Punishing sun and relentless regulations

The 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.

The view from Mountain View: No going back

When 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.

A fellow retiring physician: what are the odds?

It 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?

It 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.

On steering away from shore

The end of summer is approaching. Technically we have until September 22nd before the Autumnal Equinox. Practically speaking, on the coast of Maine summer ends in the middle of Labor Day weekend.

The town is quiet. Eighty percent of the summer jerks [Ed. note: aka “people” but I let it go. – Debbie] are gone. By Sunday another ten percent will depart. By Monday five more percent will depart and only the extended summer folk will be left. I am trying to become one of them.

Stonington’s Main Street has been packed for the last six weeks. Parking on both sides of the road has narrowed it to a single lane in many places. Tourists, treating it like a pedestrian mall, have further snarled traffic. The restaurants have been crowded for breakfast, lunch and dinner. Now there is room to spare and traffic flows smoothly.

The weather is cooler. The days are shorter. Autumn is in the air.

Trying out loneliness

I feel lonely. I want to try loneliness.

I have had the six summer weeks of my dreams including weeks of perfect weather, boating, sailing, island hopping, golf, birding and planning. Never before have I had so much of Maine. The previous pattern was one week here, two weeks there and fighting weekend plane traffic. It has been no more spectacular than before, and some memories have already been lost as the days blend together, but the absence of travel hassle has been wonderful.

Now we get serious, however, as we look into the future of beautiful autumn weeks with far fewer people to share them. This was part of the Gap Year plan; to test a quiet time; to step into another void.

Matinicus Island: 22 miles offshore

This week we cruised to Matinicus Island. It is described as a “godforsaken rock” by many. Indeed, it is a small community of lobstermen, their families and minimal support services, twenty-two miles off the mainland.

It was the first time that I personally steered my boat away from shore and to an invisible point out in the ocean. I was alone with Debbie. We looked toward the horizon. Nothing was there. [Were we looking at empty ocean all the way across the Atlantic? – Debbie] We had every advantage of modern nautical instruments that allowed us to “see” over the horizon so we knew, intellectually, the island was there.

Pointing to the unknown

Debbie and I have traveled beyond the horizon many times with others at the helm. But emotionally and metaphorically, this was a special moment. We were steering our own little boat into the unknown. The next morning, making our way back through pea soup fog it took no extra strength to sail home on instruments alone. We had already taken the big step of sailing away.

Of course, hundreds of thousands of people set sail over the horizon everyday, mostly for work, sometimes for pleasure. I will do so again, someday. It may seem like just another day to them. I suspect they remember their first turn off shore.

The total engagement of coastwise piloting

All of my personal boating has been coastwise piloting. This is the term for making one’s way from place to place around the shoreline. In Maine the coast is particularly unforgiving with granite ledges, spirited seas, tidal changes and ephemeral, often violent, weather. It takes the use of every sense (and supplementary technology: radar, plotter, depth sounder, radio) to do it safely.

It can totally engage, and in my case, satisfy the intellect. I had a random thought while returning by boat from dinner on another island last week. Monitoring the horizon, the compass, the radar and the seas I was completely “connected” in a way that social networking can’t replicate.

Today I toured the Sunbeam. She is a 75- foot vessel operated by the Maine Sea Coast Mission that supplies medical, spiritual, economic and youth development programs to the Maine island communities, including Matinicus. The captain and crewmembers were a pleasure to meet. I am jealous of the never-ending wonder of the ever-changing coast that they get to enjoy.

Looking for new safe harbors

As I poke my nose into health care issues both large and small around the Coast of Maine I am looking for a place to resume my life’s work. As I turn away from my former routine, indeed, as I turn from former shores and safe harbors, I am looking for new challenges and new safe havens.

I have just learned that I will never sail solo around the world. [When we were scanning the horizon for Matinicus, I believe I said I didn’t think we were destined to sail around the world together. – Debbie]

The challenge of coastwise piloting in a boat, or in life, suits me fine.

Do WFMCs (World Famous Medical Centers) offer the best care?

