| 13 March 2015
Dear Interested Readers,
Inside This Letter
This week marked another 50th anniversary in the movement for Civil Rights. The high point of the commemoration was the speech given by the President at the Edmund Pettus Bridge in Selma, Alabama, the site of Bloody Sunday, March 7, 1965. As I listened to the President’s speech, I was moved deeply by his words. I was able to track the arc of the change he described through my own experience.
A speech that gets you thinking is a good speech. His speech reminded me of the similarities and connections between the struggle for equity in opportunity and the struggle for equity in healthcare. There is evidence that Dr. King linked the two and I hope this letter supports an argument that Dr. Robert Ebert saw the link also and that link continues as the motivation for pursuing the Triple Aim. The letter is a little longer than usual because of the incorporation of significant portions of two great speeches. I hope you find it worth your time.
Don’t forget to visit strategyhealthcare.com from time to time. Your friends can sign up there to get their own mailing of this weekly letter. I am hoping that the site will be a useful resource in the journey toward better care. Your comments are welcome.
Remarkable Speeches About How Hard It Is To Change Culture
Last weekend was the fiftieth anniversary of the Bloody Sunday march from Selma, Alabama to the capitol, Montgomery that is about 50 miles East on old US 80. Between 1954 and 1961 my family drove US 80 from Texas to the Carolinas at least once a year to visit my grandparents. A favorite part of the trip for me was crossing the wide expanse of the Mississippi on the towering bridge at Vicksburg where we would occasionally pause to visit the scene of the famous battle won by General Grant the day after Gettysburg. The twin victories marked the beginning of the end for the Confederacy and gave control of the Mississippi River to the Union.
In the fall of the same year as the Selma march I sat on our team bus after we had been thoroughly savaged by the Crimson Tide of Alabama in Tuscaloosa. “Bear” Bryant and his boys had just whipped us soundly on their way to the National Championship. I was quite surprised when Alabama’s segregationist governor, George Wallace, stepped aboard the bus. George was accompanied by his wife Lurleen who would become governor in 1967 when he was prohibited from another term by the Alabama Constitution. George and Lurleen graciously smiled and thanked us for coming for our whipping. The real contrast in the retrospective view of that day and today’s reality is that there was not one African American on the field playing for either team, and I doubt that there was even one African American in the more than 70,000 people who watched the game.
What was more remarkable than the fact that there were no African Americans on the field or in the stands, and that the Selma March had occurred only about eight months before that lovely fall November day, and that the Voting Rights Act had been signed into law only three months earlier by President Lyndon Johnson on August 6th, was that no one seemed to notice or care that the afternoon had been an all white affair. It was our culture. The point of novelist David Foster Wallace in his little book This Is Water, that was originally a commencement speech to the Kenyon College class of 2005, was that we rarely pause to think about our culture and how it affects us every day and isolates us from opportunity.
If you have never read the speech that became the beautiful little book This Is Water, and you might want to read it you can save yourself the $9.74 it will cost you to download it on your Kindle or the $11.29 plus shipping that a hard copy will cost you. It is shorter than one of these weekly letters and available for free as an eight page PDF at:
http://www.metastatic.org/text/This is Water.pdf.
For me the high point of all I saw and read about the 50th anniversary celebrations at the Edmund Pettus Bridge in Selma last weekend was the speech that the President gave. It will take you less than ten minutes to read it:
https://www.whitehouse.gov/the-press-office/2015/03/07/remarks-president-50th-anniversary-selma-montgomery-marches
You can watch the whole speech, which is about 30 minutes long, on YouTube:
https://www.youtube.com/watch?v=gvAIvauhQGQ
In case you do not have time to read it or watch it let me try to peel away some of the beauty of the entirety to deliver the core of its message in an abridged fashion that is about one third as long for you to read. I have bolded areas that seemed even more noteworthy.
“We the People…in order to form a more perfect union.” “We hold these truths to be self-evident, that all men are created equal.” …These are not just words. They’re a living thing, a call to action, a roadmap for citizenship and an insistence in the capacity of free men and women to shape our own destiny…It’s the idea held by generations of citizens who believed that America is a constant work in progress; who believed that loving this country requires more than singing its praises or avoiding uncomfortable truths. It requires the occasional disruption, the willingness to speak out for what is right, to shake up the status quo. That’s America.
