| 27 March 2015
Dear Interested Readers,
Inside This Week’s Letter
The main course of this week’s letter is a discussion of what I learned on a trip this week to Vermont where I am peripherally involved in the state’s effort to transform and innovate the delivery of care in its journey toward the Triple Aim. I think the process is fascinating and I am eager to share with you what I saw there. The remainder of the letter is the second installment of a piece of original fiction. If you missed the first part last week, you may want to look at that letter, previous editions of the Musings are now archived and available to you. The link is:
https://app.getresponse.com/archive/strategy_healthcare
There will be a permanent link to the archives in each week’s letter. After the final two parts are delivered over the next two weeks, the story will be posted in its entirety along with the archived letters.
Once again let me ask you to look at strategyhealthcare.com and remind you that if you know someone who might enjoy these letters that there is a place on the website for them to sign up to receive the letter. There is also a signup on the archives page. I think that everyone who has received the letter in the past has now been transitioned to the new delivery system for the letter. I really appreciate the help that many of you have provided. The hope is that in a small way these efforts will contribute to the larger effort to achieve the dream of the Triple Aim. There are parts for all of us to play in that effort.
There Is A Lot To Learn In Vermont
This week my wife and I drove north to Burlington and Montpelier to what I sometimes affectionately refer to as the People’s Republic of Vermont. My wife is a big fan of their outspoken Senator, the Honorable Bernie Sanders. She frequently posts quotes from him on Facebook. My own love affair with Vermont goes back to the summer of 1981, which was a very transitional year in my personal life. That spring and summer I developed a great affection for the beauty of the Champlain Valley, Lake Champlain, and the little towns of the valley like Middlebury, Vergennes, Bristol and Charlotte.
That summer I was thrilled by each trip from Boston to the Champlain Valley. Over the years I have explored the back roads off the gorgeous Route 100 as it winds its way up the narrow valley between the mountains. I love the trip over the mountain from Hancock past Texas Falls, through Robert Frost’s Ripton, and down into the valley at East Middlebury. Over the intervening years my wife and I have enjoyed unstructured adventures in all seasons tooling around the state in our old TR6 without agenda, as we look to poke around in new and interesting places where we can spend the night in a quaint B and B.
On these jaunts my wife frequently says that she is surprised by how different Vermont looks from New Hampshire, even though they are separated by only the Connecticut River. In Vermont there are fewer lakes, tighter valleys, steeper hillsides, deeper ravines, broader vistas and at least one deep gorge cut through stone by the persistent rush of Ottauquechee River and reminiscent of a scene from the Rocky Mountains.
It has only been recently that my wife’s observation has been explained to us by some geological insights from the understanding of plate tectonics and the scientific discoveries of geology. What is less easily explained is the different sense of community that sits on the two sides of the river. Both states have town meetings but New Hampshire is famous for its “live free or die” state motto that in recent years has felt less patriotic and more like an expression of self-centered libertarian thought; during the same fifty years Vermont has experimented more and more with what some would describe as socialism or progressive social policy.
I am now involved in a small way with the Vermont Healthcare Innovation Project that is the latest of several efforts in Vermont to move away from healthcare that is fragmented, inefficient and expensive. Despite efforts to move toward value-based reimbursement and the presence of three ACOs in the state (the largest, OneCare Vermont, sees about one hundred thousand Medicare, Medicaid, and commercial patients), the current system of care in Vermont continues to be predominantly constructed on a fee-for-service economic infrastructure. As is true everywhere, a fee-for-service infrastructure and the associated volume based approach to finance does not provide all citizens equity of quality and access to care. Over the last twenty or more years a growing number of Vermonters have dreamed of a system that delivers better care to individuals, creates a healthier community, improves the work life and professional satisfaction of healthcare professionals, and operates as an economically sustainable expense for individuals, taxpayers, employers, and governmental agencies.
