Friday, August 22, 2014

Combatants for Peace

If you are feeling frustrated and powerless with regard to the current state of relations between Israeli and Palestinians, here's a way to help.

The “Combatants for Peace” movement was started jointly by Palestinians and Israelis who have taken an active part in the cycle of violence; Israelis as soldiers in the Israeli army (IDF) and Palestinians as part of the violent struggle for Palestinian freedom. After brandishing weapons for so many years, and having seen one another only through weapon sights, we have decided to lay down our arms, and to fight for peace.  Our mission is to actively spread the message that a non-violent solution to the conflict is possible, and our hundreds of members and participants are living proof that it is.

They are conducting an Indiegogo campaign to raise funds to spread the message and build political support on both sides of the conflict.  The money will be used to:

· Hire and set up Bi-National media teams, which will work to get our story out and to act in order to influence public opinion in Israel, Palestine and the rest of the world.
· Bring consciousness to both publics regarding the hopes and suffering of the other side, and to create partners in dialogue.
· Educate towards reconciliation and non-violent struggle in both the Israeli and Palestinian societies.
· Create political pressure on both Governments to stop the cycle of violence, end the occupation and resume a constructive dialog.
· Reach beyond the region and connect with people around the world who believe in non-violence and the importance of allowing a new story to emerge - one of peace, coexistence and interconnectedness.

Please give if you are so moved.

Thursday, August 21, 2014

It's too crowded here!

Hi, I'm back from a trail-riding trip in the Chilcotin Mountains of British Columbia.

Long quiet days on the horses, through woods and flower-filled meadows.

Expansive views.

Not many people.  It's a bit hard to come back . . .

But lots of blog topics have piled up.  Watch this space next week.

Monday, August 11, 2014

Off duty

I'm taking a blogging break for several days.  Comments on old posts are still welcome, but they will not be moderated (i.e, published) until I get back on duty.

Friday, August 08, 2014

Finally, we hear from the AG candidates

We are fortunate in Massachusetts to have two excellent Democratic candidates for Attorney General.  With just 30 days to go until the primary election, you'd have thought the local press would have asked them for their opinions of the proposed deal inked by the current AG and Partners Healthcare System.  After all, it is the biggest antitrust and health care matter currently pending in the state, and the one with the biggest financial impact on businesses and consumers.  Wouldn't it be good to know if the candidates support the deal as written and also feel comfortable in their potential role of enforcer of the agreement over the coming years?

Well, finally the questions were asked, at a forum held by the Newton-Needham Chamber of Commerce.  The answers were captured on tape, which can be viewed here.

Warren Tolman spoke first (at minute 45:14 or so).  Here are some outtakes:

I have some misgivings about the agreement.

I have some concerns about it, frankly.

First, when I look at price controls and you have a disparity in prices in year one and you lock into [that] ... the disparity in prices will grow over time.  And that increases the power of the have's over the have-not's.  So that's one area that is of concern to me.

Secondly, I believe we need to promote transparency in health care, above all other things.  Consumers ought to know [about pricing differentials] as they make their health care decisions.  The disparity in prices is not reflected in a disparity of quality.

Third, [and here he diverges in the problem of substance abuse.]

Fourth, [on enforcement] a real challenge and commitment of resources. Some of the provisions are going to be very difficult and awkward at best.

Maura Healey was next (at 47:42):

This is a really important issue.  The agreement is now before the Court and the public has been invited to submit comments, which I think is really good because I think it's really important that this decision be made thoughtfully and carefully.

The next Attorney General is going to have a critical role to play in terms of monitoring and taking action in the health care space.

I have some concerns about this agreement.  There's a lot of frustration out there given what we all are frustrated about, which is the high cost of care in this state; but I know that what this agreement tries to do is to put some time limits on it and some caps, put some price limits on things; and it's going to require really vigilant, aggressive monitoring by the next Attorney General, and I would make sure that happens.

I agree with Warren's point that we need transparency.  I am committed to making sure that we are there to provide facts and transparency.  This is going to require vigilance and aggressive monitoring by the next Attorney General.

So, there you have it . . . so far.  This was not a very extensive discussion, but it was a start.  Tolman seems to understand the structural flaws in the agreement.  Healey didn't elaborate on her concerns.  Both understand the complexity of enforcing the agreement.

