Local Hero

By Marie Shields, Editor

As a community leader in his own Boston neighborhood, Brigham and Women’s Hospital President Gary Gottlieb works to correct healthcare disparities at the grassroots level. But as Marie Shields finds out, he hasn’t lost sight of the need for reform on a grander scale.

“The emphasis on near universal population access to insurance and appropriate healthcare, not only in moments of crisis, is a splendid and wonderful vision”
-Gary Gottlieb, President, Brigham and Women's

It happened because Gary Gottlieb told the mayor of Boston exactly what he thought. Not about the mayor’s method of running the city, but about what he saw as an opportunity to improve the lives of its large immigrant community. Very soon afterward Gottlieb, who is President of Brigham and Women’s Hospital, was asked to head up the Workforce Investment Board, part of the mayor’s Private Industry Council. The board, comprised of leaders from business, education, government, labor and the community, oversees the distribution of public workforce development funds, charters Boston’s three one-stop career centers and works through them to implement workforce development strategies.

The board plays a key role in encouraging and improving education in the city, as Gottlieb explains, “It’s the way in which all federal and state workforce dollars are channelled into the city, and it has several elements. One is a compact with the public school district on creating pipelines to improve the completion of public education, creating linkages to post-secondary higher education, increasing graduation rates and reducing dropout rates. It also creates training programs that start with summer jobs in a variety of specific programs that create opportunity in various industries. It’s a combination of CEOs, union leaders and key public entities.

“The other element relates to career centers that support people who are unemployed, training components that create pipelines for the under-skilled, and English language learning opportunities for immigrant populations to be trained in various industries. I’ve used some of the assets and things I’ve learned there to help to create access to the Brigham as a major employer, as well as a set of career paths for people even at the entry level or pre-entry level from our communities.”

It’s a role he clearly enjoys. His original involvement was founded on the notion of enlightened self interest: the realization that he could do good and do well simultaneously. “If you look at the population base in Boston and nearby southeastern Massachusetts, it’s relatively flat in terms of growth. The only real growth is in immigrant populations. Our businesses have been developing remarkably in terms of doing more sophisticated and technical business, and there’s a very substantial skills gap between the level of training the people in the community have and the level of training, and particularly post-secondary training, that’s necessary to do the type of work we have now and what we’ll need in the future.

“The notion of being able to embrace our community, which is a critical part of the mission of the institution, and at the same time, to be able to help deal with some of the long-term employment needs and improve people’s lives seemed to me to be a terrific opportunity.”

Challenging times
Since becoming President of Brigham and Women’s in 2002, Gottlieb has faced a number of opportunities and challenges, as he explains, “Bringing all of the parties together to share a vision around how to deliver on the tripartite mission that we have in the context of a very, very dynamic healthcare marketplace and changes in the demands related to discovery and science and funding, as well as the way that providers are trained; I would say that those have been both the challenges and the opportunities. There’s been real dynamism in all those areas, and at the same time, they all require substantial attention.

“It’s been my responsibility to convey to people that all three legs of that stool are critical to our being able to deliver on our promise and our mission, and we’ve been successful in honing that focus. Each of those areas has improved in some remarkable way, and we’ve been able to justify the investments we’ve made in the enterprise, whether they’ve been physical capital investments or investments in people around making certain that we could deliver better on our fiduciary responsibilities.”

The healthcare sector is also facing challenges on a national level, with the introduction of President Obama’s healthcare reforms. Gottlieb supports the President’s vision, but points out that any changes must be made carefully and with great delicacy.

“President Obama has expressed a vision for healthcare reform and created placeholders for funding its reform, and that vision is inspiring. The emphasis on near universal population access to insurance and appropriate healthcare, not only in moments of crisis, is wonderful.

“Given that the cost of healthcare has inflated so remarkably as a proportion of gross domestic product, the concerns about the impact that creating universal access will have on government and business – because at the moment we still have employer-based insurances – are reasonable because we don’t want to create a fiscal drag.

“At the same time, healthcare is driving the employment base, and to disrupt that will have substantial secondary and unanticipated ramifications unless it’s done thoughtfully. It’s also driving entities like the Brigham, and Mass General, and others where science is embedded in the care that we do. IT is driving the growth of the United States as a powerhouse in biotechnologies, in the life sciences where we remain a discovery leader and in the development of new cures to illnesses.

