Monday, January 19, 2015

Thursday, January 15, 2015

Where are the medical associations?

Over the last several years, many of us have raised issues concerning the propriety and appropriateness of doctors receiving funding from medical device companies.  For my part, I consider such payments as harmful, violating the trust between doctors and patients.  In some cases, they clearly influence the clinical behavior of doctors.  In other cases, they simply raise doubts about doctors' loyalty to patients' interests at a time when we should be enhancing that partnership, rather than eroding it.  When I make these points--in general or in specific--many US doctors respond by saying, in essence, "Well, everyone does it."

In contrast, people from other countries are appalled when they read of these kinds of payments.  They are viewed as unseemly, at a minimum, and often as corrupting of the relationship between doctors and patients.

But how likely are thing going to change in the US?

There are a plethora of US medical associations, each representing a specialty in the field, e.g., urology, obstetrics and gynecology.  They perform useful and helpful functions, from board certification to publication of professional journals to continuing medical education.

However, many of those associations themselves solicit and enjoy the sponsorship of those same companies that provide funds to individual doctors.  So how can we ever expect that they would adopt meaningful prohibitions on these matters for their members?

Until and unless the specialty associations start to take decisive action on these issues--for themselves and their members--the press and other observers of the health care system will write about examples that raise doubts about whether the public trust is being fulfilled.  Doctors may very well say, "That's not fair!"

Sorry, but it seems to me that "everyone does it" isn't a good enough answer any more. 

Wednesday, January 14, 2015

ACO: Let's start with organized

Dartmouth's Eliott Fischer once asked whether accountable care organizations would be accountable, caring, and organized.  For this concept to succeed, things are going to have to work a lot better than set forth in a friend's recent note about her elderly parent:

After Mom spent the night in the ER a week ago, I asked the hospital to send the assisted living place the discharge summary (which they had requested, to their credit.)  The hospital said they would when it was dictated.  I got the fax number for them and, of course, it never happened.

So now the assisted living place, which has its own physician, wants to draw her blood tomorrow to do lab work. I mentioned that, when we interviewed this facility, I had been told they had a computer connection to the hospital, and was this not so?

They hemmed and hawed and said, "Yes, maybe."

I said, "Then why don't you look in the computer and get her lab work from the ER visit and then you will have the information you want? "

"Um, well, I guess we could try to do that. "

So then they said, "Are you saying you don't want us to draw her blood tomorrow? "

I said, "Yes, that's what I'm saying. It would be better for everyone if you get the lab work that already exists." (Mom is a difficult stick anyway, by the way.)

It's like the 2 facilities, 3 miles apart, just function in parallel as if the other place doesn't even exist!! It absolutely boggles the mind. And of course they would charge Medicare AGAIN for the lab work-- which, if it had any sense, it wouldn't pay for.

I just sit here and say, it's really, really obvious why health care costs so much here. If you multiply this little stuff by the millions, and remember it includes repeat imaging studies, it really adds up, doesn't it?

End-of-Life Conversation Ready on WIHI

Madge Kaplan writes:
The next WIHI broadcast — End-of-Life Care and How Communities Can Become “Conversation Ready” — will take place on Thursday, January 15, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:
  • Jean Abbott, MD, MH, The Conversation Project, Boulder County; Faculty, Center for Bioethics and Humanity & Professor Emerita, Emergency Medicine, University of Colorado
  • Diana Silvey, MA, Program Director, Winter Park Health Foundation
  • Kimberly Flowers, MSW, LICSW, Senior Outreach Social Worker, Elder Services of the Merrimack Valley (Northeastern Massachusetts)
  • Kate DeBartolo, National Field Manager, The Conversation Project, Institute for Healthcare Improvement
Enroll now
It doesn't necessarily “take a village” to have a conversation with loved ones about wishes for end-of-life care. But it can help to have others in the community to turn to for ideas, resources, and support — especially if the “kitchen table” conversation with important people in one’s life isn’t happening so readily. Sometimes it’s easier to start this conversation with peers who get together once a week at the community center. Or with a rabbi or minister. Or, initially, with perfect strangers who’ve started to meet at the local library to talk about death and dying. 
With an aging population, and too many people not dying as they’d choose, community groups all across the US are creating more ways and places for people of all ages, and states of health, to articulate their end-of-life care preferences, and to make sure their preferences are known and respected by loved ones and local health care alike. We’re going to look at some efforts underway in Winter Park, Florida; Boulder County, Colorado; and in the Merrimack Valley of Massachusetts, on the January 15 WIHI: End-of-Life Care and How Communities Can Become “Conversation Ready.”

For many community programs, the resources offered by The Conversation Project, including the Starter Kit, are often foundational. And, as you’ll learn on this WIHI, for a community to become Conversation Ready, meeting people where they are in their lives (literally and figuratively) is key. This could be at a homeless shelter, the Elks club, or a class at a community college. There are no right or wrong answers when it comes to people’s end-of-life care wishes; and, as you’ll hear from our terrific panel on the January 15 WIHI, they’d like there to be no wrong doors, including those of health care providers, for having a discussion that couldn’t be more important to us all. Join in and tell us about efforts in your own communities on the January 15 WIHI.

You can enroll for the broadcast here. We'd also appreciate it if you would spread the word about the show via Twitter.

Monday, January 12, 2015

More on fast food in Melbourne children's hospitals

My post on fast food in children's hospitals received a lot of comments.  Here's the latest chapter from Melbourne, an opinion piece in The Age written by Alessandro Demaio.  He says, in part:

As a medical doctor and as a public health scientist working internationally, I can assure Victorians that there is good scientific evidence to support our concerns. This is not about banning or taking away choices in a nanny state. Excluding a US multinational from selling junk food inside our public hospitals is simply sound health policy. It is about sending a clear and consistent message to the community, and particularly young people, about what is healthy. 

Having a McDonald's embedded in a respected, taxpayer-funded institution like the Royal Children's Hospital does wonders for its brand power. McDonald's spent more than $1billion in 2013 alone on advertising junk food and any parent will tell you how powerful the golden arches are when children see them. There is good research showing that having a McDonald's next to hospital clinics makes people think its food is healthier than it is and that eating it will support the hospital. On a clinical level, it is counter-productive, too.

Boiling the public debate down to reductive rhetoric, Mr Andrews said "people who would like to tell parents every single thing they ought do and not do" is "nanny statism" that undermines legitimate government warnings for parents. 

Mr Andrews has missed the point. This was never about a ban, or creating a "nanny state", or about telling parents what to do. This was and is about a consistent message, defending our world-class public health-care system, and protecting the health of families across our state. It is about having a proper public debate and considering the health of the children in these hospitals, but also the health of the millions of young Victorians increasingly at risk from obesity-related disease. 

