Subject: [SHC] Dr. Gene Lindsey's Healthcare Musings Newsletter 27 Apr 2018

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27 April 2018

Dear Interested Reader,


Comments, Thoughts on Comey’s Book, and an Introduction to This Week’s Main Subject

I am usually full of hope and expectation in the first few hours after this letter is published each Friday. The large majority of comments arrive in the first two hours after the letter goes out. They dribble in after that. Those two hours were particularly fruitful last Friday. One reader who regularly comments was quick to say that he too agrees that the social determinants of health should be a major strategic focus and then commented on the long history of inappropriate relationships between the press and those in power. Another regular reader who went through her internship and residency here after gaining her medical degree in Europe lamented that both she and her husband, who is also a PCP and immigrated here from Africa, are about ready to leave the country over the combination of issues of race and the administrative demands and focus on finance that robs them of the joy of practice. That says a lot since they both work for large delivery systems in Eastern Massachusetts.

Then came a remarkable response from an old friend and colleague Carole Allen. I first met Carole when she was recruited to be the Chief of Pediatrics at Harvard Vanguard Medical Associates many years ago. Carole is an activist. She has held positions of responsibility in the Massachusetts Medical Society and has been the President of the Massachusetts Chapter of the American Academy of Pediatrics. After retiring from Harvard Vanguard and Atrius Health a couple of years before I retired, she served on the initial Health Policy Commission for Massachusetts for several years. She is “retired” in the new sense of the word. She is not practicing, but she is fully engaged in leveraging her years of experience to the continuing benefit of the community. Last week’s letter resonated with her so I was rewarded with a note from her that I want to share with you because she underlines the importance of focusing on the toxic issues of poverty for children. Carole and I agree that we can never make much progress toward a healthier community if we do not focus on children. Carole’s activism extends to Washington as you can deduce from her letter.

Hi Gene,

I don’t always get to read your musings but this one really resonates with me. I too have been outraged by the toxic inequality that in particular threatens the health, well-being, and futures of our nation’s children, especially those who are disadvantaged or of racial and ethnic minorities. I am not as well read as you, but I think we drink from the same fountain of understanding - that addressing social determinants is the only way to move forward on population health. The work of Nobel laureate Jim Heckman shows the enormous return on investment from providing high quality early childhood education to disadvantaged children. And we know that adverse childhood experiences (ACE’s) have long term impacts not only on mental health but in creating chronic diseases as well, often spanning generations through epigenetic mechanisms. About 20% of kids nationally live in poverty. But broken down by race it’s more like 37% of black kids (granted there are fewer of them than white kids) and close to that percentage for Hispanics.

I don’t subscribe to the notion that those in power are ignorant of the potential to solve these problems by addressing poverty and racism. I believe they understand the potential ROI and deliberately want to go in the opposite direction. Ryan’s poverty plan, for example, was extraordinarily racist and discriminatory. When I asked his aide if they included job training and child care, because two large poverty groups were single mothers and returning vets, the aide said no. Look at what the R’s want to do to Medicaid and SNAP with work requirements. Trump constantly stirs the racism pot to appeal to his base. We desperately need to change the power structure in DC - hoping the midterms get us partly or mostly there.

I’ve rotated off the HPC and am looking where next to contribute. I did obtain an MBA through the Heller School last May in a new executive MBA program for physicians. Currently working on a powerpoint/ curriculum to teach political types the basics of healthcare and looking for my audience.

Hope you are well.

Carole


When I read Carole’s letter I immediately did two things. I connected her to Joe Knowles and I resolved to connect her to you. My plan is to continue to write often on the issue of toxic inequality. This week’s Strategy Healthcare posting, a shortened version of last Friday’s letter, drew a thoughtful comment from a healthcare professional in Minnesota whom I do not know. He wrote:

I am working with a health care organization to update a tool called the Culture Care Connection. (http://www.culturecareconnection.org/). In the update, we want to address issues of implicit bias and provide health care organizations and health care providers with tools that will help them overcome those biases. If you have insights into tools or resources that would be helpful, please share as you have time.

A second question is more theoretical, and I wonder if you have an opinion.

When we look at low-income patients or at African American patients (as examples), we could attribute the disparities in health outcomes to the various burdens of poverty or racial discrimination. But is it valid to flip the question a bit and ask: How do the biases of health care providers affect these outcomes? I.e., Do African American patients receive lower-quality care because of biases of the providers? A well documented piece of evidence is that African American women have worse birth outcomes than white women, REGARDLESS of their level of educational attainment (African American PHDs have birth outcomes similar to high school educated white women) (numerous studies document less frequent use of pain medicine for African American patient, etc.) So rather than having to cure poverty is it possible we could work on reducing bias in providers? Your Thoughts.

