| 5 June 2015
Dear Interested Reader,
Inside This Week's Letter
This week’s letter contains a couple of stories told to me by an old colleague and friend of more than 30 years. They are not feel good stories and I fear that there are many other untold stories out there that physicians and nurses carry around as heavy burdens. Are these stories a root cause of burnout? I do not know but I know that healthcare professionals find both joy and sorrow in their work. Many of us carry scars. I think it helps to tell the stories.
It is rare that I recommend a meeting but in this letter I do give you a connection to a meeting that I think many might enjoy. Check it out. I hope that you will also continue to checkout strategyhealthcare.com and tell friends and colleagues that they can sign up to get these letters each week on that website.
Doug's Stories
It has been a wonderful week, a week that I have anticipated for many months because for the first time in a couple of years we were going to spend a few days with our friends from Portland, Oregon, Leslie and Doug Beers. Leslie is a nurse who works for the county seeing homebound patients. She has never worked for a VNA but her work is similar to that of a VNA because her practice is essentially with homebound patients struggling with the complexity of age, chronic disease and social issues like isolation and poverty. Doug has worked for the last 31 years at Emanuel Hospital and Legacy Healthcare in Portland where he has taught and supervised housestaff. His practice has been primarily a medical home for patients with HIV, Hep C, drug abuse, and all of the chronic manifestations of disease associated with socioeconomic dysfunction. As its name implies, Emanuel Hospital’s origin is religious. It was founded by Lutherans and it provides care to a disproportional share of the underserved in Portland.
Most of Doug’s patients come from the population that lives around the fringe of society in any large metropolitan area and who have sought care from the charity of Emanuel because there is nowhere else for them to go. A few of Doug’s patients are quite successful and a couple are known internationally in their fields and chose to see him because of the reputation he has for high quality personalized management of complex medical issues. In a way it seems ironic to me that there are some people with substantial wealth who could see anyone and the person that they would chose to see is someone whose practice is primarily filled with those who from their own resources can afford to see no one.
Doug moved to Portland to assume his role at Emanuel in 1984 just as HIV was in its ascendancy as a scourge for many of the population that sought care at Emanuel. Doug quickly became involved in the care of patients with HIV and still follows about 450 HIV patients in his practice. The face of disease is rapidly changing. He told me this week that he has diagnosed 42 new cases of syphilis in the last eighteen months. What has always seemed to me to be remarkable about Doug is his equanimity in the face of a heavy work-load with complex patients. As I was anticipating their arrival, I knew that we would enjoy our usual conversations to “catch-up” but I decided that I would ask Doug if I could treat part of the conversation over the four days like a rolling interview about his approach to practice and what he thought about the issues that all physicians experience now.
I wanted to know how he viewed the issues that seem to be dominating the discussions in healthcare today like value based reimbursement and new alternative compensation models. I wanted to know what he thought about the role of Lean in practice transformation. Was he seeing physician burnout? Did he see a need for practice transformation? What changes were underway where he worked? I envisioned a rolling conversation with a purpose beyond our usual exchange of anecdotes and family stories that are the basis of most of our semi annual get togethers. Before I pass Doug’s wisdom on to you let me give you a little background about Doug and my personal history with him. Our lives have been intertwined for about thirty five years.
Doug grew up in California in Berkeley and Lafayette in the East Bay. His family’s roots are deep in the history of California. His first relative to live in California came to San Francisco in 1828. His dad was a mechanical engineer who was a graduate of the University of California but through a variety of positions was never wealthy and Doug would describe his family as always challenged financially. Doug was the second son and has two younger sisters. His older brother was an academic star and went to Harvey Mudd as a scholarship student after making a perfect score on the college boards. In the mid-sixties that accomplishment was even more noteworthy than it would be today.
