Let us dedicate ourselves to that, and say a prayer for our country and for our people.The California Presidential Primary is the last one in each presidential primary cycle and in 1968 it was more important than it had ever been before. Kennedy had lost in Oregon to McCarthy the week before, and he had to win California to have a chance to win the nomination. The drama was high. I watched some of the early returns, but then went to bed because I had a test the next day.
1968 did not get much better after Bobby Kennedy died. The Democratic Convention in Chicago was an exercise in old guard control as Humphrey was nominated inside the hall while riots occurred on the street outside. Then Nixon won.
Bobby Kennedy was a complex man with high ideals and a compassionate vision of how to achieve a better world that has inspired me whenever I have paused to consider his life. In 1966 while visiting South Africa he gave us a thought worth holding in memory and projecting into a complex future as we remember him on the fiftieth anniversary of his death.
Each time a man stands up for an ideal, or acts to improve the lot of others, or strikes out against injustice, he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring those ripples build a current which can sweep down the mightiest walls of oppression and resistance.
Sometimes I ask myself “what if questions.” It’s a depressing exercise. What if Lincoln had not been assassinated? What if any of
the plots to kill Hitler had succeeded? What if John Kennedy had not gone to Dallas?
What if Bobby Kennedy had not changed plans and had not gone to the hotel? I guess the exercise proves how little we really control. History does more than repeat itself; it sets itself up. Outcomes often seem so absurd that it is easy to see how fortune tellers can make a living. Uncertainty plagues us and makes us so anxious that some of us prefer to believe in “fate”, others in the alignment of the stars and astrology. When surprising events occur we bring out the old reliable, “God’s will.” When I look back over the last fifty years, I am still saddened by Robert Kennedy’s death and all that we lost, and have as a result endured. When I think these depressing thoughts I am provided a little hope by Kennedy’s obvious belief in the benefit of continuing to make millions of small positive efforts with the hope that their confluence will eventually succeed in bringing some peace and justice to a troubled world.
Examining “Joy in Practice”Through the Lens of Personal ExperienceIt is rare for me to have a hard time deciding what to write about. What usually happens is that a comment or an article gets me thinking and I realize that I am halfway home on the idea. Another frequent source of ideas is a call or email from one of you with a request. That was the story for this week.
Last year I was delighted to write a preface for the book on patient and family centered practice written by Anthony DiGioia and Eve Shapiro, The Patient Centered Value System: Transforming Healthcare through Co-Design. This week Eve emailed me with the request that I help her find some healthcare professionals, “doctors, nurses, and others” from the front lines of patient care who would be willing to be interviewed for thirty or forty minutes on the telephone. Her note said that the interviews will “focus on what providers say they need in order to experience joy and meaning in work--specifically under what circumstances they have experienced it (or not), what promotes or inhibits it, and what people say they need in order to realize it.” She would also like to talk to some healthcare CEO’s and medical managers so that she can “understand the connection, or disconnection between the perspectives of front line providers, CEOs, and other medical managers.”
Eve needs to talk to you! I told her that I would pass along her contact information so that you could connect with her and give her your perspective. If you are interested, and I hope that you are, her email is
eveshapiro912@gmail.com. Eve’s request is an opportunity for you to exercise some guided “self observance.” There is nothing that helps you understand your own view of the world like the opportunity to explain it to someone who really wants to know how you see the world and yourself in it.
As I was thinking about Eve’s request I said to myself, “I need to write about my perspective on what Eve wants to know!” I do not practice anymore, but I have not forgotten the full range of the experience from unsurpassed joy to utter frustration and a sense of victimization by a system gone off the tracks. I am no longer heading out early each morning to discover what joys or frustrations await me in the office or at the hospital, but I do spend a lot of time thinking about all the ups and downs of almost fifty years of training and practice. I also know both the joy and frustration of having the responsibility to make the experience of practice better for those those working in the delivery system, as well as the experience of trying to work through others to improve the experience of care for those seeking service.
The experience of “joy” is very personal, as is the flip side of joy however you may define it, be it frustration, world weariness, tedium, disappointment, or outright anhedonia. If we are to describe how we personally experience joy we need a little bit of personal history. We are all different, although our joys have many intersections. I find great joy in fly fishing, walking, trying to make music, eating avocados, mushrooms, and raisins. My wife gags on avocados, mushrooms, and raisins! That means that I get them all to myself. I fish while she gardens or happily paddles around in her kayak. She will occasionally consent to a short walk because even though it will leave her hurting she knows it is good for her. My joy is her trial. I think we need to keep personal histories and preferences in mind as we consider “joy in practice.”
It is said that if one is in the right work for them it never really feels like work. That was my experience in practice. My parents modeled a life of responsibility and service. Money was important for the opportunities and securities it might provide, but it was never a prime motivator for them and as a result a secondary concern for me. My parents believed that we all have “a calling” and that we individually had the responsibility to discover the nature of that call. They came at everything from the context of Divine direction.
As I tried to rationalize their world view, my own interests, and the science that I eventually learned, it was not a big leap from their sense of “a calling” to an amalgam of natural talents (genetic gifts), nurtured interests, culture, and experience. They created an environment that encouraged exploration and conversations about the experiences along the way. I never took a job because of the high pay it might offer, although I took a lot of jobs because I had financial obligations. Again, their stated philosophy was always “God will provide what you need” although their belief was based in the expectation that most of what God provided was the energy and intelligence to take care of yourself.
