Perhaps I am exercising too much whimsy but the first section of the letter this week is an attempt to connect some of the insights from the book, The Phantom Tollbooth, to healthcare. I hope that stretch is not preposterous.
The second section attempts to explain some of the issues that face us today in terms of two competing agendas. My thesis is that the tension between these two quite different approaches to healthcare have made the improvement in what we do harder.
The third section in the letter contains comments from my friend and “Interested Reader”, Michael Soman. He comments on some of the issues discussed last week and has graciously allowed me to pass his thoughts on to you.
My trip to South Africa continues and we will have a brief visit to Zimbabwe before returning home. References and observations from the trip are scattered throughout this letter.
Please remember to tell friends that they can sign up for the letter at strategyhealthcare.com. I hope that you will also follow Michael’s lead and send along your comments about this letter or any concern that you feel needs to be discussed. There is nothing quite like the power of dialog.
The Phantom Tollbooth: Lessons For Healthcare
During my "research" a few weeks ago on the phrase "like digging a ditch with a teaspoon" Google led me to an interesting human resource blog posting by Robin Schooling who writes about HR issues.
http://hrschoolhouse.com/are-your-employees-digging-ditches-with-a-shovel-or-a-teaspoon/
I was fascinated by her reference to a book, The Phantom Tollbooth, that I remember my children reading. I never read it, but did remember noticing the interesting illustrations. The book was published in 1961 by Norton Juster and the illustrator was none other than the very talented cartoonist, playwright, and author, Jules Feiffer. I have enjoyed his cartoons in the New Yorker for many years.
I did an email survey of my four sons and their spouses and indeed, several of them remembered reading the book. Perhaps you also have read it and remember the story. One daughter-in-law who is a librarian reported to me that the book had been made into a movie in 1970 and I could see it on YouTube.
https://www.youtube.com/watch?v=Llg5VODW6n4
After watching a little of the movie and learning that Juster never liked the movie version of his book, I decided that my time would be better spent reading the book. I discovered that my local book story had one copy. I ran out and got it just in time to have it to read on the long flight to Africa. I was intrigued from the moment that I read the blog posting and then my interest was heightened by the well written foreword by Maurice Sendak (author of the classic for children, Where the Wild Things Are). Sendak’s words of appreciation were added to the 1996 edition that was published for the thirty fifth anniversary of the book. Sendak says that the book is "concerned with the awakening of the lazy mind". He goes on to say: [The bolding is by me]
The book treats, in fantastical terms, the dread problems of excessive specialization, lack of communication, conformity, cupidity, and all the alarming ills of our time. [Hardly the traditional subjects of books for children.] Things have gone from bad to worse to ugly. The dumbing down of America is proceeding apace. Juster's allegorical monsters have become all too real. The Demons of Ignorance, the Gross Exaggeration (whose wicked teeth were made "only to mangle the truth") and the shabby Threadbare Excuse are inside the walls of the Kingdom of Wisdom, while the Gorgons of Hate and Malice, the Overbearing Know-it-All, and most especially the Triple Demons of Compromise are already established in high office all over the world. The fair princesses, Rhyme and Reason, have obviously been banished yet again. We need Milo! We need him and his endearing buddies, Tock the watchdog and the Humbug, to rescue them once more. We need them to clamber aboard the dear little electric car and wind their way around the Doldrums, the Foothills of Confusion, and the Mountains of Ignorance, up to the Castle in the Air, where Rhyme and Reason are imprisoned, so they can restore them to us.
Sendak mentions in comparison Alice in Wonderland, The Wind in the Willows and Pilgrims Progress. Those references are pretty heady company for a book sold for readers 8-12 years old! Based on Sendak’s endorsement and my curiosity after reading Schooling’s blog posting, I decided that there was a possibility that there might be lessons for us now as we "awaken" to our new roles in healthcare. Could we learn something useful to apply to our vexing challenges from a book written for children?
My time reading the book was well spent. Now I can appreciate Schooling's statement that even though she first read it at age eight, she is not ashamed to say that she has read it again as an adult. I think Jester wrote The Phantom Tollbooth for adults or like Sesame Street it is art ostensibly meant for children but layered with deeper meaning for adults. I found wisdom on every page and filled the margins with notes after underlining much of the text.