You can read my attempt to answer his questions on the Strategy Healthcare site. I sent the questions to Joe Knowles who responded:

...I had picked out the same point from the NYTimes Magazine piece on African-American child births, that inherent racial bias cut across differences in educational status. But to his question of whether to “cure poverty” or reduce bias among providers, two responses come to mind: first, I believe either effort would help advance the other; second, it seems a false choice, as I believe there are resources and motivated people to pursue each.

I mention in last week’s letter that I bought James Comey’s book A Higher Loyalty:Truth, Lies and Leadership on the first day it was out after much reading of prepublication articles and seeing him on television and hearing interviews on NPR. I have read the book now and have my own thoughts. I should emphasize that Comey’s book does not have a direct impact on healthcare, but it is a legitimate resource for these complicated times because it gives a startling and informative picture of how partisan forces within Washington develop policy on many internal and external issues while established institutions like the Department of Justice and the FBI attempt to enforce rules and preserve the rule of law.

Comey describes the tensions that leaders of those institutions of public trust personally feel as partisans seek to promote the issues that are important to them and their supporters. The book is really a memoir or autobiography. Comey tells his own story and reveals his personal philosophy of a life of service and leadership. He reveals many of his most personal concerns and failings. It is for the reader to decide how full and complete his personal analysis is. Comey’s writing demonstrates that he understands that the reader must form an opinion about his reliability and honesty as an observer and interpreter of events to be able to decide whether to accept his concern that the president is unfit for his responsibilities. A lot of people are reading the book. The publisher has already sold 600,000 and is planning on selling more than a million. It is the very best seller of many best sellers already out about the president and has eclipsed the sales of Hillary Clinton’s book about the 2016 campaign. I am now reading her book.

I have read multiple positive and negative reviews of the book. It is a short but complex book that I would divide into several sections. First there are childhood and young adult experiences and the lessons he learned from mentors that made him who he is or endeavors to be. Next there is the story of his early professional life and family life. He rose quickly in the Department of Justice as an assistant US Attorney working with Rudy Giuliani in the 90s to prosecute the Mafia. He has a very positive, supportive wife who seems to keep him on course. They have five living children, four daughters and son. He tells the terrible tale of losing an infant son to a strep infection after his wife’s obstetrician failed to identify that she was an asymptomatic carrier. The Comeys joined a national movement that increased the awareness of peripartum strep and the need for routine testing.

The next section describes conflicts and lessons learned as the Deputy Attorney General under John Ashcroft. In this section you learn a lot about his conflicts with Dick Cheney and George W. Bush’s administration over unlawful surveillance of Americans after 9/11 and the CIA’s use of torture. He resigned and left government for the private sector for eight years when Bush named Alberto Gonzalez as Attorney General in 2005.

The next story is of his relationship with Barack Obama who surprised him by recruiting him, even though he is a Republican, as FBI Director in 2013. He then continues with the painful story of his part of the investigation of Hillary Clinton’s use of a personal email server as Secretary of State. In this section he describes his thought processes that led to actions that many think cost Clinton the election and gave Trump the presidency. It is not until Chapter 11, page 188 of a 278 page book that he gets to Donald Trump. You might say, as some have, that the whole book is a set up for the last 90 pages.

If you want to read a negative review and a sharp attack on Comey’s failings, check out the article by Jennifer Palmieri in Politico. She was the communications director in Hillary Clinton’s campaign and her criticism of his book primarily relates to his impact on the 2016 election and her refusal to accept his explanation for his actions. I can easily remember how upset I was with Comey when on October 28, 2016, less than two weeks before the election, he sent a letter to Congress announcing that the FBI was reopening the investigation of Hillary Clinton’s use of a private email server.

Comey is clearly tortured by the criticism he has sustained for his qualified description of her innocence but carelessness in July 2016, and the reversal of fortune Hillary Clinton perceives as the result of his reopening the FBI’s investigation so near to the election when many more of her emails were found on Anthony Weiner’s laptop. He makes a good defense for his actions based on how the public would have reacted had she won and then there was a leak that the investigation had been reopened but the information suppressed. There are parallels to Barack Obama’s decision not to announce the intelligence that the Russians had such a large scale operation underway to disrupt the election. They both say they expected Clinton would win and were trying to prevent the storm that would be created if Trump’s supporters felt that information had been manipulated to favor Clinton. As Comey tells it he was faced with a hard choice between bad options. He quickly admits that others might have made a different choice. It is a complicated story, and I appreciate the new information and insights that he presents, even though I still have some doubts. It is easy to understand how all of the negative reviews that I read focused on the Clinton issues or on his self righteousness. It seems now that just as Hillary Clinton has done, we must accept the past as the past and realize that if Comey has anything to offer it is information about Donald Trump and the hope for a preserved future.