Time to think about Telluride

The deadline for applying to the Telluride Patient Safety camps has been extended to February 15.

Repeating my earlier post here:

Here's a lovely video summary of the Telluride Summer Patient Safety Camps that are conducted for residents and medical students.  The official name is now: Academy for Emerging Patient Safety Leaders: The Telluride Experience.  If you know anyone who might be interested, please have him or her apply, here.

True transparency in hospital PR campaigns

mediocre
GOMER blog, which modestly refers to itself as the earth's finest medical satire news site, provides the ultimate in hospital transparency in this recent post, Hospitals Unleash New, Brutally Honest Slogans.

Here are excerpts:

Forget the days of the compassionate and uplifting slogans like “A Passion for Healing,” “Because Your Life Matters,” or “Every Day, a New Discovery.” With record numbers of nurses and doctors burning out and hospitals busting at the seams with sicker and sicker patients, hospitals are waving their white flags and this is being reflected in new, brutally-honest slogans to deter patients from seeking care.

The first hospital to make the change is New York Medical Center, who earlier this month changed their decades-old slogan of “Advanced Medicine, Trusted Care” to “Death is Inevitable”.

Intentionally or not, the site then reflected the faddism that characterizes hospital advertising compaigns:

Other New York hospitals were quick to follow suit, calling the move “brilliant” and “revolutionary.”

But geographic diversity is evident:

In the Southeast, new hospital slogans are financially motivated. 

In the Midwest, slogans show a little more frustration.  

In the Southwest, hospitals have taken a different angle by trying to remain modest at best while focusing on flaws as a major deterrent to patient care.

And the body politic jumps on the bandwagon, just like in real life:

“This is an important moment in our country’s history,” said President Obama at the White House, with both Democrats and Republicans united in support behind him. “This is outside-the-box thinking at its finest.  What better way to decrease healthcare costs than by decreasing healthcare access and decreasing patient care across the board.”

Saturday, January 10, 2015

Lightning goes to ground

I respect and admire Lucien Engelen, the spirit behind the REshape Center for Innovation at Radboud University Medical Center in the Netherlands, so when he recently posted an article entitled, "10 TED talks that change(d) healthcare," I was intrigued.  Who doesn't love TED talks, after all?

But then I concluded that he was off base.

Not because the talks aren't great.  They are great.  They are stimulating, well presented, thoughtful, and challenging.

But they have not changed health care.  Look through the talks and see what's imagined in them. Now, compare them to what's happening on the ground in most places.

(By most places, I am talking about the economically developed countries.)

What we see in those countries is the presence of two inexorable forces.  One force comprises underlying demographic factors.  The old are living to an ever-older age and are putting unprecedented demands on the health care system as we take care of their chronic and acute illnesses.  Meanwhile, the next generation (the Baby Boomers) have entered the age of hospitalization, compounded by an extremely high level of entitlement.  ("I hurt my knee playing soccer.  I need to be able to play as soon as possible.  I demand an MRI and arthroscopic surgery to repair that rip.") And, finally, the next generation is characterized by a sedentary lifestyle, which has and will lead to obesity, diabetes, and the sequelae of those diseases.

Meanwhile, in the face of this demand, pharmaceutical and technology companies invent new diagnosis, treatments, equipment, and supplies.  They seek to grab their portion of the growing health care budget.  Very few of their inventions, whether efficacious or not, lower the cost of health care.  They tend to be additive.  (And, by the way, many are not efficacious.)

So what we find around the globe is a persistent growth in health care expenditures.  Because there is a limit to society's ability to absorb such expenses, the costs are being pushed down--step by step--to those least able to seek alternatives, the general public.

Daniel Palestrant, the highly thoughtful CEO of Par80, has recognized this phenomenon and has likened it to Benjamin Franklin's most important invention, the lightning rod:

In this country, when it comes to healthcare, lightning has indeed struck.  Like a bolt of lightning hitting a colonial building (which were largely made of wood), the energy must find a path to ground as quickly as possible, scorching everything on the way down.  The question isn’t whether it will find ground, it is only how much collateral damage it will do as it gets there.  The healthcare crisis is lightning hitting our society.  If it isn’t managed carefully, it will burn down the house.

As healthcare costs have exploded, the cost and responsibility has been shifted from private companies paying for employee benefits, to physicians, to insurance companies, the American taxpayer, and most recently, the Chinese (who we have been asking to lend us the money to pay for these costs).  In turn, each of these parties has now found a way to either defer the liability or signal they are no longer willing to finance the effort to sustain the status quo.

Lightning grounds when costs and responsibility are shifted back to the only remaining entity….the patient.  That’s where we are heading.


Daniel offers a hopeful prediction:

It’s not all bad, though.  Directly engaging consumers in their own healthcare will inevitably lead to two trends:

Disintermediation - As the lightning accelerates, it will look to cut out as many intermediaries as possible.

Price to Value - Once consumers are more responsible and accountable for the cost and manner of their own care, it will become more likely that healthcare goods and services will be priced on relative value, rather than an arbitrary value set by a third party.


Well, maybe. I think that some consumers will have those opportunities, but I think that most will not.  Taking just one recent item, the trend to high deductible health plans, we already see the growth of inequity based on income.  Lower wage people choose the high deductible plans to reduce their monthly premium, but then they systematically choose to avoid spending more of their disposal income by deferring or avoiding appropriate medical care.

As the Institutes of Medicine recognized years ago, a health care system that is not equitable is one that fails.

I bet if we surveyed the viewers and listeners of TED talks, we would find a bias towards higher educated and wealthier people.  Sure, they're really excited about the ideas Lucien proclaims as changing the system in the direction of higher quality, greater safety, and lower costs.  And sure, many firms in the marketplace will aim their products and services to those groups.  How much will trickle down to the rest of society?

My fear is that what trickles down will not be the innovations that bring about higher quality, greater safety, and lower costs.  What makes me pessimistic?

Frauds already abound, attacking the economically weakest in society.  As Al Lewis, Vik Khanna  and Shana Montrose have documented, the so-called wellness industry has started to impose its own form of tax on the health care system.  In cahoots with the HR departments of firms that have pushed deterioration of employer-sponsored plans, the wellness companies offer a "goody bag" of options that appear to help you save money on your premiums.  Well, that's the first step.  The next step is that you get penalized if you don't "comply" with the wellness plan your employer has chosen.  Who won't be able to comply with the exercise and diet programs?  I'm willing to predict it will be disproportionately the lower wage earners.