For her piece entitled “Are your Employees Digging Ditches with a Shovel? Or a Teaspoon?” Schooling chose to use a scene from near the end of the book . By the time Milo, our hero, has reached the “Mountains of Ignorance” on his journey to save the princesses Rhyme and Reason from their entrapment in the Castle in the Air, he and his friends have already encountered and overcome many challenges.
As they “reached the crest [of the the road], only to find that beyond it lay another one even higher, and beyond that several more, whose tops were lost in the swirling darkness. For a short stretch the path became broad and flat, and just ahead, leaning comfortably against a dead tree, stood a very elegant-looking gentleman.
He was beautifully dressed in a dark suit with a well-pressed shirt and tie. His shoes were polished, his nails were clean, his hat was well brushed, and a white handkerchief adorned his breast pocket. But his expression was somewhat blank. In fact it was completely blank, for he had neither eyes, nose or mouth.
Feiffer’s rendering of this character is pretty scary looking and perhaps worth the $7.99 that I paid for the book. The well dressed man without a face was initially pleasant and amiable but quickly made it clear to MIlo and his friends that he wished them to help him with a few tasks. The first task was to move an enormous pile of sand one grain of sand at a time from one place to another, using tweezers. The second task he requested was that they empty one well and fill another using an eyedropper since he had no bucket. Finally, he asked them to dig a hole through a solid granite mountain using a needle.
One of Milos friends, Humbug, cheerfully started the work drilling the granite with a needle, since he was “never as happy as when he had a job that required no thinking at all”. Tock, the watchdog, began the chore of moving the water with an eyedropper. Milo started working on the sand piles with the tweezers.
After hours of work Milo realized that doing the jobs the way they were working them would take each of them eight hundred and thirty seven years to finish! Realizing the futility of their efforts Milo tells their faceless boss that what they are doing is not worth the effort or in other words not all that worthwhile. He was surprised by the response from the faceless man.
“WORTHWHILE!” ...Of course it’s not important...I would not have asked you if I thought is was important… what could be more important than unimportant things? If you stop to do enough of them, you’ll never get to where you are going… I am the Terrible Trivium, demon of petty tasks and worthless jobs, ogre of wasted effort, and monster of habit.”
It was after this pronouncement that I realized that this was a book about Lean! I had used my metaphor about digging ditches with a spoon to suggest that our noble effort to transform healthcare was going to be a long and arduous task, but if we stayed faithful to the course we would get there just like Tim Robbins was finally able to dig his way out of his prison cell to freedom. I also was suggesting that as we became proficient in our use of Lean we would be trading in our teaspoons for shovels, or perhaps even a backhoe, and be able to pick up the pace in our journey toward the Triple Aim Plus One. Long suffering effort is noble but if you can improve the tools, the job can be completed sooner. There is no virtue in doing any job the hard way.
What my metaphor did not stress was the truth that the tale of the Terrible Trivium reveals and that is the Lean principle that much of the waste in healthcare comes from doing things that add no value or equally as wasteful, “doing things the way we have always done them” out of habit and in a fashion that is inefficient.
I am the Terrible Trivium, demon of petty tasks and worthless jobs, ogre of wasted effort, and monster of habit.
Every time I have seen Lean used to look at a process in our method of practice, it has been the same story. Once you can see waste, you see it everywhere, and much of the waste is from over processing or in the waste of human capital, employing people to diligently do things that add no value.
Like Milo and his friends who were freed to continue their quest when they were able to see the futility of the tasks they were asked to do, we can expect to pick up speed toward the Triple Aim Plus One which is our “Castle in the Air”. We will bound ahead toward efficiency and effectiveness when it dawns on us that there are huge amounts of waste present in the work of executives, mid level managers, all clinicians and all support staff. We must eliminate the waste of doing tasks that add no value for patients, and costs them money right out of their pockets in an era when more cost is transferred to the patient.
An article on the NPR website this week quantitates the enormous bite that premiums and deductibles are taking out of the household budget of the average family.
Beside being a waste of resources and an indefensible expense to patients, doing unnecessary things that add no value and wastes the work of people who have too much to do adds to the problem of “burnout”. Enormous amounts of waste in healthcare become obvious when you look at what we do through with the insight that Lean provides. We can not accept the advice of the Terrible Trivium:
“Think of all the trouble it saves! If you only do the easy and useless jobs, you’ll never have to worry about the important one which are so difficult. You just won’t have the time!”
