LYNN NEARY, host:
This is Talk of the Nation. I'm Lynn Neary in Washington sitting in today for Neal Conan. Going to the hospital for a medical emergency is scary enough. But how many of us know just how good that hospital is in making sure we survive the crisis that brought us there in the first place? Last week, the Centers for Medicare and Medicaid Services, part of the Department of Health and Human Services, shed new light on that question. They added comparisons of hospital death rates around the country to their Web site. It's called Hospital Compare, and you'll find a link to it at our Web site, npr.org/blogofthenation.
So, what does this information mean for you? How can you use it? What else do you need to know about a hospital's safety record? That's our topic today. A bit later in the program, with two weeks of political conventions under way, we continue our series of conversations called This American Moment. Today we speak with Univision anchor Jorge Ramos.
But first, surviving hospitals. Is this something you're concerned about? What questions do you want answered before you check in? Give us a call. Our number here in Washington is 800-989-8255, and our e-mail address is email@example.com. And joining us now is Dr. Donald Berwick. He's president and CEO of the Institute for Healthcare Improvement, a nonprofit organization that works with hospitals to improve care and reduce errors. And he's with us from the studios of Audiolutions on Martha's Vineyard off the coast of Massachusetts. Welcome to the program.
Dr. DONALD BERWICK (President and CEO, Institute for Healthcare Improvement): Thanks a lot, Lynn. It's nice to be here.
NEARY: Now, maybe you can explain to us exactly what this Web site, Hospital Compare, is, and what the new information that's being added to it is as well.
Dr. BERWICK: The government, through the Centers for Medicare and Medicaid Services, which is the funding agency for Medicare and Medicaid, are using data the hospitals supply to them to characterize their performance of thousands of hospitals in the United States. And now, they make it publicly available on their Web site, hospitalcompare.hhs.gov.
NEARY: Yeah. Has this information been secret in the past?
Dr. BERWICK: Not really secret. Healthcare has really not turned the lights on in its own performance through the past few decades. But it's starting to change, and Medicare's been a real leader in that. So, the public now can get access to measurements that they couldn't have gotten before. It's partly technology developing correctly, but it's also a social change, I think.
NEARY: Yeah. What is this sort of social change that has led to this information now being made available?
Dr. BERWICK: A commitment to transparency and accountability as a good thing, a good thing for the public to have, and by the way, a good thing for the professions and the hospitals to have because hospitals, if they want to get better, can't do that if they don't know how they're doing compared to others. I think it's a real sea change and very welcome.
NEARY: Now, what are the criteria that are used to judge a hospital's overall performance?
Dr. BERWICK: Well, Medicare is not the only agency that's releasing data publicly. But on their Web site Hospital Compare, there are four basic kinds of performance that are displayed to anybody that inquires. The first are called clinical process measures. Do the hospitals do the right thing? If you arrive in an emergency room with a heart attack, do you get the correct drug for a heart attack? There are eight measures of proper care for a heart attack, for example. That's the care process.
The second are reports on patient surveys. There's now a standardized survey called HCAHPS that's been developed scientifically very well over the past decade or more. And now, HCAHPS results for hospitals are also available on that Web site. They show you what patients are saying about their experience.
The third is information on payment. How much is the hospital getting paid? They vary, vary - the hospitals vary a lot in the amount of money they get paid and in the volume of their care. The fourth area, the one that you're focused on, I think, today is mortality measurements, standardized mortality, 30 days after hospitalization for three conditions: heart failure, heart attacks and pneumonia.
NEARY: Why those three conditions? Why are they so important to focus on?
Dr. BERWICK: You need numbers, first of all. In order to characterize a hospital, there has to be sufficient volume of patients that you can do statistical calculations. And these are very common causes of admission in the Medicare population. These are people over 65. So the data - these are conditions that affect a lot of Medicare patients, and it's sort of where the money is at the start. I'm sure there'll be more conditions added as methods get refined, but these are the big ones.
NEARY: Now, one problem - as I understand it - in the past with releasing this kind of data at all or even getting good numbers is the fact that, you know, some hospitals might be caring for people who come in, in worse condition than other hospitals. Is that right?
