4 November 2016
Dear Interested Readers,
A Few Memories and What’s in This Week’s Letter
Everything is on hold waiting to learn what happens on Tuesday. I feel like I did in the last few minutes of the Patriots’ last Super Bowl victory. My team had played hard for the whole game and in the last quarter it was defending a small lead. I was anxious because there had been a change in momentum, and their lead had narrowed greatly. Now in the waning moments of the game the Seahawks were about to score again. I could not look. I could not avoid looking. My stomach was tied in knots. I was not sure that I could survive the tension. I considered going outside to walk around in the dark until the game was over. My friend with whom we were watching the game lived in Seattle, and we were visiting him and his wife at their home in the Baja. The restaurant where we were watching the game was full of people from the West Coast and Canada. They all hated the Patriots.
My friend, an “Interested Reader”, was sure that his team was about to win. He had a big smile on his face. He was beginning to be conciliatory. I really appreciated his attempt at social grace, but frankly it was hard for him to veil the delight he was feeling. Then there was one final surprise. Pete Carroll, the earnestly competitive coach of the Seahawks, called a play that made absolutely no sense, no matter how many times over the next few weeks he would try to explain the logic behind his reasoning. Carroll gave an unlikely hero, Malcolm Butler, the opportunity to make the play of his life. I was delighted and a little ashamed by my joy that was at the expense of my friend who just as suddenly looked like he had been shot. He seemed consumed by his grief. He and all of the Seattle fans suddenly vanished while my wife and I were soaking up the joy of the Patriots players. In the midst of our jubilation I suddenly realized that we were alone in our celebration in a nearly vacant room. We had to find our way alone back to his house through dark and unfamiliar streets.
I am also thinking of election night 2000. Early on that night Al Gore was looking like the winner. Around ten o’clock one news source said he had won. Another said not so fast. It was unclear who had won Florida. Ultimately the outcome hung on a few “hanging chads” and a conservative Supreme Court majority. We all hung in suspense for what seemed like a year until December 12 when the Court, voting along political lines 5-4, elected Bush as our next president. The only high point in the whole nightmare was that though Gore had won the popular vote by over a half million votes, there was an orderly transfer of power.
Looking back at the turbulent sixteen years between that memorable election and what faces us now, one wonders if Gore would have pursued a war looking for weapons of mass destruction. If Al Gore had been president would we have continued domestic policies that resulted in the great recession of 2008 from which we are still trying to recover? I guess those thoughts are as useless as wondering what might have been different during Reconstruction had not Lincoln been shot by John Wilkes Booth. What I do know for sure is that waiting for this election with this much suspense about who the president will be for the next four years is making writing about healthcare strategy very difficult. I just hope that the answer will be certain by sometime Tuesday night. I will not mind staying up late next Tuesday evening to see who wins like many of us did this Wednesday during the nail biter between the Cubs and the Indians, but I sure do not want to wait until sometime in December or January for the courts or the House of Representatives to decide who is our 45th President.
If you read on, you will discover that I was able to overcome my apprehension long enough to write about things that relate to the “soft side” of healthcare. In part I draw on the sensibilities that David Brooks expressed in a column that he wrote this week in the New York Times. Part of my source for this week’s letter is my own experience of practice. A major motivator has been my search for perspective as I review my work life from retirement, and realize that all my life I have wanted to be pulled forward by something that might be transcendent.
My guess is that you would be surprised if I did not try to extract some kind of message from the Cubs victory in the dramatic seventh game of the World Series. There is no tribute essay to the Cubs at the end of the letter but I do mention them. I also write a brief account of my effort this week to extend my joy from fall with another mountain adventure and a trip to Cape Cod. Pondering the hidden meanings of professional life, the mystic moments of sport and the last gasps of a gorgeous fall are the best that I can come up with as I try to contain my anxiety waiting for the outcome of the election and “gird my loins” for what may follow.
I hope that you have already visited strategyhealthcare.com this week. The most recent posting entitled “Healthcare Costs Too Much” has been up since Tuesday. I hope that you will share it with your friends.
Searching For Meaning In Healthcare, In Tough Times
For years now I have facetiously declared that medical school is simultaneously an elaborate vocabulary lesson and an immersion in a cult. I was not prepared for practice when I graduated and I do not believe that my medical school really expected me to be prepared. They were probably hoping that I would really learn how to practice during my experience as a house officer and fellow. In retrospect I can say that I was still learning how to practice many years into the experience of practice. Looking back on it now from the perspective of retirement, I see that I was learning things on the last day I worked that I wished I had learned in medical school.