Moving Beyond “Repair Care”
If you Google “repair care” you will find articles about wood products and electrical appliances. If you plug in “repair care, healthcare” you get articles about healthcare reform. Some time ago I began to think of our efforts to provide care as bimodal. There is the traditional care of practitioners over the centuries which is about trying to restore health. It is about fixing things that are broken, in essence, managing pathology. Over the last century we have gradually added preventative concepts to our skills. As we have understood the origins of pathology we have tried to create strategies to avoid disease but these efforts have never had the draw or allure of acute “fix it” care or “repair care”, if you will allow me such a crude description for our noble traditions.
It is just a personal opinion and one that I have rarely shared with others, but I think that we have long exalted episodic “repair care”, and despite universally giving lip service to preventative care or health maintenance strategies, the practice of avoiding pathology has never had the drama or pull of “repair care”. By and large hospitals, specialties, clinician training, the majority of research and basic science have been focused on strategies and methodologies to “fix it” more than the strategies to “avoid it”.
The HMO era was perhaps our most concerted effort to elevate the clinical and the practical sense behind health maintenance, but it never really captured the imagination of most practitioners or patients who continued to focus on fixing things. Our concepts of chronic disease management seem to fall in between the two poles that I am trying to describe. Chronic disease management is closer to preventive care than “repair care”.
As a cardiologist I always sought to use procedures and medications to get patients to as high a functional status as possible; that was the repair care part. The key then was to use knowledge of what might undermine that improvement to maintain the highest possible functional status for as long as possible. I was seeking to help the patient avoid the return of symptomatic disease and function as wholly as possible, for as long as possible. It was mostly a preventative care strategy.
“So what?”, you might say. What is the point? I think a major point is limitations for improvement associated with the clinical attitudes and the healthcare finance mechanisms that flow from the “repair care” mindset. Any casual review of medical economics would reveal that we spend the larger portion of our medical resources on “repair care”. We are gradually coming to understand the folly of this, especially in many end of life situations. Any attempt to control future healthcare expense will require avoiding more and more "repair care" by keeping the population healthier.
We can never have much chance of getting away from compensation based on volume as long as we are in a predominately “repair care” mindset. Value based or population based payment is the compensation system of health maintenance that best supports care for the healthy and those with chronic disease. I think that the source of much of the tension about the future is from the continuing “repair care” mindset.
Medicine was essentially always episodic “repair care” (depending on how you view childbirth) until we began to use vaccines. People have always had a tendency to go to the doctor only when they were sick or had a concern. We have never learned how to mine the full potential of the “annual physical” to be a major part of a preventive care program. Many are scheduled as a way of resolving a concern or initiating the resolution of a progressive problem. Since the fifties we have added management of hypertension and over the last forty years the list of those things that we try to avoid or manage as chronic disease has gotten longer. Making finance work for preventive care in a fee for service environment is close to an impossibility. We all know that it is hard to manage the finance of healthcare off of the fee schedules for the office practice of preventive care or chronic disease management without using ancillary testing and procedures that move preventative care back toward something that looks like “repair care”.
Several years ago I was fascinated by Atul Gawande’s discussion of ignorance compared with incompetence. His thesis was that we are no longer ignorant. We know quite a bit about pathology, pharmacology, diagnostics, and various therapeutic techniques. On my visit to Cape Town this week I was thrilled to pass by the hospital where Christian Barnard performed the first heart transplant almost fifty years ago. The last half century has been remarkable. What we suffer from now is not ignorance about disease and therapeutics; it is our incompetence in managing the equitable distribution and sustainable finance of all we know.
My argument is that we are emotionally and professionally preferential as an industry to treating disease rather than preventing it. It is that preference that makes us continually incompetent when it comes to saving resources and reducing the cost of care. The origin of our incompetence is also deeper and more complicated than I have discussed so far because I have not discussed any of the social determinants of health which are foundational to health preservation.
My visit to South Africa has been interesting for many reasons, not the least of which is the discovery that over the last decade the life expectancy of South Africans has increased almost ten years, from the low fifties to the low sixties.
Those gains have been made even as so many black South Africans live in abject poverty. The economy is stalling now, largely as a function of the fact that China has reduced their use of South Africa’s raw materials. The unemployment rates of non whites are five times higher than the white minority, 40% versus 8%.
