20 March 2015
Dear Interested Readers,
This Week’s Letter
After some introductory remarks about the fifth anniversary of the ACA, today’s letter contains a description of my positive experience last week at the Advisory Council of the Health Policy Commission of Massachusetts. The last section is a piece of a story that I wrote in 2001. Like looking at old photographs, I now wonder who was that fellow that once was me. There are lessons to be learned from the past.
Spring and Other Big Dates This Week
If you are reading this week’s letter after 6:45 PM on Friday March 20th, it’s spring! The vernal equinox has arrived but in reality we continue to live in expectation. Theoretically the day is an even 12 hours of light balancing 12 hours of darkness. Vernal is Latin for spring and the word has always been associated in my mind with green because things are green in spring or perhaps because Vermont is the “Green Mountain State”. As I look out of my window I can only dream of green and spring because what I still see is white and winter. The tune still playing in my head sounds more like the mournful “In The Deep Midwinter” than “Good Day Sunshine”.
In the bleak midwinter, frosty wind made moan,
Earth stood hard as iron, water like a stone
Snow had fallen, snow on snow, snow on snow...
Today is also “Match Day” 2015. The long process that will determine where about 18,000 senior medical students will spend the next several years of their lives came to a close with the release of the “matches” at 1 PM. I can well remember the day I “matched” back in 1971 and I am absolutely certain that many an “Interested Reader” can recall a similar experience. Like spring, the match announcements are about events that will happen a little way into the future.
Another big date on the near horizon is the fifth anniversary of the signing of the Affordable Care Act. Barack Obama used 22 pens on March 23, 2010 to sign the most important piece of social legislation so far in this young century. If you have about seven minutes, you can hear Joe Biden’s introduction of the President at the signing. Biden’s speech is pretty laudatory and positive but he does not overstate the significance of the President’s accomplishments where others have failed and the historic nature of the legislation. His remarks have become famous because at the end of his speech he leaned into the President’s ear and said, “Mr. President, this is a big [expletive] deal…”
http://www.nytimes.com/video/health/policy/1247467430190/biden-s-remarks-at-health-bill-signing.html?action=click&contentCollection=Money %26 Policy&module=RelatedCoverage®ion=Marginalia&pgtype=article
The New York Times article the next day put the event and the challenge ahead in perspective because it also presented the mindset of the Republican leadership on that day that persists to this day.
“This is a somber day for the American people,” said Representative John A. Boehner, the House Republican leader. “By signing this bill, President Obama is abandoning our founding principle that government governs best when it governs closest to the people.”
A few sentences later we get their focused objective that persists to this day, “Repeal and replace”.
http://www.nytimes.com/2010/03/24/health/policy/24health.html
Five years ago it would have been almost impossible to imagine the persistent resistance that the ACA would experience despite a reelection of the President and the victory over the challenge heard in the Supreme Court two years later. This week there have been reviews of the many positive accomplishments of the last five years despite the fact that many states continue to resist the expansion Medicaid. Amid the high points of the accomplishments there are memories of the disastrous website performance during the rollout of the exchanges. Even as we look at the success, King v. Burwell has been heard in Supreme Court and it is impossible to know which way one or two of the conservative justices will come down in that decision or what the end result of a ruling for King would mean to all that has been accomplished. Yes Joe, it was a big deal and it remains a big, important deal.
Last weekend I was surprised by an email reminding me of the meeting of the Advisory Council of the Health Policy Commission created by Chapter 224 in 2012. I had submitted my resignation after moving to New Hampshire but it had not been acknowledged. The first meeting of 2015 was a victim of a snowstorm. I responded to the email last week by saying that I would not be at the meeting because I had resigned. I was surprised by the response to my note: “...you are welcome to stay on the Advisory Council regardless of residency. We want and welcome your perspective and experience for as long as you are willing…”.
Wednesday I arrived early and eager to participate as a member of the Advisory Council in the business of the Health Policy Commission. The agenda was focused on the work accomplished by the HPC in 2014 and the objectives for 2015. As I listened to the reports and participated in the dialog it crossed my mind that no matter the fate of the ACA in King v. Burwell and no matter who won the elections in 2016 some things had changed forever.
