Punishing sun and relentless regulations

Google_blue_skyThe sun in Mountain View can be relentless. Although there were several overcast hours, the vast majority of the time the sky was a cloudless azure blue. The air was so dry I could feel the UV rays burning my skin.

I have a college reunion coming up in ten days. One of my classmates is a U.S. Senator. He has asked me (more likely, everyone in the class) to come to an election fundraiser at the end of our reunion weekend. He has promised to send the details by email on two separate occasions but they have yet to arrive. Are missives from the U.S. Senate rejected as spam?

From the U.S. Senate to Hospital Regulations

The fact that his staff has failed to contact me after either conversation is of no real consequence. I will get the details eventually and the Senator has been good enough to return my calls. What gets in my craw is HCAHPS. The first call from the Senator preceded a meeting I chaired at my hospital about patient satisfaction. The call back from the Senator followed that meeting. Both calls ended with the promise of an email with details. HCAHPS reared its ugly head.

HCAHPS (Hospital Consumer Assessment of Health Plans Survey) is a nationally standardized survey developed by CMS (Center for Medicare and Medicaid Services, the current name for the organization administering Medicare and Medicaid) that is used to rank hospitals against one another based on patient (“hospital consumer”) satisfaction.

The hospitals have a third party administer a survey on patient satisfaction and report these results to CMS. CMS then ranks the hospitals on a confusingly relative sliding scale and bases a small percentage of Medicare reimbursement on the hospitals’ relative ranking and its improvement, or deterioration, in the rankings as other hospitals rise or fall.

All hospitals are crowded into a small band based on absolute value of the results and then that band is expanded to place all hospitals within that band in a relative display. For example, if 100 similar community hospitals are being compared it is likely that all the hospitals will score between 75 and 89 on the absolute value satisfaction reports. Within that 14-point spread each hospital will be re-ranked relative to the others. So a hospital scoring 79 might have a ranking in the 25th percentile while one scoring 85 might be in the 75th percentile. To move between percentiles becomes increasingly difficult as all hospitals cluster toward the top of the absolute score.

CMS then uses the final percentile to either withhold one or two percent of the previously scheduled annual reimbursement for “poor” performance or to pay a similar bonus if the hospital moves up in the relative rankings.

Author’s disclaimer: If I have misrepresented the system it is either because the government has changed it since my last review of Sibley Hospital’s performance or I have oversimplified the process because only CMS troglodytes can understand it. No Defense Waived. – SPH

As you, good reader, can see, eventually all hospitals will be crowded into the 90-99 absolute satisfaction score range and then most of them will be punished for falling below some relative satisfaction scale.

Gaming the system and getting cheated in return

Curiously, I do not have a deep emotional reaction to the CMS program. I have developed a deep cynicism toward all aspects of the medical care financing process. I believe that most providers have been gaming the system too long and deserve to be cheated in return. What really causes me to have a visceral reaction to this process is the way that hospital administrators have embraced it.

In an ideal world, you might expect a coordinated response by the AMA and the AHA (American Hospital Association) to reject this law and, in an act of civil disobedience, to refuse to see any more Medicare patients. Instead, hospital administrators have turned to the medical, nursing and administrative staffs and told them: “Move us up in the rankings.” This madness has spawned whole new administrative offices that are devoted to patient satisfaction. At some institutions a new division has been added to the administrative flow chart, topped by a VP of Patient Experience.

Discussions about “teaching to the test” are everywhere and the whole process reduces physicians and nurses to the level of car salesmen and service representatives asking to be ranked 5 or “Always” on every question.

Of course patient satisfaction depends on multiple factors, many of them well beyond the immediate control of health care providers. The most important factors are environmental. Private rooms will always trump “semi-private” which means two patients to a room and no privacy whatsoever. The engineering of a hospital (nursing station locations, rugs, sound baffles, etc.) will either reduce noise or not and little can be done about that in a timely manner.

