Subject: [SHC] Dr. Gene Lindsey's Healthcare Musings Newsletter 29 June 2018

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29 June 2018

Dear Interested Readers,

There’ll Be Some Changes Made, Unfortunately

I envy guitar players. I wish that I was decent plucker of strings. I have been trying to make progress in this area for forty years. Two of my greatest disappointments in life are that I have never become proficient enough with any musical instrument to feel comfortable playing for others, and that despite efforts to learn German, French, Spanish, and Mandarin, I remain monolingual. A few years ago I read in a book, Guitar Zero: The New Musician and the Science of Learning by Gary Marcus, an NYU neiroscientist, that there has never been a professional guitarist of note who began the instrument after age 17. I guess there is little hope that I might be the next Eric Clapton, although I can still learn a few new “licks” if I am willing to make a very focused effort. Old dogs can learn new tricks. It’s just a long and painful process.

Two of my favorite guitar players who can make their instruments talk are the late Chet Atkins and Mark Knopfler of the British band Dire Straits. I was delighted when years ago, actually in 1990, they put out an album together that was appropriately titled “Neck and Neck.” There is a lot of whimsy and banter on the album mixed with some great guitar playing. I think that in a few of the cuts from the album you can convince yourself that they are presenting some deep philosophical considerations. If they did not intend a deeper message in the neat, humorous piece, “There Will Be Some Changes Made,” I have gleaned a message for myself to go along with their catchy little tune. I hope that you will click on the link and listen to it before reading further. If time is an issue, here are the words to the first verse.

There'll Be A Change In The Weather And A Change In The Scene
How Is That?
I'm Gonna Start Wearin' Leather And Change My Routine
I'll Wear Dark Glasses Maybe A Toupee
I'll Get Down And Boogie And Become Risque
I'll Start Wearin' Make-Up Like Jackson And Prince
You'll See Me Ridin' In My Mercedes Benz
Nobody Wants You When You Just Play Guitar
There'll Be Some Changes Made Tomorrow
There'll Be Some Changes Made

The tune and the phrase, “There’lI be some changes made,” has reverberated. through my mind on a frequent basis over the decades since I first heard the tune. It is one of those tunes that become a “earworm” or as I call them “mind worms,” ditties that are triggered by events and become a soundtrack you can’t get out of your mind. With all the changes in healthcare and in my own life you can imagine that I am thinking about Knopfler and Atkins on a frequent basis.

From personal experience it is hard to escape the conclusion that change is a constant reality that we continually disregard or go to great lengths to deny. I am frequently surprised by the obvious physical changes that have occurred to some old friends when I unexpectedly see them after not seeing them for many years. It is hard to accept that in a reciprocal way they may be having the same thought about me. Paradoxically, despite our passive denial of change and our surprise when we see it, we frequently talk about making changes that we never make. We make a lot of unfulfilled promises to ourselves and others about getting ahead of the curve of the inevitable or making the changes that will improve some long standing deficiency that needs rectifying. “Transformation” is a word we use a lot as we wallow in the status quo. There seems to be a real connection between broken promises and an inability to initiate change. A recurrent theme in country music is the request for forgiveness with the promise of change and the fact that all will be well going forward.

Even harder than an individual being able to make the personal changes necessary to preserve a relationship is the task of a group of individuals to make the changes necessary to improve their practice or preserve the mission of their organization. On an almost daily basis I see reports form Becker’s Hospital Review and FierceHealthcare, the “throwaway” online healthcare media outlets, announcing yet another hospital or health system failure. The better alternative to failure for many physician practices and hospitals who could not “transform” themselves in anticipation of change has been to give up autonomy and accept the protection of a for-profit entity like Optim or a larger non-profit system with a stronger market position.

The choice that has faced all healthcare organization has been to transform themselves in anticipation of external changes in finance and performance requirements that are beyond their control, or to try to continue to do business as usual while cutting programs, looking for “low hanging” choices, for “one time only” savings, or revenue opportunities from selling assets that enable them to post a positive bottom line for another year while waiting for a miracle. In time most everyone learns that you can’t cut your way to success, and that the elusive growth necessary for continued success is not possible while staff is stressed by the sacrifice of critical programs and optimal staffing ratios. The change that they can’t avoid comes down as outright failure or the loss of autonomy.

At strategic retreats and staff meetings we hear bold statements about our positive missions and the commitment to change, but then the work of the next day sucks us dry of the energy necessary to affect those changes. We speak positively about what we will do to prepare, but the status quo is hard to overcome and in the end we rationalize why delay is prudent. We hear speeches about avoiding unintended consequences, and fall victim to the fearmongers. Before we settle the question of what to do, and come to a consensus about what needs to change, and what must be inviolate, the moment of opportunity to direct change or prepare for change passes, and then change does occur, and we have little or no control over the outcome. If we do recognize the inevitability of change then the fall back position is that we will do it later; mañana will be soon enough, or that others will do it for us.

