3 June 2016
Dear Interested Readers
What’s Inside This Week’s Letter
This week’s letter begins with an attempt at a whimsical/philosophical look at looking at the future and then continues on to some more serious speculation about the experience that patients may have in the proximate future. In subsequent letters I will be looking at the future experience of practice for all clinicians as well as “innovation” and how that will affect both sides of the patient/provider axis. After looking at clinicians and innovation, I hope that I will be able to continue the journey in subsequent weeks to look at the issues that lie in the future for employers and insurers and even speculate about the changing role of lawmakers and regulators. My focus is on what we can see and project from current trends and realities.
Charles Handy, the Irish philosopher/thinker/business guru who has spent a lifetime thinking and writing about where business, politics and society may be headed, describes prophets and futurist as people who can see what “is” and the current trends that are observable but that most of us are not noticing, and then project those observations forward in time. I like that concept. It is less fanciful than the Buck Rogers type concept of the future that characterize so many attempts to look ahead. Handy has been remarkably productive into his mid eighties. I highly recommend his latest book of essays on various topics projected into the future, The Second Curve: Thoughts on Reinventing Society.
My ideas about the future for patients segway into a brief review of a remarkable piece published in the New York Times this week by David Brooks, my favorite conservative. Even if you do not have the energy or time to read what I have given you about what he has given us all, use this link to read what Brooks has written in his piece entitled In Defense of Big Love. I think that this piece connects to what motivates so many of you who care about the Triple Aim as you labor to eliminate the inequities and imperfections that are a part of our current delivery of healthcare. I would be really interested in knowing how this piece resonates with your personal sense of purpose.
It has definitely been an interesting week for the old town team. I know that I must bore many of you who do not share my love of the game. Perhaps you share my love for baseball but care deeply about another team, like maybe the Pirates, Cubs, Braves or (ouch!) the Yankees or Orioles. If baseball doesn’t stimulate the release of positive neurotransmitters for you, accept my apologies for these weekly swoons about the Sox.
I hope that sometime this next week you will find a posting by a “contributing” writer on strategyhealthcare.com. If you did not read the first letter in this series about the future, an abridged version is now available on the site. Check it out. The gods of the Internet (Google) smile and pour blessings on me every time someone goes to the site! Your patronage is appreciated.
Don’t Stop Thinking About Tomorrow’s Patient Experience
It is always difficult to think about the future. It is so hard to be sure about what to expect. Will it be more of the same? Can we see something inevitable on the horizon? Is there something that will be totally unexpected that dominates every other factor?
As is true in Cormac McCarthy’s novel, The Road, many of the visions of the future in literature and film are post apocalyptic or “dystopian”. We seem to have had a hard time getting over our fears of a dark future after a nuclear holocaust and if we have made any progress in overcoming worries about a future that contains a nuclear disaster, perhaps we have transferred those worries to new concerns about terrorists, “global warming”, our uncertain global economy, or new infections like zika or some super virulent bacteria that are resistant to all of our antibiotics.
Do you remember “On the Beach”, the 1959 post apocalyptic presentation of the world after a nuclear disaster? Perhaps, like me, you were scared out of your wits as a little kid by a ‘B” film of the fifties, “Five” (1951), a chilly black and white piece of film noir about the “start over” future facing the last five survivors (four men, one woman) in a post nuclear world. Have we lost our sense of hope and our willingness to take an occasional flight to unsubstantiated optimism for a future made wonderful by the application of computer technology to every aspect of our lives? Maybe you are rethinking that vision of how computers will enhance the future of healthcare as you struggle at 11 PM to “close” the thirty or so “open” charts left over from a busy day of practice. I feel your pain. I have been there.
Thinking about the future does not usually correspond to the laughs we had watching the Jetsons or even the sense of adventure with Mr. Spock and Captain Kirk on Star Trek. Recent attempts to focus on the future seem to come down on the “what’s to become of me/us” side of emotions rather than the upside presented by Fleetwood Mac in the rousing anthem “Don’t Stop Thinking About Tomorrow”. Fleetwood Mac advises us to give up bemoaning the past. Although they never quite say it, one assumes that a focus on the past is just too easy and leads to wallowing in the miseries of the moment.
