Report to the Maimonides Board on Stepping Down as Chair of EM

Thank you for the opportunity to address you once again. Last September 2009 when I presented a status report on the Department of Emergency Medicine, little did I expect to find myself here again so soon.

15 years ago at a board meeting very much like this one you created a new Department of Emergency Medicine for Maimonides. I was fortunate to be selected as the Founding Chairman of that new department. I’d like to spend a few moments recounting a chronology of the department’s physical and program development and then share another aspect of the department’s development–one perhaps less apparent to you, yet a facet of the department’s development I hope you’ll come to view as significant as facilities and program.

The first step towards the construction of the Weinberg Emergency Department took place in May 1996 with the move of the Ambulance Department from a trailer on the corner of 49th and Ft. Hamilton parking area to a garage on 39th Street. Maimonides operated 6 tours daily in the NYC EMS System. At about the same time, the Department moved into its administrative home at 965 48th St.

June 1997 brought the opening of the adult ED in the newly constructed Weinberg Emergency Department and the following month, residents from the Kings County/Downstate Emergency Medicine Residency began rotating with faculty in our ED.

March 1998 brought the opening of the Sephardic Friends Pediatric ED and the Bruce Birnbaum Administrative Suite where our department leadership was housed through 2001 until the Cardiac Cath lab expanded in 2002. In 2000 we had our own CT scanner installed in the suite on the main hallway.

In late 2000 we began developing an application for our own Emergency Medicine Residency, an application that was approved in 2002, leading to the graduation of our first class of EM residents in 2005. In February 2004, the MMC Ambulance department moved to its present location on 38th Street operating 12 (8ALS/4BLS) tours daily in the FDNY EMS System.

The Department initiated both a 3-year Pediatric Emergency Medicine Fellowship and a 1-year Emergency Ultrasound fellowship training program in 2008. Our sixth class of EM Residents graduates tomorrow evening.

As a capstone, the hospital opened the new ED in January 2009 and installed a 64-detector/dual-source CT scanner in August of 2009.

I’d like to turn to the other development that I mentioned earlier. Over the past 15 years the staff of the Department of Emergency Medicine have truly incorporated the many communities we serve as partners in improvement and incorporated improvement into the daily work of patient care.

The staff of the department, whose roles as clinician, technician, administrative and operational support are centered on individual patient care, have also incorporated into their core work improving how patient care is delivered at the bedside. Particularly in this latter role, the hospital’s community partners have been invaluable for their ready advice. Partnering with community representatives hasn’t always been easy and neither we nor our community partners have always gotten it right in our initial efforts, yet much of the improvements accomplished can be attributed to the interdisciplinary team in the department of EM and to effective collaboration with the community and its representatives.

I’ve experienced a thrilling and challenging 15 years.  As your steward for the department of emergency medicine I’ve done my utmost to fulfill your vision for program development supported by the facilities and resources you’ve invested. I trust you can equally value the extant culture of the department of EM which fully engages the necessity of continuous improvement in caring for patients as a fundamental element of daily work. The creation and existence of this culture is a source of considerable satisfaction to me.

Year End 2009

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Hello from Brooklyn where as I write cookies are baking and some
hens are laying—though molting hens reduce egg production. This past January, the
family winter vacation plan took us all to Costa Rico with some friends for the
warmth and explorations. The environment was warm, the beach and the Pacific
were a bit farther away than perfection would argue for, yet the stay was
marvelous for the rest, adventures in organic farming and (the kids) zip-line
canopy touring along with the untimed sleep, good grub and rum drinks.IMG_1073_crop DSC_0670
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The tour
of the mangroves along the coast was early in the trip and one of the
highlights as we were swarmed by capuchin monkeys, but also saw less disturbed
examples of the local flora, fauna and their ecological interactions. Our
guides in the mangroves and the national park were young men who impressed us
with their ingratiating personalities, knowledge of the environment and generous
storytelling.

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In late spring Steve’s ER was nearly overwhelmed by a doubling of daily patient volume as the H1N1 “Swine” Flu moved through New York. Our year over year growth continues and we’ll finish the year having seen well over 100,000 patients, more than a doubling from the time of Steve’s arrival in 1995. Amazing to realize how long Steve’s been at Maimonides.

Masha made the move to an apartment share over the summer
while continuing at Hunter where she’s full-time in the fall session. She’s happy to be out of the parent’s house, though came home to bake cookies with Mom. Zoey imported his Mom for cookie baking this past weekend to his better this year West Philadelphia apartment where he’s living with three close school friends. He’s in his senior year at Penn and uncertain as to what’s next which seems like a normal state of affairs for this time of his life.

This past summer, Simone and Steve enjoyed a month of long weekends around NY and on LBI with Grandma Claire and a full week with friends Bill and Peggy on the North Fork of Long Island. Zoey joined us for several of those days driving over from Brookhaven National Labs where he spent a few weeks working at the end of the summer.