“There is a narrow ledge that one has to walk along in regard to how these plans are implemented, but the vision is inspiring, and to have somebody truly taking this on and not shirking the responsibility to make certain that people in the United States ultimately have the best healthcare in the world is critical.”

Gottlieb agrees strongly that there need to be greater efficiencies. He points out that the nature of the relationship between payers and hospitals causes substantial inefficiencies, “We’re doing retail transactional business, where we have to hire substantial parts of overhead to make sure that we get paid for what we’re doing, and additionally, the incentives that have been created for the long run in indemnity-based insurances, in Medicare, have had some perversions associated with them. We have to narrowly walk along the line to reduce either those that lead to more care being produced for no reason – provider-induced demand; or those that create inappropriate barriers to access to care, as we saw during the years of capitation.”

Electronic records
One aspect of the reform proposals revolves around the nationwide conversion of patient records to electronic form. Gottlieb says this won’t pose any problems for BWH, “One hundred percent of our primary care doctors are on computerized records and all of our specialists will be using only e-prescribing and will be on electronic health records by the end of the year. Virtually our entire network in the Partners HealthCare system requires one to have adopted one of two electronic health records several years ago. We’ve already had people leave the network because they were not on electronic records in time. That was a deadline that we had in the past year for the whole system, specialists and primary care doctors.

“The question is what is the cost of local implementation and training beyond just the individual costs, because how those then affect the ability to simultaneously deliver care during implementation will be critical for some of these entities that are under a lot of pressure. Not for us, because we have made very substantial investments in creating system-wide goals and have met very rigid criteria. We are probably among a tiny handful of entities in the country that have adopted computerized physician order entry. We’re fully bar-coded and are in the process across the system of introducing an electronic medication administration record for safety purposes and in having system-wide electronic health records.”

Introducing an electronic system for patient records and providing the best care for patients are not the only focuses of the hospital’s work. BWH is internationally known for the high quality of its clinical translational bench and population-based research studies. Two big clinical trials in the last year alone are sufficient to illustrate this.

Groundbreaking research
“One really big one that hit the headlines was the JUPITER trial,” Gottlieb says. “That was Dr. Paul Ridker, who is identified with the focus on C-reactive protein as a proxy for inflammation and identifying the importance of inflammation in risk for heart attack and other components of atherosclerotic cardiovascular disease.

“Until a few months ago, there was no proven method to detect and prevent many heart attacks and strokes in patients who had normal or low cholesterol. JUPITER was a trial of almost 18,000 patients, with scientists from the Brigham running trials across the world. They found that one of the statins reduced by almost 50 percent the risk of heart attacks, stroke and cardiovascular disease among people who otherwise had normal cholesterol. This is whole group of people that we previously we were making safe through one type of screening, and now we find that they could benefit from treatment. The C-reactive protein is a proxy that showed they had a high risk for cardiovascular disease.

“This was a huge finding, and will likely save a lot of lives, because doctors will now know they have to treat many people who have abnormal C-reactive proteins even if their cholesterol is normal. There’s about 250,000 heart attacks, strokes, and re-vacuolization procedures, or cardiac deaths, that could potentially be avoided in the US if the strategies that were recommended in the trial are applied over a five-year period.”

Other current BWH research work that Gottlieb is excited by includes that of Dr. Scott Weiss, a pulmonary specialist who works in genetics and genomics. Weiss has identified that the vitamin D receptor in our bodies is associated with a gene for asthma. “He and his colleagues believe that during pregnancy, vitamin D can affect the way a fetus develops his or her immune system and lungs,” explains Gottlieb.

“They’re testing this hypothesis by observing large numbers of pregnant women and have found that women who had less vitamin D during pregnancy were much more likely to give birth to babies with asthma and allergies.” Weiss recently received funding from the NIH through the National Heart, Lung and Blood Institute for a $10 million randomized control trial of 800 pregnant women to see whether, if they are given vitamin D supplements, they will have a lower risk of their babies having autoimmune and inflammatory disorders, particularly asthma.

