Friday, December 12, 2008

The Blagojevich complaint: hospitals and political corruption

The news about Governor Blagojevich's alleged corrupt behavior has focused, understandably, on his scams to try to get payback for Obama's Senate seat. Intrigued by some incidental details about a shakedown of a children's hospital CEO, I searched for the word "hospital" in the affidavit. It appears 22 times, with two separate incidents, the first being about a "Certificate of Need" for another hospital and the other being the Children's Memorial incident. The "Certificate of Need" saga will be familiar to those who were already following the Tony Rezko trial, but since I hadn't realized how deeply the Rezko trial was entangled in hospital construction, I include this along with the Children's Hospital CEO.

It's just a reminder that healthcare, perhaps the largest segment of our GDP, is just another industry, immune neither to shakedowns by the corrupt, or corruption of its own.

Here are the appearances of the word "hospital" in the affidavit.


The first group of references concerns a small hospital which a planning board staff felt was unnecessary because there were already plenty of hospitals in the area. The hospital chain wanted to build a hospital anyway. Imad Almanaseer, who provided the crucial vote from the planning board to overrule the staff recommendation not to allow the hospital to be built, is a physician. It was his vote that allowed political corruption to overrule any semblance of the sensible allocation of healthcare resources. For handy reference I've inserted the title "Doctor" before his name, although the affidavit does not do this in the original.

35. As described more fully in the following paragraphs, Mercy Hospital, which sought permission from the Planning Board to build a hospital in Illinois, received that permission through Rezko’s exercise of his influence at the Planning Board after Rezko was promised that Mercy Hospital would make a substantial campaign contribution to ROD BLAGOJEVICH. Rezko later told a member of the Planning Board that Mercy Hospital received the permit because ROD BLAGOJEVICH wanted the organization to receive the permit.

36. Levine’s criminal activities included his abuse of his position on the Planning Board to enrich both himself and Friends of Blagojevich. The Planning Board was a commission of the State of Illinois, established by statute, whose members were appointed by the Governor of the State of Illinois. At the relevant time period, the Planning Board consisted of nine individuals. State law required an entity seeking to build a hospital, medical office building, or other medical facility in Illinois to obtain a permit, known as a “Certificate of Need” (“CON”), from the Planning Board prior to beginning construction.

37. Levine, as well as Planning Board members Thomas Beck and [Dr.] Imad Almanaseer, testified under oath at the Rezko Trial. Beck testified that he asked Rezko to reappoint him to the Planning Board and that Beck thereafter followed Rezko’s directions regarding which CON applications Rezko wanted approved. Beck testified that it was his job to communicate Rezko’s interest in particular CONs to other members of the Planning Board, including [Dr.] Almanaseer, who were loyal to Rezko. Beck testified that he understood that Rezko spoke for the Blagojevich administration when Rezko spoke to Beck about particular CONs. [Dr.] Almanaseer testified that Beck instructed him that Rezko wanted [Dr.] Almanaseer to vote a particular way and that [Dr.] Almanaseer should follow Levine’s lead in voting on CONs. [Dr.] Almanaseer testified that before certain Planning Board meetings, he received notecards from Beck indicating how to vote on certain CON applications. Beck testified he provided these notecards to [Dr.] Almanaseer and certain other members of the Planning Board to communicate Rezko’s directions about certain CON applications.

38. During his testimony, Levine described a plan to manipulate the Planning Board to enrich himself and Friends of Blagojevich. The plan centered on an entity commonly known as Mercy Hospital (“Mercy”) that was attempting to obtain a CON to build a new hospital in Illinois. Levine knew the contractor hired to help build the hospital. In approximately November 2003, on behalf of the contractor, Levine checked with Rezko to determine whether Rezko wanted Mercy to obtain its CON. Rezko informed Levine that Mercy was not going to receive its CON. According to Levine, he asked Rezko whether it would matter to Rezko if Mercy’s construction contractor paid a bribe to Rezko and Levine and, in addition, made a contribution to ROD BLAGOJEVICH. Levine testified that Rezko indicated that such an arrangement would change his view on the Mercy CON.

