An image-guided craniotomy ensued, yielding a cerebellar specimen. Photomicrographs of that specimen, at progressively higher magnification, follow:

The top picture exhibits normal cerebellar cytoarchitecture on the right giving way, on the left, to an internal granule cell layer that has transformed into larger gangliocytic neurons. The bottom picture demonstrates the cytologic appearance of these transformed ganglion cells.

This is an example of dysplastic cerebellar gangliocytoma, otherwise known as Lhermitte-Duclos disease (LDD). Dr. Peter Burger and colleagues, in their Surgical Pathology of the Nervous System and Its Coverings (4th edition, page 274), make this comment about LDD: “In the parlance of bird-watching, an endeavor with many similarities to surgical pathology, Lhermitte-Duclos disease is an entity not likely to be found on the ‘life-list’ of most pathologists.” Well, this rara avis is now on my life-list!

When I came upon this tumor, I immediately thought of Dr. Ty Abel (pictured to the left), neuropathologist at Vanderbilt, who in 2005 authored an immunohistochemical study of 31 cases of Lhermitte Duclos disease. I emailed him this question: “What is the current thinking on LDD? Is it a hamartoma or a neoplasm or something in between?”

Ty’s response: “Something in between may be the best answer. We suggested in our paper that it was a ‘hypertrophic phenomenon superimposed upon a developmental malformation’. Our observations, as well as those in Suzie Baker’s mouse model of this, suggest that aberrant signaling in the pathway disrupts granule cell migration as well as leading to their hypertrophy. Histologically, there is little proliferation, so the increase in tumor size over time may be due to cellular hypertrophy or to the abnormal myelinization of the molecular layer or both.Still, they do grow and sometimes come back after resection, making them tumor-like. Does your patient have evidence of Cowden’s?”

No, my patient does not have other clinical evidence of Cowden syndrome. But Ty put me in touch with a leading authority on Cowden syndrome at the Cleveland Clinic, Dr. Charis Eng (pictured to the right) who emailed me this comment: “What we found in our initial series is that adult-onset LDD is almost always associated with germline PTEN mutations, i.e., has Cowden syndrome.”

Whether or not this patient gets germline PTEN testing, she should be closely surveilled for breast, thyroid, and endometrial cancer, as there is a high incidence of these tumors in patients with Cowden syndrome.

And now a recut slide of this rare bird gets filed away in my teaching set, only to be let out of its cage again by the eager inquiry of a resident.

After dinner, a new attendant was on duty. He asked for the ticket. I said, “It’s the Chevy.” He said, “I’ll get it right away.”

I think they were happy to have it off their lot.

Actors are a Scala abstraction for multiprocessing. I’ve only really played with multiprocessing once, back in my waning days at Harvard. I tried writing some multithreaded Java code, and the results were pretty ugly. The code soon became cluttered with locks and unlocks and synchronized keywords, but my programs still locked up consistently. Multiple processes can be a real headache.

But, there’s also the benefit — especially since I have a brand new smoking fast oligoprocessor box (I keep some mystery in the precise number). Tools such as bowtie and BWA are multithreaded, but it would be useful to have some of the downstream data crunching tools enabled as well.

Actors are a high level abstraction which relies on message passing. Each Actor (or non-Actor process) communicates with other Actors by sending an object. The Actor figures out what sort of object has been thrown its way and acts on it. A given Actor will execute its tasks in the order given, but across the cast there is no guarantees; everything is asynchronous. Each Actor behaves as if it has its own thread, though in reality a pool of worker threads manages the execution of the Actors — threads tend to be heavyweight to start up, so this scheme minimizes that overhead and thereby encourages casts of millions — but I won’t emulate de Mille for some time.

My first round of experiments left me with new bruises — but I did come out on top. Some lessons learned are below.

First, get the screenplay nailed down as much as possible before involving the Actors. Debugging multithreaded code brings on its own headaches; don’t bring down that mess of trouble before you need to. For example, in the IDE I am using (Eclipse with the Scala plug-in, which some day I will rant about) if you hit a debugging breakpoint in one thread the others keep going. In my case, that meant a println statement from my master process saying “I’m waiting for an Actor to finish” — which kept printing and thereby prevented me from examining variables (because in Eclipse, if Console is being written to it automatically pops to center stage).

A corollary to this is after several iterations I had improved the algorithm so much it probably didn’t need Actors any more! I really should time it with 0, 1 and 2 Actors (and both permutations of 1 actor — the code runs in 3 stages and a single actor can do either the last one or the last two) — the code is about 2/3 of the way to enabling that. Actually, one reason I went through a final bit of algorithmic rethink was the fact that the Actor enabled code was still a time pig — the rethought version ran like a greased pig.

