| 25 November 2016
Dear Interested Reader,
Reflections on Thanksgiving, Apologies for Election Obsession and What Else is In This Letter
I Am Thankful for You and for the Relief of Thanksgiving
Thanks for opening the letter! I always wonder if anyone reads this weekly missive over holiday weekends. I hope that today you are totally relaxed after a great day Thanksgiving Day with your family and friends. If you can resist all of the “deals” being offered on “Black Friday” at the big box stores and at the malls, the Friday after Thanksgiving can be a great day for relaxation and reflection.
Years ago my son wrote a song celebrating what a wonderful time of year this is. His song, which was only the third in his project of writing a song a week which is now 314 weeks long, was about the healing that can occur with friends when they all gather back at home for Thanksgiving in late November. If you click on the link you can also read his tribute to friends and Thanksgiving that accompanied the music. To orient you, he had sprained his ankle just before Thanksgiving. The first lines set the mood:
I can’t walk at all this week
I got a wounded limb, I don’t wanna speak
They were here, they were back, now they’re gone again
But still it was nice to see absent friends
To hear their stories and tell them mine
This time of year can be pretty nice
For that sort of thing
Back in 2010 it was my impression when he wrote the song that his bad ankle was the least of his miseries and concerns. He was seeking to find his way by challenging himself with an audacious project. He was playing to his strength and passion and was thankful for the support of friends. The first line aligns nicely with these times. Sometimes it is easier to focus on our recent pains than the other deeper sources of pain and concern in our lives. Jesse’s song suggests to me that the recent election is more like a national sprained ankle. Our challenge is to discover what is really going to be our passion for the years ahead.
Jesse’s song this week is the first song of his seventh year. It is an attempt to find his way to “carry on” after the election.
I’ve got the strangest feeling
Coming over me
Like we’ve all been down
This stretch of road before
So we bend our knees
And pray for restitution
And carry on carry on carry on
If you check out the song, be sure to take advantage of the free download of what he considers to be his best thirty songs of his sixth year.
On Wednesday I had lunch with a new friend. We met while working to get out the vote in New London. He surprised me by saying that he had been unable to read anything that had been written since November 9. He is avoiding print and broadcast media. He just can’t think about or talk about the election yet. I have not known him long but we share a bonding trauma. I understand and respect his response as he seeks to process his disappointment. He is a painter, an artist in his retirement after a long career in architecture. I am envious of his talents and opportunities. He is focused on his art, his plans for winter travel and his expectations for Thanksgiving with his children and grandchildren, all as distractions from the pain and sense of loss associated with this election.
We talked about other disappointing election outcomes of the past. Those loses felt different. They were just about which politician would be our leader for the next four years. This year was more than a loss for our candidate. It felt like a loss of many neighbors. The real pain of this loss was about realizing that somehow we had lost a sense of who many of our fellow citizens are. They feel like strangers and that is painful.
My hope is that your Thanksgiving Day was about healing and finding perspective. I hope that there were no family feuds around the Turkey and the experience was one of personal healing as you were in the company of those you love.
Jesse’s Thanksgiving song continues:
It’s like everyone dies and then lives again
And if I’m only alive when I can see my friends
Then I’m only alive this time of year
And I’d bury it all just to have you here
All of you who’ve sewn my soul together
For the past few years or so
God bless you and yours
I hope that by now my new friend and you are feeling as if your soul is being sewn together again. Perhaps the election did not feel as devastating to you as it did for my friend or for my fourteen year old granddaughter who was upset for many days. I hope so. Either way, this letter is the second effort about developing a strategy that can carry us for the next four years. I apologize for putting it into your inbox if all you feel up to is the task of trying to decide whether to drive home on Saturday or spend yet another day away from the tedium that awaits you back at work. I hope that you will be able to write off all the traffic that you will encounter on Sunday as just another cost that is worth paying for another day where you really want to be.
So What is This Letter About?
Over the last three months, since the conventions of the two parties, most of these Friday letters have been focused on the healthcare implications of the outcome of the election. It has been hard to think about much else. We did not know for sure what would happen after the election. There was a lot of ambiguity. Now there is less ambiguity and we can begin to focus on how to go forward into a slightly different world that we did not expect where the foundational principles of our passion for people have not changed.