Dr. BERWICK: Yeah, exactly. The barriers to release are partly social and political, you know. Turning the lights on is tough. It's playing hardball. But there are technical issues here. For example, as you said, if there are two hospitals, one may be treating patients who, at the beginning, are more serious than patients who arrive in the other hospital, and maybe the population is older. Maybe disease prevalences are different in the two hospitals.
And so, some kind of adjustment needs to be made to do what the technical people call leveling the playing field, so that you're getting comparisons that really are meaningful between hospitals. Over the years, these methods, statistical methods for adjustment, standardizing risk, have progressed a lot, and Medicare is now using those measures in their modeling that allow you to have some confidence that these are comparable populations.
NEARY: So, this is one of the things that I imagine hospitals have some problems with, with regard to releasing any of this kind of data, that there are variables like that that have to be accounted for.
Dr. BERWICK: Yeah. I mean, hospitals are frightened by this. Their medicine - hospital care especially is highly competitive. They're afraid they'll be damaged. Whether the data are frankly fair or unfair, they fear they could be hurt. So, there is going to be pushback. But that's not the only pushback. There's also a technical pushback. Scientists disagree. The scientists in our country who do mortality measurement are not of a single mind as to what kind of adjustments are correct. And I think you'll see, in response to this Medicare release, different scientists taking different positions as to how trustworthy these comparisons really are.
NEARY: You know, in one of the articles I read, I was sort of fascinated by this example, a hospital that actually rated very highly in terms of dealing with heart-attack patients, I believe it was, but one of the things they mentioned that they learned in going through a certain process was, well, we realize that, you know, we have to put a hold on all the elevators so we can get the person on the elevator faster because it'll save us two to three minutes, you know? And that's not saying - that's not science. It's just kind of practicality and process. And I was really interested by that kind of a detail that has to be looked into and how much a difference that could make.
Dr. BERWICK: Yeah. Think about the good news here. Suppose we could know, as we now are starting to be able to know, that there are some hospitals in the country that are doing exceptionally well on heart-attack care or heart-failure care. Well, if you're just interested in the market, you can say, well, those places should get all the business. But actually, I think the most important thing going on here is learning, which is that other hospitals, and clinicians, doctors and nurses, can inquire. They can see, well, what are they doing? How can they be so good? Let's go visit them. Let's figure this out so we can be as good as they are. And I actually think that, more than the competitive use of this information, is going to be the dynamic that makes transparency so valuable.
NEARY: Well, what can hospitals do to improve their performance? I mean, that's a very specific, small, little example but there must be sort of, you know, larger kinds of issues that they could look at, I would think.
Dr. BERWICK: Well, beginning - the first step is to know your performance. So, join this movement toward transparency, welcome it. Don't resist it. You know, hospitals can suppress this information. They can opt out of some of this public reporting, and I'd be very worried about a hospital that's opting out unless it's a tiny hospital that doesn't have enough numbers. So, the first is turn the lights on, become curious about your own performance, and then become ambitious.
You don't have to stay at the level of performance you're at. You can ask a very important question, which is, who does it better than we do? And by the way, you can ask that question if you're deficient, but you can ask it if you're average also. Somewhere out there, there's a place better than you. Go find out. What you're going to find out that the hospitals that are doing well are invested in reliability.
They want to do the right thing every single time, and they automate processes, make them absolutely reliable. They're invested in teamwork, so that the doctors, and nurses, and others are cooperating. They're invested in patient voice, so patients are invited to comment and speak up. There are processes, and managing toward excellence needs to become the norm throughout American health care.
NEARY: We want to bring another voice into this conversation. Dr. Robert Wachter is professor of medicine at the University of California, San Francisco, and chief of medical service at UCSF Medical Center. He's also a pioneer in the field of hospitalists. Welcome to the program, Dr. Wachter.
DR. ROBERT WACHTER (Chief of Medical Service, UCSF Medical Center): Thank you, Lynn.
NEARY: Now, can you explain what is a hospitalist?
Dr. WACHTER: Well, hospitalist is a field that's emerged about over the last decade, and it's an interesting evolution. Until about 10 or 12 years ago, if you were my patient and I was your primary care doctor and you were hospitalized, you would expect that I would be your doctor in the hospital, and that understandably makes a lot of sense to a lot of people. One of the things we realized starting about a decade ago was in many circumstances, it wasn't working very well. Patients in the hospital were exceptionally sick. Things were happening in real time over the course of the day, and primary care doctors were very busy in the office.
