| 15 July 2016
Dear Interested Readers,
Inside This Letter
For several weeks I have been writing about “what might be” in the future of healthcare. My purpose was to try to put where we are today in the context of an arc in time. Part of my motivation for talking about the future was to provide some meaning to the sense of struggle and discomfort that is such a burden for so many of you who are healthcare professionals. Some of you who are interested readers are not providers of care, but you are consumers who are just as interested and concerned about the future of care. You worry about what lies ahead for yourself and your family. The series was meant to be of benefit to you also.
What I learned in the processes is that conceiving is not the same as doing. I had originally imagined that I would also write about the future from the perspective of commercial insurers and then move on to the new world for regulators and providers of public coverage. Perhaps I will come back to those subjects in a few weeks. In retrospect each of the essays could be substantially expanded. I hope that what was produced has offered you some benefit for the time that you have invested as a reader. Abridged versions of all of the essays in the series on the future are now posted on strategyhealthcare.com where I hope they we be easily available to everyone.
This week’s letter is about the options that healthcare professionals have available where they are right now. Think of it as one man’s answer to a question that you may be asking, “How can I make a difference today?” Perhaps you have a different question, “How can I survive today?” Both questions may have the same answer. The meat of this letter is a discussion of what we can do today as individuals where we work everyday, no matter what others are not doing. It is also a journey back of sorts for me to the joy of practice.
Never a day goes by in retirement that I do not reflect on my forty plus years seeing patients and interacting with colleagues. Despite all that I remember fondly, never a day goes by that I do not think of some event that I could have better managed. At night dreams of “do overs” in the hospital and office have become more common than my old favorite “do over” dreams of high school football, college classes, romantic interludes and repeating medical school. Now on the “other side” where do overs and opportunities for improvement can only be the substance of dreams and never realities, I hope to communicate what I know, even though I am unable to do it myself. I hope to pass on something to those of you who are still on the field. My assumption is that if you are an “Interested Reader” you have already self selected into the group of healthcare professionals who find meaning in the statement:
Care better than we have ever seen, health better than we have ever known, cost we can all afford, …for every person, every time.
This week’s letter would be deaf to the realities of our world if it did not recognize the fearsome events of this last week in Baton Rouge, Minneapolis, and Dallas. I think that it is important to attempt to capture some of the wisdom from President Obama’s amazing speech in Dallas. He eloquently reviewed the reality of our collective condition and his advice has meaning that spills over all of our shared endeavors including the desire to equitably heal our bodies, our minds, our spirits and our sense of community spirit.
I am taking a week off from my usual last chapter of sports observations and analogies. Baseball took its mid summer vacation this week. I have never had much interest in “all star” games. Somehow the latest chapter in the persecution of Tom Brady has not captured much interest as everyone accepts the concept that the Supreme Court has better things to do than to be sure that he is on the field for the first four games of the year. I close the letter by celebrating that it has been a good week just to enjoy being away from a hostile world.
What Can We Do Today?
This week two interesting emails pinged into my in box. I was not expecting either of them. The first to arrive was from the Health Policy Commission of Massachusetts (HPC). Despite the fact that I no longer live there, I have continued to serve on the Advisory Council to the commission. I guess my continuing presence is somewhat justified by the fact that, like many in neighboring New England states, my wife and I frequently drive the 200 plus mile round trip to Boston for our medical care.
The HPC was announcing to its advisors the completion of the report on provider price variation in Massachusetts that had been written on the basis of the 2015 cost trends analysis and three separate days of highly developed hearings that occurred over the winter and spring. If you are interested in the enormously important issue of price variation, all of this data and analysis is now available to you on the HPC website or you can download a PDF of the report.
The second interesting email was notice of the “free” article in JAMA by President Barack Obama, “United States Health Care Reform: Progress to Date and Next Steps”. The article is accompanied by three editorials that are also online for free from JAMA and has been reviewed by the New York Times. I have read the President’s article and the report from the Health Policy Commision and commend both to you for perusal if not complete consumption. Many weeks either communication would be a delight for me because I would be assured of a certain worthy subject for this letter. This time around I am passing on the opportunity that such rich material offers and will be satisfied to give you notice so that If you have not seen or read them you are notified of your option.