Doug followed along after him and trumped his accomplishments. He also scored a perfect 1600 on the boards. He was accepted at Harvard, Stanford and the University of California. While trying to decide where to go he met with Harvard alums in the Bay Area and discovered that those who had gone to Harvard as grad students were very impressive but that he was less impressed with those who had their undergraduate experience at Harvard. He enrolled at Stanford. One of his most significant experiences as an undergrad was the half year he spent in Germany and Austria where he did everything from read Freud in Freud’s home to singing musical theatre and a little opera.
After graduating from Stanford, Doug headed to Seattle for a Masters program at the University of Washington in zoology. He soon decided that he wanted to go to medical school, and returned to the Bay Area to attend UCSF for medical school. He interned in Medicine back in Seattle at Virginia Mason Medical Center. I first got a glimpse of Doug at the Brigham where he came for his residency in Internal Medicine. I was already working at HCHP and was delighted to discover that we hired him as a PCP when he completed his residency.
Doug was a star. He was a great colleague and we became close friends, primarily through our wives. As chance would have it my wife and I were shopping at the Chestnut Hill Mall one evening when I saw Doug or he saw me. We stopped to talk. We introduced our wives to each other. They were both pregnant and we began a close friendship that drew us together beyond just the excellent collegeal relationship that we had already developed.
The more I got to know Doug the more amazed I became. He had an encyclopedic knowledge of science, medicine, art, literature, politics, philosophy, gardening, masonry, electronics and carpentry. He was personally building a 2200 square foot addition on to a small antique stone cottage that they had purchased in Sudbury. He rode his bike round trip 27 miles each way most days, weather permitting, from Sudbury to our offices in Kenmore Square. He did not brag! I learned these things and all I know about him one little fact at a time over many many years and many many walks and long chats deep into the evening on weekends that our families shared together.
Knowing someone with Doug’s skills and accomplishments is breath-taking, especially when he never talks about them as anything other than mundane realities. Doug is more than five years my junior and I am older by several years than his brother yet, in many ways I began to look at him as an older, wiser guide and source of information. What Doug knew and did, I was interesting in knowing and doing. I read books that he read that I might never have found if he had not introduced me. I still have dozens of books to read that are on my to-do list that I bought because Doug recommended them. My wife and I were distraught when Doug announced in early 1984 that he was taking his position at Emanuel in Portland. I could not believe it. It was a difficult time. I blamed his wife and developed the idea that it was her idea. [Leslie was not Doug’s wife then]. His marriage ended in Portland within a few years of the move.
As Doug left for Portland in the summer of 1984 we agreed that we would stay connected, and we have. Our first visit to Portland was not long after Mount St. Helens erupted and there was still ash on the wind in Portland and smoke on the horizon from the mountain more than fifty miles away. Our families vacationed together in the Virgin Islands a year or so later as their marriage was failing and all four of us cried knowing that their separation would change forever what we had enjoyed even more than it had been changed by their moving three thousand miles away.
We were present when Doug and Leslie married on New Year’s eve in 1987. One of our sons went to Reed College in part because he had been to Portland so often to see Doug and Leslie. Over the last decade, many of our trips have been to the home that Doug and Leslie built with their own labor and the help of their two sons in the lovely town of Manzanita on the Oregon Coast where they retreat from the stress of work. It has been a very long term relationship. An intertwining of families and a great friendship where often life might interrupt the conversation for two years, but it always returns with the same intensity the moment we get together again.
Now Doug is beginning to think about how to “cut back” and he has been able to free up a little time on Fridays. Knowing the intensity of Doug’s practice and knowing how so many of our colleagues are jaded and feel burned out I was eager to ask Doug whether he ever felt “burned out”. When I did he looked a little puzzled and then answered, “No”. He would admit to being frustrated and at times feeling abused. Performance was never an issue for him. He is a master user of “Dragon” and Epic and even when he sees a heavy schedule with residents he is out of the office with records closed and an empty “in box” within an hour of his last visit.
