Friday, November 20, 2009

Thoughts from a Colleague

A good friend of mine has posted something on his own blog about an experience unique to - and really uncommon in - chaplaincy: being present when organs are recovered for donation.  Take a look.

New Words at Episcopal Cafe

I love good, reflective word play.  (For that matter, I like not-so-good word play, too.  I generally appreciate a pun in proportion to the pain it inflicts.)  So, my newest piece at the Cafe involves reflections on some words we sometimes use interchangeably - but, I don't think they really mean the same thing.

While you're there, take some time to read what others have written, too.  And if you have a response to make, please leave a comment.  That process has gotten easier, I hope.  TypeKey has changed their process, and now folks can log in using logins and passwords they already use for Google, Yahoo, etc.  So, take a look and leave a note.

Wednesday, November 18, 2009

This Week's Lesson in Comparative Effectiveness

Before I came to my current hospital and health system, I served in a large tertiary referral hospital. My areas of responsibility included several intensive care units. In those units physicians were working with the APACHE System. APACHE stood for “Acute Physiology, Age, Chronic Health Evaluation.” APACHE was a means of predicting outcomes for patients admitted to intensive care units. It went through several generations (some institutions are still using APACHE III), but all were based on the same process. Information about thousands of patients was recorded over time, including their conditions at admission to the ICU and the outcomes of their stay. The point was to use that information to project the outcomes of future patients based on similar conditions at admission.

This was explained to me by a medical resident. He could put in the characteristics of a given patient, and have the computer to compare them with past patients. Based on the results with those past patients, the computer would come out with a set of ratios. For example, they would look at Patient A and put in his circumstances. The computer would then give some percentages – say, of those historical patients with these circumstances, 70% died and 30% lived to leave the ICU.

As I reflected on APACHE and discussed it with physicians, I realized two things. First, it could offer some guidelines that could be helpful. If the statistics were, say, 90% and 10%, the prediction could be pretty clear. However, it also still required a physician, for all the automation. It still required a physician to look at this specific patient – say, Patient A – and make the professional assessment as to whether Patient A more likely fell into the 90% or the 10%.

That came to mind again with the announcement that the U.S. Preventive Services Task Force (USPSTF) had published new guidelines for mammography and breast self examination. The new guidelines were significant change. Indeed, they were so significant that the American Cancer Society (ACS) and the American College of Obstetricians and Gynecologists (ACOG) have publically disagreed, saying they will continue to follow earlier recommendations.

Most folks are aware of the changes from extensive news coverage (I would suggest looking here or here.) What I think makes this interesting is that it coincides with discussions about health care reform, and highlights one of the important issues in that discussion. You see, this is a straightforward example of the promise and the difficulties of comparing effectiveness of procedures in evidence-based medicine.

Comparing effectiveness is how we got to these recommendations. USPSTF is an independent panel of functioning under the auspices of the Department of Health and Human Services (HHS, and specifically under the Agency for Healthcare Research and Quality [AHRQ]). The panel is independent in that none of its members are employed by the federal Government, nor do they represent agencies within the Government. The purpose of USPSTF is “to evaluate the effectiveness of clinical preventive services that were not previously examined; to re-evaluate those that were examined and for which there is new scientific evidence, new technologies that merit consideration, or other reasons to revisit the published recommendations;…” They want to bring the best science to considering and reconsidering those steps we take to prevent illness and reduce its severity.

Of course, changes in science should bring new consideration and so new recommendations. On the other hand, we’re seeing clearly how those new recommendations themselves can bring their own questions. ACS and ACOG and many women are asking about these new recommendations, “What are the risks that disease (and for the women involved, “my disease”) will be missed with fewer screenings and a downplaying of breast self-exams?” And there is certainly some risk that some patients’ lumps will be missed. Actually, there’s near certainty that there will be women whose lumps will be missed and who will suffer as a consequence.

At the same time, the new recommendations are based on some other certain risks. False positives do result in unnecessary procedures, from additional radiological studies to additional biopsies to unnecessary surgeries; and each of those additional procedures has its own inherent risks. An additional x-ray is a radiation exposure. Unnecessary surgeries include the risks of infection and other complications, both from the surgery itself and from the required anesthesia. And that’s without the impact on the lives of women of additional anxiety and disruption of their lives and relationships, all based on false information. Unfortunately, with the current recommendations these unnecessary risks are happening.

Both sets of risks are measurable, at least across populations. That is, looking at medical practice as a whole, these experts can make good estimates of what those risks are.