I have a mixed record with change. I see the need for it in others much more clearly than I see it in myself. Not only do I see the need for change in others, including the need for institutional changes, but I can clearly see what the outcome is likely to be if change does not occur. I became a CEO with a clarity in mind of the changes that needed to occur in our practice and over five and a half years many changes did occur. Some of the moves we made stuck and continue to be an asset to the organization. Other moves did not yield the desired result or faded when I retired and turned over my leadership responsibilities to others. The sum total of the analysis five years after the fact is that just knowing that change is necessary and vigorously trying to affect change is not a guarantee of success. Shakespeare had Cassius say to Brutus,

"The fault, dear Brutus, is not in our stars,
But in ourselves, that we are underlings."

My experience suggests that Cassius is almost right. External events and forces largely out of our control do create the majority of the challenges that we face. Our responsibility to prepare for those changes that are inevitable does lie within ourselves. My observation, I am sorry to report, is that many healthcare organizations have delayed the transformations that they needed to make to insure their ability to protect their mission or even the commercial success of their private practices or entrepreneurial concerns that they are now imminent “road kill” in the very competitive and stressed world of healthcare in America in 2018.

What is sad for me is not that individuals will move on from failed organizations to other opportunities. I have no worry about unemployed orthopods or cardiologists. Empty buildings do not worry me. I expect that assets will be purchased, and new owners will redefine the business objectives and decide whether the old concepts of mission will fit the new paradigm dictated by the realities of 2018 and what follows. What I am not so sure about is how those who were still underserved, despite a sense of mission of many fading organizations, will fair in the reorganization of care that will follow the relative reduction of resources from public support that now seems inevitable.

I do not know how the events of this last week will play out going forward for the underserved. Will a Supreme Court with a guaranteed conservative majority for decades to come ever consider access to care as an entitlement? It seems possible that we will discover that the right to determine their own future that women have enjoyed since Roe v. Wade came down 45 years ago will prove to be a passing aberration. Will more and more of the briefly enjoyed benefits of the ACA be deemed an overreach? Our future is uncertain. The gains of the last twenty years in the extension of coverage to children and the underprivileged may become interesting history and not continuing realities.

Perhaps it is just an old man’s reaction to events beyond my control, but as I contemplate what might lie ahead based on the outcome of recent events, a cloud seems to pass between me and my sense of continuing hope in a near term realization of the Triple Aim. I do not see a majority of clinicians or medical institutions looking beyond their short term concerns with a willingness to prepare for better care for everyone at a cost that we can all afford. Those of us who do desire a day when all our citizens can be assured of the healthcare they need, as well as the education and employment opportunities that will allow them to realize their full potential, are swimming against a strong current of resistance that has been created by the fear that any privilege or help offered to someone in need will come at their expense. In that circumstance we may all become the victims of the fate determined by the stars since we have failed to take advantage of the changes we could have made when we had the time and opportunity, and should have known the challenge was coming.

Yea Teamwork!

The header for this week’s letter needs a little explanation. You might remember a header from this spring that pictured a group of guys surrounding an outdoor maple sugaring operation. The operation belonged to my friend Steve who is the organizer of many social service activities in our community. Steve is on any local board that seeks to provide opportunity to the underserved, or protect our environment. He is a mentor to young adults and a helping hand to the elderly who do not know how they might continue to live independently. He is a lawyer with expertise in energy production, but if he was a doctor he would be a PCP in a health center that served the rural poor. Steve likes making maple sugar and he wants a new “sugar house.”

What you see is several old men engaged in pursuing a goal. Our ancestors and the people who lived where we live now would come together to “raise” barns. We came together to raise Steve’s sugar house. We were fueled by the common goal of producing more maple syrup next year and the expectations of many happy hours watching the sap boil down to the product we desire.

As you can see, it will be a solid “post and beam” structure. I also see the picture as a metaphor. All of us are engaged in the effort to achieve a goal. None of us alone could lift the beams that have been pre shaped into a wall. Someone did the prework. Someone organized the raw materials. Others cut the beams and joined them into a potential wall. Together we lifted the wall into place and held it steady while a few secured the braces that will hold it in place while it awaits the other walls that will join it to make the sugar house. One lone fellow holds a rope that will protect our gains from falling back on us while we do the work to secure what we have accomplished.