If Clinton had been elected the ambiguity about the ACA was whether she would be able to find some way to broker bipartisan movement toward what we might have called ACA 2.0. My unspoken fear was that the cacophony and brutality of the election would translate into more “gridlock” and persistent hostility that would make the Obama years look like an era of harmony and goodwill. I imagined that with Congress controlled by the same voices that shouted “Lock her up” there would be a bill of impeachment passed in the House before Inauguration Day followed by four years of continuous harassment. We saw the resistance and disrespect that met a black president who experienced nothing but continuous unrelenting resistance and disrespect for eight years. I imagined that a competent white woman might even be harder for some to imagine as their leader. Those worries about four years of continuous “anti Hillary” behavior passed during the very early hours of November 9 and were replaced by another and very different set of unknowns.
A Comment From an Interested Reader and an Opportunity
If you would like to be oriented for this piece and missed last week’s letter, let me suggest that you check out last week’s letter in its abridged form on strategyhealthcare.com where it is posted as “Donald Trump’s Promise”. Paul Dechant wrote me following last week’s letter:
Hi Gene,
Once again you have provided a masterful letter that gives me both much to think about and some solace in challenging times. One concern I have with your letter is that I see it missing adequate emphasis on process, particularly on fixing the broken processes that lead to burnout.
Two places in the letter concern me. “Now our President Elect is prepared to lead us in a different direction without much more assurance than the unfounded claim that he can “fix it”. In healthcare what needs fixing is cost, access and quality.” Perhaps it’s at a deeper level, but we need to fix the complexity of incentives that lead to our dysfunctional processes, which in turn make our workplaces ones in which individuals succeed in caring for patients in spite of, rather than because of, the workplace itself.
“Never before has there been a greater need for all of us to focus on how we lower both our operating costs and our prices. Money will be coming out of the system. Unless we replace the certain reductions with efficiency, the burden of cost on individuals, state government and employers will result in empty beds and empty offices for the wrong reasons.” I am concerned that Don Berwick’s nine steps to Era 3 don’t adequately recognize the dysfunction of the healthcare workplace, or that this factor is not communicated effectively. I am concerned that it is too easy for the leaders of provider and payer organizations to miss this key point if it is not explicitly stated.
Just my two cents. Thanks for always teaching me and stimulating my thoughts,
Paul
I was impressed with how closely and thoughtfully Paul had read the letter. Paul has just written a book with Diane Shannon, MD on physician burnout that will be available in December, Preventing Physician Burnout: Curing the Chaos and Returning Joy to the Practice of Medicine. Click on the link to read more.
I was quick to respond to Paul:
Paul,
I am in total agreement with your thoughts and actually share them. I was trying to begin a conversation and not finish it. The era 3 recommendations are at [the] 100,000 feet [level]. You are bringing the conversation down close to the ground. I plan to take it closer to the patient because that is where there has never been greater need on either side of the transaction. On the clinician side it is an undoable job without reengineering and on the patient side it is an insurmountable cost and access issue. Lean is agnostic to the ACA. It was a good idea before the ACA and an even more important option after the ACA in what will surely be an era of more downward pressure on revenue.
May I quote you next week?
Paul consented and as I promised, this letter does begin to move the discussion of what we can do a little closer to the clinical interface with the patient. I have read much of his new book and hope that you will read it also when it comes out in December. It is being published at a very appropriate moment. Perhaps this letter serves you best by giving you a heads up for the book. If by chance you are planning on being at the 28th IHI Meeting in Orlando in early December you can hear Paul present much of his work!
He and Diane Shannon will be presenting with Steve Swenson from Mayo and Pierre Barker from IHI in Session C7, “High Engagement and Low Burnout: Solutions for Your Workplace”. If you are interested sign up fast because 279 attendees have already enrolled.
Despite the election and the promised repeal of the ACA, there is much to be thankful for as we look forward to making progress toward the Triple Aim over the next four years. I am thankful for the IHI and for experienced clinicians like Dr. DeChant who will continue to do their best no matter what party is leading. I hope as you continue to read you too will be thankful for what we have and what we might accomplish as the next four years quickly pass. Read on.