We have yet to hear from the Republican candidate, John Miller, but perhaps these initial comments from the Democrats will provoke some interest by area reporters to ask more questions of all the candidates.

I wonder if any of the candidates will publicly ask the current Attorney General to pull the proposed settlement from consideration by the Court and defer the entire matter to her successor.  After all, it would be only fair to let the next Attorney General help frame the enforcement requirements of the agreement, rather than inheriting terms set by his or her predecessor.

That's "informed" consent

My friend and colleague, Doug Hanto (a world class transplant surgeon) reports on Facebook about the birth of his grandson at St. Vincent Carmel Hospital in Indiana:

Interesting. Lindsay is about to have a C-section this morning, and we will welcome John Douglas into the world. The nurse handed Lindsay informed consent for C-section, anesthesia, blood transfusion, circumcision, and HBV vaccine with no explanation. Like signing the agreement you have to sign when updating your OSX or windows software. They all say "Your physician has explained ..." No one has explained anything. Trust is alive and well in the real world. This is "informed consent?" Hmmmmm!

Gee, I thought the purpose of informed consent was to be informed.  I also thought it was illegal for nurses to administer them, or, if not illegal, certainly inappropriate. 

Indiana hospital licensure rules say:

Sec. 13.4. "Informed consent" means a patient's authorization or agreement to undergo surgery or other invasive procedure that is based upon communication between a patient and his or her physician regarding the surgery or other invasive procedure. (Indiana State Department of Health)

Thursday, August 07, 2014

Maybe the AG could help

Bruce Mohl at Commonwealth Magazine reports:

Steward Health Care is refusing to turn over to state officials its audited financial statements, setting off a behind-the-scenes tug of war that could lead to fines being assessed on the for-profit company.

Steward, which is owned by the New York private equity firm Cerberus Capital Management, is notoriously tight-lipped about its finances. The only reliable source of information on the company's overall performance and its financial relationship with Cerberus has been its audited statements. For the past two years, Steward filed the statements with state regulators, who turned them over to CommonWealth in response to public records requests.

But this year, Steward is refusing to turn over the financial records. Mark Rich, Steward's chief financial officer, said in a June letter to state officials that the company provided detailed financial information on all of the hospitals it owns. Rich said Steward was not going to turn over the 2013 consolidated financial statement of the company as a whole because it "combines the results of hospital operations with our non-hospital businesses that are not covered by the regulations." 

Nancy Maroney, associate general counsel of the state's Center for Health Information Analysis, has insisted that state regulations require Steward to turn over the consolidated financial statements. She said in a June 9 letter that Steward could be subject to reductions in its Medicaid payments and other financial penalties if it refuses to comply.

I really hate to see such disputes escalate, and I have a suggestion as to how this one could be quickly resolved. Back in October 2010, when the Attorney General recommended approval of Steward's takeover of the Caritas Christi hospital system, she was able to get the following agreement:

Steward, and any successor-in-interest to Steward, will, notwithstanding its for-profit status, fully cooperate with any investigation, inquiry, study, report, or evaluation conducted by the Attorney General under her oversight authority of the non-profit charitable hospital industry to the same extent and subject to the same protections and privileges as if Steward were a public charity.

So all it takes is for the Attorney General to announce to Steward that she wants this information as part of a joint study with CHIA.  Perhaps she will make that offer to CHIA.

What residents teach us about residency programs

Medscape has issued its 2014 Residents Salary and Debt Report.  Here are some interesting charts, along with their associated description and my commentary:

Although 25% of residents have no debt, over a third (36%) still owe more than $200,000 after five years in residency. The Association of American Medical Colleges (AAMC) reports that the median four-year cost to attend medical school for the class of 2013 is $278,455 at private schools and $207,868 at public ones. Given these high tuitions, resident indebtedness has risen much more rapidly than inflation or resident compensation. According to the AAMC, medical school debt has increased by 6.3% since 1992 compared with the Consumer Price Index increase of 2.5%.

Perhaps, as we consider the high cost of health care in America, we should factor in the need for doctors to recover their education costs, something not necessary in many countries of the world, where there is little or no tuition charged to medical students.