The language of the council included phrases like “the Triple Aim”, total cost of care and readmission rates that had all evolved as part of our collective vocabulary and concerns since the historic passage of Chapter 58 made it possible for all the citizens of Massachusetts to have access to healthcare. Data from our new data source CHIA (the Center for Healthcare Information and Analysis) revealed that total healthcare expenditures in Massachusetts increased only 2.3 % last year, well below the benchmark of less than the growth in the state’s GDP. We also learned that an analysis of EW use in 2012 completed in 2014 showed that 48% of the visits were avoidable; that is an opportunity. We learned that the Cost Trends Report mandated by Chapter 224 demonstrated many opportunities for improvement in post acute care, readmission rates, behavioral health, and in the further development of alternative payment models. There was a straightforward statement that “the importance of transparency and data availability was evident throughout the work”. It is hard to improve if you cannot measure where you are or use data to demonstrate the opportunities.
The conclusions from the analysis of 2014 were that there were significant opportunities to enhance the value of healthcare in Massachusetts, addressing cost and quality. The HPC identified four primary areas of opportunity for improving the health care system in Massachusetts. Here are those opportunities verbatim from the report:
- Fostering a value-based market in which payers and providers openly compete to provide services and in which consumers and employers have appropriate information and incentives to make high-value choices for their care and coverage options,
- Promoting an efficient, high-quality health care delivery system in which providers efficiently deliver coordinated, patient-centered, high-quality healthcare that integrates behavioral and physical health and produces better outcomes and improved health status,
- Advancing alternative payment methods that support and appropriately reward providers for delivering high-quality care while holding them accountable for slowing future healthcare spending, and
- Enhancing transparency and data availability necessary for providers, payers, purchasers and policymakers to successfully implement reforms and evaluate performance over time.
The agenda included specific recommendations about how to pursue these goals in 2015. There were detailed reports and plans about how we are investing in the performance of many of our hospitals that provide critical services in economically depressed communities and to underserved populations. I was impressed and inspired by the content, focus, and engagement of the conversation.
The meeting was open to the public and the room was packed with people from the press, from payers, from organizations of nurses, doctors, home care services, patient advocates, community hospitals and academic medical centers. Things are changing and it seems unlikely that what has changed can be put back in the box. The future will be about further evolution and change in the pursuit of the Triple Aim.
Partly Truth and Partly Fiction, For a Purpose
Over the last several months it has been increasingly clear that as we contemplate the work of achieving the Triple Aim through cycles of continuous improvement, whether organized around traditional management methods or around new tools like Lean, our work must engage physicians. Beyond just engaging physicians, in many areas we must be lead and be inspired by their willingness to accept changes that challenge much of the culture and status quo of the organization and culture of their profession. Dr. Ebert recognized culture and the inertia of the status quo coupled with volume based reimbursement as core problems to be addressed fifty years ago. Dr. Ebert envisioned changes in the process and culture of the education of medical students, interns and residents as an effective way to support transformation toward a system of care that could achieve Triple Aim objectives. The speech that I referenced in my last letter contained the statement:
“The social values of the physician come from the environment of the medical school and the hospital in which he receives his internship and residency training. He does not learn them in the classroom but rather from his preceptors. He is likely to assume the social values of those he respects and for the remainder of his professional life he imitates what he has seen and experienced as a medical student and as a house officer… His opinions are formed in the clinic, and it is here that he ultimately comes to accept whatever social responsibility he carries.
Those students or house officers who had the good fortune to learn from men of great wisdom, such as Francis Peabody '03, Soma Weiss, Howard Means '11 and Walter Bauer could not help but be influenced for the remainder of their lives. Those students taught by men of narrower vision accepted more limited horizons for American medicine. Unfortunately, more students are taught by teachers of limited vision than by the "greats," and for this reason the actual environment in which teaching is done has a narrowing influence. What does the student (and house officer) actually see within the modern teaching hospital? Let me preface these remarks by saying that there are exceptions, but the experiences which I will describe are all too common…”.
Over the last fifty years the education of the student, intern and resident has improved but there is a continuing need for improvement. The echoes of continuing defects and the scars of past injuries still have a powerful impact on the attitudes of practice. There are many of us who have experiences from our years as physicians in training that have continuing effects in today’s practice. Traumatic and regrettable events still occur. The suicide rates among trainees remains a concern. We must be worried about future leaders who are trained in an environment that continues to have a culture that is not always respectful of patients or other professionals. Training programs are run less like a boot camp for combat with disease where trainees averaged 120 hours a week of work than they were during my training but the hours are still long and the stress levels remain high; and then we wonder why some doctors turn us a cold shoulder when we talk about their need to participate in transformation.
