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Archive for April, 2010

Saving Cleveland, One Year Later

I was in Providence again last weekend. I really need to stop visiting because every time I go it reminds me of how little has been done to save Cleveland since I wrote my article last year ( “Saving Cleveland” ). I mean, for crying out loud, just look at the headlines in the Cleveland Plain Dealer on Sunday: “Medical Mart budget hidden from County cCommissioners”. Seriously? A $500 million project and the guys running the show can’t see the bill? Really?

I guess it’s time I admit it. I missed the boat. I assumed that we had folks in Cleveland running the show who might have something in common with the people who ran Providence during its resurrection. BZZZZZT. Sorry! Johnny, tell Dr. White about our lovely parting gifts.  We unfortunately have elected politicians and other leaders with mis-matched talents. They are either men and women   with enormous hearts and limited abilities (think city government), or politicians blessed  with enormous talents and limitless intellect who are saddled with hearts the size of a pre-Cindy Lou Who Grinch. For crying out loud our politicians can’t even get corruption right! The guys in Providence were “effectively corrupt,” lining their pockets while getting the job done. Ours? Well, you read the same newspapers I do.

Nope, I was wrong. Saving Cleveland is not going to come from our entrenched leaders, be they politicians, businesspeople, or community  organizers. Saving Cleveland is not going to be a “top-down” process; saving Cleveland is going to come from the bottom up. Judging by the stunning lack of success our “leaders” have had with their “swing for the fences” strategies, I was at least a little bit right in “Saving Cleveland”– Little Ball is still the game that needs to be played to save our city. One year on, though, and the strategy becomes a little more clear. We need lots of little people playing little ball. Thousands of bunt singles will still score runs. What we need is a bit of an insurrection.

Alright Smart Guy. Lots of fancy words in there. Just what you mean by “bunt singles”  and how exactly do you propose we do this? I think it’s a back-to-the-future kind of thing. When I was looking for a place to live all of my college classmates who had grown up in Cleveland were dying to get back to the City. Mind you, this was when the Cuyahoga River was on fire. And yet all of my friends were “pants on fire”  hauling back to Cleveland. I think that’s the key; I think that’s the group, those are the same people who need to embrace the Save Cleveland movement. We need another generation of young people, high school and college aged kids who decide to “love” Cleveland and bring everyone else along with them.

The saying is way easier than doing, of course. It always is, eh? In this case the say is easier still because we don’t even have to create the blueprint — it’s already been done several times in several places. We, someone, preferably the kids need to do three simple things: PROTECT Cleveland (demand that our officials make our cities safe), BUY Cleveland (always choose products made by, or services provided by local companies), and CELEBRATE Cleveland (that “love bomb” thing I talked about before).

A couple things have become clear to me over the course of the last year. I already mentioned my profound disappointment in our “leaders”, but I’ve been equally disappointed in other civic and business organizations. Our main newspaper, the Cleveland Plain Dealer, continues to take potshots at Cleveland. No fruit hangs too high if the picking will produce a story knocking the city. For the most part our television stations and radio stations are equally guilty of this type of behavior. This is not the information infrastructure that will be necessary or useful in saving Cleveland.

What we need is a new way now, the stuff that our young people use as a matter of course in their daily lives. I’m talking, of course, about social media. Facebook, twitter, Linked In, even that old standby MySpace… the way our young people talk to one another. New music is shared on Facebook. An ad, a video, or a movie goes viral on YouTube or Hulu. The “game” of saving Cleveland, all the little examples of Little Ball will take place in the stores and shops in the streets of Cleveland and the surrounding suburbs, but the talking about it will take place in the “blogosphere.”

PROTECT Cleveland. Our young need to take back the streets. They need to take back the malls and the stores and the schools. They need to be encouraged and supported when they “call out” bad stuff. They need to be encouraged and supported when they demand that our elected officials make every nook and cranny of Cleveland safe. This is the table-stake; we simply can’t throw them under the bus on this one. We can’t lose the next Flats.