The review in the Washington Post by Carlos Lozada was balanced and is worth your time as was the review in the NYT by Michiko Kakutania. In another NYT piece Comey talked about the books that he reads. I was not surprised when Comey mentioned Jonathan Haidt’s Righteous Mind: Why Good People Are Divided By Politics and Religion. Almost all of the reviewers, both positive or negative, really do not know what to think of a man who is so self observant and so dedicated to leadership and doing the right thing that he makes choices and takes actions that confuse people who function on conventional thinking and expediency. Early in the book Comey reports his discovery of Reinhold Niebuhr, the theologian of social action, while in college and refers to him, Martin Luther, and Martin Luther King, Jr. frequently throughout the book. He reports that he has read Dr. King’s “Letter From the Birmingham Jail” many times as an adult and made it part of the training program for FBI agents.

He does not talk about his religious activity in the book although he does mention his wife’s involvement in their church. A little time on the Internet reveals that he was raised as a Catholic but as an adult has been active in the Methodist Church and attended a Congregational Church when he was living in Connecticut and working in the private sector. Like Jimmy Carter, he has been a Sunday School teacher and has held active leadership positions.

I think, like Jimmy Carter, it is the reality of his attempt to live a very positive life and his obsession with making the hard but moral choices in a complex world that makes him seem less than credible to some of the reviewers who just can’t seem to accept that anyone could really try as hard as he says he does to do the right thing. The most enlightening interviews I saw were with David Remnick of the New Yorker. Remnick pushed him hard on the Clinton issues, but was more accomodating in the discussion of his experiences with Trump. The first 188 pages of the book are necessary to allow you to decide whether or not to lend credence to Comey’s straightforward conclusion on page 275:

Donald Trump’s presidency threatens much of what is good in this nation.

I think that statement includes healthcare. Comey continues by expressing his confidence in the hope for a better future:

But I choose to be optimistic. Yes, the current president will do significant damage in the short term…[he inserts a long metaphor about the benefit of forest fires and then continues]...Far from creating a new norm where lying is widely accepted, the Trump presidency has ignited a focus on truth and ethics.

My impression after reading his book is that I wish we had more people in public service who were as concerned about doing the right thing as I believe Comey is. I can accept their mistakes if their intentions were noble. The book was helpful to me because I was quite upset about the way he appeared to cost Clinton the election. I wish that I could have read his book as a text on how to lead a compIex organization before I became a CEO. I fear that he has told us all that he can tell us, and that further resolution and the future of the nation is up to others. That is his expectation. He is impressed by the commitment to service of young people. He trusts Robert Mueller. He hopes that his words:

“...will be useful to readers long after the flames are doused, by inspiring them to chose a higher loyalty, to find the truth among lies, and to pursue ethical leadership.”

Comments and Comey aside, the main section of this letter is a return to a discussion of innovation. Adam Ward is an engineer who produced innovations for Honda and other corporations before he signed on with Simpler Consulting as their “innovation coach.” I met Adam while I was CEO of Atrius Health when we sought to move beyond just improving our processes to searching for new ways to provide care that would delight both patients and providers. On first encounter I knew that Adam knew a lot of things that I wanted to learn. Over the time I have known Adam he has changed the way I think about innovation. I’ve come to understand that “innovation” does not usually arise from a bright idea striking someone special like Steve Jobs, like a bolt of lightning. It is hard work best accomplished by a team. It arises from a focus more like Malcolm Gladwell’s 10,000 hours of tedium and practice that leads to competence than from innate genius or serendipity.

I was quite honored when Adam contacted me recently and asked if I would read the rough draft of a book that he was writing about innovation. I have read the book and have asked Adam if I could share what I have learned with you.


If Innovation Is the Answer are You a Player or a Spectator?