Recently I have been reexamining my own practice experiences over a long career. Conversations with Melissa Cronin whose blog melissacronin.com I have recommended because of its insightful treatment of PTSD, TBD, and issues of elder care, reminded me of events in my own past history as a trainee. Like Melissa I tried to improve my own understanding by writing about my experiences. I remembered that I had previously written about some experiences in my training and early years of practice and described one of my stories to her. About fifteen years ago I had tried to write a book of stories that would provide insight for both clinicians and patients as a way of increasing my own understanding. I wrote the equivalent of a book and then set the project aside dissatisfied with my effort. The stories have sat on my computer files unopened since 2001.
After talking with Melissa I decided to read what I once considered to be the best story again. You might imagine that it is long and it is almost 13,000 words. It occurred to me that I could offer it to you in a serialized form over four letters. I will also eventually post it in its entirety on strategyhealthcare.com. I offer the story with a reference to Marcus Borg who wrote about the Native American concept of the truth in fiction. The storyteller begins by saying, “Now I don’t know if it happened this way or not, but I know this story is true.”
Elizabeth McCarthy’s Story [Not her real name]
I was an intern in the distant past when we worked every other night. The 48-hour cycle usually consisted of thirty six to forty hours at the hospital followed by eight to twelve hours of recovery before it started all over again. Those were the days when I would take a nap at stoplights and learned to love coffee. I thrived on coffee and beepers and was sustained at times by the adrenaline stimulated by the fear that the message announced by the beeper would be a challenge that exceeded my skill and knowledge.
For the first twenty-four hours I was admitting new patients and caring for the ones who were already on my “service”. The day after my night “on call” I would try to get the issues on all my patients stabilized so that the nurses could watch them without much help from my fellow intern who shared the every other night cycle with me. After thirty years I can still picture the various places where I was standing when my beeper went off to announce that I had a new patient, a patient that I might never forget, a patient to whom I would always be in debt for having given me more than I ever gave them.
It was that way when the beep announced Elizabeth McCarthy. I was sitting at the nursing station on F2 with a pile of charts and an order book in front of me. It was sometime after midnight three or four months into the “year”. Outside the early fall air had a damp bite and I had just walked out into the courtyard off the “Pike” to use its nip as a kicker to my most recent cup of coffee. I knew I had enough work to keep me busy writing notes and orders until after three. Each night I was on call I maintained the hope that if I got my work done by three and the EW remained quiet, I might get almost four hours of sleep before I had to get myself ready for rounds at seven. It rarely happened that way but I was eternally optimistic. I always started the evening with optimism and held on to it as long as possible. Miracles do happen. Ask anybody who ever took care of sick people.
In those days beepers just beeped. There was no screen on the beeper with numbers or messages as we have now. A beeper was a little metal and plastic box on your belt that had just one note. It was a strident signal to call the operator who would then announce who was looking for you. I did not really need to call the operator. I knew it was the EW and my fantasy was dead for another night. I called the operator to get the message because if I did not call her she would keep at it until I responded. I mimed the words as she said, “Dr. Lindsey, the EW is looking for you.” “Thank you, I’ll call them.” I said. I was always courteous to operators. They were just the messengers. It was suicide to anger nurses or operators. Many an intern was “beeped” with a “message” an hour or so after going to sleep. Control was a big issue in the hospital culture.
I called the EW. My hope now was that my “hit” was a simple “rule out”. (We would call our new patients “admissions” or even more expressive of the pain they produced in our sleep-deprived lives, they were called a “hit”.) Sometimes the new patient was named by the slang for their presumed diagnosis, which in retrospect was obviously a way we turned them into objects or problems rather than the sick, frightened people that they were. The slang used for the presumptive diagnosis of a possible heart attack was “rule out MI”. Ninety percent of patients who are admitted for observation for heart attacks have something else less serious than myocardial injury so it is often true that they are just “put to bed” and there is not much real work to be done. I wanted a “rule out” because by the fourth month of my internship that was work I literally did in my sleep. I had a template “work up” and set of orders that were drilled into my head like a cherished family recipe handed down from generation to generation of bleary eyed future Oslers. I could do the drill in less, much less, than an hour and with the patient comfortably tucked into bed, I would head to my bed in the “on call room” down the hall. With luck I might salvage three hours of sleep, which would not be too bad.
