| 24 July 2015
Dear Interested Readers,
Inside this Week's Letter
What can you imagine about better health while attending a meeting of the Little Lake Sunapee Protective Association? This week’s letter explores that question and then jumps into a discussion of the importance of extending the concept of patient engagement to the larger challenge of community engagement. Also included and closely related is a discussion of the disabling biases that prevent us from making the decisions and choices that are needed for transformation to a better system of care.
This last week several new interested readers have signed up and some seem to be from Canada. I hope that they will write me with their perspectives on how concerns vary across the border. I would expect that we have a lot that we can learn from them about the connections between how healthcare is delivered and the health of the community. If you know anyone who would like to receive this letter each week, please tell them that they can sign up for the letter at strategyhealthcare.com.
Working With Others To Protect What You Care About
A few Saturdays ago my wife and I got up early so that we could be sure to arrive on time for the annual meeting of the Little Lake Sunapee Protective Association. The meeting is held on the grounds of the New London Historical Society in a replica building of an old town meeting hall. The meeting of the Protective Association is an event that I always looking forward to attending. A typical meeting has about fifty plus attendees.The coffee hour that precedes the meeting is a great opportunity to meet new people and to get to know your neighbors. When the meeting begins, the agenda becomes a combination of an environmental teach-in and an old New England town meeting.
This year the educational segment of the meeting was a thorough discussion of the threat to the lake from invasive species of plants like Eurasian watermilfoil and animals like zebra clams. These invaders and many others are threatening the quality of the lakes of New England and New Hampshire. A couple of years ago at the meeting I had my fund of knowledge about Loons expanded beyond my wildest expectations during a 30 minute presentation from the Loon Preservation Committee. Loons are a constant presence and joy in my environment. They visit me as I move around the lake fishing from my kayak and they call to me through the night with their mournful wails.
The educational section of the agenda can be just like being back in my tenth grade biology class where I decided to be a doctor. Who knew that Loons were monogamous, or that small lakes like ours usually support only one breeding pair, or that their success rate bringing forth offspring is about the same as David Ortiz’s batting average during this miserable year for the Red Sox? I was floored to learn that there are only a few more than one thousand loons on the nine hundred or so lakes of New Hampshire. Many loons die of lead poisoning and the Loon Preservation Committee has been effective in getting lead fishing gear banned by law in New Hampshire, yet there was a recent loon death on a nearby lake and the autopsy of the loon revealed lead poisoning. Loons are most threatened by the encroachment of our communities into the protected natural environment that they need for reproduction.
All the information that I get at the meeting engages me. What inspires me is the engagement by the audience in both the meetings and then in the community action that occurs between meetings. The “business” portion of the meeting includes the usual review of finance but is augmented by informational reports from the working committees. The whole process is oriented to measurement. At each meeting the committees give reports on the various metrics about the quality of the lake that they observe and manage between the meetings. There are multiple teams that patrol the lake for invasives and there are others who are regularly assessing the water quality. Water clarity, mineral content, pH, oxygen content, phosphorus content, and a whole laundry list of other important measures are constantly monitored.
As I was listening to a report on water clarity, it occurred to me that with all the data we were collecting and discussing we were accepting the sage advice of Peter Drucker.
If you can't measure it, you can't improve it. - Peter Drucker
Perhaps Drucker should have said, “You do not manage effectively what you are not measuring regularly”. In a gathering of concerned individuals good data should generate a productive discussion and the expectation of those involved should be that the effective application of data is tied closely to a process of continuous improvement. W. Edwards Deming, the great authority on continuous improvement and a key teacher and source of insight to the Japanese as they developed Lean said, "In God we trust, all others must bring data."
My mind tends to wander in meetings but as it wanders it usually follows a road that runs parallel to the agenda. As I listened I began to be increasingly impressed by the earnest engagement of all the people who had come out so early on such a beautiful summer Saturday morning. “Engagement” is a special word for me as we are always thinking about engagement in its various forms as strategies for improving healthcare. Intuitively we accept that healthcare will improve after we all get involved.
We all agree on the need for “physician engagement”, as I discussed last week. It is also true that I rarely attend a meeting of physicians where someone doesn’t say that the problem with healthcare is that patients are passive, non compliant and demanding and that a more effective form of “patient engagement” is necessary. Those wails usually sound like an excuse to me for the poor quality and high cost of care that is perpetuated by our collective behavior, but I do agree that effective “patient engagement” is a key strategy in the quest for the Triple Aim or just plain old mundane financial success in a world of value based reimbursement.
Things change when even a small number of people become engaged around a uniting cause. Lean thinkers like to talk about the power of the square root of “n” (n= the number of people in the group) as being an effective minimum coalition within an organization. That formula probably holds for communities as well. It does not take many people who are dedicated to a cause to make a difference, especially if they are effective with the use of data. The work of the Loon Preservation Committee is an example of what a few dedicated people can accomplish. My mind continued to wander along as the meeting progressed. I was looking for more similarities and strategies that could be applied to healthcare as the meeting continued and I did my mental walk down the familiar path of the Triple Aim.