…Because of campaigns like this, a Voting Rights Act was passed. Political and economic and social barriers came down. And the change these men and women wrought is visible here today in the presence of African Americans who run boardrooms, who sit on the bench, who serve in elected office from small towns to big cities; from the Congressional Black Caucus all the way to the Oval Office…Because of what they did, the doors of opportunity swung open not just for black folks, but for every American. Women marched through those doors. Latinos marched through those doors. Asian Americans, gay Americans, Americans with disabilities -- they all came through those doors. Their endeavors gave the entire South the chance to rise again, not by reasserting the past, but by transcending the past.
What a glorious thing, Dr. King might say. And what a solemn debt we owe. Which leads us to ask, just how might we repay that debt?
First and foremost, we have to recognize that one day’s commemoration, no matter how special, is not enough. If Selma taught us anything, it’s that our work is never done. The American experiment in self-government gives work and purpose to each generation.
Selma teaches us, as well, that action requires that we shed our cynicism. For when it comes to the pursuit of justice, we can afford neither complacency nor despair.
…What happened in Ferguson may not be unique, but it’s no longer endemic. It’s no longer sanctioned by law or by custom. And before the Civil Rights Movement, it most surely was.
We do a disservice to the cause of justice by intimating that bias and discrimination are immutable, that racial division is inherent to America. If you think nothing’s changed in the past 50 years, ask somebody who lived through the Selma or Chicago or Los Angeles of the 1950s. Ask the female CEO who once might have been assigned to the secretarial pool if nothing’s changed. Ask your gay friend if it’s easier to be out and proud in America now than it was thirty years ago. To deny this progress, this hard-won progress -– our progress –- would be to rob us of our own agency, our own capacity, our responsibility to do what we can to make America better.
Of course, a more common mistake is to suggest that Ferguson is an isolated incident; that racism is banished; that the work that drew men and women to Selma is now complete, and that whatever racial tensions remain are a consequence of those seeking to play the “race card” for their own purposes. We don’t need the Ferguson report to know that’s not true. We just need to open our eyes, and our ears, and our hearts to know that this nation’s racial history still casts its long shadow upon us.
We know the march is not yet over. We know the race is not yet won. We know that reaching that blessed destination where we are judged, all of us, by the content of our character requires admitting as much, facing up to the truth. “We are capable of bearing a great burden,” James Baldwin once wrote, “once we discover that the burden is reality and arrive where reality is.”
There’s nothing America can’t handle if we actually look squarely at the problem. And this is work for all Americans, not just some. Not just whites. Not just blacks. If we want to honor the courage of those who marched that day, then all of us are called to possess their moral imagination. All of us will need to feel as they did the fierce urgency of now. All of us need to recognize as they did that change depends on our actions, on our attitudes, the things we teach our children. And if we make such an effort, no matter how hard it may sometimes seem, laws can be passed, and consciences can be stirred, and consensus can be built.
…With effort, we can roll back poverty and the roadblocks to opportunity. Americans don’t accept a free ride for anybody, nor do we believe in equality of outcomes. But we do expect equal opportunity…
For we [Americans] were born of change. We broke the old aristocracies, declaring ourselves entitled not by bloodline, but endowed by our Creator with certain inalienable rights. We secure our rights and responsibilities through a system of self-government, of and by and for the people. That’s why we argue and fight with so much passion and conviction -- because we know our efforts matter. We know America is what we make of it.
…We are storytellers, writers, poets, artists who abhor unfairness, and despise hypocrisy, and give voice to the voiceless, and tell truths that need to be told.
… We respect the past, but we don’t pine for the past. We don’t fear the future; we grab for it. America is not some fragile thing. We are large, in the words of Whitman, containing multitudes. We are boisterous and diverse and full of energy, perpetually young in spirit...And that’s what the young people here today and listening all across the country must take away from this day. You are America. Unconstrained by habit and convention. Unencumbered by what is, because you’re ready to seize what ought to be.
For everywhere in this country, there are first steps to be taken, there’s new ground to cover, there are more bridges to be crossed. And it is you, the young and fearless at heart, the most diverse and educated generation in our history, who the nation is waiting to follow.
Because Selma shows us that America is not the project of any one person. Because the single-most powerful word in our democracy is the word “We.” “We The People.” “We Shall Overcome.” “Yes We Can.” That word is owned by no one. It belongs to everyone. Oh, what a glorious task we are given, to continually try to improve this great nation of ours.
Fifty years from Bloody Sunday, our march is not yet finished, but we’re getting closer. … When it feels the road is too hard, when the torch we’ve been passed feels too heavy, we will remember these early travelers, and draw strength from their example, and hold firmly the words of the prophet Isaiah: “Those who hope in the Lord will renew their strength. They will soar on [the] wings like eagles. They will run and not grow weary. They will walk and not be faint.”
