29 October 2009

I was most interested to see Glenda, David’s mother, soon after I arrived. She was her usual cheerful and composed self, and I was assured by others who knew her well that she wasn’t putting anything on. And so I started back into my work in the communities. The first few days are, as typically, split between the tiny health center and community clinics. Working with Maria and Roberto, most of the patients this time have the typical plethora of pneumonia, intestinal parasites and body aches. Those who are identified with chronic medical problems are started on medicine and will be followed when I leave by the two nurses according to protocols that I have written and reviewed with them. I see several of such patients that I saw on my last visit, all three of the previously untreated epilepsy patients are now almost seizure free. Unfortunately only half of the adult diabetics are doing well, the rest struggle with medication and diet compliance….universally nothing new here.

On the drive to the community of Pamuc this morning, the warm clear weather gives clarity to the jagged volcanic mountains that I have not seen here before — quite remarkable considering that typically it is socked in with month’s long fog and rain this time of year (the locals call it “chipi-chipi”). Amid the bright green treed areas are well demarcated quadrants of corn being harvested that go most of the way up the incredibly steep slopes. (Local joke:” Did you hear about the Guatemalan farmer who fell off his field?”). As we drive by Abeleno’s house, Roberto tells me that the old man made a full recovery and has been harvesting his corn. By the time we arrive at the community clinic site, the day’s patients are waiting to be seen in an orderly fashion, thanks in part to Glenda’s prior organizing of these clinics. There are enough challenging patient problems that the day passes quickly without my realizing that it was six months ago in that very room that Nicholas told me that David had just died.

When I returned to my room in San Cristobal this afternoon, I noticed Glenda nearby attending an outdoors Bible study. I didn’t pay it any mind until I overheard her ask the pastor if one could recognize others in heaven. You see this Sunday is The Day of the Dead. Glenda and her family will go to the small grave, decorate it with flowers and colorful streamers, and will have their midday meal. And all around them children will be laughing as they fly their kites trying to avoid the trees that have ‘eaten’ more than a few. It’s the windy season.

Michael

As my regular readers know, my former partner and longtime friend, Dr. Michael Polifka, now works as a medical missionary in developing countries. From time to time, I post updates from him that I get by e-mail. Here is the first of two posts about his trip to Guatemala this past April and a return in October.

San Cristobal, Alta Verapas, Guatemala

6 April 09

The rainy season is about to begin here in the central mountains. It is wet most of the year with mist that mutes the green of everything. But the sun is bright and the flowering bushes around the aged wood planked homes, the early corn in the fields and the vague outline of the peaks instantly reorients me. I am working with Roberto and Maria two locals who are associate nurses and are the primary care providers in this region of a dozen communities of Pocomchi Maya where roads access less than half of them. Some days we will see patients in the two room rural health center, others we will hike with back packs full of medicine from one to two hours and run the clinic in the community.

On the first day in Providencia, a community of 850 families we see about 50 patients, almost all with chronic medical problems, either not diagnosed or untended for more than five years. In the morning there is a man with symptomatic heart disease, another who has had a stroke, and one with dangerously high blood pressure. Next is a middle aged woman with severe emphysema from cooking fire smoke in her house, followed by a thirty year old in earlier stage of disease, and then a young mother with a 6-year-old, profoundly retarded child and another at home looks to me for a miracle…I obviously have none. The last patient of the morning is a 22 year old with disfiguring oral tumor that has been noticeable for at least a year and is now starting to cause problems swallowing. The afternoon is pretty much the same. I start treatment for those that I can, advise some simple changes at home when appropriate, offer to make a referral for those whose treatment is way beyond what I can do (none accept), and advise that they are doing the best they can already when nothing more can be done. Each patient leaves expressing in one way or another that they are grateful that I came. At the end of the day, walking out on the narrow, tropical flowered lined path, it was crystal clear to me that I was exactly where I should have been at that moment. A week later, haunted by the events that unfold, I would question that.

