17 June 2016
Dear Interested Reader,
About This Letter
It is really hard to sit down to write in the aftermath of tragedy. Three weeks ago I began a series on the expectations of the future of healthcare with an overview of the tools and concepts that would be helpful for a more productive future in pursuit of the Triple Aim. In the second week the the study moved on to considering the future from the perspective of the patient. Last week’s letter examined how the work of care delivery would change for providers. In my systematic long range planning for this week, I had assigned myself the topic of the future from the perspective of boards in nonprofit healthcare organizations.
My primary professional identity has always been that I am someone’s doctor. My secondary identity has been as a board member. I have been on one or more boards in healthcare as a member of the board or as board chair for more than thirty years. It is clear to me that the performance of boards and good governance practices will continue to be distinguishing factors between those organizations that will succeed or struggle in the future. The challenge to boards and many of their members who are not healthcare professionals is to understand that the complexities in the rapidly changing environment of healthcare are greater now than ever before. It was very late in my work life that I became a manager. A discussion of the future challenges for managers will follow the examination of boards as a subject for a letter in the near future.
I feel that finishing the work that I had laid out is important to my sense of order. There are things that I feel are of great importance left to be said. I have long contended that it is good to have a plan and to stick to it until external realities suggest the need for a course correction. This week’s letter is a response to the negative externalities that we are sharing as healthcare providers. It is a worthy part of this series because I believe that healthcare professionals should be contributing participants in the discussion about gun violence and should be leaders who help shape overall policy in a society where we function from a position of respect and do have opinions that need to be considered as the discussion progresses.
Many people listen to our opinions with respect and we do have the ability to offer advice that those who trust us will consider and sometimes accept. Individually, we have the responsibility of any ordinary citizen to participate in this important conversation. Individually and collectively we have a larger professional responsibility to our community. In this letter I discuss my feelings about the options for our collective response to the threat to the the health of the public posed by easily available military grade weapons. The discussion is enlarged to look at the responses to terrorism that are available to us as citizens and as healthcare professionals during troubling times and disturbing events. As the President so eloquently said in his first televised response last Sunday:
“...we have to decide if that’s the kind of country we want to be. And to actively do nothing is a decision as well”
Last week’s letter is revised and condensed on strategyhealthcare.com. I hope that you will check it out and my hope remains that you will consider offering your ideas to all of us by submitting an essay that that we can post in the near future.
Preparation, Participation and Attitude for a Better Future
In the aftermath of the horrific mass shooting at the Pulse nightclub in Orlando I find myself challenged to justify the very positive view of the future that I have been trying to generate in these letters. As was true of the medical response to the Boston Marathon bombing in 2013, I do feel awe and a great sense of appreciation and pride for the nationwide demonstration of the foresight and competence that has enabled almost every community in America to be able to respond to the sudden challenge of caring for a large number of victims from a bombing or mass shooting. The medical community of Orlando has performed admirably in the face of a tremendous and unexpected challenge. What is ironic to me is that we live in an age when for almost every other public health threat, be it AIDS, the opiate epidemic, or the developing concerns about zika, we develop two processes. We have learned that to focus on treatment alone is never as effective as developing and deploying a plan for prevention. I can think of no other menace or threat to the health of the public than gun violence where we have not been able to generate and deploy some effort at prevention.
Donald Trump promised the American people earlier this year during a debate and later in multiple interviews during the primary process that if elected he would abolish Obamacare, but reassured us not to fear because “no one will die in the streets”. I am interpreting his comment to mean that during his presidency people would not be dying in the street without care from conditions like cancer, heart disease or stroke because, as I have pointed out before, by law since the passage of EMTALA in 1986 every hospital in the country is required to provide care to anyone who is brought to them without regard to the status of their insurance coverage or ability to pay.