When asked about relationships with nurses and physician assistants, there was very little difference in the opinions of male and female residents, with 62% of women and 66% of men saying that their relationships were very good to excellent. The most common complaint among write-in comments from residents with poorer relationships was the lack of respect paid to them by nurses. A small study of pairs of residents and nurses found a lack of shared perception and expectations.

Here's where many residents live in a dreamworld.  Their perception of the positive relationship with nurses is, in my experience, off-base.  There is extremely little communication at all--measured in minutes per day, and then often in machine gun format: "Do this."  When I've talked to nurses, they often say that the residents don't respect their abilities and greater knowledge of the patient's status.  Many residents display a lack of trust in nurses, and this does not go unnoticed by the nurses.

A number of studies have found a decline in idealism among medical students beginning as early as the second year of school. The Medscape survey suggests that idealism declines further during residency. In comparing responses by residents in post-med school years 1-4 with years 5-8, a shift occurred, with fewer residents finding patient gratitude rewarding in the later years (61%) compared with in their early years (67%), and more residents in later years looking to make "good money" (43% versus 36%). Authors of a 2014 study commented that as "students make choices in their medical careers, such as specialty choice or consideration of primary care, the influences of job security, student debt and social status increasingly outweigh idealistic motivations."

So we start with highly motivated and idealistic young people and beat it out of them!

Female residents tend to cite more idealistic rewards of their job than male residents do, with 72% of women selecting patient relationships compared with 62% of men. And only 28% viewed money as rewarding compared with 43% of men.

Remind me to request a female resident next time I am in the hospital!

When residents were asked to give their opinions on the quality of their training, 43% thought their own was superior and 29% felt that it was equal to others'. This was an informal opinion, based on perceptions only.

This is similar to the Lake Wobegon effect. Once you've matched, you really want to believe that you've made the right choice. 

We know, from hundreds of residents who attend the Telluride summer patient safety camps, that most trainees get virtually no training in quality and safety, in obtaining truly informed consents, in disclosure and apology for medical error, and in reporting adverse events and near misses.  In that regard, virtually all training programs are substandard and don't meet the requirements the ACGME says are expected.

Wednesday, August 06, 2014

Safety is joy

Brian Daily is a medical student (class of 2017) at Georgetown University School of Medicine. After attending our Telluride-East summer patient safety camp, he saw this construction truck on campus at Georgetown the other day and sent it to several of us faculty members because he thought we’d appreciate the bumper sticker.

And indeed we do.  Safety in the clinical setting, too, is joy.  At heart, it is result of a collegial work environment with excellent communication among the clinical staff and a true partnership with the patient and family. When all that occurs, it feels really good!

Tuesday, August 05, 2014

Post #4038, eight years later

The eighth anniversary of this blog slipped by on August 2.  That's 4038 posts, including this one, drawing several million page views.  From time to time, I've thought about stopping, but then a whole new set of topics emerge, and I say, "Not just yet!" Thank you all, especially the regulars, for reading.

My purpose is to serve as an advocate for patient-driven care, eliminating preventable harm, fostering transparency of clinical outcomes, and encouraging front-line driven process improvement.  When I take on people who act in ways counter to those goals, I do so in the hope of stimulating discussion and, yes, putting some pressure on those people, but not with ad hominem attacks.  In contrast, when I praise people who are acting in accordance with those goals, I mean it to be very, very personal--thanking them for their leadership and, sometimes, courage.

The following compendium might or might not surprise you.  Key words in posts have included:

Quality -- 902 posts
Doctors -- 708
Patient safety -- 642
BIDMC -- 601
Harm -- 407
Nurses -- 356
Lean -- 348
Leadership -- 3222
Transparency -- 310
Residents -- 230
Institute for Healthcare Improvement -- 188
Partners Healthcare -- 158; Brigham and Women's -- 95; MGH --53;
Medical students -- 156
Soccer -- 135
Careers -- 113
Blue Cross Blue Shield -- 109
Preventable -- 108
Incentives -- 73
Infrastructure -- 70
SEIU -- 68; Corporate campaign -- 36
NHS -- 61
Global payments -- 60
Don Berwick -- 55
Robotic surgery -- 43
Ohio (especially children's hospitals) -- 41
Jim Conway -- 34
Brent James --34
University of Illinois -- 32
Telluride Patient Safety Camp -- 30
Peter Pronovost -- 27
Bob Wachter -- 25
Saskatchewan -- 21
Jeroen Bosch Hospital -- 19
Gene Lindsey -- 19
e-Patient Dave deBronkart -- 18
Proton beam -- 18
Gundersen Lutheran Medical Center -- 18
Contra Costa Regional Medical Center -- 10

