Monthly Archives: August 2012

Benevolence Sunk!

This is the headline – emblazoned on a facsimile of a yellowed newspaper front page – that greeted me when I opened my home town newspaper, the Vallejo Times-Herald, yesterday morning.

USS Benevolence was  laid down on 26 July 1943 as a transport ship, SS Marine Lion, at Sun Shipbuilding and Drydock Company in Chester, PA. A year later, facing a surge in casualties in the Pacific Theater of Operations,the U S Navy designated her a hospital ship, AH-13. Todd Erie Basin Shipyard in Brooklyn completed her conversion to hospital functions, and she was commissioned on 12 May 1945. Benevolence transited the Panama Canal on 22 June, and after a brief stay in Hawai’i, made her way to the Eniwetok lagoon, where she provided care for war-wounded and sick Marines, sailors and soldiers until the end of hostilities. After a period of time at Yokosuka, where she gave care and comfort to liberated US POWs and civilian internees, she brought her first 1000 patients back to San Francisco in November. By 15 February 1946, she had completed her third “Magic Carpet” mission of bringing service personnel from Pearl Harbor back to  San Francisco.

USS Benevolence Anchored in Bikini Atoll for Atomic Tests, 1946 (Photo: NavSource Online: Service Ship Photo Archive, http://www.navsource.org/archives/09/12/1213.htm, accessed 26 August 2012)

From May to September 1946, Benevolence provided medical support for the Bikini atomic tests. After a 19 day rest in San Francisco, she deployed again, this time to serve as a station hospital off Tsingtao, China. After nearly six months, she returned to the US, this time to be decommissioned at Hunters Point Naval Shipyard in San Francisco. She was laid up in the Pacific Reserve Fleet until the outbreak of the Korean Conflict. She underwent refurbishment at the Mare Island Naval Ship Yard.

On her return from sea trials, with a small medical contingent and a large number of civilian technicians aboard, in heavy fog and zero visibility, Benevolence collided with the commercial ship SS Mary Luckenbach. The stricken hospital ship sunk within 25 minutes. Fortunately, all but 31 of her crew and passengers of more than 500 were able to get off the ship and into the frigid waters off San Francisco Bay. 18 people died or were lost. If she had had patients embarked, the tragedy could have been much worse.

USS Benevolence on her side off San Francisco Bay, 1950 (Photo: NavSource Online: Service Ship Photo Archive, http://www.navsource.org/archives/09/12/1213.htm, accessed 26 August 2012)

The ship lay in the shipping lane for 16 months while attempts were made to salvage her. When these were unsuccessful, salvage workers used three explosive charges to demolish her. She was stricken from Navy rolls on 20 December 1950.

I extracted the ship’s history  from Navy records, accessed 26 August 2012, http://www.history.navy.mil/danfs/b5/benevolence-i.htm
 
©2012 Thomas L Snyder
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A Step Away From the Past and Into the Present and the Future – An Old Doc’s Look at Health Care Reform

My son James recently sent me a link to a New Yorker article on health care delivery with this question: “Is Kaiser [-Permanente] like the Cheesecake Factory?” He might also have asked, “Is military medicine like the Cheesecake Factory?”

Health Care Reform - Change and Hope

In “Big Med – Restaurant chains have managed to combine quality control, cost control, and innovation. Can health care?”, Boston surgeon and medical writer Atul Gawande tries to apply the lessons he learned, as a result of a meal at a Boston-area Cheesecake Factory, to health care delivery. While noting that the Cheesecake Factory chain has managed – very well – to control both cost and quality while assuring an excellent customer experience, Dr Gawande points out that medicine doesn’t do nearly as well.

According to Dr Gawande, even in the erudite halls of Boston’s vaunted teaching hospitals – presumably models of the best medical care America has to offer – physician approaches to patient care are individualistic – even idiosyncratic; this results in patient complication rates that vary by as much as threefold within the same hospital; and patient / family experiences have historically been almost invariably wretched. While these hospitals may be at the forefront of research and innovation in health care, they don’t seem to be doing a very good job of delivering quality “every day health care” to “every day patients”.

What are the lessons health care could learn from Cheesecake Factory?