Simone again served as a site coordinator with the Cobble
Hill Community Supported Agriculture program that supports local farmers and supplies us with fresh produce. She continues the Brooklyn branch of the German Shepherd Dog Rescue, just celebrating its tenth anniversary, that she helped establish when we were in Philadelphia. Our old GSD Hillary finally died at nearly age 14 early this summer and so after more than a year of not doing so, we’ve recently taken in a foster German Shepherd dog, Alma, a long-legged female ~2-year-old named for a longtime friend of Simone’s. Leo, our terrier mix in sheep’s clothing is not entirely thrilled with the new addition.P1000323_crop

We’re fortunate that our mothers remain active and mostly
well though not without some of the challenges of great age. These family
tidings remind me of friends who are struggling with their health and life
itself. I hope you are taking care of yourselves and enjoying the world around
you. We would love to host your visit to New York in 2010.

Trust: In Healthcare and New Media

A Twitter friend turned me on to Julien Smith and Chris Brogan's Manifesto on Trust Economies. Which got me to thinking of an early morning exchange I had with a panelist at the Health 2.0 Conference in October 2008 in San Francisco.

The panel was a second presentation of the Edelman Report on Infoentials in Healthcare which was held early the second morning of the conference after the previous day's scheduled presentation was mobbed. I found the Edelman Report quite a cause for optimism, mostly because of the observation, that on-line information coupled to expertise scored significantly higher in confidence among infoentials than did on-line information alone. "The most credible source for health information is 'my doctor or healthcare professional' (96 percent)."

This observation on value added by the trusted physician provoked me to comment to the panelist that trust is multilayered and  begins when the parties involved: practitioner (or per Edelman a website or service) and patient/consumer find one another "trustworthy". Trust evolves as the parties experience one another and grows as this experience of trusting serves those involved.

Smith and Brogan's "Manifesto" makes the point explicitly and in rather utilitarian fashion. I've also been reading Robert Solomon & Fernando Flores, building trust in business, politics, relationships, and life since Kent Bottles of the Institute for Clinical Systems Improvement told me about.

I'm further prompted in these comments by Michael Millenson's comments on the Health Affairs Blog about Jay Katz. I loved Millenson's piece because with an experienced essayist's precision, Millenson lays out Katz's skepticism for the practice of medical research and medicine as he knew it in his era with its wholesale abrogation of physician trust for the patient.

Given that Katz in The Silent World of Doctor and Patient was writing during and about an era for which I still hold remnants of a romantic fantasy and confidence in the righteousness of those physicians I idolized either personally or by reputation, Millenson's essay both calls me to finally shed that fantasy and imbued me with the energy to complete this post.

In the practice of medicine, historically trust began with patient and physician finding one another "trustworthy." The sheepskin on the wall, the neighbor's recommendation and the practitioner's physical appearance ("like me" in physiognomy; "better than me" in habitus and often wealth) gave the patient reason to find the physician "trustworthy."

During the twentieh and now twenty-first century, the physician has been explicitly trained to suspend disbelief–presume the patient trustworthy. Certainly we practitioners have also learned to look beyond the bare bones narrative for what the tale may obscure or imply as much as what the patient's recounting discloses; still, the clear theme has been and continues, "The patient tells you the diagnosis if you'll but listen."

Out of this suspension of disbelief and presumption of trust, the physician and patient sought a caring and comforting relationship which in historical terms was about "Curing sometimes, relieving often and comforting always." Or as Francis Weld Peabody put it (J Clin Invest. 1927 December; 5(1): 1.b1–6.) "One of the essential qualities of the physician is interest in humanity, for the secret of the care of the patient is in caring for the patient."

Writing here as a physician trained in the 1970's and the son of a physician who was trained in the 1940's I'd like to fantasize that I still maintain a strong connection to that ethos and the trust that may be developed through "caring for the patient."

Though I lead and teach physicians as my life's work and I engage this issue every day with a hopeful mien; at my core I despair: Few physicians of my acquaintance approach each patient interaction with a suspension of disbelief and a presumption of a trustworthy patient. No, fortunately such suspicion is not universal, but it is widespread, particularly in my own field of emergency medicine. If my reading of general medical journals and many websites and blogs is to be believed, others see it as well. Perhaps you think I'm suffering from the "availability heuristic"?

There are many possible contributors to this state of affairs, perhaps the medical negligence environment contributes, regulatory structures around advising victims of domestic violence, the well-founded and appropriate concern for finding and reporting abused children–complete with a penalty for the physician who fails to do so–all contribute and create an inherent suspicion around many injured patients regardless of the compassion of the practitioner. I'm sure some will dispute these suggested contributors and perhaps you identify a more critical factor I've overlooked. Please add your comments below.

In short, there are environmental as well practitioner (and patient/consumer) contributors to trust deficiencies in healthcare today and in the absence of maintenance, entropy takes over and trust decays.

It certainly has done that in practice and it is unlikely that primary physicians in 15 minute encounter will rapidly rebuild it. A troubling conundrum indeed.

Just Recertified–Am I competent, good, outstanding . . . or not so much? Bob Wachter wants to know.