I recently learned that a cousin has been diagnosed with brain cancer. He is a few years younger than I am. It was a stunning revelation. My response to all things medical is generally muted. I have given bad news to hundreds of patients and been the first physician to recommend hospice care to dozens. Still, when cancer strikes within the family it reverberates.

I found myself telling family members, “Well, he will be cared for at the World Famous Medical Center (insert the WFMC of your choice: Dana Farber, Sloan-Kettering, MD Anderson) and that is the best we can hope for.”

And then I ask myself, how does one know? How does one know they have the right doctor or facility?

The simple answer is that one doesn’t know, but one can hope. It starts with trust in your primary care physician. It moves on from there.

WFMC and other acronyms

WFMC is an acronym used in the admission notes of interns and residents where, understandably, abbreviations abound. “This is the first WFMCA for this 75yo W LOL in NAD” is the initial line in scores of hand-written notes at tertiary medical centers across the country. Translated it says, “This is the first admission to this hospital for this 75-year-old white Little Old Lady in No Acute Distress.”

It means, with a  tone that is at once self-mocking and disparaging, that this woman has mild symptoms, probably evaluated elsewhere on several occasions and now she has been referred to the “Mecca” (a WFMC) for final assessment.

As an aside, I wonder how these abbreviations fare in the world of Electronic Medical Records. Although free texting exists in EMRs there are also a lot of check boxes, pre-populated phrases, and cut/paste opportunities. I digress.

The point is there is an appropriate suggestion of cynicism in the use of WFMC as well as a little pride.

Keep in mind that WFMCs are giant institutions with giant PR machines that promise hope and brag about their US News & World Report rankings.

What you can expect from a WFMC

I have had plenty of experience with WFMCs. In my opinion the physicians are generally not exceptional and the care is less than extraordinary. The physicians tend to be very intellectually engaged and offer wild diagnostic possibilities. But their diagnoses are no more accurate, nor does their treatment offer better results.

My opinion has been formed over decades, however, and currently the national movements to monitor patient satisfaction, quality and outcomes as mandated by the Joint Commission and the CMS, are making these institutions perform as well as their PR machines have claimed in the past.

I have frequently used WFMCs to supply a third opinion about a patient who has a symptom that is not diagnosable. When a group of MDs at the Mecca fails to find a cause for the complaint, it reinforces to the patient that their care has been adequate to date. Sometimes I have sent the patient with a cynical agenda on my part because I believe he or she is malingering, and sometimes because I am truly worried that I could not find the answer to a real problem.

Even in the hallowed halls of a WFMC you should remain alert and skeptical. There are many stories to tell but here is one that is most informative.

When a WFMC surgeon was wrong

Years ago, one of my favorite elderly relatives called with an intermittent and severe GI symptom. Her primary care physician started standard treatment for diagnosis X. After our phone interview it was clear that simple X was not the diagnosis and Y was quite likely. If the tests I outlined were conclusive and Y was confirmed then surgery would be the treatment.

Y was confirmed and after consulting with several surgeons my relative sought the opinion of the chief of surgery at a WFMC a few hours from home. The surgeon outlined the surgical options and described the risks and benefits of doing it laparoscopically versus by open surgery. He opined that the procedure MUST be done open and that ONLY he could get the promised results.

My relative called to report. It became clear that the surgeon was self-important, older, uncomfortable with the new laparoscopic technology and unable to admit it. His advice was unconscionable and at a minimum he should have brought a laparoscopical surgeon into the room to present their results.

I advised my relative never to see him again. Another surgeon performed the procedure laparoscopically and the results were immediately effective. Long term I have heard no complaints.

Questions to ask a WFMC

This experience highlights some issues with WFMCs. They are institutions with the associated inertia. Here is an older, past-his-prime, physician. He is “revered” by some and his reputation masks his current failings. The other surgeons know that his laparoscopic skills are inadequate and that his recommendations are old-fashioned but they are unable to unseat him.

