Modern Healthcare Commentary

Excited to share my thoughts this week with Modern Healthcare on the intersection of analytics, technology, and humanity in healthcare:

When we strip away everything in healthcare that humans do not absolutely have to do, all that remains is the raw humanity ingrained in person-to-person interactions. Better technology CAN thus both enable and expand our humanity by facilitating more of the right kinds of human-to-human contacts—even if they wind up being through FaceTime.

I’d love to hear your thoughts – agree, disagree, or otherwise – either here or at the magazine’s link below!

http://www.modernhealthcare.com/article/20180331/NEWS/180339999

 

March Metric Madness

While others spend the month taking in NCAA’s March Madness, as a self-proclaimed Quality Nerd I was truly fortunate to spend a day in DC focused instead on Metric Madness.  I was invited to Washington by Peggy O’Kane and her core team from NCQA, the group known for (among other things) driving value in healthcare through health plan accreditation and pioneering Primary Care Medical Home certification.  But I wasn’t in town to discuss HEDIS or PCMH – instead, the NCQA team wanted to discuss one of the most pressing issues facing continuous improvement in healthcare today – measurement burden.

Before we go further it’s important that I clarify one thing – I am an enormous believer in the power of measurement.  As a Chief Quality Officer, my role description quite literally requires me to spread the gospel of data-driven quality improvement 24 hours a day, 7 days a week, 365 days a year.  And yet I acknowledge that the problem of over-measurement is real, and it threatens to stall the momentum of any continuous improvement flywheel.

To give you a flavor of what we covered, I’ll outline just three of the major universes of metric programs in which an integrated healthcare delivery system participates:

REGULATORY REPORTING

To begin, let’s look at just the regulator-driven metrics that hospitals and physician groups report as part of CMS and Joint Commission’s various programs.  These programs combine claims-based measures (metrics automatically generated through tracking individual patient bills) along with abstracted measures.  Despite advances in electronic submission, clinical abstraction remains largely the work of individual people as the promise of fully-automated electronic reporting remains in its early stages.  And some of these manually-abstracted measures require finding no less than 80 discrete data points in a medical record to submit just one metric for one patient.  For infection-prevention related metrics, the data definitions alone can run 30 pages.

PAYER REPORTING

Moving into the second ring of metric reporting, we arrive at the groups of measures associated with contracts that hospitals, physician groups, and networks sign with both government and commercial payers.  These payer contracts range from arrangements to join an Accountable Care Organization, to relationships with Medicare Advantage plans, to measures likely to be in future population health contracts – like those proposed for North Carolina’s transition to managed Medicaid – that delivery systems must be already measuring internally to drive improvement.

Despite efforts to harmonize metric sets across payers, each contractual relationship carries with it different reporting requirements, different methods of submitting data, different ways of counting attributed patient populations, and even different interpretations of exactly the same metric definition.  This menagerie occasionally results in the same metric being measured, analyzed, reported and graded in three totally different ways for three different payers.  If that’s not a recipe for chaos I don’t know what is.

INTERNAL REPORTING

Finally, moving past the metrics we have to report brings us to the metrics that health systems choose to measure.  These are the metrics systems use to drive local improvement at the hospital, unit, region, group, practice, provider and patient levels. They include an enormous universe of metrics crossing every aspect of the continuous improvement landscape, including effort to drive clinical outcomes, operational outcomes, access to care, and patient and team member experience.  These metrics are the bread and butter of the DMAIC continuous improvement process and conservatively add thousands more metrics to the previous total.

SO WHAT?

Why, you may ask, should we care if health systems measure thousands of metrics across hundreds of providers and hundreds of thousands of patients?  The answer is simple – measurement is only ONE step in the define, measure, analyze, improve and control process of continuous improvement.  We need hospitals, health plans, providers and patients to focus their energies on EACH step in the continuous improvement process, getting past just reporting metrics and into actual, tangible outcome improvement.

Accomplishing this goal means measuring fewer things but doing more about the things we measure.  It means aligning things like metric definition, interpretation, submission, and reporting requirements across all payer programs, and upgrading the electronic medical record infrastructure across all vendors to accurately and reliably report these core measures.  It means connecting the “why” behind each mandatory metric to actual clinical outcomes that matter to both patients and providers, and it means seeking improvement first and accountability second from those required to measure and report them.

