Half full. Half empty.

At a recent presentation, a respected doctor expressed some frustration with the criticism that is sometimes directed towards the medical profession. He pointed out that the medical community has actually done a very good job taking care of serious illnesses in the population. He noted that this is because doctors really devote their lives to improving patient outcomes.

To support this point, he presented the chart above from the AHRQ Center for Delivery, Organizations and Markets (full study here) that demonstrates improvement in hospital risk-adjusted mortality for important diagnoses and procedures. Whether you have a heart attack or pneumonia, or whether you have an aneurysm repair or a hip replacement, your chance of dying in a hospital has gone down over the years. (I know this data ends in 2004, but I would be confident that the trends have held.)

I hope you, like I, am impressed with these numbers. They are a story worth telling and retelling.

But there is another story that has to be retold, too. It remains a bit of a paradox for me, one I discuss in my speeches. The paradox is how this group of extremely able and well intentioned clinicians, while accomplishing these great things, also constitute an important public health hazard, in terms of the number of people who are killed or otherwise harmed while in hospitals.

The famous Institute of Medicine Report, To Err is Human, was published in 2000. It documented, in a way that many people find uncomfortable, the number of unnecessary deaths that occur in hospitals. We now understand that much of this harm is caused by the systems of care, by how work is organized in hospitals, by excessive levels of variation, or, to put it another way, by insufficient levels of standardization based on process improvement principles. I summarized Brent James on this point in a post below:

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

And, as noted below, we also often do not draw on our greatest resource, patients, in the design of care delivery. And finally, many hospitals and doctors are held back by a fear or reluctance to publish clinical outcomes in real time so that organizations can hold themselves accountable.

Is the glass half full, or half empty? As in such cases, probably both. Let's give tremendous credit to the medical profession for what it has accomplished. But let's hope that members of the profession also take to heart the fact that the job of reducing harm is not nearly done.

In memoriam: Robert Ark San Lee

This is not about anybody famous. In part, it is a personal remembrance, but it is also a story of a fulfilled American dream. A college roommate and close friend of mine, Bob Lee, died a few days ago after a lengthy illness. I thought some of you would enjoy a section of his obituary, into which I have inserted a personal story, too:

Robert A.S. Lee, a mulitalented mechanical engineer, musician, singer, and connoisseur, died Friday at age 62 after a lengthy illness.

He was born March 26, 1948, as Bobby Chin, and his parents, first-generation Chinese immigrants, settled in Cambridge. All of his relatives came into the US by way of San Francisco in the late 1940s, but his mother, Mary Lee, decided that all of her children would go to MIT and continued on with her husband, Henry, to Cambridge. There, they opened the Silver Eagle Laundry, next door to their good friends, the Berkowitzes, who had just opened the Legal Fish market - the precursor to Legal Seafood - in Inman Square. Bob grew up ironing and folding shirts at the Silver Eagle alongside his father. There he played stickball in the alley while he was babysitting his youger brother, Ed, and his sister, Lana.

Since he was the first-born in an Asian family, Bob always had steak for breakfast while Ed and Lana were only given scrambled eggs.

After attending Longfellow School, he went on to graduate from Cambridge High School. In accordance with his mother’s plan, Bob attended MIT, obtaining both his graduate and undergraduate degrees in mechanical engineering. It was there that his love of music was encouraged by John Oliver, who conducted the chorus at MIT.

Here's where I insert the story from me:

Bob had a habit of "conducting" with one hand while he was singing, reflecting the rhythm of the part he was singing. One day, John Oliver stopped the entire chorus and turned to him and said, "It's triplets, not dotted eighth notes." Bob said, "How did you know I was doing it wrong?" John said, "Because you were conducting in dotted eighths!"

Also during that time Bob felt a passionate objection to the Vietnam war. He participated in many local protests and also attended the Moratorium to End the War in Vietnam on October 15, 1969. Millions of Americans took the day off from work and school to participate in local demonstrations against the war.

After graduation from MIT, he was hired by the engineering firm of Stone & Webster in Boston. Because of his command of German from singing classical music, he was assigned to work at an engineering firm in Mannheim, Germany, for BBR. He and his wife, Marleen, had the oppportunity to travel all over Europe, but the overriding joy of being in Germany was his love of BMWs. He demanded that if he were to agree to the German assignment, Stone & Webster would have to supply him with a BMW. He spent much of his free time at the Hockenheim Ring on Sunday afternoons, and took driving lessons at the famed Nurnburg Ring.