Other aspects of patient satisfaction are self-evident and should not require the governmental carrot and stick to implement. Administrators, if your staff (nursing, technical or janitorial) is impolite or surly, retrain them or dismiss them. Medical Staff President, if your physicians are uncooperative, disruptive or self-important, re-educate them or sanction them. But do not reduce your nurses to customer service satisfaction representatives. Or, in hospital jargon, “service recovery agents.”

The correct variables of patient satisfaction: safety and education

Patient satisfaction efforts should be focused on two things, patient safety and patient education. The common factor here is patient expectations. Teach patients about their disease, their medications, their treatments and what they can expect to happen and you will have improved the quality of their care and their satisfaction simultaneously.

There is no limit to what a physician can and should teach their patients and if your doctors will not embrace this concept get a new medical staff. Do not let your physicians be reduced to car salesmen, however. Medical care may be the most important service industry but its devoted health care providers should not be reduced to PR agents.

Back to the U.S. Senate

So what does this have to do with the United States Senate? If a doctor tells a patient that they will send an email or make a call with clinical information and if they do not follow through, that is a cause for dissatisfaction. It leads to anxiety for the patient and should result in a negative evaluation. Therefore I find it ironic that the institution that makes laws governing patient satisfaction will not govern itself with laws regarding electorate satisfaction.

The Northern California sun is relentless but no more punishing than the endless regulations applied to the health care system.

Advertisements

The view from Mountain View: No going back

Lius_Ba_Sept2013When we left the Coast of Maine a few days ago, the goal was to conflate a few disparate agenda items into a short trip. We needed to transport a few fragile items from our DC home back to Maine. The invitation to chair a board-level meeting at my hospital inspired us to revisit civilization, arrange the items for transport and take a non-stop to California to visit my son, daughter-in-law, and grandson. There are no direct flights to anywhere from Down East, Maine. So if you have to get in your car to take a flight you might as well get other things done, or vice versa.

The meeting I chaired went well and I hope will contribute to a small step forward in patient safety and education.

Subsequently, a lunch meeting I had with the former hospital CEO was very pleasant. It concluded with the observation that after a career dealing with systems he wanted to devote part of his retirement energy to helping one family at a time break out of the cycle of poverty. I represented the obverse. After a career helping one patient at a time, I have developed a desire to change the system.

Reflections from Mountain View

I am now writing and reflecting from Silicon Valley where my lawyer son is “secunded” to Google. It is great to see him in action and great to see my daughter-in-law thrive. Currently that is taking the distinctive form of an eight-month pregnant belly. It is the greatest to see my grandson; more about that later.

Silicon Valley is not what I expected but I have not yet seen it all. What I have seen is Mountain View. It is not much of a valley, having true mountains on only the west side.

I have been to San Francisco several times over the years, including side trips to Monterey and Napa Valley, and I am surprised at how like Southern California the architecture and the demographics are here.

Demographically, Maine is the poorest, whitest, and oldest state in the Union. Here the streets are alive with East Asians, South Asians, Central Americans and, if my appreciation of foreign languages is accurate, Eastern and Western Europeans. I suspect I will miss that diversity during the long winter months in Maine so my plan is to soak it up now.

From my modest hotel in a neighborhood of bungalows I have yet to see the evidence of conspicuous consumption that I suspect dot com money has inspired (unless you think that walking your dog at night with an illuminated collar is an unnecessary indulgence), but I am sure it is out there. I am advised that the bungalows go for a million dollars, or more.

The boulevards seem to be unnecessarily wide and every business along El Camino Real, whether thriving or shuttered, is surrounded by near-empty parking lots. Gun shops, massage parlors and beauty salons stand cheek-by-jowl with upscale day care centers. The commercial architecture favors one to three-story structures without eye appeal. It is hard to tell apartment complexes from hotels or brake-and-lube shops.

Although the ethnic diversity is appealing, the services it has inspired – particularly the restaurants – lack the sophistication of Brooklyn, another rationalization to soothe me during the long winter months in Stonington.

Hard to describe the excitement of Google

We toured Google this week with my son. The energy and excitement are hard to describe. The pleasant workspaces, reasonable hours and pro family attitudes make it an appealing workplace. Expectations are set high but with the added comforts of on campus carwashes, haircuts, oil changes, dry-cleaning, etc., employees are inspired to produce.