Vermont may be a smaller stage, but as is true everywhere, the scale of change required to actualize this dream can only be described as transformational and this latest effort at transformation with a focus on innovation is yet another attempt within Vermont to pursue what has been understood for more than fifty years, which is a need to move healthcare from a cottage industry to a more organized community effort or enterprise. Vermont has understood the vision of the Triple Aim for some time yet it has also been another example that vision is necessary but insufficient for large-scale change. Vermont has been and will continue to be on a difficult journey from the status quo of volume driven fee-for-service medicine to the dream of the Triple Aim. Dr. Ebert had it so right when he said in 1965,
“The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”
Perhaps as much as any other state including Massachusetts, Vermont has been vigorously searching for that elusive “conceptual framework and operating system that will provide optimally for the health needs of its population”. There has been significant and measurable success in the effort to broadly introduce the principles of team based care and population health. As noted earlier, there are now three new ACOs in Vermont. Across the state leaders are exploring the practical application of the new economic and clinical organization of care to the urban and rural practice environments that exist in Vermont; but the majority of practices are still early in their transformation despite the state’s several year effort to promote the movement of every citizen into a Medical Home.
http://hcr.vermont.gov/sites/hcr/files/pdfs/VTBlueprintforHealthAnnualReport2013.pdf
Leadership within the ACOs, The Vermont Medical Society, forward looking and socially oriented members of Faculty at the UVM Medical School, the leadership of state health agencies, members of the legislature, the governor and the local leadership of the regional health areas all have a high degree of understanding of the principles of the Triple Aim, the domains of quality as described by the IOM in Crossing the Quality Chasm and its functional description of a better healthcare organization. The individual understanding of leaders may exceed the measured success of their many combined efforts.
Despite all of the efforts to foster change in Vermont it appears that many physicians and many patients do not understand what is happening and are not actively engaged in the process of transformation that others are promoting. It is hard to imagine that change can go forward or that patients will ever understand or appreciate the promises of universal high quality and affordable care if their physicians are not engaged. One faculty member who is actively engaged in the process of transformation in Vermont suggested to me that at least 85% of practitioners are so busy with “today’s work” in the volume based fee-for-service economy of current healthcare economics that they are minimally informed and have limited participation in all that is happening. Individual physicians are not optimally engaged and as a result they may be resistant to or do not understand much of what is happening around them.
The widespread engagement of physicians as leaders and facilitators of change is the single most important strategy in healthcare transformation. Physicians must understand and accept the compelling need for change and be willing to contribute to the evolution of the operating model and the economic platform, or at a minimum, support and accept the efforts of their colleagues who are willing to more actively engage. Each physician has personal views and fears about the process of change in healthcare but the following hypothetical statement seems to apply to a majority of those who are at least willing to listen:
I am going to be very resistant to change unless I have reason to believe that the change is good for my patients and me and that there is a very compelling reason for me to participate. I need to know and understand how the changes I am being asked to make contribute to a larger organizational and social vision. I need to know that my colleagues and clients believe that this is something that we should do. I need to believe that those to whom I look for leadership believe that this is something that we should do—and show it in their behavior and commitment, personally and organizationally.
I can successfully change if I have the physical, mental, and emotional capacity required or have the support to fill the gap between what I have and what is needed while I grow. I need support to acquire the knowledge required to change. I will need assistance to acquire the new technical skills required by change. I need to trust that when I ask for help I can find it. I will change if I can exchange ideas with others on the journey and have metrics to help me reduce the ambiguity and understand my progress and our collective progress toward shared goals. I need assurance that there will be personal and structural incentives and facilitators for making change.
[This statement by a physician was imagined by me as a response from a hypothetical physician and structured from a template offered by emeritus BU professor of education, Dr. Alan Gaynor that I discussed a few letters back. It could also apply to other healthcare professionals and with minor modifications be the statement of a concerned consumer,]
The new push in Vermont is supported by a three year, $45 million State Innovation Model (SIM) grant from CMMI that was awarded to the state in 2013. The grant offered Vermont a renewed opportunity to build on previous work and to take a great next step toward the dream of better care for all Vermonters. The anticipation was that the grant would “Fund activities inside and outside of state government over the next four years to expand and integrate innovative health care provider payment and health information technology that supports more effective and efficient care.”
The SIM grant will theoretically enable the VHCIP to more effectively communicate the reasons for change, the options within the pathways of change and the opportunity to participate in the process of change and innovation that are available to individual clinicians who either want a better understanding or an opportunity to participate. The VHCIP stated its vision at the beginning of the work: “VHCP will provide a forum for coordinating policy and resources to support development of the organizations, technology and financing necessary to achieve the shared public/private goals articulated in our State Health Care Innovation Plan: development of a high performance health care system for Vermont.”
