Photo of Dr. Tom McDonald

Dr. Tom McDonald

I’ve been thinking a lot lately about luck, maybe because one of my close friends died recently.

His name was Tom McDonald, and he was an incredibly well-respected internist at the Palo Alto Medical Foundation. We were roommates in college and in medical school, and our families grew up together here in the Bay Area. Up until the moment he collapsed while biking in the hills near his home on the Peninsula, Tom was the healthiest contemporary I knew. He climbed mountains in crampons in Nepal, snow-camped in the Sierra, and rode his bike up the steepest hills he could find. But unbeknownst to him or anyone else, he had an atherosclerotic plaque in one of his coronary arteries, which thrombosed suddenly one Sunday afternoon, while he was out biking alone. A stroke of bad luck.

By contrast, my father had good luck.  He had much the same thing happen to him one evening at the airport in San Francisco. But I was standing next to him, and fortunately was able to resuscitate him. To make a long story short, he had heart surgery at Mills-Peninsula shortly thereafter and lived for almost another decade. Which he spent telling people how lucky he was that I had not gone to law school, as he had initially hoped.

They say that luck is the residue of design, but I don’t think any of us can ensure that someone who knows CPR will be nearby if we are unlucky enough to have a cardiac arrest. I do feel fortunate to be able to wish all of you Happy Holidays, with my sincere best wishes for 2013.  May we all have a healthy and joyful year, with more than our share of  luck—by which I mean good luck—thrown in for good measure.

*Note: As this year wraps up, I will be taking a break from my blog to work on an exciting new look for 2013.  I hope you’ll check back here around the end of January as I look forward to sharing more musings about CPMC and all that the new year will bring.

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Image of Health Sciences Library spiral staircase

Spiral Staircase

We just celebrated another centennial this month—the 100th anniversary of CPMC’s historic Health Sciences Library. If you’ve never been inside the Library (located on Sacramento Street, near the corner of Webster), you really should pay it a visit. I find the Library especially comforting on a miserably rainy day, but it’s also beautiful when the afternoon sun is streaming through its west windows. Climb the spiral staircase to enjoy the collections of some of CPMC’s illustrious physicians.

Image of Health Sciences Library Vestibule

Vestibule

Designed by Albert Pissis, a Mexican-American architect who moved to San Francisco as a small child (his father was a doctor in the City), the Library is CPMC’s finest building. Its Beaux-Arts style  features many wonderful architectural details and murals. Pissis was the architect for several other well-known buildings in San Francisco, including the Sherith Israel synagogue (on California and Webster Streets, also worth a visit), the Hibernia Bank downtown, and the dome for the original Emporium Department Store, which was subsequently incorporated into the Westfield Centre on Market Street.

Certificate showing proclamation from San Francisco Mayor Ed Lee

Mayor Ed Lee has issued an official proclamation honoring the Library’s centennial, in recognition of its architectural and historical significance, as well as it ongoing importance as the Library that supports both CPMC and the University of the Pacific Arthur A. Dugoni School of Dentistry. You can see more pictures of the Library on either our intranet or the internet.

Photo of Anne Shew

Anne Shew

Our sincere congratulations to Anne Shew, the Health Sciences Library director, and her staff (Carol Brendlinger, Florence Cepeda, Terryl Gregg, Kathy Kimber, and Tilly Roche).

Many CPMC’ers, especially those at the Cal campus, have met Dr. Oded Herbsman, our Vice-Chair of Pediatrics and a cherished pediatrician.

Image of Oded & Cheryl Herbsman

Oded & Cheryl Herbsman

Some of us know that he received his M.D. at Duke University. A few have heard how he met his wife at summer camp in North Carolina, when they were both much younger, especially Cheryl. Some of us know that she wrote a book for young adults about a girl who develops a summer crush on an older boy (Breathing, by Cheryl Renee Herbsman).

And now we have some very special news: Cheryl’s dad, Dr. Robert Lefkowitz, a Professor at Duke, recently won the Nobel Prize in Chemistry for his groundbreaking research on cell receptors. That work has led to a new understanding of how adrenergic signaling works—think epinephrine (adrenaline), as well as medications that activate those receptors (to treat asthma and COPD), or block them (to treat cardiac problems). Click here to read about Cheryl’s response to her father’s award.