On this blog, I've documented aspects of how direct-to-consumer approaches have empowered medical device companies to charge consumers for unnecessary costs.  I've pointed out how the medical-industrial-government complex aids and abets such practices through opaque rate-setting and rule-making procedures highly influenced by those same companies.  When those higher costs get passed along directly to consumers, they act as a regressive tax on those with lower incomes.  When they get passed through indirectly through Medicare, they end up stretching the government's budget.  Searching for budget relief, CMS engages in arbitrary penalties for failure to meet arbitrary quality metrics.  Which organizations tend to do worse on those metrics and pay the penalties?  The hospitals serving the lower income portions of society.

Let's look at other industries that have moved in the directions predicted by Daniel for health care--disintermediation and price-to-value--like finance and banking and telecommunications..  While we can point to overall societal gains in each of these fields, the predominant part of the value obtained from these structural changes has tended towards the wealthier components of society.  Why should we expect health care--which is intensely more complex than any of those other sectors--to behave otherwise?

I don't offer these thoughts out of some socialist desire or expectation.  I offer them to remind Lucien and others that their job isn't done until or unless there is a greater democratization of the benefits of all those innovations.  That democratization will not arise from lovingly produced TED talks viewed by the elite in society.  It will require a movement from the patient advocacy world.

That world, however, remains inchoate.  Many patient advocates arrive to this field as a result of personal injury to themselves or a loved one.  They are not trained in the skills needed to build coalitions.  They are on their own, without sufficient resources to get their own word out, much less have the time and energy to meet with other and build a national movement.

There is no established organization in America or, from what I have seen, other countries that has devoted itself to the promotion of a vibrant, widespread patient advocacy movement.  Those that might have done so have shied away from this kind of engagement--perhaps because they know that any movement so constituted will be unpredictable and beyond their control.  Yes, some hospitals seriously try to engage patients in a clinical partnership, using advisory councils and the like, and these efforts are useful.  But they only go so far in that they are islands of activity with little or no crossover beyond the catchment areas of each hospital system.

Years ago, I came to know a wonderful man, V.B. Mishra, who was engaged in trying to stop the pollution of the Ganges River.  He decried the lack of political support for this effort, saying, "The river needs its Gandhi." Well, the truth of the matter is that Gandhi's and Mandela's and M.L. King's come along very seldom and usually only in times of great change and crisis.  During most times, it is not a single leader who brings about change: It is a coalition of many local leaders who figure out how to join hands and bring persistent pressure on the body politic.  Until the patient advocates figure out a way to create that coalition, the lightning will go to ground in a manner that many of us will consider inequitable and inconsistent with the objectives of political stability and economic prosperity for all.

Do they need to get over themselves?

One of the things I enjoy about Australians is the tendency for straight talk, but I wonder if the Premier of Victoria will come to have second thoughts about a recent comment concerning the availability of fast food in the state's children's hospitals.  Here's the issue:

A group of people feel strongly that allowing McDonald's to have a franchise in the lobby of children's hospitals is not appropriate.  As noted in a story by Julia Medew in the The Age:

Public health experts are calling for the new Monash Children's Hospital to exclude fast food outlets and say the Royal Children's Hospital should dump its contract with McDonald's because it is creating a "healthy halo effect" that sends the wrong message to families.

With one in four children overweight or obese, Melbourne University public health professor Rob Moodie said Australia's leading paediatric hospitals should not be supporting multinational fast food chains like McDonald's that targeted children.

"It's hard enough to encourage people to eat healthy foods at the moment. We don't need the branding of some of Australia's most prestigious hospitals lending their support to something that is fundamentally promoting a poor diet. There's a real clash of purpose there."

Premier Daniel Andrews' response to this was offered in Medew's next story:

"I'm also a parent and frankly the notion that it is somehow a bad thing to give a sick child a treat, to give a sibling of a sick child a visit to McDonald's, that is just nonsense and we'll have none of it, none of it at all," he said.  

The premier added that "people who would like to tell parents every single thing they ought do and not do" was "nanny statism" that undermined the power of other advice governments give parents.  

"The McDonald's is here to stay in this health service as part of a balanced offering and that's exactly the outcome we'll achieve at Monash Children's as well," he said.

"There will be no prohibition as some would like and frankly, they need to get over themselves." 

The response:

Professor Moodie and Obesity Policy Coalition head Jane Martin, who both spoke out about the issue last month, said Mr Andrews had missed the point.

"It's not really about whether children should be having these treats or not, it's about whether a children's hospital should be seen to be endorsing the kind of food that McDonald's basically sells. They basically sell nuggets and fries," Ms Martin said.

"Hospitals are dealing with a huge burden of diet-related disease ... This is our new smoking."

The whole issue has been brought into the public consciousness worldwide by a coalition called Value [the] Meal Campaign organized in great measure by Corporate Accountability International.  It seeks "to restrict predatory junk food marketing to children" and block such restaurants in children's hospitals and in schools.

What's your take on this issue?  Please offer comments below.

Friday, January 09, 2015

Young doctors suggest use of evidence and disclosure

A follow-up to an earlier post. Jonathan Giftos, a resident phsyician in primary care and social medicine at Montefiore Medical Center, and his colleague Dr. Sam Cohen attended this session:

Lenox Hill Hospital, part of the North Shore-LIJ Health System, is offering a free informative evening on Thursday, January 8th from 6-7:30 p.m. with David Samadi, MD, chair of urology and chief of robotic surgery, about what women can do to help keep the men in their lives healthy and happy.  

I include excerpts of Jonathan's report on Facebook without further comment:

Drinking a beer with Dr Sam Cohen after going toe-to-toe with David Samadi at his shameless, chauvinistic, pandering and misleading talk promoting en masse PSA screening in an unselected patient population, described famously by Shannon Brownlee as "the loss-leader for robotic surgery." 

Unsurprisingly, there was no conflict of interest disclosure. Gross deception as he described "screening" as a uniformly good thing that the government is trying to take away in order to save money. Characterizing women as emotional, shop-a-holics and then exploiting their worries over their husbands' health to promote evidence-less medicine for profit was also a highlight. That an academic medical center like North Shore-LIJ Health System allowed this to happen is deeply problematic.

Sam and I got the mic for about 5 minutes. Challenged his blatant disregard for USPSTF recommendations. Challenged his conclusion that because there isn't a better test out there we might as well continue using one that is known to cause more harm than good. He dodged the conflict of interest question and essentially told us to go back to Brooklyn. 