Now over a year into the grant much has been done to get work groups up and running and some innovation grants have been delivered. Ironically the new work of the VHCIP has added to the confusing wealth of statewide Internet websites, work group reports, annual reports and white papers that tell the story of what is happening in Vermont. One physician observer at the Vermont Medical Society has suggested that success will be a function of leadership and effective communication coming from a guiding coalition that will succeed in engaging physicians and their patients in the process of transformation.
I hope that in the paragraphs above that you can appreciate my trip to Vermont as an experience in the gemba seeking information from those that are doing the work. If you read closely you may be able to extract a reason for action, a description of “current state”, a suggestion of an “ideal” or improved state, a rudimentary box four analysis of barriers and necessary competencies that either must be built or removed for the emergence of the ideal state. All that Lean analysis brings us to the speculative search for solution. What follows is a little bit more box four analysis and then the construct of suggestions that could follow the format, “If we did XYZ would we see progress toward the ideal state?” Formulating suggestions for a communications strategy was the reason for my trip to Vermont. Please let me know if you have ideas to add. I think that there is much that can be learned in Vermont that will have value elsewhere. I would think that was at least part of the reason that CMMI gave Vermont 45 million dollars.
In the transformation process there is much to be learned, much to be created through innovation, much to be solved in terms of assets to be created or renewed (General surgery, general orthopedics, and urology were given as examples) and much to be understood and accepted (the role and mechanics of value based reimbursement, team based care in the Medical Home, and the understanding of how to collaborate with existing agencies in the community to deliver population based care.) The following communications based tactics may support the overall strategic intent of the VHCIP process.
- Leadership support with materials to “tell the story” in a consistent and aligned manner. Clarity about what the “aligning” questions to be answered might be.
- A speaker’s bureau coordinated with meetings that practicing physicians attend.
- CME offerings of programs that explain the nuts and bolts of how value based reimbursement, team based care, and population management skills are employed in successful practices now in Vermont. These would be demonstrations of “what good looks like”, with tips from those who are already on the learning curve.
- An overview, organization and indexing into a “user friendly” format that tells the story in a regularly updated fashion of all of the various resources that are available in Vermont on the Internet. The resource should includes a timeline with milestones of past achievements and agreed upon milestones for expectations leading up to and going through the end of the SIM grant.
- Outreach Internet and social media based presentations of “what every doctor needs to know” and “what good looks like” with a listing of opportunities for participation for individuals, practices, institutions, and specialty groups. There was much activity in this area that preceded the SIM grant and the work that will be facilitated by the SIM grant resources needs to be viewed much like a moving walkway in an airport that speeds you on the path that you were following toward your gate.
- Media presentations of efforts by individuals, groups, and organizations within the work supported by the SIM grant through the VHCIP. The goal would be to encourage “pull” by physicians for the same opportunities.
- Facilitated town meetings in the ten regional practice areas for information, discussion, and recruitment to projects and dissemination of critical information to individual practitioners. The meetings would be yet another attempt to spread information, create pull, provide an opportunity for meaningful input and to gather suggestions and hear concerns and complaints.
One might comment on the redundancy and overlap in these communication modalities; but remember that doctors are similar in many ways but there is no one universally effective communication strategy. Further complicating efforts at communication in Vermont is the fact that physicians in Vermont are experiencing the same “negative externalities” experienced by practices across the country. Across the country the attempts to persist in illusions of clinical autonomy and make fee-for-practices “work” are leading to never before experienced levels of “burnout” and cynicism as each day brings word of new regulatory changes, IT systems to master and the continuation of the downward pressures on revenue in the face of rising operational costs.
Transformation to a new operating system and finance methodology is the answer but the process requires substantial “adaptive change” at a time when levels of trust are frequently low. Lean offers a pathway but is often received as a challenge that is the equivalent of a new automated record system or a new set of regulations. In moments like this there really is no such thing as too many leaders and too much effort to communicate through an active dialog with those who are weathering and inventing the change process. I think that Vermont is an interesting “laboratory” for us all to watch because of its unique size and mix of urban and rural environments.