The best part of the trip was to be recognized by my grandson with whom I had not hugged for three months. It is heartwarming when that happens.

At age 22 months, his grasp of the English language resembles my grasp of French, a language with which I am trying to become reacquainted. We both understand more than we can articulate. We both suffer the occasional catastrophic misinterpretation, hearing and believing the opposite of what was intended. Even when we do understand perfectly there is a problem integrating and then synthesizing a response, resulting in a ten-second delay between instruction and action. Our pronunciation is tortured.

We both view the world with chronic perplexity.

He is great fun.

So where do these reflections take me?

News Flash from GYA60

If you do not have specific plans to go back to your old life, do not try to do so. Look forward.

GYA60 is neither a sabbatical nor a gap year between levels of higher education. Rather, it is a little of both and then some. A traditional sabbatical is underwritten by your place of employment with the understanding that you will recharge your brain cells and return to work re-inspired, re-energized and with improved efficiency. A traditional gap year is paid for, or at least subsidized by, your parents with the understanding that you will return to school re-energized and more mature and that you will apply yourself to your studies with renewed focus.

A Gap Year After Sixty is subsidized by your children…

GYA60 is paid for by your children (with money they will not inherit). The understanding is that you will recharge your batteries and return to the work force as a new person with different motivations. You have looked at your career to date and said, with satisfaction, “Been there, done that.” And gaining maturity has nothing to do with GYA60. Been there and done that, too. Revitalizing may require throwing off a layer of responsibility and maturity to let the inner you grow.

In planning my GYA60 I wanted to maintain contact with DC job prospects. I wanted to hold my options open. I wanted to shelter the possibility of returning to a semblance of my former career. After three months of reflection and active self-redefinition I am realizing there is no possibility of returning to my old work life. I will never be a full time clinician again. No time. No where.

No going back

So do not hedge your bets. Do not waste that time and energy. Change and then make change happen.

With each day forward I am a step further away from my old career. There is no going back.

Why I no longer lust after a job at Google

Google_DebbieI’m sitting in a bustling Peets cafe in Mountain View, CA, two miles from Google’s offices. Yesterday we had lunch at the main Google campus with our son, who is newly working there as a lawyer. The sky was blue. The temperature, in the low 70s, was perfect. The campus is marked by green lawns and lush planting, colorful Google signage, giant sculptures outside the Android building and, everywhere, Google bicycles with distinctive yellow frames and green wheels.

Inside each building are “mini kitchens” loaded with every kind of healthy (free) snack you can think of, from farm-fresh cherry tomatoes to crisp fall apples to artisan chocolates and lentil crackers. Oh, and of course, several espresso machines. The push-button kind in addition to a real espresso bar, where, our son explained, a barista sometimes shows up in the afternoons to pull shots.

Sounds pretty cool, doesn’t it? At one point, I would have described this as nirvana. How I longed to work in an environment like this.

But let me back up. I’ve been online since 1992 and, since the late 90s, have been enthralled with Silicon Valley and its tech startups. Although it was never realistic, given that I was ensconced in a life in DC to which Sam was tethered, I lusted after a job at Google. Or Facebook, or more recently, Twitter.

Google_T_and_momPushing the envelope, discovering or inventing the next new thing as it relates to the Web – and doing so in an atmosphere of daring and possibility – intoxicated me. I’m not an engineer but I pictured a job in Silicon Valley as a product manager or in marketing or business development. So I expected to feel more dazzled when I stepped foot onto Google’s famed campus.

I was fascinated, even delighted, but I didn’t feel pangs of longing or envy. Something has changed. I’ve moved on. It’s worth a moment of reflection because it also explains why I’m taking a Gap Year with Sam.

Permit me to scroll back to the time I lusted after a job at The New York Times. My first career was as a journalist and print reporter. I grew up outside New York City and regarded the Times as the pinnacle of newspaper journalism. I wanted, specifically, to be a Times foreign correspondent.