There were no other dissenting views in the room. He ignored my question as to whether someone who earns close to $8 million dollars a year off this test should disclose their conflict of interest when promoting a test so indiscriminately. He responded to Sam's question re: the data that shows en masse the PSA to be more harmful than good by bringing up the wife of a former patient who was diagnosed with early prostate cancer to go on record and "teach us" why the PSA saved her husband's life. The audience clapped. The intellectual dishonesty was tough to watch. He concluded by saying that Elizabeth Hasselbeck is on board with his approach, as we should be. 

All in all, an enormously frustrating event to attend. But glad to stand up against the shameless exploitation of our patients and our healthcare system for financial gain.

Now, what to do with this lousy t-shirt.

With Roger Bannister in London


I can't let this week close without reporting what a treat it was to present a paper in the Roger Bannister Audtorium at Imperial College London.  Here's the setting (above).

The seminar was organized by Susan Burnett at the NIHR Imperial Patient Safety Translational Research Centre.  My title was "Being willing to see things clearly: Looking at the essential role of transparency in clinical process improvement."

Many thanks to Susan!  It was a lovely evening with a great audience, but the highlight for me was to be able to stand there at gaze at this famous picture of Roger breaking the four-minute mile:


It's hard to remember today, but many people thought that the human body was incapable of this feat--that if you did it, you would keel over and die immediately afterward.  There is a spectacular book about the quest called The Perfect Mile, which I heartedly recommend.  Here's the summary from Amazon:

There was a time when running the mile in four minutes was believed to be beyond the limits of human foot speed, and in all of sport it was the elusive holy grail. In 1952, after suffering defeat at the Helsinki Olympics, three world-class runners each set out to break this barrier. Roger Bannister was a young English medical student who epitomized the ideal of the amateur — still driven not just by winning but by the nobility of the pursuit. John Landy was the privileged son of a genteel Australian family, who as a boy preferred butterfly collecting to running but who trained relentlessly in an almost spiritual attempt to shape his body to this singular task. Then there was Wes Santee, the swaggering American, a Kansas farm boy and natural athlete who believed he was just plain better than everybody else.

Spanning three continents and defying the odds, their collective quest captivated the world and stole headlines from the Korean War, the atomic race, and such legendary figures as Edmund Hillary, Willie Mays, Native Dancer, and Ben Hogan. In the tradition of Seabiscuit and Chariots of Fire, Neal Bascomb delivers a breathtaking story of unlikely heroes and leaves us with a lasting portrait of the twilight years of the golden age of sport.

Thursday, January 08, 2015

Just wondering

Beth Kutscher at Modern Healthcare reports that for-profit hospital chains have done well and are poised for higher profits as a result of the Affordable Care Act, "because they've cut costs and adopted new initiatives to bring in more patients."  Why is it then, that the largest for-profit system in Massachusetts has not been part of this trend?  Indeed, it has had to close one of its hospitals for bad performance, "after the long-struggling hospital finally succumbed to the intense competition [from the non-profit hospitals] for patients south of Boston."

The firm has also resisted state requests for its most recent financial reports.  Is that a sign that the numbers are so bad that the company doesn't want them to be disclosed publicly?

I recall an official from this firm commenting in 2011 about the virtues of private equity ownership compared to the management of non-profit hospitals: 

At a recent conference, one private equity official derisively talked about the inadequacies of local lay leaders eating their "stale bologna sandwiches" at Board of Trustees meetings, to draw a contrast with the unsentimental businesslike behavior of a board chosen by his firm.

What's next? How will this pain end?  How will essential hospital services be provided to host communities if the company is unable to meet financial targets?  As I noted in 2011:

Those seeking to regulate the behavior and financial decisions of for-profit hospitals will find that their post hoc authority will likely be insufficient to protect the public interest . . . .
 

Investors may come and go, but the community depends on its local hospital to provide high quality service. It is the residents of the community who are left holding the bag if the hospital corporation reaches the conclusion that ownership is not financially viable.

A reporter who cares, too

Right after New Year's Day, I commented on a "top ten" list prepared by Akanksha Jayanthi at Becker's Hospital Review that contained the priority patient safety issues for 2015.  I indicated discourgameent because so many items on the list had persistently remained there, emblematic of lack of leadership and progress in so many health care settings.

Well, afterwards Akanksha revisited the subject, "partly in response to your blog and partly just to voice some of my perceptions and frustrations with the industry from the vantage point of a healthcare reporter."  She offered a number of personal reflections on the Becker's blog.  Excerpts:

As a healthcare reporter, I continuously research the industry, speak with healthcare professionals weekly and write about the issues daily, all of which objectively informs my perception. 

And the perception I have of the healthcare industry is one wrought with contradiction. Hospital executives, physicians and staff claim their No. 1 priority is the patient. It's upheld as the universal truth. But in this industry, talk seems oh-so-cheap because 440,000 deaths from preventable errors don't relay the message of "safety as a priority." If hospitals and health systems truly hold patient safety as a main concern, there is no excuse for such a figure.

And then she asks the key question:

When will leaders actually make purposeful moves toward addressing these issues and tangibly demonstrate their commitment to the patient?

Time is going quickly, and these safety concerns aren't budging.

And then she concludes:

So where does that leave us?

One of the main pillars of journalism is objectivity in reporting. Journalists are not to involve themselves with the stories they write. I apologize now to the professor of my ethics and communication class, because in this case, I would be remiss to not get involved.
I don't want to include hand hygiene on future lists of patient safety issues. I don't want to include medication errors. I don't want to keep writing about HAIs.

It's a new year, so let's develop a new focus on the most basic tenet of healthcare: caring for the patient. Re-visit my list of the top 10 patient safety issues for 2015 and push those to the top of your resolutions.

And this year, I hope to write a different story — one void of discouraging repetitiveness. We owe that progress to the patients.

Brava to Akanksha.  There is a lesson here for all health care journalists: Maintain your objective reporting standards in each story, but be sure that the stories you choose to cover are not restatements of industry pablum or self-serving press releases.  Find the drama in the fact that people are unnecessarily being harmed and killed.  Document and expose those cases.  Probe and explain to the public and the profession what has and has not been done to improve the situation.

Also, when new (often expensive) medical devices and therapies are introduced, ask the question:  Do these actually make care better for people?  On the AHCJ listserv recently, Norman Bauman noted:

A study in this week's BMJ found that when news stories exaggerated the results of health research, the original press release was usually exaggerated. About a third of the press releases had exaggerations. 

They scored the original papers, press releases, and news stories on (1) Advice to readers to change behaviour, (2) causal statements drawn from correlational research, and (3) inference to humans from animal research that went beyond those in the papers.

40% (CI 33% to 46%) of the press releases contained exaggerated advice

33% (26% to 40%) contained exaggerated causal claims

36% (28% to 46%) contained exaggerated inference to humans from animal research.