In a year-old post on The Health 2.0 Blog Bob Wachter points to the activities of commercial ventures including Healthgrades, Zagat and Google to begin rating doctors right along with your favorite city magazine. As is typical for his straightforward style, Dr. Wachter puts himself in the position of seeking information for his own care and concludes that he wants all the differentiating information he can get–including Board Certification ranking of some sort. He would prefer a doctor who scored at the 87th percentile to a doctor who scored at the 5th percentile. That sounds like it makes sense–doesn’t it? Seems pretty sensible–a lot of face validity in that opinion–don’t you think so, too?

Not so fast; I’m not so sure it works out so well for all doctors.

In the post Dr. Wachter discusses a presentation by Dr. Kevin Weiss, the president of the American Board of Medical Specialties made to the American Board of Internal Medicine (ABIM). Bob Wachter also reveals that he serves on the ABIM and Google’s Healthcare Advisory Board; I served for nine years on the American Board of Emergency Medicine (ABEM) and I still read the periodic newsletters from the Executive Director there–I have some idea of what’s going on in my own specialty certifying process. I also took and passed my recertification exam this year.

Our board, ABEM, uses criterion referenced examinations rather than norm referenced examinations. I’m not certain our specialty is still alone in that distinction, but at one time we were. While I’m not a psychometrician and I don’t play one on TV, either, I’ve come to understand that our exam is pretty good at distinguishing a doctor who know 74% of the tested material from a doctor who knows 75% of the tested material. The latter will pass; the former will not. As I understand the nature of the exam and the scoring, while it is fair to say that the doctor who knows 100% of the tested material certainly knows more than the doctor who knows 75% of the test material, it’s not at all clear that one knows a third more than the other or that the test can tell that the doctor at 100% knows more than a doctor scoring at 90%; it becomes even less certain as the differences become smaller; consequently, the American Board of Emergency Medicine probably can’t put its diplomates on a percentile scale as Dr. Wachter suggests may be appropriate, at least probably not based on the testing approach in use today. Not to say that the testing couldn’t be changed at some future time.

So Dr. Wachter’s smell test notwithstanding and the people’s desire for physician ratings very much still in evidence, it’s not at all clear to me that the route to the goal is as direct as Dr. Wachter suggests.

Greater transparency in support of better decision-making for patients is a desirable, laudable goal. Reliable physician ratings is probably not coming soon, though city magazines, HealthGrades, Zagat and Google are either already or shortly to begin publishing their own ratings–user beware.

Primary Care Backlash Unfortunately begins with an Emergency Physician

I’m saddened to learn of Jonathan Glauser’s column in the December 2008 Emergency Medicine News from KevinMD. He notes, “With the primary care shortage starting to gain traction within the mainstream media narrative, it’s inevitable that some will lash back against generalists. (via Bob Doherty)”

Jonathan’s a very smart guy and I don’t doubt the experience that underlies the conclusions he’s drawn and the recommendations he’s making in his column, yet, he’s missing the bigger picture and as Bob Doherty’s blog and associated comments demonstrate the data support investment in primary care–not disinvestment. I regret that I can’t support your view, Jon.

Daschle: What Can We Expect Of The Health Czar In Waiting?

Jeff Goldsmith in this Health Affairs blog entry summarizes what we might look forward to in the New Year. I found his pointer to the McKinsey study useful since I’ve been uneasy for years in my support of PNHP’s view of the source of savings in single payer healthcare. Goldsmith’s three key ingredients for a health policy book by a Democrat seems on point:

1–Personal interest horror stories;
2–Debunking of Himmelstein/Woolhandler/PNHP assertion on 31% of health costs due to "administration". (See the McKinsey Global Institute’s 2007 “Accounting for the Cost of Healthcare in the United States” for a more rigorous analysis);
3–Mention of the WHO study ranking the USA 37th in the world in health care.

The piece goes on to discuss the Federal Health Board and why it might work and what political barriers to implementation it could face. I’ve been fascinated for years by the hesitancy to adopt a technocratic approach to the underlying issues of coverage and benefit–the diseases and technology to treat them are arcane. Perhaps at this moment the body politic suffers from sufficient fear of the complexity and of the financial abyss confronting employer paid healthcare so that rationalization whose goal might be improving upon "the failure of the intermediation system to provide sufficient incentives to patients and consumers to be value-conscious in their demand decisions, and establish the necessary incentives or mandates to promote rational supply by provider and other suppliers." (McKinsey Report cited above).

Ah, "incentives or mandates . . . ". Physician, heal thyself.

VA Chief, Prinipi, Quits with Budget Cuts Looming

So the VA Chief, Prinipi, is quitting. It probably doesn’t have much to do with the $900 Million plus cut anticipated in the DVA budget which will mostly fall on healthcare since that’s the largest part of the DVA budget. This at the time when our military men and women will be returning from Iraq. Just a small precursor of the coming cuts in Medicare. Stay tuned.

Bloomberg Dec 9 2004 1:24AM GMT [Moreover – moreover…]