THANKS

Since my pancreatic cancer diagnosis last year, readers have continued to send their best wishes my way. I’m grateful for all of them. Many of you have also asked how I’m doing. The answer is: remarkably well.

Last year, my daughter Emma spearheaded our family’s participation in the Pancreatic Cancer Action Network’s walk in San Francisco, where she and her husband live. This year, they’re coming to Chicago for the 5K on Saturday, April 30.

In 2016, pancreatic cancer deaths will exceed the number of lives lost to breast cancer. By 2020, they’re expected to surpass the annual number of colon cancer victims. If you’d like to support efforts to increase research funding and find a cure, then please click on this link.

You don’t have to attend the 5K, but you’re welcome to join our team — TEAM WILLIS. For non-walkers, clink on the “Donate Now” button on the linked page. If you want to come along for the walk that I plan to make with the team, click on the “Join Team” button just above it.

Regardless of whether you make a monetary donation to the organization, please know that all of us Harpers appreciate your continued support.

Meanwhile, I’ll keep writing…

MY DAUGHTER NEVER GIVES UP

Those who have been following my personal health challenge over the past year might find my daughter’s most recent appearance on KTVU in San Francisco interesting. Here’s the link: https://www.youtube.com/watch?v=cUm2FZMYF1U&feature=youtu.be&app=desktop

And yes, we are still working on the book documenting my family’s journey with me through our dysfunctional medical system.

AMERICAN AIRLINES AGONY

Rarely do I use this forum to discuss personal issues. Earlier this year, I made an exception to inform readers that an unwelcome medical diagnosis of pancreatic cancer had interrupted my weekly posts. As it happened, my 48 days in the hospital provided a unique perspective on our dysfunctional medical system. So as I gained strength, I wrote about that experience. (A book is in the works.) In any event, I’m pleased to report that my progress and prognosis are good.

The outpouring of sympathy and support has been overwhelming. But it hasn’t been universal. Which takes us to the headline for this post.

American Airlines: “Doing What We Do Best”

Twenty-four hours before the first of what would become my five hospitalizations between February and June, my wife and I were scheduled to fly from Chicago to San Francisco on American Airlines. The University of San Francisco School of Law had invited me to its annual Law Review Symposium for a discussion of my book, The Lawyer Bubble – A Profession in Crisis.

Blood test results prompted my doctor to send me to the ER — pronto. Instead of boarding a plane, I was boarding a hospital gurney. After several months of procedures and tests, doctors finally located the source of episodic and life-threatening internal bleeding. One long-term consequence of my condition is that I will remain grounded indefinitely — no air travel.

American Airlines: “The New American is Arriving”

Once it became clear that I would not be able to rebook a flight on American during the one-year period required for our non-refundable tickets, I contacted the airline to seek a refund. (As my principal caregiver, my wife can’t use her ticket either. For better or worse, and for penalties associated with non-refundable tickets…)

The ticket value is significant, but not overwhelming ($870.19 each — for a total of $1740.38). Still, it was worth pursuing.

I called American’s preferred customer number because I’ve been a loyal American flyer for decades. The person I reached was pleasant and cooperative. He found our original reservation, provided ticket numbers, and directed me to the American Airlines website. There, I would click on the customer service link and complete a refund request form.

Shortly after submitting the on-line request, I received a response seeking a physician’s letter confirming my medical plight. Within 24 hours, I scanned and emailed my doctor’s letter describing the cancer diagnosis:

“The complications of his illness include intermittent internal bleeding that renders him unable to travel by air for the foreseeable future… His wife is also my patient and his principal caregiver. As a consequence, she likewise will be unable to travel by air for the foreseeable future.”

Two days later, a customer relations person acknowledged receipt of the letter with this ominous note:

“I have forwarded it to personnel in our accounting office. They are the specialists who review such requests. They will do so and be in touch with you directly.”

American Airlines: “Going for Great”

I knew I was in trouble. The “accounting office” was going to make the final decision about the seriousness of my medical condition in deciding whether to permit a $1,740 refund: “They are the specialists.”

In what?