Inertia can be good or bad. Do not put yourself on the “bleeding” edge of new technology without deep thought. Equally important, do not ignore advances in technology. Finally, examine the ego of the physician and the collective self-importance of the institution. If the physician says, “Only I can do this well,” then you are probably in the wrong office. If the institution’s PR machine makes promises that sound too good, they probably are.

So what about my cousin, his brain cancer, and the WFMC? Most of what I have written pertains but hard-to-treat cancer is a special case. A team of physicians will be involved here so no single ego is likely to pull them off course. The early phases of brain cancer therapy are fairly well regimented across large institutions so “pie in the sky” promises will not be made. Yet, because of the WFMC research, clinical trials will be available to consider at some point in the future.

For my cousin the WFMC is the place to start. My hopes are with him.

[Ed. note: when I chose the MD Anderson logo to illustrate this post, Sam pointed out that “eradicating” cancer is what the WFMCs and their PR machines promise – and it is a promise they cannot keep. That makes him angry. – Debbie]

Bombast, swagger and lobster boats

It’s 0530h. West Penobscot Bay is throbbing with the sound of diesel motors, thousands of horsepower under the decks of hundreds of lobster boats. The sun has been up for twenty minutes. By now, many of the lobstermen have been hauling traps for two hours.

I have an appointment to take the gasman to the island to fix the stove’s thermostat. [Ed note: it is wildly out of whack, resulting in charred brownies and other disasters. – Debbie] He better bring the right fittings; it’s a long way back to his truck on the mainland. He is taciturn and a man of few words even when pushed into conversation.

Self-absorbed bombastic bloviators

Occasionally I will meet a self-absorbed, bombastic bloviater (SABB) here in Maine. You know the kind of person. It’s usually a guy, very confident and always very opinionated. They control every conversation and always have the last word. If you meet such a person in Maine, they are usually from “away.” Because they are from away they are usually on vacation and if they can afford to be here on vacation they are usually “successful.”

Such behavior is more common in the big cities which, in my experience, means New York or DC. How it leads to success is what I do not understand. Bombast leads to lack of communication and poor communication leads to failure. Yet, SABBs survive.

Defining the SABB syndrome

Let me further define this SABB syndrome. I do not mean an ignoramus. I do not mean someone who is simply verbose and pompous. I mean a person who dominates a conversation, finds themselves on the wrong side of the facts and then is unable to accept that. Finally, by the end of the exchange, they are still trying to convince me they are right; i.e. that black is white. Or, they may use a technicality to change their position while never acknowledging that they were wrong.

They not only survive, they thrive in the world of business and politics. There is an old expression, “Close only counts in horse shoes and hand grenades.” But it must be good enough in a lot of business dealings to make money. “Close” does not count in medicine. In medicine you have to get it right.

SABBs in the operating room

Of course bombastic bluffers do exist in medical practice. They are frequently marginalized, but not always. If I was asked to see a patient by a newly-acquainted physician and I found the doctor overbearing, I would finish my consult and treatment plan and that would be the last elective consult I accepted from them.

More importantly, the SABB personality is frequently associated with or confused with the surgical personality. “Frequently wrong but never in doubt” is an old saw applied to surgeons. In fact, surgeons may never be in doubt but a good surgeon is well trained and rarely wrong. They have to make hundreds of intraoperative decisions that both the patient and the physician must live with forever.

When the SABB-like personality appears in the operating room or on the wards it plays out as a physician dressing down a subordinate physician or a nurse. This used to be considered a part of the natural order of things in a hospital. “The doctor is always right.” Things have to be done their way. But as patient safety studies gained traction in the ‘80s and ‘90s it became apparent that these abusive physicians were, in fact, responsible for treatment errors and because of their poor communication skills were associated with a disproportionate percentage of the malpractice cases.

The euphemism applied to this  kind of behavior is “disruptive physician” and it is equally represented among male and female physicians. Medical staff leaders monitor such behavior at the peer review level and correct it or rescind privileges. The less obvious cases are hard to define and lead to lots of friction among the medical staff. Because of the important association of this disruptive behavior with medical mistakes, it must be eliminated.

Why is SABB behavior tolerated?

