Solomon Tenenbaum Lecture Notes - January 28, 2018

On June 10, 2017, at a gala celebrating the 1917 opening of Camp Jackson, now Fort Jackson, a top government official in South Carolina, the keynote speaker, declared that the greatest danger to the future of our democracy are professors, judges, and journalists, while the greatest defenders of our democracy are the men and women in our military.

At a recent Solomon Tenenbaum lecture in Columbia, the keynote speaker was a professor.  But, I don’t think that many, if any, in the audience believe that this professor, or any professor, is, because of a career choice, a danger to democracy.

Professor Deborah E. Lipstadt, PhD, from my alma mater, Emory University, spoke at the lecture on “Contemporary antisemitism: an enduring form of prejudice and hatred”.

Some people in our society, and in our world, she observed, label someone as undesirable and dangerous, based simply on their personal and social characteristics.

During the years before and during World War II, the German government sought the extermination of a specific group of people who excelled in their work as shopkeepers, teachers, artists, writers, and business leaders, but who were declared a danger to the future of the German state.  The solution was to eliminate, according to a carefully designed plan, Jews in Germany, Poland, and other countries. 
During this time, a third of Jews in the world - men, women, and children, were systematically killed in German-designed and operated “death camps” in Europe.

The Holocaust is, Professor Lipstadt says, a heavy gong that American Jews sound to make a point about the extraordinary level of hate within the German state in the 1930s and 1940s and within America today among alt-right groups.

The issue with which we must concern ourselves, she says, is the prejudice and hatred in the U.S. and elsewhere toward people who are Jews, blacks, transgender or in any other defined group.

One person in the audience said he lives in Israel.  He reports that Israelis rarely, if ever, evoke the Holocaust and simply work toward improved recognition of the ethnic, religious, and national rights of Jews among people in the Middle East and Europe.

Recalling the Holocaust can be a strong tool when getting recognition and equality for Jews, in that many Jews died in the gas chambers, not as punishment for anything they did or didn’t do, but simply because they were Jewish.

However, just as there are people who deny that Neil Armstrong ever set foot on the moon, there are those who deny that the Holocaust ever happened.  The Jews, the deniers say, are, in effect, looking for an emotion-charged excuse to get sympathy and political support for Israel as a Jewish state.
There are, Professor Lipstadt says “soft-core” deniers, who don’t say the Holocaust never happened, but simply downplay the significance of the Holocaust.
 
I noticed one person in the audience, probably in his 80s or 90s, who was wearing a “Holocaust Survivor” name badge.  As those who experienced life in the German camps pass away, there will be only secondhand reports of what happened in these camps.

There are complaints, from scholars, Jewish or not, that some books written today about World War II fail to mention the Jews and others being exterminated in German-operated concentration camps.
Meanwhile, mention was made by an audience member about a 2017 bill passed in the South Carolina House (H. 3643) and sent to the Senate for further consideration that defines “anti-Semitism” for use in colleges when considering civil rights issues.

Professor Lipstadt declined to say whether such a bill should become law. However, based on her earlier comments, I expect that she would say that laws should protect the rights of anyone who faces discrimination based on their personal and social characteristics.

It is good for all of us, whether a professor at Emory or a soldier at Fort Jackson, and for the defense of our democracy, to be reminded about events in the history of the world and current events in South Carolina and in the United States that may deny anyone of unalienable rights given to all human beings and which our government, state and federal, was created to protect.

Questions to ask your doctor about that prescription

When your doctor, physician's assistant, or nurse practitioner writes you a prescription for a drug, ask a few questions before you leave the office.

1.  What is the name of the drug or medication you are prescribing for me?
2.  Is that a brand name or the name of a generic equivalent?
3.  If it is a brand name, ask, What are the generic forms of this drug, if any?
4.  Why are you prescribing this drug for me?
5.  What is the active ingredient in this drug?
6.  Is this active ingredient available "over-the-counter" at a lower dose in the drugstore?
7.  If "Yes", ask: Is the over-the-counter drug just as good for me as the prescription version?
8.  What are the possible side effects of this drug?
9.  What is the cost of this prescription drug?
10.  How long do I need to take this drug?
11.  Can this drug be habit-forming?