From his comments I am not sure that he includes care during the slow course of chronic diseases, the debilitation experienced by the underserved that is attributable to the unequal approach to protection from the social determinants of disease, or from vulnerability to sudden death arising from firearms. His comments and opinions on healthcare and healthcare policy, as well as the comments and opinions of Hillary Clinton on healthcare, as well as all other issues that face us as a country must be carefully considered because one of them now, almost certainly, is destined to be the next president. How we answer the questions that impact the interpretation of the second amendment that guarantees the right of individuals to bear arms, with the responsibility of government to protect all members of society, is one of many questions that currently divide us. With each recurrent episode of violence our frustration with our inability to find a consensus solution is creating increasing polarity and contempt between those on either side of the question.
In his first statement last Sunday after the massacre at the Pulse, President Obama was chilling in his direct but truthful statement about control of the access to firearms and the collective concessions that we must make to each other if we are going to achieve an improved, if not ideal state. He said:
“...we have to decide if that’s the kind of country we want to be. And to actively do nothing is a decision as well”.
As the minister he felt that his most significant responsibility was not performing weddings and funerals and all of the other important functions that provide comfort and reassurance to troubled souls, but to inform everyone whom he encountered that they had a fundamental decision that they needed to make. For him “proclaiming the truths of the gospel” was always preparatory to the presentation of the question, “What are you going to do?”. His commitment to evangelism and the question that he considered to be central to his mission lead him in mid career to accept the responsibility for directing all of the evangelical efforts of the Baptist Church in South Carolina. In the late sixties he assumed responsibility for directing all evangelistic efforts in metropolitan areas across the country for Southern Baptists, the largest “protestant” denomination in America.
In local churches, in state gatherings and in efforts in large cities across the country, Dad delivered the same message at every opportunity to be heard. His theme was that we all have problems that we can not solve alone. The answer was that we needed the divine assistance that was available to us if we would only ask for it. The key change was to make a decision to ask for help. The inability to decide to pursue a change in your life by asking for help was the equivalent of deciding to reject the idea of changing. To do nothing was to do something. At important moments in life inaction is action.
I learned years ago when I was trying to be more effective in helping a patient to quit smoking that I had more success if I used a carefully aimed question that was an honest inquiry. I got this advice from a senior colleague who was a wise and respected mentor after experience had taught me that I rarely convinced a person who enjoyed smoking, and had been doing it for years, that they should give up the pleasure by saying that they should stop before they had a fatal complication. After decades of warnings from the Surgeon General and numerous other agencies as well as concerned family members, those who could quit on the basis of either information or dire warnings probably had already done so. If you are still smoking, it is a combination of a choice and physical addiction. Information and reason are insufficient to motivate you to change.
I discovered that I was more likely to be successful if I asked questions rather than made statements or presented data proving how dangerous their behavior was to their health. Questions were necessary but insufficient if I did not prepare the moment. My questions needed to be asked after my patient trusted that I felt a sense of responsibility for them. They needed to trust that I would respect them and not reject them, no matter what happened as an outcome of the process. My inquiry needed to be sincere. I could not ask questions that were a setup for a “gotcha” conclusion.
When the right moment came, I would ask from the perspective of sincere interest if my patient would tell me about the satisfaction and the joy they received from smoking. I would then try to direct the conversation to a deeper exploration of the benefits that they perceived they were enjoying. Eventually, I would ask them for a value judgement about the cost benefit trade off from their perspective. Finally, I would ask them if they would like to work with me to find alternatives that might provide an acceptable replacement for what smoking did for them. We would search together for solutions that were less costly to their health than smoking. There was almost always a positive response to my question. Before we began our work we would talk about previous failures to see if we could discover solutions to the problems that had defeated them before. We recognized that we might fail again and talked how we would deal with failure. Every patient had a unique problem but the similarities between patients were greater than the differences. After all the questions were considered, the work would begin.