The second week’s work seems framed by two patients, David and Abeleno.
After Monday’s community clinic in San Sebastian and a pleasant 45 minute hike back to the road, there was plenty of time to visit an old man who was sick in his home. The mist outside of his dirt floored home previewed the eerie scene inside. Without windows the only light inside came through the cracks of the hand hewn wood slats that made up the walls. Smoke wafted in from the adjoining kitchen’s cooking fire. The moaning in the corner bed led me to the patient in the bed in the corner who was shaking with rigors. Abeleno, appearing fully fifteen years older than the 65 years noted on his crumpled ID card, had been increasingly ill for at least a week. Initially he probably had pneumonia but refused to come to the rural health center, now he was obviously septic. After examining him, I advised him and the ten family member audience that even with the most aggressive treatment that I had, he very well might not survive the week. No doubt out of fear, their decision was not unanimous but as the old man agreed to treatment, I gave him a dose of IV fluids and medications. I made arrangements for him to have additional doses of medicines for the next few days and told him that I would return in three days though I well knew he might succumb to his illness.

Upon returning to my room in San Cristobal, Glenda, one of the translators (from Pocomchi to Spanish) brought her two year old son to see me for a second opinion about his condition. David had been frequently ill since his birth and had been recently been put on another antibiotic for ‘tonsillitis.’ David is not particularly small compared to other Mayan children and for his age is remarkably engaging; the kind that smiles as adults irresistibly tussle his thick jet black hair. I sat on a bench in the shade outside my room with and examined him as he sat on my lap; it is immediately clear that he has significant asthmatic bronchitis and was on the wrong treatment. I changed his treatment to three medicines, appropriate for his condition, and asked his mother to bring him back to me in a few days feeling certain that he would likely be profoundly better. The next three days went by as they had the first week.

Thursday morning as Roberto was making his presentation about a patient that we were seeing together at the community clinic in Pamuc, Nicholas, our driver, came in to say that just heard from the town that David had suddenly died that morning. The rest of the day focusing on patients took all of my professional discipline; teaching the nurses was impossible. On the way out of town we stopped to see Abeleno who in spite of my pessimistic but realistic expectation was making a turnaround from his deadly course and was now likely to make a full recovery; but my mind was on the little boy. For the hour drive back down the mountains my mind raced over and over the smallest details of my interaction with him. What had I done, what had I not done, what did I miss….?

That evening at the wake in the family home there were dozens of Maya in traditional dress, weeping, consoling each other, as coffee and bread was brought around. As I was introduced to one then another family member, I couldn’t help feel responsible (my sentiment not theirs) for the child’s death, though intellectually I knew differently, considering the profound limitation of resources here for testing or treatment, things we so take for granted in the U.S. I hugged David’s mother and told her how sorry I was, but I couldn’t imagine the intensity of her grief. Mostly I was dumbfounded as I sat there looking at the small white coffin. Then the sky opened up and rained for an hour, a deluge of tears that I was too numb to express.

I’ve learned some interesting lessons recently. As my career has taken several unexpected detours, I have experienced some things I have been discussing with patients for a long time.

Uncertainty is a reality for all of us. Life has all kinds of risk- lots of which we deny or avoid thinking about. It is uncertain how things will turn out. We make choices, and they influence the future. The environment can throw us challenges we did not expect. We choose how we respond, and I know the choice of response can be hard, but it is up to us.

One of the most important and difficult conversations I have with patients is about the lack of certainty of their diagnosis or treatment outcomes, and often both. Oh sure, I am a scientist, and I have lots of data, but when the patient in front of me wants to know how certain I am, or how likely it is that their treatment will work…well those are just tough questions. Even the best evidence available to me is based on groups of patients and give me ‘averages’ with which to help the person in front of me. Is this patient like the ‘average in the group studied? This patient could be like the ones who did way better than average, or….way worse. So this conversation about the uncertainty of medical prognosis is critical to trust and patient centeredness. They need to know we cannot be certain, so neither can they. And that can be a gift- it could turn out really well even in the face of uncertainty- I have hope!