39. Levine’s testimony regarding Rezko’s actions to change the Planning Board decision concerning Mercy’s application for a CON based on contributions for ROD BLAGOJEVICH is confirmed by attorney Steven Loren. Loren testified at Rezko’s criminal trial and, before that, in the grand jury. According to Loren, in approximately December 2003, Levine informed Loren that Rezko was against the Mercy CON. According to Loren, Levine relayed to Loren a conversation between Rezko and Levine during which Levine asked Rezko whether a political contribution to ROD BLAGOJEVICH would make a difference for Mercy’s CON, and Rezko responded to Levine that such a contribution might make a difference.

40. Thereafter, and confirmed by the testimony of Levine, Beck, and [Dr.] Almanaseer, as well as recorded conversations, Rezko switched his directions to Beck and informed Beck that Mercy was to receive its CON. According to [Dr.] Almanaseer, although he previously had been told by Beck that Rezko did not want Mercy to receive its CON, he was later told that there had been a change and that Rezko now wanted Mercy to receive its CON.

41. Mercy received its CON as a result of a controversial and irregular vote at a public Planning Board meeting. [footnote: There was extensive testimony regarding the irregularity of the vote at the Planning Board meeting. In summary, during the vote, Levine got up from his seat and went to speak to Beck and to [Dr.] Almanaseer. After these discussions, [Dr.] Almanaseer then changed his vote to be in favor of Mercy receiving its CON. Beck then voted in favor as well and by a vote of 5 to 4, Mercy’s application for a CON passed.] The vote brought significant publicity to the Planning Board and ultimately led to the disbanding of the Planning Board. [Dr.] Almanaseer testified under oath in the grand jury that not long after the Planning Board vote on Mercy’s CON he saw Rezko at a fundraiser. According to [Dr.] Almanaseer, he was still embarrassed about what had occurred at the Planning Board vote on Mercy’s CON and Rezko’s role in the vote. [Dr.] Almanaseer testified that he asked Rezko why Rezko had switched the vote on the Mercy CON. According to Almanaseer, Rezko stated: “The Governor wanted it to pass.” [Dr.] Almanaseer understood the reference to “Governor” to be a reference to ROD BLAGOJEVICH.

[Before moving on, let's celebrate the internet's ability to provide some historical context, here from Crain's Chicago Business. Here's an excerpt from a 2004 article I found about the original decision:

Mr. Levine and Jacob Kiferbaum, president of Deerfield-based Kiferbaum Construction Corp., serve together as trustees of Rosalind Franklin University of Medicine and Science, formerly known as Chicago Medical School. Mr. Kiferbaum also contributed $45,000 to former state Attorney General Jim Ryan's 2002 campaign for governor, for which Mr. Levine served as finance director.

Mr. Levine, an attorney and investor from Highland Park, didn't return calls seeking comment for this story. A transcript of the April 21 meeting shows he led the board in discussing the Mercy application, encouraging members to vote in favor of the hospital and to disregard approval criteria he called "hopelessly outdated.''

During the roll call vote on the application, Mr. Levine voted for approval and walked across the room to talk with Imad Y. Almanaseer, a Glenview physician, who had abstained, according to two people who attended the meeting. After the conversation with Mr. Levine, Dr. Almanaseer changed his vote to "yes,'' giving the Mercy project the fifth vote needed for approval.

Dr. Almanaseer is resigning from the board July 1, when his term expires. He didn't return calls last week, but in an interview several weeks ago, he denied feeling pressured to vote in favor of Mercy.

"I honestly don't feel it,'' he said. "(Mercy) made a case for the need for more physicians in that area, and we agreed.'']