When press releases contained such exaggeration, 58% (CI 48% to 68%), 81% (70% to 93%), and 86% (77% to 95%) of news stories, respectively, contained similar exaggeration.

 
They said the responsibility in such cases rested not with the journalist, or the PR office, but with the researchers who let the press release go out with those claims. . . . So the action points are to read the original paper, or at least the abstract and discussion, not just the press release.

In pursuit of the big data Holy Grail

About every six months, one of the young brilliant and enthusiastic "big data" people who hang out in the MIT neighborhood near Kendall Square or in the Bay Area of California comes to me for advice as to how to break into the health care market.  He or she is inevitably prepared to deliver the Holy Grail to a waiting health care world, i.e., a real-time decision support system that will codify the world of evidentiary medicine and help clinicians reduce length of stay, the number of unnecessary readmissions, and the cost of care.  The person has sometimes, but not always, set up a "comparable" company in another field, analyzing big data and improving industrial processes, and s/he has often sold that business for a handsome sum to a multinational corporation or private equity firm.

I love meeting with these young people.  They are true believers with no shortage of confidence, and they are fun to hang out with.  So, I'm a bit reluctant to offer this blog post because I am going to set forth my advice in writing--knowing that I might perhaps make future personal meetings redundant. (But I'm hoping they'll still call.)

To obtain the Holy Grail, you need to satisfy the following interrelated conditions:

1) A sophisticated data management system that, indeed, provides clinical advice that will be accurate in the vast majority of cases;
2) A plan to integrate that system into the various support systems that exist in a hospital so that it can be used in real time, i.e., as patient care is being delivered;
3) A plan to convince doctors and others to use the system;
4) A strategy for getting the procurement approved by the various high-ranking clinical and administrative officials in the hospital.

On the first point, what level of accuracy do you think is required to offer a decision support system that could have the confidence of doctors?  How would you test that accuracy?

On the second point, how long will it take to invent the interface between your system and the variety of clinical and administrative information systems that exist in your targeted hospital(s)?  Think about it this way:  How likely do you think it will be that you will get the time and attention of the CIO to install your system, as s/he is a bit busy with Meaningful Use projects?

On the third point, well, you know the issues.  Please don't think that because you've satisfied #1, above, that adoption by MDs will be assured.

On the final point, who within your targeted hospital(s) will carry the water for this project in the strategic and budgetary reviews with the CIO, CNO, CMO, CFO, and CEO?  Lots of people in a hospital can say "No."  Which of these people will say "Yes" and become your internal advocates?

If you can figure this all out and stay capitalized long enough to make sales and bring in revenue in a timely fashion, all will be well . . . if your approach truly offers a comparative advantage to the dozens of others trying to enter this arena.

Tuesday, January 06, 2015

Disaster for the public as cancer treatments succeed!

I know I shouldn't make fun of this because it is a serious topic, but when you read the headlines in the British press, you might wonder if there was terrible news.

Here was the actual headline at the BBC:

Cancer crisis: Cases to reach 'record high in 2015'

And at the Telegraph:

Cancer 'becoming a crisis of unimaginable proportions'

And again at the International Business Times:

Cancer: Record high UK numbers creating 'crisis of unmanageable proportions' for NHS 

The actual story was about how many more people are living with cancer than years ago, with record survival rates.  For example, the story in the i noted:

Better detection of cancers and the increasing success of treatments have led to half of cancer patients today expected to survive.

Among the over-65s, the numbers living with cancer has gone up by 23 percent in five years.

That, of course, is good news.  The point of the stories was that many of these folks will need ongoing care, with some facing ill health or disability after their treatment.  This, in turn, will create financial strains on the NHS.

This is a legitimate public health issue, but the headlines left me chuckling a bit.  It felt a bit like snatching defeat from the jaws of victory.

New transparency website from WSHA

I always love hearing from my buddy Beth Zborowski at the Washington State Hospital Association.  That organization and its members have been at the forefront of transparency for years, and they keep pushing the envelope.

Here's her latest note:

I wanted to share with you WSHA's new quality transparency website and would welcome your feedback: http://www.wahospitalquality.org 

We've organized the site to provide relevant information to services patients (or their loved ones might be seeking.) For example, in the past, someone going in for surgery might only look at the specific measures related to their type of surgery, but may not think to look at other relevant or overall quality indicators, like CAUTI.  

We've included data along with a visual indicator highlighting the "opportunity gap" between performance and the goal for each metric. Another new addition is the inclusion of tips for patients when they're going to the hospital. In feedback from consumers so far, this visualization takes a little trying to get, but they appreciate having both the number and some kind of visual indication of performance. We're working on a clearer widget for the next version of the site. (We're committed to expanding and improving the site, this isn't intended to be a launch it and forget it project.)  

I would love to hear what you think.

So, please check it out and post comments here or send them directly to BethZ [at] wsha [dot] org.

Monday, January 05, 2015

Seeking a system that treats us all humanely

As 2015 begins, let's turn back to last January's aeon article by Ilana Yurkiewicz.  Simple, direct, and incontrovertible.  (Thanks to long-time reader Mitch for the reminder.)  Key excerpts:

Creating a culture of respect is not just about feeling good, for its own sake. It’s better for patient care.

When someone is unpleasant or demeaning, something switches in the minds of those on the receiving end: they sacrifice honest communication to save face. I’ve seen it in action so many times that the pattern has become predictable. Preoccupied with fear of appearing incompetent, team members keep uncertainties under wraps. Other times the opposite occurs. Annoyed that they’re being denigrated and prideful themselves, others fight back – even when they’re unsure of the thing they’re fighting about. Once I saw two residents argue back and forth in front of the attending about a finding on a physical exam; the issue was unrelated to the patient’s illness, and the fight, a clash of egos, took mental energy and focus away from the patient’s needed care.

Contrast that with cultures steeped in mutual respect. I’ve been on some truly outstanding medical teams that worked in opposite ways. Though everyone knew their place in the hierarchy, it also felt more egalitarian. Patients came before pride. The senior staff told others how to reach them and opened the lines of communication. Nurses attended morning rounds with the doctors; their input was valued and they were kept in the loop at every step. One night, we were on call with a ‘watcher’ – that is, a patient who could take a turn for the worse quickly. The resident made clear her door was open – literally and metaphorically. The nurses came by often and clarified orders. When the patient began to look even slightly ill, the nurse immediately got the doctor. They examined the patient together as the doctor explained what to do next and why. Questions were encouraged. Communication was crystal-clear. And the patient did well.

How to fix this?