So now I find myself thinking through that same conversation with myself (and my wife and friends). I don’t know where my career is going. A job I enjoyed is no longer available to me. Other jobs are. What choices will I have? What do I want? So the doctor/planner has to accept the essential existential reality- I don’t know! And the doctor/planner/father/husband/friend relearns the lesson of ‘breathe, listen, stay open, savor today and right now, and know that the uncertainty is OK.”

Recently I published a blog about the elements that I think need to be part of any serious effort at health care reform.  I had just been interviewed by local editor Andrew McKeever. Here is the complete interview courtesy of WBTN. It is in two parts.

Health Care Reform Interview Part 1

Health Care Reform Interview Part 2

Enjoy

As the national debate and legislative process creates a narrowing of the options, we are beginning to see pictures emerge.  For me it still feels a bit like we are putting together pieces of a jigsaw puzzle without benefit of the box cover — hoping the picture will work out. I recently had the opportunity to talk to Andrew McKeever, editor of the Manchester Journal, about this topic on our local radio station’s show called The Banner on BTN. I hope to post the audio of the show soon.

The goals of health care reform are in three dimensions:  access, cost and quality.  From my perspective the legislation so far seems to focus mainly on access. While a key goal of social justice, I fear that opening access to the current system without any redesign will only lead to bigger problems with cost. The system is fundamentally flawed already. Insurance pays for doing things to patients, not for good outcomes. It should not surprise us that now we get lots and lots of things done to patients at very high cost. The primary focus on reform ought to be on system redesign and changing what is paid for. Right now, if our local health system figures out how to improve care at lower cost, all the savings go to the insurance companies and government payors.

The Dartmouth Atlas research has taught us that more is not better. In fact, areas of the country that have lower costs, like Vermont, have better outcomes and better patient satisfaction. Vermont has just been named the state with the best health care system in the country, because of its balanced approach to access, care of the chronically ill, and resource use. http://www.commonwealthfund.org/Charts-and-Maps/State-Scorecard-2009/DataByState/State.aspx?state=VT . States that do so well with their care deserve a different approach to payment changes than states or health systems that are twice as expensive. Imagine what would happen if across the board fee cuts were applied equally to Vermont and Texas.

A recent article in Health Affairs discusses hospital costs in Wisconsin shows that hospital care can cost 30% less while improving care, by focusing on coordination of care. However, the hospital loses $2000 a case if it does so. Payment must be reformed so the hospital can keep some of the savings to reinvest in further improvements. Of course, society needs to keep some of the savings also.

Health care is extraordinarily complicated. Solutions will not be simple. The policy makers will need to get providers and patients in the room as the details get hammered out. Improving access without changing the system will be a disaster. Changing the system and rewarding good care would be a stimulus to better outcomes and slowing the rise of costs at the same time. The best practices to achieve good care at lower cost are already known.

Yesterday, I posted the first part of my friend Michael Polifka’s recent trip to Nicaragua. Here’s the second part for your reading pleasure.

Mark

This morning we headed south and after half an hour left the main road heading toward the coast and bumped along the 15 km dirt, pot holed road passing only Icaro trees whose ‘fruit’ is so dry and hard that it can almost be picked and used as the gourds that they will.  A breeze picks up as we pass the flats where ocean water is evaporated to make table salt (hence the community’s name) and arrive at Ernesto’s house.

Medications are laid out on a table for distribution to the populace.

Ernesto, a 45 year old man with multiple sclerosis, had most of his family’s land confiscated by the Sandinistas after the revolution 30 years ago even though they supported the cause; he now lives simply and quietly in a simple house on the beach with his dog, Scrappy.  (Scrappy, who stands less than 12 inches from the floor to the top of his head, apparently earned his name when he successfully satisfied a female Rottweiler who was in heat……but that’s another story.)  In spite of his disability, Ernesto is a community leader and has organized the day’s clinic at his place.  And so in the shade of the tile roof open ‘rancho’, with a constant cooling sea breeze, I lay out the meds for the day on a large picnic table where I see the the sixty patients of the day at a leisurely pace.

