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The Heroism of Incremental Care

This excellent article by Dr. Atul Gawande in the New Yorker, January 23, 2017, shows how society’s focus on procedure-oriented Specialty Care at the expense of Primary Care medicine needs another careful look, so that the needs of patients are balanced.

http://www.newyorker.com/magazine/2017/01/23/the-heroism-of-incremental-care

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Medicine and Art

This is an article which is definitely worth reading.

PERSPECTIVE
Art–Science Collaborations — Avenues toward Medical Innovation

Caroline Wellbery, M.D., Ph.D.
http://www.nejm.org/doi/full/10.1056/NEJMp1509788

 
Cardiovascular stents represent a successful scientific advance, but they may have their origins in art: some stent designs have been inspired by the principles of origami, the Japanese art of paper folding.1 Indeed, art can inform medical science in myriad ways — providing not only inspiration but also insight and a humanizing touch. A collaboration among physicians, artists, and humanities scholars in Britain entitled “Life of Breath,” for instance, is investigating the understanding of breathlessness in chronic obstructive pulmonary disease (COPD), seeking ways in which a multidisciplinary approach can enhance the diagnosis and treatment of this increasingly prevalent disease. Elsewhere as well, it’s increasingly common to find artists working closely with medical scientists. Such efforts are an offshoot of broader interdisciplinary art–science collaborations that have a venerable history.
The organization Leonardo — evoking the interdisciplinary investigations of Leonardo da Vinci — was established in 1982 as a forum for exploring the mutual influences of art and science. Similarly, the Media Laboratory at the Massachusetts Institute of Technology emphasizes an “antidisciplinary culture,” using media arts and sciences to create new technologies. The National Academies Keck Futures Initiative recently convened a conference to explore “art and science, engineering, and medicine frontier collaborations,” encouraging interdisciplinary discussions focused on solving real-world problems. The Djerassi Resident Artists Program in Woodside, California, devotes a month-long session each year to art–science collaboration. Countless other organizations are promoting similar work.
Art–science collaborations illuminate methods or procedures used in various disciplines that could enhance medical practice. One point of intersection lies in observation. Artists are deep observers: they use their senses and then assimilate their findings, transforming their insights into artistic expression. But close observation has long been equally essential to scientific investigation: in the 19th century, for example, biology emphasized description and classification, and earlier scientists carefully observed the natural world, even as they contributed to advances, such as the microscope, that enhanced their observational capacity.
This kinship of observational skills allows art to make two important contributions to medicine. First, artists can create representations of structures that are otherwise difficult to visualize. Who can’t conjure up an image of representations of Watson and Crick’s double-stranded helix in multicolored balls? Physicians are familiar with the anatomical drawings of da Vinci and Frank Netter and can appreciate both their accuracy and their beauty. In the digital age, art can represent such complex phenomena as the human genome, including dynamic interactions; for example, animations of the cell’s “micromachine” dynamics created by medical illustrator David Bolinsky exemplify the fusion of “truth” and “beauty.”
Second, such visual representations, even as they convey an artist’s particular vision, can communicate the fruits of scientific work to the public. For example, the artist Fré Ilgen collaborated with neuroscientist Partha Mitra to represent human neural networks, creating the sculptures “Albert 1” (see photo
Albert I, 2009.
) and “Marie.” These creations include appropriate labeling of various brain loci, with neural circuitry represented by multicolored wire. A more abstract but more pointed approach to educating the public, entitled “Your Brain Is Your Brain,” entailed the installation around Berlin of 110 billboards designed by artist Adib Fricke. In vibrant color, each billboard offered a message about the brain’s functioning; for example, “Your memories are unreal” alluded to speculations about the unreliability of memory, and “Your ideas alter your brain” introduced the notion of neuroplasticity.
Such artwork is often interpretive, far exceeding mere depiction of medical concepts. The Austrian artist Christina Lammer, in a collaboration with surgeon Manfred Frey, attempts to convey through a sort of choreography of gestures how surgeons’ hands move during an operation, but her video installations also offer meditations on surgical rituals and their kinship with prayer. In her work on malaria, artist Deborah Robinson joined researchers Julian Rayner and Oliver Billker in their laboratory to learn about the disease. She notes that her investigative videos, set to a disturbing soundtrack of mosquitos’ buzzing, intend to draw viewers beyond science into malaria’s meaning and mystery.
Beyond this public-relations function for scientists, whether such art can exert a direct influence on science is an open question. Clearly, scientists cannot change the factual realities explored by their research to accommodate flights of fancy; their protocols and methods protect against idiosyncratic interpretations. But there seem to be two areas in which scientists can learn from artists. First, many scientists admit that epiphany and serendipity play important roles in scientific discovery. Physicist Richard Feynman described watching the wobble of plates tossed in a cafeteria as the inspiration for his work on quantum electromechanics — an exemplar whose liberating “playfulness” resembles that of art as a source of creative spark.
Just as important for Feynman’s hypotheses was the fact that initially he had no idea what his demonstrations of wobble were for — he was just enjoying himself. By working with artists who see the world through a different lens, scientists invest in the opportunity to develop ideas that defy conventional rubrics and are untethered to outcomes. This potential for transformational innovation underlies the entreaty to applicants for the U.K. Longitude Prize to “embrace interdisciplinarity and realise the potential that `sciart’ collaborations have to strengthen ideas” and to recognize that “truly novel innovation often happens in unexpected ways.” Mitra, the neuroscientist, tells me that such freedom from compartmentalization is what motivates him to pursue art–science collaborations; his study of the neurocircuitry associated with birdsong led to the Ilgen collaboration, which in turn led him to develop hypotheses about human musical and artistic behavior.
Second, art–science collaborations influence scientists’ perceptions of their culture — from the microcosm of the team to its institutional and cultural context. Malaria researcher Rayner engages with the malarial parasite at the cellular level, but collaborating artist Robinson “doesn’t care about the molecules,” Rayner notes, “and her language, her lexicon is completely different. It’s an exercise in finding common ground and seeing things from the other side.”
More broadly, science, and particularly medicine, functions at the intersections of empirical investigation and cultural beliefs and practices. This realization is at the heart of the “Life of Breath” experiment, which explores the biomedical elements of COPD, its impact on lived experience, and its relationship to physical and social environments. Engaging scientists and physicians more deeply with medical science’s implications for the public motivates participants to improve outcomes for patients beyond the boundaries of their research or protocol. In one Canadian project, artists, physicians, social workers, and engineers collaborated to design a pediatric waiting room whose floor tiles children could activate to project images on the wall. While administrative efforts aim to reduce waiting times, this project targeted patients’ qualitative experience of waiting.2
We appear to be in the midst of an evolution toward interdisciplinary cross-pollination. Similar coalescence during the Renaissance or in fin-de-siècle Vienna proved to be game changing. Eric Kandel makes a case that the autopsies that pathologist Carl von Rokitansky performed at the Vienna General Hospital arose from the same essential intellectual shift as the mission of both Sigmund Freud and visual artists to “look beneath the surface,” which yielded insights about human psychology and biologic disease.3 Today, globalization, the Internet, and increased understanding of neurophysiology reinforce our focus on complex networks, which suggest connections between apparently disparate elements of our biologic and social organism. These developments are, I believe, at the root of our interdisciplinary fervor. The centrality of networks as a key tool and metaphor of our age provides both an explanation and a conceptual justification for art–science collaborations.
Professional artists with an interest in medical care could prove enlightening assets to teams of medical scientists or practitioners. Learning from them involves some risk, since art–science collaborations raise questions that may not be answerable in conventional formats and may lead in unanticipated directions. But that is precisely their strength. A major tenet of the art–science movement is that the creativity inherent in such collaborations is synergistic and facilitates the development of radical new products and ideas.