Both articles are extremely interesting and it is absolutely true that they contain information about the high level direction that healthcare reform is headed. Both articles struggle with the recurrent issues of finance, the question of what is value, and how we provide equity across all institutions and providers. The issues discussed in these articles will shape the future that so many of you will experience, but these issues are far beyond the pale of any practical day to day influence that you may have. The issues in healthcare that will determine our future seem as far beyond the control of the individual healthcare professional or patient as the issues of the economy, trade policy, and social inequity are to the individual citizen. As healthcare professionals and as citizens it is right for us to be informed. It is right for us to have opinions. And, it is most important for us to ask, “What can I do right here and right now?”.
In our civic lives our influence is not just limited to an ability to vote. It is very clear that in this election many citizens have found that collectively they can advocate for a new direction and show their support at meetings and rallies as well as offer donations to the candidates and causes with whom they are aligned. As TIp O’Neill famously said, “All politics is local”. Don Berwick has advised us that if we want to see true reform in healthcare that achieves the Triple Aim we must think globally but act locally.
Don also has said:
Leaders must emerge who regard themselves as defenders not of organizations but of the underlying purposes that have temporarily created those organizations in their current forms. Leaders will have to be willing to unmake the very organizations they hold in trust. That’s a big job. It requires the kind of courage that is rare among human beings, including organizational leaders.
(From “Seeking Systemness” Healthcare Forum Journal, March/April 1992)
I am taking Don’s “leader” and expanding the definition to include everyone who cares enough about the future of healthcare to ask themselves, “What can I do?”. Such a person would also realize, as Don implies, that practices and institutions exist for a purpose, and if that purpose is in jeopardy or if it is not being achieved, then change must occur, even if it means individual and institutional transformation.
One of the most frequent complaints that I hear as I move from conversation to conversation with physicians who are friends and colleagues is that they have lost the joy of practice. Burnout is indeed a huge concern. The usual complaint is “This is not what I signed up for!”. George Bernard Shaw had a balanced but rather blunt response to such complaints. He advised us that to find true joy in life we must expect to be “used up” by a mighty purpose and not be focused on grievances.
There is the true joy of life; to be used by a purpose recognized by yourself as a mighty one; to be thoroughly worn out before being thrown on the scrap heap; to be a force of nature instead of a feverish, selfish little clod of ailments and grievances complaining that life will not devote itself to making you happy.
I see harmony between the admonitions of O’Neill, Berwick and Shaw. We all have the opportunity to be involved in improving things where we live and work. Leadership is much more about being an example that others notice and follow than about titles and institutional powers. A focus on self almost never leads to anything that has enduring satisfaction. There has never been a better time than this moment in healthcare for those who felt compelled to work in healthcare to have an opportunity to make a difference.
One of my most favorite lines from all of pop music comes from Paul Simon’s brilliant song “Kodachrome”: "When I think back on all the crap I learned in high school, it's a wonder I can think at all.". That song came out in 1973 when I was in the middle of my postgraduate “training”. Even then I was aware of the incomplete nature of my preparation for practice. In my head the line became "When I think back on all the crap I learned in medical school, it's a wonder I can think at all." When I joined Harvard Community Health Plan in 1975 as a PCP and its cardiologist, the line morphed further into "When I think back on all the crap I learned in medical school, internship, residency and fellowship training, it's a wonder I can think at all." [In 1975 it was the culture of HCHP that all medical specialists also do some primary care. Specialists were freed of this requirement in the early 80s but by then I was reluctant to give up the joy and enhanced perspective as a PCP and so continued to have a small primary care panel through more than three decades.]
Just as I was ill prepared from my training for the challenges of office practice in an innovative capitated practice of the mid seventies, I hear and see that most physicians and other medical professionals question their preparation for the demanding fast paced and poorly supported realities of practice today where there is never adequate time for the ideal patient interaction. The time that they once had, or always imaged that they should have, to give to their patients is now consumed by time spent on compliance with regulations and doing the documentation of their every action that seems to add little value for anyone other than those in finance.
They complain that they are asked to spend more time staying up with external regulatory and business changes and both internal and external policy and procedural changes than they are maintaining an up to date fund of knowledge in the science and innovations of their practice. It is easy to understand the anger, depression and burnout that is associated with such a reality. It may seem preachy and insensitive for me to reference a moralistic quote from Shaw that outlines a path to “true joy” and seems insensitive to pain when it admonishes one to “...to be a force of nature instead of a feverish, selfish little clod of ailments and grievances complaining that life will not devote itself to making you happy.” But, your mindset and sense of purpose are your own choice. Your attitude as you face your daily challenges as you try to do your best giving care is the only factor over which you have complete control.