BUY Cleveland. This one should be easy, right? I mean, we’ve got pretty much everything we need here in Cleveland. That’s what makes it so utterly amazing and infuriating when we learn about how difficult it is for great businesses in Cleveland to get Cleveland business. Did you know that the city of Cleveland’s website was designed by and is hosted by a company in Denver? Seriously. Denver! How wrong is that? It’ll apparently have to start from the bottom here, too. Every kid, every young executive, every young professional will need to seek out others just like them who live and work in Cleveland and do business with THEM.

CELEBRATE Cleveland. If our established institutions insist on accentuating the negative we’re just going to have to find another way to drop that big old “love bomb” on Cleveland. How about a campaign where the kids tell the story of every Cleveland experience they have, every Cleveland business they use, every Cleveland  place they visit where something about it was good? Do it on Twitter. Do it on Facebook. Post video on YouTube. Tell your buddies, and tell them to tell theirs. A fight for Cleveland, a fight for the hearts and minds of Clevelanders, each one of them a reporter with a sideline pass!

There you have it. Saving Cleveland, from the bottom up. Thousands of Cleveland people, Cleveland’s young people, coming to bat and bunting for singles. Little ball. Opening Day is today. Why not?

Batter up!

EMR and Underpants

Skyvision Centers has a subsidiary company called the Skyvision Business Lab. We do business process research for pharmaceutical companies, medical device companies, and other medical businesses in the eye care arena. One of the companies we have worked for is a very cool company that produces animated educational videos for  ophthalmologists and optometrists. I had an interesting experience while talking to their chief technology officer. It was interesting because the conversation proved our basic reason for existence at the Business Lab, that it is impossible for any company to develop, sell, and install any kind of product in our world without understanding the ins and outs of every day activities in an eye care practice.

Of course, I always find it extremely interesting when I’m right!

It was a tiny little point, really, but how could you know something as small and seemingly insignificant as our discovery unless you had spent time on the “frontline” of medical practice? The chief technology officer for the video company was frustrated because doctors and their staff were not using this really cool product that they had purchased. Furthermore, because they weren’t using it, they were failing to buy downstream products from the video company. As it turns out the salespeople for this company were telling the doctors that this particular product should be “turned on” by the staff at the front desk of the office. This is exactly the wrong place because the front staff personnel simply have neither the time, nor the understanding, nor any incentive whatsoever to do this. The product actually works beautifully if it is “turned on” by the back-office staff. Bingo! Problem solved.

So what does this have to do with Electronic Medical Records (EMR), and for heaven’s sake what does this have to do with underpants? It’s simple, really. When was the last time you bought a totally new type of underpants, underpants that you had never seen before, and underpants that you had certainly never worn before, without trying them on? Furthermore, what’s the likelihood that you would allow someone else to design, fit, and choose a style  of underpants for you if that someone has not only never met you but has never even seen a picture of you?!  That’s the image I get every time I read an article about EMR.

In theory the concept of an electronic medical record that would allow permanent storage of every bit of medical information, with the ability to share that information between and among doctors and hospitals involved in the patient’s care, is so logical and obvious that debating the point seems silly. If you have ever seen my handwriting, for example, you’d realize that the entire field of EMR was worth developing just to make doctors stop using pens and pencils! Trust me on this… the doctor hasn’t yet been trained who is also a specialist in penmanship.

I actually trained at  two of the pioneering hospitals in the use of electronic medical records, and indeed in the use of computers in medicine in general. Dr. Larry Weed and Dr. Dennis Plante at the University of Vermont were pioneers in the concept of using computing power to make more accurate medical diagnoses. Both the University of Vermont Medical Center and the Maine Medical Center were among the very first institutions to develop and implement digital medical records for the storage and use of clinical data like lab reports and radiology reports. In theory both of these areas make sense, but in practice the storage and display of clinical data is all that’s actually helpful in day-to-day practice.

If this is the case, if the acquisition, storage, and retrieval of critical data is helpful, the next logical step must be to do the same thing with the information obtained in doctor’s offices, right? Well, in theory this makes a ton of sense. The problem is that nearly none of the EMR systems now in place have been designed from the doctor/patient experience outward; they’ve all been designed from the outside in, kind of like someone imagining what kind of underpants you might need or might like to wear, and making a guess about what size would fit you. With a few exceptions, tiny companies that are likely to be steamrolled in the process, every single EMR on the market is the wrong fit for a doctor and a patient.