“Innovation” is frequently offered as the “way out of the woods” for American healthcare. And why not? As Americans we are reminded of the power of innovation to reshape our world many times a day as we tap on our cell phones to find our way through traffic to a place we have never been, purchase a new pair of shoes from an online retailer, or check out our friends on Facebook as we pass the time in the waiting room of a specialist to whom we have been referred. It’s not just consumer electronics that demonstrates the power of innovation in our world. If you have ever flown on Southwest Airlines you know that they have transformed air travel with a new business model. In a negative way international conflicts have been transformed by those willing to move beyond conventional warfare and use terrorism as an “innovation.”

Much has been written about how healthcare is a contrary industry. The “invisible hand” of the market does not seem to be able to find the handle in healthcare that opens the door to lower prices, profitability, and consumer satisfaction. Financial incentives seem to raise costs without improving performance. Despite growing concerns about unsustainable financial burdens and growing workforce shortages that will cost many access to care even as hospitals are shuttered, practices vanish, and many doctors and nurses are driven to early retirement or alternative careers, innovation does not seem to be able to save our day or bring a new day as it has in so many other industries.

Some say that innovation requires substantial resources and a larger enterprise. The rationale that a larger organization will be able to “innovate” has been frequently offered to regulators as justification for mergers that create virtual regional monopolies in healthcare in many markets. I am unaware of any of these promises that have yielded much fruit although I am aware that some large systems like Kaiser, Cleveland Clinics, UPMC, and Geisinger have been more innovative than others.

Is innovation too expensive for most organizations to attempt or sustain? Is there a shortage of talent or creativity? Is today’s workload too heavy to allow most organizations to look beyond the moment toward a future accessible only through innovation? Should innovation be left to groups of bright young engineers and entrepreneurs who will ship out solutions to all of our problems from Silicon Valley? Does innovation in healthcare fail because leading innovation requires a mindset not found in most healthcare executives? Do the “internal politics” of stressed organization preclude innovation? All these and many other questions come up in Adam Ward’s new book Lean Design in Healthcare - A Journey to Improve Quality and Process of Care.

Do we need a new book on innovation in healthcare? To answer that question I recently employed the innovation that has made going to the library a rare activity for me. I went to Amazon and typed in various configurations of phrases like “Healthcare Innovation.” My “research” produced fifteen books written since 2010. Titles like Innovation and Entrepreneurship in the Healthcare Sector: From Idea to Funding to Launch (2011) and the more recent Managing Innovation in Healthcare (2016) were intriguing, as was Before Disrupting Healthcare: What Innovators Need to Know (2016). Surely it would be a good idea to buy Innovation the Cleveland Clinic Way: Powering Transformation by Putting Ideas to Work. There are many options but none seemed appealing and the books themselves would probably be rather dry and technical and amount to yet another barrier for a busy leader or management team that had come to the conclusion that they must become innovative. It is barriers like that that keep consultants employed. Unfortunately, just hiring any consultant does not guarantee much more success than buying a boring book.

I have always been drawn to stories, and early in my tenure as a CEO I was delighted to discover Patrick Lencioni’s little gem, The Five Dysfunctions of a Team: A Leadership Fable. After reading the “fable” I gave a copy of the book to everyone on my leadership team. Later on I discovered John Kotter and Lorne Whitehead’s little book, Buy-In: Saving Your Good Ideas From Being Shot Down, another “fable” pregnant with great advice. Just last year I wrote the preface to another healthcare fable, The Patient Centered Value System: Transforming Healthcare through Co-Design by Anthony DiGioia, MD and Eve Shapiro. I hope that is enough proof to establish that I really like “how to” books that use narratives to help the reader absorb information that is experiential but is denied to them because they have not “had the experience of…” To my list of favorite books that offer difficult to acquire wisdom and knowledge through “experiential” fables I will now add Lean Design in Healthcare - A Journey to Improve Quality and Process of Care.

The subject of innovation is complex and there is no settled or widely accepted set of practices. As the story implies there are experienced “gurus” or coaches who have received knowledge from other wise ones and often been part of the practiced art in industries that live or die on the ability of teams to constantly develop products that attract and delight customers. Adam Ward has such a background. He worked for many years for Honda and other innovative companies before he brought established industry concepts of innovation, that he personalized and advanced through his own experience, to healthcare.

One of my most positive experiences as a CEO was being a part of the introduction of Lean to Atrius Health. As we got into the work of improving existing systems of care with Lean, it was easy to see that what we were doing was similar to what audio engineers were doing in the dying days of analog recording. You could wrestle incremental improvements from the old way of doing things, but what was really needed were innovations that enabled more portable and widely available devices for both recording and enjoying music. Once the shift was underway it did not take long for my old turntable to be moved to the attic. Our early work with Lean led me and others in our practice to realize that “running faster and more efficiently” was a move in the right direction, but it was time to begin to think about a whole new ballgame. Healthcare transformation meant redesign with bold objectives as the goal. Near the end of the book there is a conversation between two of the characters that captures part of the concern that made the need to develop our own innovative skills seem so important to me:

“Patients don’t always want the next available appointment, they want the appointment when it works best for them.”

