+++++++++++++ +++++++++++++ +++++++++++++ +++++++++++++ [ ] +++++++++++++ v2n1 2013 +++++++++++++ a PHYSICIAN publication from +++++++++++++ +++++++++++++ the north shore-Lij Health System +++++++++++++ +++++++++++++ +++++++++++++ +++++++++++++ +++++++++++++ +++++++++++++ +++++++++++++ +++++++++++++

Advancing Medicine Shedding New Light and more on Prostate Cancer Page 14

Developing Medical Leaders Page 16

Role Reversal: Doctors as Patients Page 23

Favorite Fictional Physicians Page 33 > accelerating the Leadership Message Advancing: growth or progress of

I came of medical school hungry for the basics of medicine: the on-your-feet age when the computed critical thinking that leads one young doctor to tomography (CT) scan diagnose carbon monoxide poisoning by asking the debuted. I watched all right mix of questions about a Thanksgiving dinner. sorts of scans follow — You’ll read about doctors who save lives outside ultrasound, magnetic hospital walls —­­ whether it’s on an ambulance, at resonance imaging (MRI), the scene of a fire or in a small village on the other side then positron emission of the world that has very limited opportunities tomography (PET) — and I for healthcare, these doctors can’t take medicine learned at the hands of my sitting down. mentors that clinical exams I have witnessed a lot of important changes in were somehow taking a backseat to these promising medicine. After my medical training, I spent years technologies. In short order, the glamour of the image in general internal medicine practice. Diabetes was on a screen, which offered a window into the body, was so prevalent among my patients that I knew I could thought to say more than the touching, questioning not possibly have enough time to treat and educate and churning of the mind under fire that drew many all of them. A nurse practitioner answered the of us into medicine in the first place. calling and trained to become a specialist in diabetic Yes, this ability to get under the skin, through the management. She helped so many people learn bone and inside the brain added dramatically to the the skills of staying healthier — and I learned that science of medicine, but this infatuation with gadgets medicine is a team sport. seemed to replace critical thinking. Today, the refrain, We are now training medical students to become “I don’t know what’s wrong; let’s order a scan,” has critical thinkers and to put technology behind a careful led to patient frustration, runaway costs and very and thorough assessment of their patients. We don’t average doctoring. want doctors to lose trust in their clinical skills, only Medicine has to change, and there are advances in to feel they need to rely on technology for an accurate science that are game-changing and necessary. As you diagnosis. Even when technology is necessary to help will see in this issue of Doctoring, there are better ways make a diagnosis or manage treatment, it is my hope to diagnose prostate cancer and detect tumors earlier, that physicians use it together with deep thinking on and melding two imaging technologies may be just what their feet. That is the art and the science of medicine. the doctor needed to be able to tell patients when a tumor is present and requires attention. You’ll see how physicians and hospitals are challenged Sincerely, by the issues of modern medicine in a story on medical Lawrence G. Smith, MD errors and another on rehospitalization soon after physician-in-chief and dean, discharge. You’ll meet the latest resident generation North Shore-LIJ Health System

North Shore-LIJ Editorial Board True North Custom Media R se ecy Terence Lynam Charlie Milburn a c e l

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P Doctoring is published three R g e n m li Brian Mulligan Ashlea Roark ov yc times annually as a service of the e ec Ins R Assistant Vice President, Public Relations Art Director/Designer North Shore-LIJ Health System. erts Before Maria Conforti Ed Lammon Director of Editorial Services Managing Editor Jamie Talan Science Writer To subscribe or unsubscribe, call 800-624-7496.

Doctoring : v2n1 v2n1 dRdoctoring . contents

Gadgets & Gear Look inside for 04.... A View from Above ...... Showcasing Science tablet edition exclusives...... Brainy Books Locate these icons throughout Doctoring ...... Beyond Paper and Ink magazine to learn where you can enjoy supplemental content in the tablet edition:

Tablet-Exclusive Photography On Call:resident profile Tablet-Exclusive Podcast 5 05.... Siblings in Residence Tablet-Exclusive Video Chart Notes 07.... From Loss Springs Life 21.... Reducing Readmissions

Culture hey doc, 10.... Q & A: Curbside Consults Do you 16.... Moving into Management: have an Doctors as Administrators iPad? 33.... Doc in the (Electronic) Box: Who’s Your Favorite? Get your tablet edition Outreach subscription to 12.... Transforming Lives Doctoring from the 12 a World Away App Store today. 36.... Dual Roles: Doctor Follow these steps: and Firefighter Newsstand (1) Download our app from the App Store. (2) Open your newsstand app. (3) Subscribe to Doctoring. (4) Download issues and enjoy!

Breaking Ground 14.... Bringing Prostate Biopsies Out of the Dark

FINANCE & INSURANCE 19… ACO: Embracing a New Model 26 Wellness 23.... Healers Humbled: When Physicians Become Patients

In Profile 26.... Branching Out: Neurosurgeon Doc Doubles as Olive Farmer 38.... Fostering a Culture of in the Accountability (Electronic) Art & Science 28.... Finding the Melody in Medicine

Tutorial Box 30.... Learning from Medical Errors: 33 36 A Path Less Taken

v2n1: Doctoring G gadgets & gear > A roundup of medical office and/or personal equipment and other products of interest to physicians. by Jamie Talan 1 A View From Above /// While small, unmanned aerial vehicles (UAVs) can be as simple as a remotely controlled model plane or helicopter with a GoPro camera attached, Lehmann Aviation (LehmannAviation.com) has developed what may be the ultimate eye in the sky. The Lehmann LV580 is a full-auto-pilot-capable, auto-take-off, eagle-sized UAV. It features a day and night vision two-axis motorized camera and a ruggedized ground control system enabling full flight and camera control, plus live viewing of what the camera sees. Lehmann Aviation flew a UAV over the Palace of Versailles. Watch the video at http://bit.ly/castlevideo.

2 Beyond 4 Paper and Ink /// Showcasing science /// What would it take to build a medical device? It all starts with an idea, of PBS NewsHour recently introduced two new regular science features: Science Wednesday course. But savvy inventors might and Lunch in the Lab. The Science Wednesday segments, which began this winter as part of also need to get acquainted with the PBS Exploration Wednesdays, explore science and engineering. The biweekly Lunch in the new world of 3D printing. By using Lab column covers offbeat and fun science news Mondays and Fridays at pbs.org/newshour. digital models to create solid, three- dimensional objects, 3D printers break through the limitations of the 3 two-dimensional printed page. Used in a wide range of fields, including space Brainy Books /// exploration and the aerospace industry, the possibilities are nearly unlimited. Researchers at the Wake Forest Annie Murphy Paul had a brilliant idea — many of them, for that matter. A science writer, Institute for Regenerative Medicine Ms. Paul fills The Brilliant Blog (AnnieMurphyPaul.com/blog) with insights into learning, have combined a traditional inkjet creativity and the path to brilliance. She has written several books, among them The Cult of printer with an electrospinning machine Personality, a cultural history and scientific critique of personality tests, and Origins, a book to create a 3D printer that produces about the science of prenatal influences. Crown will publish her latest book, Brilliant: The tissue constructs with properties typical New Science of Smart, later this year. of elastic cartilage. The scientists have already implanted these printed structures — made from synthetic and natural materials, including cartilage cells from a rabbit ear — into Want to Learn More? mice; and mechanical force testing Use your smartphone to scan these QR codes for easy access. has demonstrated the potential for implanting 3D printed structures in people. Although the technology is still in its infancy, 3D printers are already used to create dental fixtures and prosthetic limbs. The printers start at $1,000 and can cost as much as $500,000. Learn about the Wake Forest 1 2 3 4 team’s research at http://bit.ly/cartilageprinter. Lehmann Aviation PBS Annie M. Paul 3D Printing

Doctoring : v2n1 5 resident profile resident on call: call: on in Residence Siblings by Jamie Talan

Sean Howse, a third- year resident at LIJ Medical Center, walks through the Emergency Department (ED) with his sister Elizabeth. “Hey, Dr. Howse,” is the common refrain as the duo passes. Both turn their heads. They are a brother-sister team in the ED.

he first brother-sister residents in emergency medicine derbird School of Global Management and worked in finance at the hospital, they don’t talk much medicine at home. for several years before heading to medical school. He always T Although the two entered college with different aspirations wanted to become a doctor but understood that he needed roots — Sean was interested in economics, Elizabeth in law — they ended in business to guide his practice in medicine. Even though his up following their parents’ paths into medicine. Their sister is also family is stacked with physicians, he said he didn’t know a lot of pursuing a medical career by training to become a psychiatrist. The doctors who knew the business aspects of medicine. two siblings’ penchant for solving puzzles in a hurry drew them to Dr. Sean’s business acumen helps during weekly ED staff meet- emergency medicine. ings that cover cases that could have gone better. The ultimate goal “Every patient is a mystery — and for each one, you have is to create a more efficient experience for both patients and staff. to decide what is known and what isn’t known, what tests to “The hiccups can be anywhere,” Dr. Sean said. order, and whether or not the person needs to be admitted,” ED doctors may not follow up on patients, but they do refer Sean Howse, MD, explained. patients for post-ED care. Education is also part of the equation. “Here, we don’t worry alone,” he added. “There is definitely an art and a science to it,” Dr. Sean said.

The Business of Medicine Piecing the Puzzle Together The siblings are best friends. Born and raised in San Francisco, Elizabeth Howse, MD, said she loves diagnosing patients. they went to medical school at Wake Forest University in North After Hurricane Sandy and on the heels of a Thanksgiving Carolina after finishing their undergraduate training in three dinner, a woman in her 60s showed up with complaints of years. Dr. Sean went to Switzerland for an MBA at the Thun- cough and chills.

v2n1: Doctoring 6 resident profile resident

on call: call: on “What time did the symptoms start?” Dr. Elizabeth asked. “Did you make dinner?” The patient said that she cooked and brought the meal to her children’s house. No one else was sick. She asked about the woman’s electricity and discovered it had been out since the storm. And here was where the puzzle pieces snapped into place. The woman confessed that she started cooking on an outdoor grill, but when it got too cold, she moved the grill inside to finish up the chicken. The diagnosis: carbon monoxide poisoning. After six hours of oxygen therapy, Dr. Elizabeth’s patient felt well enough to go home. The diagnosis could have been missed. The patient came in thinking she was having a heart attack and had a history of coronary heart disease to support her suspicion. Because the blood tests showed no sign of a heart attack, Dr. Elizabeth used the rapport she had developed with the patient to ask the right questions and find a solution. “If you only look at one thing, you don’t know what you might miss,” her brother said. “We do a lot of head-scratching,” Dr. Elizabeth added. “What is it that we know, and what is it that we don’t know?”

“We do a lot of head- scratching,” Dr. Elizabeth Howse added. “What is it that we know, and what is it that we don’t know?”