I see the current efforts to extend healthcare to all Americans to be an extension of the issues of equality of opportunity that were expressed by the President. Ironically, it is hard to imagine a great country with more than an eighth of its population denied access to one of the fundamentals necessary to be a productive member of society. Statistics often hide even more disturbing facts.
If you ask what percentage of the 40 million or so Americans without access to healthcare (which does not include the majority of undocumented people which is more than 10 million) are white and non-Hispanic you discover the answer is 46% or about 19 million. The minorities including African Americans, Hispanics, Native Americans, Asians and others are 54% of the uninsured or over 22 million. Even those numbers hide the truth because as of the last census, white non-Hispanics were 63% of the population or about 200 million. That means that if you were white you had over a 90 % chance of having healthcare. Our total population is a little north of 310 million, meaning that if you were not part of the white majority you had only about an 80% chance of having access to healthcare.
“So what’s the big deal?”, you may ask. Well, the big deal is that the uninsured die at rates higher than the insured and they suffer disproportionately. Ironically, because of our current combination of social services and the disproportionate application of the Medicaid extension of the ACA by the choice of states following the ruling the ruling of the Supreme Court and further threatened by King v. Burwell, the uninsured of all races are the working poor and not the welfare recipients that so many of our politicians seem to loathe and deride as they use negative emotions and fear to win the votes that keep them in office.
There is a huge amount of data that allows us to imagine the true costs of these facts to individuals and to us collectively as a society. Just as an example let me direct your attention to a document about the health status of African Americans to emphasize what the President refers to as the “urgency of now”.
http://www.hhs.gov/healthcare/facts/factsheets/2012/04/aca-and-african-americans04122012a.html
As I was pondering the nuance behind the facts that the Presidents speech led me to consider and the lack of deep awareness or concern rooted in the slow evolution of culture and social awareness that existed across the South of my childhood, I was able to see many similarities between the struggle for civil rights and the struggle for better healthcare now.
Sitting on that bus I knew that George and Lurleen did not represent anything that I wanted to be a part of in the future. Even earlier as my family crossed the South on highway 80 year after year and we would stop at motels and restaurants that would not even consider serving a black customer, or when I went to the toilet at a service station and was confronted with signs that read Men, Women, Colored on three different doors, or saw a separate water fountain marked “colored” or “white only”, I knew that something there was not consistent with what I was taught in Sunday school. There was confusion as culture clashed with what seemed right. That same clash is still there as witnessed by the fraternity incident at the University of Oklahoma this week.
I thought about how fortunate I was to escape those experiences and be exposed to new ideas by the good fortune of enrolling in a medical school that was led by a physician, Robert Ebert, who was driven by the understanding that change is necessary but also knew that it is slow and hard to achieve because it requires evolutionary cultural change. I matriculated at Harvard Medical School in the September 1967. On October 19, 1967 Dr. Ebert gave The Kate McMahon Lecture, at Simmons College, just a few hundred yards from the Harvard Medical School quadrangle. His lecture was about the social transformation of medicine and the creation of socially responsible physicians. In his speech he touched on many of the realities of change that the President’s speech last Saturday considered. That speech about 48 years ago is very empathetic to physicians and describes their innate commitment to service but suggests that they change the focus of their concern from just individual patients to the larger view of the population. He recognized that team based care was necessary even as Medicare and Medicaid had hardly started.
I have often quoted a statement that Dr. Ebert made in a letter in 1965 not long after the Selma March and about the time that Johnson signed the Voter’s Rights Act. I have used the quotation from Dr. Ebert more than any other quote because I think that it represents an early description of the Triple Aim and still accurately describes the work that we must do and have not done.
“The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”
Dr. Robert Ebert 1965
The full text of the Kate McMahon Lecture is available in the Harvard Medical Affairs Bulletin of the spring of 1968. If you would like to read it in its entirety, just scroll through and you will easily find it among all of the other news.
http://archive.org/steam/harvardmedicalal423harv/harvardmedicalal423harv_djvu.txt
Below is an abridged edition that I have extracted for you. As with President Obama’s speech, I have bolded thoughts that stand out for me:
Much has been written in recent years about medicine and the physician. In keeping with the "Madison Avenue" approach of our culture, a good deal of rhetoric has been lavished on the "image" of the doctor, and even more on the dramatic advances in the science of medicine. A cursory survey of what has been written in newspapers as well as weekly and monthly magazines permits the conclusion that medical science comes off rather well and the doctor's image not so well. One gains the impression that doctors as a group are motivated by money, are becoming less and less interested in patients as people, and are socially irresponsible.