And so a new field emerged of generalist physicians, physicians who were not subspecialists but take care of all kinds of problems, who basically live in the hospital and become essentially your primary care doctor in the hospital, coordinating your care, making sure you're getting the right information and the right tests, talking to your family, talking to your primary care doctor. And then when you leave the hospital, returning you back to your primary care doctor - hopefully with a very good hand-off of information back to that doctor.
There's some information that says that doing it this way improves - certainly improves efficiency of care. Patients spend less time in the hospital, and I think that's good, and some information that indicates they - that the quality of care is improved as well, as you might expect for physicians who are there all the time and focus on this, and can be there if you deteriorate in the middle of the day or in the middle of the night.
NEARY: Do you find that people are afraid of hospitalists? Not hospitalists - hospitals.
Dr. WACHTER: Oh, sure.
Dr. WACHTER: And it's understandable that they should be. I think Don makes the point quite eloquently that hospitals are not as safe as they should be, and all the data that we've amassed over the last couple of decades say that death rates from errors are higher than they should be, and we get it right too infrequently. We don't have reliable, standard processes, and it means that, you know, when I go onto an airplane, I can pretty much trust that I will be flown from point A to point B safely, and a lot of patients come into hospitals not having that level of trust.
At some level, that's a good thing because it does lead to the kind of policy changes that Don was talking about. The kind of transparency we're seeing now is in part a reflection of people being worried that they're not as safe as they should be. We don't want to scare people unduly. Most hospitals are doing a very good job, people are working very hard, and the right things are happening. But they are not as safe as they should be, and this is a little bit like Alcoholics Anonymous, that we have to stand up and say we have a problem before we have the wherewithal and the political push and the resources to fix it.
NEARY: We're talking about what you need to know about your hospital, and our guests are Dr. Donald Berwick and Dr. Robert Wachter. We're taking your calls at 800-989-8255. You can also send us an e-mail. The address is firstname.lastname@example.org. We'll continue our discussion after a short break. I'm Lynn Neary. It's Talk of the Nation from NPR News.
(Soundbite of music)
NEARY: This is Talk of the Nation. I'm Lynn Neary in Washington. A guest on this program once said that people spend more time researching their kitchen appliances than their hospital. Today we're talking about new information that's available to patients, how you can use it, and what you need to know before you're admitted.
Our guests are Dr. Don Berwick, president and CEO of the nonprofit Institute for Healthcare Improvement, and Dr. Robert Wachter, professor of medicine at the University of California, San Francisco, and chief of medical service at UCSF Medical Center. What do you want to ask the doctors about hospitals? The number is 800-989-8255. The e-mail address is email@example.com, and we're going to take a call now. We're going to go to Cara, and Cara is calling from Newark, Delaware. Hi, Cara.
CARA (Caller): Hi. Thank you for addressing this subject. I really appreciate it. My question for Mr. Berwick, at the top of the hour, I believe he said that hospitals supply some of this data, and I'm wondering how much you can trust them to supply accurate data. I think also U.S. News and World Report rates hospitals according to what the hospitals provide to them, and I'm wondering how their own data is evaluated by these organizations.
NEARY: Dr. Berwick?
Dr. BERWICK: Sure, Cara. Well, some of the data are coming off hospital claims forms, where the hospital is billing Medicare, and it would be illegal, and in fact, quite risky, for a hospital to intentionally to try to deceive Medicare or anyone about this, and hospitals in general that would be caught cheating on this data would suffer some consequences. I think your point's well-taken, though, around a different issue, which is accuracy of the records themselves.
We do have some information that shows that we've got a lot of work to do to make the medical records and the other source documents in hospitals better so that this data can be more reliable. By the way, the more we move toward electronic medical records, automated medical records, and hospital records, the better. So it's a concern, Cara, but I think overall, these data are just going to get better over time.
CARA: But at the present time, I found through personal experience that they're not. I actually did go to the hospital rated the highest in the Philadelphia area after a serious car accident, and I was treated very badly there, misdiagnosed, mistreated, misrepresented. And to this day, they have not released my records even to my primary care physician. They also refused to contact any of my contact persons, and lied to me telling me they had.