Shared Experience Both residents have diagnosed their fair share of cancer in the ED. The brother recently examined a middle-aged man who arrived complaining of a bitter taste in his mouth. His oxygen saturation was low, his heart rate was too fast, and he had shortness of breath. It turned out he also had pneumonia. In addition, the patient had cardiac tamponade that required a cardiac surgeon to place a drain in his heart. All of these problems were due to one missed thing: lung cancer. The Howse residents have also gotten to know the “frequent fliers” of the ED — patients who return often enough to know their ED doctors by name. The siblings also clearly get a kick out of walking through the halls together. As Dr. Elizabeth’s 12-hour shift ended, Dr. Sean’s shift was beginning. They shared a hug in passing. “I love you,” he told his baby sister. She smiled. She was off to get some sleep before seeing the next round of patients.

Doctoring : v2n1 7 chart notes chart From Loss Springs Lifeby Jamie Talan

The calls come in, and it’s never good news — at least on the caller’s end.

hese are the family members of gunshot victims, stroke victims, sudden and fatal heart attack patients. They will grieve their losses yet want something to remain Needs in T of their departed loved ones. They are calling doctors who understand their limits in healing but also see the potential to save another life. These are the people behind organ donations. Ninety-eight hospitals and acute care centers in the New York metropolitan area have direct, daily contact with the New York Organ Donor Network (NYODN). By law, hos- pitals must notify the network’s 24/7 call center following an imminent or in-hospital 6,400 death, said Helen Irving, president and chief executive officer for the NYODN. Once the waiting for call comes in, the train is out of the station at high speed. The first order of business is to kidneys see whether the patient is part of the New York State Organ and Tissue Donor Registry. If a potential donor is on the registry, the NYODN does not require consent from a relative, but works with family members to carry out their loved one’s wishes. If the 1,400 potential donor is not on the registry and doesn’t carry another donor-designation docu- waiting ment, the NYODN dispatches a counselor to the hospital to talk with family members for livers or an authorized decision-maker about donation. About 58 percent of families agree to donate their loved one’s organs at death. Constant Need 250 About 8,000 people are on the waiting list for an organ transplant in NYODN’s service need a heart areas, Ms. Irving said. She works closely with all area hospitals to ensure that staff under- stands when to call and what to do preceding or following a death. The calls for donation lag far behind the demand for organs. In New York, 6,400 people await kidneys, 1,400 58% await livers and 250 need a heart. A smaller number of sick people are on the lists for pancreases, lungs and intestines. Tissue donations include heart valves, cardiovascular of families tissue, bone and skin. A great need also exists for corneas. donate a People who want to donate organs and tissue can sign up online, when renewing their loved one’s driver’s licenses or nondriver IDs, or by specifying their wishes on end-of-life documents organs such as a healthcare proxy or living will.

v2n1: Doctoring 8

chart notes chart Sue Kontak, RN, has spent almost 20 years in a variety of positions at the NYODN. As a clinical manager for the Long Island region, she is not routinely on-site evaluating patients or approaching families. Instead, she educates doctors, physi- cian assistants, nurses and other health professionals about organ donation and what to do when they are expecting a death to be pronounced. The NYODN can actively cover 10 to 22 active cases a day. Its staff includes donor evaluation coordinators, transplant coordinators (typically registered nurses), family counselors, surgeons and physicians, as well as hospital service specialists. Ms. Kontak and her colleagues receive calls involving patients undergoing brain-death testing, terminally ill patients who are about to be removed from ventilators or donation after car- diac death (DCD) cases. When a call comes in, an NYODN team is immediately dis- patched to the hospital so that the clinical coordinator can as- sess such critical elements as family dynamics, the patient’s medical and social history, organ function, and a clinical evalu- ation for DCD cases. Clinical coordinators also conduct medical assessments, including ones pertaining to neurological reflexes, the type of medications the patient is receiving and respiratory function. Once the coordinators complete the assessments, they discuss the findings with the network’s medical director to see whether the person is a candidate for donation. Following a declaration of brain death, the patient’s physician usually gets involved in donation discussions with the potential donor’s relatives, collaborating with NYODN staff to ensure the best communication and consent outcomes for the family. Screening Potential Donors physicians When a neurologically devastated patient who does not prog- ress to clinical brain death is referred to the NYODN, the case can be kept open for potential donation after cardiac death. are our This process is activated when the patient’s healthcare proxy specifies criteria for ventilator disconnection and continues with the evaluation of the likelihood of cardiac arrest within greatest one hour after disconnection. Such a case occurred last summer when a young woman .” arrived at the North Shore University Hospital Emergency advocate Department in a coma. She had overdosed on street drugs. Doctors determined that her heart had given out, and her —Helen Irving, president and chief family asked that she be removed from mechanical ventilation, executive officer for the NYODN but the NYODN’s medical supervisor felt that she would not likely expire within one hour. When cardiac death was finally pronounced, hours after removal from ventilation, ischemia and hypoxia that ensued during the terminal weaning process rendered her organs nontransplantable. The NYODN Tissue Department has strict rules as well. If this young woman met criteria as a viable tissue donor, the NYODN would send a team to recover her cornea(s), heart valve(s), skin and bone. But with her drug history, the tis- sues were not recoverable.

Doctoring : v2n1 9

Supporting the Family and Team notes chart Hospitals routinely support NYODN staff members’ consultations with patients’ families, because network staff members are trained to deal with bereavement and crisis. Hospital physicians often work with NYODN family counselors and other clinical coordinators; they talk with family members about donation after brain death or removal from mechanical ventilation, if the patient is a candidate for organ donation after cardiac death. Local recipients usually receive organ and tissue donations, al- though sometimes NYODN allocates for transplants outside the patient w is region based on the severity of a recipient’s condition or failure e ad n d to find a local beneficiary. a e People like Ms. Kontak on the “donation side” of transplant d y t r seldom get to see the happy results of this complex affair — the o e

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p a to donor families and recipients to provide support and counseling. l Inspired by Tragedy Ms. Irving trained as a cardiothoracic nurse in the United Kingdom, where she grew up. In 1988, she was taking care of a man waiting for a heart. When the call came that a heart was available, the staff couldn’t wait to deliver the news. But the man had a fever and couldn’t receive the transplant. The heart went to another person, and Ms. Irving’s patient died. Have you come across a A year later, a 17-year-old was in critical condition following a particularly motor vehicle accident. The family refused to donate his organs. interesting medical case? “I remember feeling that it was a life lost and that another life could not be saved,” Ms. Irving said. Have you encountered a medical She came to the United States in the 1990s to work in the case that might be a good Intensive Care Unit at Lenox Hill Hospital and saw an ad for candidate for “Chart Notes”? a job opening as a transplant coordinator at the NYODN. Send a brief description to Maria Remembering the teenager whose organs could have saved a Conforti at [email protected]. man in need of a heart, she talked her way into a job. In 1995, she went to work at the NYODN. She later did a stint at Mount Sinai Hospital, then came back to head the network in late 2011. Ms. Irving has many goals, including increasing organ dona- tion in New York and reducing the number of people who die waiting for a transplant. “We lose nearly two patients a day, and a new patient is added to the state list every 2.5 hours,” she said. New York State is well below the national average in enroll- ments on the Donate Life Organ, Eye and Tissue Donor Registry — 21 percent compared to the national average of 45 percent. Last year, there were 358 deceased donors in New York State. In the field, said Ms. Irving, “physicians are our greatest For more information on donation, call the NYODN at 646-291-4444. advocate.”

v2n1: Doctoring THE PHYSICIANS

Andrew Adesman, MD, chief, Developmental and Behavioral Pediatrics, Steven and Alexandra Cohen Children’s & Medical Center of New York Q A Curbside Consults by Jonelle Todd

How should a physician respond to outside-the- office requests for medical advice? The situations can be awkward, and the best way to handle them Jacqueline Moline, MD, chair of Population Health for the North isn’t always clear. Shore-LIJ Health System Doctoring spoke with North Shore-LIJ Health System physicians in a variety of specialties to learn how they handle informal requests for medical advice from friends, family members and acquaintances.

Vijay Rasquinha, MD, Doctoring: How do you typically respond orthopedic surgeon with to requests for medical advice outside a North Shore-LIJ Medical Group 1 clinical setting? Jacqueline Moline, MD: It depends on the nature of the request. If it is for general information, I try to respond. If it requires advice, I suggest the person discuss it with his or her own physician, though I do tell people never to make changes to treatment plans.

Vijay Rasquinha, MD: I keep my comments general, but first I try to clarify exactly whom and what we are talking about; sometimes, people Noah Rosen, MD, director of the Headache Center at the Cushing are asking on behalf of a friend or family member. If another medical Neuroscience Institute and program professional asks, and the question is in my specialty, I may discuss director for Neurology at the Hofstra diagnosis, treatment protocols or surgical options. North Shore-LIJ School of Medicine Noah Rosen, MD: With close relatives, I have the opportunity to help and to hold their hand through the process. While I don’t think it’s a good idea to treat people close to you, they can rely on me to help direct them to the right resources and care providers. Usually, my family understands and respects my limitations, and their expectations of me are the most realistic.

Carolyn Shih, MD: I try to give them a very thorough answer if it’s in my specialty. If not, I never fudge. I will refer them to a trusted resource, Carolyn Shih, MD, ophthalmologist with North Shore-LIJ Medical Group professional or Web site.

Doctoring : v2n1 11

2 culture Doctoring: How do you handle questions about a procedure or condition with which you have no experience versus one you know well?

Andrew Adesman, MD: For conditions with which I am very familiar, I will try to help anyone who asks. For topics I do not feel immediately comfortable addressing, I may refer the person to an appropriate resource, or I may read up on a less familiar topic. In select circumstances, I may reach out to one of my pediatric colleagues.

Dr. Rosen: When I am asked a question outside my area of expertise, it is much like asking an electrician about a plumbing problem. My level of basic medical knowledge is well above that of the general public, but it is best utilized in leading someone to the appropriate care provider.

Doctoring: What if someone Doctoring: What are some of the ways asks for your opinion of advice-seekers react to your answers? another doctor or the 3 treatment that physician 4 Dr. Adesman: Parents are almost always grateful for the recommends? information and suggestions I try to give them about their children. Even when a child’s developmental problems Dr. Moline: If I know the physician, I are serious and cannot be minimized, parents generally try to highlight his or her strengths. For appreciate my candor, especially if my feedback is given example, if a colleague is technically the in a sensitive and empathic way. best around but has a brusque bedside manner, I would warn folks about that Dr. Moline: Usually, they respond with thanks that while making it clear I wouldn’t hesitate someone actually listened to them. to refer a family member or myself. Dr. Rasquinha: Most people are satisfied with general Dr. Rosen: If a procedure or treatment observations, but if they press for specifics, I ask where doesn’t entirely make sense to me, I say so. they got their information — usually, it’s the Internet. That way the patient may feel motivated to I tell them “Dr. Google” is not the right place to go. That seek out another informed opinion. tends to defuse the situation.

