Sep 022014
 

You never know what will happen after a chicken salad sandwich. As it turns out, that was not the problem. The real problem caused me to have some unexpected abdominal surgery and spend time experiencing first-hand the fabulous care provided by physicians, nurses and staff from the Brody School of Medicine and our partners at Vidant Medical Center.

Why I’ve disappeared is not important right now, except that in many ways this absence has been a gift as I have regained insight

  • about our profession,
  • of our hospital,
  • about our health care system,
  • about my own physiology.

There is no need to address the specifics for now. Just know that I am on the mend and your generous support has been keenly felt. Please accept heartfelt thanks to all of you, for both myself and my family. It has been a long journey but quite an adventure. I am looking forward to returning to Brody and to the incredibly important and noble work we all do. I don’t know exactly when that will be. I am allowing my daily recovery and improvement to dictate the exact timing. I am in regular communication with university and Brody leaders and have every confidence in them and you to keep Brody moving forward.

As you know, it is not my style to provide answers but to open a conversation. So, here are a few intriguing questions, particularly for our medical students:

  1. What does it mean when a patient uses large quantities of potassium and phosphate?
  2. Describe the pros and cons for the use of a nasogastric tube.
  3. What is the first convincing sign of relief of a bowel obstruction?

When you have a moment, come see me and I’ll tell you the rest of the story.

Paul

Jul 172014
 

Hello Brody Pirates,

As I write this, there are a whole variety of activities and happenings that are influencing my thoughts.

Recently, we all experienced the Fourth of July annual celebration. This national holiday accents the real significance of one of the most profound developments in the history of our country. During these festivities, there are those of our colleagues who were “on call” and otherwise serving the citizens of eastern North Carolina. Even then, there was time to reflect on all of our relationships, including those close to us. I would include our personal families as well as the members of our professional teams. What are the unmet personal goals and ambitions that are only possible based on the culture and country that we live in? In what ways does all of this thoughtfulness bring meaning to the Brody School of Medicine as we support our mission?

It is easy to find a simple answer. In real terms, all that is necessary is that we work hard and serve well. Of course, the challenge is to apply this approach to every day experience, with all practical detail. Achieving clarity in our real world context demands much in the way of careful thought and implementation.

About two months ago, I received an email unexpectedly. It came from one of my patients who had a kidney transplant about 28 years ago. The patient and her kidney are in really great condition.

My patient and her dog, UsherThis remarkable grandmother has given me permission to post her picture here, and is in remarkably good health. She admitted that the secret to her success lay in the regular consumption of cherry pie, washed down with a popular fermented beverage. One has to eat the whole pie to assure success, she admitted!

You may share my skepticism that this is not the whole answer to her success. For certain, she has a vibrant sense of humor. Maybe it is the fact that she continues to work and engage life in the most positive manner that has contributed to her success.

For certain, there are more biologically complex and profound answers to this survival experience that we have not yet discovered.

There are similarities with a complex set of conversations that we are having within the School. As an example, the leadership team of both Vidant and the Brody School of Medicine met recently for an hour to engage in a discussion of two complex and challenging clinical cases.

The group attempted to resolve and explain some unexpected outcomes and came up with many plausible answers for the issues that were presented. The conversation was emblematic of the complexity of many of our processes. When faced with these complexities, we typically apply basic principles and then venture well beyond. There are many other applicable dimensions to consider, including human factors and behaviors, interdependent medical processes and extrapolated assumptions based on biological diversity.  The best minds use all of this information in creating opinions and the necessary solutions. Even then, this is sometimes just the beginning of an even more complex process.

Unavoidably however, it is human nature to look for the simplest of answers. It takes real world experience and professional discipline to find the very best explanations.

Our tripartite mission here at “the Brody” simply defines the priorities. It takes constant attention to the contemporary dynamics of medicine for our mission to refresh and remain relevant.

Best regards,

Paul

Jun 182014
 

Hello!

This will be a part of an ongoing conversation that I will be having with you. Yesterday, the Chancellor distributed a memorandum to the Brody faculty and staff. I most certainly echo all that he has said. I also wanted to let you know a bit about how we are working to sustain our missions of education and service to the region.

First thing – we must continue to recognize that we have been very successful in creating primary care doctors for North Carolina and supporting a mission of service over the years.

We contribute mightily to the research efforts of the university. We provide quality health services to an increasing number of patients who do not have the ability to pay for their health care, and are recognized as a transformational force in the region.