Even Don Berwick, the Godfather of continuous improvement in healthcare, agreed in an editorial written nearly two years ago in JAMA (emphasis added):

First, Reduce Mandatory Measurement

Era 2 has brought with it excessive measurement, much of which is useless but nonetheless mandated. Intemperate measurement is as unwise and irresponsible as is intemperate health care. Purveyors of measurement, including the Centers for Medicare & Medicaid Services (CMS), commercial insurers, and regulators, working with the National Quality Forum, should commit to reducing (by 50% in 3 years and by 75% in 6 years) the volume and total cost of measurements currently being used and enforced in health care. The aim should be to measure only what matters, and mainly for learning.  With that focus, all health care stakeholders could know what they need to know with 25% of the cost and burden of today’s measurements enterprise. The CMS has, to its credit, removed many process measures from programs, but progress toward a much smaller set of outcome measures needs to be faster. Such discipline would restore to care providers an enormous amount of time wasted now on generating and responding to reports that help no one at all.

My role gives me the first-hand experience to know that it’s not easy to winnow a measure set to “only what matters.”  Yet our national history is a compilation of intersections where we’ve chosen not to take the easy path.  To paraphrase from Kennedy, we choose to do these things:

and do the other things, not because they are easy, but because they are hard; because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one we intend to win.

With the energy and leadership of groups like NCQA, and the words of both Godfather Don and President Kennedy ringing in our ears, I am confident we can succeed.

Deriving the Prescriptive Analytics Function

While Gartner’s 2017 Healthcare Provider Hype Cycle still places most prescriptive analytics solutions on the rising-to-peaking portion of the curve, not all “prescriptive” analytics are created equal.  In fact, I’d argue that providers who aren’t engaged in some way in this highest quadrant of the analytics maturity model are leaving significant improvements in quality, efficiency, and velocity of care on the table today.

In advance of my upcoming talk at HIMSS, this post frames a view of prescriptive analytics that’s more function than solution.  It’s a concept that hit me while on a run this weekend past the outlook shown in the image above – specifically:

Prescriptive Capability of an Analytics Solution

Technology + (People * Continuous Improvement Process)

With a nod to the operating model’s “Golden Triangle,” at the heart of realizing the power of any technical analytics solution is a process that requires purposeful intent and deep integration across people in governance, strategy, support, and operations.  HOW to achieve this integration will be the main focus of my platform sessions at both HIMSS and Becker’s Health IT + Clinical Leadership later this spring – here, I’ll argue that varying technical implementations across the analytics maturity model below can still get to prescriptive with the right people and processes behind them.

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The promise of prescriptive analytics is a world where our models not only answer the questions “What happened?” and “Why?” but also tell us what will happen next AND what actions to take.  In its most autonomous form, I think of prescriptive analytics like the algorithm-driven trading dominating Wall Street.  Countless investment house algorithms train on mountains of data, look for patterns, test predictions, and find the actions that led to the best historical outcomes.  Once let loose upon the market, these same models then monitor trading in real-time, executing actions in vivo based on the patterns they’ve learned in training while simultaneously digesting each new day’s worth of data to refine and learn new pattern / action combinations.

While most of the clinical delivery of healthcare can’t presently (and arguably will never be) *fully* autonomous of human action, we CAN make much better use of prescriptive algorithms today that optimize real people’s time and energy.  At this most technically “prescriptive” end of the Technology + (People * Continuous Improvement Process) function lives Mission’s first internally-developed machine-learning algorithm – Readmissions Predictor.  Powered by a model developed by Dr. Andrew Johnson and his Data Science team – one whose development we spoke to in detail at HAS17 and will highlight again at #HIMSS18 – the LASSO Readmissions Predictor model was trained on millions of rows of data including hundreds of variables from Mission’s own enterprise data warehouse.  Importantly, the model not only serves a prediction on likelihood of 30-day readmission for every discharged patient on the day immediately post-discharge, but also provides the user with the variable that most strongly drives the model’s prediction for each patient.

Though the model handily beats LACE and maximizes the “Technology” portion of the prescriptive analytics function, without the right workflow to drive the right people’s actions it still would sit like a Ferrari in the garage gathering dust.  Instead, because the model was co-developing with clinical leaders from the outset, version 1.0 is now live in pilot form with transitional care managers actively tweaking the model and its user interface with the technical team each day.  Serving care managers with both better and more actionable data lets them spend more time doing what they’ve trained to do:  using their experience and brainpower to figure out HOW best to support the most concerning patients rather than spending time ferreting out WHICH patients most need their help.