Also, Oded worked in Dr. Lefkowitz’s lab while he was at Duke, even writing a research paper with his father-in-law and other colleagues: Collins S, Altschmied J, Herbsman O, Caron MG, Mellon PL, Lefkowitz RJ. “A cAMP response element in the beta 2-adrenergic receptor gene confers transcriptional autoregulation by cAMP.” J Biol Chem. 1990 Nov 5;265(31):19330-5. I wonder how he got that job?

Congratulations to Cheryl and Oded (who are heading off next month to Stockholm), and of course, to Dr. Lefkowitz, from all of us at CPMC.

The Chapel at St. Luke’s

It always brings me great pride to tell people that CPMC has been providing great hands-on care for more than a century. This week, we’re celebrating one of the visual reminders of our rich history: the Chapel at our St. Luke’s Campus, dedicated 100 years ago.

It’s hard for those of us who care for patients in the 21st century to realize what it was like here in 1912. Perhaps a few quotes from a St. Luke’s publication from that time period will help.

The hospital’s rules about who could be admitted were very clear: “No case of a contagious nature will, under any circumstances, be admitted to the Hospital.” Of course, there was a good reason for that—there were no effective treatments for contagious diseases.  So, although this was an Episcopal facility, patients were “allowed every facility for receiving the consolation of their own churches,” which they most likely needed.

Stained glass window in St. Luke’s Chapel

The hospital was proud to announce that “The corps of Attending Physicians and Surgeons is composed of men of known reputation and ability.”  On the other hand, the nurses were all women. Fortunately, Dr. Charlotte Brown and her colleagues had built an all-women medical staff across town at the Children’s Hospital, now our California Campus.

There were three classes of patients: those who could pay for their hospital stay and their physicians; those who could pay for their hospital stay—but not their doctors; and a third class, “composed of those who are unable to pay anything to the hospital, and are admitted to the free beds.”

Transportation-wise, we’ve moved backwards. One hundred years ago, St. Luke’s was on several trolley lines, and described as “easily accessible by the Valencia Street cars, which pass the door; also by the Mission Street line and the San Francisco and San Mateo electric cars, which pass within a block.”

Choir loft at St. Luke’s Chapel

Not only was it easy to get to the hospital, the costs of care were quite reasonable.  Ward beds were only $17.50 per week, whereas private suites with bath were $70 per week, including “board, lodging and the attention of a nurse on general duty.”  However, there was an extra charge of $25 per week for a graduate-nurse, as opposed to a student-nurse.  Of course, this was before the days of health insurance, so all “Fees must be paid weekly in advance.”

But some things never change. The hospital’s marketing literature bragged that St. Luke’s “is situated on Valencia Street, near the junction of Mission Street, surrounded by well-kept grounds.  It is free from the cold winds, fog and noise of other portions of the city.” It still is. And I hope it will be for at least another 100 years.

Dr. Martin Brotman and Jack Bailey

As most of you know, our former Executive Vice President, Jack Bailey, died last week, here in the hospital he loved.

Jack came to CPMC at a time when we were struggling; many were concerned whether the medical center would even survive the changes that were occurring in health care. When he retired 15 years later, at the end of 2009, we were one of the most successful medical centers in the country, with vibrant clinical programs that remain the envy of many university hospitals. In partnership with Dr. Martin Brotman, Jack accomplished this with a unique mix of intelligence, effort, knowledge, and a relentless emphasis on doing what was best for our patients.

L-R: Jack Bailey, Grant Davies, Linda & Eric Horodas

Jack understood that by encouraging excellence, he could change the world. Jack’s profound insights, his attention to detail, and his deep knowledge of hospitals helped teach a generation of health care leaders, including me.  Jack was direct, even tough when he thought it necessary, but he had a heart as big as his beloved state of Texas.  I will miss the way he would shake his head while grimacing “wb, WB, WB—you can’t be serious” when one of my ideas struck him as particularly ludicrous. And I will miss his broad smile and teary eyes when one of his many mentees made him proud.

All of us who work in hospitals know about life’s end.  But rarely, we meet someone whose inner force looks inextinguishable, whose vitality appears invincible, who seems immune to the mundane laws of biology and the universe that govern the rest of us.  Jack was such a person, which perhaps explains why those of us who had the privilege of knowing him are grappling with his absence.

Our sincere condolences to Jack’s wife, Dr. Marsha Nunley of our medical staff, and family, including our own Craig Vercruysse, Jack’s son-in-law and the father of his youngest grandchild.