Before you get your prescription filled, ask your pharmacist whether this is an appropriate drug for your diagnosis and whether this drug would have negative interaction with other over the counter or prescription medications or supplements you are taking. Ask the pharmacist also whether there is a way to get this prescription at a lower out-of-pocket cost to you.

That's a lot of work. But each of us needs to be in control of our health, rather than depending entirely on medical professionals to do all the work on our behalf.

Do you have anything you want to add or remove from this list? Any story to tell about a prescription? 

Hospitals need to lead the discussion on measles.

First there was Ebola

In 2014 it was Ebola getting international attention, starting in May.  For most hospitals, however, it wasn't until October that there were press conferences to acknowledge that Ebola is a killer.  When hospitals used the word Ebola in a written communication, they quickly stated, sometimes in all capital letters, that "There is no one with Ebola at our hospital." This was followed by a subliminal message: "If you or someone you know has a fever and diarrhea, please go to another hospital!"

In fact, other hospitals, large tertiary facilities, were identified, for each state, as places that were willing and presumably able and ready to at least evaluate people who have symptoms.

One person was identified, at a small rural hospital in South Carolina, as not only having fever and diarrhea, but also has having recently visited Houston, Texas. That made the news.  Houston is about 260 miles from Dallas, the infamous epicenter of Ebola.

Now Ebola appears to be mostly under control in Africa and in the U.S.

Enter Measles

But a disease that is home grown is now spreading across America and featured on the national news but rarely in hospital communication with the public. That disease is measles.  Most parents have dutifully seen to it that their children have been vaccinated for measles and other childhood diseases.

But there will always be well-meaning parents who love their own children so much that they do not want to take a chance that the vaccination will have, as they have heard from sources they believe to be reliable, unintended side effects, particularly autism.  Other parents either cannot afford the trip to the doctor or the vaccination -- or just don't get around to getting their children vaccinated without any thought of side effects.

Hopefully, some of these parents will recognize that their failure to vaccinate their own children may lead to serious and very real consequences, including death, in other children and adults.

Who can best communicate with parents? Primary care physicians supported by infectious disease specialists and local hospitals can provide parents with opportunities for discussion among those who question medical science.

Scientists question themselves and work to find answers to their own questions and those of physicians as well as parents. Evidence needs to be provided in a setting of rational inquiry rather than in a setting of fear and suspicion.

Should hospitals in the US keep silent about Ebola?

Some hospital systems are keeping their website, Facebook and Twitter users informed about the changing status of Ebola in Africa. Most hospitals, however, are silent about Ebola, even though people in their service areas are watching news reports daily on Ebola and worried about such diseases coming to the US.   

Ebola can showcase the excellence of hospitals, physicians, and public health in America in keeping infections contained. Emory University Hospital took a calculated risk when it agreed to accept two American missionaries in West Africa who were infected.  Both patients recovered, giving Emory and its partner, the CDC, a gold star in public perception and in infectious disease control in the US. 

Isn't now the time to talk about both far-away Ebola as well as infectious diseases right here in the USA, such as the flu - which killed 49,000 people in the US in 2013.  

Is this a time, when we have the public’s full attention, for education on infectious disease control and population health?  Or should hospitals continue to stay silent?

Branding

What's in a brand?  Every organization, whether it is a hospital, a law firm, or coffee shop, has a brand - known, in various forms, to its employees, suppliers, investors, customers, and others who have been exposed to the product or service.

Defining a Brand

A brand is a name, word, symbol, logo, tag line, likeness, action or behavior that becomes associated with a product or service.  It is a brand which may or may not be registered as trademark. 

Not much different from the branding of cattle, to identify the owner.  The brand told potential buyers, who had a perception of the brand, something about how the calf, cow, bull, or steer had been raised.

Starbucks is a brand of coffee shop.  Mayo and Duke are names representing brands of healthcare systems. Marilyn Monroe is a brand for a beautiful, deceased movie star.

By seeing the name, logo, tag line, or symbol (such as the shape of a Coke bottle), we may have an image in our minds as to what the product or service is like.   If we're in Lagos, Nigeria and see a bottle of Coke in a store, we can be fairly sure that we know what this bottle of Coke will taste like and feel like in our mouths.

If we see the letters BMW, we think of a prestige automobile, known for precision German engineering.

Not everyone in the world, however, knows what to associate with the words Starbucks, Mayo, Duke or with the letters BMW.  

