PERSPECTIVE BALANCING AMCS MISSIONS AND HEALTH CARE COSTS of health care. Fortunately AMCs From Brigham and Womens Hospital Massachusetts Health Aff (Millwood )2003 specialize in innovation. We must (E.GN), Massachusetts General Hospital 22: 130.41 (T.G. F, P L.S. ) and Partners Health Care 3. Milford CE, Ferris TG. A modified"Gold- now apply that capability not just (E.GN, T.G. F, P.L. S)-all in Boston n Rule"for health care organizations. Mayo to scientific aspects of medical Clin Proc2012;87:717-20 care but also to the systems de- 1. Schoen C, Lippa J, Collins s, 003-2011: rodin forms provided by the authors (Commonw Fund)2012; 31: 1-39. pioneer-aco-year-l-results aspx are available with the full text of this article 2. Mechanic RE. What will become of the DOl: 10.1056/NEJMp1309179 medical mecca? Health care spending in Copyright @. 2013 Massachusetts Medical Society BECOMING A PHYSICIAN Signal in the Noise Raphael P Rush, M.D. he first time I heard an Iv The now-gentle tones of IVs pro- families had left and the lights pump beeping was my first vided the root chords of a melody were turned low, patients and time in the hospital as a medical made of the cadences of snoring house staff alike would be left student. Sent to examine a loud, patients and the trills of ringing alone with their to-do lists and cantankerous patient, I became phones. concerned when his IV pump be- Certain songs, with their dis- Silence evoked an urge to fill gan frantically shrieking. After 30 tinctive instruments, repeate and it was in those rest beats I pulled a resident out of the hall monitor, accompanied by the st that i often found myself cross- seconds of panic and uncertainty, themselves. The beep of a hea into the patient's room, where, in of mechanical ventilation, provid- room to stop, to sit, to examine a maneuver that shocked me then ed a backbeat for the trance mu- again, to catch what I had missed but has since become part of my sic of the ICU. Alarms and suc- during the day. Night was the repertoire, she promptly hit the tion and overhead pages backed time to notice and address the "Silence Alarm"button and con- up the lead vocals and hea leavy- softest sounds: a subtle valvulop ed with her own work metal stylings of the Code Blue athy, fine crackles, quiet weeping Hospitals are noisy places, an team leader behind a curtain after a patient assault on the ears. As a new At night, after the lullaby of had received difficult news. It visitor, I was greeted by an array the overhead announcement ush- was a chance to talk with my pa of beeps, whistles, and shouts ered visitors out of the hospital, tients, hear the lyrics of their histories again, chat about the Now, i was expected to pronounce news or do crosswords with them as i looked over their shoulders someone dead for the first time I began rounding a second time each day, after dark, the quiet night music serving as my own made by people and machines, after the formal and choreo- lullaby before I returned to loud each with a distinct agenda, every graphed day teams gave way to work in the emergency room or one of them desperate for atten- the improvised jazz of the night- evanescent refuge in the stillness tion. The impression was of an time residents, the wards would of the call room. unholy, disorganized din. go dark and silence would fall. One night, early in my resi- Yet cacophony gave way, Not in the grungy emergency de- dency, I was listening to the pat- to music. The soft partment, which would be loud- ter of rain against the call-room of arriving elevators mixed er, busier, and more frantic, but window and sipping midnight hatter at the nursing station. on the wards, where once the coffee when my pager went off. N ENGLJMED 369: 11 NEJM. ORG SEPTEMBER 12, 2013
PERSPECTIVE 996 n engl j med 369;11 nejm.org september 12, 2013 of health care. Fortunately, AMCs specialize in innovation. We must now apply that capability not just to scientific aspects of medical care but also to the systems delivering it. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org. From Brigham and Women’s Hospital (E.G.N.), Massachusetts General Hospital (T.G.F., P.L.S.), and Partners HealthCare (E.G.N., T.G.F., P.L.S.) — all in Boston. 1. Schoen C, Lippa J, Collins S, Radley DC. State trends in premiums and deductibles, 2003-2011: eroding protection and rising costs underscore need for action. Issue Brief (Commonw Fund) 2012;31:1-39. 2. Mechanic RE. What will become of the medical mecca? Health care spending in Massachusetts. Health Aff (Millwood) 2003; 22:130-41. 3. Milford CE, Ferris TG. A modified “Golden Rule” for health care organizations. Mayo Clin Proc 2012;87:717-20. 