On the less technically-advanced part of the maturity model curve are the merely “predictive” and “descriptive” analytics solutions.  While a report – even when multi-sourced and served in real-time – can never be truly prescriptive on its own, I believe these analytics solutions can get to prescriptive when integrated into a well-oiled team’s continuous improvement platform.

Take two of the other examples we’ll cover at HIMSS – the Care Process Model (CPM) Explorer and Ambulatory CPM Explorer dashboards.  These dashboards drive the work of over 60 CPM teams across Mission Health focused on improving specific clinical issues (like preventative screening) or disease states (like sepsis, cellulitis, and heart failure).  By providing a CPM team – composed of physicians, ACPs, nurses, pharmacists, performance improvement guides, informatics and analytics professionals, clinic or hospital leaders and support staff, and many others – with real-time data at the individual provider and individual patient levels, these dashboards plug directly into a continuous improvement flywheel and serve the team with the information they need to drive subsequent turns.

Want to know whether the most recent revision to the “rib fracture” electronic workflow is working?  The inpatient CPM team can pull up the dashboard and compare outcomes like mortality, readmission, length of stay, and cost per case in the pre/post intervention periods and find out what’s working, why, and where to focus its next PDSA cycle.

Need to have a discussion with a specific trauma surgeon?  The CPM team’s surgeon lead can pull up the dashboard and compare her CPM usage statistics and those of her partner along with their respective patients’ outcomes side-by-side.

The same is true for Ambulatory CPM Explorer, where teams are driving improvements in areas like the management of COPD exacerbation, preventing both ED visits and inpatient hospitalizations while increasing GOLD guideline adherence.

Again, its the “People * Continuous Improvement Process” portion of the CPM equation that drives a predictive function much greater than the Technology component alone could justify.  But without the technology these teams would have a much harder time knowing what happened, why it happened, and where to focus next.

Finally, the CPM process is only one of several continuous improvement examples that get into prescriptive analytics by leveraging more “basic” analytics technology while driving “People * Continuous Improvement Process.”  Teams today are using similarly creative dashboards in real-time or near real-time to drive significant improvements in emergency department throughput and inpatient length of stay, optimize surgical scheduling, and manage through incredible periods of patient surge while achieving better outcomes for patients and the community.  These teams are committed to a common goal – getting better, and better, and better, and better… – and their work is driven by predictive/descriptive analytics that become prescriptive when coupled to purposeful people and powerful processes.

Thus, while HIMSS18 will be filled with the incredible promise of technology – and it is quite amazing – I invite you to pause and remember the power inherent in the people who’ll be using it.  People and our processes make the world go round… equip the right people, using the right process, with powerful technology, and there’s nothing beyond our reach.

About the Author

Dr. Chris DeRienzo is a dedicated husband, a proud father, and a mediocre triathlete. He’s also a doctor dedicated to improving the quality, safety, experience and sustainability of healthcare for all Americans. You can read more about him at www.drderienzo.com or follow him on Twitter

Rings of Prometheus

This is Prometheus, a Pinus longaeva thought to be the oldest living thing when he was felled 1964.  At nearly 5,000 years old, the rings in Prometheus’ massive trunk tell the story of a bristlecone pine whose life stretched from the end of the bronze age through the beginning of the space age.  Thick rings recall years of plentiful water and good health, thinner rings a sign leaner times and drought, and more than a handful of rings wearing the unmistakable scars of battle with fire.

The history of our nation is no different.  For nearly 250 years, America’s story can be read in the lives of Americans – through famine and plenty, health and disease, strife and peace, the health of our people tells a story just as vivid as the rings of Prometheus.  Each new generation of Americans has lived both longer and better than its forebears, as two centuries worth of innovations in industry, commerce, and technology have been matched by advances in sanitation, clean water, food safety, vaccination, and healthcare.

Yet despite our still-growing technical and economic prowess, for the second year in a row Americans’ life expectancy WENT DOWN.

That’s right – Americans today are now expected to live SHORTER lives than we were in 2015.  Admittedly this isn’t the first dip in our national life expectancy curve, but most dips in the last 150 years are attributable to war or infectious pandemics (think the 1918 Spanish Flu).  And since World War 2 the curve’s noisy rise has largely settled into a fairly smooth, consistent upward deflection.