Once again a few words were enough to dash my hopes. It was going to be a long night. I hated the voice of this particular “admitting phys”(the senior resident who made the decision to admit a patient and to whom). This one was a cowboy. “Gene, it’s a zoo down here and I’ve got one maybe two hits for you. You’re up for the next admit, right?” I politely answered, “Yes, I’m up. Who do you have for me?”.
“I’ve got a sweet old lady who was in pulmonary edema when the EMTs brought her in. She tuned up quickly with O2, MS and some tourniquets. Her rales are down to mid chest now and she gotten 40 of IV Lasix. I think we’ll roll her through x-ray and up to you or you can come and get her.” His crisp words transmitted a familiar mental and tactile image. She would look like my grandmother and would have wispy white hair. She would be a little over weight with puffy cheeks bulging around the facemask delivering O2. Her skin would be a pale blue and have a cold moist feel. She would speak in little breathless bursts, with a background rattle and would look very scarred with the darting eyes of a person on the brink of disaster who was having trouble with the wash of stress hormones over an oxygen starved brain.
I liked pulmonary edema. Death clearly was lurking just outside the door but ninety five percent of the time a few quick maneuvers chased him away. His flight was dramatic. The meds usually worked fast. In a half an hour or so things were often so much better that you wondered, “Was there really a problem?” Pulmonary edema can hit like a storm. When it came on like an unexpected late summer afternoon storm we called it “flash pulmonary edema or just said, “the patient flashed”. I thought that there was no problem that was more serious or dangerous that an intern could single handedly drive away than pulmonary edema. It was amazing to watch as the cheeks became pink, the skin dried and the breathing became less labored in a few short minutes; just because you knew what to do. It was like hitting a home run.
Over the year I would admit many similar men and women but I remember Mrs. McCarthy best. I helped her that night but I failed her big time later.
I met her in the EW and picked up the process of her care from the team. It was like the passing of a baton. I noted her IV lines and quickly assessed what her veins looked like after she had been attacked by my colleague. He had earnestly and enthusiastically tried to get in a good IV in the midst of her gasping and struggling for air. It must have been a frantic effort. He didn’t have the touch to do it when a patient was comfortable and certainly lacked the dexterity to do it with a patient who was moving about on a gurney in a desperate search for air. He had botched the antecubitals and the best forearm veins. There was a pathetic butterfly IV hanging from the back of her right hand. It was beginning to infiltrate and the hand was swelling.
“Nice work”, I said sarcastically for the pure relief of expressing my generalized frustration at some legitimate target. I resented him because I knew he was just paying his clinical dues before fading into a lab for the rest of his life to write papers and advance the science of medicine. Our internship group had several like him. Some of them are famous now. A few could start IVs. This one never could. He mumbled something as he backed through the curtain that served to provide a little privacy for the cubical.
I automatically picked up her left hand and pulled a rubber tourniquet from my belt and cinched it around her upper arm. In one smooth automatic move I began to pat her forearm looking for an overlooked vein into which I might slip a more stable IV before she flashed again. I’d seen a person die for lack of an adequate IV access. A good IV was something you always were sure you had before you needed it. She was still fresh from her ordeal and I was not at all sure there would not be an aftershock. I introduced myself, discovered a good vein, reached for an angiocath IV and checked her vital signs and rhythm on the monitor in one continuous move that lasted less than fifteen seconds.
“Mrs. McCarthy, I’m Doctor Lindsey and I will be helping to take care of you while you’re here.” Truth be known, it would pretty much be me. She had no private doctor. She was being admitted to the “ward” service. I was supervised by a senior resident and a distant “attending physician” who was technically responsible for her but showed up five days a week for teaching rounds. Assuming she survived, I would be discharging her with the invitation for follow up in my outpatient “clinic” where I saw patients one afternoon a week under the supervision of another “attending physician”.