If you clicked on the links above you might have read one analysis that said:
It wasn't the first time President Obama denounced a hate crime in the aftermath of a mass shooting, and it wasn't the first time he expressed resolve in the face of a terrorist attack. And it certainly wasn't the first time he called for action to keep firearms out of the hands of would-be killers. But Sunday's remarks following the Orlando nightclub shooting were the first to incorporate all three of those themes.
Finding a simple solution for such a complex set of problems that respectfully addresses all the associated concerns is probably impossible. Within our community I believe that the majority of people across all political groups reject hate crimes. To say that a person does not reject hate crimes because they do not want to limit gun ownership in any way is a non starter for any productive conversation. I reject the idea that more than an infinitesimally small minority harbor enough hate or have enough xenophobia, homophobia or fear of people of other religions or political ideologies to advocate murder. We all share a deep concern about the existence and persistence of terrorism even if we have not evolved solutions that any of us are confident could work. We have tried many things that have not worked and continue to debate what could work. That discussion has not reached the level of impasse that we have reached on the issues of gun ownership and the proper place of firearms in our society.
I have been encouraged that the focus of many has been on how we can make progress together in our effort to reduce all fatalities related to guns. I applaud comments made by Bill O’Reilly this week on Stephen Colbert's late night program on Monday night. It was not a discussion that was totally harmonious. Both men represent positions that they can well defend, but to my surprise after the predictable declarations of certitude from both men, O’Reilly extended an opportunity to find some common ground. In the link above the author says:
Interestingly enough, the two found common ground during the conversation, with O'Reilly admitting that the government needs to dictate which guns should be banned in the United States, namely high-capacity rifles.
Another glimpse of hope could be seen in a New York Times report yesterday that reviewed the Senate debate and filibuster on a bill to limit access to assault rifles. Both Hillary Clinton and Donald Trump are mentioned.
Democratic presidential candidate Hillary Clinton joined Senate Democrats' call for action. Presumptive GOP presidential nominee Donald Trump weighed in with a tweet suggesting he would meet with the NRA and support efforts to keep guns out of the hands of terrorists. Exactly what he would support was unclear.
Trump, the presumptive Republican nominee for president has been endorsed by the NRA. He jumped into the gun debate by saying he would meet with NRA leaders to talk about barring people who are on terrorism watch lists from buying guns.
"I'll be looking at it very, very seriously - the terror watch list and the no-fly list, I’m going to be talking to the NRA about that and starting a real dialogue. I think a lot of people agree with me but I want to really hear what they have to say," Trump told Fox News on Wednesday night.
I for one am hopeful that we may see some progress if we keep the discussion at a mutually respectful level. The example of O’Reilly and Colbert may be worth more of us studying and emulating. As I related with my description of a strategy for smoking cessation, I believe respect and inquiry offer more opportunity for progress than contempt and the recitation of grievances. I should declare that all of my adult life I have been a progressive Democrat. I have often been unsympathetic and disrespectful of people who see the world differently. I need to recognize that divisiveness and increasing rancor in our political conversations is going no where any of us want to go. I need to change my perspective if I am asking other people to do the same thing.
Because of my Southern evangelical heritage I have many family members and friends in the Southeast and Southwest, as well as friends and neighbors in New Hampshire, who have worries and concerns that are diametrically opposed to my own position on many subjects. I have been disrespectful and contemptuous at times and they have reciprocated. I think that with this election we are at risk of collectively going to positions of mutual contempt form which we may not return.
I think that as healthcare professionals we have a role to play as brokers of a more respectful conversation about how to manage access to assault rifles and all the other issues that face us all. Much of our current political debate seems to be around two sets of issues. The first set contains at least five very personal and interconnected issues: the right to bear arms, the reproductive rights of women, the right to love and unite with the person of your choice, the right to be the person of the gender you feel most comfortable being, and the right to pursue your religious convictions without the intrusion of the state.