After getting a Masters in Journalism from the University of Wisconsin (where Sam earned his medical degree), I worked for The Atlanta Constitution. A reasonable enough stepping stone to the Times, but the logistics didn’t work. I was happily married to Sam and didn’t want to live apart, in a different country. Soon enough, I was the mother of three young children.

That desire and dream passed. The demise of newspaper journalism as a viable career, along with my incompatible life stage, snuffed it out. So be it. Life goes on.

Later, I went to business school to get an MBA. That’s when my Silicon Valley dream began to bloom. I did work briefly for Network Solutions, one of the original “dot com” companies. Headquartered in Herndon, VA, NetSol was about an hour’s commute from our home in DC. So the logistics were fine. The job was not.

I worked in marketing and was confined to a cubicle. My boss was a woman. She stole my ideas and took credit for them. She wouldn’t permit any flexibility in my working hours and had no understanding of my wider life as the mother of three young adults. How I hated her.

As the dot com bubble slowly burst, so did my enchantment with working for a big company. I can remember my visceral desire for a corporate business card that would identify me as a Director or Assistant Vice President (as opposed to the more lowly, Manager). How ridiculous.

My longing to rise through a corporate hierarchy faded. In fact, I began to relish the idea of working outside the system and creating my own business. That’s what I’ve been doing for the past decade as a creative entrepreneur. And it suits me fine. I’m not corporate. I don’t like rules.

Google, for the record, is a very big company. Through our son, I’ve gotten a glimpse of its eccentric corporate culture. There are no “rules” per se. Employees can come and go as they please and you see them everywhere, nonchalantly bicycling to lunch or a meeting. The only rule, it seems, is that good will and good sense should prevail. You can schedule a 30-minute rest in a nap pod anytime you wish. But presumably you won’t nap all day.

As far as the next new thing, there has been an industry shift as well. The changes in what’s new are incremental these days (if you leave out Google glass). Who cares if Facebook changes its algorithms? Or if Google changes the Gmail interface? (Frankly, it’s annoying.) The cool factor is still there but it’s not as insistent.

Of course, many new things are on the horizon as far as real change. The Internet of Things is fast becoming a reality (a car that talks to you when it needs an oil change or a Siri-like presence inside your smartphone that is more predictive and helpful).

Still, I must admit that a part of me has been waiting for something new and shiny to drop from the skies during our Gap Year. Some boltning light of insight about what my work should look like in the next decade. Or how Sam and I will carve out a uniquely flexible, yet still productive, life. It hasn’t come to me yet.

I’m starting to feel more comfortable with that.

A fellow retiring physician: what are the odds?

BarbieIt was one in a million. Debbie and I were furling the sail on my son-in-law’s 22-foot sailboat after a short sunset cruise in Stonington harbor. The fishermen were in for the day. The wind was dying down. The water was calm.

We were exulting in a flawless trip. The outboard worked as designed. The knots held. No halyards snarled. We took the mooring in a single try. As sailors we are not adventurous. We take pride in the small victories over the wind and waves. We do not heel.

I noticed a sharp-looking Avon skiff approach with a pair of well-dressed travelers. Matching aviator sunglasses, clean fleece tops and pressed blue jeans. Not locals, yet most summer folk are gone and there is only the occasional yacht passing through.

I was wearing my full AARP; a Tilley hat, Cocoon sunglasses and Keen boat shoes. I looked like a pervert. Debbie was also dressed for the elements and, therefore, unrecognizable but her female presence legitimized my appearance enough to allow a stranger to approach. The female of the couple called out, “Which is the town dock? Please.”

I responded, “Barbie…..? Barbie!!”

It was Barbara. Barbie was my college classmate as well as an occasional college roommate of Debbie’s. We had not seen her for years. My instant recognition was based on her voice, her movement and her silhouette. It was not based on a true visual identification.

We reconnoitered on shore and after sharing a brief overview of our recent past we learned that she and her husband, both physicians, had retired and had been living on their 44-foot sailboat for 15 months. Their travels to and from the Caribbean made our sailing excursions seem small but the shared excitement of the moment overwhelmed this self-deflating perception.