Does this happen in the corporate boardroom? I do not know personally but I am confident that it does. The threshold for culling someone from the organization, however, would be quite different. If they produce, if they make money, if they are “successful.” I suspect more SABB behavior is tolerated.

I wonder if health care systems should not require personality profiles before hiring physicians. It is easier to withhold a position than to withdraw it. Most of these disruptive physicians can be identified in advance. Some malpractice insurance companies have started this practice and do not offer policies to the SABB physician.

I am no longer in practice. My peer review responsibilities are shrinking. I have never been corporate. Now I only experience SABB behavior at social events where it is irritating but inconsequential. Maybe that is why I let it get under my skin.

Or maybe I wish I had a little more chutzpa myself, more self-confidence untempered by decades of behavior moderated for a professional medical setting. I admit that achieving a bit more self-expression is a Gap Year goal. Leaving the World Domination Summit I did affect a bit of a swagger.

Or maybe I wish I were out on a lobster boat where the organizational chart consists of one captain and one crewmember.

*Image credit: Guy Biechele / Flickr

Gap Year metrics: how to fit it all in

Andy*, this one is for you, but you have to read to the end to get the rant.

It has been about two weeks since I returned to Maine from visiting my father in Milwaukee. This is peak summer vacation time and, indeed, that is what I have used it for.

A Gap Year principle that I am passing along is: do not over schedule; you will fail. That’s especially important when your body clock says “Maine! Vacation!”

As I have said before, if I could practice medicine, run the business of a private practice, serve on non-compensating boards and committees, maintain a family life as well as a Washington social life AND… write a book, reform health care and plan exotic trips, then I would not need a Gap Year.

But I cannot do all those things and so I need a break in August.

Reminder: why a Gap Year

Now that I have the time to enjoy an extended family visit in my favorite place on the planet, I still do not have the mental energy or strength to pay my day-to-day bills, play golf, sail, repair motor boats, babysit for two toddlers, prepare fresh seafood for island guests and in-laws AND research health care reform, research French lessons, research exotic travel (safe, yet outside the “tourist bubble”) and think about job opportunities for next year.

Something has got to go.

I have to remind myself that when I first began this year I knew that June would be a month of transition, July would be a combination of events and projects (finish the guest house, go to the World Domination Summit, visit my father) and August would be spent trying to have an extended summer vacation without the time pressure of past visits.

Measuring the perfect eight-hour day

The lesson I have learned is that while I had hoped to plan and research my Gap Year projects simultaneously, that is not going to happen.

My dream of a structured eight-hour day of research reading, personal growth reading, exercise, writing (touchy-feely blog posts, health care rants, personal notes), French exercises, etc. has not worked. I am unsettled over the fact that I cannot do it all and cannot decide what to do first.

Therefore, I am letting my grand plans wait a few more days until my grandbaby toddlers decamp and I can dial down in-law visits. Then, I promise I will get my schedule set and Debbie and I will start and end each day with briefings, progress reports and a review of Gap Year “metrics.” [Ed note: looking forward to this. – Debbie]

And now… a rant about healthcare metrics

Ok, let me rant about metrics for a minute. Does your business have metrics? Is it ruled by metrics? Do they work?

I suppose metrics have a role in terms of dollars and cents, time sensitive production issues and quality control of widgets. They may even have some role in the management of hospital systems and medical care.

I will grant that keeping the “post sternotomy blood sugar below 200 mg/dl” is associated with better outcomes and fewer wound infections (I’ll bet most of you don’t know what that means and never thought it would be measured) and is a laudable goal.

But is it a metric we should pursue? Everything can be turned into a metric. Should we do so?

Our rankings have slipped; what metric shall we improve?

I remember well a quality committee meeting at a WFMC (World Famous Medical Center, to the uninitiated) where the business people outnumbered the health care providers.

Three issues come up over the course of an hour. These were how many patients were dying of septic shock per month; how many patients dying of septic shock should be or were palliative care patients; and how much time elapsed between the first symptoms of septic shock, its diagnosis and the initiation of treatment.

Because of the high mortality of septic shock patients at this WFMC, its standings in the U.S. News and World Report rankings had slipped and the bean counters wanted to improve these metrics.