While it would be fair to assume profound medical advances are largely responsible for these gains – the 20th century did see the advent of antibiotics, coronary artery bypass surgery, surfactant therapy for premature infants, and much, much more – over 80% of our improvement in life expectancy since 1900 is attributable not to medicine but to public health.  And its our public health that’s to blame for our falling life expectancy.  The story our rings tell today isn’t one of stalled medical advancement, massive infectious pandemic or world war, but rather of two preventable and treatable public health epidemics.

We’ll start with obesity.  Barely 16 months after publishing this story with the headline “America’s Obesity Epidemic Hits a New High,” NBCNews was compelled to publish another story titled “America’s Obesity Epidemic Reaches Record High.”  Why?  Because in just one year – from 2015 to 2016 – the CDC estimated another 4.5 million adults and 1.1 million children and adolescents joined the ranks of the obese with body mass indexes (BMI) cresting 30.

Based on our current estimated population of around 325 million, this means around 111 million Americans are driving between $150 and $200 billion in excess healthcare costs and $4.3 billion in lost economic productivity each year while living shorter, sicker lives.  At that cost, we could buy every obese American 6 months of three healthy meals per day and a full year’s gym membership and still save $33 billion a year.  

While some signs point to a flattening of the obesity curve, our nation’s second acute public health crisis – substance abuse and specifically the Opioid Epidemic – worsens by the day.  Data published just last month shows that one American dies every 7-8 minutes from an overdose.  Two-thirds of those overdoses are opioid-related… and rising.

The annual total number of deaths related to drug overdoses now tops 63,000, more than all American fatalities in the Vietnam War and Operation Iraqi Freedom combined.  In comparison, motor vehicle accidents kill just under 40,000 Americans a year and HIV/AIDS kills just under 10,000.  Each have benefited from multi-billion-dollar research and intervention efforts that have successfully brought down fatality rates over the last 30 years.  The Opioid Epidemic has not.Picture4.pngTo stem the tide of these two massive waves, we need to fundamentally re-think how America invests in health.  Investments in public health interventions are dwarfed by mammoth public and private investments in acute care and pharmaceuticals, and are still falling as a relative share of our per capita healthcare spending.  While we’ve finally  begun experimenting with ways to sustainably bring “social determinants” interventions into the healthcare ecosystem, it’s not nearly enough.

In a cruel twist of fate, Prometheus was felled ostensibly in the spirit of research.  Imagine killing the oldest living tree while on a quest to discover just how long the oldest trees can live.  That’s what happens we we don’t pay attention.

As a nation we’ve been too willing to repeatedly clip dandelion heads off our public health problems than do the harder work of digging them out by the roots.  It’s time to pay attention – our rings are telling the story and we must heed their call.

It’s Time to Believe in Each Other Again

As 2017 draws to a close, authors across the nation will spill their ink recapping the year as one of great polarization.  Today’s vocabulary is replete with extremes, as paid political operatives from the left, right, center and sidelines all declare these to be the worst, most divisive, most challenging times anyone has ever faced.

Hyperbole may sell advertising… but it’s simply untrue.

The truth is that fear, division, and hyperbole are tyrants’ tools, and no matter how divided the Twitterverse says we are, America has weathered far worse.

Want to see real American division?  Try April 1861, when brothers took up arms against each other in a war whose echoes are measured not in decades but in centuries.  What about truly living on the tenterhooks of imminent nuclear attack?  Try October 1962, when sirens that sent school kids skittering under their desks were moments away from actually being put to use (though to what effect remains unclear).  How about an America actually on the brink of total economic failure?  Try 1932, when unemployment hit 25% and worldwide gross domestic product bottomed-out 15% below its 1929 peak.

As a nation we cannot, we must not allow ourselves to be torn apart by tyranny born of mistrust for – and misunderstanding of – each other.  Instead let us remember that the braids that bind us are far stronger than the spaces that separate us.  We are a nation forged of different metals, alloyed into a whole that becomes stronger than the sum of its parts.  We are better together, not because we are all the same but because we are different, and when we disagree we would do well to remember that our forebears enshrined the right to disagree in the words of America’s most hallowed national text.