“Are you feeling better now?” Her response startled me. “Aren’t you such a nice looking young man? You have such wavy hair. It’s a shame some girl didn’t get it and isn’t that a pretty tie”. I stepped back. “Well thank you”. I was not to be deterred; I had things to do if I was ever getting to bed. There was a liturgy of questions to be asked and answered. I was the one to be determining the pace and direction of our conversation. My hair was pretty close to my shoulders and my tie was a broad bow tie with pastel flowers on it. It was 1971. My generation was protesting a war and making love on the grass in Golden Gate Park. I was not there but that’s probably a longer story.
“Have you had chest pain? Are you short of breath when you walk? Can you sit for me, please? Do you have a doctor? Can you take a deep breath for me? Again, please. Are you being treated for any medical problems? Squeeze my hands. Have you ever been in a hospital before?" I was rattling off the questions as I looked at her neck veins, percussed her chest and rapidly did my “physical”. I noted a loud murmur consistent with mitral regurgitation associated with a summation gallop and recognized evidence of an old myocardial infarction on her EKG. I pretty much had the situation sized up and all I had learned from her was that she liked my hair and had been dwindling.
“I think I’ve been in a little de-cline lately”, she finally offered in summation of her recent medical history with an emphasis on the first not second syllable of the directional word. “ I don’t have much energy anymore. I’ve moved in with my daughter and her husband. I’m sort of in the way.” I think I said something trite like, “I think it’s nice that your daughter can help you. That’s what families are for.” I was too busy to note that her daughter was nowhere to be seen.
The nurse and I rolled her to x-ray. I was not about to wait for the escort service. I was fifteen minutes into the process and was falling behind. I knew the situation but the history was limited to the disclaimer “The patient is an elderly woman who is a poor historian and presents in acute pulmonary edema. No prior history of chest pain or MI”, which I began to scribble as she was getting x-rayed. No moment was to be wasted.
I was not surprised by the x-ray. Her heart was enlarged. She had what we call a “wall to wall heart” with vascular redistribution and bilateral pleural effusions, the fluid on the right greater than left. Which translates to “a large failing heart with lungs engorged by blood that the heart is too weak to pump”. The x-ray picture fit with a “de-cline”. She’d been in the dwindles for a while. There were old scars in the upper lung fields. A “bad cold” decades ago had probably been TB. I was guessing the labs would reveal an anemia and some renal failure. She would probably have pneumonia before long. At least she wasn’t in AF, yet. I guessed in the end she would “rule in for an MI”. The elderly never have crushing chest pain with their MIs. They just “don’t feel quite right”, then go into pulmonary edema.
I rolled her down the long connecting basement hallway between the EW at one end of the hospital and the open ward that was our destination a city block away. I felt vulnerable. I hated this part. I always imagined a cardiac arrest with just me and the nurse in the basement 200 yards from the EW and 200 yards from the tiny elevator to the second floor of the “F” building that was our destination. Lord be with me. The elevator moved inch by painful inch and then we emerged into the damped yellow light of the hallway in front of the nurse’s station. I announced our arrival by saying to the floor nurse, “Martha, meet Mrs. McCarthy our new patient. Which bed would you like her to have?”
The two beds in a small room across from the nursing station were traditionally occupied by the patients who required the closest observation. The room was a sort of mini ICU. Sometimes I imagined it as the launching pad to the afterlife. It seemed that most of its patients were discharged to mortuaries. One bed was occupied by a desperately ill young mother who was “bottoming out” after her first round of chemotherapy for her acute leukemia. The only thing the drugs seemed to have done were kill off the few good white cells she had. Her blood was still populated with “blasts”. She would die of infection and uncontrolled bleeding the next night when I was “off duty”. The other bed had a woman who looked elderly but was actually in her mid forties. They must have been hard years. Her arms were restrained by leather cuffs. She had the DTs and pneumonia. Not a happy combination of issues but rather common on the “ward”.
The rest of the floor consisted of one large rectangular room with ten beds in a line on each side separated by a few feet and curtains. The nurses usually moved the beds around so that the sickest patients were closest to the nursing station. There was a corridor down the middle of the room about eight or ten feet wide. In the afternoon the patients were often up in chairs at the foot of their beds. The nurses would wrap them in soft white cotton bath blankets and sheets and turn them so that they were all in a line on either side of the corridor looking toward the nursing station which was the center of activity.