Conflating improved patient care with improved metrics

Suddenly these issues were conflated into a single management tool. It was proposed that a Septic Shock Rapid Response team could be created and the time from notification to treatment could be monitored.

Recognizing that much of the delay in treatment (and therefore the success of treatment) could be attributed to family discussions about appropriate care in a palliative care situation, it was proposed that diagnosis and treatment be instituted before a definitive family decision.

Well, if you have not seen the initiation of a septic shock work up you do not want to see one now. And, if you have you would not wish it on a family member in or near a palliative care status. It is brutal.

Fortunately, reason prevailed, at least briefly, and the metric managers looked elsewhere for something to monitor.

Patients are not widgets

People are not widgets. ER throughput of patients (another metric) should not be about filling beds to make more money but should be about getting the patient to the appropriate care level in the appropriate time period (a judgment, not a metric).

I am going to play golf, but I am so angry thinking about metrics that I am not going to keep score.

[Ed note: thanks to cousin Andy for being a loyal reader of this blog. As for golf, Sam reported back that he was six over par after six holes. Then he quit. – Debbie]

Life on an island: an annual hard reset

There is nothing like your own island.

It’s a private island but we’re not talking Richard Branson’s Necker. We have spent the last week on a single-family eight-acre island off the coast of Maine. In other words, it’s a piece of property that happens to have water around it.

We timeshare it with other family members. There are five rudimentary cabins. There is no electricity. There are gas lamps and gas refrigeration. There are three flush toilets and three buckets. There is running water in two of the five cabins.

We have spent several of the nights alone and several with friends.

An island is a hard reset for your brain

I say again, there is nothing like your own island. An island evokes a kaleidoscope of feelings that is so reproducible from year to year that it acts on the brain like a hard reset on the computer. There are feelings of isolation, power, exceptional independence, safety, danger, vulnerability, and (curiously) a primitive eroticism.

As I look at the sunrise across the water I feel the protective moat that surrounds me and buffers me from the world of high society and health systems. I feel the wonder of disconnection. I am the master of my domain. It is a geographic domain, not a social or business domain, and that geography feeds a primeval sense of self.

An island’s physical and emotional challenges

An island is a physical challenge. It requires loading and unloading – like cruising on a boat but raised to an exponential power. Everything to be used on an island (and I mean everything, including firewood, drinking water, food, propane gas, clothes, laundry, construction materials, repair equipment, replacement parts) has to be carried from the mainland onto the boat and then off the boat for distribution to the various cabins or project sites on the island.

Later, the process has to be reversed. Everything has to be collected, carried down the dock, transferred to the boat, transported to the mainland, transferred to the town dock, up the ramp and distributed to the waiting automobiles, homes, trash dumps and other destinations.

This is physically strenuous work. Because the cabins are sited on hills and along root strewn pathways significant climbing is involved. The main cabin is sited thirty feet above high tide. That means the ramp is a stiff climb up if it’s low tide. [Ed note: one of the pleasures of Maine are the 10-foot tides.]

An island is an emotional challenge. Although the mind can be occupied for a good deal of the day with the details of coordinating meals, repairs, and everyday logistics it is always possible to lean back and let feelings of peacefulness, aloneness, power of domain, isolation, and vulnerability sweep over you. Although the power of one’s personal domain is inspiring, to look across the bay and see a storm line build is a reality check of unequaled dimensions.

I prefer life on a small scale

I have always preferred to live life on a small scale.

I wanted to practice community medicine and never had designs on leadership positions or an academic career. I never wanted to be on the “bleeding edge” of new technology.

I enjoyed caring for Washington celebrities, socialites, ambassadors and cabinet secretaries but I did not seek them out. I preferred a few friends to a complicated social life.

I enjoyed the public golf course and preferred a pub with a “heavy pour” to a country club or social club.

Maine, a low-density state, is small scale and this island is the smallest scale possible. I am not a hermit and I do not want to stay here forever, but now is my chance to learn how long I can enjoy it.

