The Ebola virus epidemic in Africa is hopefully winding down.  The uproar, if not panic, over Ebola virus in the US has been eclipsed by the latest  internet craze.  However, we are still learning from the echoes of the brief, and thankfully very localized US experience with Ebola.

In particular, the country's response to the virus should continue to inspire unease about how our supposedly market based, managerially focused health care non-system can handle real public health threats.

Background - Ebola at Texas Health Presbyterian

Starting on October 2, 2015, we discussed numerous concerns about whether problems with leadership or management at Texas Health Presbyterian hospital, part of the Texas Health Resources system, contributed to the poor outcomes of its Ebola patients.  First, InformaticsMD raised questions about whether a badly designed or implemented electronic health record at the hospital enabled the initial misdiagnosis of Eric Duncan, the first patient to present with the Ebola virus on US soil.  These questions were reinforced when hospital managers gave conflicting responses on this issue.  He expanded on these questions here.

A week later, I wrote about the "mystery of the discharged Ebola patient," asking:  why don't we know yet exactly what happened when our Ebola patient zero first appeared?  I wondered then whether a decision by management to shift the health system's emphasis from acute care to "population health management," whatever that is, might have lead to problems addressing what was a severe, acute medical problem (albeit with public health implications.)    About a week later, I wrote about the questions raised by inconsistencies in hospital managers' statements, about Mr Duncan's clinical status and the failure to initially accurately diagnose his infection, about the hospital's readiness to handle Ebola patients, and about whether hospital professional staff may have been silenced by administrators, and if so, why?

By late November, 2014, a Texas Health Presbyterian nurse had gone public with accusations that the initial care of Mr Duncan had been chaotic; Mr Duncan had died; and two nurses who cared for him after he was admitted after his second emergency visit to Texas Health Presbyterian had contracted Ebola infections; but no new Ebola cases had been diagnosed in the US, and Ebola was starting to fade from the media.   At that time, I wrote that the three questions above remained unanswered.  However, Texas Health Resources, the parent system for Texas Health Presbyterian, had hired Burton-Marsteller, a big public relations firm, and  managers of both companies generated considerable verbiage, but no specific answers and no real enlightenment.  Hospital managers had already pointed their fingers elsewhere, at the US Centers for Disease Control and Prevention (CDC) for inadequate guidelines, unnamed third parties for exploiting the crisis, and the media for sensationalizing it. Hospital managers had sponsored a pep rally, but the health professionals who appeared there either seemed to stick to talking points, or remained "tight lipped."   The hospital settled a lawsuit filed by Mr Duncan's relatives, and Micahel Barden, the THR president, submitted to an interview in which he boasted of a "high level of communication" and asserted the system had "maintained the trust level," but did not supply any specifics.

Since November, 2014, no further specifics have appeared about what happened at Texas Health Presbyterian.

The Public Relations Burnishing of Texas Health Resource Management

Instead, since October, 2014, a series of events and media reports seemed more about burnishing the management of Texas Health Resources, and particularly its CEO, Barclay Berdan, than about learning from the problems that occurred when the US first encountered the Ebola virus.

On November 29, 2014, Modern Healthcare published an interview with Mr Berdan including leading questions like:

Has this Ebola crisis caused you to take a broader look at hospital-acquired infections?

How were you able to maintain high staff morale throughout this crisis?

The answer to that last question was particularly upbeat:

It was really important to make sure that we had a high level of communication and that we maintained trust inside the organization while we were in many cases being attacked from the outside, as the world moved from science to political science to social science to superstition and fear. That helped us keep the morale of the organization up and to keep people focused on the fact that we had a lot of patients to take care of.

Even though our patient census dropped by 20%, we told everybody we weren't going to reduce staffing. We were going to keep people working at their regular rates and times. We kept everybody really focused on this challenge, that we had to stay strong and get through this period of time.

Note that this implied communications had always been good, trust had always been maintained, and morale had never declined. There were no followup questions, particularly whether staff morale could have seemed good because dissent had been silenced? 

On December 5, 2014, the D Healthcare Daily reported on an event in which Mr Berdan participated, and treated him as an honored expert.  Berdan was quoted, for example,

The best thing you can do—if you’re a local hospital, if you’re a rural hospital or an urban hospital—is to try and figure out how to manage the safety of your employees, the safety of your institution, the safety of patients who may present with, in this case, a disease that already causes people great fear.

The article trumpeted how selflessly Berdan has led THR to teach other hospitals about Ebola, with the underlying assumption that it had valuable lessons to teach:
THR has shared what it’s learned with other hospitals, both in North Texas and across the country. It held a webinar with 1,200 medical professionals to share what it learned and changed....

On December 5, 2014, D Healthcare Daily also noted that at the event, an award was given to caregivers who dealt with ebola at Texas Health Presbyterian, but who accepted the award on their behalf? 