Introduction to Elizabeth McCarthy’s Story, Part 2
For those of you who may have missed last week’s letter, I began the serialization of a “partly truth and partly fiction” story of my interactions with a patient from my internship in 1971. Some of the fiction may arise from what we call “false memories”. Other elements of the “fiction” may be due to the thirty-year interval between the events in the story and when I wrote it in 2001. Also at play was the need to respect confidentiality and yet deliver a story that accurately demonstrated real stresses and traumas experienced by young doctors and the patients they try to serve. The physical environment of the old Peter Bent Brigham Hospital is very accurately described and I think any doctor or nurse can appreciate the picture of the patient and the events as plausible. I hope that those things add up to a representation of the truth.
Last week I did not say that my inspiration had been the writing of James Herriot. Many of you may remember the serialization of his books as yet another British import of the nineties on Masterpiece Theater. I read all of his books to my youngest two sons. I was amazed by how his stories gave great insight to our understanding of caregiving, both from the point of view of animal owners who in my mind are surrogates for families and other caregivers and to the thoughts, fears and professional concerns of providers.
In part one I was called to the EW on a busy night to assume care for an elderly woman who was emerging from a “flash” of pulmonary edema. Hopefully the reader is beginning to recognize that I am as much focused on my own survival as her “medical” problems. Perhaps that dynamic is not limited to internships experienced long ago.
Elizabeth McCarthy’s Story, Part 2
I called the operator and asked her to call me at six. It was four. I’d finish my notes and orders before rounds. I slept in my clothes. Mercifully the phone did not ring until six. After the two seconds it took to figure out where I was, I thanked the operator and briefly wondered what had happened to that other “hit” in the EW. Maybe the patient had a doc and ended up on the private service or was young enough or sick enough to get one of the precious beds in the CCU. Mrs. McCarthy did not meet any of those criteria.
I was amazed when I saw her. The Lasix and digoxin I had ordered had transformed her in a few brief hours. Martha had “installed” the Foley catheter and the bag hanging from the bed frame was bulging with pale yellow urine. Urine always made me happy. If your patient can make urine and has a little bit of blood pressure you can work with there are miracles in the making. I said, “Good morning Mrs. McCarthy”, as I slipped my stethoscope under her Johnny.
The nurses always called the patients by their first names but I was raised to always address older people by their surname. My tongue would have gone into spasm if I had tried to say “Good morning Elizabeth” or “Good morning Betty” which sounded fine coming from Martha. Besides, she looked like someone who might have been an authority figure earlier in my life. I could see her as my elementary school teacher or a librarian at the public library who would be watching if I tried to find something racy like Marjorie Morningstar or The Naked and the Dead. At the least, she was a lot older than I was.
I was filled with awe once again with the power of the processes that were under my control. Where just three hours earlier there had been a loud murmur and a galloping lub double, lub double, lub double at a rate of 110, there was now a gentle lub push dub, lub push dub, lub push dub at a pedestrian rate of 76. The bases of her lungs were almost clear. Her respiratory rate was 16 despite the fact that the oxygen mask was delivering O2 to her forehead. She was still dull to percussion at both bases and her ankles and lower legs were still pitting to the pressure of my thumb. It would take a few days of continuing treatment for the edema to clear.
“Well don’t you look good this morning Mrs. McCarthy”, I crowed. I had something to show for my lost night’s sleep. I was a little full of myself. Things got even better as I looked at her lab work. She had a crit of 35. Her creatinine was only 1.4 and she was not a diabetic. The cardiac enzymes were normal so far. She had not had an MI.
In the morning light I could see that on my exam the night before I had missed the arcus senilis. It’s a faint, milky, circular deposit of cholesterol around the outer part of her iris. I covered up my discovery by saying; “Don’t you have pretty blue eyes”. I was guessing that her cholesterol would be 300.
Rounds started a few minutes late. My counterpart showed up shaved and refreshed from his twelve hours at home. I became aware of the metallic tasting film that coated my own mouth and I wished that I had taken fifteen minutes to brush my teeth and step into the shower. Unfortunately, the showers were at the other end of the building about a quarter mile away where the residents slept and not worth the effort. I had settled instead for coffee and custard.