We are now and have always been a nation of believers in things deeper than ourselves, and when we stand for something, engage with each other, and disagree both passionately and peacefully, we remind the world that disagreement does not need to equal hatred.  This truth forms the core of what makes America great today, what has made us great for nearly 250 years, and what will make us great 250 years from now.

So in this time of purportedly extreme division, when “everything is at stake” and “things couldn’t possibly be worse” I say this:

America needs less intimidation and more inspiration to unleash the torrent of energy, innovation and compassion held back by dams built by those who profit from fear, division, and hyperbole.

We need to listen carefully and openly to each other, instead of listening only to those who scream the loudest.

We need something to believe in, not someone to berate.

I for one believe first and foremost that the American dream is not the promise of success, but the freedom to pursue success in the way each of us defines it without restriction by birthright, gender, race, sexuality, or creed.

I believe there is no problem that the promise of American ingenuity combined with the power of American perseverance cannot overcome.

I believe that standing up for an ideal requires strength, and that strength is born of character and courage, not bluster and bravado.

I believe that strength and violence – in word or deed – are not synonymous, and neither are love and weakness.  Rather, it is love of family, of country, of community, and of God that fills America’s deepest wells of strength.

I believe the greatest gift of my public-school education is the ability to both listen to others and to think for myself, skills rarely fostered by today’s echo chamber of judgment.

Finally, I believe it is always morning in America because Americans refuse to remain fixated on the past.  Fixation on the past guarantees that we miss the future, and America’s future is always brighter than its past.

In Lincoln’s first inaugural address, given just weeks before the fissures in 19th century American society fractured into open war, the President implored an injured nation to look inward and heal itself, saying:

We are not enemies, but friends. Though passion may have strained it must not break our bonds of affection. The mystic chords of memory, stretching from every battlefield and patriot grave to every living heart and hearthstone all over this broad land, will yet swell the chorus of the Union, when again touched, as surely they will be, by the better angels of our nature.

It is high time our nation’s demons and our better angels once again had a fair fight.

About the Author

Dr. Chris DeRienzo is a dedicated husband, a proud father, and a mediocre triathlete. He’s also a doctor dedicated to improving the quality, safety, experience and sustainability of healthcare for all Americans. You can read more about him at www.drderienzo.com or follow him on Twitter

Making a Human Connection

“I’ve never wanted to make nurses feel like they have to convince me to come to a bedside. I’ve always said, ‘If you want me to come look at the baby just say so and I’ll come.’ Ninety percent of the time it is clinically worth the trip. The 10% of the time that everything’s OK is still well-worth the visit just to build a two-way trusting relationship.” -Dr. Chris DeRienzo

This month I was fortunate to chat with Dr. Bridget Duffy, Liz Boehm, Evan LaBranche, and Ben Fleury from the Experience Innovation Network for a report called Clinical Communication Deconstructed.  I’m a huge believer in the power of communication to transform outcomes in healthcare (and elsewhere in life for that matter), and the EIN team has done yeoman’s work bringing together these seven elements of effective clinical communication.

The full report is available here and its a fantastic read.  Below I’ve reproduced with permission the case study we created together:

Case Study: Caring Conversations for Difficult Diagnoses

Like many of his peers across specialties, Chris DeRienzo, M.D., MPP, System Chief Quality Officer, and a neonatologist at Mission Health, has had to deliver his share of bad news to his patients’ families.

It’s never easy.

Early in his medical training, Dr. DeRienzo received guidance and opportunities to practice so that he could deliver hard news with as much compassion and empathy as possible, despite his discomfort.

“We first learned the basics of structuring a difficult compassionate conversation, then we actually practiced while being recorded. It was awful watching yourself but invaluable to improving as a communicator because seeing and hearing yourself dramatically increased the velocity of change.”

The basics Dr. DeRienzo learned included beginning with a “warning shot,” pausing long enough so families could absorb the emotional impact of the difficult news, and offering the first steps in a path forward. “By the fifth time we went through the practice sessions, pausing for seven seconds of silence didn’t seem so awkward.”

Dr. DeRienzo recounted the first time he had to put those skills into practice, telling young parents in the emergency department that their child had cancer.

“I will forever remember that day, the room we were in, even what they were wearing. When I close my eyes I can still see their eyes at the moment my words turned their whole world on end, and how hard it was guiding them back into orbit. I was so glad I had practiced.”

