Sunday, July 20, 2008

Levi’s Gone About As Fer As He Can Go

A couple of weeks ago, a surgeon at the Harvard-affiliated Beth Israel Deaconess Medical Center (BIDMC) operated on the wrong side of a patient.

A few days later, Dr. Kenneth Sands, Senior VP, Health Care Quality, and Paul Levy, CEO, issued an e-mail to all BIDMC staff reporting the incident. The e-mail and related postings can be seen in Levy’s blog at www.runningahospital.blogspot.com. The e-mail includes a link to the story of the event as it appeared in the Boston Globe.

Not so many years ago, a hospital would have kept such an incident as quiet as it could. No more. Paul Levy, to his eternal credit, faced the issue publicly and directly.

But he did not go far enough for some. In his own blog (www.the-hospitalist.org/blogs) Dr. Bob Wachter, a health care quality guru at UCSF said that when Levy prefaced his e-mail remarks by noting that the surgery occurred on “a hectic day,” he overlooked the fact that most days in surgical suites are hectic, due to the continuous pressure to maximize productivity, with lower priority being given to safety. Wachter suggested that as part of the corrective action being taken, Levy needs to address this cultural issue.

Wachter’s second point related to the recommended safety protocol in surgery which includes a “time-out” in advance of each case, at which time each member of the surgical team agrees that the right surgery is about to be performed on the correct side of the right patient. According to the Sands-Levy e-mail, this did not happen in the case being reported. In his posting, Wachter expressed some skepticism that this was an oversight on the part of every member of the team, implying that the surgeon may well have been one of those who did not comply with this standard. He suggested that if this were the case, disciplinary action should have been taken against the offending surgeon.

Wachter has a point, but it also deserves to be mentioned that in doing what he did, Levy was already pushing the edge of acceptable executive behavior in hospitals. According to the e-mail, he got the BIDMC medical chiefs to approve his taking the matter public. Had he also gone for disciplinary action, he might well have lost their support. And had he lost the support of the chiefs, he almost certainly would have lost the support of his trustees.

Paraphrasing the words of Kansas Citians in the musical Oklahoma, I suspect he’s gone about as fer as he can go.

Monday, July 14, 2008

Dr. Michael DeBakey, Last of His Kind

Dr. Michael DeBakey died last week of “natural causes” at the age of 99.

Anyone over the age of 50 will remember Dr. DeBakey as a pioneering heart surgeon - possibly the world’s most well known doctor during the last half of the 20th century.

The offspring of Lebanese immigrants, Michael Debakey was one of those rare individuals uniquely suited to his time and place.

The heart has always had an ability to excite the emotions. It is the symbol of both love and life. When it stops, life stops. For most of history, the idea that it could be surgically repaired was pure fantasy if not irreverent.

At some point, scientific and technical progress had advanced enough to make it possible, but it took someone with DeBakey’s combination of intelligence, judgment, energy, ego, ambition, charisma, hubris and PR instinct, together with a hospitable American milieu, to make it happen and to create the surgical empire in Houston that made him famous.

It is said that he made his first artificial blood vessel on his wife’s sewing machine. He is also known for having invented the first practical pump to take over for the heart during surgery. By now, opportunities available to an individual doctor for inventing his own medical appliances have been pretty much exhausted. Furthermore, the law would no longer allow it.

Medicine, and even surgery, now depends on systems as much as on individuals. Those who knew Michael DeBakey would find is hard to imagine subjecting him to the discipline of an institutionally imposed system.

So let us honor the memory of Michael DeBakey.

There won’t be another one.

Wednesday, July 09, 2008

Senator Grassley of Iowa

Chuck Grassley has been the Republican Senator from Iowa since 1980. During each year of his tenure he has visited every one of Iowa’s 99 counties. Last Thursday he visited Shelby County where we keep a home in the county seat town of Harlan. We were there that day and went to the session, along with some 30 or 40 local people..

Senator Grassley is the ranking Republican member of the Senate Finance Committee. Health care is one of the eight major headings of his web page.

At one point during the session he recognized my upraised hand. I mentioned the high and rising cost of health care and asked if he had any prediction on how that issue was likely to be resolved. Old pro that he is, the Senator responded by rattling off malpractice, prevention, paying for value rather than quantity, and other buzz words politicians have found to be safe for use in such circumstances.

The next comment came from a local physician who described a practice improvement initiative undertaken at the local hospital under the sponsorship of the American Academy of Family Practice and urged the Senator to learn more about it. The Senator said that while his staff members who dealt with health issues did not visit Iowa frequently, perhaps it could be arranged for them to come by the next time they were in the state.

I then raised my hand again and expressed the opinion that the Senator ought to be both encouraged and instructed by what had just been said, in that real progress in health care reform depended in the end on the efforts of people actually involved in the provision of care.

The exchange was featured in the local newspaper report of the meeting. One hopes the Senator got the point.

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