Learning
From Bob’s Focus

By

Leonard
Zwelling

       A story.

       One of my medical school friends (let’s
call him Bob) has done very well. After a distinguished laboratory career while
continuing to practice clinical cardiology, he ascended to the position of
Chief of Medicine at an academic center you would recognize by name. In this
position, he also led the busy internal medical clinical service in a bustling
urban hospital.

       His professional life, up to the point of
his chair appointment, had been limited to research and clinical issues in
electrophysiology. Now he was in charge of all of the sub-specialty divisions
in a complex department in which grant funded basic research competed with
clinical care as the most important revenue streams to sustain the department.

       After several years of building the
department, hiring new division chiefs, putting together a variety of research
programs sustained by NIH and pharma dollars, and learning the ins and outs of
a large hospital and the attendant administrative and operational challenges of
such a place, Bob thought he had done a good job of building, but one division,
endocrinology, made him uneasy.

       The division was led by a world-class
expert in juvenile diabetes and despite this being primarily a pediatric
concern, this adult division chief had a large clinic focused on the care of
adolescent diabetics and their unique challenges. Bob was receiving reports for
two years of problems with the care in this clinic and on the endocrinology
service in general. The clinic and hospital floor nurses were reporting highly
variable care with much of it not being up to modern standards. The nurses and
nurse practitioners also said that each of the 5 diabetologists had his or her
own way of caring for patients despite their being acknowledged standardized protocols for
this care.

Bob saw the liability of not acting, but
repeated requests for help from upper administration in the medical school and
the hospital went unanswered. And Bob knew his cardiac electrophysiology made
him an inadequate arbiter of the behavior of the endocrine faculty when they
were delivering clinical care. So he did what any good academic would do. He
got a little help from his friends and invited some outside experts to review
the program.

Bob and his administrative team put large
notebooks of data together for the visitors to review. This site visit focused
entirely on the clinical care issues at hand. There were no research papers or
grant lists in the packet and research was not the focus of this outside review.
There were included in the packets some frank, but confidential memos about
faculty behavior. Bob had determined that without these documents the visitors would
not understand the depth of his concerns or the focus of them.  These memos were all stamped “confidential
and proprietary”. The site visitors all signed confidentiality agreements once
they arrived on Bob’s campus. This was a visit primarily about clinical care in
an area in which Bob was not sufficiently knowledgeable to act on what he
thought was some bad faculty behavior and sub-standard medical care.

Bob also sent copies of the visitors’ packets
to the head of the hospital and medical school dean.

The day before the site visit, Bob was called
to the dean’s office and severely reprimanded for having sent out the
confidential information. By the time a formal meeting took place with Bob, the
dean and the hospital leader, the site visitors had come and gone and had
substantiated all of Bob’s concerns about the possibility that some of the patient
care behaviors exhibited by the endocrinology faculty were suboptimal and
needed to change immediately. Bob’s suspicions had been borne out by the
visitors.

       Despite this clear threat to patient well-being,
all the dean and hospital chief wanted to discuss was whether or not Bob had
violated some arcane federal regulation when he sent the “confidential” memos about
specific personnel to the site visitors.

The lesson here is a simple one. Keep your eye
on the ball. For several years Bob had tried to alert his bosses to potential
threats to patient care posed by well-funded faculty without a dedication to
patient care. He was largely ignored. Rather than settle for blaming others
should a true clinical disaster occur, Bob took matters into his own hands and
found his suspicions substantiated by the site visitors.

Believe it or not, the story is not over.
The lawyers are still examining whether or not Bob violated the privacy rights
of the faculty whose faulty clinical care was duly reported in the memos he
shared with the site visitors. Still, no one seems to care that the quality of
the medical care being given to fragile juvenile diabetics was not world-class
despite the medical school asserting that it was.

I am still waiting for Bob to tell me
whether he will be formally reprimanded or even relieved of his chair position
for doing the right thing.

 I
have already written about how we Dukies are cookie cutters not cookies and
would never let any bureaucratic nonsense stand between us and the best
possible patient care.

Please learn a lesson from Bob. If you see
something, say something. If you believe the care at Anderson is truly the
best, great. But if you do not, insist on outside eyes viewing what is being
done and hold nothing back in the way of information that might get you the
best possible consultation, no matter how embarrassing or personally
painful—even to you.

When I got to Anderson, we were always more
concerned about what happened to each and every patient than whether or not US
News and World Report would rank us number one. We already knew we were number
one and did not need anyone to confirm what was obvious. When did that change?

Ask yourself when MD Anderson cared more
about what others believed about the patient care at Anderson than the actual
confirmation of its excellence with real data?

There is a lot said about the care at
Anderson. As I have said many times before in this blog, I believe some of it
to be first rate. Some, but not all. It is the job of the Division Heads and
now, Dr. Buchholz, to sort out the good from the bad and to do so with outside
help if the forces within trying to improve things remain largely ignored or
suffer from leadership without the focus of Bob. This review should be done
with all deliberate speed for in the end, the excellence of the care at 1515,
not at franchise sites around the nation and the world that buy the Anderson
name, will determine the well-being of MD Anderson for years to come.

The men and women that constitute the
greatest cancer fighting faculty in the world are here in Houston where the
true focus of excellence remains. That focus cannot be exported at will for any
price and even if it could, before it is exported, it would be worth checking,
as Bob did, that it is as good as the leadership likes to say it is.

Leonard Zwelling