Five weeks later, I received this nameless form response from a “do not reply” email address:

“After reviewing the documentation submitted, it has been determined the request does not meet our exception requirements.”

“[I]t has been determined…” The passive voice covers a multitude of sinners. But it makes you wonder what the “exception requirements” are and who sets them. More precisely, if my situation doesn’t qualify, what does?

The response continued:

“The ticket purchased is non-refundable so we cannot offer a refund, issue a travel voucher, or transfer this ticket to another person. However, the ticket will remain valid in our system for one year from the original date of issue, at which time it will expire and all value will be lost.”

I know. I can never use the ticket. That’s why I sought an exception.

“The unused non-refundable ticket may be applied to future travel as long as all travel is completed prior to the expiration date.”

Anyone who had read the letter from my physician could never have included that sentence.

“The new ticket will be subject to a change fee based on the fare rules, in addition to any difference in fare or fees that may be in effect at the time of travel. We are forwarding your case to our Customer Relations department for consideration of a waiver for the above stated reissue fee that would be assessed to use your ticket for future travel.”

Lucky me! I might get a fee waiver for a ticket that I will never buy. No one who read my doctor’s letter could have written that, either.

“Please allow time for Customer Relations to review your situation and respond to your case before making additional contact.”

In other words, don’t bother us anymore. My wife received the identical message.

Wrong Without a Remedy

Readers may recognize the subheadings in this post. They are American Airlines’ advertising slogans over the years. The last one — “Going for Great” — is the most recent. Based on my experience, it will never get there.

There’s a lesson for anyone contemplating a flight on American Airlines. When you book a nonrefundable ticket, even the prospect of death from an intervening terminal illness that results in grounding you permanently will not qualify as an exception to the airlines’ “no refund” policy.

There’s a larger lesson, too. American Airlines’ handling of my request is emblematic of a larger societal phenomenon: myopic short-termism. When accountants’ incentive structures displace customer service, the culture of an organization follows that lead.

By the way, feel free to pass this along — retweet, post on Facebook, etc. — and to share your thoughts directly with American Airlines’ customer relations. (After clicking here, select TOPIC: Customer Relations; SUBJECT: Complaint; REASON: Other. After that, you’re on your own.)

I’m sure they would love to hear from you.

IT’S NOT TOO LATE…

As my regular readers know, in February I received an unwelcome medical diagnosis: neuroendocrine pancreatic cancer. For those who have inquired, I’m happy to report that after spending 43 of 56 days in the hospital between January 28 and March 27, I’m now celebrating my eighth week at home recuperating. All things considered, I’m feeling quite well.

Readers also know that my daughter, Emma, lives in the Bay Area and is actively involved in an upcoming event to support pancreatic cancer research: Purple Stride San Francisco 2015 — a 5K family run/walk in San Francisco on May 31.

My entire family is grateful for the response of friends and readers to this cause on my behalf. For those who have not yet joined “Team Willis” — Willis is Emma’s longstanding nickname for me — you don’t have to be a runner or, for that matter, anywhere near San Francisco now, on May 31, or ever.

Anyone interested can make a tax-deductible contribution — even a nominal one is significant — to the Pancreatic Cancer Action Network. Just go to this site and click on “Donate Now.”

Thanks, again.

SOMETHING NICE TO SAY

My thanks to the many readers who have contributed to my daughter Emma’s fund-raising effort for pancreatic cancer research. My February diagnosis (neuroendocrine pancreatic cancer) has made the cause quite personal. The breadth and depth of your support for our family has been been humbling.

For anyone interested in contributing — even nominally — to a worthy non-profit organization (the Pancreatic Cancer Action Network), there’s still plenty of time. Because she lives in the San Francisco Bay area, Emma is promoting a specific upcoming event, Purple Stride San Francisco 2015 — a 5K family run/walk in San Francisco on May 31. But to join “Team Willis” — Willis is Emma’s longstanding nickname for me — you don’t have to be a runner or, for that matter, anywhere near San Francisco now, on May 31, or ever. Just go to this site and click on “Donate Now.”

Now, Back to Our Story

After my series of posts about dysfunction within the American medical system, it’s worth pausing to reflect on its positive attributes.