So that - because I was in the car accident in a neighboring city, and I gave them - I was conscious through the whole process, so I was able to give them all of the numbers, and I already had an advanced directive in case of emergency and a person in charge of that, and family members and co-workers, all of whose numbers I supplied to them. And they told me they had contacted everybody when, in fact, they hadn't, and I wound up on the missing persons list and being looked for by police all over my state, and...
NEARY: Well, let me see if the doctors can take any information that you're giving them right now and relate it to this topic about, you know, are hospitals safe, and I appreciate your calling in, Cara.
CARA: Thank you.
Dr. BERWICK: We have a long way to go. Cara's point is well-taken. This is a step. This movement toward public release of information on mortality and process, it's all adolescence in our industry. I totally sympathize with Cara's point. We need to move in a much more wholesale way toward transparency as a norm, transparency of all types. People should have absolute access to their own medical records. The idea something could happen to you in a hospital and you not know about it, I don't think is acceptable any more. We have a ways to go, but I think we can celebrate this as an early and important set of steps.
NEARY: We're going to take a call now from Steve in Detroit, Michigan. Hi, Steve.
STEVE (Caller): Hi, how are you?
NEARY: Good. Go ahead.
STEVE: Good. I'm actually a physician but as a medical student, I saw something that sort of disturbed me. It was sort of a practice of while this patient is getting real sick, or maybe this patient is ready for hospice because they're going to die soon, so let's get them sort of moved along so that the mortality doesn't get hit against our hospital, as it hit against the hospital we're transferring to, or the hospice. How does the Medicare sort of take that sort of thing in consideration?
NEARY: That's a good question, Steve. And I'm going to ask them - we're having a little trouble hearing you. I think you might be on a cell phone. So I'm going to ask the doctor - Dr. Wachter, why don't you take that issue?
Dr. WACHTER: Absolutely. It's a very, very good point, that...
NEARY: Thanks for your call, Steve.
Dr. WACHTER: That he makes. The crafters of the system that Medicare is using were very clever about that, and Steve raises a couple of major concerns that people have: that the system will get gamed, or a hospital will send a patient out to die rather than having it, quote, look bad, on their record. The way the system works is that death rates are calculated for 30 days after the hospitalization.
I think that was a very - that was a crucial decision because A, you don't want to create an incentive system where hospitals will not make the right decision about keeping a patient in the hospital to die, if that's the appropriate place for them to get end-of-life care. And secondly, one of the things we've discovered is you can provide really good hospital care and screw things up very badly at the time of discharge, and so we often look at that period as almost a black hole.
There a lot of things that have to happen in order to keep the patients safe, and one of the things the 30-day mortality rate does is causes hospitals to begin looking at its discharge process to be sure that they're making the connection back to the primary care doctor, and back to the patient's home appropriately. The other point Steve raised was, does a hospital get dinged for accepting a patient in transfer after the patient leaves the first hospital? A big academic hospital like mine often does get patients from other hospitals that have done poorly for whatever reason, and we do our best to save them.
The policy decision that Medicare made was to use the first hospital as the source hospital for the mortality rate. So, it's the hospital you come into initially. If you get transferred to UCSF, or to the Mayo Clinic, or the Cleveland Clinic, or John Hopkins, those hospitals are not attributed, your mortality, hopefully you do well, but if a patient dies it's not attributed to the receiving hospital - it's the original hospital.
NEARY: All right. Let's take another call now from Joan in Oklahoma City. Hi, Joan.
JOAN: (Caller): Hi.
NEARY: Go ahead.
JOAN: Yes, I'm wondering - about two years ago or so, I worked for a hospital and - involved with going through our medical record, electronic medical record, and getting the data for these performance measures, and I thought at one time that they were reporting the infection rates at the hospitals, like for common procedure groups like gallbladder surgery, knee and hip surgery, things like that, but I can't find that data anymore. Is that something that's going to be reported soon? Because when I deal with family members and friends and neighbors, more people are concerned about infection rates than - they just really don't think about going into the hospital and dying. It's still kind of a surreal scene for them.
NEARY: Yeah, I agree with Joan. I think that's people's biggest fear right now because everybody knows a story about somebody who's, you know, gone in for some minor procedure and gotten deathly ill and maybe even died as a result of infection that they got in the hospital. Dr. Berwick?