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About the Author

Dr. Chris DeRienzo is a dedicated husband, a proud father, a storyteller, and a mediocre triathlete. He’s also a doctor dedicated to improving the quality, safety, experience and sustainability of healthcare for all Americans. You can read more about him at drderienzo.com or follow him on Twitter

Convenience and Coordination

Thanks to the folks at HealthLeaders Media and reporter Debra Shute for interviewing me for this story.

One of the key messages we landed on was this:

“…the push toward accountable populations while simultaneously meeting consumers in their living rooms are dual trends that will definitely need to be resolved within the next 10 years.”

I am confident that telemedicine will play an enormous roll to help bridge the gap between the convenience of 24/7 access and the high degree of care coordination that a medical home can provide.  Combined with walk-in primary care and a fully leveraged single electronic medical record, I believe we can find a balance between these dueling forces and actually improve population health outcomes in the process.

If you work in healthcare, how is your health system finding the balance between the pull of consumerism and the increasing push of population-level risk onto providers?

If you don’t work in healthcare, how is your team of doctors and hospitals (both primary care and specialty care) working to help you meet your 24/7 needs as a consumer while maximizing your care coordination?

 

Lessons

It’s hard to believe it’s been a year since our family’s longtime friend and canine companion Bartlet passed away. This is a post I wrote at drderienzo.com last year to celebrate his life and share the lessons we learned from a pound puppy with a white shock of fur, an inexplicable fear of water bowls, and an obsession for walking backwards into rooms. I think the content rings as true today as it did then, and it’s still good for both a good laugh and a good cry. -Chris

Today marked the end of an era.  Our dog Bartlet – named after the fictional POTUS from The West Wing who (true story) I wrote-in for President last year when I couldn’t bring myself to vote for any of the real candidates – died this morning at 08:32.

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He was a pound puppy, adopted from the Orange County shelter in 2005 by a 23 year-old medical student living in a cramped apartment.  He had a blazing white chest and a congenital smile.  We got to be kids together, grew up together, and grew older together (albeit at slightly different paces).

He died today an old man, having shared his home at various times with three kids and a wife (mine not his), three other dogs, a plethora of unfortunate fish, and a lifelong feline nemesis he barely managed to outlive.

He lived on farmland and in cities, roamed wooded acres and paved cul-de-sacs, drank equally as long from puddles as from the Atlantic Ocean, and rolled in the feces of nearly every mammalian species on Planet Earth.

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I learned from Bartlet that there is no downside to approaching others with boundless happiness.  He shared our home for over twelve years – for twelve years I tried to keep him from jumping on and prodigiously licking anyone who walked through our door, and for twelve years I failed.  Even when his octogenarian hips were too weak to stand without groaning, most days he’d beat our much younger puppy to the door when I’d get home late from work with the same ridiculous smile plastered to his face.  He simply had no other face to make.

He was also remarkably observant and a master of the stealth attack.  After our cat retreated to a life of quiet solitude in the laundry room, he would periodically sneak silently up the stairs to steal plates worth of Gizmo’s $75-a-bag prescription diet food anytime we forgot to close the gate.  I remember catching him tiptoeing upstairs for the first time after our cat died – I followed him to find out what he’d do upon finding out his delicacy had disappeared.  The look on his face is best expressed in GIF-form:

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The dog knew what he wanted, when he wanted it, and how it wanted it, and no amount of chiding or banishment to the deck was going to keep him from getting it:

Bartlet also taught me that we get to choose how we approach life’s unpredictability.  When we first moved to Efland just after my wife and I got married, he had freedom to roam our full six acre spread.  Creeks, beaver dams, pastures, and more deer s-it than any dog could possibly cover in a single lifetime – he was master of his domain.

A year later we built a fence so my wife’s two dogs who’d stayed with her parents (both of whom were runners) could move in too, and his domain rapidly shrunk to a shared 400 square-foot yard.  He was just as happy, and gained twenty pounds eating from the auto-feeder we bought to keep them all fed.  It was during that time his nickname transitioned from “sausage” to “meatball.”