I hope that you are part of an enlightened practice that is pursuing a leadership role toward the Triple Aim. I hope that you are blessed with local leadership that understands their responsibility as described in the quote from Don Berwick. I hope that where you work there is enthusiasm for positive change and the work to provide new workflows and a redistribution of responsibilities that will ameliorate burnout and improve your ability to serve patients is well underway. But, if you are in an environment that is still struggling, what can you do?
For some reason when I ask myself this question, the children’s song “This Little Light of Mine” comes to mind. Maybe you learned the little song in some religious environment or at summer camp. Maybe you first heard it as you kids listened to Raffi sing it, or if you are a millennial perhaps you learned it from Raffi. You know the words I am sure. There are several versions. You heard a longer version if you clicked on the last link or you can read the words from Raffi’s version below. There is a lot of repetition but it makes a point.
This Little Light Of Mine Lyrics
This little light of mine, I'm gonna let it shine.
This little light of mine, I'm gonna let it shine.
This little light of mine, I'm gonna let it shine.
Let it shine, let it shine, let it shine.
I'm gonna take this light around the world and I'm gonna
let it shine.
I'm gonna take this light around the world and I'm gonna
let it shine.
I'm gonna take this light around the world and I'm gonna
let it shine.
Let it shine, let it shine, let it shine.
This little light of mine, I'm gonna let it shine.
This little light of mine, I'm gonna let it shine.
This little light of mine, I'm gonna let it shine.
Let it shine, let it shine, let it shine.
I won't let anyone blow it out, I'm gonna let it shine.
I won't let anyone blow it out, I'm gonna let it shine.
I won't let anyone blow it out, I'm gonna let it shine.
Let it shine, let it shine, let it shine.
This little light of mine, I'm gonna let it shine.
This little light of mine, I'm gonna let it shine.
This little light of mine, I'm gonna let it shine.
Let it shine, let it shine, let it shine.
Every day, every day, I'm going to let my little light
shine.
I have not lost my mind. What we often lose that makes us ineffective is our original sense of purpose that prevents others from “blowing out” our light. To sustain that sense of purpose over the long haul of a career we need both a methodology as well as ritual, comradery, and a sense of community to support us. As Robert Fulghum postulated in his little book All I Really Need To Know I Learned in Kindergarten, things do not have to be that hard if we stick to basics that a five year old can understand or sing about.
Playing games with numbers, I have tried to calculate how many office sessions and patient visits I had over the course of my career. My guess is that I had at least 150,000 unique office visits. I can’t say that I never had a bad day or that I never failed to give my patient what they needed, but I can say that at some moment before most sessions I did what I always did before an athletic event. I paused long enough to think about what was ahead and focus my mind on the challenge and how I would try to perform my responsibility. In my reflection I tried to be grateful that I had the opportunity to accept the challenge to be of help to someone. I distinctly remember being aware of the joy of working with people I loved and respected. I remember conceptualizing that I needed to try to realize that for the last patient of the day I had the professional responsibility to focus on their need with the same intensity as I brought to the first patient.
My first responsibility was to be present for every patient and to try to understand their concern free of my own issues and fatigue. I was grateful for the support of all my colleagues, no matter their title or responsibility. I was mindful that I had assets that were given to me to use for others and in coordination with others. I quickly learned that a bad day, a day that I regretted, was not a day when I was asked to do too much, but a day when I failed to keep my needs secondary to the needs of the patient. When I lost sight of the patient’s needs and succumbed to my own self serving strategies I was more likely to provide care that seemed expedient for me but in the long run was neither safe, timely for the patient, an efficient use of resources, or equitable or fair to the patient. In the end I was invariably the looser. When I prepared myself to focus and serve and had the self control to follow my professional instincts, even if it cost me time or required me to triage my day, things were better for everyone, including me.
Looking back I learned some simple rules that unfortunately I did not always follow and those failures are the source of my “do over” dreams in retirement:
- Do not hide in the office under the pretense that you are overburdened. Be an active part of what is happening around you.
- “Rely on the kindness of others”. When you do not know an answer or have a task that seems to be more than you can do well for your patient, reach out to colleagues for help.
- Thank people for the help that sustains you.