Monday, August 04, 2014

What Mona learned

Mona Beier attended last week's patient safety camp in Maryland (aka, Telluride East) and posted some deep thoughts after the experience.  Here's an excerpt:

I have had some really negative realizations of myself during these past few days. I hate to admit this, but during a lot of the talks and the videos, I saw things that I had done, and I have seen my colleagues do time and time again. It is almost a daily occurrence that I hear people labeling patients as “high maintenance” if they ask questions about their healthcare or if they “challenge” our decisions and our actions. 

I have replayed imagery in my mind about how many times I have rushed through explaining informed consents, or felt hurried to get histories and physicals because I have 48392 other things to do (seemingly). Or, how many times I have interrupted and not listened. 

I have thought about times when I have anchored, or had premature closure of patients I was taking care of—and it wasn’t until they were not getting better or something was going wrong that I ever stopped and thought that, hmm I could be wrong or that I was missing something. The talks at the conference have made me realize that I should be doing this every day–stopping, taking time to think–and say, is this what’s going on? what would be the worst thing that I could miss? should I go back and get more history? does this make sense?

Moreover, I thought about times when something actually did go wrong–when patients on my team have gone to the ICU or have died. I tried to replay in my mind,  and again, I saw myself saying “oh, they were very sick”–almost trying to justify it to make myself feel better. Being here these past few days is going to make me view this completely differently. I am going to take the time to think about what happened when things went wrong. Was it preventable? Was there something else we could have done? Why did this happen in the first place? What were the series of events that led up to this? Did I call the family? And more importantly, was my conversation meaningful with the family? Did I address their needs and reassure them? Was I there for them like I would want someone to be there for my family member?

There are a lot of other lessons I have learned. All I really know is that I am walking out of here a better person than when I came in. This conference has inspired me to take a deeper look into who I am—what kind of physician I want to be—and what kind of person and role model I want to be to my peers, my patients, and really everyone in my life.  I am inspired to try and break the mold of the culture we have grown so accustomed to—the culture where everything seems to be about me–and remind both myself and others that is not why we are here.

How to make RI a healthier state. Any takers?

Richard Asinof at Convergence RI challenges people in the state to map a future of sustainable health care.  Will anyone step up to the challenge?

Sunday, August 03, 2014

Hooper's Store

A now for a totally different subject, a little bit of Americana:

Many of us with children--and our children--recall Hooper's Store on Sesame Street. Wikipedia summarizes:

The fictional store was said to be founded by Mr. Harold Hooper in 1951 as a general store. The food menu was extensive and suited to the different characters that lived on Sesame Street, a fictional Manhattan street. Along with traditional American diner-type food, the store sold a wide range of goods from dry goods to soap dishes and stranger goods such as empty cigar boxes (in Christmas Eve on Sesame Street) and birdseed milkshakes for Big Bird.

I recently learned the origin of this concept.  The set designer for the program was from Massachusetts where he had lived near Manchester-by-the-Sea and the Trask House on Union Street across from the Public Library.  As noted here:

The house was built in 1823 by local businesswoman Abigail Hooper, who ran a thriving general store and millinery shop on the premises.  That same year, Abigail married Captain Richard Trask, one of Manchester’s most prominent merchant ship captains, who had lucrative trade relationships with England and Russia.

The set designer decided Sesame Street should also have an old-fashioned general store like Hooper's, and the rest is history.

A friend of mine who purchased the store several years ago and owned it for a while reports that it carried all kinds of items, like this axle grease.  Also, when prominent families (like the Bundy's) would plan to come back to summer in Manchester, they would contact the store to have their houses set up with supplies.  These would be delivered in wooden crates that had been used to send inventory to the store.  Like these:

So the idea of stocking empty cigar boxes in Sesame Street's Hooper's Store is not so improbable after all!