In Blackwater Woods (by Mary Oliver)

Look, the trees
are turning
their own bodies
into pillars
 
of light,
are giving off the rich
fragrance of cinnamon
and fulfillment,
 
the long tapers
of cattails
are bursting and floating away over
the blue shoulders
 
of the ponds,
and every pond,
no matter what its
name is, is
 
nameless now.
Every year
everything
I have ever learned
 
in my lifetime
leads back to this: the fires
and the black river of loss
whose other side
 
is salvation,
whose meaning
none of us will ever know.
To live in this world
 
you must be able
to do three things:
to love what is mortal;
to hold it
 
against your bones knowing
your own life depends on it;
and, when the time comes to let it go,
to let it go.

Like many of you, I suspect, I watched more of the Olympic Games this summer than I thought I would.  Though my personal athletic skills are best described as “under-developed,” I was still absorbed by the drama of the competition and, I hesitate to admit, the daily medal count.  My favorite moment occurred when the tiny nation of Bahamas (population: 316,000) won the men’s 4 x 400 meter relay, beating us (meaning, the U.S.; population: 314 million) on the last lap.  I was OK with that victory because I knew that we had already passed China on the medal leader board, though Australia (population: 23 million) won on a medals per capita basis (we were eighth).

Shannon Rowbury, two-time Olympian

Shannon Rowbury

But did you know about our (meaning CPMC; population: around 7,000) connection to the London games? Shannon Rowbury, whose mom Paula Rowbury is program supervisor for CV, Diabetes and GI Services, finished sixth overall in the 1,500 meter race, in a time of 4:11:26, only about one second behind the gold medalist. Her finish was the highest by an American, and bested her own performance in the 2008 Olympics in Beijing, where she placed seventh. Although many Olympians begin their careers at an early age (3, in the case of some gymnasts!), Shannon didn’t start her running career until high school. She hasn’t slowed down since, and there’s hope that she’ll compete again in the 2016 Games in Rio de Janeiro. Congratulations to Shannon and her proud mom Paula.

I still remember my first day in San Francisco: September 13, 1974. I had been traveling with a friend from college. We had a few weeks off after our summer jobs before our senior year of college started in late September, so we drove across the U.S. in a drive-away car that belonged to someone who had moved to California.  Jon (Sheffer) and I had been lab partners in a college biology class that was filled with freshmen; both of us had decided relatively late in college to think about applying to medical school, so we were two of the older students in the class. (As it turned out, John never did become a physician. He was—and is—a very talented musician.  http://jonathansheffer.com)

The evening before, I had called my dad from Berkeley, where we were staying with my friend Eliot Nelson (who’s now a pediatrician in Vermont). My dad was glad to hear from me, especially since I had received a letter from the University of California at San Francisco while I was away. He hadn’t opened it, being respectful of my privacy. When I encouraged him to do so, we both learned that I had a medical school interview the next day. So I scrambled through the closets in Eliot’s house until I found some semi-appropriate clothes and shoes that would fit me, and Eliot dropped me off in Golden Gate Park the next morning to wait for my interview.

Courtesy: SF Lawn Bowling Club

The only reason I remember the date as the 13th is because it was a Friday, a beautiful September day; people were out early at the lawn bowling courts in Golden Gate Park, strangers were remarkably friendly, and my interviews went well. While waiting for one of them, I diagnosed a white fly infestation on a droopy coleus plant, which I’m pretty sure explains why I was admitted despite a very incomplete set of premedical courses.

What’s all this got to do with July 2012, almost 38 years later?  Well, after my interview, I had several hours with nothing to do, so I set off as a young (albeit overly dressed) tourist to explore the City. I wandered around the Haight and Chinatown.  Later, a Muni driver dropped me off at the base of Coit Tower, after checking with the other passengers whether it was OK “to go a little bit out of our way to let this young visitor off?” That was the day I fell in love with this City, and I decided that if I were lucky enough to be offered a spot at UCSF, I’d come.

I certainly never thought that I’d spend the rest of my adult life here, and eventually become the CEO of CPMC, working on our Rebuild project. For one thing, CPMC didn’t even exist then—it was still four separate hospitals (Pacific Presbyterian, Children’s, Franklin, and St. Luke’s.)  For another, like most 20-year-olds, I had about as much interest in hospital administration or City politics as I did in coal mining or sheep herding, probably less. But times change and so do people, and here I am. And when I’m asked, “How do you keep going despite all the criticism of you and CPMC?”  I like to remind myself of that September day. I still think San Francisco is a wonderful place to live—I just wish it were easier to get things done.