After returning to the US, he and Marleen started a family of three daughters. He was extremely proud of his daughters' accomplishments in academics, dancing, and gymnastics, and their musical abililty on piano, violin, and oboe. He continued to sing when he wasn’t traveling with Handel & Hayden and the Stoneham Community Chorus. He also served for many years on the Stoneham Finance Board.

Around the same time, he went to work for Foster-Miller in Waltham (an MIT R&D think tank), where his ability to speak many languages was put to use marketing his robot CECIL. His retirement from Foster-Miller was celebrated with his favorite, cognac, being served.

Patients will teach us how to be compassionate

I have reported below on Dr. Epstein's remarks about the place of compassion in medical care. (I provided the video excerpt because seeing it said is inspirational.) Who can doubt the worth of doctors like the two Dr. Epstein's as they consciously practiced this form of care delivery with their patients? We are so fortunate to have people like them.

But compassion has to show up in the actual physical delivery of care as well. We need to be ever alert that the day-to-day actions we take in the hospital can inadvertently send a signal that we don't care. Even when we have the best of intentions.

Here is an example of a lapse. The bad news is that it occurred. The good news is that our staff immediately responded when it was pointed out.

Here was my initial email to a couple of senior level clinical and administrative leaders:

I'd like you please to look into this and apply a Lean approach to the problem. The instant case was my friend Mary [name changed], but she says she has experienced it before and has seen other chemotherapy patients go through the same problem.

She is a chemotherapy patient who comes in for periodic CAT scans. The chemotherapy affects the blood vessels and makes it difficult to insert an IV for the contrast agent. The techs are not trained to insert these difficult IVs. They try several times, causing pain and swelling of these cancer patients, and then finally the special IV team is called. When Mary has asked for the special IV team to be called at the outset, she is told that there is no way to coordinate those teams with the CAT scan outpatients.

That, to me, is an unacceptable answer. These patients come in on a known schedule. They have a known problem. We do not respect that problem sufficiently to avoid the discomfort and pain that comes from multiple attempts to place the needle.

I saw Mary's arm after her appointment. Much of the lower portion of her arm was discolored and swelled up and painful to her. That is no way to treat a patient with metastatic cancer. We have to do better. Please keep me up to date as you resolve the issue.

In just a few days, I received the following response.

An update on the venous access situation. The working group consisting of the individuals listed below has met. Amy G. is investigating the best way to create a flag in BIDMC systems for those patients who are "difficult sticks", with the accompanying ability to unflag (many patients change vein status as their health conditions change). Once the flag system is functional, clinicians will be trained on how to generate flags for these patients in the system. Amy is also investigating how to provide an electronic dashboard to the Venous Access nurses, so that they know every morning where and when flagged patients have appointments during the day so as to be available when needed. Currently there is a white board/paper/phone based system which doesn't enable proactivity.

As these capabilities come on line, Barbara C. will work on scheduling her team for on-time availability, Donna H.will train Radiology schedulers on the new process to follow when scheduling flagged patients, and training will be deployed to insure that the nurses know how and when to flag and de-flag appropriate patients. No doubt there will be additional actions required as these changes are implemented.

While these improvements are underway, heme onc and radiology will continue their current process for managing patients with difficult veins:
1) When any patient requests the special IV team to insert an IV, the Venous Access Team is called. No one else attempts to insert the IV.
2) Some "frequent flyer" patients are known by the nurses and techs to be difficult sticks and special assistance from the Radiology nurse or Venous Access Team is initiated. The tech will call for Radiology nurse or IV nurse assistance as needed. Right now they can't be flagged ahead of time, so there can be a wait for nurse assistance.
2) For patients who do not make a special request, and for whom there is a reasonable expectation that insertion will be successful, the radiology tech will attempt to insert an IV once. If it is unsuccessful, the tech will determine whether an IV nurse is needed or whether a second attempt is likely to be successful (most insertions are successful by the second attempt). If the 2nd attempt is unsuccessful, the tech will call for either a Radiology nurse who has advanced skills in difficult sticks or for an IV nurse to insert the IV.

I think you will agree that these are good responses, and our folks deserve credit for their quick action. But, thanks to the training I have received from people like IHI's Maureen Bisognano and Jim Conway and e-Patient Dave, I then proposed one additional step:

One more thought on this, which is excellent work.

Why not convene a small focus group of such patients and go through the suggested new process with them to see if they like it or have other suggestions? Wouldn't that be consistent with our attempt to be more patient centered and engage patients in our decision-making?

You see, compassionate care does not occur solely because there are well-intentioned clinicians. It has to result from thoughtfully designed work flows that avoid harm to patients -- work flows that are not dependent on patients' self-advocacy when they are in vulnerable settings.