Barclay Berdan, CEO of Texas Health Resources, was center-stage on Tuesday at the Sheraton downtown, flanked by more than a dozen staffers representing the 100-plus caregivers who helped treat the three Ebola patients in October.

The Dallas Regional Chamber presented the caregivers of Texas Health Presbyterian Dallas with the Courage of Public Service Award, an annual recognition that honors groups or officials who 'demonstrated significant leadership on important issues.'

After Berdan gave his little speech, next up on stage were:

Texas Health Resources Board Chair Anne Bass and Presbyterian Hospital Board Chair Stan Rabin walked up first,... 

Although the actual caregivers were supposedly being honored, airtime and coverage went to board chairs.

Then last month (February, 2015), it began again. Another interview with Mr Berdan appeared in D Healthcare Daily. It allowed Mr Berdan to pontificate on issues like the hospital system's growth plans, and to go back to the idea of population health as more important than acute care,

I think we’re looking always to find good opportunities to improve the health of the people in the communities we serve, and that’s our mission. In fact, we have really changed the scope and direction of our organization over the last four or five years from being a great acute care hospital company—you referenced all of our hospital properties in North Texas—to really being a health company.

Ebola, and the questions I raised above, were not featured. 

Finally, in the March issue (available in late February, 2015), D Magazine published, "How Texas Health Managed its Ebola Crisis," focused, of course, on CEO Barcaly Berdan. It featured a large color photograph of Mr Berdan.  It seemed to suggest that the most important issue was maintaining the reputation of the hospital system, rather than for example, being transparent about and learning from mistakes. It featured a big informal portrait of Mr Berdan, and started with how Mr Berdan managed the first news conference about Ebola, rather than, for example, the details of Mr Duncan's encounters with THR.

To Berdan, it was important to show that Presby—one of Dallas County’s largest and busiest hospitals—was safe and open for business.

The article described Berdan as an "unassuming man who speaks with confidence and fatherly authority," an "able communicator," a man whose "word is his bond," and eventually, "a battle tested CEO." It stated that "the treatment of Duncan - and the safety of the men and women who volunteered to care for him - rested squarely on his shoulders." Yet, of course, Mr Berdan's highest degree was an MBA, from University of Chicago, no less. He may have had a public relations battle, but he did not have to walk into a room containing a highly infectious Ebola patient. He actually should not have had any authority over the actual treatment of Mr Duncan. That should have been in the hands of the patient's doctors and nurses.

The article obliquely addressed the unanswered questions, but did provide substantive answers. Why was Mr Duncan not diagnosed accurately?

Privacy laws prevented the hospital from discussing the care provided Duncan until he permitted them to....

Was the hospital prepared to take care of Ebola patients?

We were moving in parallel with the CDC's ongoing recommendations....

Were health professionals silenced? The hospital paraded four nurses in front of 60 Minutes' cameras:

On the evening of Oct. 26, wearing blue scrubs and seated in front of a jet-black background, nurses Sidia Rose, John Mulligan, Richard Townsend, and Krista Schaefer offered a poignant and moving narrative of Duncan’s treatment. It was the most substantive account offered to that point.

The final section of the article was entitled, "On the Mend." Again, the emphasis was on PR.

THR had positive momentum. Once a pin-cushion, its public reputation was improving.

The hospital settled a lawsuit with Mr Duncan's relatives for an undisclosed sum. After the settlement was announced, Mr Duncan's nephew proclaimed:

This facility is an outstanding facility, and we as humans are not perfect.

Maybe getting a big sum of money can make one more philosophical about human imperfections.

The article ended up describing how

North Texas seems to have appreciated the efforts of THR under Berdan....

It all sounded so rosy, at least for a few days.

A "PR Pawn" Strikes Back, or, Nina Pham Administers a Corrective

Only a few days after the D Magazine piece appeared, the Dallas Morning News published an article about Nina Pham, the first THR nurse to have been infected with Ebola virus after caring for Mr Duncan.  Pham had never previously been portrayed as a dissident, and had been seen in the media as a young professional gamely facing down the virus and supporting her fellow nurses.  Now, however, rather than participating further in the feel good celebration of THR and Mr Berdan, Ms Pham announced she would be suing the hospital and THR.

She says the hospital and its parent company, Texas Health Resources, failed her and her colleagues who cared for Thomas Eric Duncan, the first person in the United States diagnosed with Ebola.

'I wanted to believe that they would have my back and take care of me, but they just haven’t risen to the occasion,' Pham told The Dallas Morning News

Pham reaffirmed the contention that Texas Health Presbyterian was not prepared to care for Ebola patients.

In her 90-minute interview, Pham described working in chaotic surroundings at the hospital with ill-prepared nurses who received little guidance on how to treat Ebola and protect themselves.

In particular,

She said the extent of her Ebola training was a printout of guidelines that her supervisor found on the Web.