*Note: I will be taking a break from blogging until August, but hope you’ll check back then for more news about the happenings at CPMC.

Last Wednesday, I attended the “Topping Off” ceremony for the new San Francisco General Hospital. What’s a Topping Off?

SFGH Topping Off (Photo from: SFGH Foundation

It’s the stage in a building’s construction when the foundation has been laid and all of the steel, save a single piece, has been assembled. Before the final I-beam is lifted and welded into place, people get to sign their names on it, have a ceremony with a few speeches, and then watch as the steel is hoisted into the air to the top of the structure.

I spent a good part of my internal medicine residency at SFGH—on the inpatient wards, the intensive care units, the emergency department, and every Monday afternoon in the general medical clinic—and had an office there for a few years in the clinical epidemiology program. So I have a great deal of affection for the “County” (as we called it), and the people who work there, and got to see some of them at the ceremony. Knowing that San Francisco is rebuilding our main trauma center (with a 60-bed emergency department that can double in capacity in the event of a major disaster) and a safety net hospital is an achievement we can all take pride in.

I’m glad that their rebuild is well underway, and am confident that ours will soon be as well. I look forward to our own Topping Off ceremonies at the new hospitals we are planning to build at St. Luke’s and at Van Ness & Geary. Now… I’ll just need to think of something clever to write on the I-beams!

As I mentioned in my previous post, affordability is an important issue in healthcare these days, and we take it very seriously. It affects all of us – patients and employees alike. But we are working on solutions.

First, through the Quality Delivery System (QDS), we are concentrating on reducing waste, like medical errors, which can lead to complications and unneeded expenses. Our approach includes simple stuff—like handwashing and reorganizing medication rooms—as well as more complicated approaches, such as developing systems for reconciling patient medications.

Man Sleeping on AirplaneSecond, we want to use our resources to their full capacity. Some of us may miss the days of half-empty airplanes when we could stretch out across an entire row of unoccupied seats, but the reality is that many of those airlines went broke—and thousands of airline employees lost their jobs—because of those empty seats. That’s why we’ve been emphasizing the importance of starting surgical cases on time, discharging inpatients in the morning or early afternoon, and encouraging throughput in our emergency rooms and procedural areas. And, if necessary, temporarily closing units when the census is low.

Next, we are part of a Sutter-wide initiative to reduce the costs of our support services, those that don’t provide direct patient care, like accounts receivable, payroll, and information services, through better processes and consolidation.

Finally, we are planning for changes in the ways that we are reimbursed for providing medical care. Right now, we are mostly paid on a “fee-for-service” basis, which means that the more care we provide, the more we are reimbursed: every time a patient gets admitted to the hospital, we get paid. In the not-too-distant future, we will be reimbursed based on capitated rates, in which we will receive a set amount of money to provide all of the healthcare services that a group of people require. That will mean working with our physicians and staff to identify the best ways to care for our patients, which usually means working to keep them out of the hospital.

I once had a wise teacher who warned of the dangers of “mural dyslexia”—the inability to read the handwriting on the wall. Instead, let’s keep our eyes and our minds open.

“Why do we spend so much time talking about becoming more affordable?  Don’t we care about anything else? Must everything be related to the bottom line?”

These are some of the most common questions that I’m asked, and I understand why people are asking them.

 We have certainly been paying more attention to the issue of affordability recently. Let me try to explain why.

  1. The U.S. already spends far more per capita—more than twice as much—on healthcare as other developed countries (including Japan, Britain, Australia, Sweden, France and Germany), and it’s not at all clear that we are getting our money’s worth.
  2. Even though our health care system is expensive, it actually doesn’t even cover the costs of much of the care we provide.  For example, it costs CPMC about 20% more to provide care for Medicare patients than we receive from the government. Some might say that the problem is that Medicare pays us too little, but I think we can all agree that’s not going to improve. The situation with MediCal is even worse.
  3. Those “unreimbursed” costs, as well as the costs of providing care for uninsured patients, are passed on to everyone else—those of us who have commercial health insurance. Read the rest of this entry »
Warren BrownerWhat's it like to run a hospital spread out across San Francisco on six campuses and more than a dozen medical buildings? I'm starting to find out! This blog will share some of what I learn with you, and hopefully start a conversation about the best way to deliver the best care.
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