- Realize that in the end “cutting corners” leads to defects and is ultimately inefficient. Look for what Lean calls “the best least waste way” to get the job done. At a minimum be analytical about what you can control in your own work and practice, what TQM called “quality in daily work life”, even if everyone else seems distracted.
- Listen closely to your patient and try to understand their question or concern in the context of their worldview or perspective and not your own.
- Respectfully bring your concerns to your supervisors and if possible endeavor to be part of the solution and not part of the problem for others.
- Be truthful about everything and to everyone including yourself. Do not attempt to hide your inadequacies, especially from yourself. Be able to say “I do not know, but I will try to find out”.
- Try to understand how you are perceived by others. If they misunderstand you, ask yourself why and what in your presentation or performance leads them to the wrong opinion of you.
The list could be much longer but I will leave it there. My objective in creating my list is to suggest and encourage you to create your own list. My enthusiasm for Lean is because its philosophy and methods carry the spirit of this list from the acts of an individual to a process that can be shared by everyone in the organization. In the end, perhaps the best individual advice comes from Gandhi, “Be the change that you want to see in the world”. I recognize that in this complicated world that advice is easy to provide, but hard to follow. Brian Morton, a professor at Sarah Lawrence, summed it up five years ago in a New York Times op ed piece:
Thoreau, Gandhi, Mandela — it’s easy to see why their words and ideas have been massaged into gauzy slogans. They were inspirational figures, dreamers of beautiful dreams. But what goes missing in the slogans is that they were also sober, steely men. Each of them knew that thoroughgoing change, whether personal or social, involves humility and sacrifice, and that the effort to change oneself or the world always exacts a price.
Being an agent of change, making a difference, is not easy work. Being a self interested source of disharmony may be transiently satisfying and a role that seems more fitting at times, as seems to be true in this political year, but as professionals we should realize that we have chosen to accept the responsibility to try to solve the problems that face us and our patients . Just complaining about how tough the job is will never do anybody any good.
Trying to Extract Meaning From Tragedy
There is hardly anything that President Obama can say or do without his harshest critics seeking to find some political motive in his words and actions. One of his most frequent tasks over the last nearly eight years has been to speak at memorial events following the tragedies that fill us all with despair and concern. I can understand why his critics complain about how he fulfills these “head of state” responsibility because the wisdom and feeling he demonstrates usually is a call for us to all to subjugate our self interest to some sense of equity, community, or the greater good.
I had conceptualized what I wanted to say in this week’s “Musings” before the President spoke in Dallas. I was out on my daily walk with the expectation of listening to Terry Gross on NPR when they gave me his speech instead. If you did not hear it, or if you did not click on the link to the YouTube broadcast presented earlier in this letter you may want to read the speech. As I listened on my walk I heard him either intentionally or through a slip, substitute “deadlocks” for “dreadlocks”. I did a little research and dreadlocks are obviously a way of wearing your hair that is popular among African Americans and they are never called “deadlocks”. Equally obvious is the definition of “deadlocks”: “a situation, typically one involving opposing parties, in which no progress can be made”. Was it a “slip” that reveals deeper meaning? Check it out yourself. The text of his speech is available here courtesy of Time magazine.
The slip to “deadlocks” occurred as he was describing Philando Castile who literally died on Facebook after being shot after a traffic stop. Incidentally the name Philando means “lover of mankind”.
Just as we should hear the students and co-workers describe their affection for Philando Castile as a gentle soul. Mr. Rogers with deadlocks, they called him. And know that his life mattered to a whole lot of people of all races, of all ages, and that we have to do what we can without putting officers’ lives at risk, but do better to prevent another life like his from being lost.
As a nation it seems that with most of the issues of substance we are “deadlocked”. I do not accept as plausible Thomas Friedman's assertion that the solution is an overwhelming rejection of the Republican Party in the elections this fall. I believe that there was great wisdom in the President’s speech that can inform us not only in the artificial dichotomy of “Black lives matter” versus “the proper role of police”, but even provide insight into our journey toward better healthcare and a more equitable society. All these issues are connected. For resolution they all require respectful conversation, compromise, and hard work by everyone.
I have taken the liberty to lift up some of the special parts of the President’s speech which some are calling his best ever. My hope is that you will take the time to read these excerpts even if you do not have time or want to listen to the whole speech which is about forty minutes long. I have bolded words that resonate deeply with me.
Scripture tells us that in our sufferings, there is glory, because we know that suffering produces perseverance; perseverance, character; and character, hope. Sometimes the truths of these words are hard to see.