Doctoring: What is the most memorable experience you have had with a non-patient asking your 5 medical opinion? 6 Dr. Moline: After a talk I gave to a group, one of the audience members Doctoring: Any final came over, lifted up her shirt and asked me what I thought of her rash. thoughts? Needless to say, I advised her to see a dermatologist. Dr. Adesman: Especially in the Dr. Rasquinha: A neighbor wanted my opinion of her elbow pain. I felt context of an informal consultation, her elbow and discussed options in general, but she was convinced she I think physicians have to be needed an MRI. She went to several doctors to get one. When a physician mindful that some people seek repeated what I and several others had told her — that physical therapy and are able to digest a wealth and home care were enough — she wanted me to read the MRI. Well, her of information; in other cases, elbow is finally better — but now her hand hurts. “less is more.”

Dr. Rosen: A close friend and fellow physician called in the middle of the Dr. Rasquinha: My experience night after his wife had a seizure. I explained seizures are generally more has been that, even when you give frightening than dangerous. I described different types of seizures, how people free advice, they are not to manage them and limitations she might face. After our talk, he was in satisfied until they spend money. a much better position to discuss the subject with her doctor.

v2n1: Doctoring 12 outreach

by Jamie Talan Transforming a worlLivesd away

Doctors and nurses from LIJ Medical Center donated their time to underserved patients in Ecuador.

Ronald Burakoff, DMD, chair of dental medicine at North Shore University Hospital and LIJ Medical Center, had been living vicariously through residents who branched out worldwide on medical missions to help indigent people. After a decade of watching from the sidelines, he decided to pack his dental bags and hit the road.

Doctoring : v2n1 13 outreach

he destination: Quito, Ecuador. There, he and his For one thing, the hospital could not afford heat and had no hot colleagues spent a week working with children with water. The anesthesia unit had no scavenger system, so a hose was special needs, all of whom could never expect to get run out the window. T the care they needed without the help of international In Quito, a city of 2.5 million people, the average weekly wage specialists. The team of 31 healthcare providers included seven for a dentist is $75. Most indigent people can’t afford to have work from the North Shore-LIJ Health System, among them LIJ Medical done on their teeth. Some of the children who showed up had Center’s Garry Ritter, Maria Giraldo, Susan and Bill Kuncewitch, never used a toothbrush. Dr. Burakoff and his colleagues filled and Bernadette Amitrano, RN. dental caries and extracted diseased teeth. Others on the team Dr. Burakoff brought along his wife, Arlene Bregman, who is performed cleft palate surgery, scar revisions and remodeling of fluent in Spanish. Rafael Barrera, MD, the director of the Surgical inner ears. They also made interceptive orthodontics to separate a world away Intensive Care Unit at LIJ Medical Center, organized the mission. the arches of the cleft palates and provided education about Originally from Ecuador, he is also a director of Medical Missions for taking care of teeth, Dr. Burakoff said. The special needs of the Children, an organization that sends teams of health practitioners children meant that many required general anesthesia for routine into underserved communities around the world. dental care. Local dentists participated in the delivery of care so they could Meeting a Need also learn techniques to use after the teams returned home. This year, as in other years, notices went up in churches around “These children need care and can be ostracized by society the area announcing that surgeons and dental specialists would ar- without it,” Dr. Burakoff said. rive in October to work with special-needs children. By the time the One elderly woman made a long trip with her 10-year- North Shore-LIJ team arrived in Quito, 75 children and their fami- old grandson, whose cleft palate was repaired years earlier lies were making their way to the hospital for screenings and evalu- during another mission. They had heard a speech pathologist ations. Some took buses. Others walked. One woman arrived with would be part of the team this time. The grandmother two handicapped children who had been abandoned by their family. made the trip back and forth from their home every day of The kids were packed into a single wheelchair. the week so the boy could work with the speech therapist. The dental team was accompanied by otolaryngological surgeons from the Mayo Clinic in Rochester, MN, and Mount Sinai Medical An Inspiring Experience Center and New York Hospital Cornell Medical Center in New York Dr. Burakoff and Ms. Bregman said the warmth and appreciation who helped children with cleft lips and palates. The team worked from the families was the most uplifting part of the trip. 12-hour days, conducting an average of 10 general anesthesia cases a “You can just see how important our work was,” said day, and treated many others who did not require anesthesia. Three Ms. Bregman. surgeons and eight nurses helped 40 children with cleft palates dur- On the team’s last morning at the hospital, many families re- ing the mission. Three surgical rooms were operating 12 hours a day. turned to offer thanks. The New York couple said this would be the “We are back year after year, so we know the patients very well,” first of many missions in which they will participate. said Dr. Barrera. During the past 10 years, more than 2,000 children “To see these children transformed is inspiring,” have had corrective, life-changing surgery, and “now they can eat Dr. Burakoff added. and look normal and live a fruitful life,” he added. “Everyone was there for the right reason,” added Ms. Amitrano. “The mission was an extremely rewarding experience, especially “It was wonderful seeing the patients and their families from previ- when seeing the smiles and expressions of gratitude and relief from ous missions. When we brought the parents into the Post-Anesthe- the parents,” said Ms. Amitrano. “One mother couldn’t stop looking sia Care Unit, they would have huge smiles on their faces and say at her baby, smiling and repeatedly saying, ‘She looks like there was that they remembered us. I think it gave them a sense of relief to never anything wrong.’ We give up something so small [time and have a familiar face.” vacation] so others can benefit tremendously — we help provide a “My heart was filled with joy and satisfaction when the parents better quality of life.” held their children for the first time after surgery,” she continued. “They couldn’t take their eyes off of their children. The first thing Overcoming Obstacles that many said was ‘Qué hermoso!’ [How beautiful!]. “We had no idea what to expect,” said Dr. Burakoff. “It was “It’s an amazing feeling to know we’ve been able to change the challenging.” lives of so many children.”

v2n1: Doctoring Do 14

c breaking ground torin g :v2n1 Out oftheDark the prostate, but30percent cancers of are this zone.” of outside of techniques the back only sample “Traditional part Dr. Rastinehad. prostate of in the diagnosis cancer, Dr. said Rastinehad. heard didn’t initially they agamethey changer canbe —butit —telling have news patients like they sound good cancer when patients whohad already received may negative biopsies.not It system can pick an up additional 37 to 45 percent cancers of in prostateabnormal The tissue. arenumbers impressive — the system to target fusion-guided (MRI-US) imaging/ultrasound resonance a national of study testing magnetic a new part been Institute for Urology, can barely contain his excitement. He’s In Smith at the Arthur oncologist urologic Smith DO,an interventional at the Arthur oncologist urologic aninterventional prostate tumors to up one centimeter. procedure missedatumr. this zone.”this the prostate, of back but30percent part cancers of are outside techniques the only sample “Traditional Dr.said Rastinehad. prostate of in the diagnosis cancer, Dr. said Rastinehad. heard didn’t initially they agamethey changer canbe —butit —telling have news patients like they sound good cancer when patients whohad already received may negative biopsies.not It system can pick an up additional 37 to 45 percent cancers of in prostateabnormal The tissue. arenumbers impressive — the system to target fusion-guided (MRI-US) imaging/ultrasound resonance a national of study testing magnetic a new part been stitute for Urology, canbarely contain hisexcitement. He’s T ultrasound, onl Imagine havi ng aprostate biops “We can now see cancers“We cannow see that we couldn’t inthe past,” visualize said DO, Rastinehad, Art era era days and and these these anew dawned, dawned, has has But “We can now see cancers“We cannow see we couldn’t inthe past,” visualize opsy techniques do not detect almost half of all opsy techniques all almost of half detect do not reveal Studies the early1980s. that traditional bi men who have undergone prostate biopsies since for the unfortunatehat scenario been many has y t o findutmonthsryearslater that the - - y, one guided b (NIH), hired Dr. Rastinehad for an interventional oncology and and oncology (NIH), hired for Dr. aninterventional Rastinehad ingresident at whowas working the Nationalwith Health Institutes of Bradford Wood, MD, the director the NIHCenter of fellowship. Dr. oncology Pinto and was urologic work cology Peter Pinto, MD, Health Shore-LIJ aformer System North beginning. just was urology of interventional field The new ria. prostatic for hematu embolization rial refractory patients with Turning theLightsOn for prostate biopsy inMarch 2013. System™ fromFusion Biopsy Turning theLightsOn Invivo, part of Philips Healthcare, that stressful canbe for them and their families. or radiation treatment rather thanundergoingsurgery served merely whenpatients canbe caneven ob determine careSurgeons merely whenpatients canbe and even ob determine to tailor to apatient’s better tailorfrommationtion apatient’s better from the enhanced imaging the enhanced imaging care. that more more canuse can use areinforma infor surgeons surgeons detailed detailed moremore powerful, powerful, and inaccurate along the way. diagnoses Now scans that MRI the resulting along multiplebiopsies, with tient complications Health on (NIH), hired for Dr. aninterventional Rastinehad System resident at whowasworking the National Institutes of Peter onto arte a studyselective when he school, signed beginning. medical of Pinto, MD, Health Shore-LIJ aformer North just was urology of interventional field The new hematuria. prostatic for embolization refractory patients with arterial onto selective a study whenhe of signed school, medical of The Food and Drug Administration clearedThe the UroNavDrug and Food It’s error, basicallyasampling butone that cancost the pa It’s error, basicallyasampling butone that cancost the pa Dr. Rastinehad began doing research began histhirdDr. year during of Rastinehad doing research began his thirdDr. year during Rastinehad y atransrectal by JamieTalan ------

15 breaking breaking ground

Fast Facts MRIs pick up an average of 2.2 lesions. The chance of having a clinically meaningful cancer not seen on an MRI is around 2.5 percent.

Art Rastinehad, DO, and Bob Moylan, interventional radiology technician, review images of a fusion-guided prostate biopsy.

urologic oncology fellowship. Dr. Pinto was working with Bradford Prostate cancer is slow-growing, and the trend is to treat few- Wood, MD, the director of the NIH Center for Interventional On- er patients in the early stages. But the question is this: How do cology, and the two physicians were well aware that the number of you know whom to treat? Current nomograms (risk-assessment false negatives in the prostate cancer field was too high. tools) make statistical calculations based on other patient data, “It’s like driving at night on a mountain with the headlights comparing it to the blind 12-core biopsy to determine the sever- off,” Dr. Wood was fond of saying. “When you turn the headlights ity of the patient’s cancer. on, you can navigate better and actually see where you are going.” In the early results at North Shore-LIJ, 71 percent of patients The lights were out in the prostate. Doctors needed to see on active surveillance were upgraded and needed treatment. Two where they were going. major shortfalls of traditional biopsy methods drive this — the Their work at NIH led to the current MRI-US trial that has en- lack of targeting specific lesions, and not sampling the entire rolled more than 700 patients. North Shore-LIJ is the second U.S. prostate. site to validate the initial NIH results. The design of the study “Our goal is to inform patients of the amount of can- is simple: Any patient with an elevated prostate-specific antigen cer they have and what treatment options are available,” (PSA) level or who has received a previous negative biopsy and Dr. Rastinehad said. “The standard of care is no longer good for whom an MRI of the prostate raises suspicions of cancer is enough. We want to offer this technology to see 100 percent of eligible to enroll. Researchers use the detailed MRI plus an MRI- the prostate. Our goal is to redefine the way we screen, diagnose US navigation system to guide them when performing the biopsy. and treat patients with prostate cancer.”