“Our doctors’ panels average 2,000 patients. We are pushing them to increase that number to 5,000 with our goal set at 10,000. There won’t be enough physicians in the future to keep panel sizes low,” Georgina explained.

“Even now, giving the patient the time most convenient for them is difficult. When we double or triple the number of patients for each doc, we have to focus on who sees the actual doc and who doesn’t need to,” Hoggs added.


The story demonstrates how vulnerable the idea of setting up a systematic approach to innovation will be to potential failure. It is not an overnight process and in organizations that are dominated by “operations” with leaders desperate to have results that are obvious within the next quarter there is little chance for success. It would be nice to think that good leadership would guarantee success but that is not the story that is told. There are many subplots of misunderstanding, resistance from senior executives with alternative strategies, and just the hard work of team building in an environment where there is all the volatility, uncertainty, complexity, and ambiguity in an industry under attack for its failure to produce a sustainably affordable service for everyone. There were moments in the story when the lines of Rudyard Kipling’s famous poem “If seemed to be playing in the background:

If you can keep your head when all about you
Are losing theirs and blaming it on you…

Not to be a spoiler, but at the end of the fable there is still uncertainty. It is a real story. What is accomplished is that a team has been created. The innovation team, the CEO, and probably most of the surviving management team has learned that innovation is the product of intense curiosity that requires thousands of hours of inquiry and research with potential customers. It is not a solo act. It’s success is grounded in the patience required to try and try again. They have learned that a guide that can coach, mentor, and encourage them to be patient and trust one another is an essential catalyst. If the team stays together, and if ripples of understanding of the process can begin to create understanding in the larger organization while expectations of miracles are managed along with those who would go another way that offers an easier path that is a blind alley, then there is hope.

It will be several months before you can read the story. I have only skimmed the surface. For those who want a more explicit debate of various concepts of the management of the process of innovation, do not despair because those ideas are all woven into the plot. My suggestion is that the place to start is with an internal assessment of your organization’s readiness to entertain change. If you are trying to survive by cutting programs and cranking up individual productivity without attention to the welfare of your employees and to the service you provide to your customers, then you are among the walking dead. If you realize that you can’t cut your way to lasting success but need to manage for efficiency and improvement, you are taking the first step toward thriving through innovation.


Spring at Last: The Ice Is Out

Late on Monday I returned from a weekend trip, first to Columbia, South Carolina for my 55th high school reunion last Friday evening, and then to visit my father in North Carolina on Saturday and Sunday. The weather was fabulous and sported clear skies and a bright sun. All the flowering trees, like the dogwoods, were covered with blossoms and there were flowers everywhere. Spring leaves are a lighter green than summer leaves, and light green was the dominant color on any hillside.

When I return on Monday evening I saw that we had lost a lot of snow over the weekend. On Tuesday morning I was surprised to see so much open water on the lake. If you look back at the header from just three weeks ago you will see that the image was split between Opening day for the Red Sox and the same scene of my lake totally frozen in a snowstorm on April 3. Today’s header taken on Tuesday April 24, just three weeks later and shows a lot of clear water. Today there is almost no ice.

I was so excited by the open water that I dusted off my kayak, got my fly rods out of the attic and had my first day fishing for 2018. Like the Red Sox on Saturday against the Oakland A’s, it was a “no-hitter” but unlike baseball where each game produces a winner and a loser, the are no losses when we are on the water. It is just a scale from good to awesome.

I hope that Spring is here to stay for you and that you will be involved with soaking up awesome this weekend. Reading Jonathan Haidt recently exposed me to a quote from Ralph Waldo Emerson that resonated with me:

Standing on the bare ground, — my head bathed by the blithe air, and uplifted into infinite space, — all mean egotism vanishes. I become a transparent eye-ball; I am nothing; I see all; the currents of the Universal Being circulate through me; I am part or particle of God.

My hope for you is that sometime this weekend you will get out into nature and have an awe inspiring “Emersonian” experience.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,

Gene

Dr. Gene Lindsey
The Healthcare Musings Archive

Previous editions of the "Healthcare Musings" newsletter, by Dr. Gene Lindsey are now archived and available to you at:

www.getresponse.com/archive/strategy_healthcare

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