused on a personal relationship with a former employee of the Medical Center. The Board found that over time the situation created an improper appearance and became a distraction within the hospital.

The Board believes that Mr. Levy should have recognized this situation in a more timely fashion and should have conducted himself in keeping with business protocol appropriate for the office of the CEO.

Mr. Levy agrees that it was a serious lapse in judgment and agrees with the Board’s conclusions. He has apologized to us and to the entire staff of the hospital.

Although our outside counsel found that Mr. Levy did not violate hospital policy, the board determined that he showed poor judgment and the board expressed its disappointment. Accordingly, the board has voted to take appropriate actions by:

1. imposing a financial penalty of $50,000 to be paid to the hospital in the current fiscal year.
2. instructing that this matter be considered in determining the CEO's compensation for the next fiscal year.

Although in this instance, Mr. Levy has not lived up to the standards we set for our CEO, the Board also considered his exemplary record over the course of his tenure at BIDMC, the current performance of the hospital, his role as the chief architect of the hospital’s leading position in quality and safety, and his bold voice of leadership on public policy. Under Mr. Levy’s direction, the hospital has reclaimed its rightful place as one of the region’s preeminent providers of health care, medical education and research. The board again expressed its full support and confidence in his continued leadership, and considers this matter closed.

I have issued the following statement, which has likewise been distributed to the media and to the entire hospital community.

I appreciate the Board's thoughtful consideration of this issue. I agree with their conclusions that I made an error of judgment, and I believe the Board has acted appropriately.

Today I met with the Board, apologized to them again, and accepted their actions in resolving this matter. I regret that my behavior had such wide repercussions for the entire BIDMC community, and I will always feel sorry for any discredit I brought upon BIDMC. With the Board's vote, I look forward to putting this chapter behind us and working together in carrying out our public service mission.

I now here also issue these statements to my other community, the loyal readers of this blog, but I have one other comment.

For those of you who have come to rely on me for my pursuit of quality and safety of care and continuous process improvement in our hospitals, I hope that this series of events and revelations will not undercut the importance or validity of what I have been saying. I especially apologize to you if you feel that I have let you down and, in so doing, in any way weakened the case I have been making. We in the medical community have much to do in these areas. I hope we can together continue to engage in vigorous activity to help make health care safer and more patient-centered. I can't imagine more important goals for all of us to pursue.

Susan Mackie tells us the value of DNKs

Dr. Amy Ship writes:

"Hats off to Dr. Susan Mackie, whose lucid, thoughtful, powerful essay "The Value of DNKs" is published in this week's New England Journal of Medicine.

"We are lucky to have her and her voice!"

Some excerpts:

DNK (pronounced "dink" and always uttered wistfully by the residents in my program) is the abbreviation that appears on our online schedule when a patient "did not keep" an appointment. DNKs obviously represent suboptimal care for the DNKing patients, as well as a financial loss for the practice. But as residents, we have all been guilty of hoping for DNKs in our schedule. I had always thought of this desire as a sign of laziness, but on that day, I began to suspect that the reason I felt I was a good doctor was largely the result of my two DNKs. DNKs create time. Time allows us to build relationships. And what is primary care about if not relationships?

. . . As I progress in my career, pressures to improve the quality of the care I provide will inevitably grow, as will my patients' expectations. Less certain is what will happen to the amount of time I can devote to the care of each patient. Enthusiastically, and perhaps naively, I have mentioned to my mentors that I look forward to a future in which I will be able to share responsibilities with nurse practitioners and physician's assistants in such a way that my appointments with patients will be fewer, more thorough, and more satisfying for everyone involved. None of the experienced physicians I've talked to have confidently embraced this vision. Perhaps they have seen too many changes for the worse to believe that a change for the better is possible.

. . . I firmly believe that adequate time — not simply perceived time, but real time — is an indispensable component of our encounters with patients if we are to be good doctors. How sufficient time can be most effectively incorporated into the structure of primary care delivery, given its payment constraints and expectations of quality, should be the subject of ongoing research, as new policies are codified. In the meantime, I will continue to take guilty pleasure from DNKs.

Know Your Chances

A friend highly recommends this book by some folks at Dartmouth Medical School, entitled Know Your Chances. The idea is to provide a simple description of how you can evaluate publicly propagated information about diseases and therapies. Here's more. An excerpt:

From drug companies to disease advocacy groups, everyone "is trying to grab your attention by making their disease sound as common or as dangerous as they can," says Dr. Lisa Schwartz. But in the process, lots of messages get exaggerated. It can be tough for patients to cut through the hype and determine what—if any—accurate information remains.

So Schwartz and two other members of the DMS faculty—Drs. Steven Woloshin and Gilbert Welch—wrote a book to help people assess messages about health statistics.