It occurred to me that we treat each part of the Triple Aim as an independently difficult journey. By design all of the goals in the Triple Aim, or if you prefer, the Triple Aim “plus one”, are connected and interdependent and though each part can be a separate discussion and effort, none of the parts can really succeed without them all succeeding. It surprised me when I realized that we are trying to get healthcare professionals to engage collectively but we still talk about patient engagement as a mostly individual activity. We rarely expect much from the community acting in concert.
I must admit that I have frequently assumed that the best way to achieve the goal of improving the health of the community is to ensure the access to quality healthcare of the individuals within that community. I know that the concept of managing a population remains an enigma to most physicians and organizations. Because of patient choice and multiple providers in most communities, it is hard to define populations and geographies that allow anything other than defining virtual populations who must live in a virtual community. Despite several years of discussing population health most practitioners show little real interest in thinking about anything other than the care of the individual. The allopathic approach to care, which is to “repair and restore”, still seems like a preference for most doctors. It seems we would rather focus on medicines and interventions for the care of the individual after they are sick or have a defined problem. We have less interest in discovering the complexity of the intermingling of social and physical issues that remain as impediments for creating healthier communities. Do we find committees, associations and programs in our communities as metrically oriented to improving the health of humans as we have working to protect and improve the health of my loons or the lake?
We pay lip service to “prevention” but when we talk about prevention it is usually about how to achieve the goal through enlightened individuals. We celebrate efforts at the individual level like exercising more or controlling our weight, but we rarely get into the sort of collective action within a community that improves the environment in such a fashion as to reduce the incidence of problems like drug abuse and obesity. We rarely go up stream to search for the origins of the problems in the community.The environment that ultimately generates the diseases we want to treat is not managed effectively. More than fifty percent of all premature deaths arise from social and behavioral health issues that could be better managed if we were to work together more effectively.
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For most physicians, patient engagement is the concept of engaging the individual in the treatment of their condition, as described in a recent blog posting by Health and Human Services. The blog post is the testimony of one woman’s journey to developing self management skills for the treatment of her own hypertension and diabetes. Her tale is inspiring and we want to have every patient become as focused on participation in the management of their own care as she is, but we will never achieve the Triple Aim without more coordinated action as a community.
Almost every day’s newspaper confirms threats that are greater to our health as functions of our inability to act together than the threats to my little lake. This week while walking and listening to New Hampshire Public Radio I learned about the threat to the health of thousands of children because of the resistence in my new home state to improving the management of lead in the environment of more than 60% of the rental property. Then to my surprise I learn while reading the Boston Globe this Wednesday that the same issues exist in Massachusetts.
As the meeting moved on to the discussion of the pH of the lake and to its phosphorus concentration that is a function of the runoff into the lake of chemicals that we use on our lawns, I wondered why we do not become more collectively concerned as a community about the root causes of healthcare disparities and premature death. Why do we allow the conditions among us that are associated with opiate abuse. We seem to be better at ridding our lakes of Eurasian watermilfoil than our streets corners of meth, cocaine and heroin. How ironic is it that the state of New Hampshire can pass laws that attempt to reduce lead poisoning in loons because they are an important contributor to income from tourism, but we can not protect our children from the devastating long term effects on their health from lead? Perhaps if we recognized that there were more public dollars at risk from lead poisoned children than lead poisoned loons we could find the will to elect officials who would address human suffering with the same enthusiasm that they address the protection of a tourist attraction.
Considering How We Are Fettered By Various Forms of Bias
Paul Levy published an article this week on the web page of Athenahealth that gave me a little insight into why things do not change. His article, “Do we really learn from our mistakes?”, explores some key concepts from behavioral economics that might explain some of my frustrations with our inability to act as a community for our collective benefit. Levy quotes another author who quotes the deceased tyrant Mu’ammar Gaddafi of Libya who said:
“The truly strange thing in your lives is that you not only fail, but you fail to learn a lesson… No matter how much your beliefs betray you, this is never accepted by you. You are distinguished by your inability to recognize the truth, no matter how irrefutable.”
Levy moves on to discuss the causes for our inability to learn from our errors in terms of cognitive errors and our inherent biases:
- Anchoring: the tendency for your first observation to carry disproportionate weight in your decision making.
- Confirmation bias: often accompanied with anchoring, our confirmation bias values evidence that seems to support our view while discounting evidence that is contrary to our view.
- Recent experience: Even statistically irrelevant recent events carry more power merely because of their placement in time.
- Patterning: We are prone to see patterns that don’t exist. Our minds like order, and we will assert the existence of dispositive parameters-even when the actual pattern of events is totally random.
Levy goes on to make the insightful observation that although we can learn that these biases exist we also know that we will continue to fail to recognize them if we function just as individuals. He adds that to protect ourselves fully from the errors induced by these natural biases we need to buy into systems of group behavior that protect us from ourselves. Levy gives an example where a nurse can prevent a doctor from making an error based on bias, if they are functioning as true team members and their relationship is more collaborative than the historically vertical doctor/ nurse relationship.