More often than not an author will point out that his own doctor is a good fellow but that the remainder of the profession is grasping, money- hungry and dehumanized. There are gross inaccuracies in what has been written about the medical profession, just as there are in what has been written about big business and labor unions. But it is more important to ask why there is so much interest in the doctor than to evaluate critically what has been said about him.
I believe it stems from an uneasiness on the part of both the public and the medical profession. The public has been indoctrinated to believe in the miracles of modern medical science, but the reality of delivery falls short of the expectation. The doctor is uneasy because his traditional role seems to be changing. He can no longer act solely as an individual, for he has become increasingly dependent upon others — other doctors, others in the health field, and above all upon the many people who work in the hospital. This changing role is related to his changing social responsibility and he is ill-prepared for the change.
The doctor is a frequent target for attack because he is said to lack a feeling of social responsibility. I believe this to be unfair, for in my opinion the average physician has a strong sense of social responsibility but it is a highly individualistic feeling which is largely invisible to the critical public. There is, as one might expect, great individual variation in the degree to which this feeling is developed but the same can be said for any other group in our society. How is the sense of social responsibility displayed by the physician? It is primarily manifest in the relationship between doctor and patient. Traditionally, the physician assumed a total responsibility for the health of the individual patient who sought his care. This relationship was maintained until the doctor discharged the patient or until the patient discharged the physician. As we shall see, this relationship is no longer quite so simple, but in one way or another the physician continues to assume that this one-to-one relationship between doctor and patient represents his primary responsibility toward society.
[Some of Dr. Ebert’s language may not sound politically correct to our 2015 ears. My class of 120 had 10 women in it so it is not a surprise that all references to physicians use the male pronoun. Now the class is half male and half female. All forms of diversity are represented. I once joked that for 1967 I was a diversity student and was probably admitted to satisfy the need for a certain regional and educational diversity. I was a white male from a southern state university.]
There are two other traditional ways in which the physician has sought to discharge his social responsibility. The first is by the provision of free care to the poor; the second is by teaching without financial reward. But these roles are also changing, and part of the modern physician's dilemma is the impending loss of this highly personal kind of giving…. The most profound has been caused by scientific and technological revolution in medicine.
Medicine is a far more complex art today than it was a generation ago, and the omnipotence of the individual physician in providing for all the needs of his patient has been lost. The science of medicine is changing at a logarithmic rate; therapy, whether manipulative or pharmaceutical, is becoming more specific, more potent, and more dangerous, and no physician today would claim that he can keep up equally well in all fields of medicine, even if he were to devote full time to such an endeavor. The physician has been forced to specialize because he cannot maintain competence in every field, with the result that today only 14 per cent of medical graduates plan to enter general practice.
Inevitably, these dramatic changes in the science of medicine have affected the manner in which the physician discharges his primary social responsibility — that is, the care of the patient. In a simpler age, the physician knew not only his patient but the patient's family; he was familiar with the patient's social and economic background, and he was able to provide care with a kind of personal understanding often absent today. The physician was able to do far less medically than he can today but no one could do much more; the general practitioner could safely provide most of the care needed by a family.
Understandably, there is a nostalgia for this kind of relationship and it is reflected in many of the articles written about the changing image of the doctor. Where is the understanding, fatherly physician of another generation? Why has the physician changed, and why has he become coldly scientific and uninterested in the "whole patient?" These are the questions asked again and again. The answer, of course, is relatively simple. The physician did not change because he wanted more money or was dissatisfied with a role enjoyed by a past generation. He changed because medicine changed and society changed. And in many ways the physician is as uneasy about the change as the public seems to be.
No longer can he provide for every need of the patient. He must call for help from a variety of experts, or if he is expert in one area himself he restricts his practice to that one area. Even if he is a general practitioner, he lives in a more complex society and is likely to know less about the patient's role in the community than did his counterpart a generation ago. The result is a more specialized and a more fragmented kind of medical care, often with no one coordinating the total care for the individual, much less the family. … We have developed a science of medicine which requires the skills of specialized medicine in everyday practice.