Why is this? How could this possibly be with all the lip service that is being paid to the doctor /patient relationship and the importance of getting better care to patients? It goes back to that same tiny little problem that the medical video company tripped over: it’s really hard to know how something should work unless you spend some time where the work is going to be done. Electronic medical records in today’s market are responsive to INSTITUTIONS, insurance companies and governments and large hospital systems. System before doctor, doctor before staff, staff before patient. Today’s EMR’s have been designed with two spoken goals in mind: saving money and reducing medical errors. Should be a slamdunk at that, right? But even here the systems bat only .500, producing reams of data that will eventually allow distant institutions to pare medical spending, but neither capturing nor analyzing the correct data to improve both medical outcomes and medical safety. Fail here, too, but that’s another story entirely.

So what’s the solution? Well for me the answer is really pretty easy and pretty obvious. Send the underwear designer into the dressing room! Program design, programs of any type, are one part “knowledge of need” and one part plumbing. How can you know what type of plumbing is necessary unless you go and look at the exact place where the plumbing is needed? How can you know what size and what shape and what style of underwear will fit unless you actually go and look at the person who will be wearing the underwear? It’s so simple and so obvious that it sometimes makes me want to scream. Put the program designers in the offices of doctors who are actually seeing patients. Set them side-by-each. Make them sit next to the patients and experience what it’s like to receive care.

THEN design the program.

I’m available.The  Skyvision Business Lab is available. I have a hunch that the solution will hinge on something as simple and fundamental as my example above — front desk versus back office.  It doesn’t necessarily have to be me, and doesn’t necessarily have to be us, but it absolutely is necessary for it to be doctors and practices like Skyvision Centers, places where doctors and nurses and staff members actually take care of patients. Places where patients go to stay healthy or return to health. Places where it’s patient before staff, staff before doctor, doctor before system.

For whatever it’s worth I’m 5’8″ tall, I weigh 150 pounds, and I’m relatively lean for an old guy. I guess it’s a little embarrassing to admit this… I still wear “TightyWhiteys”, but I’m open-minded. I’m willing to change.

Just take a look at me first before you choose my underpants for me.

May I Take Off My “Dr. White Hat”?

She was 89 years old, my last patient, sitting demurely in my exam chair. I think I’ve known her for about 10 years. If I’m remembering correctly we’ve been through two cataract surgeries together, and I’ve done a little bit of laser work for her left eye. In fact, she’s in the office for us to consider some laser for her right eye, but she doesn’t really have any problem with the right eye today. It’s her left eye that’s giving her a little bit of trouble.

“It’s hard to describe. It’s like I have a headache or toothache around my left eye. I don’t have any problem at all with my right eye. I’ve had some sinus problems on this left side. That headachy feeling goes away with a Tylenol and a little bit of warm water. What do you think I should do?”

I look at her chart. I’m starting to remember more about who this extraordinary  woman is. There’s no mention of a family doctor in the chart. “Oh no, all of my doctors have died! All of the department heads and bigwigs I used to see are long dead,” she chuckled. More of her personal history is starting to come to me. 89 years old and she still does the books for her family business. Does all the payroll — files all of the taxes. With the exception of the pain around her left eye the only problem she will admit to is running out of steam in the office earlier in the afternoon then she did a couple years ago.

I start to slip into “Dr. mode” because, well, that’s what I do! That’s what all doctors do. We are presented with a problem, a symptom or disease, and we seek a solution. One of the wonderful things about being ophthalmologist is that I can almost always identify the problem, and once identified I can almost always find a solution. Indeed, I’m kind of intrigued, a little amused even, because this is the very rare time when a sinus problem is actually the cause of eye pain! Just like the majority of my patients with headaches think that the problem is coming from their eyes, so too do most of my patients with pain in the front of their face believe that it always comes from their sinuses. In fact, neither is very true very often. But in this case my patient is actually correct; her pain is referred pain to her eye and her eye socket from sinus problems. We can probably “fix” this, and I start to run through my mental Rolodex of good doctors near her home.