These facts have been heralded by others at local, regional and national levels.

At the same time, we are all aware that health care is undergoing a transformation and, as a result, we must also change.

In recent years, we have been significantly challenged to continue to provide excellence in education and clinical service to all people of our region.

In the last five years, Brody has absorbed a cumulative, permanent state budget cut of $9.2 million, or nearly 19 percent of our state funding. These cuts mean we have had to teach our students and take care of our patients with fewer resources.   Losses in funding for support staff and operations has made it more difficult and costly to hire and retain qualified employees, to keep essential basic functions operating smoothly, and to keep needed medical equipment up-to-date.

Much of the shortfall resulting from these legislative cuts was able to be “back-filled” with money from the ECU Physicians practice.  More recently, our ability to continue to backfill through our faculty practice has been further compromised seriously by legislative actions, which have effectively eliminated millions of dollars from our previous and future practice revenue.

We are working very diligently on efforts to convince policymakers and payers to alter actions they have already taken, and to change or abandon consideration of additional actions that are harmful to Brody’s financial sustainability. Proactively, and on a daily basis, we are informing and educating key leaders about the impacts of their decisions on Brody. Although that work will continue very aggressively, we must concentrate most of our efforts on those things we can impact directly – the Brody School of Medicine and ECU Physicians practice.

Realizing that this compounding series of factors were coming together to fundamentally alter the historical environment in which Brody has operated, I and members of my senior leadership team have been working with department chairs and external consultants to conduct a comprehensive analysis of the school’s operations and funding sources, and those of the ECU Physicians practice. Our goal was to develop a detailed understanding of our current situation and the factors that contributed to today’s reality, as well as a very clear vision of where we need to go as an institution in order to secure a bright future for the school while becoming more self-reliant in the process.

Early in 2013, we hired Hunter Partners, a consulting group specializing in the issues we face, to help us conduct an extensive evaluation of the ECU practice plan and make recommendations for how we might best position ourselves to continue our success.

We have some outstanding and extraordinarily productive faculty. That productivity is in clinical practice, in education and in research. I intend to publicly recognize and celebrate these most vital individuals.  What we have also found is that these super-performers are often not just under-appreciated, but they are also under-compensated for what they do. Once firmly underway, the transformation and restructuring of Brody and ECUP will allow us to include appropriate increases in compensation to reflect the disproportionate contribution these high-achievers make.  To these high-performers, I ask that you continue your great work and actively engage your colleagues to encourage them to emulate you.

We also have found that the majority of people are solid performers who consistently contribute to the Brody mission.  To you, I say thank you!  You are the sturdy backbone of our school and practice plan. Please continue your good work.  I appreciate everything you do. Additionally, I ask you to identify ways – big and small; personally or systemically – that will help improve what we do and how we do it. If your insights can help us find ways to mentor and inspire one more student, care for one more patient in a day, seek another opportunity to secure a research grant, or implement myriad other enhancements, you will be helping to meet the challenge we all face.

There are also a small number of under productive faculty, and these will need to be coached, and monitored. Compensation will be adjusted accordingly.

Change for Brody provides an opportunity for all of us – faculty and staff, as well as our extended university family and the community – to imagine and build our future together.

The Brody School of Medicine is neither alone nor the first medical school to undergo transformational change. Emory University School of Medicine, Wake Forest Baptist Medical Center and a peer community-based medical school, University of South Carolina School of Medicine, have all begun significant restructuring in order to position themselves for the changes affecting all of us.  Mergers, acquisitions, integration of clinical practices, “right-sizing” and new management arrangements are everywhere one turns.

Four decades ago, when the ECU School of Medicine was created, a tripartite mission was clearly established and has become deeply rooted within our values and our daily work.

Today, in the midst of tectonic shifts in health care and medical education, and increasing pressure on state funding and practice revenue, our vision remains clear and our mission remains constant.  Brody is and will remain dedicated to training our doctors and treating our citizens.

While we remain dedicated to our mission, we must adjust how we are organized and how we operate to accommodate today’s realities.

It is important to know that in every way possible, the decision to take an action is objective – based on analysis of our own data, as well as review of the evidence and peer-based benchmarks. I ask your full support to implement them.

We will continue working very hard to educate leaders in Raleigh about the value and critical nature of retaining the Medicaid Upper Payment Limit, or UPL, and SODCA, for ECUP’s financial stability.