Dr. BERWICK: I'm with Joan and you on this one, Lynn. I think infection rates and monitoring them is one of the most important variables we can be following. There are process measures in the Medicare data set on that Hospital Compare Web site around surgical infection care. But I personally hope that we move very quickly toward public measurement and reporting of infection rates, and that involves some science, which is making sure that the measurement systems are standardized and adhering to good definitions such as CDC, the Centers for Disease Control, can provide. But I do think hospital infection rates ought to be a major target of improvement, and I look forward to increasing transparency around that issue itself.
NEARY: Thank you. Go ahead, Joan.
JOAN: Well, a second part of that is, I know that we're looking at Medicaid/Medicare not paying for hospital-acquired infections in that regard. Is this something, you know, moving policy-wide toward - what Medicaid/ Medicare did in the beginning was reward those who did report their data related to performance measures versus those that didn't report their data to help, you know, kind of stimulate that process.
NEARY: Thanks for your call, Joan.
JOAN: Thank you.
NEARY: Dr. Berwick.
Dr. BERWICK: Joan is referring to a very, a rather courageous move on Medicare's part, which is to cease paying for certain kinds of avoidable infections and avoidable complications of other sorts. This is, of course, very controversial, but I think it's going to raise the stakes, raise a lot of attention to this issue, and very importantly, I think hospital boards of trustees and governance and senior leaders in hospitals are going to be alerted by that move. And they are not alone. There are business groups that are urging not paying for things that can be avoided, and hopefully that would intensify interest in those kinds of improvements.
NEARY: Dr. Wachter, we've got an intriguing question here from an e-mail that I'd like to read to you. This is from Lynn in Washington, Missouri. She says, interesting topic, but a lot of us have only one or two choices of hospitals, and the ones that have more choices need to go where the doctor practices. I think that's a really good point. I mean, or, you know, in an emergency case you're going to be taken to whatever hospital they take you to. I mean, how does it - how does a consumer use this information to their advantage if they don't have much choice, Dr. Wachter?
Dr. WACHTER: I think it's a very important point, and I think it's part of the reason that many of us are - remain a little bit skeptical that these data will be used in the same way that you choose where - what car you buy, or what washing machine you buy. Patients do have limitations, geographic limitations, or other connections to their local hospital. And I'm with Don. I think the most important thing that this transparency does is create internal pressure for change within hospitals.
I can tell you that my hospital, which is a terrific hospital, has looked at these issues in a much more forceful way over the last five or 10 years - because of public reporting and transparency - than it did before. The reason that is so important is that the way we thought about medical mistakes and the quality of care up until about 10 years ago was absolutely wrong, and Don Berwick has really been the pioneer in this. We thought about these as manifestations of human failings, and that if I as a doctor committed an error, it was because I was a bad person or wasn't working hard enough.
And we now know - Lynn, you brought up the point earlier about the elevator - we now know that that is the nature of health care, that to get it right has a little bit to do with how smart the doctor is, and how well-trained the nurses, but has probably more to do with does the system work well, is it reliable, does the information technology work, all those sort of pieces that none of us learned about in medical school are critically important.
So, what this transparency does is force every hospital in the country to look in the mirror and say, wow, we're not as good as we thought we were, not as good as we should be. And it creates tremendous internal tension for change, and sometimes for investment. It may be that you've got to spend $20 million on a computer system, and absent this kind of transparency and scrutiny, yesterday you might not have done it and tomorrow you will.
I think that's the most important thing. The consumer choice piece of this, I think, will grow over time as people get more comfortable with this, but a lot of people really are limited to one or two hospitals in their region, and they're not going to get on an airplane and fly 1,000 miles to a better hospital.
NEARY: All right. Let's take a call from Stephan in Salt Lake City. Hi, Stephan.
STEPHAN (Caller): Hi guys. I wanted to get the doctors' opinion of the disparity between the good and the poor hospitals. I mean, in Salt Lake City, there's a couple of hospitals maybe within five, 10 minutes of each other. But the next one is 20 to 30 minutes away for a drive. I mean, would it be really worth it in an emergency situation to risk those 20 minutes, which is a very critical time, to be going to a, quote, better hospital, unquote, when you can just go to one that can take care of you and get it done?
NEARY: Dr. Berwick?