The second group of references comes in relationship to the desire of the governor to exchange an increase in reimbursements for pediatric care for a campaign contribution from a Children's Hospital CEO:

65. According to Individual A, on October 8, 2008, during a discussion of fundraising from various individuals and entities, the discussion turned to Children’s Memorial Hospital, and ROD BLAGOJEVICH told Individual A words to the effect of “I’m going to do $8 million for them. I want to get [Hospital Executive 1] for 50.” Individual A understood this to be a reference to a desire to obtain a $50,000 campaign contribution from Hospital Executive 1, the Chief Executive Officer of Children’s Memorial Hospital. Individual A said that he/she understood ROD BLAGOJEVICH’s reference to $8 million to relate to his recent commitment to obtain for Children’s Memorial Hospital $8 million in state funds through some type of pediatric care reimbursement. As described in further detail below, intercepted phone conversations between ROD BLAGOJEVICH and others indicate that ROD BLAGOJEVICH is contemplating rescinding his commitment of state funds to benefit Children’s Memorial Hospital because Hospital Executive 1 has not made a recent campaign contribution to ROD BLAGOJEVICH.

66. According to Individual A, during this same meeting, ROD BLAGOJEVICH began discussing recent media reports about the possibility that Antoin “Tony” Rezko was cooperating with the government. According to Individual A, at one point in the
conversation, ROD BLAGOJEVICH said words to the effect that he was not concerned about Rezko’s cooperation because he was not involved in illegal activity with Rezko. According to the Individual A, Fundraiser A then said words to the effect of, “unless
prospectively somebody gets you on a wire.”

a. On the morning of November 12, 2008, ROD BLAGOJEVICH talked to Fundraiser A. During the course of the conversation, which principally concerned the status of campaign fundraising efforts, Fundraiser A told ROD BLAGOJEVICH that Fundraiser A had never heard from Hospital Executive 1. Fundraiser A said, “I’ve left three messages there so I’m gonna quit calling. I feel stupid now.” ROD BLAGOJEVICH asked when the most recent call was, and Fundraiser A replied that it was two days ago. ROD BLAGOJEVICH said that if “they don’t get back to you, then, then, last resort is, I’ll call.”

b. Later on November 12, 2008, at approximately 2:14 p.m., ROD BLAGOJEVICH spoke with Deputy Governor A, a Deputy Governor of the State of Illinois. The following exchange began the conversation:
ROD BLAGOJEVICH: The pediatric doctors – the reimbursement. Has that gone out yet, or is that still on hold?”
DEPUTY GOVERNOR A: The rate increase?
DEPUTY GOVERNOR A: It’s January 1.
ROD BLAGOJEVICH: And we have total discretion over it?
ROD BLAGOJEVICH: We could pull it back if we needed to – budgetary
concerns – right?
DEPUTY GOVERNOR A: We sure could. Yep.
ROD BLAGOJEVICH: Ok. That’s good to know.

c. On November 12, 2008, at approximately 8:26 p.m., Fundraiser A called ROD BLAGOJEVICH and reported the status of fundraising efforts. During the conversation ROD BLAGOJEVICH instructed Fundraiser A to call Lobbyist 1 the following day and ask Lobbyist 1 what to do about the fact that Hospital Executive 1 is not calling Fundraiser A back and inquire whether it was possible that Individual A had instructed Hospital Executive 1 not to call back (see Paragraph 65). ROD BLAGOJEVICH asked, “what do we do with this guy, [Hospital Executive 1]?”

d. On November 13, 2008, at approximately 10:05 a.m., ROD BLAGOJEVICH talked with Fundraiser A. The discussion concerned the status of fundraising efforts. During this call, ROD BLAGOJEVICH asked about Highway Contractor 1. Fundraiser A stated that Lobbyist 1 is still working with Highway Contractor 1. Fundraiser A also advised ROD BLAGOJEVICH that he will be meeting Lobbyist 2 to meet with an individual at Weiss Memorial Hospital. ROD BLAGOJEVICH states: “Yeah, now be real careful there. I mean, the FBI went to see [Lobbyist 2]. You understand?” Fundraiser A also said that he had a call into Individual A and that Fundraiser A will talk to Individual A about Hospital Executive 1.

g. On November 14, 2008, ROD BLAGOJEVICH talked to Fundraiser A. During the conversation Fundraiser A told ROD BLAGOJEVICH that he had spoken with Individual A, and that ROD BLAGOJEVICH needed to call Hospital Executive 1. ROD BLAGOJEVICH said that he would call him.