He is frustrated by “systems issues” but has adopted a stance of acceptance. His concern about his patients and his commitment to teaching seem to make most of the mundane frustrations that plague many practitioners not a concern for him. He earns large performance bonuses but is not motivated by them and actually seems to not care that much about his total compensation. His “supervisor” is a someone whom he trained when she was an intern and resident. He respects her and tries to comply with the managerial programs that come down to him but in essence the standard that he sets for himself far exceeds corporate expectations and therefore he is immune to the corporate attempts at manipulation.
I asked him about Lean in his organization and was interested to know that “Lean” was being used. I was also not surprised that he was unimpressed with the process because, when I described how it should work, he said that in his experience the management arrived with a set of solutions to a problem that they had developed and were “installing”. Solutions had not been developed through anything like a collaborative process that included respect for those doing the work or the participation of the team in the discovery of solutions. I wondered just how many physicians experience Lean in this same “directed way” rather than as a participatory process where their ideas and experience are tapped for solutions.
What has emerged over the years is that Doug has worked hard within a system as an exceptional teacher and as an example of a talented and committed physician who treats every patient as the most important patient in his practice. He cannot abide the concept of a concierge practice because it is exclusionary, but ironically he is so gifted that what his patients get is a higher level of care than most concierge physicians delivery for a much smaller and wealthier population. I can think of no physician I have ever met who is more patient centered and patient oriented than Doug. The one area where we had the greatest alignment of thought was our agreement about the negative impact of revenue driven practice. We both agreed that Gawande was right about a culture of “overkill” or over processing in healthcare and that healthcare remained driven by individual and corporate concerns about maintaining income and revenues.
As our time together rolled on my “interviewing” energy waned. We fell into our usual banter on a long walk and then at lunch. During this time two remarkable stories about patient care emerged that are worth repeating because I think that they represent the conflict and pressures that even a doctor as skilled and committed as Doug will encounter. The sort of stories that could be the origin of burnout for some.
As doctors do, I was talking about cancer and the impact cancer had had on some close friends and families. When we talk about the cancers that strike like lightning we almost always talk about pancreatic cancer. My rambling led me to talk about Steve Jobs, and then the conversation touched on the fact that Jobs delayed treatment for a theoretically less serious form of pancreatic cancer and perhaps missed his opportunity for cure. Doug confused me when he said he had a patient who died because he was treated too soon and too aggressively for pancreatic cancer. I asked him to explain.
The patient was a man in his sixties who had gall bladder disease and recurrent attacks pancreatitis. He had some weight loss and complained of vague abdominal pain. Recurrent imaging studies and lab work revealed little information until on one exam the radiologist felt that there was a small "something" unexplained in the pancreas. He suggested following it to see if it changed. Doug agreed since the symptoms waxed and waned and were at the moment better.
The uncertainty of the radiology reading created great concern for the man’s wife. They sought a second opinion from an academic and well respected gastroenterologist who proceeded to make multiple attempts to get a tissue diagnosis with more and more sophisticated techniques as each biopsy came back negative. The lesion was not changing but the concern of the patient's wife grew with each unsuccessful biopsy. Finally after a biopsy of the pancreas was performed using endoscopy and once again had come back negative, the gastroenterologist advised treatment. Along the way the man would return to Doug and get advice to wait. He would agree but when he went home his wife would push harder to do something. Finally the gastroenterologist, an oncologist and a radiation oncologist agreed to begin treatment without ever confirming a diagnosis with tissue. Before the treatment began Doug had asked his partner to review the case to see if she could find something that he was missing. She was equally surprised with the decision of the specialists to begin treatment.
The treatment was brutal but the doctors were happy because the lesion did not grow. Everyone reported this as a great success to the wife and husband. They were encouraged to accept another round of treatment and “saints be praised”, the “tumor” though still present was still not growing! Surely it was a sign that they were on the right track because was it not reasonable to assume that if they had not been treating the lesion it would have grown by now? A third round of treatment was recommended during which the man died, not of metastatic pancreatic cancer, but of a complication of his radiation and chemotherapy. No autopsy was done perhaps because “he had been through so much”. The wife was distraught but proud that her husband had battled cancer. The gastroenterologist, oncologist and radiation oncologist did not respond to Doug’s inquiries.