Over the last decade or so there has been a lot written about the importance of “being present” in all our interpersonal and professional relationships. Closely connected to being present is “emotional intelligence”, or EQ. For years I labored under the influence of superficial descriptions of EQ. Those descriptions suggest that we be focused on being aware of our own emotions and empathetic to the feeling of others. This point of view is summarized by Michael Akers and Grover Porter, two writers who have given us a brief article describing EQ that is available on the Internet. There is truth in their five part description:
The Five Categories of Emotional Intelligence (EQ)
1. Self-awareness. The ability to recognize an emotion as it “happens” is the key to your EQ. Developing self-awareness requires tuning in to your true feelings. If you evaluate your emotions, you can manage them. The major elements of self-awareness are:
- Emotional awareness. Your ability to recognize your own emotions and their effects.
- Self-confidence. Sureness about your self-worth and capabilities
2. Self-regulation. You often have little control over when you experience emotions. You can, however, have some say in how long an emotion will last by using a number of techniques to alleviate negative emotions such as anger, anxiety or depression. A few of these techniques include recasting a situation in a more positive light, taking a long walk and meditation or prayer. Self-regulation involves- Self-control. Managing disruptive impulses.
- Trustworthiness. Maintaining standards of honesty and integrity.
- Conscientiousness. Taking responsibility for your own performance.
- Adaptability. Handling change with flexibility.
- Innovation. Being open to new ideas.
3. Motivation. To motivate yourself for any achievement requires clear goals and a positive attitude. Although you may have a predisposition to either a positive or a negative attitude, you can with effort and practice learn to think more positively. If you catch negative thoughts as they occur, you can reframe them in more positive terms — which will help you achieve your goals. Motivation is made up of:- Achievement drive. Your constant striving to improve or to meet a standard of excellence.
- Commitment. Aligning with the goals of the group or organization.
- Initiative. Readying yourself to act on opportunities.
- Optimism. Pursuing goals persistently despite obstacles and setbacks.
4. Empathy. The ability to recognize how people feel is important to success in your life and career. The more skillful you are at discerning the feelings behind others’ signals the better you can control the signals you send them. An empathetic person excels at:- Service orientation. Anticipating, recognizing and meeting clients’ needs.
- Developing others. Sensing what others need to progress and bolstering their abilities.
- Leveraging diversity. Cultivating opportunities through diverse people.
- Political awareness. Reading a group’s emotional currents and power relationships.
- Understanding others. Discerning the feelings behind the needs and wants of others.
5. Social skills. The development of good interpersonal skills is tantamount to success in your life and career. In today’s always-connected world, everyone has immediate access to technical knowledge. Thus, “people skills” are even more important now because you must possess a high EQ to better understand, empathize and negotiate with others in a global economy. Among the most useful skills are: - Influence. Wielding effective persuasion tactics.
- Communication. Sending clear messages.
- Leadership. Inspiring and guiding groups and people.
- Change catalyst. Initiating or managing change.
- Conflict management. Understanding, negotiating and resolving disagreements.
- Building bonds. Nurturing instrumental relationships.
- Collaboration and cooperation. Working with others toward shared goals.
- Team capabilities. Creating group synergy in pursuing collective goals.
Despite resonating with their description of EQ, I now think that I was missing a major point which is also very important to “being present” and mindful. If one possesses a highly developed emotional intelligence and can be truly “present”, one must be able to be both accurately aware of their impact on others, and also care about how they are experienced by others.
O would some Power the gift to give us
To see ourselves as others see us!
It would from many a blunder free us,
Equally remarkable is the frequency with which I have said that the first step a leader should take in the attempt to resolve a problem is to ask the question of herself and those she leads, “What part of the problem am I / are we?”.
It is easy to see the impact of these defects in others but very difficult to recognize one’s own deficiency, especially when there is an element of certainty in the “rightness” of one’s cause or opinion. I think that it is missing in many healthcare professionals, clergy, politicians and many people who earnestly want to be leaders and contributors to improvement. It is easy for me to go on and on about Donald Trump’s lack of EQ, his narcissism, his seemingly defective awareness or lack of care about how what he says pushes many people away from him and hurts or deeply worries others. I know many people who feel the same way about Hillary Clinton that I feel about Donald Trump.
Both candidates say to the world that they deeply care about Americans, all of humanity, our country, and all of the people in the world who are suffering from inequity. Both candidates probably believe that others should trust them when they swear their motivations and internal beliefs are aligned to address what is important to all of us. Both seem not to be able to understand why a significant part of the electorate loathes them. The result is that we are likely to elect a person who is despised by the smallest number of voters who are not a part of their base.
Ten years ago, even three years ago when I retired, my self deception about my superior EQ would have allowed me to assert that I was earnestly and completely patient centered and deeply respectful of all patients. I would have been offended if someone had suggested otherwise. Ditto on how I thought I was perceived by close colleagues. I was right about how some patients and colleagues reacted to me, but not aware of the fact that some people were not so sure that my self interests were not the first order of my business. I was secure in my opinion that some patients were not engaged and that some colleagues had an agenda that was not exactly aligned with mine, even though we could all salute the Triple Aim and describe quality care as being patient centered, safe, timely, efficient, effective and equitable.