The first is a consistent – and consistently good – product. In the restaurant business, consistency means “standardization”, a consistent way of doing the same thing over and over again. My first lesson in medical consistency came during residency: I trained in a Chicago hospital that catered both to “carriage trade” patients and people from a very poor “mile-square” area in the City. In caring for our patients, our attending physicians very early on cautioned us to use the same care procedures for both the very rich and the very poor, because the instant we tried to “customize” our care (either for the rich or for the poor), we risked introducing opportunities for  medical mistakes. Undoubtedly, in medicine just as in the cooking business, you need to apply the individual judgement of a well-trained and experienced professional to each case. But doctors are notoriously a restive group, very protective of their independence. How do you get a “herd of cats” to practice in a consistent manner, even while permitting those individual judgment calls that hone the standardized approach to each individual patient’s needs? Here, I believe, is the first place my Kaiser-Permanente and my military experience becomes instructive. In both Kaiser and the military, practitioners are salaried. Thus, they aren’t competing with each other for patients and for income. I believe this makes for an environment that encourages true collegiality and a sense of “we’re all in this together”. When you combine true collegiality with a strong culture of “best practices”, I think it becomes relatively easier to develop a department-consistent (or even a hospital-consistent) approach to any aspect of medical care delivery. Of course, this takes effective leadership – something both the military and the Kaiser-Permanente model have spent some resources in cultivating.

Another lesson from my experience not necessarily highlighted in Dr Gawande’s piece is the importance of “doctor-based” decision-making. My favorite example comes from northern California Kaiser-Permanente. I was the chief of urology at my Kaiser hospital. At one of our quarterly Chiefs meetings at the Oakland, California headquarters of The Permanente Medical Group, the 13 of us were pondering a question brought to us by the Chief of the 13 Chiefs of Medicine: what should “company policy” be regarding the use of PSA screening for prostate cancer? Then, as now, with the possible exception of one or two very well circumscribed situations, the data are not at all certain. And then, as likely we would now, we argued the pros and cons at some length. Finally, with no consensus forthcoming, we turned in frustration to the representative from “Higher Headquarters” and begged “What do you want us to do?”. The answer was “You are the content experts. When you decide a policy, that shall be the policy of Kaiser-Permanente.” (We’d probably be urged, today, to look for a “best practice” model to follow, subject to change, of course, as experience and research refined our understanding of the medical matter at hand.) What a reassuring message I could bring back to my colleagues, and to my patients! No “bureaucrat” is making health care decisions for you!

Back to the Cheesecake Factory, Professor Gawande takes notice of the extensive use of computers, with screens at face level throughout the kitchens. These provide the company recipes and serving suggestions, readily accessible throughout all 160 restaurants in the chain. Both the military and Kaiser-Permanente have adopted extensive computer operations throughout their systems. In fact, Kaiser was looking to introduce system-wide computerized health care records and data sharing as early as the late 1980s. Computerized systems permit a secure sharing of medical information – lab test results, radiology images and medical history information – at every hospital and clinic in the system. The value of this is immeasurable in the reduction of unnecessarily duplicated tests and exams, and the easy discussion of such things as Xray images between specialists within the system. When my wife was facing arthroscopic knee surgery recently, her orthopedist just pulled her MRI images up on the screen right there in the exam room and went over them with her and me in detail! With the computerization of health records comes a similar easy collaboration between primary care provider and a specialist or specialists who might be located – at least in the military – half way around the world. The Kaiser organization offers an electronic version of a patient’s health record – on a thumb drive – that he or she can take on vacation, at nominal cost.

The Cheesecake Factory has an active product development establishment that produces an updated menu about every six months. Each of the military services has the equivalent – a research arm which searches for innovations in preventive medicine and the special health requirements of people operating in challenging environments whether that be in submarines, in space, or in the mountains of Afghanistan. The Kaiser-Permanente Division of Research, based in Oakland, California, has published more than 4000 peer-reviewed medical articles in its 50 year history. In 2010, its budget of nearly $100,000 supported more than 50 researchers involved in more than 200 research projects largely but not exclusively oriented to the health of large populations.

Both the military and the Kaiser-Permanente systems of health care offer a feature Dr Gawande doesn’t mention – the regionalization of very specialized care. For example, in northern California, Kaiser-Permanente’s more than 3 million patients receive their cardiac surgery at specialty centers in San Francisco and Santa Clara. Neurosurgical care is centered in Redwood City and in Sacramento.  The military system has similar echelons of care, from clinics to primary care hospitals to specialty hospitals. This regionalization avoids unnecessary duplication of expensive specialty care and equipment, and, as a bonus, assures that super-specialty surgeons and physicians are constantly busy – one determinant of successful outcomes.