This work touches on Gottlieb’s personal interest in healthcare disparities: “You see a big disparity in black kids with asthma. The best way to raise your vitamin D levels is through sunlight, particularly in people who have light skin and not a lot of melanin in their skin. Black women need a lot more sunlight in order to convert more vitamin D, and they have to take many more supplements to get their levels up. When their grandmas used to give them cod liver oil they were doing fine, but when the vitamin D enriched milk was introduced, people stopped taking vitamin D supplements, and black women are at much higher risk for vitamin D deficiency. It happens that black children, at least in urban communities, are at very high risk for asthma. So if we can link these two together we might be able to ease a healthcare disparity.”

Personal care
In July of last year, Brigham and Women’s opened the Carl J. and Ruth Shapiro Cardiovascular Center. As Gottlieb tells us, the new center is at the cutting edge of patient care. “One of the overall strategies for the Brigham has been to create patient and family-centered care, and in so doing to create care that’s at the convenience and the benefit of patients in the greatest possible way.

“We’ve done that in Partners with the Dana-Farber Cancer Institute. We have 13 different disease centers that bring together surgeons and medical oncologists and radiation oncologists together in the same place to be able to to provide care without somebody having to schlep all the way around, and also so that our doctors don’t end up contradicting one another.

“We built the same principles into the new cardiovascular center, but to an even greater degree. It’s a 136-bed inpatient unit. All the beds are private, and every room, including ICU units, allows family members to sleep in the room with patients, which has made us a leader in the mission of family-centered care. With those 136 beds, and the other 50 med surg beds we have in the tower, and about another 100 beds in obstetrics and gynecology, we have nearly 300 of 777 beds in which family members can sleep overnight. That’s a big deal. We need to train doctors and nurses to manage things differently, and also how to work with family members, but it allows a real family-centeredness at a time when people are at great vulnerability.”

The rooms themselves allow state-of-the-art care. Gottlieb underlines that as more care is done out of hospital or is at a lower level in a community hospital, and inpatient care is increasingly reserved for the sickest people, there is the need for a resource with the technologies to monitor every aspect of potential instability within that environment.

The Shapiro Cardiovascular Center also contains ambulatory clinics that juxtapose providers from different disciplines; cardiologists, cardiac surgeons, vascular medicine specialists, vascular surgeons and cardiac imagers are all in the same clinical space. “You can go from one to the other, if that’s necessary, or they can consult with one another around the patient and his or her needs in order to be able to provide the best possible care,” Gottlieb says. “They’re also specially outfitted with very flexible diagnostic procedures, as well as ORs that were conceptualized to bring together various disciplines and more minimally invasive approaches.”

With his work in health disparities in the local community, his focus on maintaining the highest quality patient care at BWH, and his strong views on national healthcare reform, it’s no surprise that Gary Gottlieb regularly appears in lists of the most powerful people in healthcare. In these challenging times, the healthcare sector needs as many champions like him as it can get.

Gary Gottlieb is President of Brigham and Women’s/Faulkner Hospitals; a position he has held since March 1, 2002. He is also a professor of Psychiatry at the Harvard Medical School. Gottlieb became the first chairman of Partners Psychiatry in 1998 and he served in that capacity through 2005. In 2000, he added the role of President, North Shore Medical Center, where he served until early 2002. Prior to Boston, Gottlieb spent 15 years in positions of increasing leadership in health care in Philadelphia.

Brigham and Women’s Hospital

Brigham and Women’s Hospital is a 777-bed nonprofit teaching affiliate of Harvard Medical School and a founding member of Partners HealthCare, an integrated healthcare delivery network.

In July of 2008, the hospital opened the Carl J. and Ruth Shapiro Cardiovascular Center, the most advanced center of its kind. BWH is committed to excellence in patient care with expertise in virtually every specialty of medicine and surgery.

The hospital has roots in medicine that date back to 1832. BWH formed in 1980 with the merger of three of Boston’s oldest and most prestigious Harvard teaching hospitals: the Peter Bent Brigham Hospital, the Robert Breck Brigham Hospital and the Boston Hospital for Women.

BWH combines clinical care with initiatives in quality improvement and patient safety initiatives and dedication to educating and training the next generation of healthcare professionals.

Through the investigation and discovery conducted at its Biomedical Research Institute (BRI), BWH is an international leader in basic, clinical and translational research on human diseases, involving more than 860 physician-investigators and renowned biomedical scientists and faculty supported by more than $416 million in funding.

BWH is also home to major landmark epidemiologic population studies, including the Nurses’ and Physicians’ Health Studies and the Women’s Health Initiative.