The second set of issues and questions are connected in a web of complexity to those core issues and are equally important to our collective and individual ability to pursue life, liberty and happiness. What is the proper role of government in all aspects of life? What does equality of opportunity and responsibility in our domestic affairs mean for each of us? What is a proper safety net of social services? Is it our collective responsibility to provide housing, health services and nutritious food to the disadvantaged and disabled members of our society? What are our collective responsibilities to educate our children and to what level of achievement? How do we we best care for the old, the disabled, and the disadvantaged? What is America’s proper role in the wider world? How do we fairly assess individuals and enterprises to support our collective agenda (who and how we tax).
I am sure that there are issues that I have omitted. To be absolutely correct in naming all the issues is not the point. The point is that even an election will not definitively solve any of these complex problems. The road to resolution is a long journey that requires all of us to commit to a process of respect and inquiry. We must remind ourselves that we share an obligation to those who gave us the freedom we enjoy, as well as an obligation to preserve the progress that has been made for those who will follow us. We are all struggling in a huge process of adaptive change in an environment of worldwide challenges that can only become greater problems if we continue to go after one another in an environment of contemptuous disrespect.
The President and my father are both right. We are at a moment of choice. There are questions to be decided and a choice to be made about how we will search for solutions together. To make no choice is to make a choice. The first choice that I advocate is the choice to approach our problems with shared respect and a reciprocal process of inquiry with a willingness to compromise to find solutions that preserve and enhance for our children what we have inherited together from those who imagined a better future for us. The outcome of not embracing the choice to work together across differences as we foster continuing contempt for our neighbors with a different point of view is probably unacceptable to us all.
Seeking Relief From An Uncertain World
As the picture in the header suggests, I have been on the road where it is easy to set aside the hassles of an uncertain world and think about all the wonderful possibilities that should exist in a country as bountiful and blessed as ours is. What I see convinces me that even with all of our worries and with all our current concerns about terrorism and inequality, our country has more possibilities for a wonderful future now than it has ever had before. All that prevents us from being greater than ever before is making the choice to reach together for what is possible.
The scene in the header today is from the marina at the waterfront in Coconut Grove in Florida. I went there last weekend to watch my granddaughter participate in a very competitive beach volleyball tournament. The games were played up in Pompano Beach earlier on Saturday before the events in nearby Orlando. This weekend and early next week she will be participating with her AAU team in a multi day tournament in Orlando which I will miss. She is thirteen and she loves the competition in volleyball. Beyond her fascination with volleyball, her life is full of exceptional possibilities.
Whenever I visit my grandchildren I am reminded that the lives of my grandchildren, your children or grandchildren and all of the young people of the world are vulnerable to the choices we make. Our objective should be to work together to multiply the possible choices for every child. The lives of the young should be full of exciting choices. It is our collective challenge to expand, not contract, the possibilities that every child has.
Ironically one of my first adventures in the wider world occurred in that marina in the picture. In late May in 1952, just before my seventh birthday, my father took me out of school a few days before the end of the year so that I could travel by car with him and a colleague to Miami. He was attending the annual convention of Southern Baptists which was held at the Convention Center that until a few years ago was just a few yards to the right of the scene in the picture. The trip to Miami was an exciting adventure for me. Living in Oklahoma, I had never seen the ocean or palm trees.
The convention was not so exciting. I quickly tired of the program. Somehow I convinced my Dad to let me do some exploring. After checking out the interior of the hall and visiting many of the displays and various items that were for sale, I ventured out of the building. Parental concerns and precautions must have been different in the early fifties than they are today because I wandered around outside the hall and then over to the marina where I walked up and down the piers between the sailboats and cabin cruisers. It amazes me that today things seem pretty much the same in the marina, although the convention hall was torn down a few years ago. I still enjoy walking around “The Grove” and now my granddaughter lives less than half a mile down Bayshore Drive!
Wherever you are this weekend I hope the weather is fine and you get to enjoy sometime outdoors with people who inspire you to think about what we might accomplish in harmony with one another as we chose to pursue solutions to our shared problems.
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