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Planned Parenthood

The hysteria surrounding  planned parenthood, abortions and fetal tissue, as exhibited by our “distinguished” members of congress and their allies is completely unfounded. Please look at two extremely well written articles in The New England Journal of Medicine, dated September 3, 2015, and are referenced below.

1. Planned Parenthood at risk by Topoulos, et al (http://www.nejm.org/doi/full/10.1056/NEJMe1510281)

2. Fetal tissue fallout by Alta Charo (http://www.nejm.org/doi/full/10.1056/NEJMp1510279)


Given the amount of time and money being spent on this issue, I am reminded of the story of ” the blind man looking for a black cat in a dark room when the cat wasn’t there”!

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Abu Dhabi & NYU

Tej Maini, MD

Northborough, MA 1 hour ago

As someone who lived in Abu Dhabi for 3 years as the CEO of a hospital, this story is typical of what has gone on in Abu Dhabi for a long time. For instance, construction workers, by and large, are not covered by their health insurance for accidents and there are no OSHA type regulations. The immigrant workers’ living conditions are despicable. While we complain about Abu Dhabi in the news media in this country, the problem can only be resolved if the government takes the initiative to conduct reform. Otherwise this noise will fall on deaf ears and the Abu Dhabi government will continue to deny that the problem exists.

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The Case For A Merger Of Two Boston Hospitals

By Tej Maini, MD, FACS
President, Maini Consulting Group

The announcement that Boston Medical Center (BMC) and Tufts Medical Center (TMC) are considering a merger is welcome news. This assumes additional significance in light of a recent ruling by Judge Janet Sanders who rejected the union of Partners Health Care with South Shore Hospital and Hallmark Health System (Lawrence Memorial and Melrose-Wakefield Hospitals).