Friday, August 01, 2014

They said what?

The health care world is full of companies that make outrageous unsupported assertions as they pursue profitability.  Generally, the media accept what is said and don't ask hard questions.

Now somebody is asking.

Al Lewis has started a blog called They Said What?, on which he posts the assertions made by companies and asks questions that probe the accuracy.  He offers the company an advanced chance to respond.  Here's the summary:

TheySaidWhat? asks questions that identify possible mistakes in high-visibility contexts and offers those who committed the mistakes the opportunity to correct, apologize for or retract their mistakes…or explain how their positions are correct and we have made a mistake by questioning them.   As described in the FAQs, we offer the perpetrators of the possible mistakes fully five courtesies that very few other critics would allow:
  1. Though in many cases these “mistakes” were likely not innocent ones, we make no accusations but rather simply ask questions and offer the opportunities for answers;
  2. We provide “equal billing” – the perpetrators can write their answers directly following the questions;
  3. We don’t ambush the perpetrators – we send these questions a week in advance, to allow them ample time to respond to these questions before publishing them;
  4. Even though there is significant cost to us in analyzing these case studies and posting these questions, and significant value to the perpetrators in being able to identify and correct their mistakes and not mislead their prospects and customers (and hence avoid the possibility of embarrassment or even a lawsuit down the road), we do not charge for this service – the perpetrators may respond gratis during that week.  After one week, they may still respond, but there is a charge.
  5. Uniquely, we also offered these organizations $1000, payable to them or their favorite charity, to answer these questions honestly.  This is probably the first time in history that anyone has offered bribes to people to simply tell the truth.
Several companies are already included.  Only one has chosen to respond thus far.

Readers can also submit nominations.


A reminder from David Mayer to medical students participating the Telluride East Patient Safety program.

Thursday, July 31, 2014

On pain

Janice Lynch Schuster offers first-hand advice on ways of managing chronic pain, here.  She notes:

I am not my pain. I am a wife, mother, worker, writer, sister, daughter and friend. My world is rich and rewarding. I want for nothing – save pain relief.  In fact, although the pain may be a permanent fixture, the sensation is impermanent.  Some days are better than others.  I must choose how much I want to let it control my experience—or how much I want to control it.

Powerful and helpful, both, for you or a loved one.

Wednesday, July 30, 2014

Tom's Reason to Ride is back

With great disappointment, I sadly announce that “A Reason To Ride’s” founder, Tom DesFosses’ cancer is back.  While Tom started to "A Reason to Ride" because he wanted to give back and raise funds for research he never made the Ride about himself.  Tom founded the ride because many of us have reasons to ride.  His energy and enthusiasm persuaded me to give full logistical support to the ride when I was running the hospital. Now, the ride is run solely by Tom and his friends, with tremendous support from Fuddruckers restaurants and the other firms noted below.

We still have reasons to ride, and it’s never been more important than now to ride.  I hope you'll join me on September 7 in Danvers, MA.  Here is Tom in his own words:

Why A Reason To Ride? I have a new reason, personal as it is. I have just been re-diagnosed with brain cancer. This year was to be my 10th year cancer free, but alas it came back in spades. A few weeks ago I visited BIDMC for my yearly check up and a MRI.  For the past nine years we looked at the MRI and smiled and then said "See you next year." Not so this time, the cancer has returned BIG time. Since that Thursday my life has been a blur: Thursday blood work, Friday more MRI’s and body scans, Monday spinal tap, Tuesday out-patient chemo, Wednesday in patient chemo, released Sunday, sick and tired as hell up to Thursday, start the whole process again next Tuesday for at least 4 more times. Then what, probably every other month for a year and a half, then?

If you’re wondering if I am upset, sure I am, because most of the research funding is raised by groups like ours and we don’t have the full support Federally to fund all the medical research necessary to find a cure.  This is why I started the event and why your support is so important to OUR fight. 

Remember, “A Reason To Ride” is 100% grass roots with 100% of funds going towards research.

Finally, I’m asking for your help, not for me, but for our future.  Please forward this email to your friends, ask them to ride, ask them to donate and spread the message.  Yell out your reason to ride and join us on September 7 as we fight cancer together.

Click here to register or donate

Thanks for your time and helping us fight cancer.
Tom DesFosses
A Reason To Ride

Them's fighting words!