“Initial results are impressive,” Dr. Rastinehad said. “Imaging Tablet edition Exclusive: Watch a video lets physicians assess a patient’s risk of having low- versus high- highlighting our New prostate tumor- grade disease.” detecting Imaging Technology.

v2n1:v2n1: DoctoringDoctoring 16 culture

Moving into Doctors as Administrators by Jamie Talan

Healthcare is transforming quickly, and we need exceptional physician leadership to help with this transition.

Doctoring : v2n1 17 culture Looking back, it makes sense.

ason Naidich, MD, went to medical school at Cornell University and did his radiology residency at NYU School of Medicine. Two fellowships followed. When J he arrived at North Shore-LIJ Health System in 2004, the system was making its foray into outpatient radiology, and the physician found himself working with a clinical and administrative team determined to build the best imaging center imaginable. The group started with an empty slate and began building a palette — meeting with architects, designing the facility, se- lecting equipment and hiring staff. “In medical school and residency, things often felt rigid and predefined,” Dr. Naidich said. “There was little opportunity to express your creative side.” Early on, as the director of the Diagnostic Imaging Center at the Center for Advanced Medicine, he developed hands-on experience building a practice from scratch — with patients at the center. Looking back, Dr. Naidich realized that he had an entrepreneurial spirit and liked the feeling of being able to help patients on a larger scale, in addition to the one-on-one interaction of his clinical work. Pretty soon, he wanted to understand more about the business of healthcare and was accepted into the MBA program at Yale University. He graduated in 2009. Today, Dr. Naidich gets to put this experience to use as vice president of system imaging services. Over the past several years, the imaging service line has not only expanded access through a combination of construction and acquisition, but also has integrated hospital and outpatient practices, standardized policies and procedures, improved patient safety (particularly radiation safety) and delivered better financial performance. Medicine is a team sport, Dr. Naidich believes. Now, he’s on the inside track in the health system — one of 50 doctors hand-picked for a new training program to create a generation of doctor/administrators. Natural Influencers The seed for the Physician High Potential Program germinated several years ago when North Shore-LIJ President and CEO Michael Dowling asked the then-small number of physician administrators to grow their ranks. It was clear that physicians could bring insight to the business of medicine.

Healthcare is transforming quickly, and we need exceptional physician leadership to help with this transition. — David Battinelli, MD, senior vice president and chief medical officer at the North Shore-LIJ Health System

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“I want to build an army of physician leaders,” system. That is changing. “We are working Mr. Dowling said. to integrate the administrative and medical culture Health system executives believe the program leadership programs. We now have people talking is critical to the growth of the organization, the same language,” said Dr. Napp. said David Battinelli, MD, senior vice president Kevin Bock, MD, trained in pediatric critical and chief medical officer at the North Shore- care medicine. By the time he arrived at Cohen LIJ Health System. “Healthcare is transforming Children’s Medical Center of New York for a quickly, and we need exceptional physician fellowship, he was beginning to blend his love leadership to help with this transition,” he said. of computing into his work with patients. At The program’s inaugural class will finish two the same time, information technology had years of training by the end of 2013. The next touched down at North Shore-LIJ in big ways, class of 25 physicians began training in February. and the electronic health record was on its way to “We’ve been looking for natural influencers,” becoming a reality. He began designing computer said Dr. Battinelli. models for healthcare delivery and, by 2000, Dr. Battinelli spent 25 years with the Boston was splitting his time between informatics and University School of Medicine, developing unique critical care medicine. care in an urban environment for patients ranging Almost a decade later, in 2009, Dr. Bock we are from the most affluent to the most vulnerable. He accepted a position as director of clinical was integrally involved in planning and executing information systems for North Shore-LIJ. He still working to the formation of Boston Medical Center, which sees patients on service a few times a month. Last integrate the was the result of a merger between Boston City year, he joined the inaugural class of the Physician Hospital and Boston University Medical Center. High Potential Program. administrative Marking, according to Dr. Battinelli, the first and “I am learning things about the process of most successful merger of a public and private delivering care that inform what I do every day,” and medical hospital, its founding mission was “exceptional Dr. Bock said. leadership care without exception.” Boston Medical Center He’s also six months into a master’s degree was founded on the principle of a single standard in Healthcare Delivery Science at Dartmouth programs. of care driven by patient safety and quality. College. “Looking back, it is easy to see how I got Senior health system administration, the here. But if you asked me a decade ago where I We now have Human Resources Department and the Center would be today, I could not have predicted any people talking for Learning and Innovation (CLI) collaborated of this.” to develop the Physician High Potential Program. the same The training focuses on identifying and enhancing Feeling More Empowered leadership skills with an eye toward emotional Susan Scavo, MD, sees things the same way. language.” intelligence and effective communication She has spent her career as an obstetrician/ strategies. Participants learn from today’s health gynecologist in private practice, and the health —Marc Napp, MD, system executives. Ultimately, they will learn system acquired her practice almost two years North Shore-LIJ’s skills necessary to drive change. ago. She and her partner, Sherri Putterman, MD, vice president of medical affairs “This is not a mini-MBA,” said Dr. Battinelli, have known one another since their medical although physicians do learn about healthcare fi- school days at SUNY Health Sciences Center nance and economics. “The business of medicine at Syracuse. The two are both in the Physician is important, but developing leadership skills is High Potential Program. Now, they are on the core of the program.” the opposite side of the table negotiating Physicians are nominated for the program, possible acquisitions of other community and an interdisciplinary team of health system obstetrics/gynecology practices for the executives decides who will enroll. expanding health system. In addition to clinical expertise, “physician “The program has taught me how to be a more leaders need to think about how we organize effective problem solver,” said Dr. Scavo. care, the quality of the care, the distribution of Her new skills allowed her to figure out that resources and performance. It is a different view the health system was losing money on intra- than what is taught in medical school,” said Marc uterine devices (IUDs) by paying more than it Napp, MD, North Shore-LIJ’s vice president of was reimbursed for them. Rather than increasing medical affairs. the cost for patients, she worked with purchasers to negotiate a much lower price. Driving Change Every day, she feels more empowered in both Until recently, senior executives had a handful her practice of medicine and in her role at the of physicians guiding decisions at the health negotiating table.

Doctoring : v2n1 19 finance & insurance finance

Embracing a new model

by Colin Stayton

As hospitals nationwide continue to react to ongoing and impending You will find great success with healthcare changes, the the new aco model. North Shore-LIJ Health System is taking a more proactive approach. But how will the changes pan out for physicians?

ince taking effect in 2010, the Patient Protection and Afford- Medicare will hold North Shore-LIJ accountable to an agreed- able Care Act has slowly but surely changed the way most upon global payment for patients admitted to participating hospitals S people think and talk about healthcare. Many believe 2013 for one of the aforementioned DRG categories. This global payment will mark the year of greatest change, as healthcare leaders begin to will include the index hospitalization, readmissions, professional implement what has so far only been theorized. fees and all post-acute care delivered during an agreed-upon post- “The trepidation of physicians rests with the entry into an discharge period. If North Shore-LIJ is able to deliver appropriate unknown,” said David Battinelli, MD, senior vice president and chief care under cost, the physicians involved in that patient’s care will medical officer at the North Shore-LIJ Health System. “All of them share in the savings. If Medicare’s cost of care for these patients have cut their teeth with fee-for-service arrangements, and most are exceeds the agreed-upon price target, the health system will pay very comfortable with that model.” Medicare the difference.

Bundled Up Stemming the Tide of Overutilization North Shore-LIJ will undergo a significant transition this year As a middle ground between fee-for-service and capitation — in to an accountable care organization (ACO) model for care delivery which the hospital assumes full responsibility for preventable care and reimbursement. A key facet of the ACO model is incentivizing costs — bundled payments are an ideal transitional model on the quality care through bundled payments. As of January 2013, path to incentivizing quality over patient volume. North Shore-LIJ North Shore-LIJ has enrolled four of its hospitals in a three-year has already developed risk-sharing contracts with several insur- pilot program sponsored by the Centers for Medicare & Medicaid ance companies, including Oxford and Healthfirst. These arrange- Services involving a variety of diagnosis-related groups (DRGs). ments help North Shore-LIJ and its physicians avoid financial shell These include: shock while also providing incentives for physicians to deliver the ƒƒ Chronic obstructive pulmonary disease (COPD); cardiac surgery best care. — LIJ Medical Center “The current incentives associated with the fee-for-service ƒƒ Orthopedics — Huntington Hospital model have created a maelstrom of overutilization,” said ƒƒ Stroke; cardiac surgery — North Shore University Hospital Kristofer Smith, MD, vice president and medical director of ƒƒ Cardiac surgery — Southside Hospital advanced illness management at North Shore-LIJ.

v2n1: Doctoring 20

Much of what physicians are doing now in terms of health management is not reimbursable, but in the future it will be. finance & insurance finance Meanwhile, physicians will still be getting a fee-for-service payment. I believe the ACO model represents a unique opportunity to regain control of the continuity of patient care while maintaining or growing the current levels of reimbursement and practice lifestyle. — David Battinelli, MD, senior vice president and chief medical officer at the North Shore-LIJ Health System