At noon there is red snapper caught that morning that is cooked in foil on an open fire simple and sweet.  And the day passes causally.  As the last patients are seen the sky clouds and opens up and pours for 20 minutes.  When it slows, I walk out onto the charcoal grey sand and along the empty beach looking at the veil of spray that blows off the top of the waves as they break close to flat low tide shore, happy content and now cool for the first time since I arrived.  Monday I will be up in the mountains, they tell me I’ll need a sweater at night.  We’ll see.

Hasta luego,

Michael

Children from one of the villages Michael visited.

Those of you who have heard me talk about why I choose to work in “administration” have probably heard me talk about “a sense of meaning in our work.” Some of my physician colleagues are troubled by the image of me sitting behind a desk rather than directly helping patients have better lives. When I talk about improving systems so that patients, and their providers, receive care and work in an environment that is more reliable, more efficient, and produces better outcomes, I can see the sparkle of some understanding among my colleagues. One of the more interesting observations I share with my good friend Michael Polifka is that the meaning in our work comes not from the giving that we all do, but from the sincere pleasure of seeing a life improved in whatever way.  Michael and I chose to work together in primary care for over 20 years, and have since then taken very different paths. I have embraced “system improvement” as a way to find meaning in my work.  I know  that large groups of patients receive better care because of system improvements I have been a part of building. These system improvements support those patients’ doctors and other clinicians to be able to deliver care more reliably.

And why should a doctor do this work? Because of the deep personal appreciation I share for the meaning in this work. It matters. So Michael has chosen a different path to fulfill his need for meaning in his work. Please enjoy his latest travel journal from Nicaragua. I can tell that, for him, this is more about what he gets from the people he sees than what he gives. There is grace and good will in the world. I would rather read this any day than the headlines in the typical ‘news’. I’ll post the whole over two days.

Salinas Grande, Nicaragua
26 August 2009

It’s best to start the clinics early because by one in the afternoon it is pushing 100 degrees.  It actually feels hotter than that here in the northwest lowlands because of the heat rising up from the Pacific volcanic ‘Ring of Fire’ the passes below; it is as if being in an oven on both bake and broil.  The rainy season usually starts by now, but El Nino has returned so the rain is scattered when it does occur.  A while ago when driving with my friend Rubio, I noted a visible pocket of rain off in the distance. He responded in typical Nicaraguan humor: “Well my country is very poor, we can’t afford rain everywhere.”

Dr. Michael Polifka preparing to remove a skin cancer.

Day one, patient number one portends my time will be as rewarding as previous trips.   Seventy year old Rafael asks only about his blood pressure but not about the obvious, large, ulcerating, skin cancer on his face.  Both he and I know that even if he could afford to have it taken care of at the hospital in Leon (he can’t), it would be at 6 to 12 months before he would be seen.  So, when I offer to remove it now in spite of my local guide’s, Marcos’, summarizing comment “Here?” Rafael readily agrees.

A pew from the church brought outside is the procedure table, Dr. Flores, my Nicaraguan counterpart for this trip, eager to learn, assists and in twenty minutes there are seven sutures and a grateful smile on Rafael’s face.  The rest of the day and in fact the remainder of the weekdays pass with relative efficiency save for the constant moving of our two chair-small table consultation stations to stay in some semblance of shade.

The patients are the usual mix of acute and chronic problems all not tended to because of a combination of poverty and lack of available doctors.  There are enough (too many?) children with pneumonia among all those with stuffy noses who really need antibiotics, hard working adults (men and women) with disabling tendonitis among all those with aching muscles who benefit from a steroid injection, and elderly with poorly treated hypertension, diabetes, or heart disease among all those with other problems I am unequipped to treat who are dispensed a year of medication to keep me on my toes in spite of stifling heat.  The deeply expressed gratitude from virtually every patient makes my physical discomfort a non-issue.

(more to come)

So it’s August, and summer has finally arrived here in the Northeast. Congress is in recess so they can connect with the public. As someone who is responsible for the effective use of some local healthcare resources, I find it sometimes difficult to really understand everything being said out there. And what is with all that yelling? Of course people feel disenfranchised. And others fear change because things could get worse.

I will make a couple of observations, and share why I think a good deal of the noise is on the wrong topic.