As a physician who wanted to be trusted and who hoped that all patients and colleagues would sense my empathy for them, my respect for their point of view, and my expressed willingness to blend my efforts with theirs for something better, I did not really understand or sense accurately when and how I failed to connect. What I am offering for your consideration is whether or not there are many health professionals who, like me, are often not completely aware of how they are perceived. Despite talking about universal access to healthcare for seventy five years and focusing on quality for a quarter century and having the Triple Aim as a clearly defined goal for almost ten years, is it possible that our continuing problem with the high cost of care has something to do with our industry’s collective lack of EQ? Do we fail see ourselves as others see us?
A few years ago I got caught up in the transcendent African theological concept of Ubuntu. Six months ago Ubuntu was central to one of these letters and to the posting on strategyhealthcare.com. You might remember the post because the picture was from the 2008 Celtics who under coach Doc Rivers won an NBA championship focusing on their understanding of Ubuntu. In that post back in May I quoted Desmond Tutu:
Bishop Tutu… Ubuntu is the essence of being a person. It means that we are people through other people. We can’t be fully human alone. We are made for interdependence, we are made for family. Indeed, my humanity is caught up in your humanity, and when your humanity is enhanced mine is enhanced as well. Likewise, when you are dehumanized, inexorably, I am dehumanized as well. As an individual, when you have Ubuntu, you embrace others. You are generous, compassionate. If the world had more Ubuntu, we would not have war. We would not have this huge gap between the rich and the poor…This is God’s dream.
Some discussions of Ubuntu usually also make references to the Jewish theologian Martin Buber and his concept of “I-It” versus “I-Thou”. A South African theologian, Selaelo T. Kgatla, has emphasized this point in an article published earlier this year:
The concept of Ubuntu is known intuitively rather than reflectively as Martin Buber argued in his work Transcendence and Relationality (1958). According to Martin Buber, transcendent experience which he calls ‘pure experience’ (Ubuntu in an African context) is based on encounter but not reflective thought but on active engagement. Ubuntu requires full participation in the life of the other; participatory experience rather than reflective experience. The emphasis in Ubuntu is on the betweenness that relate people to each other in mutuality. This betweenness, as first coined by Martin Buber, calls love as expressed in human relationships and experience. Ubuntu requires humility, an act that requires the ego to deny its impetus to establish itself as primary and as the centre of human experience; overcoming the ego to establish foundational relationship with the other as used by Buber.
That may be a little heavy but I think that he is explaining that meaning in our lives, and I would add in our professional lives, arises from getting involved with others. Whatever your religion, or even if you loathe organized religion, the point is that as humans we feel most fulfilled when we are “present” and actively involved with others in community. I would add that it is even more satisfying if we are so “out of ourselves” and our concerns about ourselves and our institutions. It is best when we are aware and focused on our communities and those to whom we have professional responsibilities, and are aware of the feelings of others at a level that allows us to fully understand how what we are doing may or may not be working to help others. That level of awareness would allow us to see that the high cost of healthcare is a problem that our communities wish we would address because it is killing so many and failing those that it does not kill.
I was delighted on Tuesday to read in the New York Times a column entitled “Read Buber, Not the Polls!” by David Brooks that was focused on our national malaise.
Brooks hooks the reader with the first line:
If America were a marriage we’d need therapy.
A little further down the page he introduces Martin Buber as the appropriate therapist for us.
As an antidote for all this, I’ve been reading the work of Martin Buber, the early 20th century Jewish theologian who dedicated his career to understanding deep intimacy. Buber is famous for the distinction between I-It relationships and I-Thou relationships.
He explains the I-It relationships and I-Thou relationships:
...I-It relationships are truncated versions of what should be deep relationships. You’re with a friend, colleague, spouse or neighbor, but you’re not really bringing your whole self to that encounter. You’re fearful, closed or withdrawn — objectifying her, talking at her, offering only a shallow piece of yourself and seeing only the shallow piece of her.
I-Thou relationships, on the other hand, are personal, direct, dialogical — nothing is held back. A Thou relationship exists when two or more people are totally immersed in their situation, when deep calls to deep, when they are offering up themselves and embracing the other in some total, unselfconscious way, when they are involved in “mutual animated describing.”
Brooks goes on to say that a doctor has an I-It relationship with a patient when he treats the patient like a broken machine. A doctor is in an I-Thou relationship when she sees the patient as a person like herself and responds to her pain and suffering because of their shared humanity. Brooks was not really writing about healthcare. He had a larger scope, but if we apply his points to healthcare we might see that as a profession, and often as individuals, we are in I-It relationships with our patients and our communities.