What has changed in the era post apartheid is that more people have the hope that life might get better as segregation by law is replaced by improved access to education and healthcare. There is growth of a black middle class despite the fact that so many remain in abject poverty. Despite its economic woes, healthcare is a universal though less than optimal entitlement in South Africa.
South Africa is making progress albeit slowly, matching the rhetoric of equality and opportunity to the realities of a complex economy still transitioning from centuries of social injustice. It is a slow process. Despite their continuing problems there is much to praise and celebrate.
What can we say for ourselves? Am I off base? Do we need to ask ourselves how to move away from our fascination and glorification with hospital and specialty based practice and do more than give lip service to the pursuit of health preservation and the management of chronic disease as an objective that is equally important both economically and in terms of professional satisfaction and respect to “repair care”? Can we ever achieve our Triple Aim Plus One objectives without a shift of resources from “repair care” to a system of care primarily built on a philosophy of disease prevention and the improvement in the social determinates of health?
From The Mailbag, a Little Bit Serious and a Little Bit Fun
Michael Soman, the retired President of Group Health’s Medical Practice is not only an Interested Reader, but he is a frequent responder to these “musings”. He writes:
Gene
Enjoy your travels.
2 observations:
-I LOVE your tone in the first part of your letter re: our industry failing our citizens. Great to see you (hear you/feel you) so fired up. Fact is unless/until our profession stops acting like a special interest group and fails to consistently and universally take the public interest as our duty, we will be walking in quicksand!
-I really hoped you would have a "say it ain't" so section about Tom Brady backing The Donald. Great opportunity to talk about our athlete/musician/actor heroes and what it means when they take public stands like these....
My comment back was thanks for the compliment and a request for his opinion about whether or not the piece actually went as far as it should have gone. I told him that I would get back to him about Brady when I had a chance to explore the facts.
Michael wrote me back again and said that last week’s letter would have been more effective if I had delivered a “knockout punch” rather than a soft admonition of our failure to put the best interest of patients and the community ahead of personal professional interest or the interest of our institutions and our industry. That was quite fair. In retrospect I think that I was reluctant to be as explicit as Michael would have liked. I am really not an angry warrior. I just try to say inoffensive things that might trigger some thoughts and change a few attitudes.
He also came back full force on my dodge of the Brady issue. [You must remember that Michael is a Seattle Seahawks fan and suffered mightily at the end of last year’s Super Bowl.]
-Re: Tom Brady supporting Trump, here are some thoughts:
When I was a very young sports fan, I somehow believed that "my team" was made up of good guys that undoubtedly were thoughtful, kind, socially conscious, and wise. When I was around 10 or 11 I happened to fly on an airplane with several members of "my" LA Dodgers. It was hard to ignore that many of them were loud, cocky, obnoxious, rude to the stewardesses, and arrogant. That was my first sense that my sports heroes were just people and that they likely had all of the foibles, strengths, weaknesses, and diversity of human behavior that I experienced with "normal people".
Over the years, I have continued to be an unabashed sports fan, but I stopped putting these athletes on a pedestal for anything other than their sports skills long ago. In fact I have had several sports heroes that I have seriously respected as people, thinkers, and even social critics. These include people like Bill Russell, Kareem Abdul-Jabbar, Muhammad Ali, Bill Walton, Sandy Koufax, and Serena Williams. But I no longer accept a famous athlete's political or social beliefs as particularly influential to me (although I am sure they influence others, particularly children). I now listen to what these folks are saying and evaluate the thoughts individually.
It was with this background that I read about Tom Brady supporting Donald Trump. I was surprised that I cared who he supported. Then I thought maybe he was a victim of the "CTE" (chronic traumatic encephalopathy) that has been in the news so much lately among football players. Finally I realized that I have no idea what motivated Mr. Brady, but I did lose some respect for him. My children are grown up now, but I do have a grandson almost old enough to discuss the concept of sports heroes and their opinions (and add actors, musicians, and other famous people) about politics and social issues and how he might think about them.
I did check out the Brady/Trump issue. Michael is right in all regards. It is true that shortly after I arrived in South Africa there was a flurry of media reports that I missed about the close relationship between Trump and Brady and Brady’s casual response to a question about a Trump cap in his locker that could be construed as some kind of endorsement. I must have missed the story while I was focused on trying to see rhinos. In case you too missed the story,
Although it seems like the 2016 presidential free for all has been going on since 2012, I do not want these letters to become a sounding board for discussion of the individual political figures. My guess is that if you care you can probably guess my position on most of the candidates. In general I can say that there is a big difference between what most candidates are willing to say to get elected and what they are willing to risk when in office. I am empathetic. I do not envy them their role or the difficult positions in which they so often find themselves in the bidirectional process of getting elected and then serving in office.