First, there are three levels of change that are needed in healthcare, and they are not all about the money.

The first change that is needed is in system design. Without changing the system, most of the reform proposals will put more people who indeed need care into a system that will consume ever more resources more quickly. This will exacerbate the financial problem. The system needs to be redesigned to reduce waste, and increase efficiency and quality. Those are easy words to say, but there are great examples in this country and internationally of doing this right.

The second change that is needed is in the payment system and its financing. The payment system needs to be aligned with the outcomes we really want, and its financing needs to be simpler and more fair across the entire healthcare industry and the geography of our nation. Disparities in payment for different kinds of care and across different regions of the country must end.

The third change that is needed is in our culture. And that culture is in two large and overlapping dimensions — the culture of healthcare providers, and the culture of our view of our health and how it is sustained. The culture of healthcare providers and healthcare consumers both needs to move away from the “more is better” idea that is now known to be not true. Consumers and providers need to agree that limiting some interventions and tests actually produces better health and quality of life. Providers need to help patients accept the large degree of uncertainty that still exists in healthcare, and consumers need to accept more responsibility for the choices they make to sustain their health.

A recent New York Times op-ed piece summarizes the existing examples of low-cost high-quality care that exists in the United States. If all America spent at the rate of these 10 areas, we would spend 16% less on healthcare. And the growth rate would slow. A current initiative by the Institute for Healthcare Improvement to study the most important features of low-cost high-quality care provides rich data and ideas for improvement.

So healthcare reform must acknowledge the complexity of the delivery system. Of course improving access to those without it is a core social value, and needed quickly. And eliminating lack of coverage for pre-existing conditions is critical. Shifting payment to reward practices that are low cost and high quality is an absolute necessity. And changing the conversation between providers and patients to focus on value in reducing utilization will help drive the culture to support good practice.

Finally, I agree with former Oregon governor John Kitzhaber that we as an American society should provide for the basic needs of our population with a publicly financed system. Not all medical interventions are of equal value. American citizens should be able to purchase insurance products that cover beyond the publicly financed core set of services.

When Michael Polifka and I were planning our practice together, we had many discussions about the “privilege” of practicing medicine. That’s what it’s called when you get “permission” to practice in a hospital — “privileges” to practice. In those long discussions about what we wanted out of our careers, we spoke about the intimacy involved in the conversations and plans we made with patients around their deepest fears and the uncertainties of prognosis, especially with serious disease. It is a privilege to have that degree of trust placed on the doctor-patient relationship.

As I reflect on the last few months, and the gravity of the situation that now faces our hospital, that same word “privilege” jumped into my head today as I rode my bicycle on some gorgeous back roads among these green mountains. This week I announced to the organization and the public that our financial performance is significantly worse than expected. I spent the day Thursday and Friday interacting with managers, medical staff leaders, employed physicians, and staff. These conversations led me to a feeling of privilege. That may seem odd in the face of such an “uncertain prognosis”, but it is based upon the reaction of the people who work in this wonderful institution.

While people are extraordinarily somber, the themes that are emerging are quite hopeful. Of course there is anger about how we got here. However, most folks are looking forward. And the remarkable thing is that everyone wants to help. I am sure there are those who wonder if they should continue working here in all this uncertainty. Most of those talking with me, however, want to learn the lessons of the past, and are looking forward to a better future.

At medical executive committee, physicians began to think about how they could participate by better medical record documentation to support charge capture and our revenue cycle. They also spoke about our culture that is still too “provider centric.” Are we really the most patient centered place we could be? Do we fit in patients who really want to be seen today? Has our competition learned how to serve patients in a more timely manner than we have? Physician leaders are concerned about losing patients to other health systems, and want to understand how we can maximize loyalty to our own medical staff and hospital.

The managers in our organization see wasted time and processes that require “rework.” They decry the poor budgeting tools that have left them with inadequate financial reporting tools to manage their areas of responsibility. They look forward to better understanding our organization through improved financial reporting.