The puzzle of turning vacation days into “real life”

When we started my Gap Year we planned to spend the first few months doing for weeks what we used to do for days. [Ed note: hat tip to my favorite Uncle Bobby’s naughty variation on this phrase.  – Debbie] We planned on turning our vacation days into our “real life.”

At first, that plan seemed to lack imagination, both when describing it to others and while living it ourselves. But now it feels right.

At first I was disappointed that the extra time did not lead to an explosive personality change and the inspiration to take on giant new challenges. Now it is ok.

Embracing my old, small world feels right. Enjoying it now without time and schedule constraints is right. Our plan is a good one. By finding our old selves we will learn to find our new selves and expand our horizons.

There is nothing like your own island to help you see your horizon.

Embracing a new sense of time: slow but luxurious

I recently returned from another week with my 92-year-old father. It was very pleasant and very quiet. The humidifier hums. The doors creak. The clocks tick. There is the occasional chime of the doorbell.

His world is shrinking around him and he knows it. It is hard to watch. It is frustrating. But people learn to put up with a lot of limitations. Life seems lesser and yet… it remains the life we have.

Time moves slowly in my father’s apartment

Time moves slowly in his apartment. He has so much time but is physically unable to use it. He suffers from fatigue that limits his physical abilities, including the ability to read extensively as he used to. He can think clearly but he rests most of the day to marshal his strength. His mind is strong but his limited reading limits its expansion.

Time stood still for me for that week. I never had so much time. It was a great luxury to be with him – and also a burden to bear.

Of course, time is not a luxury available to the primary care physician. There is never enough of it. One goal of my Gap Year is to embrace that new luxury and experiment with it.

My first opportunity occurred on the flight out to his Midwest City when storms over Detroit diverted all flights and created a five-hour delay. Uncharacteristically, I was completely relaxed.

For the first time, a travel delay didn’t matter

Traveling alone and without a critical agenda, with a weeklong visit ahead, what did a delay or even an overnight stay short of my destination really matter?

While I was practicing medicine, every day off was precious and every trip a surgical strike. To lose a day to a travel delay on the outbound phase was to lose a day of vacation, of well-planned time off, of valuable relaxation or of time with an elderly relative (my dad, for example) whom I didn’t see enough. To lose a day on the return threatened my colonoscopy schedule.

Knowing that patients were starting their colonoscopy preps the day before their exams while I was returning from a trip, shuffling through the boarding gate with boarding pass in hand, was a time of real tension for me.

If the flight was delayed or cancelled due to weather or a mechanical delay, could we make alternative plans to get home to DC in time? Should I call each patient and ask him or her to stop the prep and reschedule?

Some patients embraced the prep as a day of fasting and cleansing. Others stumbled through it without complaint. Some tried to squeeze it in around an otherwise jam-packed schedule of meetings and travel.

But most felt that the prep was a significant burden. It was disruptive, unpleasant and the worst part of the procedure. To finish the prep and to be told to reschedule was not an option for them. They would not do it twice in a five-year time frame.

When I was practicing, I couldn’t let my patients down

Alternatively, in the scenario where I failed to get back for the morning exams I could have asked my partner to cancel his schedule and take over my procedures. This was anathema to me. These patients had chosen me. They trusted me. They were purging for me.

They believed in my expertise and my touch. To let them be treated by someone else (even my own partner, who was equal or better than me) was impossible for me to consider. It would mean that I had an acceptable substitute.

This was unacceptable.

I have just described the balance of the personal versus the professional in living one’s life. As a former practitioner, the professional commitment can be all consuming. To complicate this balance I have inserted a third factor, physical ability or well-being.

My father is retired and, clearly, at age 92, has time to spare. But his physical condition has shrunk so that he has little left to fill his days. My professional commitment weighed heavily on me for decades, leaching time from my personal space. Now I have time.

The luxury of enjoying time AND good health

I have shed the responsibility that only a treating physician can shoulder. I miss that trust. I miss the sense of self-importance, inflated though it was.

But I am enjoying the carefree freedom of time while I am physically able and before age or disease slows me.