The association between a name, set of letters, symbol, logo or tag line is learned.  We learn through using a product or service, through hearing people talk about a product or service, or through our imagination of what a product or service is like.

Branding

Many hospitals, such as one we'll call Community Memorial Hospital, became branded, known for specific services and care, over the years as people used the hospital and heard about the hospital.  At one point, nearly every town or city had a hospital, a place where people could come for an emergency, to get care for an illness, or to have a baby.  The brand was created by the experience of doctors, nurses, patients, administration, business leaders, and residents in the community.  

But now Community Memorial Hospital wants to expand outside its county by putting physician practices in four adjacent counties. Community Memorial, we'll call it, also  wants to buy other hospitals in the area and call itself Community Health Care System.  Before and after the name change, CHCS had a brand, a reflection of experience people had with the hospital.

In order to document what the brand is for CHCS, we have to listen to people talk about the hospital, including employees (very important), physicians, patients, community leaders, and people who live in the communities where CHCS has hospitals and/or physicians.

Community Health System has a small but diligent marketing department.  They have heard that they need to "rebrand" their hospital system since it and its service area have changed.  There are some options.  One is to let the experience create or adjust the brand as people experience the hospital and visits to physicians, including putting the CHCS name on all hospitals and physician practices. Another option is to hire a "branding" company to fabricate a new name, logo and image of the system.

With either option, the hospital system's brand will be created by the people who use the system and by the people who hear stories about the new system.



Changing Roles for Hospital

Our hospitals have been, traditionally and intentionally, places that fix people who have health problems.  As a reward for the fix, hospitals were paid very well by insurance providers.  In the early days, many hospitals were paid 100 percent of what they billed.

Then Medicare came along and started paying based on what were called Diagnostic Related Groups (DRGs).  Procedures were carefully coded by the hospital to get maximum reimbursement for as many DRGs as could possibly fit the patient and the treatment.

Today, Medicare wants to pay hospitals based on the performance of the hospital, its success in treating a patient. If too many patients are readmitted to the hospital within thirty days of discharge, the hospital is penalized in  reimbursement for services rendered. Hospital are also penalized if their infection rates were above a certain level for infections from catheters and from central lines, such as intravenous tubes.

Tomorrow, hospitals will be reimbursed based also on the health status of the community, based on how long and how well people live as well as on obesity, smoking, and other health factors in the population.

Some hospitals have made this transition by being a part of an Accountable Care Organization (ACO). Other hospitals are doing what they can to make the transition.

Hospitals are not meant to take on the burden of community health status on their own.  They are a part of a team, including public health organizations, municipalities, major industries and businesses, schools, universities, restaurants, grocery stores, banks, and other organizations in the community.

For too long, hospitals and physicians have been the upfront players in health care.  They will still be on the stage, but need to have many supporting actors to improve health status, reduce obesity, and get smoking eliminated altogether.

Some see this as a "social" agenda or even as a "socialist" agenda.  It is simply people helping other people in their community to live long, healthy lives.

Hospitals Worth the Trip

Medical travel, popularly referred to as medical tourism, usually means foreigners coming to a hospital in the United States for a procedure or US citizens going to hospitals abroad.

However, when someone in Fort Worth drives fifty miles to Dallas' Baylor University Medical Center, that is medical travel as well.

Medical travel happens when a woman leaves her own neighborhood, where there is an acute care hospital, and goes to another hospital outside her neighborhood. It can be travel within a community, city, county, state, or country -- or outside the country.

People are medical travelers when they pass by a local hospital that offers the same procedure as the hospital to which they travel. It is understandable when people pass by a local hospital that does not offer a procedure, treatment or test that the distant hospital provides. That is medical travel too.

A hospital in Orangeburg, South Carolina that offers maternity services is concerned when a healthy woman from Orangeburg travels to Columbia, South Carolina for what is expected to be an uncomplicated and normal vaginal delivery. If the woman expects to have a difficult delivery or the mother or fetus has health problems, then it is understandable if an Orangeburg resident travels to a hospital in Columbia where there is a neonatal intensive care unit.

What makes travel to a hospital outside your neighborhood worth the trip?

The status of "worth a special journey" (***) has been used for years by the Michelin Guide to characterize the very best restaurants. Their next lower rating is "worth a detour" (**). This is followed by "very good" (*). The lowest rating, with no asterisks but recommended, is "good at moderate prices". While some may disagree with the ratings, the person in search of a dining experience, in a city in which he or she is unfamiliar, is likely to have a pleasant meal when they go to any Michelin-rated restaurant at any rating level.