“In the new healthcare landscape, the goal is to reconfigure the incentives so patients and physicians don’t overutilize.” Dr. Smith says overutilization is a special challenge in the post-acute care arena. Excess capacity and per-diem reimbursement are driving rehab centers, hospice providers and skilled nursing facilities to keep patients as long as possible, which Dr. Smith describes as “a recipe for high-cost medicine.” Hospitals as Insurers “There are opportunities to be more efficient in the post-acute setting,” Dr. Smith said. “Bundling payments will uncover those opportunities and One of the more innovative trends help us sort out which patients are being sent to post-acute facilities inap- to arise in response to the Patient propriately.” Protection and Affordable Care Act is hospitals and health systems assuming A Different Culture of Care the role of insurer. North Shore-LIJ’s In short, the goal of the ACO model is to keep patients out of the transition to an accountable care hospital. Achieving this goal requires an emphasis on preventive care, model is the first step in developing integrated delivery across the care continuum, more thorough education its own health insurance plan for of patients upon discharge and reduced overutilization. From a physician’s consumers. Currently, North Shore-LIJ perspective, bundled payments offer an opportunity for gain-sharing Premium serves as a complementary based on achieving certain quality metrics involving disease management insurer for affiliated physician and rehospitalization rates. However, Dr. Smith doesn’t expect these practices. Within the next few years, changes to occur without trial and error. North Shore-LIJ has plans to obtain “These are cultural changes that can only happen over time and will an insurance license and begin selling require all of us together to successfully navigate,” Dr. Smith said. “For an insurance plan to patients, as well. physicians, the risk of standing on the sidelines is to be ignored and miss Under this plan, the network would the opportunity to guide in solution-making.” include more than 9,000 of the health One way referring physicians can actively participate in the transition system’s affiliated physicians. to an ACO model is to join North Shore-LIJ Premium. A program of care North Shore-LIJ is also partnering integration operating within North Shore-LIJ’s Independent Practice with UnitedHealthcare Group, the Association, Premium is designed to align community-based physician nation’s largest health insurer, to offer practices with North Shore-LIJ hospitals. Physicians who enroll in Premium a suite of supplementary insurance enter contracts that stipulate financial incentives for value-based care that plans known as UnitedHealthcare results in reduced hospital readmission and decreased overutilization. North Shore-LIJ Advantage Plans. As of January 1, 2013, these tiered benefit Making Value Pay plans are available to small and large Despite fears about waning reimbursements, Dr. Battinelli said entering businesses in Nassau, Suffolk and into an ACO model will be a win-win for North Shore-LIJ physicians. Queens counties. “Much of what physicians are doing now in terms of health management is not reimbursable, but in the future it will be,” Dr. Battinelli said. “Meanwhile, physicians will still be getting a fee-for-service payment. I believe the ACO model represents a unique opportunity to regain control of the continuity of patient care while maintaining or growing the current levels of reimbursement and practice lifestyle.”

Doctoring : v2n1 21 chart notes chart Reducing

Readmissions by Jamie Talan

The 103-year-old man had been in and out of the hospital three times in six months. He was set for another discharge when Dana Lustbader, MD, head of palliative medicine at North Shore University Hospital, picked his name at random for a visit. Frail and admitted again and again, he was one of 26 patients older than age 80 in the hospital that day.

Lustbader and her colleagues with roasted sausage. His son and daughter- hospice care because he was slowly are involved in a pilot pro- in-law check in on him regularly. declining and did not fulfill the stringent Dr. gram to reduce readmission Severe diarrhea and an infection trig- requirements Medicare uses to pay for the rates among patients at the highest risk for gered his last hospitalization. He’d been in service. The insurance covers rehabilitation it. By studying these high-risk patients — for a week when Dr. Lustbader showed up at for 20 days post discharge, as unrealistic two per week — they believe they can figure his bedside. His health was declining, yet he or unwanted as that plan may be. He was out how to better serve patients and keep was on the discharge list. The hospital was eligible for home hospice care, but the son them out of the hospital if they don’t need sending him for rehabilitation, a benefit worried whether it was possible. There was to be there. fully covered by Medicare. no good solution, and the patient ultimately Three months into the pilot program, an Dr. Lustbader met the patient’s son, who went to rehab, though he was obviously increasing number of frail, elderly patients was there with the requisite discharge ward- unable to participate. The family is now were receiving hospice and palliative care robe in hand. reconsidering home hospice. interventions. These patients received “They told me he is going to rehab,” the better end-of-life care and proper symptom son told the doctor. “But I think he is dying.” Facing the Challenge management and, as a result, did not return She looked at the patient. He wasn’t eat- All across the country, hospitals are ad- to the hospital, Dr. Lustbader said. The 30- ing, and it was clear he could not get himself mitting too many people and readmitting day readmission rate fell from 25 percent to out of bed. He was in bad shape and said, them too often. Many of these patients are 10 percent. “I’m done.” frail and elderly and suffer from chronic con- “I think you are right,” she said to the ditions like heart failure. Readmission rates Case in Point patient’s son. She saw that rehabilitation are also high among those initially admit- The case of the centenarian tells the story wasn’t a realistic goal. End-of-life care was ted with pneumonia and acute myocardial of what is happening across the North more in keeping with the patient’s wishes infarction, so Medicare is tracking readmis- Shore-LIJ Health System and throughout and more realistic given the advanced state sion rates for these conditions and levying a the country. Four months ago, the patient of his illnesses. hefty financial penalty on hospitals that go began complaining of significant bouts “Let’s sit down and talk about a more over a certain readmission rate. This is the of dizziness, followed by the occasional appropriate discharge plan,” she told first year the penalty has been in effect, and fainting spell. He lives at home with a the son. the North Shore-LIJ Health System wound housekeeper who tends to his basic needs And so they did. up forfeiting $4 million in Medicare funds. and cooks his favorite meal — rack of lamb The patient did not qualify for inpatient Medicare penalized around 70 percent of the

v2n1: Doctoring 22 chart notes A TeamEffort home,” Dr. said. Smith daysof discharge. first 30 failurefor the to within patients the who return hospital heart Department Shore University Hospitalin the North Emergency place. The task unit force the observational testing began recently in home on the proper family with and medicines nursing support care based programs to hospitalization. help avert failure carechallenges heart of inorder community- to design Failure Heart Shore-LIJ North Task Force, the which analyzes is inappropriate he admissions.issue, said, Dr. cochairs Smith the readmissions that thetax health system and the country. The big what it’s like don’t and to they inthe hospital, be want to there.” be months. 15 a40percent reduction admissionsreports inhospital over the past patient’s to Dr. the hospital. a trip warrant Smith symptoms truly whena to determine whenneeded visits wellas emergency as the careorganize for patients callsregularly these and make house admitted.patient physicians Six gets and two nursepractitioners which increase that the likelihood a Department, Emergency chronically illelderly people. community-residing, House Program, Shore-LIJ which Calls deliversNorth care to 800 advanced for illness management the health system, oversees the why MD, Smith, Kristofer vice president director and medical of to closer in the home, home if not itself. This is are served best for chronic patients with conditionscommunity support who increase will topenalties 3percent by 2014. to 1percent ahospital’s allof of Medicare reimbursement. These For this sampled. year’s it hospitals penalized, those loss wasup LIJ HealthLIJ System. vicesenior president Shore- officer medical and chief at the North for chronic other according conditions, to David MD, Battinelli, to care develop of models similar community —isanopportunity symptoms arise. treatmentproviders, modifying thus inthe home plans new as provide collaboration better inpatient clinical and with outpatient home from can Dr. the hospital. nursespecialists these said Smith failure care inheart patients heading with nurses whospecialize apalliative carewithin or hospice program. have Some paired also multiple readmissions to evaluate served whowould better be Hospice Care failure Network for patients older than80with heart “We are that we seeing candeliver care them and send inthe ED For that inpatients, means that ready should be they to go Dr. administrators and other Smith merely believe that isnot it are“These the sickestof the sick,” Dr. know said. “They Smith visits to the The program works to prevent unnecessary hit also Theoffered financial challengea to develop stronger This change in healthcare delivery —from intoThis the hospital change in healthcare the delivery health systemSome are hospitals teamingthe also with up

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23 wellness

Healers Humbled: PhysiciaWhenns Become

Patientby Thomass Crocker

Physicians are accustomed to having answers to healthcare questions at the ready. However, when faced with medical crises of their own, they are cast in the vulnerable role of patients seeking insight into their health.

v2n1:v2n1: DoctoringDoctoring 24 wellness

The vulnerability of being a patient definitely gave me a different perspective. As a family medicine physician, as much as I made an effort to ensure the patient was at the center of everything I did before my medical event, I take even more care now to ask patients if they have any questions and ensure they receive as much information as possible. ­ —Tara Zahtila, DO, interim director of medical education at Plainview Hospital

or many physicians, the role of patient is uncomfortable, an intense, focused nerd to someone who was completely humbled but it also teaches the ultimate walk-a-mile-in-someone- by a medical condition. I told her I appreciated her being there and F else’s-shoes lesson. Two North Shore-LIJ physicians re- thanked her for helping me. cently shared their thoughts on times when becoming patients She said, “Honey, I love you on narcotics. You should take drugs themselves helped them better understand their own patients’ more often.” fears and, most importantly, how to communicate effectively with I returned to work the next day but was unable to pass the kidney the individuals in their care. stone. Eventually, following another painful attack, I underwent placement of a ureteral stent. The Key to a Happy Marriage? As physicians, we work closely with patients every day, but there Bruce Hirsch, MD, infectious disease specialist at North Shore is something about undergoing a medical experience that truly University Hospital (NSUH) and LIJ Medical Center, is a self- helps you understand and empathize with patients. described “nerd” who “works intensely during the day and takes things very seriously.” One day, he found himself in a situation he Championing Patient Rights had never envisioned: receiving treatment in the NSUH Emergency Tara Zahtila, DO, interim director of medical education at Pla- Department (ED). inview Hospital, has worked on the North Shore-LIJ Patient Rights Dr. Hirsch: My wife, Susan Hirsch, MD, is an internal medicine Taskforce — whose central mission is to safeguard patient visita- physician at NSUH. I devote lots of attention to my patients, but tion rights — for more than a year. Last summer, when she experi- when I get home, I’m never interested in discussing work with my enced a potentially serious medical event, all she wanted was to see wife because I am so focused on it during the day. her husband and daughter, a desire that reinforced the value of her One day approximately three years ago, I was seeing patients patient rights advocacy. at the hospital when I noticed a severe pain in my left side. I kept Dr. Zahtila: On June 1, 2012, as I stood in my kitchen preparing working, and the pain eventually slackened. A little time later, in to cook dinner, I experienced dizziness and neck pain. The symptoms the middle of writing a progress note, the pain became so intense passed, but, during the next few days, I developed nausea, headaches I couldn’t ignore it. I decided I must have kidney stones, which I’d and a change in vision. My primary care physician thought a cervical never had before. neck issue that stemmed from a past bout with cervical disc disease I called my wife and asked her to come and take me to the ED. She might be the cause of the symptoms. He advised me to take it easy met me as I hobbled toward the elevator, unable to do anything ex- and follow up if the symptoms persisted. cept concentrate on breathing through the pain. Imaging performed I continued working throughout the week, but by Friday, in the ED confirmed the presence of a kidney stone. As pain medi- I felt lousy. I met my husband at home and he drove me to the cations began to reduce my discomfort, I looked over and saw my Emergency Department at Glen Cove Hospital. A colleague on wife staring back at me. She was amazed at my transformation from the Patient Rights Taskforce, John D’Angelo, MD, senior