Stunned at Barbie’s retirement

Barbie expressed no surprise at my Gap Year announcement. She seemed completely understanding. I, however, was stunned that she had retired. She was the most energetic and committed physician that I can conjure up. She had an academic/research/clinical career as a hematologist and during past meetings was bubbling about her students, her fellows and her patients.

Although her retirement decision was clearly multifactorial I did pick up on comments that resonated with me. “I just got tired of documenting every 15-minute patient interaction for their insurance companies,” she said, off handedly. I could sympathize with that.

She also noted that her career was not going to become more rewarding. I know she had established a great reputation, she had contributed to the literature in her field, she had saved patients and she had done lots of good.

What I heard her telling me was that the rewarding aspects of her distinguished career were being squeezed out by the unrewarding requirements of more documentation, more metrics to observe, less face-to-face time with patients and less appreciation as measured by salary or patient gratitude.

Finally we also shared the philosophical perspective that many physicians, and others, acquire as we observe the deterioration of our patients, friends and family. Disease and disability come to us all. We do not know when it will arrive or what form it will take but it happens with more frequency as we age. If we want to take advantage of our health to do something other than practice medicine we have to make our own calculation and seize the moment.

Great physicians are looking elsewhere for satisfaction

I suppose it seemed like a “One in a million, Doc” moment [Ed note: obscure Seinfeld reference – Debbie] when Barbie’s boat neared ours, but that is not the point of this blog folly.

What I am trying to say is that medicine has changed so much during my generation that the personal sense of pride, accomplishment, appreciation, service, humanity, communication, human interaction and compassion has been so diminished by the institutionalization and dehumanization of metrics, technology, documentation and production pressures that many great physicians look elsewhere for satisfaction. .

If one of my peers had asked me: “What are the chances Barbie will take early retirement?” I would have replied, “One in a million.”

Addendum: gone is the intoxicating pleasure of being in charge

The next generation of physicians was born computer literate and is unaware of the difficulties of the transition from paper to EMR (Electronic Medical Records). They are also unfamiliar with the practice of medicine with fewer third-party overseers, regulators, and a wall of technology between patient and physician. They are members of teams of providers and are not likely to know the intoxicating pleasure of being completely in charge.

The transition from the minimal documentation of the generation before me to the EMR has been quite a struggle. I remember consulting on a terminally ill patient, with constipation versus partial bowel obstruction, 30 years ago.

Doctors don’t get paid for “The last chapter”

The primary care physician spent a long time with the patient and family counseling them on the decline and the expectations they should have for the last few days of her life. I joined in for a bit of edification. His final note for the day read, “The last chapter.”

Woefully inadequate for this day and age, and documenting nothing except his palliative care orders, this physician could not be reimbursed for anything now. Yet he did his duty then; I saw him do it.

I also remember the handwriting police. I was one of them and also the occasional offender. I never understood how some doctors took pride in their illegible notes that could lead to medical errors.

The EMR will solve the documentation issues of “date and time.” It will replace the frustration of multiple signatures with the frustration of multiple log-ins. It will allow the creation of notes that satisfy the regulators and payers and it will do it with reams of information created by pre-population, cut and paste, and endless templates. It will not make the care of patients better.

Summer is over: what comes next?

Fog_flickrIt is Sunday, September 1st. It is early morning. The lobstermen are not fishing. The summer people have left. The fog is thick. The air is heavy. It is hours before the local church bells ring. The locally-ground 44 North Sumatra coffee is dripping. The quietude is total.

The pleasures of not commuting

It is the first day of the second quarter of my Gap Year. I have summered in Maine. I have not traveled to and from DC attempting to steal a weekend here or a fortnight there. I have not suffered the indignities of the TSA or the vagaries of East Coast weather and associated flight delays.

Rather, I have basked in my time here. I have not tried to cram a sail or a motorboat cruise or a golf game or a bike ride into limited available hours. I have let the time roll over me and the activities happen. It has been blissful and now it is quiet.

Admittedly, the days have blurred together. This is in part the result of better-than-average weather so that good stretches are not defined by bad stretches. It’s also because there is danger in the luxury of time. The best times are not separated and highlighted by downtime. The special activities segue from one to another and in doing so lose a bit of what makes them special.