I just shook my head in disbelief but all the while had no problem accepting the story. I need not list all the problems in the process of care and there were many. The story stands as an example of how difficult it is to practice in a system that does not follow a protocol and where thinking is initially flawed and treatment is begun after questionable concepts are never questioned and a lack of “change” is misinterpreted for either self-serving or anxiety reducing motivations as a success. Most likely there was never a problem other than a fibrotic lesion in a man who had good reason to have one. It is chilling to think that the man may have died because of his spouse’s anxieties and three specialists who never let themselves question their initial decision. Did the man die from pancreatic cancer or did he die from the fear of cancer?
As chilling as that story was and as likely as it is to be repeated in the complexities of practice, Doug’s other story disturbed me more. I discovered the story quite by accident. We were sitting on the dock chatting with my neighbor who had just given us a tour of the lake on his boat. The conversation turned to our long term friendship and I commented to my neighbor that I had never forgiven Doug’s wife for wanting to move to the West Coast. It had truly been my misconception that Doug had responded to her desire to leave Boston when he took the job in Portland. Doug responded, “Not so!”
His response was that there were several factors but after a disastrous case he lost all enthusiasm to remain in our practice and left for a new beginning. I immediately was pretty sure of what he was speaking but asked him to tell our friend the story.
Doug recounted that he was on call for the weekend and that one of our colleagues was not going to be available to a patient for which he had concern and he wanted Doug to see the patient on Friday afternoon so he could then respond to the man over the weekend from the perspective of knowing him, if things changed. Doug agreed and the man came to the urgent care office late on Friday as Doug was beginning his weekend responsibilities.
The man had a history of migraine and had been having recurrent headaches for more than a month. The headaches seemed somewhat like his migraines but were a little different. Neuro exams had been normal but the problem persisted. There was a history that at least two doctors including a respected neurologist, and a nurse practitioner had gotten of a bump on the head without loss of consciousness four or five weeks earlier. The neurologist was not impressed and was convinced that the headaches were an alternative expression of his migraine and that no further work up was indicated.
When Doug saw the patient he did a careful exam and noted no pulsation of the retinal veins, a potential sign of increased intracranial pressure. Doug was concerned that the bump on the head was significant and that it was possible that a CT should be done to rule out a subdural. When he tried to schedule the test at the hospital as an emergency, the on-call radiology resident refused unless the patient was seen again by a neurologist who would order the scan. As luck would have it, the neurologist who had seen the patient earlier was still in his office wrapping up for the day. He refused to see the patient.
Negotiations went on for sometime with everyone holding their position and the patient remaining in pain. The neurologist would not see the patient. Radiology would not do an emergency CT based on the concern of a lowly internist. Finally a neurology resident at the hospital agreed to see the patient after he had taken care of some other issues. Apparently he was swamped with work with consults and with his patients. Doug got everyone to agree that the patient would come to the emergency room and have the CT after being seen by the neurology resident. Unfortunately after waiting for over three hours with no sign of the resident coming to see him anytime soon, the man signed himself out of the ER AMA, against medical advice. He went home where he died of his subdural hematoma six hours later.
Doug recounts his anger at the neurologist, the radiology resident, the neurology resident, and himself. It is ironic that in this day and age our concern is overuse. Back then with everyone salaried and concerned about their own time and workload on the weekend, finance was not the problem but several people to whom the system gave responsibility used the “rules” of the system to protect their own time and personal interests and the outcome was an avoidable death.
Doug was so angry with the system that he had to get out of it. When Doug had finished his story I realized he had experienced a trauma and subsequent PTSD like response from what some like Dr. Jonathan Shay call “moral injury” . It is a concept that has been around for more than a thousand years and perhaps is an important part of the explanation for so many suicides among soldiers returning from the Middle East.