Rounds began with Mrs. McCarthy and I suddenly became aware of how little I really knew about her. I knew everything about the last four hours of her life and next to nothing about the previous 79 years. I finessed the history with medical clichés but realized that it would never fly for “attending rounds”. The resident was in the moment. He didn’t care where she came from or what series of events had led her to our ward. He took all that for granted. He was focused on what we (I) were (was) going to do for (with) her. He wanted to discuss whether I thought we ought to tap off some of the fluid from her chest. He was an invasive guy who liked nothing better than to do a thoracentesis or a spinal tap. It seemed like a lot of unnecessary work to me.
The “attending” would want information. He would be looking for all sorts of minutia. What was her family history? Had she ever been a smoker? Does she drink? What work had she done? I had work to do. After rounds I would have a few minutes to fill in the gaps.
The day nurse was just finishing Mrs. McCarthy’s bed bath when I returned from rounds. I sat down on the metal chair next to her bed and tried to quickly glean the information I needed. I wanted a two or three word answer to each of my questions. Now that she could talk without gasping for breath she wanted to tell a story as the answer to each question. Without a little discipline the process could take hours. She wanted to talk.
I learned that her parents had “passed away” rather young. Her mother died during childbirth in her thirties and her father a few years later of pneumonia. She was the oldest of five and had gone to an orphanage when she was twelve while the younger children were dealt out to various relatives. A sad story that got worse but it did not illuminate her current problem. She became a domestic servant when she left the orphanage at sixteen. She married “late” to a man who drank too much and died in an industrial accident in his early fifties. She had three children only one of which, her youngest daughter, was in Boston.
When I asked her about her medical history, I learned that except for having children she had “never been sick a day in my life”, or at least did not recognize that she was ill. It had been years since she had seen a doctor but over the last year she had not gone out much and had moved in with her daughter “for a lot of reasons”. She did not go out much because “coming home you have to walk up a hill and I get short of breath and have to stop”. “Doctor, I’m getting old but I wasn’t sick. I’ve just been slowing down”. As I expected, she admitted to a significant weight gain over the last few weeks and a crescendo of her symptoms that she had not recognized until she sat up at night unable to breathe.
It’s an old old story. It was called the dropsy when in seventeenth century England. Dr. William Withering first wrote about the powers of a tea made from the leaves of the foxglove plant by old rural women. The tea was an effective treatment for what we call congestive heart failure. It was a struggle but I filled in all the blanks and was ready for the attending rounds before the team tromped off to x ray rounds.
My attending was a well-known cardiologist whom I greatly respected because he was not only a significant contributor to medical science but he was also a master from the old school of bedside clinicians. Each morning we would try to pick a case from the previous day’s admissions that would be interesting for him to use as the focus of teaching us. The intern or a medical student would present the case and then be drilled for information that was missing or not recognized as important. The teaching was usually Socratic, which can sometimes be annoying. Why does the person who knows the answer ask the question? The person who does not know much and would therefore benefit by being able to ask questions is the one who must produce the answers. Socrates was a sadist. Just ask medical students and interns who are educated by constantly struggling with questions they can’t answer. I guess it gets you ready for the practice of medicine, which is often about knowing what to do when you do not know what to do. Mostly it’s about controlling your anxieties until you know what to do.
Dr. Dexter loved it when I presented Mrs. McCarthy. He was a pillar of the Boston medical establishment and had been seeing older women with CHF for more than thirty years. He was also a grand old professor and loved his role. He was to Boston medicine as Cardinal Cushing was to Boston Catholicism. He had flair and loved the act of charming older women like Mrs. McCarthy. When he took her history he started off with a dignified, “Good morning Mrs. McCarthy, I hope that you are feeling better this morning!” and in a few short minutes she was laughing at a little joke he made and he was calling her Elizabeth. With a gesture he asked and was invited to sit on the edge of her bed. Now she was looking at him on the same level and not up at him standing with a crowd of young doctors behind him. I had the flash that they were both in a position and relationship that they intuitively understood. There was mutual respect but social deference. She might well have been a valued and respected domestic servant who had loyally worked in his home for forty years and took great pride in considering herself a part of his household.