Brooks stresses the point that:
...Buber argued that it’s nonsensical to think of the self in isolation. The I only exists in relation to some other.
My point is that as healthcare professionals and as a profession or industry we have meaning when we are in relationship to the “other” of all patients and our communities. That is what I discern after reading:
Buber’s writing reminds us to be intentional and brave about relationships. But it also has communal and political implications. Some organizations and leaders nurture openhearted bonds. Such communities usually began, Buber wrote, with some sacred Thou moment — like the Exodus story for the Jews or the revolutionary struggles of the early Americans. Leaders connect current problems to that “living effective center” and set the table for situations of caring and trust.
Brooks is writing about the election but he is trying to explain how we got to where we are and what might be a productive path to follow after the election.
I like the way he ends his piece, but I will insert a few of my own words to try to make the point to you that I have tried to extract from his thoughtful consideration of “ I/Thou” and apply to healthcare.
Today, America is certainly awash in distrust. [We could equally say that healthcare is awash in distrust] So many people tell stories of betrayal. [So many patients and so many healthcare professionals feel betrayed.] So many leaders ...model combativeness, isolation and distrust... the only way we get beyond depressing years like this one is at the level of intimacy: if Americans [including those of us who care about the pain and access of patients] reconnect with the living center of the national story [and to the wisdom of the Triple Aim] and ....rebuild Thous at every level.
As I look back on my years of practice and attempts at organizational leadership, I wonder how often I was approaching the moment with an I-It mindset. That feels like a professional concern that transcends EQ. Being in the moment and mindful is a step forward, but I believe striving for an I-Thou relationship patients, colleagues and community would be even better and more fulfilling.
I join Brooks in the hope that after Tuesday there might be many people who will be willing to try to pick up the pieces across the nation in all aspects of our lives together in community, including healthcare, and go forward with an I-Thou worldview. Do we think that any other way could work?
Mountaintops, Fleeting Fall: Cubs Don’t Need to Wait Until Next Year
I wrote last week about the great time a friend and I had climbing Mount Kearsarge to get another view of the fabulous colors of this wonderful fall season. Last weekend was a downer weather wise, but it was good for knocking on doors to make sure that people planned to vote. My friend and I could see that Monday was going to be dry and in the fifties so we decided that we would push our luck and try to extend our enjoyment of fall foliage by climbing Mount Cardigan.
My friend has climbed Cardigan many times and described its beauty by pointing out that it had great views to the north toward the Presidential Range. Cardigan has better views than Kearsarge because it has a much larger granite cap. To my surprise as we approached the mountain it looked like there was snow on the top. Despite the snow, we decided to give it a try. We figured if it was too icey we could abort our climb. I got a little worried as the higher we got the colder it was, and indeed we were getting into some snow. The last half mile of the climb is a scramble over sheets of granite. The snow had been blown into crevices in the granite and in spots there were drifts about a foot deep. In many places the granite was left with a fine patina of “black ice”, but we pressed on.
The view was worth the climb. The few scrub trees growing out of the granite on top were covered with “hairy” ice and a beautiful top coat of snow. The wind was brisk. It was really cold but the cloud cover had lifted enough to see great distances in all directions. The fall’s colors were muted but beautiful was still the right adjective for the view. I took my pictures and then discovered that climbing up over ice is one thing; going down over ice is another thing altogether. In the tough spots I elected to slide down on the seat of my pants rather than fall down the mountain.
My wife and I love to go to the Cape after the crowds are gone. We meant to get there sooner than the first week of November, but things have been busy. As you can see from today’s header, we did enjoy some nice weather as the picture attests. The weather was warm and the sky was clear. P-town was a virtual ghost town. It felt like we had all of those great views between the Sagamore Bridge and Race Point to ourselves. Many of the galleries and stores that cater to tourists were closed which was fine for me. To our delight the passing of fall on the Cape seems to be more than a week behind where we live in New Hampshire.
There is reassurance as well as beauty in the cycle of the seasons. There is even a little reassurance in the knowledge that both the Red Sox and the Indians will have a chance in less than five months to try again to snatch the crown for themselves and return the Cubs to the ranks of the losers. Summer has gone. Baseball is over and fall is going, but both will return again. I see my responsibility as being available to enjoy the cycle of the seasons for as long as possible, doing anything I can along the way to play a role in our collective pilgrimage toward a better world.
My walk this Sunday will be in between as many doors as I can knock on before the darkness comes at 4:30. If anyone comes to the door, I will be asking them if they plan to vote, and if they need a ride to the pole. I hope that your plans for Tuesday include voting unless that is a responsibility that you have already fulfilled.
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