It does not take advice from Fleetwood Mac for you to know that along with uncertainty, all the promise of something better lies in the future. Their advice is that if the past and the moment leave you hoping for more then “Don’t Stop Thinking About Tomorrow”. The lyrics say it all, “Yesterday’s gone...you’ll see things in a different way...It’ll be better than before...Why not think about times to come...Don’t stop, it’ll soon be here.”
The song never quite made it to number one. It topped out in third place on the “hit parade”, but it was definitely one of my favorites back in the late 70s. Bill Clinton liked it so much that it was his theme song for his presidential campaigns and he still uses it when he makes appearances.
Unlike my intro to this week’s Musing what the song doesn’t do is review the possibility for disappointment in the future, nor does it advise taking the errors and learning of the past into consideration as we plan and prepare for tomorrow. It’s just a pop song and I guess Christine McVie, who was the keyboardist for Fleetwood Mac and the composer, was hoping that a better tomorrow would arrive if she just got into the right mindset and was ready for better times. Take a couple of minutes to get out of the funk of my introduction and into the anticipation of a better future built on the foundation of what we have learned. Click here to hear the music or just read the words as the tune rolls through your head. I am sure you can dredge up the tune from the iTunes repository between your ears.
Don’t Stop
If you wake up and don't want to smile
If it takes just a little while
Open your eyes and look at the day
You'll see things in a different way
Don't stop thinking about tomorrow
Don't stop, it'll soon be here
It'll be, better than before,
Yesterday's gone, yesterday's gone
Why not think about times to come
And not about the things that you've done
If your life was bad to you
Just think what tomorrow will do
Don't stop thinking about tomorrow
Don't stop, it'll soon be here
It'll be, better than before,
Yesterday's gone, yesterday's gone
All I want is to see you smile
If it takes just a little while
I know you don't believe that it's true
I never meant any harm to you
Don't stop thinking about tomorrow
Don't stop, it'll soon be here
It'll be, better than before,
Yesterday's gone, yesterday's gone
Don't stop thinking about tomorrow
Don't stop, it'll soon be here
It'll be, better than before,
Yesterday's gone, yesterday's gone
(Ooh) don't you look back
(Ooh) don't you look back
(Ooh) don't you look back
(Ooh) don't you look back
It is hard to think realistically about the future without thinking about the future of politics, but I do not have the time, and you probably do not have the patience to go that deeply into those negative possibilities of the future. I could recommend that you read Jochen Bittner’s op-ed piece from The New York Times this week, “Is This The West’s Weimar Moment?”. Likewise as we think about the future it is probably reasonable to wonder when the next recession will hit. We are eight years into a weak recovery and probably do not have the political consensus necessary to avoid another one in the next five or ten years, if not sooner.
There is no question that in 2008 we were all worried about the future of healthcare as the investments that made up much of the financial strength of the endowments of healthcare organizations were threatened by the huge losses that were experienced by institutional investors and the public. Will another recession eclipse a better future for healthcare by undermining an already vulnerable economy that has not recovered from its last near death experience? Despite the experience of the 2008 recession and the subsequent years to analyze its effects there is little for certain that we can predict in terms of what the next recession will do to our efforts to achieve the Triple Aim other than the generalization that it will make it harder.
Out of all the uncertainty, what can we say that may be positive about how patients will experience care in the next decade? That is the question that put me into the hopeful space of “Don’t Stop Thinking About Tomorrow” and focused me on what I could say for sure, assuming we stay on our current trends and have the good fortune to experience slow but continuing economic growth and a gradually improving political climate that might emerge after taking a scary look into the political abyss that the current political campaign offers. It’s not that I am just a Pollyanna, it’s more that I am like Christine McVie. I am tired of today and yesterday and long for something better, so why not talk mostly about the upside possibilities of the moment for patients and realize that we have the opportunity even though we may not take advantage of it, to move into a better tomorrow.
I have spent the better part of fifty years thinking about what patients want and trying hard to figure out how to meet their expectations. Every patient is unique, but I believe that they hold many desires in common. The question is will we meet the expectations of more of our patients in the future? Patients have always wanted to be known. Beyond that desire for a relationship, at the core of what every patient and their family wants as they contemplate their care for the future, are two questions. First, will I have access to the care that I will need? Second, will I be able to afford the care I need?