According to the newly published research analysis:
  • 1,904 women between the ages of 39 and 49 would need to be invited for screening to have one breast cancer death prevented.
  • 1,339 women between the ages of 50 and 59 would need to be invited for screening to prevent one death.
  • 377 women between the ages of 60 and 69 would need to be invited for screening to prevent one death.
On the other hand, “about 60% more false-positive results could be expected for every 1,000 mammograms performed when screening is started at age 40 instead of 50.”

So, why all the attention and the anxiety? The numbers make it look straightforward to change practice – unless you’re a woman already anxious, or at least alert and attentive, about your individual risk of breast cancer. Why should 1900 women suffer unnecessarily to prevent the death of the 1901st? It’s a good question, but doesn’t address the difficulty that we can’t know who which woman in those 1901 will actually be the one whose death is prevented.

Now, a part of the answer is the same in this case as in APACHE: it’s up to physicians to speak with their patients and say, “In your case, with your personal and family history and your risk factors, this is what I recommend.” However, there are other potential complications. Most insurers, from Medicare to the smallest commercial insurer, reimburse doctors for procedures and not for conversations. Will the doctor, however well intentioned, feel she or he has the time? Most insurers, from Medicare to the smallest commercial insurer, want to avoid paying for “unnecessary” procedures. Will they be willing to make exceptions? And how much effort will it take from patient and doctor for exceptions to be accepted?

This will be an ongoing issue if our standards for guiding practice are based on evidence of comparative effectiveness. We will continue to struggle to balance good general practice with good practice in specific cases. We will continue to wrestle with how to make the important exceptions to the structures we put in place to spare risks and costs for the majority of patients; for those important exceptions are people first and foremost.

I’m still a great believer in “comparative effectiveness.” I think it will be an important step in “bending the cost curve” in health care – which is just a fancy way of saying that we want to slow the pace at which costs for health care go up. At the same time, we need to be aware that to change based on “comparative effectiveness” will not be easy. It will take more work, and not less. It will involve especially more hard thinking by doctors and professionals, and more hard conversations between professionals and patients. “Comparative effectiveness” will come with its own difficulties; and the current discussion about recommendations for breast cancer screening are giving us a good example.

Monday, November 16, 2009

A Nice Moment

So, today at a meeting of hospital leadership the CFO spoke about a new software package the health system had purchased.  The reason to buy the software was to simplify the process of recording time spent on activities for “community benefit.”  We keep track of those activities because we want to demonstrate each year that our tax-exempt status is appropriate.  After all, the justification for exempting certain organizations from taxes is that they provide benefit to the community equivalent to the benefits that taxes would otherwise pay for.

The CFO said, “All the managers who need to be trained in this software have received email telling them to attend training.”  But, I hadn’t received any email.  And I do a lot in the community, both in churches and elsewhere.

So, after the meeting I stopped the CFO, and said, “I didn’t get the email.  Certainly, I need the training.”

The CFO answered, “No, you don’t.  We consider all of your work to be of community benefit.  You don’t need to keep track of your community benefit hours, because we’ll simply count all your hours.”

It’s nice to be appreciated!

Tuesday, November 10, 2009

What's In It for the Romans

Well, there’s a great deal of conversation (and a certain amount of consternation) about the Apostolic Constitution  Anglicanorum Coetibus.  If it hasn’t come to your attention, you can find some good commentary at Thinking Anglicans

This Apostolic Constitution has been prepared after years of requests and discussions with the Traditional Anglican Communion, a community whose founders left churches in the Anglican Communion beginning a generation ago over the ordination of women.  At the same time, it arrives in an interesting context.  First, there are other groups of former Anglicans, who have left churches in the Anglican Communion over issues of sexuality.  Second, the Church of England, long the center of the Vatican’s (arguably myopic) perspective of things Anglican, has committed to the ordination of women to the episcopate and has begun to figure out just how to locally adapt that for their circumstances.  As a result, while the folks of TAC are ready, waiting, and basically committed, there are also others both in and outside churches of the Anglican Communion who might be interested.  Certainly, folks in Forward in Faith have certainly expressed some interest; while others, with a more evangelical perspective, have said, “No thanks.”

I have read both the document itself and the Complementary Norms.  Others have noted what this means for the orders and structures of the Personal Ordinariates for the former Anglicans.  However, what struck me about these documents had to do with relations with priests of the Ordinariates and the Roman dioceses.