Doctoring : v2n1 25 wellness

vice president of emergency services at North Shore- LIJ, met me, and we joked that I’d finally had a nervous breakdown. Caring for After I explained my symptoms, Dr. D’Angelo felt certain I was suffering from stress, but he Colleagues ordered a computed tomography angiogram of my head and neck to rule out other causes — a pretty remarkable decision representing superior clinical Treating a physician presents a unique set of challenges. judgment. My husband and I were surprised when One physician well aware of that is Nicholas Sgaglione, MD, Dr. D’Angelo, white-faced, delivered the procedure’s professor and chair of orthopedic surgery at North Shore results: The radiologist thought he saw a dissection in the University Hospital and LIJ Medical Center. Dr. Sgaglione, who left vertebral artery. I had to be transferred to North Shore estimated 35 percent of his patients are physicians and other University Hospital. healthcare providers, noted that physician patients require Put simply, I was scared. All I wanted was to see my more of his time because they often have higher expectations young daughter, Charli, before I was transferred. My for their care, as well as loftier goals. husband rushed home, picked her up and brought her to “I once performed rotator cuff repair surgery on a physician me. I held her in the bed with me until it was time to go. who became very impatient about the recovery time, despite I underwent several imaging procedures at NSUH, the fact that we had discussed it would take at least six including hours spent in a magnetic resonance imaging/ months,” Dr. Sgaglione said. “The patient’s eagerness to magnetic resonance angiogram (MRI/MRA) machine. The recover and higher expectations create unique challenges in radiologic technologist didn’t allow my husband to be in treating him as a healthcare professional who is also a patient.” the room with me during my first round in the MRI/MRA Many physicians develop impatience as a result of their machine, but he was allowed to join me for the second fast-paced, high-stress jobs, Dr. Sgaglione believes. Doctors round. His presence at my bedside and during subsequent are also used to being in control, which makes ceding the lead procedures had as much to do with my ability to heal as role to others difficult. the outstanding care I received. Following a cerebral One more factor is the depth of physicians’ medical angiogram — an unnerving procedure, to say the least — knowledge, which while often beneficial, can also create the anesthesiologist told me my family wasn’t allowed to anxiety because doctors appreciate how serious some join me in the recovery room, where I would have to lie still conditions can be and understand the limitations of certain for four hours. I began quoting patient rights to him, and treatments. that’s when everyone knew I would be okay. I have been To address some of the challenges of treating physician able to manage the dissection with medication. colleagues, Dr. Sgaglione suggests: The vulnerability of being a patient definitely gave me • Blocking off time in your calendar for longer conversations a different perspective. As a family medicine physician, • Communicating information in a comprehensive way as much as I made an effort to ensure the patient was at • Encouraging patients to seek a second opinion if they the center of everything I did before my medical event, I have doubts about their care take even more care now to ask patients if they have any • Involving the patient’s spouse or another family member questions and ensure they receive as much information in the consultation as possible. We must advocate for patients who might • Staying abreast of the latest recommendations and not have the wherewithal to ask for certain types of treatments information; we must ensure they receive it nonetheless. “Treating patients is a privilege,” Dr. Sgaglione said. “Treating We must also never forget how important it is for patients fellow physicians is an even greater privilege. Physicians to have their loved ones near them during medical crises. should treat all patients as if they are physicians by doing On a personal level, I advise physicians, no matter how whatever it takes to communicate well and be responsive.” busy they are, always to make time for their families. When I was in that MRI/MRA machine and unable to go about life at my normal pace, I realized the importance of the memories we make with our families. v2n1: Doctoring 26 in profile

Neurosurgeon Doubles Branchingas Olive Farmer Out

Ask Mitchell Levine, MD, about his passions, and you’ll get a bellyful: moving carefully in and around the cavernous spine to locate tumors, a deep appreciation of Renaissance art, and Olea europaea — the olive tree.

Mitchell Levine, MD, a neurosurgeon, and his wife own an olive farm in Italy.

Doctoring : v2n1 Branching Out by JamieTalan China. With care, With the tree and the olives produces it China. canlive for 2,000 years. thegrows rockiest of in some in the from soils world to and thrives Lebanon house. modern place leveled. astrong, Inits nowhouse sits forabandoned decades. water,no running and thewere windows had ifit as been boardedlooked up. It into and the their grandchildren90s, had to was time it The house sell. decided Proietti family since recorded history, couple butthe last to work waswell the land the 60-acre for wasup in the had plot been and all.The olive house sale, farm mon forland their and growing a keep tohouse off farmers for sell crops.But summer. every hilltop inMarche nearly two decadestwo ago.They their took children there and olive producers. oil and wine musicians, resident artists, inTavola their showproducts. off Then there isArte , afestival by exhibits with town celebrates Primavera Medievale La with , acultural event where farmers local for year’s next pruning the crop.to study the InApril, trees and do the necessary for home to use. hisown Manhattan each harvest he imports over their olives.Dr. fighting pressingLevine happy he is added the 100liters that sufferedproperty from abad crop this year,Dr. and said customers Levine were Novembermiddle of —wasgoneFarms inamatter allaround weeks. of their grown olives.2012’s And —around ready 25,000pounds, for harvest by the sale for differences the subtle they organically selling days, the in oliveare These oils. rants allover and cooks by thealack appreciation world,frustrated grew of they A Hot Commdity T spinal surgery, spinal deformities and cancer of the spine. and cancer surgery, the spine. spinal of deformities spinal includes invasive minimally for HillHospital, Lenox hisexpertise neurosurgery operateand hiscolleagues on more than 1,000patients ayear. head spinal of Also which produceolive oils inItaly. what Dr. virgin extra the callsonebest of Levine four about and spends monthsyear per farmer tending their olive trees, Italian “[Olive farming] ispure fun,” farming] “[Olive Dr. said. Levine olive oil. about TheDr. European alot now know olive tree Levine and Ms. had the the Levines beams, and tile wooden the Italian of some Salvaging It’s toNine years decided trade they ago, com for up inUmbria. afarmhouse home, more Italian their first like peasant’sThe a bought couple hovel, on a at over, to the the winter end of Italy returned the Levines the harvest With like it water,”“We use the the year, end of “By he said. it’s gone.” And oliveAnd oil. Shore University Hospital. at North He Dr. directs neurosurgery spinal Levine “It’s gets,” it as good as “Perfect.” he said. While the couple used to the couple press used the olives to themselvesit While and sell fine restau tury churches and medieval walls. Ms. Levine has become a registered becomearegistered churches has Levine Ms. and medievalwalls. tury central12th cen of with dotted Italy atown inthe heart in Bevagna, 60acresand hiswife, more Antoinette, with bought than2,000trees owner. isaneurosurgeon and olive from Island farm he kid Long He - - - v2n1: Do c torin g 27 in profile Do 28

c art & science torin g :v2n1 Medicine Finding the Melo d y in back As achild,singingwas inspired b orthdox s the onl wanted littleelsei Rabin’s mind.Shewas By thetimeshewas 7, an att she hadmemorized Hebrew songsand up cant the worldbut orney adthe y thingonJill y herfather, t o singthem. or at their ynagogue. by JamieTalan

29 art & science ut girls had to sit in a separate area of the synagogue, and Merging Music and Medicine any idea of sharing the bema with her father was not part In the mid-1990s, Dr. Rabin decided to dust off her childhood B of the score. Orthodox women could never hold the Torah, dream and become a cantor. She was 30 when she started training the most sacred document in the Jewish faith. at the Academy for Jewish Religion. Taking the long road home, Still, the girl wanted to be a cantor. She struck a deal with she is now about halfway finished with cantorial school. In the her dad: He would teach her the songs, but it must be out of meantime, she serves as a volunteer chaplain for the North earshot of anyone else. So once a week the father and daughter Shore-LIJ Health System, and on occasional Friday nights she has would sneak down to the basement, walk through three doors, said Kaddish for patients and their families. Since 1997, she has closing each one tight — and belt out the sacred music of also offered her singing skills as a student cantor at Adath Israel, their ancestors. a temple founded in 1919 by Jewish potato farmers in Newtown, She was born into music. As a teenager, her mother sang on the Conn. She was on call on Long Island the weekend that Newtown radio, and even singer Eydie Gorme, a fellow student at William lost so many of its own, including Noah Pozner, a member of her Howard Taft High School in the Bronx, called her “The Voice.” But congregation. her orthodox parents would not let her choose singing as a career, She remembers when she started singing on the bema at the so she fell in love with a second cousin who shared a similar temple that her heart would skip several beats a minute. For upbringing a few dozen miles north in Tarrytown. The couple weeks she felt she was going to faint being up there and within loved to sing. From the time Jill Rabin, MD, could remember, reading or holding distance of the Torah. music filled her ears and her heart. “I felt dizzy, but in a great way. I felt like I was flying. It was “Music in my house was always healing,” said Dr. Rabin, an strange and wonderful,” she said. obstetrician/gynecologist at LIJ Medical Center. “Music could For Dr. Rabin, music is close and personal. bridge gaps that words couldn’t.” When things are busy on the Ambulatory Care Unit, she’s been known to sing to residents and nurse practitioners. For once in my Inspired by Deafness life I have someone who needs me … The girl who loved to sing had a sister who was born profoundly A recent patient was so scared that Dr. Rabin just looked at her deaf. The family took their deaf child to health professionals who and began gently singing, Maria, I just met a girl named Maria… helped her to speak and even sing a bit. They formed Children’s The young woman’s fear melted away. She smiled, and her doctor Hearing, Education and Research, Inc. and raised funds for nerve was able to continue with the procedure. deafness research. By the time the sisters were grown, the first Dr. Rabin sings in an assortment of languages and styles. She cochlear research lab on the East Coast had opened at Albert performs in Yiddish for her older Jewish patients and in Spanish Einstein College of Medicine. Dr. Rabin’s sister received a cochlear for others. At times, someone can even pull a good aria out of her. implant there. “Music can set the tone of the room,” she said. “You have to use Dr. Rabin went off to college wanting to become an audiologist. all of yourself in a service profession.” The science of hearing fascinated her. When professors and family friends urged her to consider medicine, she initially dismissed the A Guiding Voice idea. But she remembers one morning early in her sophomore One of Dr. Rabin’s mentors was Gertie Marx, MD, a professor year when she bolted up in bed with a singular thought: “I want emeritus of anesthesiology at Albert Einstein College of Medicine. to become a doctor,” she said aloud. No one was there to hear her, Dr. Marx, a founder in the field of obstetric anesthesiology in but she took the calling seriously and immediately added a second the United States, always told her that the “secret in the care major: pre-med. She minored in music. of the patient is in the caring.” What she remembers the most By the time she was ready to graduate from SUNY Downstate about her “medical mother” is how she used her voice in talking Medical School, Dr. Rabin was already considering a career in ob- to her patients. stetrics and gynecology. She continued to sing but generally kept Last year, Dr. Rabin’s close friend Lorraine was diagnosed with her two passions separate. Until one day, when she was taking metastatic colon cancer. They had met when Dr. Rabin was a care of a nervous mother-to-be, it just happened: She started to student at Hofstra University. Lorraine was a financial aid officer sing. Out loud. and would later become an attorney and a deacon in the Episcopal “The young woman was distracted, and we both started laugh- Diocese. When Lorraine was in hospice care for three days, ing,” Dr. Rabin recalled. Dr. Rabin would sit by her bed singing all of her favorites from That was when she began to take a chance with song, melding Sunday liturgy, as well as beloved standards. music and medicine into her practice. Her friend had no more words at the end. She just opened her “I noticed people heard information better when they were not eyes, blue as a summer sky, and listened. Listened as Dr. Rabin as nervous,” she said. “Singing is such a big part of our culture. It sang Amazing Grace … how sweet the sound … makes me more human, too.”