I have felt that. I have not felt the stress of travel. I have enjoyed myself being self-indulgent. I have started some new projects. I am ready for more commitment.

End of summer signals absence

But this morning it is quiet. The roads are empty. The exercise walkers are absent. Only the locals are about. I expect to see Doug, my neighbor, and his rescue dog, Rosie, cut across my yard and then the yard of the Catholic church adjacent to our house. It is a shortcut from his house to the road. The shortcut predates our arrival here in Stonington. It is understood that the shortcut belongs to the locals.

The challenges of the next quarter of GYA60 loom. We must start our French studies before leaving for Paris in November. I must resume my short book project. [Ed. note: Sam hasn’t shared it with me. I’m looking forward to seeing what he has written. – Debbie]

Making new plans

We must cement our travel plans to Europe to benefit from early booking. We must deal with fewer options for entertainment along with fewer friends, family and recreational activities. We must embrace the bigger spaces between diversions. We must include time for household maintenance, more home cooking, more self-improvement, more meditation and more exercise.  We must organize our time better.

We must cope with being alone, together. I am ready to try this. [Good to hear. Me too. – Debbie]

Will quiet mean lonely?

It is so quiet now. Is it just the physical absence of people? Is it loneliness setting in after one day? Is it because so many people who treasure this place during the summer do not want to try to make a life here during the winter? Do I feel down because they are rejecting what I want?

Obviously, the practicalities of a life elsewhere draw them back, just as Debbie and I returned to Washington for three decades to work and to educate our children. The reason I am seriously pondering a move to a small town on the coast of Maine is because I have fewer, if any, obligations to pull me elsewhere.

What is the draw of our old neighborhood?

Why do people want to live in DC’s upscale Georgetown? Why is it so crowded? Why does it seem exciting? Is it because of the quaint architecture and brick sidewalks? Is it because of the faint smell of history? No, not really. It is because of desire.

It is exciting because it is crowded. It is crowded because people want to see and be seen. Those who can afford to, want to live there so that they can feel rewarded by the sense of superiority associated with living in a place that others desire. Radix malorum cupiditas est.

[Ed. note: I’m leaving the Latin in because Sam will protest if I take it out. But I don’t think “feeling superior” is the reason I love Georgetown. It has many charms. – Debbie]

For me, I have been there and done that. I expect the only thing I will miss in Georgetown is my local tavern with its “heavy pour” and its clubby bar clientele. [Ed. note: And a few special friends – Debbie] I do not know for sure whether I can leave all this behind. I have to try it. I have to try life with less desire and less external stimulation.

[Ed. intrusion: and I want to try a life where there is less stimulation to “buy.” So far, I spend much less money in Stonington. More about money later. – Debbie]

We are embracing serendipity

One Gap Year lesson I have stumbled on is to embrace serendipity. We have not over-planned or over-scheduled, we have only roughed out blocks of time and ideas. We had the luxury of three months of self-indulgence to start with. During that time much has occurred by serendipity.

I met a state politician with whom I might work on health care policy and reform. Socially, we met a resident of Paris who manages a professional language school and who will connect us with the right tutors and guides. We met a friend of a friend who has a non-profit educational program in Uganda and who will sign us up to work there next winter. We also met a friend of a friend who has traveled to Madagascar and will help with reliable contacts to plan a trip.

All this simply by talking and chatting and letting our contacts extend themselves. People really want to help people change, grow, shed the commonplace and divest themselves of their former routine.

Share your dream and people will help. Serendipity happens.

Next week we return to DC for some business meetings, doctors’ appointments, housekeeping chores and some catching up. The trip will test our resolve to return to Stonington for a quieter life. I hope I will remain true to my new refrain, “Away happens.”

Right now the only sound is the drip of fog from the trees.

[Ed. note: “away happens” means the undesirable necessity of leaving Stonington and Deer Isle for mainland resources such as healthcare. – Debbie]

Photo credit: Design Development (Flickr) Aerial view of the Deer Island Thorofare.