Then there is the matter of “size”. The Cheesecake Factory, with its 160 restaurants, experiences economies of scale in purchasing of everything from eggs to refrigerators. The Department of Defense medical establishment is huge – the largest in the country. If if were so oriented, its huge purchasing power could effect amazing savings of scale. One example of Kaiser-Permanente marketplace power comes from some years ago. As the story goes, one domestic insulin manufacturer bought out its competition and then announced a large increase in the price of insulin. Promptly the northern California Kaiser pharmacy operation, as a major purchaser of insulin,  reached out to a large Scandinavian insulin producer and offered to partner with them to bring product to market in the US. This effort was successful, and the price of insulin dropped promptly.

Health care reform, in my view, requires one more thing that was implicit in Dr Gawande’s New Yorker restaurant piece: competition. Even while it was struggling to grow in its early years, the Kaiser-Permanente organization realized that healthy competition is a necessity. From the early 1940s, the Kaiser mantra became something like “unless patients have choices in the care they receive, we will have no opportunity to show how good we really are”. When I was practicing Navy medicine as a General Medical Officer, lo, those many years ago, I remember resenting my patients going to the doctors “downtown”, on the civilian side, for their care. I knew we were giving every bit as good care as the “townies” did, but the knowledge that our patients had a choice kept us all on our toes to do the best we could, even in the”captive” care system that is military care.

There you have it: consistency of medical procedures while encouraging the application of sound judgement; salaried health care providers to eliminate destructive competition and encourage collegiality and unity of approach; doctors- or professionals-driven policy decision-making based on consensus best practices; extensive application of computer technology to record keeping, data sharing and promulgation of consistent practice; regionalization of super-specialized care; scale of economy based on large regional or national systems of organization; and vigorous competition among provider systems.

By way of background, I practiced medicine in all three practice settings: active duty military (Navy, for 3 years), fee for service in a small multispecialty group (5 years), and in the large northern California Kaiser-Permanente Health Care system (20 years). In addition, with 20 years in the Naval Reserve, I had contact and conversations with physicians from around the country who practiced in a variety of settings. These experiences all convince me that a salaried system of care providers virtually eliminates the extra and often unnecessary medical procedures engendered by the fee-for-service model where a physician is paid for each procedure carried out. Fee-for-service puts the emphasis, in my view, on health care providers (the more procedures, the higher the income), rather than their patients and what’s best for them. It’s much more natural for salaried providers to be driven by what’s best for their patients, since salaries are going to be paid whether procedures are performed or not.

©2012 Thomas L Snyder

Walking the Walk

This weekend is the annual Mare Faire on Mare Island, site of the first naval base on the U S Pacific Coast. Mare Island also was the home of the first Naval Hospital on the west coast. Opened informally – housed first in an unused granary – in 1864, the hospital closed in 1957. The Navy Schools Command operated the facilities until the Navy Base closed in 1997. Touro University took possession of the property in the early 2000s.

Mare Island Naval Hospital, 1871 (Image: National Archives)

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The Mare Faire is my annual opportunity to tell the story of Naval Hospital Mare Island, California, to visitors from around the country. This weekend, both on Saturday and Sunday, I give a one hour PowerPoint® presentation, Mare Island’s Hospitals–Mare Fair 2012Aug11-12. Then, I lead a walking tour of the hospital property, which is today owned by Touro University California. with the exception of one building used for instructional spaces, and three for administration an faculty offices, the original hospital structures lie empty and unused. While university officials won’t allow us access to the interiors, we are permitted to walk the hallowed grounds where wounded and sick sailors and Marines walked for nearly 100 years.

So this weekend, I literally talked the historical talk and walked the historical walk.

©2012 Thomas L Snyder

Navy Medicine in the War of 1812 – Action in the Year 1812, Part I

War of 1812 Propaganda Poster (Image: Ohio History Central. http://www.ohiohistorycentral.org/entry.php?rec=565)

The history community in the US and Canada (I don’t know about the UK) are ramping up for observations of the 200th anniversary of the War of 1812. Inasmuch as this war was in large part fought on water, it occurs to me that we should be looking, so far as we can, at the role navy medicine played in the conflict. For Part I of this discussion, I will depend largely on Professor Harry Langley’s 1995 book A History of Medicine in the Early U.S. Navy.

You’ll recall that British had raised the ire of Americans by their interference in our commerce with Napoleonic Europe, and, more importantly, by their impressment of American mariners into the Royal Navy. Initially, the US Congress retaliated with legislation – the Embargo and Non-Intercourse Acts of 1807 and 1809 – but these further decreased our overseas trade.  With New England merchants crying economic ruin, first the House (79-49 on June 4, 1812), then the Senate (19-13 on June 17) voted for war, and President Madison signed the Declaration on 18 June.