The concept of family medicine and the reality of specialized medicine are in conflict, with the result that the public is confused and the physician frustrated. Not all physicians provided free care for the poor, but the tradition was a strong one and more physicians participated in this method of giving than the general public realizes. … Now Medicare and Medicaid seem destined to end the provision of free care in the office and the clinic. Teaching has been linked with free care in the clinic and in the hospital ward, and this, too, seems likely to change now that the system of payment has changed….The problem we face is not how to provide the physician with a feeling of social responsibility but how to substitute successfully a broader kind of responsibility for one which has been intensely personal. …
There is no lack of problems to preoccupy the physicians who wish satisfaction from personal involvement in the health field. In my opinion the social problems are of greater magnitude than those which are strictly medical. Not only is there a place for the physician in the approach to these problems but he must be involved if they are to be solved. Let me describe what I believe to be some of the pressing social issues that involve the medical profession.
…Modern diagnosis and treatment demand a variety of skills and a complicated technology which cannot be duplicated in each doctor's office. The result is that more and more services are concentrated in the hospital or the medical center and the modern hospital has become the primary focus of medical care. And yet it continues to be used by the physician as though it were there for his primary convenience as an individual physician.
The organization of the hospital reflects this attitude for the administrative staff and the medical staff are usually quite separate. Most physicians look upon the administrative staff as the housekeepers, the board of trustees as money-raisers, and the medical staff as the permanent, rent-free tenants of the hospital. The result of this divisive organization is an institution singularly handicapped in planning for the health care of the community which it serves. Here, then, is an area for responsible social action which is new to the physician, which is less personal but which demands his participation. I do not mean that the physician should spend his time operating the hospital, but I do suggest that some of the energies he now devotes to the matters of how professional fees are paid might more profitably be directed toward planning for the hospital.
…Closely linked to the evolution of the modern hospital is the problem of the distribution of medical care. There are two groups who have suffered from the changing pattern of medical practice: the rural population and the urban population occupying the central city. …Once again, curiously little imagination has been exercised in seeking solutions to this problem…. It would take a different kind of organization of physicians, however, and would require a kind of teamwork with other members of the health professions which physicians have been reluctant to provide except within the walls of the hospital.
… The central city presents a different problem and one of greater magnitude. Few of the general practitioners who practiced in the city have been replaced, and the modern specialist serves the suburbs more than the city. The city or county hospital or large urban voluntary hospital provides most of the care for the urban poor. Often the actual medical care is good, particularly for the acutely ill patient, but too often it is care without dignity. Service is frequently fragmented among different hospitals for members of the same family, and even when paid for it tends to retain the trappings of charity. It is not surprising that the urban poor have sought a different kind of solution.
…First, the health problems of the urban poor are intimately linked with their socio-economic problems, and they cannot be solved by imitating the care given in the suburbs.
Second, more than the physician alone is required to provide these services; a well-organized team is essential.
Third, the community itself profits from a sense of active participation in the project. These are important lessons, and the physician can display a new kind of social responsibility in contributing to the solution of the problems of urban health.
The provision of medical care in the rural community and in the central city will require a different kind of organization of medical resources than has existed in the past. The physician must learn to work more closely with social workers, nurses, visiting nurses, in fact all of the members of the health professions. There must be a sensible division of labor so that the physician performs those services which only he can do, and other duties are delegated to appropriate members of the health team.
[Working in teams with each member having standard work and working at the top of their license is not a new idea.]
I believe this can be done but it will take innovation and will require of the physician a new kind of responsible social action. Care for the chronically ill and for the elderly, who so often suffer from chronic disease, is a particular case in point. Chronic illness is increasingly common and it cannot be handled effectively if it is thought of as an exclusively medical problem. The social, emotional and economic impacts of chronic disease must be understood and intelligently dealt with. Here the physician must share the responsibility with others who have special skills to offer.
…It is apparent from this brief listing of social problems affecting medicine that there is no lack of projects for the socially-motivated physician. Why has the physician displayed so little interest in them? I suspect the answer lies in the manner in which he has been educated.
The social values of the physician come from the environment of the medical school and the hospital in which he receives his internship and residency training. He does not learn them in the classroom but rather from his preceptors. He is likely to assume the social values of those he respects and for the remainder of his professional life he imitates what he has seen and experienced as a medical student and as a house officer….Unfortunately, more students are taught by teachers of limited vision than by the "greats," and for this reason the actual environment in which teaching is done has a narrowing influence….