Like police officers across the country, these men and their families shared a commitment to something larger than themselves. They weren’t looking for their names to be up in lights. They’d tell you the pay was decent, but wouldn’t make you rich. They could have told you about the stress and long shifts. And they’d probably agree with Chief Brown when he said that cops don’t expect to hear the words “thank you” very often, especially from those who need them the most…
All of it has left us wounded and angry and hurt. This is — the deepest faultlines of our democracy have suddenly been exposed, perhaps even widened. And although we know that such divisions are not new, though they’ve surely been worse in even the recent past, that offers us little comfort….
I know we’ll make because of what I’ve experienced in my own life; what I’ve seen of this country and its people, their goodness and decency, as president of the United States. And I know it because of what we’ve seen here in Dallas, how all of you out of great suffering have shown us the meaning of perseverance and character and hope….
I see what’s possible when we recognize that we are one American family, all deserving of equal treatment. All deserving equal respect. All children of God. That’s the America I know…
And I’ve seen how a spirit of unity, born of tragedy, can gradually dissipate, overtaken by the return to business as usual, by inertia and old habits and expediency…
We also know what Chief Brown has said is true, that so much of the tensions between police departments and minority communities that they serve is because we ask the police to do too much and we ask too little of ourselves...As a society, we choose to under-invest in decent schools. We allow poverty to fester so that entire neighborhoods offer no prospect for gainful employment. We refuse to fund drug treatment and mental health programs…
We know those things to be true. They’ve been true for a long time. We know it. Police, you know it. Protesters, you know it. You know how dangerous some of the communities where these police officers serve are. And you pretend as if there’s no context. These things we know to be true. And if we cannot even talk about these things, if we cannot talk honestly and openly, not just in the comfort of our own circles, but with those who look different than us or bring a different perspective, then we will never break this dangerous cycle...
In the end, it’s not about finding policies that work. It’s about forging consensus and fighting cynicism and finding the will to make change. Can we do this?
Can we find the character, as Americans, to open our hearts to each other? Can we see in each other a common humanity and a shared dignity, and recognize how our different experiences have shaped us? And it doesn’t make anybody perfectly good or perfectly bad, it just makes us human.
I don’t know. I confess that sometimes I, too, experience doubt. I’ve been to too many of these things. I’ve seen too many families go through this.
But then I am reminded of what the Lord tells Ezekiel. “I will give you a new heart,” the Lord says, “and put a new spirit in you. I will remove from you your heart of stone, and give you a heart of flesh.”...
With an open heart, we can abandon the overheated rhetoric and the oversimplification that reduces whole categories of our fellow Americans, not just opponents, but to enemies...With an open heart, we can worry less about which side has been wronged, and worry more about joining sides to do right...we know that suffering produces perseverance, perseverance character, and character hope.
And as we get older, we learn we don’t always have control of things, not even a president does. But we do have control over how we respond to the world. We do have control or how we treat one another.
Our character is not found in isolation. Hope does not arise by putting our fellow man down, it is found by lifting others up.
Whenever the World Gets Heavy
I am addicted to exercise. For all of my life I have found relief in movement. A few years ago I calculated that over the years I had run over sixty thousand miles. It was enough exercise to wear out one knee by sixty five, but over the last six years I have added several thousand more soul saving miles by discovering the equal pleasures of a good walk. I get in my 10,000 steps most every day. My walks are “modular”. The first and last quarter mile are up from the lake to the main road and back down from the main road. I am only on the busy main road for a few dozen yards at which time I can go left up a hill or right and down a road that follows the shore of the lake. After that first choice many others follow. My walks are “modular” and it seems there is almost an infinite number of additional choices after that first quarter mile and the “right” or “left” call. One set of choices brings me to the view that I present to you in today’s header. It is a look from Clark’s Point down the length of Lake Sunapee toward Mount Sunapee.
The view strikes you with its magnificence as you emerge from a short uphill climb through the woods. It is my own little version of John Muir’s Inspiration Point overlooking Yosemite Valley. It is a good place to pause and realize the beauty of the natural world and our challenge to bring our mundane considerations into harmony with the glory that is here for us to share. I would be surprised if there is not some accessible place for you where you can go either alone, or with a companion, and enjoy some renewal that will provide energy that will help you continue your journey. |
| Be well, stay in touch, and don’t let anything keep you from doing the good that you can do every day,
Gene
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