The ACA has done a lot, but it has not answered either question. Much of what it has accomplished was taken for granted until a patient was exposed by personal experience to one of the problems it corrected, like the inability to buy insurance because of a pre existing condition. Many people who did not have care before are now covered, but many who once enjoyed almost free care now experience care that is more expensive than before. There has been a sort of “transfer” of benefit, as well as a taxpayer funded expansion of access which is also an economic transfer, that some experience as loss while others have a much needed gain. I do not see this reality perpetuated into the future.
The finance of healthcare is in a metastable condition that must be resolved or at least mitigated. Those hurt the most, after we note that many still are denied care, are those in the broad middle class that carries a disproportionate share of the tax burden. The persistence of the healthcare finance problem also undermines our collective will and ability to use public dollars to chip away at other problems that are social determinants of poor health. It is a vicious cycle that requires an overall reduction in per capita spending while getting even more value for the dollars that we spend.
I am going out on a limb to say that in the next ten years our collective discomfort will force a political resolution or at least an improvement to the “cost” problem and eventually everyone will be covered. I believe that the patients who worry now about whether they can cover the expense of their care will get at least as good an offering as the citizens of the “socialized” states of Western Europe. Really, if they can do it, why can’t we? We have a better overall economy and a huge vault full of cash. The vault is called waste. We just need to find the combination to the lock on the vault to get at all those resources we have that are currently out of our reach. I think it is possible, but it will not be easy.
The second issue of access will be easier because it will be not be a political issue. We will solve this one with our “go to-- favorite” tools: competition, ingenuity and capitalism. We will effectively digitize healthcare enabling many “virtual touches” that will better leverage the professional capabilities of all clinicians. Patients have demonstrated their desire for e-visits, televisits, group visits and alternative forms of care already when it is obvious to them that the traditional methods of practice do not meet their access needs.
The vulnerable population to disruptive competition and innovation is not the public but rather the providers who cling to outmoded workflows and continue to try to make patients walk through their fee for service turnstiles. All one needs to confirm this prediction is to go to any public place and sit and watch as people come and go getting advice and direction from their smartphones. Who knew what a “smartphone” was in 2006? Jobs and Apple gave us the iPhone in 2007. Medicine is slow to adapt but it will not be able to resist what happened to traditional retailers, taxi drivers, and motel operators. The healthcare equivalents of Amazon, Uber and AirBnB are already here and it is just a matter of time. Some practices will get it and thrive and the others will go the way of Blockbuster. Patients will be delighted with their new, more efficient care with better access and convenience. Why waste time standing in the line at a pharmacy after waiting hours, days or weeks for an appointment when your concerns can be resolved on line and your meds can be delivered to your mailbox? I have already enjoyed that experience. The concept has been proven.
There will be ways in which patients will benefit in the future that they may not appreciate. For the last 2500 years they have been vulnerable to the “art of medicine”. Yes, I said it. The art and intuition of medical experts is a source of error and much human suffering, despite Dr. Groopman’s insistence that traditional medical practice should be treated like a religion. I do not mean to imply that I see a decline in the importance of doctors and nurses being with patients in an understanding and supportive way. I do believe in the therapeutic relationship and stand in awe of what a caring clinician can do when supported well enough to spend as much time as it takes to give every patient what they need in a timely fashion.
I just believe that the only way that will be possible in the future is for us to protect that time and offer it to everyone who needs it by improving flow using the tools and culture of Lean and aligned concepts of continuous improvement. We will create the workflows that free up the time to provide the presense and time of the doctors, nurses, and other medical professionals at the right moment when there is the greatest possibility of benefit. Just as computer analysis, machine learning, and big data have created new insights and possibilities in every aspect of science, design, art and finance, the benefits of digital technology are going to eventually knock down or go around the barriers raised by those who call progress a “loss of clinical values”.
I see the patient of the future no more desirous of coming to the office for a BP check or advice managing their cholesterol or diabetes than they would be now using a telephone with a dial on it. Patients, through their demands, and those who pay for their care will eventually partner with clinicians and systems that care to co create the care that we will need in the future. I predict that the models of care and the ways that care will be delivered will make our current processes of care delivery look about as quaint as approaching peptic ulcers with a bland diet, antacids and a gastrectomy.