Foremost are the professionals dedicated to patient care. The best of the best are willing to take command of challenging health situations, as mine surely is. They utilize their formidable talents to achieve the best possible outcomes. I was fortunate to have several of these individuals working diligently to save my life. Now they’re trying to improve it.

Like most health care workers, these doctors entered the profession with a clear purpose: to do good. Many also began their careers when the medical care delivery system looked much different from its current configuration. Physicians had more influence over hospital policies. Indeed, doctors ran many more hospitals than they do today. Primary care doctors visited their in-patients daily. Continuing relationships and direct contact with patients helped make the physician’s job rewarding.

A Loss of Personal Mission

As it has evolved in recent years, the medical delivery system has destroyed aspects of this physician-patient relationship. Many experienced doctors have lost their feeling of connectedness with patients. That’s a shame because without a vested stake, the doctor who is able to distance himself from a patient has sacrificed an important part of the personal motivation that makes him or her most effective.

Once a physician views a patient as an abstraction who parades through the system as a collection of conditions, symptoms, and test result numbers to be dealt with — and then moved along to make room for the next patient — the medical profession loses a piece of what makes it a profession. There is nothing conscious or even unique about this phenomenon. It’s human nature for people to care more about what they’re doing if they feel a sense of personal commitment to and responsibility for the outcome.

It’s Not Just Doctors, It’s People

Drawing from my own profession — the law — the most effective senior attorneys give young lawyers working on discrete pieces of a large case a sense of how the individual parts relate to the whole. Even better than that, providing a young lawyer with the opportunity to work directly with clients is the ultimate motivator.

As with older lawyers, senior physicians entered their profession in large part because of they wanted to help individuals. A personal connection to patients was important to that process. Many younger doctors — like their modern attorney contemporaries — have grown up in a different environment, namely, a culture of metrics, numbers, and protocols. In that culture, the physician-patient connection takes a back seat to a relatively new concept: medical worker productivity.

Here’s one example. An earlier post in this series discussed how my blood draws occurred at times times that were not only unrelated to patient care, but also undermined it by disrupting sleep at 4:00 am. As it turns out, that particular situation might actually be worse than I thought.

Recently, one hospital worker told me that blood draws in his hospital (not where I stayed) are timed so that all patients can be completed before a pre-determined deadline. That per-patient time limit makes some phlebotomists worry about taking too long, incentivizes them to rush, and causes the needle to miss a patient’s vein on the first attempt. It is the opposite of a patient-centered medical protocol. The alternative: hire more staff and abolish the time limit. But that would add expense and reduce the hospital’s bottom line. My guess is that the timed blood draw rule is not unique.

The current culture has resulted from non-medical personnel imposing rules in the quest for greater efficiency, as any profit-maximizing business does. But medicine and law are supposed to be different. All too often, rules pursuing efficiency and profit (even in a non-profit medical organization) ignore the impact on patient experiences and outcomes.

Myopic Metrics

The business-oriented world of metrics can’t capture the value of things that are not easily measured. Connectedness between physician and patient is one such immeasurable value that has a big impact on patient experiences and outcomes. It also has an effect — not subject to measurement or a metric — on a physician’s motivation and job satisfaction.

That’s what I’ve learned from my contrasting experiences in a single highly-regarded medical center. Once I got past the barriers that I’ve discussed — the hospitalist wall, a myopic focus on numbers, treating individual symptoms rather than viewing my entire situation holistically — I reached doctors who became connected to me. They felt it, and so did I. As a result, we all benefited.

Technology That Saves Lives

A second feature of American medicine that makes it among the best in the world is its technology. The diagnostic and treatment devices that my doctors have used are staggering in their complexity. (They’re expensive, too.) What has evolved into my positive prognosis (relatively speaking) is a consequence of that technology.

The ongoing challenge is to devise a way to preserve the best aspects of American medicine while eliminating its deeply troubling features. I don’t know how the necessary changes will happen. But as I’ve written with respect to a similar devolution of the legal profession — law schools’ undue reliance on U.S. News rankings and law firms’ preoccupation with short-term profits metrics as definitive indicators of success — the first step is exposing the problems.