Commodore John Rodgers’s quickly assembled a squadron of four ships. Soon after they departed New York, on 25 June, they encountered HMS Belvidera, 36, northeast of New York. A brief but violent action followed, with USS President, 44,  pursuing. In the end, Belvidera ran north to Halifax, having sustained the loss of 2 killed and 22 wounded. President, the only American ship to engage, experienced 3 killed and 19 wounded. Langley says “…its surgeon and mates cared for the wounded.”(1)

Commodore Rodgers and his squadron proceeded to patrol within a day’s sail of the English Channel. Despite success in capturing British merchant ships – he had 80 – 100 prisoners aboard – the squadron had to return home to Boston earlier than planned because of a widespread outbreak of scurvy among his crews.(2) Langley says that his crews were hospitalized at the Boston Navy Yard, but this care must have been given in the Marine Hospital, because a Navy hospital in Boston was not constructed until 1836.(3)

USS Constitution meets HMS Guerriere (Image: U S Naval History and Heritage Command)

On August 19, USS Constitution won a celebrated victory over HMS Guerriere. Constitution suffered 7 killed and 7 wounded while her adversary lost 15 dead and 62 wounded. Surgeon Amos A Evans(4) and Surgeon’s Mate John D Armstrong attended the American injured; when the fighting was over, the two men transferred to Guerriere to assist her surgeon, who himself had been wounded, in the care of British sailors. Professor Langley gives us an interesting detail of Evans’s care of an amputee, one Richard Dunn. Two days after his surgery, when the patient complained of stump pain, Evans “wetted it with laudanum and gave the patient laudanum mixed with wine”.(5)

In October, November and December, ships in the American navy fought three more sea battles (I’ll write about lake battles later in this series) resulting in injuries cared for by naval surgeons. Stand by for future posts.

(1) Langley, Harold D., “A History of Medicine in the Early U.S. Navy”, Baltimore, Johns Hopkins Press, 1995, p 176.
(2) It is curious that scurvy should have been seen in large numbers at this late date, as the disease had been virtually eliminated from the Royal Navy by 1800, due to the common acceptance – by medical officers and commanders alike – of citrus juice as an effective antiscorbutic. The discussion of the conquest of scurvy in the Royal Navy by Lloyd and Coulter (Lloyd, Christopher, and Jack L S Coulter, “Medicine and the Navy, 1200-1900. Volume III–1714-1815”, Edinburgh and London, Livingstone, 1961, Chapter 18) is comprehensive.
(3) Langley tells that Congress appropriated $15,000 for a hospital in Boston to care for all sailors, both merchant mariners and navy sailors in 1802. The Boston Marine Hospital was constructed in 1803, and received its first patients in January 1804. The Marine Hospitals were operated by the Secretary of the Treasury; Navy officials came to believe this was an unsatisfactory arrangement because navy sailors had a propensity to desert from these places as they recovered from their illnesses or injuries. A Naval Hospital Fund, intended to pay for construction of hospitals specifically for the Navy, was passed in February 1811 and immediately funded with $50,000 transferred from the Marine Hospital Fund. The War of 1812 interrupted plans to build a Naval Hospital in Boston. It finally saw fruition in 1836. http://www.nps.gov/nr/travel/maritime/nav.htm accessed 4 August 2012.
(4) According to a brief University of Michigan biography, Evans studied medicine with a hometown practitioner “and attended lectures by Benjamin Rush in Philadephia”. He was admitted to the Navy in 1808, served in the naval hospital in New Orleans, in USS Constitution. While on shore duty, he earned his MD from Harvard in 1814. In 1815, he was promoted to be the navy’ s first Fleet Surgeon. He resigned from the navy in 1824. http://quod.lib.umich.edu/c/clementsmss/umich-wcl-M-262eva?view=text, accessed 3 August 2012.
(5) Langley, pp 177-178. Laudanum – tincture of opium – is a powerful narcotic pain medication. In his “Materia Medica and Therapeutics” (Philadelphia, F A Davis, 1891), John V Shoemaker, AB, MD, describes its beneficial application to wounds as “an antiseptic and to relieve pain”. http://books.google.com/books?id=SqBmb4sJKoIC&pg=PA783&lpg=PA783&dq=topical+laudanum&source=bl&ots=kL0jaQRZP4&sig=FknCNMtEPs3HcW-HAorPYvDeYTI&hl=en&sa=X&ei=2oUcUImjLMiuiALs3YGABA&sqi=2&ved=0CFAQ6AEwCA#v=onepage&q=topical%20laudanum&f=false accessed 3 August 2012.

©2012 Thomas L Snyder