Gary Schwitzer offers a front-row seat to some conflicting claims.  It all starts with a news release from robotic surgeon David Samadi at New York's Lenox Hill Hospital that was picked up by the American Urological Association (AUA):

According to a new study from Detroit, Michigan, robotic prostatectomy yields highly successful long-term prostate cancer results. In fact, nearly all — 98.8% — of the patients remained prostate cancer survivors at ten years post-surgery; results comparable to the more invasive surgical method used in the past.

Oncologist Richard Hoffman replies:

“The AUA does misrepresent the data.  The 98.8% refers to the proportion of subjects who had not died from prostate cancer.  Only 73.1% were biochemically free of cancer, meaning that the rest had a rising PSA suggesting cancer progression/recurrence.  

The observational design means that investigators cannot make any meaningful comparisons of robotic surgery results with those obtained by open prostatectomy,  Thus, Samadi’s comment that robotic prostatectomy is “a preferred treatment” is not based on convincing evidence, just on the “preferences” of surgeons and patients who see the surgeons’ ads. 

Them's fighting words! Gary says, "Let’s see how the urologists duke it out." One already expressed some thoughts on Twitter.

So you think you can multi-task

A friend of mine was excitedly discussing her job with a high-tech firm.  "Our meetings are so great and vibrant.  While the sessions are going on, we are all on our computers multi-tasking.  It's so efficient!"

Well, no.  There's a lot of evidence that constant interruptions do not improve efficiency and that they also impair quality.  Here's a recent example, published in Human Factors.  It focused solely on interruptions during the course of writing and concluded:

Our research suggests that interruptions negatively impact quality of work during a complex, creative writing task. 

Observing observation status

Brad Flansbaum offers this interesting post about the ambiguities and uncertainties inherent in the current Medicare "two-midnight rule."  He refers to a recent white paper prepared by a group of hospitalists:

Months of work have led us to our white paper, entitled, The Observation Status Problem: Impact and Recommendations for Change. The release utilizes a multidimensional data set of significant size and includes a finding synthesis.  It is our hope to use the information we collected to inform Congress, CMS, media, and members on the somewhat chaotic understanding of observation status policy. 

This is well done and thoughtful and could be of assistance to federal policy makers, if they take the time to read and listen.  Look at this portion of the introduction:

The intricacies of observation policy have created a situation where observation care is now commonly being delivered on hospital wards, indistinguishable from inpatient care. The frequency and duration of observation status has also grown significantly in recent years, well beyond its original intent. This is important because observation is not covered by Medicare Part A hospital insurance, and patients under observation are ineligible for skilled nursing facility (SNF) coverage at discharge, which may leave them vulnerable to additional complications.

The results:

--Lack of knowledge and confidence in implementing the two-midnight rule
--Disruptions to hospitalist and hospital workflow
--Decrease in the ability of hospitalists to make independent clinical decisions
--Negative impacts on patients, including access to SNF coverage and highly variable financial liabilities 
--Damage to the physician-patient relationship

Tuesday, July 29, 2014


Earlier this month, Modern Healthcare published a story about the slow movement by hospitals to prevent operating room fires. An excerpt:

Despite a slew of news accounts about patients being set on fire in operating rooms across the country, adoption of precautionary measures has been slow, often implemented only after a hospital experiences an accident. Advocates say it's not clear how many hospitals have instituted the available protocols, and no national safety authority tracks the frequency of surgical fires, which are thought to injure patients in one of every three incidents. About 240 surgical fires occur every year, according to rough estimates by the ECRI Institute, a not-for-profit organization that conducts research on patient-safety issues. But fires may be underreported because of fear of litigation or bad publicity. 

“Virtually all surgical fires are preventable,” said Mark Bruley, vice president of accident and forensic investigation for ECRI, which has been tracking operating-room fires for 30 years. He blames the persistence of the problem on the slow migration of best practices across the hospital industry.  

Most surgical fires involve the ignition of concentrated oxygen by electrosurgical tools used in upper-body procedures, where patients receive the highly flammable gas through face masks and nasal devices. But a growing number are linked to the ignition of alcohol-based antiseptics.