Thursday, December 11, 2008

variation on a theme: romance of long hours

written post-call after a long ICU shift, which after I wrote it I realize is a reworking of some things I've written before

I used to work at a public health job, working for the city, with good benefits, and time to go to the gym before going home to make myself dinner. When I started talking about becoming a doctor, a lot of people said that was nuts, most of all some doctors who looked back on their experience bitterly. Others were more encouraging, and I chose medicine.

I have no idea what my life would have been like if I hadn't chosen medicine; but what I usually tell people is that although I've sometimes been exhausted or miserable or depressed or discouraged, I've almost never been bored. I hated being bored at work. Now I'm not bored.

But aside from medical training being totally absorbing, part of the dirty little secret of long work hours is that it is part of a romance that doctors and patients have with each other. Many of my patients look at me sympathetically and ask whether I ever go home, and even shake their heads over my working conditions. But many of them also seem to sort of appreciate the romantic idea that I'm some sort of insanely dedicated nut who cares only about helping people and has no life other than worrying about their telemetry alarms. I'm there all night, yes; but I'm there for them.

On the flip side, as I'm complaining to my friends with regular jobs, I'm also a little proud of myself for making a different choice. I joined the few and the proud; my life is full of drama and a sense of importance. In the dark early morning hours in my academic hospital, the halls begin sputtering with the energy of people working really hard to become who they are going to become. That's kind of beautiful, and I am proud to be a part of it. And, though usually I would only tell my mom this, I'm proud of myself. I'm proud of myself for choosing something tough. This is a common impulse: it is the basic idea of most military recruiting pitches, and it has worked to convince people to do difficult or even insane things for many generations before this one.

When I worked in a regular job, I felt that my life lacked significance or importance somehow, even though I was doing important work. That was because I lacked this sense of drama.

The sense of drama that draws doctors to our training--even as the conditions that make our training dramatic also sometimes make us bitter or depressed--is probably in the end a fiendish tool of The Man to make us work harder for cheaper, and like it.

It's also part of how doctors become self-justifying later; other people can just suck up whatever hardship they face, because we did. (As if a few years of earning an average American wage and working insane hours in preparation for joining the top tier of wage-earners and gaining inestimable social prestige is really a form of enduring suffering.)

Change won't occur until the rest of the society stops appreciating the beauty and the drama of the dedication that the medical training process represents, and starts viewing residents as participants in a high-stakes industrial process that must eliminate systemic sources of error. But the latter view is much less romantic, and much less beautiful.

For almost everyone involved, it is more emotionally satisfying and less safe to romanticize the difficulty of medical training. Perhaps this is not surprising: in many other parts of life, emotional appeal often wins out over sensible decisions. But that appeal is part of why doctors choose this life; and I think that the romance of the doctor as a special breed of person is part of what seduces patients of academic hospitals into accepting a system that is not always designed in their best interest.

Friday, December 5, 2008

Cat and mouse and us

The Hemodynamic Cat battling a swinging light switch, photos by Ms. Dr. Hemodynamics; the HC in a quiet time.

Recently, the Hemodynamic Cat did something surprising: she caught a mouse.

I would like to say that I have never doubted the Hemodynamic Cat's mouse-catching abilities, but this is not the case. She spends a lot of time pouncing on and batting around her toy mice, in a way that suggests some inner ferocity. But her record on watching cockroaches with interest rather than hitting them, and her failure to show any evidence of actual mouse-catching, left me a little skeptical. I've come to love the HC for other reasons.

Recently, I was coming to bed and saw that the HC had a mouse in front of her, and was looking up at me expectantly, as she sometimes does when she wants me to play with her and her toy mice. Then I looked more closely and saw that it was too thin and small to be one of her toys; and that in fact it was breathing.