Michelin may someday rate hospitals worth a special journey. In the meantime, the hospital industry has a variety of rating services to help us find our way to that one hospital out of many that is worth a special journey.

Recently Thomson Reuters released its list of the 100 Top Hospitals for 2009. Last year, US News & World Report published its list of top hospitals. Some hospitals, like the Mayo Clinic, appear in nearly every list, regardless of the source of the list. Sometimes there are surprises, hospitals that are not known to be exceptional either within a region or within the country.

Who are we to trust? What about our local hospital that is not on either of these lists? Should a man travel to a top one-hundred hospital that specializes in prostate surgery to get his prostate removed? Or take a chance at a local hospital that just installed the latest robotic prostate removal device? Each list-maker has its own criteria and valid reasons for using either hard data such as infection rates and costs or soft data such as physician opinion. Many hospitals not on the list are quick to challenge the list's validity. Hospitals making the list are quick to get the rating posted on their web sites.

Are these top 100, regardless of which list we are looking at, really worth the trip? Is your local hospital worth the trip?

I am asking hospital marketing and public relations directors to tell me why their hospital is worth the trip.

The public relations director at a rural hospital with less than 100 beds tells me that her hospital is not worth the trip. It exists, she says, just for the people in the community. She notes, however, that she is concerned that people from the small town where her hospital is located are going to a hospital in a nearby city. The city hospital is, apparently, worth the trip.

A hospital in a mid-sized city says it offers many services and really cares about its patients, making this hospital worth the trip for most nearly everyone.

A large tertiary teaching hospital's President tells me that his hospital is worth the trip for specialized procedures that are not offered at smaller hospitals. He advises residents in other towns to use their local hospital's services for less specialized procedures.

A well-known hospital in Bangkok, Thailand says the hospital is worth the trip because of the specialized treatments, board certified physicians, American administrators, high volume of procedures performed, good outcomes, low infection rates, short recovery times, high patient satisfaction, excellent customer service, and costs lower than those in the US and other countries.

What, if anything, makes the hospital you work for, have worked for, are affiliated with, or have used -- worth the trip?

Shouldn't every hospital have at least one carefully documented quality that makes it worth the trip?

One rural hospital, unremarkable in most respects, has a celebrated lunch buffet in its cafeteria that packs in local residents and those from nearby towns every Sunday. Another hospital has a museum of surgical devices in its lobby. Still another exclusively serves American Indians but welcomes visitors to view its exhibits of one tribe's art, artifacts and culture. Another hospital has a convention center and retail shopping mall that serves the community.

Let's hear the viewpoints of patients, hospital staff, volunteers, doctors, nurses, techs, administrators, attorneys, board members, public relations and marketing directors, people whose relatives and friends who have been in a hospital, employers, insurers, pharmacists, and other who have had experience with the hospital.

Can you make a compelling argument, with documented evidence or just platitudes, for your hospital as a destination for the medical traveler? Except for the most frail and poorest among us, travel to a hospital across town, across the country or across the ocean is an option. Insurance companies are promoting travel and will assist their members in making the trip.

Comment below about why your hospital is worth the trip or, if you prefer, simply email me. If you include your phone number, I'll call you. I'll compile the results from all sources and let you know what I hear.

What makes your hospital worth the trip?

An American Dilemma

Americans are faced with taking sides on either of two models of what roles Americans can select.

One model is what I and others have characterized as the American Cowboy. The Cowboy is independent, self-sufficient, dislikes government and taxes, and believes in personal responsibility. The Cowboy, although generous on his own terms and kind to animals and children, doesn't want to see any of his tax dollars going to support people who aren't like him. The Cowboy is happiest when he can have his own house and property isolated from the bother of neighbors.

The other model is the American Liberal. The Liberal believes that he has a responsibility to take care of the needs of others as well as himself. Government and taxes exist to support the social and economic structure of which everyone is a part. The Liberal pays taxes so that all can share in services to provide, if needed, government supported transportation, housing, food, clothing, education and job training, employment, preventive health care, hospital and physician services. The Liberal likes to work with his neighbors and cooperate to improve the community.

Of course, these are extreme examples. Many Americans move from one role to the other over time.