The SVMC medical group has been challenged by Dr. Westergan to improve productivity and reduce costs. Physicians responded positively and already working on plans to accomplish these goals. Improved productivity in the medical group would have substantial “downstream” impact on the rest of the health system, because each patient seen in a physician’s office may need other diagnostic and therapeutic interventions.

After briefing by managers, staff has begun to react to the news of our financial situation. While there is substantial fear of changing benefits, threats to our future pay, and even our staffing levels; I am very moved by the recognition of the core values of our institution, and the professionalism of our staff, and how important those values are to our fiscal recovery. One e-mail sent to me the day the results were shared represents recognition of who we are.

This employee brought her mother in to the hospital recently. She was impressed with the “caring professionalism we have always taken pride in.” Then she went on to say:
“And you know, as I sat waiting, and looking around, my first thought that came to mind, and I know this may sound stupid, was, business as usual… I mean, despite the depressing financial issues, I saw people doing their job, being professional and friendly, from those in the SDS registration, to those in the radiology department. I still saw cleanliness in the hallways, and I still saw people with friendly demeanor. It was so reassuring, business as usual.

From my point of view, tremendous credit needs to be given to all individuals involved in the management of this great institution, and for the initiative shown to keep us a great organization, and for the genuine concerns for all. We are fortunate, and I, for one, thank you.”

This is the spirit in our organization that will bring us out of our uncertain prognosis. It is not me that deserves the thanks- it is all the people managing to put aside their worries and behave as this employee experienced – professional, caring, and patient focused. We are going to be just fine. I feel privileged to lead such caring professionals.

Research shows significant variation in care around the world. How does a doctor decide what tests or procedures should be done for the patient in front of her? And how do we as a society afford to pay the costs that are rising faster than our incomes?

There appears to be an answer that aligns what we need to do for patients and getting ourselves health care that is more affordable. For our health system right now, this is critical. In the current payment system, the road to financial success can be paved with overutilization. To get more money to the bottom line we have to do more — more tests, more procedures, more hospital beds occupied.

The evidence that doing more may cause harm (and doing less is usually better) comes from the Dartmouth Atlas, a more than 20-year series of studies and compilation of data that shows areas of the US with lower utilization and cost tend to have better outcomes and higher patient satisfaction. They have higher concentrations of primary care doctors, fewer specialist visits, and fewer days in the hospital in the last sx months of life. This variation in hospitalization for patients with chronic illness at the end of life varies from 6.1 days to 21.9 days and doctor visits vary from 15 to 60. There is a list of reports available at www.dartmouthatlas.org/atlases.shtm

The data show that doctors do tend to do the right thing for patients when the evidence is good, at the same rates in high expense and low expese areas. Even those rates are too low as the science of performance improvement has only slowly penetrated medical care to improve reliability of applying the science. However, when there is not much evidence to guide doctors, the variation is much greater. And the consistent finding of the research is that ‘local culture’ seems to be the dominant feature influencing whether doctors order lots of tests or not.

A recent article by Atul Guwande in the New Yorker nicely summarizes this conundrum.

Gawande also points out that changing ‘who’ pays for care will not change these dynamics. He draws an analogy to building a house — if, instead of paying a contractor to coordinate the whole thing you paid each ‘specialist’ — plumber, electrician, cabinetmaker — a fee for each item they recommend you’d get ‘a house with a thousand outlets, faucets and cabinets at a price three times what you expected.’ Would changing ‘who’ pays for care make a difference? No, it’s the coordination of the care under a system that is accountable for the outcome.

We have learned from the Dartmouth Atlas research that “the lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. “ It a story of integration of the medical staff and the health system like Mayo.

Our health system is poised to make important decisions. The ‘clinic model’ task force of doctors, management, and Board will be recommending a more integrated system. The policy makers in Washington and Vermont are poised to change payment in a model of shared savings that would require us to behave like a system. Our health system needs to be leaner and more effective in using our resources.

These various conditions have come together at a time when we face big challenges. The good news is that we know the status quo is intolerable, and if we do the right thing for patients we will also be cost effective and ready for success under inevitable change in health care payment. So the decisions will be guided by what we do — patient centered care. Doing the right thing will be best for patients and best for us. That will make it easier to find our way.