So, your organization is not ready for the changes that have already destroyed your bottom line for the last couple of quarters or years. You think it is too late to launch Lean and you are reluctant to hire an expensive consultant to help you cut your way to success. Refocusing on teamwork may be a place to start a recovery. Realizing that no one succeeds for long in a distressed organization may be a starting place from which to build teamwork. Providing efficient effective healthcare is not a solo activity. Good healthcare is the product of a team effort. Just as there were different roles and responsibilities that enabled the raising of the walls of the sugar house, there are interconnected roles and responsibilities that I believe we have failed to adequately emphasize in healthcare. We are focused on teamwork within units, but I fear that we are not effectively focused on the teamwork involved in processes of care that involve participants from multiple services or teams. I hear more and more healthcare managers talking about achieving success within their “service line.” Several successful service lines do not add up to a successful organization that serves patients well. Single service lines, in my experience, do not usually cover a total “episode of care.” Single service lines are often in competition with one another in an ACO structure where specialists are compensated by activity based RVUs and PCPs are trying to manage care within a budget that specialists can disregard.

My contention is that since we are not prepared for the changes that are coming at us, our first step in our delayed defense must be the establishment of common goals. Hopefully the beneficiary of those goals will be patients, but if our response to the growing stress is to regress into the preservation and success of our particular “service line,” then we will all lose. Real teamwork in medicine is more than organizing doctors, nurses, PAs, and medical assistants within a unit. Real teamwork is about cross disciplinary teamwork organized for the benefit of the patient. Teamwork in healthcare is ultimately about organizing care across specialties and across ambulatory, inpatient, and post acute sites of care. Successful teamwork requires keeping the goal in mind. The only goals worth pursuing are the care of the individual patient, the professional health of the providers, and the collective benefits of the Triple Aim.

Notice of A Positive Change

I am happy to report that next week you will experience a slight change in the way you receive this weekly missive. Again, the change is driven by external forces beyond my control. Let me explain.

Cyberspace is all about change. Google drives a lot of that change. One area that is changing fast is how large distribution letters to mailing lists are handled in an era of increasing concern about cybersecurity. I think that as many as 50% of readers are no longer receiving the letter because of the way their organization manages large distribution letters. Silly things like font size and the number of links in the letter are included in algorithms that create barriers to full distribution. I have met people who have asked me why I have stopped writing when I have not. Other readers still get the notice of the Tuesday posting on the blog but not the letter. My IT guru, Russ Morgan, tells me that the solution is to post the letter on the Internet and not to continue to send it as a direct letter to you. Next week and afterward, on every Friday at three you will receive a notice and a link connecting you to a new Healthcare Musings letter. Just click the link to read it in your browser.

I hope that I will be able to use this opportunity to refocus the discussion of the clinical, the organizational, and the national political issues that you care about. There will continue to be Tuesday postings on I hope to use the two weekly postings to continue to offer thoughts and ideas that might help just a little bit to provide to you the perspective that will sustain you as we all try to pursue the Triple Aim and a resurgence in the joy of caring for the individuals and families that are our neighbors.

Doubleloon Delight

I am in the midst of my twenty third New Hampshire summer. The one thread through them all is our love of loons. There is usually one breeding pair of loons on each little lake. The question that holds us in suspense each year is whether or not our pair will produce a baby loon. The last few years have been tough and a real education about just how vulnerable loons are to the encroaching vicissitudes created by people like me who want to share the lake with them.

There is no doubt about it. The loons would be better off without us. Lead fishing tackle has been banned, but nevertheless our mother loon died two years ago of lead poisoning. The latest madam loon failed to deliver last year for uncertain reasons. One explanation was that there was competition between the old guy and a new suitor. I think that she got spooked by a storm and abandoned the floating platform that we offered as a safe nesting site when one of the cables that stabilized it broke. Whatever the causes, it has been over two years since the loons on Little Lake Sunapee produced chicks. We have been very envious of our neighbors across town on Pleasant Lake who have had two baby loons every year!

This week we have had rain, and on many days the fog has hung low over the lake. Even when we can’t see the loons we can hear them. They were talking a lot early this week. We thought that the calls seemed to be becoming more excited. On Tuesday morning my wife saw both loons on the lake together. It was a tense moment. Had Mrs. Loon abandoned the nest as she did last year, or was the new family out for a swim together? Through binoculars she saw a little bump on the back of one on the loons! She quickly posted the good news to the lake’s Facebook site. Later, to our delight, a neighbor documented that there were two babies! You can be sure that they will be prominently displayed in coming headers on these Friday notes.

Is it silly to be excited by the appearance of baby loons? I think not. Nature is a readily accessible antidote to the concerns that infuse us with fear. The loons have not been around as long as cockroaches, but it is clear that they and their recent ancestors have been around a lot longer than either us or our recent ancestors. Just like us, they are now dealing with a lot of recent change. They seem to help me settle down as the changes that flow everyday from Washington leave me in despair. I am happy there is some reciprocity in our effort to help them.

I hope that this weekend will be a great opportunity for you to renew your spirits in a natural setting. Even better I hope that since Wednesday is the fourth of July you will have the whole week free!

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,


Dr. Gene Lindsey
The Healthcare Musings Archive

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