A little bit of unease is setting in, however. My patient is 89 years old, doesn’t have a single medical problem on her problem list, and isn’t taking a single medication. She hasn’t seen a medical doctor since 1978. Her only problem is an ache  around her left eye which she is successfully treating with Tylenol and warm water.

“May I take off my Dr. White hat?  Would it be okay if I talk to you as just Darrell for a few minutes?” A little smile comes at the corners of her mouth and she nods.  Here’s what I said:

“My friend lost his dad last week. By all accounts his dad was a great guy. He led a very active life pretty much through the last day he was alive. Went for a walk. Watched a wrestling practice for one of his grandchildren. Had a big dinner and went to bed with a smile in his face. He never woke up. Your mother  lived to be, what did you say, 104 years old? I think the best chance for you and I to have you leave this world at age 103 like my friend’s dad did last week is if I DON’T give you the name of a doctor to take care of your sinus.

Here’s what will happen if I send you to a medical doctor. Any medical doctor. They will hear you, hear about your pain, and they will do what doctors do. You will get an x-ray and you will get a CAT scan. You will almost certainly get some kind of medicine for your discomfort, medicine that may or may not be any better than Tylenol and a cup of warm water. You’re 89 years old — the doctor will probably find something else “wrong” that needs to be  ”fixed”. More medicine… more tests… more time. No one has enough spare time to hang out with doctors! Think of all the wonderful things you have done for more than 30 years in all the time you HAVEN’T spent in doctor’s offices. Do you think you can continue to treat the discomfort in your left eye with Tylenol and warm water? Would that be OK?

Remember, I have my “Darrell”  hat on,  not my “Dr. White” hat. as I’m sitting here talking to you I’m thinking of my grandmother, my beloved Gama. I lost my Gama when she was 86. She broke her hip, went into the hospital, and never made it out. She was really pretty good, not terribly healthy but pretty good, right up until she broke her hip.  She thumbed her nose at all of the well-meaning doctors my Mom tried to bring her to, doing pretty much whatever she pleased right up until the end. Smoked her cigarettes while reading trashy novels…a few beers after supper every night. I’m convinced she wouldn’t have lived a day longer if every little medical problem was identified and “treated”, but I’m sure that her life would have been much less enjoyable if she had received all that care.

Do you think you can handle this discomfort? Would it be okay to continue treating it with an occasional Tylenol and some warm water? (I gently placed a hand on her knee) I really think this is the best thing to do here. I’ll give you the name of MY doctor in case you ever get really sick.”

At the end of the day, whether you are a generalist or a specialist, each of us needs to remember that we care for patients. Entire human beings. Not organs or organ systems, not symptoms or diseases or complexes. We take care of people. Even someone like me, someone who takes care of an organ not much bigger than a large grape. The eye, or the heart, or the left third toe are all connected  to a whole person.

I put my “Dr. White hat” back on. I told her I was available anytime she had a problem, and I looked forward to seeing her again next year. We walked to the front desk together arm in arm.

“Thank you, Darrell.”

My Sometime Son

It’s Easter and all of my friends have been asking if my kids are home for the holiday. It’s funny. I find myself saying that half of them are here and half of them are away. How can that be, you might ask, that I can have half of my kids home for Easter when I only have three children? How do you have half a kid at home and half a kid away? Well, I guess I should tell you about my “Sometime Son”, Alex.

Some years ago, I think it’s five  now, my kids came home and announced that Alex would be joining us for dinner. This in itself was not really all that extraordinary as Alex had been joining us two or three times a week for dinner for many months. My response was  ”great, I’m sure we have enough to eat .” What they said next was really quite extraordinary, however. “Alex is going to be here for dinner and he’s not going to be leaving.” THIS was different.

Alex is one of two boys from what is, by any definition or description, a rather troubled family. It seems that at the time Alex had been bouncing around between multiple homes as his father was working through some legal problems. His father was about to be unavailable to him for many months, and Alex was clearly having a difficult time with not having a single, secure place to call home. Alex was and is one of my son Dan’s closest friends and was also very close with my two younger children, Megan and Randy. My kids essentially decided that Alex would be living with us.