Second, remember the abstraction — everything is passed as messages and these messages may be processed asynchronously. More importantly, always pretend that the messages are being passed by some degree of copying. An early version of my code ignored this and had code trying to change an object which had been thrown to an Actor. This is a serious no-no and leads to unpredictable results. You give stage commands to your Actors and then let them work!

Third, make sure you let them finish reciting their lines! My first master thread didn’t bother to check if all the Actors were done — which led to all sorts of interesting run-to-run variation in output which was mystifying (until I realized it was the synchrony problem). Checking for being done isn’t trivial either. One way is to have a flag variable in your Actor which is set when it runs out of things to do. That’s good — as long as you can easily figure out how to set it. You can also look to see if an Actor is done processing messages — except checking for an empty mailbox doesn’t guarantee it is done processing that last message, only that it has picked it up. One approach that worked for my problem, since it is a simple pipelining exercise, is to have Actors throw “NOP” messages at themselves prior to doing any long process — especially when the master thread sends them a “FLUSH” command to mark the end of the input stream. Such No OPeration messages keep the mailbox full until it gets done with the real work.

So, I have a working production. I’ll be judicious in how I use this, as I have discovered the challenges (in addition to the problems I solved above, there is a way to send synchronous messages to Actors — which I could not get to behave). But, I am already thinking of the next Actor-based addition to some of my code — and my current treatment is pretty complicated. But, a plot snip here and a script change there and I should be ready for tryouts!

The Gordon and Betty Moore Foundation has teamed up with Sutter to explore means and methods to transform this multi-centered health care system to the next level of quality, safety, and patient-centeredness. Sutter has already done a lot of good work in these arenas, so the hope is to build on that an explore how to do still better and enhance the likely sustainability of the results.

Pictured here are Michael Dourgarian, a local businessperson who is Chair of the Board of this region of Sutter, and Karyn DiGiorgio, RN, MSN, Program Officer for the Moore Foundation. Not shown is Dr. John Mesic, Chief Medical Officer, who introduced me and has had a lot to do with the broader Sutter effort, and Sarah Marie Miller, who helped organize the retreat.

My job was to tell the story of BIDMC’s approach to quality and safety, transparency, process improvement, and patient and family involvement. As always, this prompted lots of good questions and interaction, as people considered what might be drawn from our experience and applied to their own, and as I did so in reverse from their comments.

Every now and then, he would hear of a patient, either local or international, who needed some sort of expensive medical treatment that was unaffordable for that person. Ray and his Medical Aid Foundation would provide funds for travel, treatment, and follow-up care — from conjoined twins to an Iraqi woman with a heart condition.

In spite of his not wanting attention, people wanted to recognize Ray. Here, for example, Catholic Charities gave him their Justice and Compassion Award, the first time Catholic Charities presented that award to a member of the Jewish community.

At the personal level, Ray was warm and thoughtful and engaging. He would call me from time to time with an idea or to offer support, and he was always polite and modest, never wanting to interfere or be an inconvenience.

He was beloved in our community and will be missed in so many ways.

Boiling down his proposal to a few sentences, Mr. Obama asked, “How many people would like a proposal that holds insurance companies more accountable? How many people would like to give Americans the same insurance choices that members of Congress get? And how many would like a proposal that brings down costs for everyone? That’s our proposal.”

Is that really the proposal?

As for holding insurance companies more accountable, a number of state insurance commissioners have their doubts, at least with regard to federal regulation of premium rate levels.

Will we have the same insurance choices as members of Congress? Well, maybe to the extent that they can choose from a number of plans, but that is not the full set of benefits to which they are entitled.

And, as for bringing down costs, every person in the industry knows that is just not true. David Brooks explains why in his op-ed today.

From the beginning, I pointed out that Mr. Obama was over-promising when he was offering (1) a reduction in health care costs; (2) an increase in access for people currently uninsured or under-insured; and (3) maintaining choice for people in their selection of doctors and hospitals.

Opposition to Mr. Obama’s plan is often characterized as a politically motivated attack from the Republicans. Certainly, some of that is true. But some portion of the opposition also arises from this kind of overstatement, which in turn generates mistrust or at least concern among educated members of the public.

Mr. Obama is betting, though, that his energy and passion will carry the day in motivating members of Congress in his own party to muster enough votes.