I do think that an athlete as well as all citizens who wants to do so has the right to let their support for a candidate be known. I also agree with Michael’s concept that we should be extra careful not to be influenced by the endorsements of athletes. Just because many of these athletes can do things that entertain and astound us does not mean that their opinion should guide ours more than the opinion of the man on the corner does. Equality of individual opinions is the theoretical cornerstone of our society. Mr. Brady’s opinion is nothing more than one man’s point of view on a subject that we should all consider until we develop our own opinion.
Friendly Faces, Beautiful Places, and Noble Ideals Don’t Insure the Future of South Africa
As my wife and I come close to the end of our stay in South Africa, we discover that we have developed a real affection for the people who populate this most beautiful place. We have long been inspired by the story and courage of Nelson Mandela. What we discover now is a country defined as much by its social complexity as by its natural beauty. I have been told by many of its “non-white citizens” that their lives are so much better since the end of apartheid. They are proud of their diversity which is best symbolized by “eleven official languages”. Our guide in the bush, who was a gentle man whose Zulu name meant Peace, was a fountain of information and said that he could speak all eleven official languages.
All school children are taught in their native language as well as Afrikaans and English. Everyone agrees that there is individual “opportunity” but there is also disappointment in the very poor economic status of much of the non white population. There are pockets of potentially explosive anger. Apartheid ended without any significant redistribution of wealth. You can now move away from the “Townships” like Langa pictured in today’s header where seventy thousand people are trapped in squalor. Most of the shacks in Langa have dirt floors. Some are old shipping containers. Virtually none have plumbing. People carry water and use common toilet facilities. This kind of life is virtually unimaginable to someone from America.
There are many in South Africa who do not even have a shack in a township. They are homeless and without an official address they do not get any public support because they are not documented. Everyone theoretically has “opportunity” but what does that mean when the white minority (less than 10% of the population) owns most of the businesses and property. It is a country without apartheid but ironically people still cling to the social divisions of that disgusting era. People still pay attention to whether you are black, colored, Indian, Asian or white. They argue about opportunities that are granted to one group but are denied to another.
While we have been here, the South African newspapers and television have been obsessed with the World Cup competition in rugby and we have discovered that race is also a big issue in sports despite the good feelings about sports that were present when Mandela was alive.
I was flabbergasted when I read an op ed piece in a Johannesburg newspaper where the author said that the concerns about the racial makeup of the rugby team were ridiculous because everybody agreed that whites were better at rugby and blacks were best at soccer. There is a long way to go before even sports, much less wealth and opportunity, are truly based on merit.
What has made the trip so valuable to me is that we have the same problems in the USA. They are just more subtle and do not hit you in the face with the same intensity as they do in Africa. I see hope for South Africa and for us. They have a wonderful country with spectacular resources, georgeous cities and stunning natural beauty. They have freed themselves from the onerous restraint of apartheid. Now they are working on residual racism and the maldistribution of economic resources. Change is slow. Many generations will probably pass before the world becomes free of racism and subtle forms of economic servitude. I think Dr. Martin Luther King, Jr. knew that when he gave his “I Have A Dream Speech” and Nelson Mandela knew it on the day he finally walked free after many years in prison and said:
For to be free is not merely to cast off one’s chains, but to live in a way that respects and enhances the freedom of others.
The true test of our devotion to freedom is just beginning.
I have walked that long road to freedom. I have tried not to falter. I have made missteps along the way. But I have discovered the secret that after climbing a great hill, one only finds that there are many more hills to climb.
I have taken a moment here to rest, to steal a view of the glorious vista that surrounds me, to look back on the distance I have come. But I can rest only for a moment for with freedom come responsibilities and I dare not linger, for my walk is not yet ended.
South Africa and America are on the same road. It is just a little easier to see the problems in someone else’s country than it is to see your own country’s shortcomings. I do believe that we are both moving forward. Whether your metaphor of choice is “digging ditches with spoons” or “hills beyond hills to climb” for years to come into the future, progress is visible and we should be encouraged to press on.