The importance of such a relationship is established in the Apostolic Constitution in Article VI, paragraph 4: “Priests incardinated into an Ordinariate, who constitute the presbyterate of the Ordinariate, are also to cultivate bonds of unity with the presbyterate of the Diocese in which they exercise their ministry. They should promote common pastoral and charitable initiatives and activities, which can be the object of agreements between the Ordinary and the local Diocesan Bishop.” This would be important, of course, because the Personal Ordinariates for former Anglicans will not be territorial in the same sense as Roman dioceses, and so will overlap one or more dioceses.

What this might mean (and why this might be more interesting to Roman bishops) is clarified in Article 8, paragraph 1, of the Complementary Norms, “The presbyters, while constituting the presbyterate of the Ordinariate, are eligible for membership in the Presbyteral Council of the Diocese in which they exercise pastoral care of the faithful of the Ordinariate.”  That is, while they are priests of the (non-territorial) Anglican Ordinariate, they can also be members of the (territorial) Roman diocese within which they live and/or work.  This only makes sense, because in Article 9, paragraph 1, “The clerics incardinated in the Ordinariate should be available to assist the Diocese in which they have a domicile or quasi-domicile, where it is deemed suitable for the pastoral care of the faithful. In such cases they are subject to the Diocesan Bishop in respect to that which pertains to the pastoral charge or office they receive.”  This does require a written agreement between the Roman Bishop and the Ordinary of the Ordinariate; but with that agreement (and how is the Ordinary to refuse the Bishop) the Bishop can call on priests of the Ordinariate to assist in Roman parishes.

Now, that arrangement can work the other way.  However, it’s notable that “clerics incardinated in the Ordinariate should be available to assist the Diocese;” while “clergy incardinated in a Diocese… can collaborate in the pastoral care of the Ordinariate,” but only “[w]here and when it is deemed suitable.” (Emphases mine)

That suggests to me that the real value of this to Roman bishops is as a new source of assisting clergy.  There is a clear priority of Ordinariate clergy serving Diocesan needs.  In the face of the clergy shortage any new source of personnel has to be interesting.  Moreover, they’re inexpensive personnel; for Article 7 of the Complementary Norms makes clear that the Bishops have no financial responsibility for these new clergy: “The Ordinary must ensure that adequate remuneration be provided to the clergy incardinated in the Ordinariate, and must provide for their needs in the event of sickness, disability, and old age.”  There is, of course, provision for Ordinariate clergy to have secular employment if necessary; but in neither case is the Roman bishop on the hook for these expenses.

Now, let me say again that I know this came about the accommodate TAC, and perhaps a few other former Anglicans and Episcopalians (after all, even if they’re not “former” now, they’ll become “former” once they enter the Vatican’s jurisdiction).  At the same time, it can’t have been missed that this will provide Roman bishops with a new resource for clergy, and with clear primacy of Roman bishops over Personal Ordinaries.  I can’t help but wonder if this is the sort of recognition and acceptance that the former Anglicans have in mind.  And I can’t help but wonder if this isn’t what will make this new arrangement acceptable to the Diocesan bishops who will find these folks on their doorsteps.

Monday, November 09, 2009

Where I've Been Lately

I have been on vacation.  Well, to use the trendy term, I’ve been on a “stay-cation,” since my Best Beloved couldn’t get away from her work.  But I reached an important point in the year.  I received a message from my boss who asked, “Do you know how much vacation time you have built up?  Do you know how much of it you use if you don’t lose it before December?”

So, I’ve been on vacation.  Unfortunately, vacation is something I don’t do all that well.  Oh, I can stay home instead of going to the hospital.  I can turn off the alarm and sleep in; which is to say that I can sleep until 7:00 a.m., instead of rolling out by 5:30.

I can set aside some reading.  I went to the library and picked up a couple of books.  Of course, one of them was Sanjay Gupta’s new work on wonderful new medical discoveries.  I set aside some other light reading – articles from the New England Journal and from Resuscitation.

I’m just not good at taking time off, unless I’m really away.  Let me charter a sailboat, or get away to a monastery, and after a little adjustment – okay, two to three days’ adjustment – I can stop thinking about professional things and attend just to what’s around me.  I can leave the phone off, and do nothing more professional than say Morning Prayer and Compline.

Somehow, taking time off at home just isn’t the same.  I know it’s my own fault.  There’s plenty of distraction.  The garage has to be converted back from garden staging area to auto storage.  Hot peppers and raspberries are still coming, if the tomatoes are past it and the basil has shriveled.  Leaves are accumulating on the lawn.  With winds prevailing from the west, no one on my block rakes his own leaves.  Instead each of us rakes up the leaves that blew from the trees of the neighbors to the west.  So, there’s plenty to do.