To do it right, though, compassionate care has to be designed with the help of the very patients we serve.

Try as we might, there is no way to for us to see things through their eyes. We have to welcome them to be there to help guide us.

What did you say?

A good friend (and, full disclosure, cousin*) of mine, Benjamin Kanters, recently told me about work he and others are doing to try to help musicians avoid hearing loss. I had not realized the extent of this problem, but it is a big deal, and the story has been around for a while. It is not just hard rock musicians. A quick web search, for example, turns up this paper:

A 1981 study at Sweden's Concert Hall and Lyric Theatre in Gothenberg revealed that 59 out of 139 orchestra musicians (42%) had hearing losses greater than that expected for their ages.

Here is another:

AFTER 40 years of being seated near the braying brass section in the Chicago Symphony Orchestra, first violinist Fred Spector was struck with a potentially career-ending occupational disability when he couldn't hear the violins on his left. The 71-year-old musician, who began playing at the age of 4, says over the telephone, "Believe it or not, I am having trouble hearing you."

And here is a more recent story:

Pete Townsend, the force behind The Who and 07 Tony award-winner for the Broadway adaptation of Townsend's rock opera, Tommy, has gone public about his hearing loss on several occasions. . . . Today, an older, wiser and deafer Townsend has worked to warn up-and-comers about the seriousness of sound-induced hearing loss. But its a tough sell to a demographic that believes its better to burn out than fade away.

My cousin has started an organization to spread the word and conducts workshops around the country on the topic. He was here in Boston recently presenting at a couple of the local music schools. Of course, he is not alone. The National Hearing Conservation Association comprises a diverse membership, all dedicated to the cause of promoting hearing health.

Meanwhile, too, there are equipment vendors who are making musicians' earplugs and in-ear monitors. I don't here endorse any, but here is one sample and here is another. By combining solid state circuitry with a custom-fitted ear plug, the sound distortion is reduced while providing protection to the delicate parts of the ear.

So whether you or your kids play in orchestras or rock groups, or are involved in recording them or managing their concerts, it is worthwhile to give some thought to protecting this sensitive part of the body.

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* I share no financial interests with this person. We don't even give each other birthday presents!

Studios Without Walls 2010

It is time for the annual Studios Without Walls art exhibit along the Muddy River in Boston. (You read about this here last year, too.) Here are two samples of the works. This is a great location, frequented by thousands of commuters and other walkers every day. The show will be up until June 13.

Dr. Epstein's summation

I offer the following video excerpt from Dr. Jonathan Epstein's talk yesterday. I promise it is worth your time.

If you cannot see the video, click here.

Hearing from two Dr. Epstein's

Dr. Frank Epstein (seen above in 1979), a former Chief of Medicine here, was beloved and respected. When he died, the Department of Medicine created a lecture series in his honor. The first Grand Rounds speaker yesterday was Jonathan Epstein, Frank's son (seen here with his dad!) Jonathan is Chairman of the Department of Cell and Developmental Biology at the University of Pennsylvania, where he is also Scientific Director of the Penn Cardiovascular Institute.

Dr. Epstein's lecture will appear in article form in the near future, so I don't want to steal his thunder. The main topic was congestive heart failure and the potential for new work in genetics that might be used to treat it. Today, treatment is generally based on interventions that improve the hemodynamics of the body, not treatment that helps the heart itself.

But the heart and soul of Jonathan's talk was about the relationship his father had with his patients and how that pattern of care could set an example for doctors in general. Dr. Epstein was known for taking the time necessary to get to know his patients, their family background, and other personal information that could assist in diagnosis and treatment. He realized that the most sophisticated tests and therapies were but tools in the total treatment of the patient, and that the doctor-patient relationship was all important. When a patient arrived late for an appointment and apologized, Frank said, "Don't worry, I have all the time in the world."

Jonathan's description reminded me of the speech given by Dr. Amy Ship a few months ago, which I again recommend. But then he elaborated on it by quoting a portion of his father's last grand rounds. Here's a similar quote from an article, "The Role of the Physician in the Preservation of Life." Q J Med 2007; 100:585–589.

We physicians belong to an ancient profession, standing apart from all others in its primary concern and respect for human life and its enmity to death. And in the long run, that attitude of the profession may be as important to society as any miracle that modern technical medicine can perform.

The fact is that for all our talk and our science, we do only a little. Life cannot be prolonged indefinitely, and death comes at last. But the little we can do has an importance that transcends the patient, for it carries a message to all our patients and to the world: Human beings are important.