Moral injury occurs when you are involved in an activity even against your will that violates your own sense of what is right. It is no consolation to many soldiers, and I fear some doctors, that they did their best yet because of properties within the system that essentially could be called “systemic evil” , they are part of a reprehensible outcome. The pain from such an event is hard to manage. Doug decided to remove himself from the system and has spent more than 30 years working where the system leaves him alone and is glad to have him doing work that is inspiring and perhaps redemptive.
The memoir that I published this spring from an event more than forty years ago entitled “Elizabeth McCarthy” is probably an example of moral injury. I have spent a career trying to be better and trying to make the system better all the while quite cognizant of the fact that the system and I together failed someone and that is a difficult burden to bear. It is also very difficult for individuals alone to change a system. Doug and I talked about the fact that every resident he has ever taught has heard his story. One man died because of a systems failure. Doug must hope that hundreds more who might have died lived because his residents were better critical thinkers having heard his story. Doug tells me that he stresses the importance of keeping their minds and the diagnostic question open because certainty is difficult to come by and being certain but being wrong is a deadly combination.
I do not teach residents any more but I could not agree more with Doug and I think that most of us who practice without the intellectual machinery that can generate a perfect score on the College Boards do have enough intellectual horsepower to follow Doug’s process of clinical evaluation. There is “standard work” and sometime just plain old rules of management that should be followed like, “Never treat with chemotherapy or radiation for cancer without a tissue diagnosis". That is the moral of story one. The moral of story two is harder but it is about how to approach a diagnostic problem and manage the uncertainty that is constantly a part of practice. It is also about always seeking to do what is best for the patient even when the system is working against you.
After my time with Doug this week I come away realizing that transformation is hard. Lean is misused by many. It is likely that healthcare finance is and will continue to generate circumstances where there is the potential for patient harm. It is possible that our newer generation of physicians will not have all of the bedside skills or be able to master critical clinical thinking as practiced by some of the “Old Masters” like Doug; but over all, the work ahead is noble and collectively we have the ability to support one another and improve the systems of care within which we work as long as we remember that the work is about and for patients. If we keep that in mind, it is balm for the moral injuries already sustained and prevention for others that might otherwise be suffered.
An Opportunity Worth Considering
A few years ago I meet Dr. Tony DiGioia, who is a fabulous orthopedic surgeon at UPMC in Pittsburgh. More interesting to me than his surgical skill is his interest in patient and family centered care. His Institute produces many fine educational programs. I attended one in Washington D.C. a couple of years ago and wrote about the experience. I hope that many of you will consider attending a one day conference that will cover some issues of patient and family centered care in ways that might open new doors for you and your practice. The conference is entitled Co-Creating Health:Technology and Process in a Digital Age. It will be on September 18 in Pittsburgh. More information is available at www.DeliverValue.org. I do not usually make recommendations of this sort but I believe this will be an informative and useful conference and that many “Interested Readers” will be glad they attended.
A Grey Day at Dutchman’s Pond
The picture on this week’s header is from Dutchman’s Pond. On one of my walks this week, Doug accompanied me to Dutchman’s Pond. It was a grey day but good for walking. Dutchman’s pond is less than three miles from my home and it was the site of a cabin in the woods that Dr. Ebert enjoyed for many years. I wonder if the idea for Harvard Community Health Plan might have occurred while fishing on this little pond.
May was a grey month for the Sox and June is not starting out all that well. This new habit of losing, especially in the ninth inning that the Sox have recently been demonstrating is beginning to annoy me. I am not a fairweather fan. I have endured many painful losses but don’t they realize that I do not want to go to a game in September when they are hopelessly behind by 25 games? Don’t they realize that now is the time to turn things around? I can’t believe that they will be out of the running for postseason play before the playoffs are over in basketball and hockey.
I take solace in long walks now listening to audiobooks rather than baseball. I hope that you will get out and enjoy a long walk on what looks to be a pretty nice weekend. |
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