Tablet edition Exclusive: Watch a video of Jill Rabin, MD, as she brings together music and medicine in her practice.

v2n1: Doctoring 30 tutorial

MeLearningdic Fromal Errors: A Path Less Taken by Jamie Talan

Doctoring : v2n1 31 tutorial

The physician orders the wrong How Common Are Medical Errors? As many as one-third of all patients admitted to a hospital in medicine, or the nurse at the the United States will experience a preventable adverse event patient’s bedside doesn’t provide during their stay. Fortunately, most do not cause harm. These events include medication errors, incorrect patient ID bracelets, the correct dose. The patient’s catheter-associated infections, medical/surgical errors and hos- chart lists an allergy to pital-acquired infections. penicillin, but a prescription is To reduce these risks, health system administrators have implemented a number of quality-monitoring programs to called in, and she ends up in the identify processes that result in a higher-than-expected number intensive care unit. A blood vessel of adverse events. So how does a health system with 16 hospitals, tens of is clipped during surgery, and thousands of employees and thousands of community doctors a child ends up facing months who see patients outside of hospital walls manage medical errors? Is there a way to reduce risks to the patient and the hospital? of additional rehab. A health practitioner fails to put up a Examining What Happened A patient with an allergy to penicillin is administered that bedrail, and an elderly person medication. The event is identified and reported. Patient safety rolls off the bed and becomes experts are called to the scene and meet with the staff taking care of the patient. The family must be told, but who would be entangled by a nearby IV cord. the one to share the news? And what do you say? The wrong hip is replaced. These The health system believes that the attending physician is events occur nationally and best positioned to inform the patient and/or family, however there may be times when another person may be asked to have internationally. the discussion. The important messages are to communicate what is known to have occurred, explain what will be done to care for the patient or family member, and commit to following up once a review is complete. hey are also at the heart of a significant effort by teams Michael Gitman, MD, vice president in charge of quality and at North Shore-LIJ Health System who are working medical safety for the North Shore-LIJ Department of Medicine, T behind the scenes — and often at the scene — to has a hand in these efforts to reduce risk. He’s been working on reduce risk and increase patient safety. Medical errors may ways to improve medical reporting among the house staff, includ- sometimes happen, but the health system is committed to early ing implementing a program to educate doctors about the impor- identification and communication with the patient and family tance of reporting errors. The effort is working. The number of- re when there is a serious, unanticipated outcome. ported events among house staff has increased significantly. With Transparency and disclosure are hot topics in the halls of a focus on improving performance and using lessons learned, modern medicine. Evidence points to telling the truth as an Dr. Gitman and his colleagues review each of these events to important first step in creating a culture of patient safety. identify ways to prevent them from ever happening again. “We need to recognize medical errors at every level and Hospital patient-safety experts are working to train doctors confront them,” said Mark Jarrett, MD, vice president and chief on transparency and disclosure and understanding how to tell a quality officer for the health system. patient or a family member when an unanticipated event occurs. That is precisely what Dr. Jarrett and his team do. Adverse event reports arrive at his desk every day. He works with the Understanding Risks health system’s quality and risk management teams and The Corporate Risk Management Department is integral to physicians charged with monitoring patient safety to assess the push to reduce medical errors. This department manages reports of possible mistakes in process or judgment that led to medical malpractice claims and studies adverse events to the outcomes. They evaluate the effect on the patient, mitigate look for additional ways to reduce such risks. Members of the any untoward effect, and then figure out a way to utilize any department look for risks everywhere in the health system. They lessons learned to avoid the problem for the next patient. are not just concerned with today’s risks — they also model risks Often, when serious events occur, teams get together to work coming down the road next year and even five years from now. with families and help the responsible physician, nurse or other Risk evolves daily. As more care is being delivered in the com- health professional find solutions to improve care. munity, the types of risks the health system faces change.

v2n1: Doctoring 32 tutorial

“We have a unique perspective,” explained Dorothy Feldman, What Mr. Boothman has come to learn is this: “The stereo- the health system’s vice president for risk management. “We type of the malingering patient looking for a lottery payout is are seeing what is happening in active litigation. We have a bogus. Patients do not get answers to simple questions. They dedicated claims management team focusing on every bit of turn to lawyers because of the reluctance of people in the medi- information available.” cal field to be honest. The data is utilized and shared with the claims management “Patients have also told us over and over again that they team, which along with defense counsel, determines how best feel a sense of responsibility that this should not happen to to resolve a case based on its merits. If it is determined that someone else,” Mr. Boothman continued. “If we don’t explain the case should be settled, a commitment is made to obtain what happened — and what we are doing to prevent it from an early resolution. Should the event result in an arrangement happening again — they may go to a lawyer.” for financial resolution, the health system tries to expedite the Another insight that emerged from the listening sessions is process through mediation to meet the needs of the patient that patients feel abandoned when a healthcare provider has and family sooner. The department has also been studying not shown accountability. whether the hospital’s new disclosure program works to reduce litigation, but Ms. Feldman said it is too early to know for sure. “I expect that the program will enhance the trust of our commu- The stereotype nity,” added Mariann Carroll, director of clinical risk management. of the malingering patient looking for a lottery payout is bogus. The Legal Landscape Patients do not get answers to simple Richard Boothman is the executive director for clinical safety questions. They turn to lawyers at the University of Michigan Health System. He spent the first part of his career as a trial lawyer representing hospitals and because of the reluctance of people doctors in malpractice cases. The case of a woman who sued her in the medical field to be honest. surgeon for a wound infection led him to re-examine his whole —Richard Boothman, executive director for clinical safety approach to medical errors. He realized at trial that the patient at the University of Michigan Health System and her doctor had not spoken in six years. The jury came back for the defense. Mr. Boothman had won for his client. But the More importantly, hospitals that follow this model have woman had spent her time during the trial listening to testimo- shown improvements in patient safety and a reduction ny about her doctor and, when it was over, she leaned around of claims. the courtroom podium and said words that would be a game “It is important that we resolve cases and spare litigation changer for the surgeon’s trial lawyer. when cases have merit,” Mr. Boothman said. “There is a lot of “Had I known everything I heard during the trial,” she said, discussion about disclosure and privacy. The first disclosure is “I would not have sued you.” to self by admitting, ‘We made a mistake that should not have That got Mr. Boothman thinking about the relationship happened.’ Doctors want to do this, but they also are afraid and doctors have with their patients. He spent the next decade want to be reassured that they are not going to do something talking to people who had endured bad medical experiences that will have catastrophic results. about why they went to a lawyer. He used his newfound “We are hard-wired to move into ‘fight or flight’ mode,” insight to develop strategies to reduce risk. He then began Mr. Boothman added. “Most lawyers tell doctors not to talk. sitting down with the plaintiff’s attorneys to simply talk and We don’t. Instead, we give them permission to talk. My job is try to find common ground to settle rather than go to court. sparing litigation and repairing the doctor-patient relationship, This was a change from the usual “deny and defend” tactic of and most importantly, motivating us to continually improve those in the legal field. and keep our patients as safe as possible.” Mr. Boothman said that hospitals “defend care that they Many states have apology statutes, although New York is should not be defending.” He also knew that the medical record not one of them. In practice, Mr. Boothman said, these require- isn’t enough to understand whether a case should go to trial. ments “are really not very effective at getting to the real con- Honest talking seemed to work better. cern that inhibits caregivers from talking when unanticipated Acceptance of this approach is slow, in part due to the clinical outcomes occur. Admissions against interest can still be sizeable industry that remains invested in the status quo, such admitted into evidence under most apology laws. But at least as defense lawyers who only make a living through billable they do largely protect expressions of empathy and sympathy.” hours or risk managers whose niche is inextricably tied to an He said that some hospitals are now working with courts to adversarial system. put programs in place to identify medical claim cases that re- Still, it’s paying off. quire early resolution.

Doctoring : v2n1 33 Doc culture in the (Electronic) Box: Who’s Your Favorite?

by Brian Mulligan

Let’s talk about the doc in the box. Not the physician who practices at a clinic or drugstore — the fictional kind on TV.

v2n1: Doctoring

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trained during the early ’80s. The entrance they they entrance The ’80s. early the during trained ANSWERS: 1. ER 2. ER 3. Cheers and Frasier 4. Rap Star 5. Frankenstein 6. The

watched it because that was the hospital where I I where hospital the was that because it watched Rocky Horror Picture Show 7. The Simpsons 8. House 9. Doogie Howser, M.D.

,” said Dr. Battinelli. “I “I Battinelli. Dr. said ,” Elsewhere St.

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20. Marcus Welby, M.D. 21. Planet of the Apes doppelganger. doppelganger.

the exploits in a certain Beantown hospital’s hospital’s Beantown certain a in exploits the

aius Z Dr. 21.

at the North Shore-LIJ Health System, enjoyed enjoyed System, Health Shore-LIJ North the at

senior vice president and chief medical officer officer medical chief and president vice senior MD, Marcus Welby, MD Welby, Marcus 20.

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and Casey was a neurosurgeon extraordinaire — no no — extraordinaire neurosurgeon a was Casey and Derek “McDreamy” Shepherd, MD Shepherd, “McDreamy” Derek 18.

and good-looking one, the master of everything, everything, of master the one, good-looking and

Douglas Ross, MD Ross, Douglas 17.

TV days,” Dr. Hartman said. “Kildare was the suave suave the was “Kildare said. Hartman Dr. days,” TV

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culture 34 35 culture

showed during the series was a shot of the actual hospital. The show was about St. Eligius, which was termed ‘St. Elsewhere’ because it was a poor, urban hospital that served nearly 100 percent indigent patients. It was, in reality, the Boston City Hospital. The show ran from 1982 until 1988. I arrived there as an intern in 1983 and stayed until I joined North Shore-LIJ in 2007.” Everyone was younger then, even on TV. “My favorite docs from that show are many, but topping the list were Philip Chandler, played by a very young Denzel Washington; Jack Morrison, played by a very young David Morse; and the zany Wayne Fiscus, played by an even younger Howie Mandel. I still have all my T-shirts that read, ‘Boston City Hospital, the real St. Elsewhere.’” Jean Cacciabaudo, MD, Southside Hospital’s director of car- diology, agrees with Dr. Battinelli. “St. Elsewhere was my favorite — I enjoyed the entire cast,” Dr. Cacciabaudo said. “The show was on while I was in college and medical school. It was gritty, realistic and wrapped in black humor. I couldn’t wait to start my residency, thinking it would parallel the life and times of the house staff at that institution. I ended up training at the New York Hospital, which was quite highbrow and so removed from the setting of St. Elsewhere. Despite its ‘buttoned up’ reputation, Cornell was a great place to train.”