A U.S. Supreme Court justice’s observation from long ago still rings true: “Sunlight is the best disinfectant.” In law and in medicine, many talented and compassionate people are using remarkable technological advances to do a superb job. But in both professions, we can do a lot better.

Maybe the book that Emma and I have begun to write about my 43-day hospital experience will help. Based upon the overwhelming reader reaction to this series so far, there’s an audience for it — that’s for sure.

“IT’S HOSPITAL POLICY…”

When a patient tries to get a doctor to focus on his or her specific situation, the least helpful words from the doctor are: “It’s hospital policy…” Add the doctor’s effort to calm the patient with “I understand your frustration,” and then combine it with the physician’s admission: “I haven’t reviewed your file.” Now try to restrain yourself as it becomes clear that she has no intention of ever doing so.

The VRE Mystery

In “Computerized Information Overload,” my VRE blood infection illustrated the problem of overwhelming health care workers with too much patient information. A few days after my post, a doctor’s essay in the Sunday New York Times reaffirmed more generally my observations about the problem.

In my living example, during my third hospitalization I contracted a blood infection — VRE — almost certainly as a result of minimally invasive procedures to stop a pesky GI bleed. Powerful antibiotics squashed the infection and I went home. When I showed up a week later in the emergency room, they put me in isolation. I had no idea why until 10 days later, when my nurse told me that my record showed that I had a history of VRE.

That evening, another nurse undertook a comprehensive view of my file and concluded that I never required isolation because the VRE infection was blood-based. The sign on my door came down; those entering my room no longer downed flimsy disposable “isolation” gowns.

Problem solved? So it seemed. For the next five days, no health care worker visiting me wore the plastic blue gowns.

Groundhog Day

On the sixth day, another nurse showed up wearing an isolation gown.

“I’m here to do your rectal swab,” she said.

“Why?” I asked. “Last week, a nurse went through my file to discover that I had a blood infection VRE. It’s been gone for weeks.”

“I’m just following the directions I got from the infectious disease nurse,” she said.

After I explained the backstory, my nurse acknowledged the confusion: “I’ll have the infectious disease nurse call you.”

“No,” I said. “Not a nurse. I want to talk to the infectious disease attending physician. Let’s straighten this out once and for all.”

An Incredible Conversation

About 15 minutes later, the phone rang.

“Mr. Harper, I’m the infectious disease doctor,” said the voice on the other end. “I understand you have some questions about our isolation policy.”

“No,” I answered. “I have a problem with the confusion surrounding the handling of my situation. I don’t know how familiar you are with my case.”

“I’m not familiar with your case at all,” came her stunning admission. “I haven’t reviewed your file.”

Seriously?

“I just want to explain to you what our policy is. When you have a positive VRE, you have to test negative by rectal swab for three consecutive weeks before you are removed from isolation.”

“Well, the fact that you’re not familiar with my file is the whole problem,” I said. “There’s no continuity of care in this place and important information about me is not getting through.”

I then explained my situation to her. She listened, and then responded as if she hadn’t heard a word I’d said.

“I understand your frustration,” she said. “But you understand that we have hospital policies to protect health care workers from transmitting VRE. We follow national guidelines in that respect. Hospital policy requires that you have three negative swabs — each one a week apart — before you can be removed from isolation.”

“Well, in my specific case,” I said, “about which you have told me you know nothing, you’ve already blown two other hospital policies,” I said. “No one swabbed me a week after my admission.”

Silence on the other end of the phone.

“Then, five days ago, my nurse determined that I never had VRE for which a swab is appropriate. She removed the isolation sign on my door. Every health worker since then has entered my room without putting on a disposable gown. So there’s policy violation number two.”

“You were in isolation because of your history of VRE,” she responded. Now she was talking in circles. “It’s up to the individual initiative of the nurse to take swabs that get patients out of isolation.”

“Are you an attending physician?” I asked. She said she was.

“Do me a favor,” I said as I concluded my losing battle. “In a quiet moment, I want you to reflect on this conversation. I don’t care whether I get swabbed. That’s not the point. The point is that you haven’t reviewed my file and you have no idea whether the policy you’re defending has anything to do with me, the patient.”