My experiences in an immunology lab left me well-prepared for this moment; I picked up the mouse by its tail, and eventually delivered it to a warm spot outside our apartment where I hoped it might be able to recover and go on living outside our apartment. It wasn't moving much, and I thought about more definitively snapping its neck--to finish the job that the HC had clearly started and end its suffering--but I wasn't sure that it might not be able to rally once no longer stressed and stunned, so I left it. I later found it definitively dead, in the same spot. The HC had killed the mouse.

I know that some cat owners think that the cat's habit of bringing dispatched prey to display to their owner is some outgrowth of wild cat mothering habits. In terms of the original wiring for the behavior, that's probably true--there has to be some "little tasty things I don't eat right away" circuit available to build on. But the wild forebears of domestic dogs also feed their puppies, and domestic dogs don't make a point of sharing their catch with their people in the same way that cats do.

I've always thought that this behavior is actually part of the social contract that cats and people developed with the origins of agricultural society. Recent genetic work confirms what can be surmised from history, archaeology, and anthropology: cats go with agriculture, not with hunting and gathering. When people started having grain silos, field mice started becoming silo mice, moving to where the concentrated bounty of the fields were stored. Cats followed the mice.

This seems like the moment in which the "show the mice" strategy would have been most useful. The social bond would not have come first, and so the showing of the mice is not a process of mistaking people for kittens. It is an act of seeking patronage. A cat who just seemed to wander around the village but did not show the mice she caught to anyone might be tolerated or even enjoyed. But I'm not sure that early agrarian societies would have put much energy into caring for that cat.

On the other hand, the cat who comes to the peasant farmer, drops mice at the door, and meows loudly with enthusiasm, is saying, "I am worth keeping around." What the cat loses in protein from the mouse not eaten, she gains in protein from the people who want to encourage her mouse-killing. People, and especially grain-farming people, want cats to kill many more mice than they need to support themselves; they want cats to kill every mouse in sight. The cat that brings mice is showing her dedication to this shared mission. The cats that are also social and charming get to live inside and sleep next to the warm bodies of the giant primates, but the "show the mouse" strategy might well have been the first step in the evolution of cat domestication.

Cat experts sometimes say that cats, unlike other domestic animals, domesticated themselves. This explains their more ambivalent attitude about human attention; cats have eliminated only the wildness that kept them out of the house, and sometimes not even that. The Hemodynamic Cat, her ancestors having been bred for the company of princesses, is an extremely social creature with the people she knows, but she still has a wariness of new people that shows the not-so-ancient wild cat inside her.

As I held the mouse by its tail, its lungs expanded and contracted and its little legs kicked. In retrospect, given that the mouse could not get up and walk anywhere after I set it down, I think the legs kicking might have been a lower spinal cord reflex arc. Maybe if something grabs a mouse's tail there is no need to wait for the brain to tell the leg muscles to start making running motions; but the mouse needs the brain to communicate with the spinal cord in order to coordinate its movements. A mouse is a tiny thing, but with all the wonder of mammalian evolution, and of its own special qualities. From scores of dissections, I could imagine its heart; its thin, wide diaphragm; and, as I found again and again in the lab, its comparatively large spleen, full of blood and immune cells. I didn't want to touch its fur--I didn't want to give it a chance to turn and bite me--but I could remember what touching a mouse felt like, the warm softness of it, the vitality of the quick-moving lungs and heart. The mouse was beautiful, as all mice are, and I mourned its demise.

Still, I don't want mice eating our food and having the run of our house. And so when the Hemodynamic Cat looked up at me, with the little gray field mouse breathing but laying still in front of her, I saw our cat with a new respect, and felt something ancient: our cat was earning her keep.

Our social contract forged between two species, once seemingly consisting only of bonds of affection, had renewed its ancient preamble. I had thought that I loved the Hemodynamic Cat for her inherent value as a creature, and for her love of us, whether or not she caught mice. As I took the mouse out of the apartment, I realized that I now not only loved her, but respected her in a new way. Good job, I told the Hemodynamic Cat, and she said, "Mrowww!" back. I had killed mice for science. The Hemodynamic Cat had done something much more intimate and powerful: she killed a mouse for us.