Change should emerge from within the hospital itself. Instead of looking away sheepishly when our colleagues are mistreated and apologising for bad behaviour with tired mantras, we should push back. Bullies have ripple effects. Medical students mimic the behaviour of residents who mimic the behaviour of attendings until a problem with attitude can extend from a few people to an entrenched culture. Instead of riding that wave, we could shun bad behaviour. This is easier said than done. But cultures change because people within commit to changing them; it won't come by decrees. A culture that shames bullying makes the bully look like the bad guy, rather than making the recipient look weak.

In a similar vein, we should put an end to the premium that the medical establishment places on saving face. This is a hazard. It feeds the egotistical environment that can lead to ignoring input and failing to ask for help. It creates doctors who value looking like they know what they’re doing at all times more than actually doing what is best.

Finally, we should be getting to the root of the behaviour. Why do people behave badly? Some are just jerks. Some imitate jerks. But we also can’t ignore a system that takes loads of formerly ‘nice’ people and churns out jaded, bitter, and gruff ones. We have to call attention to the external factors that can contribute. The lack of sleep. The poor hours. The system that overbooks and overworks. Environments such as these persist in part because of our unique vantage point in taking care of others at some of the worst points in their lives. How can I say ‘I’m tired’ or ‘I’m hungry’ or ‘He hurt my feelings’ in the face of such profound human suffering? Yet it’s hardly absurd to ask for better working conditions. When working in a system that treats us all humanely, we’re more likely to be humane to each other, and to our patients.

Sunday, January 04, 2015

Oh, NS-LIJ, we hardly knew ye.

In a post below, I wondered whether a publicity campign by a urologist to encourage women to get their male mates to have PSA and testosterone tests was only the product of that doctor or was it also endorsed by the North Shore-LIJ Health system.  Well, the answer has come through, thanks to Dan Goldberg and Laura Nahmias at Capital New York.  Along with quoting my blog, they reported:

Dr. Davi Samadi, chair of urology and chief of robotic surgery, has something called “The Samadi Challenge. It sounds a little like the ice bucket challenge. Women ask men in their lives to get their prostate and testosterone levels checked, then record a video challenging three other women to do the same.

 ...I asked L.I.J. for their response: “The seminar we are organizing is simply a community education/awareness initiative, pegged to the fact that women are the primary healthcare decision makers in most families. No other motivation. Because Dr Samadi maintains a high profile, he tends to be an occasional target of health care colleagues.”

We could spend a lot of time deconstructing what's going on here, but let's get to the basics:

An otherwise well respected health care system--one of the leaders in patient safety and quality of care--is now endorsing tests that have been the subject of tremendous recent controversy.  When the question is raised about this program or its tendency to promote overuse of diagnostic tests, the health system's response is to assert that the criticism is based on the personality of the doctor in question.  The system makes no attempt to address the legitimate issues of medical science raised.

Let's compare this type or response to the well considered message previously set forth in the "Commitment to Excellence" section of the system's website:

North Shore-LIJ has adopted a strategic plan for quality that is directly aligned with the national healthcare agenda. Our goal is to deliver exceptional quality service to every patient, in every care setting during each healthcare encounter. Our capacity to measure and report healthcare outcomes, realize cost efficiencies, and ensure patient safety through adherence to best practices are instrumental to providing high quality medical care to the communities we serve.

Or to this statement from the system's CEO about the system's strategic objectives:

Medical tests, which are overused in the US, will be reduced. 

Oh, NS-LIJ, we hardly knew ye.  Are the commercial wars so transformative?  How have you changed so quickly?

Friday, January 02, 2015

The worst of the top ten lists

New Year's Day seems to prompt lots of "top" lists: Top books, top movies, whatever.  Many are cause for wonder, nostalgia, or appreciation.

Here's one such list* from Akanksha Jayanthi at Becker's Hospital Review that prompts discouragement.  It is the list of the top ten patient safety issues for 2015.

Why discouragement?  Because it's virtually the same list that has existed for years.  It does not exist because of technical complexity or financial constraints.  More than anything else, it is a list that documents the failure of leadership by all too many boards of trustees, senior administrators, and chiefs of clinical service in America's hospitals.  There are, of course, some who have done better, and they deserve our thanks, but hospitals unfortunately remain one of the top-ranked public health hazards in the country.

Healthcare-associated infections. 

Antibiotic resistance.

Personal protective equipment protocol. 

Hand hygiene.

Health IT issues.

Medication errors.

Workforce safety.

Transitions of care.

Diagnostic errors.

Patient engagement. 

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* With thanks to Mark Graban for the call out.

Tuesday, December 30, 2014

A tactic worthy of used car salesmen

I understand my educational limitations with regard to making medical judgments, but I have to conclude that a recent campaign by a New York City urologist has to be skating mighty close to the ethical line.  That this would be offered by an affiliate of the North Shore-Long Island Jewish Health System, which has an outstanding record of patient quality and safety, makes it all the more strange. 

Here it is.  Excerpts:

Lenox Hill Hospital, part of the North Shore-LIJ Health System, is offering a free informative evening on Thursday, January 8th from 6-7:30 p.m. with David Samadi, MD, chair of urology and chief of robotic surgery, about what women can do to help keep the men in their lives healthy and happy.  The presentation will be followed by a question-and-answer period, and everyone is the audience will be receiving a free T-shirt.

“Woman are the most proactive healthcare champions in the family and are the driving force in men’s health,” said Dr. Samadi.   “We want women to promote men’s health issues with a particular focus on those associated with the prostate and sexual function so they can encourage healthy lifestyle choices for the men in their lives.”

Dr. Samadi will be challenging the audience to participate in “The Samadi Challenge.”  Created as a way to promote the importance of prostate health, the Samadi Challenge has gone viral over Facebook. "I asked women who have a man in their lives to get his PSA  (prostate specific antigen) and testosterone levels checked," Dr. Samadi said. "They then had to record a message that challenged three women they know to do the same and post the video.”

I'm not going to go through all the recent studies about PSA and testosterone tests.  You can do that on your own.  What I am going to say is that in neither case is there reason to believe that an unselected population of normal men should have these tests.

This doctor and through him this health system are engaged in advocacy that will cause overuse of the health care system.  Add to that the inevitability of a number false positives from the PSA tests, leading to an unnecessary number of biopsies, some of which will cause harm to patients.

So, we have to ask, is this a doctor doing this on his own, or does it have the support of the health system's administration?  Is this a scientifically based clinical program or a business development program?

Finally, the fact they are deliberately using women to get at the men and do their advertising for them is disrespectful to both. This is a tactic worthy of used car salesmen.