I hung up and summoned the nurse.

“I give up,” I admitted. “Go ahead and swab me.”

After the standard 72-hour period for processing the culture, the lab hadn’t posted the results. Day four: still nothing posted and none of the nurses could figure out why it was taking so long. Finally, five days after the swab and as I was getting discharged from the hospital, I asked the resident to see if the lab had posted the results.

“Here it is,” he replied as he viewed the computer screen. “It says ‘Rare VRE.’ I think it means ‘not very much.’ But the next time you come back to this hospital — hopefully never — it will carry forward to show that you’re VRE-positive.”

I didn’t care. After 19 days in the hospital — bringing my cumulative in-hospital tenure to 43 of the prior 60 days — I was going home.

By the way, lest you think that I have only bad things to say about America’s medical care delivery system, my next post will discuss its best feature: the outstanding health care workers who change patients’ lives for the better.

 

BIG LAW — BIG MED — BIG MESS

A month ago, I informed readers that I was taking a break from my ongoing commentary on the legal profession. Instead, I’ve focused my blog on my personal journey through modern medicine after my cancer diagnosis. The American Lawyer, which has republished all of my “Belly of the Beast” blog posts for the past five years, ran the post inaugurating my new series. But I haven’t asked it to republish my eight subsequent medically-oriented posts, which seemed beyond the interests of its primary readership. For reasons that will become evident, I’m inviting republication of this one.

Having spent almost 40 of the past 50 days in the hospital, I’ve had an intimate look at the medical care delivery system from inside one of the nation’s top institutions. I’m now convinced that many big hospitals and law firms share an important characteristic: a lost sense of mission.

This criticism doesn’t apply to most lawyers or to doctors individually. Dedicated, conscientious physicians and attorneys abound. But the devolution of the leading segments of both professions to short-term business-oriented approaches has resulted in structures and constraints within which many of those practitioners must operate. Ultimately, clients, patients, and the workers within those institutions are paying the price.

How Did This Happen?

Not that long ago, doctors ran many hospitals. Today in the United States, only four percent (235 out of more than 6,500 hospitals) are run by physicians. Along the way, the quality of a patient’s experience has suffered.

As the New York Times reported recently, “[N]ew research suggests that having a doctor in charge at the top is connected to overall better patient care and a better hospital.”

“Dr. [Amanda] Goodall [the author of the study] said the finding was consistent with her research in other fields, which has shown, among other things, that research universities perform better when led by outstanding scholars and that basketball teams perform better when led by former top players.”

Dr. Goodall goes on to observe, “M.D. C.E.O.’s are more likely to prioritize patients because patient care is at the heart of their education and working life as a physician. When it comes to making hard budgetary decisions or rationing choices, M.D. C.E.O.’s may be able to make more informed decisions.”

Keeping The MBA-Mentality In Check

I’m not an anarchist. I have a master’s degree in economics and understand the importance of data-drivien decisions. But I also appreciate the limitations of statistics and the dangers of a myopic MBA-type approach to management. There is nothing wrong with using accounting and business methods in the process running complex organizations, including big hospitals and law firms. But when those methods dominate institutional culture — setting the tone from the top of a hospital or law firm — those organizations no longer exist to serve people. Instead, they develop a new purpose: to serve the short-term bottom line.

As Dr. Goodall suggests, ““I think the pendulum may have swung too far in the favor of managers. This is partially because business schools have become so prominent, as has the M.B.A. These qualifications are helpful, but it is possibly not enough just to have a management education.”

Lawyers still run most big law firms, but the trends toward non-attorney CEOs and non-attorney managers developing increasing power and influence within big firms is well underway. More pointedly, many lawyers in big firms have obtained MBAs and are increasingly relying on their newly-learned “management tools” to run their firms. That can be okay, provided they do not become too fond of their “MBA-hats” and lose sight of their more important JD mission — to serve clients. It’s easier said than done because maximizing short-term partner profits is how such leaders — and their partners — measure successful leadership.