Dr. BERWICK: Well, actually, Medicare, on its Web site advises not to use this information in the midst of an emergency for the very reason that Stephan says. It's, get into good hands and get care is more important than making some fine distinction among hospitals. It's the longer run that I think these comparison data really help with general improvement over time. It's also important to notice that these are a little bit like baby steps still.
For example, if you look at the heart-attack outcome part of the Web site, let's say you were to compare three hospitals in Salt Lake City, you're going to discover that the Medicare rates 4,302 hospitals as similar to each other, average, nine hospitals as better than the national average, and none as worse than the national average. And that shows you that there's a little bit of timidity still in the way that we're doing these comparisons. And so actually looking at the hospitals, comparing them, is not going to give you a tremendous amount of discriminating information quite yet.
NEARY: All right, Dr. Robert Wachter is the professor of medicine at the University of California, San Francisco. And you're listening to Talk of the Nation from NPR News. We're going to take another call now from Rick, and Rick is calling from Minneapolis. Hi, Rick, go ahead.
RICK (Caller): Hi, how're you doing? I was just curious about historically, the hospital death rates. I remember as a kid, either you could go in the hospital for a week for a number of things that now might be an hour or so. So medical advances must have done something about the risk in death rates but at the same time, you know, it seems to me more people are going into hospitals for different types of things as well. So, is there some way that that gets correlated, or is there some way of saying the hospitals are safer now than they had been?
NEARY: All right, thanks for your call, Rick. Dr. Wachter?
Dr. WACHTER: We don't know whether they are safer than they have been, I think because of Rick's very point, that the nature of hospital care has transformed remarkably in the last generations. So, when I was a resident 25 years ago, patients came in for a heart attack and stayed for two weeks. Patients sometime came in the hospital for us to try to figure out why they had a fever and they'd stay for a week or two and sometimes end up having surgery.
Those patients now get diagnosed with the CAT scanner and MRI scan during their lunch break while they are seeing their doctor. And if they need antibiotics for two weeks, they don't get admitted to the hospital for two weeks of antibiotics. They get them set up at home. And so, it is a completely different landscape, and so the point that was made earlier about this kind of wonky topic that's called case-mix adjustment, which really is how we can adjust for the sickness of the patients, and the age of the patients, so that we really can have apples-to-apples comparisons. It's vitally important not just looking at one patient versus another, or one hospital versus another, but really reflecting these changes in the nature of medical care.
I can make my hospital look like it's better and safer with a lower death rate if I admit more patients that aren't that sick, but we don't want to do that. We want to be appropriate about the patients who are in the hospital. The ones that need to be here should be here. The ones that don't are probably better off not being in the building. And so the science does have to advance to a point where we can adjust a way for those variables.
And I think that the point Don made earlier is very important. We've gotten much better at it. We're not perfect at it. Part of the reason you get these kind of reports that say this broad band of hospitals that are called average is to say more than that, to say that hospital 1,237 really is better than 1,238. The science is not advanced enough to say that with any statistical certainty. So, I think the conservative approach they took - to call them average unless they are really out there as particularly good or particularly bad - I think was the appropriate way to start.
NEARY: And just to conclude, Dr. Berwick, do you find that hospitals really are - it sounds like you're both saying that this is a process that we're in, and I'm wondering if hospitals really are becoming less sort of defensive about giving out this information, or learning from this information.
Dr. BERWICK: Slowly but perceptibly. I think as a consumer of health care, you have a right now to ask your hospital to turn the lights on. And if the hospital won't, I think you have a reason for some concern. Slowly, slowly hospitals are starting to really change. I want to say that some of the leadership we have in the country now is really helping with that, the new head of the American Hospital Association, Rich Umbdenstock, the head of the AMA this year, Nancy Nielsen. These are two leaders who are saying not just it's inevitable that we are going to have transparency, but it's a really good thing because we can learn better from each other, and we can't if we don't have it. So, we're in the midst of an important change.
NEARY: All right. Thanks so much for joining us, both of you - both of you, thanks for being with us. Dr. Donald Berwick is president and CEO of the Institute for Healthcare Improvement, and he joined us from the studios of Audiolutions in Vineyard Haven on Martha's Vineyard. Enjoy the day on the Vineyard there. And Dr. Robert M. Wachter is professor of medicine at the University of California, San Francisco. I'm Lynn Neary. It's Talk of the Nation from NPR news.
NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.