One night we left all three dogs alone in the house for 20 minutes because we’d forgotten a bottle of wine to go with our dinner – when we got home, a torn paper bag was all that was left of the garlic-clove-filled Italian bread we’d left on the counter.  Not knowing the culprit, our vet recommended giving all three dogs a concoction of milk and peroxide to prevent the garlic from poisoning them.  While Bonnie and Clyde promptly regurgitated a slurry of garlic in the vomitorium that ensued, a poor dry-heaving Bartlet was left to wonder what he’d missed out on to deserve such an experience.

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He both never complained and never gave up, a combination I suspect is rarer in humans than it is in dogs.

Not long after I adopted Bartlet, I printed a small picture of him to carry with me in my wallet.  Despite the fact that Apple now lets me carry at least a million photos in my pocket, I still keep the same picture in my wallet today.

It was the spring of 2005, and a very young Bartlet is standing on my parents’ tile kitchen floor.  I’d just brought him up to spend six weeks in Massachusetts because he couldn’t stay with me in AHEC housing during my Family Medicine medical school rotation in Oak Island, and I had absolutely no one to watch him in North Carolina.

It was a crazy time in our lives – I’d just met a girl, one who’d not only join me on the 24-hour round-trip drive to pick him up two months later (one that involved both the largest coffee a Burger King in rural Connecticut had ever served as well as a 2AM fried chicken dinner) but whose cat would ultimately become a lifelong adversary, character foil, and an old friend.

In his eyes you can see the wheels whirring, the corner of his mouth turned up in a disarming smile that belied the churning of gears inside his puppy brain.  Within hours he was herding my parent’s older dog around the backyard and breaking through their invisible fence to spread his urine across the Commonwealth of Massachusetts.  He did learn and follow the rules, but never let them get in the way of any opportunity he had to bend the world towards his ideal.

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Twelve years ago I wrote a quote on the back of that photograph.  I’ve tried to live by its words ever since.

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More than anything else, for the rest of my life I will miss his daily reminder that it is possible to live this way all day, every day, under every circumstance life can throw at anyone privileged enough to have a beating heart.

So with respect to Stewie, I’ll say goodbye to a friend and teacher who in many ways was more human than many humans I’ve met in the best way I know how.

Rest well old boy – your lessons will continue reaching the hearts of many:

About the Author

Dr. Chris DeRienzo is a dedicated husband, a proud father, a storyteller, and a mediocre triathlete. He’s also a doctor dedicated to improving the quality, safety, experience and sustainability of healthcare for all Americans. You can read more about him at drderienzo.com or follow him on Twitter

Getting There

Here’s a new Chapter excerpt called Getting There – happy summer everyone!


We are standing on the threshold of both heaven and hell, dancing nervously between the gates of one and the ante room of the other.

-Yuval Harari, Sapiens

The nausea was so overwhelming it nearly sent me to the ground.  I’d spent 31 years in training (if you count preschool) preparing for this day, my first day as an attending physician running my own service, my own way.

Sure, by that point I’d been a doctor for six years and had made thousands of in-the-moment decisions that were only later validated by my supervising attending.  But this time there was no supervisor – I was the attending, the end of the line, and the final call on each decision was entirely my own.  Like a trapeze artist swinging without a net for the first time, the magnitude of that responsibility hit me in the gut like a hot iron and sent my stomach reeling through loops that put the meanest Six Flags attractions to shame.  That responsibility was why I went into medicine in the first place, and the full weight of it now finally rested on my shoulders.

Truth be told, the arc of my life had bent towards healthcare since I was in Stride Rites.  When I was five my family lived in a small Long Island town about an hour outside of New York City.  My father had torn the place down to the studs and rebuilt it for my mother before moving in.  The house soon became a bustling home, backyard replete with swing-set, batting tee, Slip-N-Slide, and a variety of bushes that had grown into what seemed to me like giant redwoods.

We were in the middle of my sister’s second birthday party, and I was outside with her playing near the bushes.  Summertime was in full swing, and the enormous bushes were covered from top to bottom with small red berries.  The kind that look just like candy to two year-olds.

I was watching her walk towards the back stoop, a firstborn son genetically incapable of not serving as guardian and protector of all in my keep, when in an instant her tiny hand darted towards the berries and she shoved a handful in her mouth.  They must have been bitter because I remember her making a terrible face, spitting them out, and then toddling off towards the Slip-N-Slide.