There are opportunities for cleaning and cleaning out.  It took me a while to work out recycling the old dehumidifier (it was both harder than simpler than I had imagined).  Some of my Styrofoam packing material was clean enough to recycle, but some wasn’t.  Still, my Best Beloved was pleased with the vacuuming.

And I managed not to check my work email – well, not more than once a day.  After all, I didn’t want to get back into the office and have several hundred emails to clear out (and I’m afraid that’s not much of an exaggeration).

But, really, I’m not a workaholic, and I did enjoy my time at home.  I still have some time to work at it.  I still have more vacation days to burn off.  I’ll take some time around Thanksgiving.

Just be patient with me.  I enjoy taking time away.  I’m just not very good at it.

Saturday, November 07, 2009

Carrying our Ministry: the Chaplains at Fort Hood

Pray for all of those who have died and suffered in events at Fort Hood, Texas.  Pray for the repose of the souls of the dead.  Pray for easing of suffering and hope for the wounded.  Pray for strength and comfort for families in shock, mourning, and fear.  Pray for health care providers, both those who were serving in the midst of the attack, and those who afterward served the injured and suffering.  Pray for the alleged shooter, that God may touch his heart and turn it from violence back to the peace which passes understanding, whether in this life or the next.

And pray for the chaplains who serve them all.  Several years ago I expressed my admiration and appreciation for my colleagues who serve in the Armed Forces.  Today at the Cafe there are the reports of those serving now at Fort Hood.  I often speak of how honored I am as a hospital chaplain to carry the ministry of the Episcopal Church to so many bedsides.  Today I am honored to be a colleague to the chaplains at Fort Hood, as well as the clergy of Killeen, who are carrying that ministry into the midst of death and injury, fear and anger, sadness and hope.

Monday, November 02, 2009

Sometimes It's Hard to Claim Middle Ground

 Published in Spirit, a new quarterly publication of the Diocese of West Missouri:

Some years ago at Clergy Conference I found myself in intense discussion with a colleague from the Southern Deanery.  He was more conservative and I more liberal, but the discussion was really good.  We were discussing how best to provide for the poor.  What made the discussion good had little to do with how.  We didn’t agree on how much at all.  However, we could agree that, however much we disagreed about how, we were called as Christians to be concerned for the poor.  We could disagree respectfully about the means because we could certainly agree about the end.

I was honored when Hugh Welsh invited me to write the first column in “The Middle Ground” in the new Spirit.  His goal for the column, as he shared it with me, was “to find a middle passage (if you will) between a hot topic with a stated pro and con.”  Certainly, there are a number of pros and cons related to universal access to health care.  Whether we speak about “health care reform” or “health insurance reform,” there are certainly different points we might consider. 

We can certainly have respectful arguments about the means.  We can ask just how much Government action is required, and how much we need to focus on personal accountability.  We can think about how to balance employer mandates and individual mandates and subsidies to help the working poor buy insurance.  We can discuss balancing cost control for physicians with tort reform.  We can discuss various means to provide access to health care for all Americans.

However, what we can all agree about as Episcopalians is that providing that access to health care is an appropriate end.  In General Convention we have called on our government to pursue health care reform since at least 1985.  We have reaffirmed it as recently as this summer, when General Convention passed three resolutions on to universal access to health care.

We take that position because it’s consistent with our faith.  It is consistent with the Summary of the Law, that in addition to loving the Lord our God we are called to love neighbor as self.  It is consistent with the Baptismal Covenant; for the Apostle’s teaching calls us to proclaim by word and example, serving Christ in all persons.  So, for us this is the end on which we can agree, even if we see pros and cons about how.

Unfortunately, there are those who do disagree that this is an appropriate end.  They may argue that we lose freedom if the government is involved.  They may argue that an informed individual can make better decisions for his or her own good than any bureaucrat.  However, if we listen carefully we will discover that their arguments come back to a single theme: that I have a right to make the decision that is best for me and mine without regard for anyone else.

That may be legal, but we wouldn’t call it “true,” because it isn’t true to the faith as the Episcopal Church has received it.  We continue to believe we are called to love neighbor as self in ways that proclaim by word and example the good news of God in Christ.  And so we agree that this goal, this service, and specific strategies to achieve it, like universal access to health care, is an end to which God calls us, even if we might disagree about the means.