TMC as well as BMC have each accumulated sizable debt loads, and in view of their recent financial performance have been forced to enter merger negotiations. Declining outpatient volumes, falling inpatient census, and decreasing reimbursement rates for medical services are among the reasons that have contributed to their poor financial status. In 2014, US News and World Report ranked TMC 6th and BMC 11th in the Boston Metro area.

To place things in perspective, TMC has had several phases in its evolution to its present position. These steps include the somewhat contentious relationship with Tufts University, a merger with Lifespan Hospital Group, which was finalized in 1997 only to be dissolved in 2002, after which TMC became an independent entity, in addition to several changes in its name. More recently, a partnership between TMC and Lowell General Hospital was announced, but it will take a long time to show positive financial results. Collectively, these are symptoms of a troubled and financially struggling entity trying to find its position in a highly competitive marketplace.

In 1996, the merger of Boston University Medical Center Hospital and Boston City Hospital led to the creation of BMC. By contrast, BMC has had a less turbulent time since its establishment, but the pressures on BMC to stay afloat financially in the presence of declining reimbursement rates, appear to have taken their toll. Since BMC is integrated with Boston University School of Medicine and TMC is a stand-alone entity, TMC remains in a weaker position.

However, any merger discussions between TMC and BMC should require the following:

  • Both parties should agree to hire an independent facilitator who insists on complete transparency. Individual hospital representatives, their egos and hubris should not be allowed to interfere in the process. There are lessons to be learnt from the 1999 Mount Sinai School of Medicine’s merger with the New York University and its eventual termination in 2007, as well as the merger of New York Hospital (Cornell University) and Presbyterian Hospital (Columbia University) in 1998.
  • Short and long term plans for consolidation of clinical, research and non-clinical space, so that eventually there is no duplication of facilities. For example, all pediatric care and cardiac surgery could be provided in one location. BMC also has a significant existing problem in that it runs two hospitals within a block of each other requiring many support services to be duplicated.
  • Both BMC and TMC are located within two miles of each other in prime territory, and recommendations need to be made regarding the real estate, sale of which could be directed towards reducing the debt load of the merged entity.
  • Although there are fine physicians and support staff in both TMC and BMC, the merger would, by definition, involve reduction of personnel, providing a winnowing opportunity and associated cost savings.
  • The merged entity’s bylaws should ensure an end to tenure; all faculty appointments would be renewable on an annual basis, dependent on productivity, performance, research contributions etc.; underperforming administrators and poor decision-making would hopefully be a thing of the past.
  • All clinical affiliations with hospitals and physicians should be re-examined and only the ones that make most sense from graduate and post-graduate training and from a financial point of view should be maintained.
  • The Attorney General’s office should be kept abreast at all times. While it is necessary to inform the Boards of Trustees of the two hospitals during the merger process, it is vital that the Boards of the merged entity consist largely of independent Trustees, who bring new vitality and vigor to the new hospital and ensure a heightened sense of accountability by the new leadership.

With health care revenues expected to continue to decline in the coming years, and with TMC and BMC getting more than their share of the poor and indigent patients, it would be wise to move full speed with this merger. This alliance would assure the future of two venerable institutions and will go a long way in ensuring that a fresh generation of physicians is trained and ready to face the new reality of health care in the country. The merger must assure complete transparency in that costs to consumers and insurers are kept under control, while the quality and outcomes of patient care demonstrate continuing improvement. Boston must lead the way, as it always has.

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News

It has been a while since I updated my blog.

Please keep a lookout for news on this site next week.

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Project Work Flows in the International Setting

By Genevieve Bautista

When I worked on a hospital construction project overseas, there were lengthy debates as to whether it would be easier and require less resources to replicate and transfer a care model and operational processes than to start from scratch. Naturally, there were many who were adamant that replicating and transferring a model that already existed should require much less effort. Of course it would – all you have to do is copy what is already being done elsewhere, right? Continue Reading →

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Preparing for a Life Abroad

By Jeanna Hardesty

The long awaited day that we had prepared for so diligently as a family had finally arrived. I felt strongly about my children not inheriting the systematic blind spots in thinking and the way of doing things that comes from the preverbal insular status quo of so many before them. I was in search of the best possible future for them. A passport they would come to brag about. My husband and I dreamed of raising pragmatic, engaged human beings that would be open to challenging their own assumptions and willing to listen to their deepest inner voice. “Globalization” and the “world is small” were here to stay, there would be no turning back, this would be our true catalyst. Continue Reading →

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Financial Modeling: Pitfalls and benefits for a new project

By Shalen Young

Financial modeling is necessary prior to any decision that is made to move forward with any new project, whether it is as small as expanding a current service or as large as building a new hospital. Before committing the necessary resources, you need an expectation of the financial impact the project will have on the organization in both the short and long run. Properly designed models will provide an expected financial impact, as well as sensitivity analysis, to easily understand the impact of changing assumptions. Continue Reading →

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