I think that social responsibility is also easier to exercise with the support of a group environment. Left to individual initiative and energy no one member of the Little Lake Sunapee Protective Association could do much for the lake. Individually we can each try to manage the little bit of shoreline that we personally own [some of my shoreline is pictured in the header] but we can’t do anything about the overall quality of the water unless we act collectively. It is also likely true that we will have to act much more collectively if we are to improve the health of our community. Individual physicians, and even individual institutions, are unlikely to be able to do much for the real root causes of disease and disparities in health in our community.
Some nations have devised systems of care that do not focus as much on individual behavior and are more capable of acting as communities through government. Given our natural and national bias against or distrust of the ability of government to improve social problems it seems that we will have to resort to more vigorous private collaboration within communities. For this “grassroots” approach to improving the health of the community we will need leadership from both institutions and individuals.
Such leadership and collaboration has been seen before in large and small ways. Mothers Against Drunk Driving is a good example of collaboration to improve a specific problem which is a threat to the health of the community through a combination of stricter enforcement, education and community awareness. The much documented collaboration of the physicians and hospitals in Grand Junction, Colorado is an example. The coalition of religious and secular groups that advocated for universal coverage in Massachusetts and succeeded through the passage of Chapter 58 is yet another example of collaborative community action to improve the health of the community.
A good question to ask is, “Why don’t we have more success with collective activity since it is clear that when we act together things do have the possibility to improve?”. Perhaps it is a stretch of the concept, but “status quo bias” may be part of the answer. The term has evolved as behavioral economists have tried to explain various forms of individual reluctance to change. As you can learn from the link, as individuals, we often chose to do nothing and stick with the status quo rather than risk personal losses in the transition to what may be a better situation or circumstance. Sometimes we just elect to sit back and let others “carry the ball”. When I was a child my father often talked about “George”. He would say, “If you don’t want to do it we can be like everyone else and just let “George” do it.” It did not take me long to learn that there was no “George”, and if the job we wanted done was going to be done, then we could not wait for “George”. We, my father and I, would have to do it, like it or not, if we wanted to be sure that anything was going to happen.
Perhaps when it comes to improving the health of the community we are waiting for George or someone else to do the work. I am sure that the reasons why we are not more aggressively pursuing the improvement of the disparities in care and the other issues of community health that are amenable to collective efforts are more complex than a simple minded explanation like “status quo” bias. Change is hard for individuals and even harder when we are looking to achieve the large scale changes that are envisioned in the wonderful dream of the Triple Aim. It would be great if it was as easy as keeping a lake clean enough to be a good place for loons to live.
A Great Note From the Mailbag
Last week’s lengthy epistle about physician engagement generated several responses. Michael Soman, the recently retired President of the Group Health Physicians in Seattle, wrote me a note that is so good that I must share it with you.
Hey Gene,
I really enjoyed reading this last issue and had wonderful images of you fishing from the kayak at the lake. I also found the physician engagement topic very stimulating and in my retirement it still seems the most important and "hard to pin down" part of the puzzle of transforming American medicine.
I would simply add this to what you have said: An effective physician leader will do all of the things that you say such as be transparent, create dialog, assure that incentives are correct, and help inspire by a shared vision. However, they will also walk the talk and spend a good deal of time in the company of their physician colleagues. They will need to really master the skills of listening and even more of really hearing the concerns and grief of our colleagues. They will be empathetic to the impact of change on physicians while gently moving the conversation forward. This involves grieving what must be lost, clarifying what will not change (usually values), and creating some excitement about things that will change going forward. It is not an easy dance and involves "soft" skills like actually being vulnerable, not having all the answers yourself, and creating the space for shared learning and trying things (i.e., Plan, Do, Check, Adjust). More than past models of leadership it requires humility and ability to bring out the leadership in others.
Thanks,
Michael
He said more clearly in 237 words most of what I tried to say in 4000. I can just add, amen and thank you Michael. Healthcare needs more leaders with your insight and passion. You are missed.
Big Things Are In the Wind
My cup will be running over with good things this next week. My granddaughter and her parents are up from Miami this week for a nice visit before the wedding of her uncle, our youngest son, on August 1. She has already gotten me busy pumping air into bicycle tires and getting all the fishing gear into shape. It is time for her to transition from worms to flies. Her goal is to haul in a big fish. She is too big and mature at 5’6’’ and 12 years old to be satisfied with catching sunfish from the dock. My grandson, age one and walking today, will be bringing his parents to town mid week and I am sure that he will soon be ready for sunfish. The house will be full.
The summer is fading fast. Of the fourteen summer weekends, only seven remain. I hope that you get out for a walk or ride this weekend and that you will not pass up any opportunities to be with friends and family. Your work will still be there next week. Long after summer is just a memory, work will remain.
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