Alarmed I took off into the house, heart pounding and hands spinning over my head like the lights on an old police car screaming “EMERGENCY! EMERGENCY!” at the top of my lungs.  I relayed the story, crushed that I couldn’t stop her from eating the berries and utterly convinced that I was going to lose my first patient before I’d even graduated from kindergarten.  A quick (and reassuring) call to poison control and all was returned to normal.  Except for the helpless bushes, as my father slipped silently away from the party to promptly turn them into wood chips.

My mother practiced nursing before my siblings and I were born, and I grew up marveling at how much she knew about medicine.  She always had an answer, a treatment, a reassurance for whatever was ailing anyone in the family, and I wanted to know just as much.  By elementary school other kids were coming to me for medical advice about bug bites and scrapes.

One day on the playground a boy bloodied his knee playing kickball and a flotilla of children came running my way.  He had a small laceration just beneath his knee cap that was indeed bleeding but would clearly stop on its own.  I vividly remember thinking to myself “Well, touching blood with my bare hands is risky but I really need to treat my patient.”  I wiped away his blood, told everyone he’d be fine, and they went back to playing.

Recess ended and I walked to the school nurse’s office, ready to face whatever horrors awaited me for touching blood without wearing the appropriate personal protective equipment.  Pale and trembling I told her what happened and that I was ready now for the gigantic needle I was convinced she needed to use to test me for AIDS.  She instead gave me a popsicle, reminded me that I didn’t have a license to practice either nursing or medicine in the state of New York, and sent me back to class.

Even at 8 years-old the strains of the American Medical Association’s 1847 Code of Ethics rang true, which says a physician must be:

“ever ready to obey the calls of the sick… because there is no tribunal other than his own conscience, to adjudge penalties for carelessness or neglect.”

It turns out that the actual practice of real medicine is rather different from what most people think.  Centuries of folklore have given us a picture of the good doctor, sitting in a dark, wood-paneled library surrounded by stack upon stack of textbooks.  The air is heavy, and you can practically feel the weight of ancient wisdom as the ghosts of Osler, Galen, and Hippocrates hover over his tense shoulders. His white coat is rumpled, glasses askew, and you can just make out his furrowed brow beneath the amber light of his table lamp as he desperately tries to connect the dots.

We watch for a moment as he moves from book to book, the gears in his mind spinning faster and faster until something finally catches his eye.  It’s a line from the 19th century Latin translation of the Ancient Egyptian Ebers Papyrus and it sends him headlong again into the stacks. Thousand-page tomes by Sabiston, Harrison, and Schwartz crash thunderously to the floor until he finally emerges with a copy of Nelson’s Textbook of Pediatrics.  Rifling through the pages he stops on page 1,754, scans the minuscule print, pounds his fist against the heavy wooden desk so hard it startles the medical students hunched in their nearby cubbyholes, and exclaims “Of course!”

He grabs the book and streaks down the library’s Gothic corridors, his white coat a blur as he enters the hospital’s main doors and re-enters its cold, sterile embrace. Taking the stairs two at a time he climbs five flights up to the pediatric ward.  Stopping only briefly at the pharmacy he sprints to his patient’s room, locks eyes with the young girl’s parents and says with both relief and triumph in his face “We’ve got it.”

He starts an intravenous line in her tiny arm, spikes the clear glass bottle of medication, opens the clamp and the mysterious drug begins flowing into her bloodstream.  Within a matter of seconds her eyelids flutter, she begins to stir, her mouth twists into weak smile and she opens her eyes for the first time in days.  Her parents rejoice while the good doctor slumps into an uncomfortable rocking chair, the weight of one life lifted from his shoulders while other lives wait in line to climb on.

Medicine is practiced like this in exactly two places: 19th century British paintings and prime-time television dramas.

My real life as a physician has never been that simple – while there have been periodic “eureka” moments, I can’t count the number of times I’ve fallen asleep on hard call-room mattresses thinking about a particularly challenging patient and woken up still thinking, struggling to find the one unifying diagnosis that would perfectly connect all the dots.

Real medicine is messier than it looks in paintings or on television, diagnoses are rarely perfectly cut and dried, and with the possible exception of doctors old enough to have actually used glass bottles and metal IV catheters in their training you should almost never allow a doctor to start your IV.  We’re just not as good at it as nurses are, a fact my wife (an oncology nurse who has in fact successfully gotten blood from a stone) finds reason to remind me about on a nearly daily basis.

MORE TO COME THIS WINTER!