Concurrently, chairs and senior leaders in my office are working to determine how best to operate ECUP practices to improve patient access to care, effectiveness and efficiency, patient satisfaction, and revenue optimization, along with anything else within our control.

We are carefully reviewing positions funded by the practice plan, and considering where this funding is appropriate, and in some cases, looking for other funding arrangements or opportunities to right size our clinical enterprise.

This work is being done thoughtfully, and with attention to medical school and residency accreditation requirements, the most prevalent medical conditions in our region, and the historical profitability of the unit.  We have established principles that help us define what is core to the function of our school.

Our clinical operations must become more efficient and consistent.  So, we have brought in Ms. Deb Brown to serve as Interim Clinical Operations Director.  Ms. Brown has experience in working with academic practice plans all over the country to successfully make the same kinds of changes and improvements she is beginning to implement here.

The changes and actions we are implementing are designed to improve patient satisfaction and health outcomes. We believe that the changes, when implemented, will lead to increased productivity and enhanced revenues that are important to support the missions of our school.  We also are focusing on measures that are aimed at assuring a high level of faculty and staff vitality and satisfaction.

More information is available by visiting “Preserving the Mission” on the Brody Web page. If you have questions or comments – either specific to your personal situation or more general in nature – you will have an opportunity to privately submit your question or comment to be addressed.

My colleagues and friends, there is no way to be less than fully transparent about the challenges we face and the concerted actions we must take. We do these things to prepare for the future of health care in eastern North Carolina. The Brody School of Medicine will remain the leader for improving the health of our population and for increasing access to care for our fellow eastern North Carolinians.

I ask you to join me in shaping an exciting future for our school and practice, so we can continue to serve the citizens of this state through excellence in education and clinical care!

Thank you.

May 222014
 

This time I am not talking about the Black River in Jamaica. It’s the one in Watertown, Upstate New York. Google them; they are completely different. Guess which one freezes in the winter?

Have you ever been white water rafting? I’ve been twice – once on the Nantahala near Bryson City in western North Carolina and the other time on the Black River in Watertown. I don’t think that I am going to repeat any of these experiences anytime soon. Falling out of the raft is not a good thing and working the rapids is for much less “mature” folks!

Dr. Cunningham and his wife, Sydney, on a whitewater rafting trip in upstate New York.

See the picture. My dear wife Sydney is at the prow of the raft, loving every minute. Where is her oar? Is it anywhere near the water? There am I amidships. Please look at the facial expression. Where is the oar? Digging deep in the water?

The helmsman was an Air Force pilot who did this job in the summer. Foolishly, to my judgment, he seemed to relish taking a group of complete strangers down a river that we would soon find out presented some seriously treacherous technical stretches. There was this place downstream where an old dam used to exist. All that was left was a submerged slab of concrete to the left bank of the river and a precipitous fall-off to the right. Across the chasm, as we could clearly see, was a cave in the wall of rock that turned the river sharply, to then plunge into a canyon beyond. Just as we arrived at the dam, we were told that the eddy current within the cave was strong enough to hold a raft in its grip indefinitely. Casually, our guide admitted that some had died there.

The helmsman barked sharp instructions: “Dig when I say so!” We maneuvered to the left bank of the river and awaited our turn. The raft ahead of us spun helplessly, it seemed, and sluiced over the slab of concrete, going backwards over the falls. All of us gasped in horror, and those in the doomed craft screamed and vanished!

Miraculously, we soon recognized that they were not sucked into the cave.

We were next.

I am here to tell the story, so, clearly, we all survived. Sydney had a wonderful time. I could barely walk when we finally pulled out for lunch; I was so physically and mentally exhausted.

I learned many lessons that day. Trust your helmsman, especially if he has done some of the same work before. It is even more compelling if he is the only helmsman that you have. It is okay to rely on perfect strangers. And make sure that you listen to precise instructions and DIG!

Some of these lessons are allegorical and related to life in general. The river flows irresistibly in one direction only. We are in the forward-moving current of life.  We will experience smooth sailing some days, and then there are both the expected and unexpected challenges that crop up. It’s all an unavoidable part of the experience.

Where there is a will and there is the skill, there is a way. Some will enjoy the ride. But for some occasions, the job is all about digging deep, all oars in the water, and being sure to avoid the eddy currents.

Take care, and that reminds me – wear sunscreen y’all!

Paul