One of the things I enjoy the most these days is looking at innovations, high tech and low tech, and thinking back over the innovations that I have experienced in life, and realizing that progress in science and engineering has been geometric. We had no fiber optics; we had no echos; we had no CT scans or MRIs when Medicare was passed in 1965. We now have many more things to offer but their benefit and distribution are encumbered by our ineptitude with equitable distribution. We often can’t get what we have to those who need it, when they need it. Our failure arises in part because we still have the basic finance of 1965 and much of the medical mindset and culture of 1965. It is our finance, our preferred work flows, and perhaps in part, our nostalgia for an era when many of us had no care but nobody knew what to do about it. Could it be that soon we will see the passing of our romantic thinking about how great it was when the classical ways of practice were honored and the classical sociology of medicine was a vertical structure with an unquestioned physician on top. The patient of tomorrow will get her questions answered or move on to see someone in a system of care that embraces the possible, even if that embrace requires some change and adaptation.
McVie had it right. Let’s not stop thinking about tomorrow. Tomorrow will be a better day when yesterday is gone. Patients will see things in a different way..It’ll be better than before...Why not think about times to come...Don’t stop, it’ll soon be here.”
“Big Love” and The Triple Aim
I frequently say to my many conservative friends, business contacts and family that I long for old time conservatives like David Brooks. I sometimes facetiously say that I might be a conservative if every conservative, (dare I say Republican) had the interest in humankind and the sensible world view that Brooks regularly expresses in his op-ed column in the New York Times, his many books, and in his broadcast commentary on public radio and television. My attempt at a joke rarely gets a laugh and I am often not even sure if my hearer understands the intent or should I say nostalgia behind my comment.
HBO is currently broadcasting a movie adaptation, “All the Way”, of Bryan Cranston’s award winning Broadway performance about Lyndon Johnson’s fight for civil rights after he became president in the wake of Kennedy’s assassination. A scene that is well played is the interaction between Lyndon Johnson and Everett Dirksen, the Republican senator from Illinois who was the Senate Minority Leader, whose support was needed for closure of the Southern led filibuster on the bill in the Senate. The film version is very close to the written record offered by Robert Caro in his extensive four, going on five volume, biographical study of Johnson. Neither of these men were saints but they could work together. Today we collective suffer from a future that is more uncertain than it need be because of our inability to find a way to compromise for the the benefit of what we all care about. The conversation that comes closest to a respectful exchange between a liberal and conservative that I regularly hear is the one aired on late Friday afternoons between E.J. Dionne, the liberal Washington Post columnist and commentator and Brooks.
Brooks’ column on Tuesday, In Defense of Big Love, really gave me a surprise lift and I think it connects perfectly with concerns that I have for the Triple Aim. Brooks is frequently criticized for being “nostalgic”, unrealistic, and even hippocritical, but I prefer to look at him through a different lense. When I saw the title of the article I was immediately intrigued because I connected it to the great sympathy that I had for the protagonist in an HBO series entitled “Big Love” that aired a few years ago. The story was a weekly view of a beleaguered Mormon husband, played by Bill Paxton, trying to live secretly in Salt lake City with three wives and all their children. Perhaps that was Brooks’ subtle “hook”, but if so, he got very serious, quickly.
His thesis was built off the theoretical difference between the beautiful and the sublime. He points out that neuroscience has located our appreciation for what is beautiful in a different part of the brain from where we appreciate the awe inspiring sublime. He calls our love or appreciation for what is beautiful in life “small love”. It is “pleasurable, intimate, romantic”. That which is awe inspiring, like a view into space, a mountain range at sunset or a brilliant mathematical analysis simultaneously inspires us and reminds us that we are small and vulnerable in a “vast cosmos”. For Brooks that feeling of awe and vulnerability is “big love”.
The jist of it all this is embodied in the following quotes from the column:
In daily life we have big and little loves, too. The little loves, like for one’s children, one’s neighborhood or one’s garden, animate nurture, compassion and care. The big loves, like for America or the cause of global human rights, inspire courage and greatness. A little love is a shepherd protecting his flock. A great love is Martin Luther King Jr. leading his people...