The Rx-360 Consortium announced the start of a pilot plan to allow pharmaceutical manufacturers to share audits of suppliers. The first part of the pilot is intended to gauge the value of sharing the existing body of supplier audit information that already exists within consortium member companies.  The consortium has an Audit Standards Working Group with 27 participants, representing 19 companies and organizations. The group is looking at standards for APIs, excipients, supply-chain security, basic chemicals, packaging, and print.

From the Rx-360 An International Pharmaceutical Supply Chain Consortium:

“Rx-360 is a consortium being developed by volunteers from the Pharmaceutical and Biotech industry which includes their suppliers. The purpose is to enhance the security of the pharmaceutical supply chain and to assure the quality and authenticity of the products moving through the supply chain. The individuals developing this concept are working in the best interest of patients. We are a non-profit organization with the mission to create and monitor a global quality system that meets the expectations of industry and regulators that assures patient safety by guaranteeing product quality and authenticity throughout the supply chain.”

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Here’s what I see. The dominant parties in the state on whose watch the disparities in the marketplace have taken place — Blue Cross Blue Shield and Partners Healthcare System — face financial and political problems, respectively. The PHS rates that are so much higher than others’ cause a major financial drain for BCBS. They do so in the short run just by the degree of current utilization. The effect is compounded over the long run, though, as PHS has a competitive advantage vis-à-vis other systems in recruiting community-based doctors and thereby brings more and more referrals into its hospitals. That these differentials have now been made public by the state creates a political embarrassment for PHS, which has often asserted that its creation brought about substantial economies of scale through integration of care.

I suspect that these factors will lead to a negotiated agreement between BCBS and PHS, where PHS takes a bit of a haircut in its current reimbursement contracts. Not so much that it dramatically affects the PHS bottom line, but enough so that both parties can say that they have cooperatively acted to slow down the rate of health care spending in the state. Will the new rates be anywhere near the statewide average? No way. Will they do anything to offset the competitive advantage that PHS has had or will continue to have? No.

Then, BCBS will come to the rest of us (including BIDMC and our physician group) whose rates are next in line and ask for a “comparable” rate reduction. Citing the PHS deal, we will be publicly and privately pressured to make similar concessions for the good of the Commonwealth. Of course, any such rate reduction would then serve to maintain PHS’ market dominance.

Here’s my proposal instead. Let us, in the presence of the state’s Attorney General, so there are no concerns about antitrust violations, all agree to rate schedules equal to the current statewide average reimbursement rates for hospitals and doctors.* Let’s create two major categories — one for academic medical centers and their doctors to reflect the societally important teaching role — and one for community hospitals and community-based physicians.**

In other words, let us recognize that the health care reimbursement system in Massachusetts is broken. It is time to get rid of the idea that rates should reflect market power. Have them instead reflect the health status of the population, with appropriate adders for medical education or other specific programs of societal value as directed by the state. Further, if the state and federal government insist on underpaying for Medicaid and Medicare patients, let us acknowledge that amount explicitly in the approved rates for the private insurers.

I know I don’t fully understand the insurance business, but I cannot figure out why BCBS and the other insurers in the state would object to this approach. I can’t see why it is to their advantage to conduct numerous negotiations for reimbursement rates or to have different rates in place for exactly the same services.

What about quality, you might ask? Well, it would certainly be great to adjust reimbursement rates for meaningful measurements of quality of care. But let’s start first by equalizing the base rates, and then we can work on quality metrics in the next step.

—
*Or if would make more sense, perhaps a different average would be employed for the Eastern and Western parts of the state, or urban versus rural areas, to reflect regional differences in the cost of living.
** While I make this point with regard to fee-for-service payments, it is certainly a prerequisite for a move towards the kind of global, or capitated payment recommended by the state’s Massachusetts Special Commission on the Health Care Payment System. As I have noted in an earlier post: If a capitated rate were established for PHS providers today based on this differential, it would perpetually reward this health care system for its market dominance.

There was also time for John to meet several of our supporters and doctors. Here, he is briefed by Maine businessman Bobby Monks and BIDMC doctor Dr. Steven Freedman,who have been working together to develop a new patient empowerment and involvement model called “Trust”.

Humorous note: Dr. Mark Zeidel, our chief of medicine, jokingly describes Trust as a template for patient-doctor interactions that would enable a husband to offer his wife a full, complete, and detailed summary of his visit with a doctor — as opposed to the stereotypical summation:

She, “What happened and what did he say?”
He, “It was fine.”