Back To Basics

Most undergraduates go to law school because they want to do good. That message has emerged loudly and clearly from my prelaw students over the nine years that I’ve taught undergraduates at Northwestern’s Weinberg College of Arts & Sciences and over the more than 20 years that I’ve taught trial practice and legal ethics courses at the Law School. A similar impulse drives most people into the medical profession. Just as every lawyer’s mission should be to serve clients, medical care should be about a single-minded mission: patient care.

The dominant big law firm model has evolved away from helping clients and toward maximizing a firm’s short-term profits through a handful of definitive metrics — billable hours, hourly rates, equity partner leverage. Likewise, big medicine — if I can call it that — has succumbed to similar pressures — maximizing relative value units (medicine’s equivalent to the billable hour metric), minimizing costs, and squeezing workers in an effort to improve “productivity,” to name a few.

Similarly, a dominant and incorrect perception in both professions is that bigger is always better. The number of law firm mergers sets a new record every year. Hospital merger and acquisition activity is ubiquitous.

Lost Along The Way

Bigger isn’t better. As with law firms, increasing the size of hospitals works against efforts to create a sense of community, collegiality, and shared mission. Likewise, cost-saving isn’t appropriate when non-medical CEOs with MBAs introduce efficiency measures that ignore the potentially adverse impact on patients.

For more than two weeks, I’ve lived through situations that illustrate my point. For example, I don’t know the metric by which administrators set what they regard as appropriate staffing levels. But one nurse told me that some floors are regarded as “heavy” — meaning that patients have conditions that can require a lot of attention. That translates into greater demands on a nurse’s time. But if there aren’t enough nurses to handle the workload, the burden falls on those who are around. Transferring to a different floor or facility becomes an escape route. It would be interesting to study the nurse “attrition rate” from the “heavy” floors.

Law And Medicine

In the prevailing big law firm model, overworking people — attorneys and staff — maximizes revenues while controlling costs. One consequence is a five-year associate attrition rate for big law firms averaging 80 percent. In other words, for every 100 associates who begin their careers at a large firm, only 20 will still be working there five years later. Other consequences are more difficult to measure so they get ignored: the decline in worker morale and the lost productivity that results.

Do extraordinary associate turnover rates serve client interests? No. Do they foster a climate in which a shared mission of client service becomes the institution’s dominant ethic? No. Do they reflect short-term profit-maximization goals that are completely inappropriate for a profession that should regard itself as better than that? You bet.

Other instances from my medical experience seem equally divorced from what should be a central focus on the patient. They may seem trivial, and none is life-threatening. But collectively they reveal something about institutional focus.

For example, a patient may require periodic blood draws, but the doctors defer the timing of those draws to whenever the phlebotomists are “doing everyone else on the floor.” That might be efficient, but on my floor, that designated time is 4:00 am. Why does efficiency in the use of phlebotomists trump the patient’s need for sleep?

Here’s another: At 11:00 pm, when all of the lights in my room were out and I’d just fallen asleep, someone came in and emptied all of the trash cans. The following morning, I asked the nurse, “Who decided that 11:00 pm was a good time to go around waking people up to empty their trash?”

“That’s just when they come around,” she answered.

These and many other dictates from above govern behavior throughout the hospital. Where does the patient fit in the process of pursuing worker efficiency? At least when it comes to blood draws and trash removal, nowhere, it would seem.

Shakespeare Updated

Scholars still debate the meaning of Dick the Butcher’s line in Shakespeare’s Henry the Sixth: “First thing we do, let’s kill all the lawyers.” Were the Bard’s words — speaking through that anarchist — backhanded praise acknowledging attorneys as the source of law and order? Or was he going for the laugh that the play evidently received from contemporaneous audiences that had become weary — as Shakespeare himself had — of the misery that litigious lawyers could inflict on a person’s life?

Regardless of that controversy, I hereby invite debate on a new version of that line. I’ve adapted it to today’s medical and legal worlds: “First thing we do, let’s kill all the MBAs in big law and big med — so doctors and lawyers can recapture their professions.”

Actually, we don’t have to kill the MBAs. We just have to keep them in their proper place.