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Addendum:  Dear readers, after reviewing the extensive and thoughtful comments below, please turn to the follow-up post on this topic, in which NS-LIJ Health System responds.

Is it businesslike or businesslike? The difference is pretty important.

Budd Shenkin offers perceptive observations in a recent blog post, following up on my story about Heartland Regional Medical Center's extreme debt collection practices.  Excerpts:

Yes, healthcare needs better business methods. But when you think about it, "businesslike" seems to have two separate lines of thought, even two different meanings. On the one hand, good business is knowing your costs and recovering them, producing a better product, increasing efficiencies, etc. On the other hand, business practices can be rapacious, grab the money, go for the gold, do whatever it takes, etc. When people say that healthcare should be “run like a business,” mostly they mean #1, not #2. But if you confronted Heartland, odds are they would say “we need to run it like a business,” and mean #2, not #1.

He continues:

But you just have to think, is profit an objective, or a constraint? If your objective is to help people one way or another, then profit can be a constraint – you can serve people, but only with the constraint that you can't lose too much money doing it, or you will go out of business and help nobody. If, however, it's the reverse, you then want to make as much money as possible, with the constraint that you do have to help some people along the way. Or at least not hurt them too much. Or at least not get caught hurting them too much, which would then start hurting profits.

So, if I look at a healthcare program, I have to think: OK, run it in a businesslike fashion, but is it businesslike #1, or businesslike #2? Are they doing well by doing good, or just doing well? The difference is pretty important.

IPI helps inform patients

There are so many well intentioned people working to improve patient care from "the outside," often focused on creating true clinician-patient-family partnerships.  I have to admire their dedication and tenacity, often in the face of passive resistance from those on "the inside."  Here's hoping they stick to it and have more and more influence over time.

Carol Cronin is one such person.  She runs the Informed Patient Institute. IPI rates the usefulness of online doctor, hospital, and nursing home report cards. "We don't rate individual health facilities or practitioners — but we'll tell you who does."

In addition, they have recently released a sixth set of tip sheets on "what to do if you have a concern about quality in a nursing home, hospital or doctor's office."  It's available in California, Connecticut, Maine, New York, Pennsylvania and South Carolina.

I am confident we can look for more to come from Carol and her team.

Monday, December 29, 2014

Tea Time with The Toast Dude Webinar

Bruce Hamilton is one of my Lean heroes, and we have used his Toast Kaizen video with audiences around the world.  Now, his host organization, GBMP, is offering a series of free webinars.  These are bound to be good.  Here's the announcement:

Free Monthly Webinars by Bruce Hamilton, aka "The Toast Dude," Kick off in January with "War Rooms & Obeyas"

GBMP, Inc. is a non-profit provider of continuous improvement training, dedicated to helping organizations become more competitive through lean manufacturing education and implementation. Each year GBMP trains more than 7000 people on continuous improvement principles through classroom and shop floor training sessions, and impacts thousands more in public workshops, on plant tours, during its annual 2-day Lean Conference and through its award-winning Lean Training videos and instructional games.

And now, GBMP is expanding its ability to reach those who are passionate about Lean and Continuous Improvement through its series of free monthly webinars. Our Tea Time with The Toast Dude Webinars are presented on the second Tuesday of each month by Bruce Hamilton, President of GBMP. Bruce is considered by many to be one of the foremost thought leaders on Lean and The Toyota Production System in the United States today. He is the producer and star of the #1 Lean Selling Lean Training DVD in the world, " Toast Kaizen - An Introduction to Continuous Improvement & Lean Principles", co-author of learn-and-do lean training workbook "The E2 Continuous Improvement System", and a three time Shingo Award recipient. In addition to being known as The Toast Dude, he is sometimes called That Old Lean Dude - which gave rise to his blog "Old Lean Dude" - which now boasts over 150 original posts and more than 1000 followers.
 

The first webinar (did we mention, they are free?) of 2015, titled "War Rooms & Obeyas", will take place on Tuesday, January 13, 2015 at 3 PM (Eastern). The webinar will discuss how many companies struggle with cross-functional collaboration in the pursuit of complex objectives and how War Rooms and Obeyas are used to align resources and maintain project focus for faster, more robust outcomes. Those who are passionate about Lean - from executive management to change agents working the front lines  - from the manufacturing, government, healthcare and service sectors - are encouraged to participate each month, and even suggest topics for future events, and every event includes 15-minutes for Q&A with Bruce, in real-time. 

To register for January's webinar, please visit www.gbmp.org and click on Events or click here.

Lean sailors win

A note arrived from The High Velocity Edge's, Steve Spear:

Here's the predicament: you show up at a sailing regatta, and when the other teams complain that they’ve never raced together, your team reflects that most have never even sailed.  At all.  And, oh yeah, your team is all MIT graduate students. 

But, HVE student Adam Traina leads with standard work and visual management to see problems, mid race and after race pauses to solve problems, and then discipline in sustaining solutions until the next problem. The team moves from dead last in the first round, to fifth, second, and finally an unassailable first in the final races.

From the story:

“We started with a huge range of sailing experience and applied fundamental principles from sailing and management to learn to operate in a new environment,” Traina said. “Our team’s positive attitude, ability to learn quickly and active listening to each other were the key elements in our success.”

The students used an array of LGO ("Leaders for Global Operations") tools to work well together as crewmates. “We implemented standard work by training each member of the team for one specialized job, and we used a visual management system to cue each teammate on when to execute their tasks,” Traina said in an email, adding that their “robust verbal communication protocol” kept team members informed. Also, between each race and at the end of each day, the team held kaizen sessions to improve their processes. “The kaizens led to rebalancing workloads and new discoveries about the operational features of the vessels,” he said.

The most challenging LGO lesson to apply, he said, was the Toyota production system practice of stopping a production line to solve problems. “In the middle of a race, stopping the boat while in first place goes against every instinct—yet stop the boat we did, making a safe environment long enough to fix rigging that was fouled on the bow so we could continue to race,” Traina said. “Stopping the boat cost us our lead, but we were able to regain control and ultimately win the race as a result of fixing our issues instead of sailing on with them.”

And here's the best part:

The winning team brought home a trophy and a Rolex watch, but coming out on top wasn’t their goal. The MIT Sloan team decided at the beginning that their mission was simple: "to come home with more friends than we left with," Traina said.

Don't be a nail just because your doctor is a hammer

A friend writes:
 
When my daughter was a year old, she was given a diagnosis of "Failure to Thrive." The definition is something like if your length percentile keeps growing but your weight percentile falls. Anyway she wasn't eating enough.