4. Partners HealthCare slows cost growth, improves quality. Press release of partners HealthCare, July 16, 2013 (http://www .partners.org/About/Media-center/articles/ pioneer-aco-year-1-results.aspx). DOI: 10.1056/NEJMp1309179 Copyright © 2013 Massachusetts Medical Society. balancing amcs’ missions and health care costs BECOMING A PHYSICIAN Signal in the Noise Raphael P. Rush, M.D. The first time I heard an IV pump beeping was my first time in the hospital as a medical student. Sent to examine a loud, cantankerous patient, I became concerned when his IV pump began frantically shrieking. After 30 seconds of panic and uncertainty, I pulled a resident out of the hall into the patient’s room, where, in a maneuver that shocked me then but has since become part of my repertoire, she promptly hit the “Silence Alarm” button and continued with her own work. Hospitals are noisy places, an assault on the ears. As a new visitor, I was greeted by an array of beeps, whistles, and shouts made by people and machines, each with a distinct agenda, every one of them desperate for attention. The impression was of an unholy, disorganized din. Yet cacophony gave way, over time, to music. The soft dings of arriving elevators mixed with chatter at the nursing station. The now-gentle tones of IVs provided the root chords of a melody made of the cadences of snoring patients and the trills of ringing phones. Certain songs, with their distinctive instruments, repeated themselves. The beep of a heart monitor, accompanied by the hiss of mechanical ventilation, provided a backbeat for the trance music of the ICU. Alarms and suction and overhead pages backed up the lead vocals and heavymetal stylings of the Code Blue team leader. At night, after the lullaby of the overhead announcement ushered visitors out of the hospital, after the formal and choreographed day teams gave way to the improvised jazz of the nighttime residents, the wards would go dark and silence would fall. Not in the grungy emergency department, which would be louder, busier, and more frantic, but on the wards, where once the families had left and the lights were turned low, patients and house staff alike would be left alone with their to-do lists and their thoughts. Silence evoked an urge to fill it, and it was in those rest beats that I often found myself crossing the threshold of a patient’s room to stop, to sit, to examine again, to catch what I had missed during the day. Night was the time to notice and address the softest sounds: a subtle valvulopathy, fine crackles, quiet weeping behind a curtain after a patient had received difficult news. It was a chance to talk with my patients, hear the lyrics of their histories again, chat about the news, or do crosswords with them as I looked over their shoulders. I began rounding a second time each day, after dark, the quiet night music serving as my own lullaby before I returned to loud work in the emergency room or evanescent refuge in the stillness of the call room. One night, early in my residency, I was listening to the patter of rain against the call-room window and sipping midnight coffee when my pager went off. Now, I was expected to pronounce someone dead for the first time
PERSPECTIVE "Patient found without vitals, was still, and her bed was inhab- ing station, becoming thicker the message read. After a moment ited not by the woman Id round- and thicker until I could no lon of panicked scanning of my sign- ed on hours before, but by what ger hear the rain. out list, I realized that the death she'd left behind The gentle rus- had been expected; now, I was tle of sheets, the whisper of are availabl forms provided by the author expected to pronounce someone breath, the scratch of pen against cle at nel e with the full text of this arti. dead for the first time doku puzzle had all gone The floor was as quiet as any Time of death, 2: 30,"I pro- Universit of toront ward at night, the nurses unper- nounced, plainly, atonally turbed, maintaining their noctur- As I filled out the death cer- Dol: 10.1056/NEJMp1305849 nal minuet. The patient's room tificate, silence engulfed the nurs- Copyright e 2013 Massachusetts Medical Society N ENGL丿MED369;11NEM。 RG SEPTEMBER12,2013
n engl j med 369;11 nejm.org september 12, 2013 PERSPECTIVE 997 “Patient found without vitals,” the message read. After a moment of panicked scanning of my signout list, I realized that the death had been expected; now, I was expected to pronounce someone dead for the first time. The floor was as quiet as any ward at night, the nurses unperturbed, maintaining their nocturnal minuet. The patient’s room was still, and her bed was inhabited not by the woman I’d rounded on hours before, but by what she’d left behind. The gentle rustle of sheets, the whisper of breath, the scratch of pen against Sudoku puzzle had all gone. “Time of death, 2:30,” I pronounced, plainly, atonally. As I filled out the death certificate, silence engulfed the nursing station, becoming thicker and thicker until I could no longer hear the rain. Disclosure forms provided by the author are available with the full text of this article at NEJM.org. From the Department of Internal Medicine, University of Toronto, Toronto. DOI: 10.1056/NEJMp1305849 Copyright © 2013 Massachusetts Medical Society. Signal in the Noise