So there you have it. Beth and I had gained a fourth child, a third son. Alex moved into Dan’s room and joined Megan’s sophomore class at the local public high school. Alex lived with us full-time for the better part of his sophomore year until his father once again had a place for the two of them to live. Although we offered Alex the opportunity to stay with us, and although leaving the White house meant changing schools, Alex’s father insisted that he leave us and live with him. Although Alex no longer lived under our roof, he was no less a part of the White family. We saw him for years most days of the week, and we continued to enjoy his company at the dinner table with great frequency. One of the two most poignant pictures that Megan keeps from her high school graduation is one of her and Alex celebrating their shared milestone.

Unfortunately the troubles in Alex’s family had simply been better hidden over the final two years of high school, and once he graduated it became too difficult for him to remain under the same roof with his father. Alex found himself working three deadend jobs in order  to stay in an apartment that he couldn’t afford. He economized on food — the rockhard bundle of muscles that graduated from high school with Megan had turned into something that looked more like the body of an elite miler. We simply couldn’t believe how skinny Alex had become.

Once again the White kids reached out. All three of them took Alex aside separately and told him, in slightly more colorful language, that he was being silly and ridiculous. “You need to quit one or two of those jobs and come home!” And so it came to pass that our “Sometime Son” came home to the White house during the summer of 2009.

When I tell this story I end up receiving all kinds of accolades, comments and congratulations on being such a wonderful person and doing such a wonderful thing. I must confess that this is quite a little bit embarrassing since it was actually my children who were responsible for this; my only contribution was that I didn’t get in the way. Frankly I’m not really sure how extraordinary this really is. If you take even a cursory glance at your family tree you’re likely to find a “cousin” or “uncle” whose lineage just doesn’t seem to have any genetic connection with yours. It turns out that in days of yore this practice of taking in folks who might be a little less fortunate than you was actually quite common. That “cousin” was in all likelihood a 1950s or 1960s version of Alex, a kid who just needed a place to call home, a place to be loved. That  ”uncle” or “aunt” was probably his mother or father. I think this probably happened a lot in days gone by, and if I think  if you look just a little bit you’ll probably find that it happens quite a lot even now.

So what’s become of Alex? All of the  ”other” White children are either in college or about to enter. Well, toward the end of last summer Alex was still working two of the dead-end jobs. We found ourselves alone chez White one afternoon watching a lacrosse game together. I told Alex that he had much more to offer, that he was much better than what he was doing at the time. You see, Alex is actually very, very bright. He’s at least as book smart as he is “street smart.” If he felt that treading water by doing low-end restaurant work was what he wanted to do at the time, why not do it in a new place? Rather than staying in Cleveland, a city that he clearly had mastered, why not do the same thing in Albuquerque or Anaheim? Miami, or even Madrid? How about college? Beth has assisted about  a dozen kids in their college process. What did Alex think about college?

I asked him about the Marine Corps. For several years Alex  had talked about his desire to be a Marine. It turns out that his grandfather was a Marine, and Alex is very fond of this particular grandfather. Alex had a couple of minor legal issues that would need to be cleaned up prior to enlistment, and I offered our assistance in helping him overcome these if the Marine Corps was still his ultimate goal. After a couple of days of reflection and thought Alex returned with his decision: he’d like to be a Marine. And so on September 11, 2009 (the date still gives me chills every time I mention it) Alex was sworn in as a US Marine, and on February 22, 2010 Alex reported to Parris Island for boot camp.

So there you have it! I am home here for Easter with exactly half of my children. My daughter Megan is home from college and my son Randy still lives with us full-time as he completes his senior in high school. My son Dan, “The Heir”, is finishing up his junior year at the University of Denver, and we anxiously await his first summer here at home since he left for school. And my “Sometimes Son”, Alex, is halfway through boot camp in the swamps of South Carolina. The collective concern that we all feel for him and the collective sense that we will have not one, but two empty seats at our Easter dinner table makes the term “Sometime” seem to be not quite right anymore. We all think about him much too much for him to be only a “Sometime Son”.

It’s Easter, and I miss both of my sons who are away.

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