The day Duncan moved to ICU, Pham said, she and the charge nurse went in with double gloves taped to double gowns and wore double booties and a face shield. The hospital did not have hazmat-type suits, and Pham said her neck was always exposed.

'We’ve had nurses that I’ve worked with that worked in other states, and they worked in hazmat suits for flu and H1N1,' Pham said. 'Why aren’t we wearing hazmat suits for Ebola?'

After days of asking, Pham said, the nurses were given hazmat suits. She said all the decisions to upgrade the protective gear and precautions were made by the nurses 'on the fly.'

 Meanwhile, the nurses devised their own hazardous waste area. In a room adjacent to Duncan’s, the nurses set up a place to take off their protective gear and shower after caring for him. In another nearby room, they placed bags of dirty linens, towels and other soiled items.


while she became the American face of the fight against the disease, the hospital’s lack of training and proper equipment and violations of her privacy made her 'a symbol of corporate neglect — a casualty of a hospital system’s failure to prepare for a known and impending medical crisis.'

She also contradicted much of the feel good public relations speak found in the articles above.  The D Magazine article had referred to Pham and the other nurses who care for Mr Duncan as "the men and women who volunteered to care for him."  In contrast, the Dallas Morning News article said "she did not volunteer to care for Duncan, but felt she couldn't say no."

During the crisis, Pham was seen in a video where she appeared gamely optimistic.  However,

She says that Texas Health Resources violated her privacy while she was a patient at Presbyterian by ignoring her request that 'no information' be released about her. She said a doctor recorded her on video in her hospital room and released it to the public without her permission.

While the hospital argued that Pham gave permission to make the video,

The day Pham was transferred to NIH, a notation was made in her medical file that 'she does not have the mental capability to make end-of-life decisions,' [Pham's attorney Charla] Aldous said. But PR people from Texas Health were trying to talk to her for a media release 'about how much she loves Presbyterian,' Aldous said.

Texas Health, with a PR firm’s help, developed a slogan — 'Presby Proud' — aimed at restoring the community’s faith in the beleaguered hospital.

Before Pham’s flight to Maryland on Oct. 16, she said, a doctor wearing a video camera under his protective hood came into her room and said he was filming her for educational purposes. Pham said she did not give permission for the video, which was released to the media.

'Thanks for getting well. Thanks for being part of the volunteer team to take care of our first patient,' a man’s voice said in the video. 'It means a lot. This has been a huge effort by all of you guys.'

'I could tell they wanted me to stay just because they kind of knew, they could see I was getting better. They wanted that ‘yes we cured her’ kind of attitude. They wanted a win, especially after a loss.' - Nina Pham

Charla Aldous, Pham’s attorney, put it all more simply:

Texas Health Resources 'used Nina as a PR pawn.'


So it looks like back to the drawing board for the public relations flacks who have been defending the "reputation" of Texas Health Resources, and, in my humble opinion, mainly the reputation of its CEO, Barclay Berdan.  After questions about its preparedness for and the care of Ebola patients, and about whether managers overrode and silenced health care professionals, the hospital system had put on a big public relations campaign, in concert with a big outside PR firm.  Yet all the questions have now resurfaced as one of the hospital nurses put before the public as brave yet ever loyal to "Presby" now says she was turned into a "PR pawn." 

Of course, the immediate response by the hospital and the CEO were to trot out the old talking points.  In the Dallas Morning News article, spokesman Wendell Watson said,

Nina Pham bravely served Texas Health Dallas during a most difficult time.  We continue to support and wish the best for her, and we remain positive that constructive dialogue can resolve this matter.

Later, as again reported by the Dallas Morning News, CEO Barclay Berdan tried to refute Ms Pham's contention that her privacy was violated by saying:

We adhered to HIPAA rules in determining what information to share publicly.  

But HIPAA rules are notoriously hard to interpret and implement.


We had Nina's consent to share the information about her that was released.

But she had contended she was too ill, and confused on pain relief medicines to give informed consent, and aspects of her record apparently corroborate that. 

So the questions about what was going on at THR persist.  The latest twist in the story does emphasize how important public relations has become to contemporary hospital managers.  One cannot avoid the notion that most of what went on in the C-suites of Texas Health Presbyterian and Texas Health Resources in response to the presence of three Ebola patients was about public relations, protecting the reputation of the hospital, and particularly celebrating its very well paid MBA CEO.  Of course if leaders focus on public relations, maybe they will not do such a good job supporting the health care professionals who actually care for patients, and ultimately supporting the patients' and the public's health.

So as I said a while ago about this case, the rise of generic managers who value, among other things, favorable public relations perhaps to the detriment of patient care, threatens the US' ability to care for acutely ill patients, especially in the context of new or epidemic diseases.  True health care reform would restore leadership by people who understand the health care context, uphold health professionals' values, are willing to be held accountable, and put patients' and the public's health ahead of self-interest.

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