Her PCP sent us to a famous gastroenterologist who said he wanted to do an endoscopy. That would mean putting her under general anesthesia and a period in the hospital. I asked, "What are you looking for?" He said he wanted to see if her esophagus was inflamed.

I then asked, "What would you do about it if it is?" He said he would give her an antacid.

I said, "Is the antacid dangerous?" He said no.

So I refused the endoscopy and told him to prescribe the antacid. It was both a diagnostic and a treatment.

End of the story: It did nothing.

Moral of the story: Don't be a nail just because your doctor is a hammer.

P.S. The daughter is thriving . . . in college.

Sunday, December 28, 2014

In memoriam: John Bewick

If John Bewick had a mean bone in his body, no one I knew ever found evidence of it.

As noted in this obituary, he died on Christmas Day,

surrounded by family, carols and Christmas light.  A loving and intelligent man, with a great heart, and a warm humor, he worked to improve the environment during his life, as well as to influence the safety of nuclear power, and to help businesses in their efforts to comply with complex environmental, health and safety regulations. He valued integrity in government.  He was Massachusetts third Secretary of the Executive Office of Environmental Affairs, and his name was engraved in granite at “Secretaries Landing” on the Charles River in Boston while he was alive to enjoy it.

Read the rest, too, because he was a remarkable and lovely person.

At least once a year, John would write me a note, asking my opinion on some matter of public policy.  He was always digging into why things worked the way they did and how they could work better.  If you wanted a definition of a public servant--even when he was no longer in the government--he provided it.

On March 12, 1996, as I was doing some research for a book on the history of the Metropolitan District Commission (an agency within EOEA), he and I talked about his career and then veered into environmental and institutional issues. In response to the question of how he became Secretary, he replied: 

Actually, it was serendipitous, and it sort of speaks to the fact that, in a lot of ways, you can't plan certain things in life, that there's a lot of chance in all this.  It's something that I didn't seek, but it came to me in a very interesting way.

I had gotten bored at Cabot Corporation where I was doing research, and so I started to get involved politically . . . in Paul Guzzi's campaign (for US Senate) and started writing position papers.  It turned out, I found out later, that I was the only person on his campaign writing position papers.  We had a number of debates at his house.  One of my recommendations to him was, do not go anti-nuclear, and he ignored that and followed his campaign wisdom advisors.  And, exactly, as I thought would happen, the money then flowed almost immediately to [Paul] Tsongas in the campaign.  All the industrial money went to Tsongas, so on election day, Tsongas had a much better election day operation than Paul.

After the election, Guzzi was very close to [Governor Ed] King.  And through our PR fellow at Cabot, I said, "Gee, I'd like to be on an advisory committee," and my resume happened by Guzzi's eyes after they had turned down about five people for secretary.  A variety of people had been proposed to King, and he had not liked any of them--to his credit--as some were political hacks.  Guzzi said, "This is interesting.  I know him and we happen to be looking for someone."

So it was totally fortuitous that King bought in.  The Governor called John Cabot, at Cabot Corporation, and Zeb Alfred, at New England Electric; and both of them knew me, so I was blessed by those two.

I was called in on a Thursday and appointed on Tuesday--King's usual careful fashion of checking people out!  I had had one meeting, and I pointed out to King that my father had built the second largest bridge on the B&O Railroad and was a civil engineer, and my brother was commissioner of highways in Delaware; and I think that, with these two things in my background, he surely thought I was a soul brother or something, a builder family, and he was quite surprised that I ended up having environmental concerns.

You might think that an "accidental" cabinet secretary would be politically naive and not attuned to how to manage in an administration.  That conclusion would be wide of the mark in this case.  For example, John always said that working with Ed King on environmental issues was a positive experience, notwithstanding the latter's less than stellar reputation among the environmental community.  But the key was that John had to set up the dynamics to move things in the direction he wanted. 

We just had a great relationship.

We did something that was very interesting.  I think I was the only cabinet secretary who had a regular meeting with the Governor. We discovered early on, that if we could get the Governor's ear first on an issue, he would take our frame of reference. So quickly I started asking for appointments once every week.  I took all my crew in.

Here [for example] was Terry Geoghegan--BC graduate, great football team, great football player--who would come in with the environmentalists.  As so there would be this quizzical look [from King], "Here come the environmentalists and there's Terry Geoghegan with them?  Hm?"

We got him to sign the barrier beach protective order, which I think was the most extraordinary in the nation.  It was an order that said that barrier beaches are nature's way of protecting the mainland, and they are shifting formations, and you should not build on them.  They have a life of their own.  Therefore, the state will not do anything to invest money in protecting them.

When [state representative] Nick Costello came down from Newburyport and said the folks on Plum Island want to spend $1 million of federal money to bring water onto their properties--after they contaminated their own water supply by building their cesspools improperly--the Governor said, "No, we are not putting state or federal money into the barrier beaches."  Needless to say, Nick wasn't very happy.

That's the sort of guy I knew as Governor that the public had very little concept of.  When the going was tough, and if he believed you were right, he would be there in the trenches with you if you needed support, in contrast to some other governors.

John was a street smart political scientist. We later got to the main topic of my interview, why the MDC, once known as one of the best regional government agencies in the country, had fallen to the point of permitting the total degradation of the sewage treatment system and the pollution of Boston Harbor.

There's a multi-dimensional answer to that.  First of all, the problems were not very visible except for the summer beach contamination problem.  Even that was blamed on a rainstorm that overwhelmed the system, so "nature is doing this to us."  Other than that, the people had water to drink, the skating rinks worked more or less, the swimming worked in the summertime.  So the problems were not visible to the public.

The second part of the answer goes deeply at the function that the political process plays in Massachusetts.  For many in power, the objective of politics was to assure job for constituents, and the agency was performing that job very well.  You had a chairman of Ways and Means from Dorchester; you had a Senate President--or soon to be Senate President--from South Boston; and numerous other reps with influence from the greater Boston metropolitan area.  In terms of the traditional view of what politics as about, it was doing an excellent job of providing jobs for those constituents.  So why change?

I would attribute that in part to the lack of a two-party system.  Even if you had a Republican governor, you still had the same legislature.  One of the things that happens when there is tremendous political influence in job creations is that there is a deep cynicism about the quality of state service and government.  Nobody is valued if everybody is viewed as having gotten there through political connections, as opposed to competence.

It took us three years to get through a management pay [increase] bill [to attract more qualified people.] [The legislators themselves] assumed they were all incompetent because "I put them there.  They can't be worth much because I know how they got their job."

While I'll miss these kinds of insights that John had of the body politic and government service, most of all I'll miss his smile and his distinctive laugh, his joyful viewpoint on the world, and his irrepressible kindness.  This was a truly good man.