All attendings eventually work the discussion of any case around to a medical subject that is comfortable turf for them. Mrs. McCarthy’s history, physical exam and management were home turf for Dr. Dexter. He had an international reputation for his pioneering work in the development of cardiac catheterization techniques to understand valvular heart disease, congenital heart disease, right and left heart failure and pulmonary emboli. He was off and running as he talked to her and then would look over his shoulder and make some charming remark about her wonderful exam to us. She was his partner in our education. In his hands she was not an object for teaching. Through him she was sharing these wonderful things about herself. When he talked her murmur was characterized as a beautiful sound. He transformed it from something that was a worrisome sign of disease to something that was fascinating about her. I almost wanted one of my own.
Mrs. McCarthy was having the time of her life. I doubt she had ever had so much focus and attention from such an obvious gentleman; or if she had, it had been a long time. As I watched them I was fascinated to see how the color of her cheeks improved as she laughed with him. He brought her to life. He got all the information that I had wanted to get in an easy flowing conversation that did not feel like an interrogation. He knew her neighborhood, some of its shops and the hill she could no longer climb. It sounded like they were neighbors but I knew that they were not. He connected. I was instructed.
As he lead the team away from her bed back toward the larger hallway in front of the elevator, the obvious pleasure he had experienced from the conversation lingered on his face for a moment before his tone became analytical and didactic. He could have talked hours about her murmur and what it meant, not to mention the edema, the possibility that she might also have a pulmonary embolism or be at risk for one. I was relieved. There would be no more questions for me. I relaxed a little.
Over the next few days Mrs. McCarthy gave up 15 pounds of urine to her Foley bag. She took her place on the bus in the afternoon sun and after the Foley came out she walked at first with a little help from nurses and then on her own. We struggled with the question of whether her mitral valve needed to be replaced but eventually reasoned that she was doing well with medical management. The decision was based on an increased operative risk because of her age and the fact that she also had significant lung disease, not to mention the fact that she said she wanted no part of surgery.
On the day she was discharged I sat at her bedside. I could not be comfortable with sitting on her bed. It seemed like her space. We carefully reviewed all of her new pills and for the umpteenth time I gave her my speech about the evils of salt and cholesterol. She understood. Thou shall never eat canned foods, especially soups. Do not partake of processed meats, cheese, beef, ham, eggs or any item upon which you can see salt, like potato chips or saltines. Never ever again put your hand around a saltshaker. Never eat fast food, pizza, or worst of all, Chinese food. Weigh yourself every day and call me if you gain five pounds.
She smiled and said she would do her best. I said to myself, “I better double her Lasix dose and see her back in a week” I excused myself to rewrite her Lasix prescription and reschedule her appointment. She was all set to go. I had never seen her family but apparently someone was coming after work to pick her up. It was my evening off. I was tired and wanted desperately to leave and did. I never met her family.
[TO BE CONTINUED]
Walking Among The Big Trees with a Little Chip
Enough snow melted this last week to put some water into my basement. Even as this winter slowly loosens its grip on us it offers continuing misery and the threat of turning on us again. It may come back with one last act of vengeance, like the persistent character played by Glenn Close in the movie Fatal Attraction who could not be disposed of by the inept character of Michael Douglas. He thought that he had finished with her and then she arose from what should have been her watery grave in his bathtub to attack him again.
As luck would have it, duty calls from elsewhere. I am in the coastal redwoods above Santa Cruz, California on the edge of Silicon Valley where my son and daughter-in-law have the awesome responsibility of parenting our grandson who is now eight months old and is a continuous motion machine crawling about, chattering constantly in a language of his own and looking for new adventures with the cat and any empty box.
His parents have had the good fortune to rent five acres on the side of a mountain slope that is bordered by a state park full of coastal redwoods. A path leads from the property into the trail system of the park so that one does not even need to exit to the road that has the romantic name “Empire Grade” to gain access to the trails which wander for miles and miles through gigantic trees. My goal this weekend before duties call me to a meeting in San Francisco next week is to take several long walks among the big trees with young Hal riding like a young prince in the super duper baby carrying backpack procured from Amazon. I hope that nature, the realities of what babies like to do, what I call baby-tech, and high tech all come together for a memorable experience.
I also hope that the thaw back home continues and that your weekend walks uncover more and more evidence of a reluctant spring and not a resurgent winter. I am predicting a late “ice-out” toward the end of April. We are on the leading edge of “mud season” and it is clear that better days are just around the corner lying somewhere in April. The question is just where in April are those days that will answer our desire for the real and final end of winter.
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