Trump Has Said What He Will Do. What Will You Do?
I can’t answer that question for you, but I am delighted to give you unsolicited advice. I was recently reminded of how important it is to remind ourselves of things for which we are “fanatical”. Let me digress.
For several years I have been trying to read David Foster Wallace’s Infinite Jest. I thought that Joyce’s Ulysses was a challenge, but it is Dick and Jane next to Wallace’s doorstopper. I have recently had success after adopting a new approach. I downloaded the audiobook of the 1,079 pages and I listen to about an hour and a half each time I walk alone. The 981 pages of text are covered in 56 hours. The audiobook does not include 100 pages of “notes”.
As I was walking and listening this week I was surprised by the dialog between two strange characters who in the book are operatives for radical French Canadians. The exchange was about the importance of identifying what you would die for. The speaker is French Canadian and has no legs. He is challenging his American colleague who is in drag.
“Marathe had settled back on his bottom in the chair. ‘Your U.S.A. word for fanatic, “fanatic,” do they teach you it comes from the Latin for “temple”? It is meaning, literally, “worshipper at the temple.”
The American made a comment that Marathe ignored as he continued with his discussion of “fanatic.”
‘Are we not all of us fanatics? I say only what you of the U.S.A. only pretend you do not know. Attachments are of great seriousness. Choose your attachments carefully. Choose your temple of fanaticism with great care. What you wish to sing of as tragic love is an attachment not carefully chosen. Die for one person? This is a craziness. Persons change, leave, die, become ill. They leave, lie, go mad, have sickness, betray you, die. Your nation outlives you. A cause outlives you.’
“You U.S.A.’s do not seem to believe you may each choose what to die for. Love of a woman, the sexual, it bends back in on the self, makes you narrow, maybe crazy. Choose with care. Love of your nation, your country and people, it enlarges the heart. Something bigger than the self.”...“choose with care. You are what you love. No? You are, completely and only, what you would die for without, as you say, the thinking twice.”... [the bolding is from me, not David Foster Wallace]
Perhaps I am stretching it, but I do think that the first step in the way forward is to remind ourselves of what we believe is important. Those are the things for which we are thankful and for which we will sacrifice, or at least work very hard. If you are “fanatical” for the Triple Aim, you will not be easily thrown off course by something as temporal as an election. If we are worshipers in the temple where the message of the gospel is:
Care better than we’ve seen, health better than we’ve ever known, cost we can afford…for every person, every time.
We will recognize that the shift that seems like a loss does perhaps offer us an opportunity. Progress before was precluded by a log jam of political resistance that was likely to have increased had we elected another Democratic president while Congress remained under Republican control. What we have now is an opportunity to negotiate toward something better while retaining much of what an unsuspecting electorate never seriously thought that they would lose.
There several things that the moment should underline for all of us:
- Care costs too much and unless the cost comes down fewer people will be covered.
- The cost can never come down unless doctors and other professionals are working in a context that allows them time to think critically and spend more time focusing on the needs of their patients.
- The cost of care can not come down when care is delivered by a growing number clinicians who are burned out and performing inadequately. Their own despair precludes collaboration, effective interaction with patients and the ability to do the critical thinking that leads to efficient, effective care that satisfies their professional expectations and delights their patients.
- Fee for service finance aggravates the problems of cost, patient satisfaction and optimal clinical performance.
- We will never have more financial resources for the population than we have now.
- Unless we can reduce the resources per person necessary to deliver quality care, we will be delivering a lower quality of care to fewer people who will be living in a declining environment of increasingly poorer health per capita.
We are fortunate that over the last seventy years we have evolved a body of knowledge that if applied to healthcare can move us toward the Triple Aim. That was the message in John Toussaint’s, On the Mend and Management on the Mend. That message was echoed in Patty Gabow’s, The Lean Prescription: Powerful Medicine for Our Ailing Healthcare System and Joan Wellman’s, Leading the Lean Healthcare Journey: Driving Culture Change to Increase Value. In his description of “Era 3” in healthcare, Don Berwick underlines both the importance of every practitioner’s effort to lower the cost of care and the necessity of using continuous improvement science to do the job.