The small attachments serve as the foundation of our emotional lives, but when you have a big love for your country or a cause, you are loving something that transcends a lifetime. You are pursuing some universal ideal and seeking excellence. A big love involves using power well, seeking honor and glory and being worthy of them...I’d say that in America today some of the little loves are fraying, and big love is almost a foreign language. Almost nobody speaks about the American project in the same ardent tones that were once routine.
Brooks spends some time building the case that we are suffering from a decline of “big love”. He posits that we have lost our collective ability to join forces for a transcendent cause. Our national mood is one of passivity and pessimism that is laced with an expectation of collective failure. We are divided and in our riven state wonder if there is any common purpose. He does not say it outright, but suggests that this lack of awe about what we can do together spurs the interest in “Making America Great Again” on the one hand, and on the other hand is a prime cause uniting the young people who have rallied to Bernie Sander’s call for a resetting of values in a new, more just, and equitable way.
Brooks believes that we can still be united behind “big love” and says,
...I’m writing in defense of the big love that once inspired big projects, like NASA, the national railroads and the creation and maintenance of the postwar, American-led world order, with the free movement of people, goods and ideas.
I wish that Brook had made a list of possible “big love” projects. I would definitely put the Triple Aim on that list. A sense of awe and possibility is what I experience when I hear Don Berwick talk about the future of healthcare and the Triple Aim, or when I am surrounded by colleagues brought together by the desire to use Lean to transform medicine, as I was at my meeting in California this week. The idea of the Triple Aim is so respectful of every person’s worth and so subtly ambitious in its scope as to inspire awe. I do not believe I exaggerate one bit when I contend that it will take a collective effort greater than was required to go to the moon, if we are going to give everyone
Care better than we’ve seen, health better than we’ve ever known, cost we can afford…for every person, every time.
I want to believe that we are capable of a resurgence of “big love” and with a shared objective about something that is important to all of us, we can still do wonderful things that inspire awe and wonder.
Life and the Sox Look Pretty Good From the West Coast
My wife and I have spent the last week in California. I had a meeting that gave us an opportunity to spend an extended Memorial Day weekend with our almost two year old grandson and his parents. The picture in the header this week was taken by my son who is an avid photographer who produces some startlingly beautiful images. As you can see he has captured the light coming through the coastal redwoods on one of the winding roads near his home in the mountains above Santa Cruz. I love wandering through the woods either on a trail or on a winding road.
The area is lovely in every way. It is just a few miles from the mountains to magnificent cliffs along the coastal highway from which hang gliders jump. Those same cliffs overlook beautiful beaches from which surfers in wetsuits paddle through cold water to where they might catch a big wave. They expend a lot of time and effort in pursuit of a moment's thrill. If the natural beauty of the area does not capture your soul, then there is plenty to do watching beach volleyball and people on the rollercoaster and the other rides down on the boardwalk. I enjoy drinking a strong cup of coffee while “people watching” and listening to street music from a comfortable bench in front of a good bookstore in funky downtown Santa Cruz.
A big joy for me from the West Coast is watching the Red Sox games on MLB.com. Living on the near edge of the future is wonderful! I can see Jerry Remy and get the NESN feed on my iPad anywhere! On the West Coast the games in the East come on in mid morning and in the late afternoon. No need to lose sleep.
The Sox remain exciting. It is hard to believe how good their offense is, but the pitching is still shaky as there scalding in Baltimore last night demonstrated. The scores tell it all. It is not unusual for them to win by scoring more than 10 runs. They also have a knack for losing because they only scored nine runs. I nearly had a heart attack last Saturday when they went ahead 8-4 but lost 10-9. They wasted multiple home runs on Wednesday night and lost 13-9 after being tied 8-8 going into the bottom of the sixth, hoping that Buchholtz might be good in his new role as a relief pitcher. Let’s just say he is having a tough time finding his groove. Let’s forget last night because they are still in first place in their division and have the best record in the American League. So far quite a ride. I am dreaming of baseball through October. I think, or hope, my dream will last.
You may not live near a redwood forest or have easy access to a surfer’s beach, but I do hope that you get out and enjoy life with friends and family this weekend. If you do not have a two year old to chase, a good walk is a great time to think and talk about what awes and inspires you. What are your “big loves”? I would love to hear from you. |