Someone would usually tie bright colored ribbons in the wispy white hair of the frailest and most dependent women. I would occasionally stand at the nurse’s station late on a fall afternoon with light coming in through the floor length windows that were at the heads of the beds. There was a halo around each of the bobbing heads and the thought would pass that it looked like a bus ride to see the leaves in New Hampshire or maybe a bus ride to eternity. I was surrounded by people in various stages of actively dying. I thought about death and “the quality of life” a lot.
I was a dedicated warrior against the inevitable and had statistics to prove it. For some reason I kept a list of all the patients I admitted to the wards during that year. Patterns soon became obvious. Almost every patient I admitted had been admitted before. If you were admitted once there was a high likelihood you would be admitted again and again. If you were admitted at all you had almost a fifty-percent chance of dying before the year was over. It looked like we were trapped with the patients in an endless cycle of spiraling disease.
We admitted them and treated them. We discharged them and then they came back sicker than when they came in the last time. It was the natural history of chronic degenerative disease encased by the limits of poverty, social isolation and the recurrent behaviors that had often caused or contributed to the disease. When we presented our patient at rounds the usual chant went something like, “This is the 8th Peter Bent Brigham Hospital admission for this 72 year old woman with a long history of diabetes, chronic lung disease and atherosclerosis now status post MI times two who was recently admitted with pneumonia who now presents with a two week history of increasing shortness of breath and edema.”
The first bed on the left was ready for Mrs. McCarthy. It was the bed most visible from the nursing station. Martha was always thinking. I was the doctor but she ruled F2. She had worked the night shift for twenty years. I never ever questioned her judgment. The practice of medicine is heavily dependent on experience. She was the pro and I was the novice. As we did the doctor/ nurse dance, she let me look like I was leading but we both knew I was always glad she was there. She knew the tune.
Mrs. McCarthy was one of those people who are pathologically polite and deferential. Even in the aftermath of the trauma of the EW she began to apologize to Martha about being so much trouble. The diuretics were beginning to work. She was speaking less breathlessly and without many rattles. She needed a bedpan. She hated to be a bother. I realized I had gotten to the EW before she was completely rigged by the nurses there with the prerequisite Foley catheter. Martha gave me a look that said, “I have enough to do. Why didn’t you let the nurses in the pit (hospital slang for EW) do their work?" To Mrs. McCarthy she politely said, "It’s no bother, you’ve had a hard night. "Let’s see if we can make you comfortable."
Suddenly I had the feeling that my services weren’t needed. Martha was in charge. I retreated to the ward kitchen to forage for something to eat. I came up with a cup of the hospital custard, which I hoped would give me the energy to finish writing my work up and her orders. There was no coffee so I settled for a ginger ale. Custard, ginger ale, coffee, and little cups of orange and raspberry sherbet sustained me in the wee hours when there was work between the bed and me. I sat down to write and soon realized I was too tired to make sense. I scribbled rudimentary orders. I wondered for a second if I should call the resident who was downstairs helping out the intern on F Main (the men’s ward) but decided against it. He trusted me but would feel obligated to review the case in search of something to teach me. I did not need more education. I needed sleep.
....TO BE CONTINUED
March Madness Is Not My Disease
I must admit that I enjoy watching a good basketball game every now and then if I have an emotional connection to the team. I loved those wonderful days of Celtic Glory and this year’s team is getting interesting. Some of the most exciting moments in my sport’s watching history occurred at high school basketball games. My oldest son’s team at Newton South High lost in the State Final Championship Game in triple overtime. The best player on the other team went on to play on a team at Villanova that won a National Championship. For reasons that I cannot completely explain, my interest in college basketball is on a par with my interest in the home repair and property shows on HGTV.
Maybe I dislike college ball because I cannot connect to the players on more than 60 teams. Maybe it is because I was turned off in college watching North Carolina beat South Carolina under Dean Smith playing a four-corner, hold the ball offense that was a defense. Watching those games was like watching grass grow.
I think that my real problem is that I just don’t like the name March Madness that smacks of marketing hype. Life is short so I will pass on all of the games in favor of a good book until the championship game after all of teams who just feel that "it is an achievement" to be there go home; but if March Madness is your passion, I hope that you have a great time watching all of the games in a basketball binge over the next couple of weeks.
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