Solid numbers on the incidence of operating-room fires do not exist. ECRI's latest estimate of 240 operating-room fires each year between 2004 to 2011 was revised down from earlier estimates of 650 fires a year between 2004 to 2007. 

While that suggests there has been improvement, studies of anesthesia malpractice claims suggest there's been a rise in incidents. “There is an inherent problem in preventing relatively rare events,” said Dr. John Clarke, clinical director of the Pennsylvania Patient Safety Authority. People think “it is not likely to happen to you in particular,” he said.

I was surprised and contacted a patient safety expert who replied, "No one believes it can happen to them, so they cut corners."

That seems to be the case in lots of places.  From the article:

Many of the best fire-safety practices developed in recent years stem from the work at Christiana Care Health System, Newark, Del., after two patients caught fire in operating rooms within eight months in 2003.

They pioneered their own process, which involves discussing the risk of fire during the scheduled time-out before surgery. The hospital hasn't burned a patient since.

Protocols like Christiana's have been widely disseminated. Yet, Christiana says it still get calls several times a month from hospitals that are just starting to implement a system. “It's a bit of an uphill slog,” said Dr. Kenneth Silverstein, chairman of Christiana's department of anesthesiology. “The bottom line is, in order to have a culture of safety in your institution, you have to get people behind it.” 

Sounds familiar.  We saw (and still see) hospitals go through the same slow process with central line infections, ventilator associated pneumonia, and other infection-related problems.  Maybe now it's time to yell, "Fire!"

2008 graphic from

Debunking the debunking

I really don't want to write more about surgical robots, but you folks out there keep sending good material.  Here's an article by a surgeon on "debunking the myths about robotic surgery."

Let's look some assertions:

The robotics technology is expensive and the whole surgical team has to be trained, which can add to the cost. But there’s also a tremendous savings compared with traditional surgery because the patient is out of the hospital more quickly and there are fewer complications.

Many times, the robotics-assisted procedures can be done much more quickly, so there’s less risk simply because the duration of the procedure is shorter. You also have the smaller incisions, and less bleeding, factors that reduce the risks.

This kind of fast and loose talk is a discredit to the profession. I wish there were an agreement that we would rely solely on sound research studies instead of this anecdotal tripe.

Will you be in Panama City in August?

This is a must-see exhibit by the Smithsonian Tropical Research Institute.  A good chance to meet Matt Larsen, STRI’s new director, too.

Keeping up with the Joneses

Just by casual observation, I have asserted that a hospital was more likely to acquire a surgical robot if a nearby competitor hospital had already done so.  But this was an untested conclusion, based on viewing websites and highway signs, particularly from community hospitals, like above.  So I was intrigued to see this great article by Huilin Li (Department of Population Health, New York University) and others in Healthcare.  From the abstract:


The surgical robot has been widely adopted in the United States in spite of its high cost and controversy surrounding its benefit. Some have suggested that a “medical arms race” influences technology adoption. We wanted to determine whether a hospital would acquire a surgical robot if its nearest neighboring hospital already owned one.


We identified 554 hospitals performing radical prostatectomy from the Healthcare Cost and Utilization Project Statewide Inpatient Databases for seven states. We used publicly available data from the website of the surgical robot's sole manufacturer (Intuitive Surgical, Sunnyvale, CA) combined with data collected from the hospitals to ascertain the timing of robot acquisition during year 2001 to 2008. One hundred thirty four hospitals (24%) had acquired a surgical robot by the end of 2008. We geocoded the address of each hospital and determined a hospital's likelihood to acquire a surgical robot based on whether its nearest neighbor owned a surgical robot. We developed a Markov chain method to model the acquisition process spatially and temporally and quantified the “neighborhood effect” on the acquisition of the surgical robot while adjusting simultaneously for known confounders.


After adjusting for hospital teaching status, surgical volume, urban status and number of hospital beds, the Markov chain analysis demonstrated that a hospital whose nearest neighbor had acquired a surgical robot had a higher likelihood itself acquiring a surgical robot (OR=1.71, 95% CI: 1.07–2.72, p=0.02).


There is a significant spatial and temporal association for hospitals acquiring surgical robots during the study period. Hospitals were more likely to acquire a surgical robot during the robot's early adoption phase if their nearest neighbor had already done so.