Lean is not a religion. It is more than a management tool. It is a foundation for a culture that enables people to work together to produce outcomes that delight patients, return joy to professionals and lower the cost of care so there will be access within our system to great care for every person. I am a Lean fanatic. I can worship in the temple of Lean and know that none of my cherished principles of practice need be violated. Not only does Lean enable clinicians to more effectively do what they believe they entered medicine to do, it offers patients more than they ever expected.
I am past the time when I will personally benefit from working in a system where my professional efforts are enhanced and supported by workflows that have been made more efficient by Lean engineering. I am thankful that although my days of practice have passed, as my needs increase as a patient, Lean is still working for me. Despite the fact that the Lean engineered Atrius practice where I receive care is 103 miles from my door, I can not let go. The Lean engineered pharmacy programs, the 24 hour phone support, the referral process that was streamlined by Lean, the fact that my PCP answers my questions online within a few hours while practicing at a pace that allows critical thinking in a Lean designed workflow all contribute to a value that I would never give up until some organization nearer can reproduce the quality.
I hope that most healthcare organizations will eventually accept the reality that as the ACA is abolished the urgency to lower costs does not go away. Through MACRA and the value based finance systems offered by commercial insurance the need to lower costs and become more competitive will become more urgent, even as their clinicians become more and more burned out. The successful healthcare organizations post ACA will realize the need to understand the care of populations. As value based reimbursement and population based care delivery become everyone’s daily reality those organizations that have prepared for the moment with Lean and improvement science will be able to meet the challenge and answer the needs of both patients and providers.
The alternative to managing processes of care through attention to the teachings of improvement science is to be condemned to the pain of working harder in inefficient systems that seek to survive by continually cutting budgets and asking fewer people to work harder doing less for fewer people. It is a choice for a downward cycle that will result in expensive processes that don’t satisfy patients and continue to burn out clinicians and other healthcare professionals.
It’s nice to have choices. Earlier this year I gave a presentation about what to do if you find yourself working in a system that does not understand or practice the benefits of Lean. Basically it was a discussion about speaking truth to power. Unfortunately there are many organizations who think they “tried Lean” or are now trying Lean in a “do it yourself” fashion that are having a hard time while they are simultaneously hiring consultants to help them make budget cuts. Call me a “fanatic” about Lean if you will, but I am thankful at this time of thanksgiving that worshiping in the “temple of Lean” does not require that you die for the cause.
Walking Off All That Dietary Excess
One thing that I would take as a sure bet is that you ate more yesterday than today you wish you had eaten yesterday. Read that sentence again if you are not quite sure what I meant. What are you to do after you understand that what’s done and can’t be undone? Whether it’s an election or a meal that went down too easily and is now the source of regret, when it has come and gone it is out of reach in the past. One of the realities for which we should be thankful is that for as long as we are alive each new day is presented as a chance for a new direction or recovery from an indiscretion that lies out of our reach in the past.
Be thankful that today, tomorrow and Sunday lie ahead full of opportunity for repair and advancement of your health and well being! Today’s header pictures the first of many waterfalls that one encounters as you walk upstream along Kidder Brook which is the major inflow to Little Lake Sunapee. Kidder Brook is fed by two other ponds higher up in the hills, Dutchman’s Pond and Morgan Lake (Pond). Both are accessible by the trail up the brook, or if you prefer, by back roads. Along the brook there are a series of small water falls that are like a stairway over several miles down to this last drop before the run to the lake. In the spring as the snow melts this little brook can be quite an impressive flow. I’ve caught gorgeous little brookies in the pools below the falls. If you look closely you may see the first icicles forming at the lip of the fall.
Of all the therapies for which I am thankful, the restorative power of a walk in the woods is near the top of the list. A good walk certainly can balance that last piece of pumpkin pie that you should have let pass. |
| Be well, take care of yourself, stay in touch, and don’t let anything keep you from making the choice to do the good that you can do every day,
Gene
Dr. Gene Lindsey
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