Tickling the Funny Bone It may seem be a stretch from St. Elsewhere to a show that featured a pubescent Barney Stinson, but the common thread is how the show relates to the physician’s phase of life. Cushing Neuroscience Institute physiatrist Shaheda Quraishi, MD, said Doogie Howser, M.D., was her favorite “because I related the most to him. I was in an accelerated medical program and graduated med school at 23. When I walk into the room, people still tell me that I look like a ‘baby’ even though I graduated med school 11 years ago. My other favorite character would have to be Derek Shepherd [“McDreamy”on Grey’s Anatomy]. Need I say more?” Tracy Breen, MD, the health system’s chief of endocrinol- ogy and diabetes care, opted for cutting-edge humor and one of TV’s highest-rated shows ever. “The only medical show I watched growing up was M*A*S*H, but I watched it a lot,” Dr. Breen said. “I have really great memories of watching this with my dad. He enjoyed the social/political commentary, and I loved the medical parts. Looking back, I appreciate not just the humor but the central message of putting the patient first — and, when called for, the importance of sticking it to ‘the man.’”

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Firefighterby Jamie Talan

Victor Klein, MD, right, and his son David share a passion for saving lives.

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As a kid, Victor Klein, MD, saw firsthand what goes on in outreach the emergency department.

went there for a deep cut in his finger that required a few stitches and again the time he got hit in the eye with a baseball. He saw stars, but what he really remembers about the experience He at Beth-El Hospital (now Brookdale University Hospital and Medical Center) in Brooklyn was watching doctors and nurses working at high speed to help people with all sorts of injuries and illnesses. Though there were no doctor role models in his family, he was drawn to microscopes the way a kid craves candy. He could never get enough. So young Victor fulfilled all of his requirements for medical school by 1976 — the second hardest year to gain entry into a program — and started the application process. After what seemed an interminable time, he received his letter of acceptance from Joseph DeRose, MD, an internist who had spent his career at SUNY Downstate and served on the admissions committee. Dr. DeRose remains his role model and mentor.

Picking His Path The medical student was swayed into obstetrics and gynecology — more specifically, high-risk obstetrics. He delivered his first set of triplets during his residency at Johns Hopkins in 1982. He was drawn to difficult and fascinating cases, and the excitement of these problem cases launched his career saving lives. Dr. Klein, now vice chair of quality and risk reduction for obstetrics and gynecology for the North Shore-LIJ Health System, has delivered 200 sets of triplets since his residency. But the operating room was only the beginning for him. Dr. Klein began volunteering for the Jericho Fire Department. Seven years ago, he and his son David, then 17, began training as Emergency Medical Technicians (EMTs). David Klein is now a lieutenant for the Jericho Fire Department and served as an instructor when Dr. Klein recently qualified to drive an ambulance. Dr. Klein’s 21-year-old daughter, Lauren, a pre-med student, is also an EMT for Jericho.

A Full Plate Dr. Klein’s years of waking up to deliver babies served him well. (He still delivers 150 a year.) He responds to more than 200 of the calls that come into the fire department each year. He also joined the Nassau County Medical Reserve Corps and is three credits shy of completing his Master of Business Administration. Dr. Klein has encouraged all three of his children to earn MBAs. Sons Jeffrey (whose MBA is in sports management) and David were both in class with their father during their education at Hofstra University.

I find it very meaningful to give comfort to people during their most agonizing experiences. I will never stop what I do. — Victor Klein, MD

It seems Dr. Klein can never get his fill of trauma. He’s been called to drunk driving scenes, to assist people who have fallen from buildings and to deal with the catastrophes caused by fires. When Hurricane Sandy hit last fall, Dr. Klein called five of his EMT colleagues and headed out to a special- needs shelter set up by the Nassau County Department of Health at Nassau Community College. He served several sessions there, bringing his son David in to help. “It’s more than just a family affair. It’s deeply personal,” Dr. Klein said. His experience in the field — and in the operating room — has led to an interest in the assessment of quality in healthcare and patient safety. “It’s about saving lives,” he said.

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in profile Fostering a Culture of

by Jamie Talan Accountability When Michael was always dissatisfied with variations in practice,” said Dr. Grosso, who for more than a decade has been in a position to facilitate the kind of change he envisioned as Grosso, MD, “I a community doctor. practiced pediatrics As medical director of Huntington Hospital, he sees his job as influencing other leaders full time, he was and the hospital’s medical board to adopt practice guidelines based on scientific evidence and expert consensus. His aim is to bring the art and science of medicine to a place that known to draft his best serves patients. Sometimes that means tempering misguided or antiquated practice thoughts about habits. His credo is simple: Medicine is dynamic, and those who stand still fall behind. At the top of Dr. Grosso’s agenda is the promotion of professionalism, which means that the practice of the needs of patients and families come first, with empathy and a scientific eye toward medicine and send every clinical encounter. them to colleagues. “The practice of medicine should always be a learning opportunity,” he said. Sometimes the Engaging Physicians message got A day in Dr. Grosso’s life as medical director of a busy community hospital often begins before the sun rises as he reviews the 30-odd emails he receives overnight. Patient safety through, but often issues rise to the top of the pile. By the time he gets to his office, he calls a meeting to take the missive was met care of the immediate problems of the day. On a recent day, he met with key staff to discuss one surgeon’s unexplained rise in in- with shrugs and a fection rates. He worked with the chair of surgery to develop a plan to evaluate the prob- toss in the nearest lem. He has always approached issues of this type in an informal, collaborative way. He’s trash can. found that most physicians go through Elisabeth Kübler-Ross’s five stages of grief, which begin with denial of the problem and end with acceptance and a more positive direction for change. “We are focused on a culture of safety,” he said. “The best care is standardized to reduce errors and aligned with the best evidence. No longer can physicians say, ‘This is just the way I do it.’” Disruptive physician behavior is unprofessional conduct and a threat to patient safety, he said. According to Dr. Grosso, about one percent of the medical staff is involved with some Goals kind of unprofessional behavior at any point in time. For Dr. Grosso, the perennial fixer, the most serious and uncorrected problems may necessitate a medical board review. “At one time, it was acceptable for surgeons to throw instruments in the OR,” Ideas Dr. Grosso said. “Now, we focus on the role of teamwork in providing effective care and catching errors before they reach the patient. Physicians who terrorize nurses or other colleagues interfere with teamwork. That behavior doesn’t meet the standards expected Vision of the medical staff.” Professionalism also means honesty, he explained. He recently heard of a surgeon who mis- represented the course of an operation; the truth would have revealed a bad judgment call. Success It went before the medical board and Huntington Hospital revoked the surgeon’s privileges. “These things need to be talked about,” said Dr. Grosso, who believes more transparency leads to fewer medical errors. He takes medical errors of any severity seriously. For example, according to the Institute of Medicine’s report on medication errors, one such

Doctoring : v2n1 39 in profile

event occurs per patient day in the hospital. “At the same time,” he said, “our large “This new field provides us with both a Although many — such as a late dose of voluntary staff brings tremendous depth of philosophy of care and a toolkit for promot- medication — are minor, others can have knowledge and skill to patient care at Hun- ing the idea that medicine is still about one serious consequences. Take the recent case tington Hospital. They are still the backbone vulnerable human being caring for other of an unexplained drop in blood sugar of the medical staff.” vulnerable human beings,” Dr. Grosso said. in a patient with no history of diabetes. “We are helping students reflect on paper, The patient was closely monitored while a Success Stories and even look to great literature as a source series of laboratory tests were ordered to Two innovations rise to the top when of insight about communication and rela- figure out what was wrong. One of the tests Dr. Grosso is asked about major achievements: tionship in health and disease.” revealed that her glucose levels were off- the launch of the first full-time critical care Dr. Grosso recently helped lead the first kilter because she received insulin — not program in a Long Island community hospital literature and medicine session at the Hofs- heparin, which had been ordered. and the creation of the hospitalist initiative. tra North Shore-LIJ School of Medicine. “These types of things can happen over “It took a lot of persuading to get wheels He has also never given up his roots in and over again without the proper systems off the ground on our hospitalist program,” pediatrics. Once a week, he heads over to in place,” said Dr. Grosso. “Errors occur at Dr. Grosso recalled. “This wasn’t the way it his private office to see his small charges. every point in the cycle, from the physician was done in a hospital like ours.” “It would be difficult for me not to do that,” prescribing to the pharmacy dispensing to But an Intensive Care Unit (ICU) staffed he said. the nurse’s bedside administration. There around the clock by trained specialists was can be 20 physical steps in this chain.” the way to go to achieve the best patient outcomes and, 10 years ago, the hospital Heading Off Potential Errors enacted the model with the financial sup- Hospital leaders are hoping to avert such port of administration and the blessing of potential errors with steps to streamline the medical board. Huntington Hospital’s I think we have a the electronic medical record (EMR). An medical staff has never looked back. endeavor that also occupies a big part of great opportunity Dr. Grosso’s day-to-day schedule, the devel- The Road Ahead opment of the EMR eliminates problems of One emerging challenge, Dr. Grosso said, illegible physician handwriting. New soft- is figuring out how to help physicians use all to create a ware will also flag any discrepancy between the clues at hand to diagnose patients. a prescribed medication and a patient’s “Clinical decision-making is the ‘final generation of history of medication allergies. Also com- frontier’ of quality,” he said. “It won’t matter ing soon is bedside barcoding to help avoid how many checklists we have if we’re treat- physicians who administering the wrong medicine, he said. ing the wrong condition.” “We are building systems that get the What Dr. Grosso finds exciting about this right information to the right people,” said issue is that it brings physicians back to the rediscover the Dr. Grosso, who is also part of the North reason they went to medical school. And Shore-LIJ Health System’s efforts to bring solving diagnostic problems efficiently and importance of physicians and medical groups on staff. with the fewest possible resources makes Huntington Hospital has almost tripled for much better patient care. thinking about its medical staff in recent years, he said. “This will be the only way out of our na- It has the largest hospitalist program in tion’s current cost conundrum,” he added. the health system, caring for more than These days, Dr. Grosso spends a lot of patients and 80 percent of internal medicine patients. time with medical students, either behind Dr. Grosso thinks the mix of full-time medi- the scenes designing curriculum or mentor- serving as their cal staff and the voluntary staff is important. ing students when they come to the com- In the old days, an internist might round munity hospital to take care of patients. trusted advisors.” once a day to see patients. Now, hospital- One of his more recent interests is in nar- ists can meet with patients and the staff and rative medicine and its application to medi- — Michael Grosso, MD monitor care throughout the day and night. cal trainees and seasoned staff alike.

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