He sees enormous preoccupation with the scientific care of the acutely ill patient but the relative neglect of the same patient once he or she is discharged from the hospital. …Too often patients are treated without appropriate dignity and it is common for a patient to wait most of the day for a visit with the doctor and for various laboratory tests.…Little of his medical school or house officer experience prepares him for anything more than responsibility for the individual patient. He has almost no exposure to the overall problems of delivery of health service to a particular population, and he tends to remain curiously detached from any commitment to the overall community which the teaching hospital serves.
Much more needs to be done. More able people are needed in the medical school environment who devote their attention to the social problems of medicine. There must be study of the needs of particular communities, and innovative plans … to test new ways of organizing medical care. There must be a greater integration of effort of physicians, social workers, nurses and others, both in the hospital and in the community.
Above all, the student must actively participate in such programs. … He must be made as aware of the social problems of medicine as he is of the biological problems.
I think that this will happen, and one reason for my optimism is the attitude of many medical students today. These students come to medical school dissatisfied with the manner in which society has handled the problems of the poor and of the Negro. They are concerned about social problems abroad as well as at home, and above all they wish to become actively involved in seeking solutions. I predict that they will provide the necessary prod to a conservative profession and to a conservative educational process.
It was against this background that Dr. Ebert founded Harvard Community Health Plan in 1969. My most important experience in medical school was my two year clinic in the Children’s Hospital Family Care program where this message of social responsibility was delivered in a nurturing environment. Dr. Ebert’s insight and vision are in many ways a medical equivalent of Dr. King’s I Have a Dream Speech of 1963. Now a half century lies between these visions that are so linked and our problems do persist, but as the President’s speech suggests there has been much progress. There is just so much more to do and as the President says:
All of us will need to feel as they did the fierce urgency of now. All of us need to recognize as they did that change depends on our actions, on our attitudes, the things we teach our children.
Dr. Ebert focused a lot on the solution lying in how we teach our medical students to be leaders with a broader sense of social responsibility than the individual patient and he challenged us to embrace as equals all of our colleagues who are medical and social services professionals. He had a vision of the Triple Aim and if you look carefully at the sum of all of his suggestions you see the image of the ACO emerge and you certainly see the foundations of population based health.
Dr. Ebert challenged physician to move from practicing in silos to practice with other healthcare professionals in teams for the benefit of the patient. He demanded that we look past our traditional commitment to individual patients to our larger responsibility to the community. He knew that it would be a slow process and that we would need to grow a new generation of leaders for students to emulate. Dr. Ebert knew that the answers for the issues we faced in 1967 and that we still face in 2015 are far beyond the capacity of individual physicians working with individual patients. The answers lie in organizing the work to make high quality care a reality for everyone. Dr. Ebert would have embraced Lean as a way of coordinating the processes or “value streams” that delivered the care that we need and he expected that the inherent social responsibility of physicians would make them leaders of the move and not barriers to its progress.
I am almost sure that Dr. Ebert was aware of and agreed with my favorite quote from Dr. King:
"Of all the forms of inequality, injustice in health care is the most shocking and inhuman."
Dr. Marin Luther King, Jr. 1966
It is fifty years and counting. Progress has been made toward Dr. King’s dream that:
"I look to a day when people will not be judged by the color of their skin, but by the content of their character."
We have been working just as long for Dr. Ebert’s dream. The greatest opponent of both dreams is a culture of self-interest that is reluctant to extend what a majority enjoys to a minority for some unfounded fear that individually somebody will lose something. Ironically “they” have it backwards; we all have so much to lose by not extending an equal opportunity to everyone in all aspects of our lives together in this nation and that certainly includes healthcare.
The Sap Is Rising
I did a quick out and back to Seattle this week. All the early flights and jet lag were made worthwhile by the warmer weather, clear skies, and flowering trees that met me there. It was such a hurried trip that my only “walks” were across Chicago’s O’Hare from terminal F where the little regional jets from places like Manchester, New Hampshire, now my home port, land and take off and terminal C where the big jets to the coast live. Both ways I was at the far end of each terminal and must have gotten in at least a mile when I decided to walk it because the lines to the bus connecting the two showed no evidence of Lean planning for good flow. There is nothing like the adrenaline rush of the fear of missing a connection to get those catecholamines pumping.
Back at home there was evidence that despite a lot of snow, which the Globe predicts will be with us until mid April, there were signs of spring. It was not crocuses that had sprouted during my absence from the byways that I walk, but rather as this week’s picture demonstrates, buckets attached to the sugar maples, that lined the roads I walk and told me that we are really over the hump of winter.
I hope that you will get out this weekend under clear skies and in lengthening, somewhat warmer weather, for a walk to look for your own evidence of better things to come.
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