Considering my family of origin, I was destined to be in some kind of “service.” I could be a minister, doctor, social worker, or teacher at any level from elementary school through grad school, or one of those jobs plus the appropriate leadership or management role, and my choice would match their expectations of me. Engineering might have been a possibility if I had appreciated and could articulate the service it provides at a societal level. Law and business were also possibilities, if I could define my interest in them in the context of the service they provided to others.
I decided that medicine was the route for me while I was in high school. I was hospitalized by my PCP, Dr. Rentz, for a work up of hypertension when I presented with a severe sore throat, and a systolic BP north of 180. My doctor was a very respected member of the community who went on to be active in the state legislature. He called in one of the most respected cardiologists in the community, Dr. Masters, who was also my Sunday School teacher. Dr. Masters was an old school doctor who had trained at Vanderbilt. He had that frumpy, empathetic professional appearance that Norman Rockwell captured in his painting “
The Doctor and the Doll.” Both Dr. Rentz and Dr. Masters took an interest in me, and in turn I saw in them a possibility for myself as a doctor. I reasoned that I was good in science and I liked the idea of serving people so perhaps being a doctor was my “calling.” My father was not so sure. He suggested that I get a job at the local Baptist Hospital where he knew the CEO. I started as an orderly making $.92 an hour and continued working off and on through school breaks for most of the time I was in college. I loved the work. I liked walking patients, giving baths, and assisting nurses with dressing changes. I “mastered” making a “tight bed.” I got plenty of exercise rolling around oxygen tanks and pushing patients form the emergency room to the floor, or from the floor to x ray. My most profound experience was helping take care of several badly burned patients and patients with fistulas on the surgical floor. Leaving for medical school (with a recommendation written by Dr. Masters) I thought I was headed to the life of a surgeon.
I had a ball in medical school. The “preclinical” years were made less onerous by frequent opportunities to tag along on rounds with attendings or go to special “clinics” on Saturday mornings where patients were presented to provide context to our classroom and lab work. Once the clinical years began I was always eager to “be” some day what I was seeing on each rotation. On OB I delivered 21 babies and imagined a life of delivering thousands. Rounding with Dr. T. Berry Brazelton on my pediatric rotation made me a pediatrician for sure. I was certain that I wanted to be a psychiatrist after working for a month on the wards at Mclean Hospital. To my surprise surgery was not quite what I thought it would be. I enjoyed working on the wards and in the emergency room on the old Harvard service of the Boston City Hospital, but when I took an elective at the Mass General with the famous surgeon, Claude Welch, I saw a hierarchical system that was my first disappointment. I would round at 3AM with his resident so that we could be sure that when the professor arrived at 5:30 things would be in order and he could complete his rounds in time to be in the OR by 7. I was impressed by the efficiency, but the process seemed to be more about the task than the personal interactions that were important to me. I also could not see myself as Dr. Welch. He was great, but he was not Dr. Masters.
As my medical school experience continued I found myself realizing that the joy for me was in the interaction with patients and families. I became involved in the family medicine practice at Children’s Hospital that was created by Dr. Joe Alper. For almost two years I joyfully served as the PCP for three families. It was the best experience I had ever had, and I thought I was headed into the joint pediatrics and medicine program then offered between Children’s and the Brigham. But then I learned that Dr. Alper was headed to Boston City as the chief of pediatrics. I became uncertain about the future of the program and decided that I should take the standard path of a medical internship and ended up at the Brigham where I had done my medical school medicine rotation. The Brigham was a good fit for me and when I decided that I would be an even better PCP if I had training in a medical subspecialty, I stayed on for a cardiology fellowship.
The greatest serendipity I have ever experienced was to become a student at Harvard Medical School while our dean, Dr. Robert Ebert, was creating Harvard Community Health Plan. At the Brigham I met Dr. Marshall Wolf who mentored me and hundreds of other Brigham house officers over a long career. Dr. Wolf was the first cardiologist at HCHP and was doing just what I wanted to do. He practiced both as a cardiologist and as a PCP. In 1975 he was offered the job as house staff director at the Brigham, and then he convinced me that I should take his practice at HCHP. It was the gift of a lifetime. I was made for HCHP. It gave me the freedom to continue to work on being a better doctor in a well supported environment that in essence was a learning lab populated by like minded souls, all committed to the concepts that would morph years later into the expression of the Triple Aim. The road forward was never easy because the status quo and the external world were always pushing back, but the satisfaction of the practice was always enough to allow me to tolerate the internal manifestations of the external world.
Over the last forty years the practice of medicine has been bombarded by external challenges. Our growing knowledge and expertise from medical science and its applications for care through innovation has not been associated with a wisdom that has made the benefits available to everyone at a sustainable cost, and in an environment that supported professional growth, satisfaction, and joy. Running harder and faster has allowed many physicians to marginally maintain their income but they have become fatigued and disheartened as they labored in environments that were not supportive in the way I found HCHP and its legacy practices to be.
I do not think job satisfaction is a function of compensation, nor do I think joy in work is the same as job satisfaction. I do think that compensation can be a huge source of job dissatisfaction and has the ability to kill any joy a job can generate. Several years ago I said “Eureka!” when I read Daniel Pink’s thoughts on motivation, compensation, and job satisfaction in his 2009 book,
Drive: The Surprising Truth About What Motivates Us. Pink asserts that most professionals value autonomy, mastery and purpose, and are more motivated by the satisfaction of heuristic activity, the ability to solve problems, than by the absolute numbers on their paycheck or the penalties that they will experience by underperforming.
Pink points out that although most of the business world has historically depended on external “carrots and sticks” (although whips may be more appropriate) for motivation that these days the greatest progress and our greatest satisfactions arise from the successful expression of “intrinsic” desires. That idea works for me. Intrinsically, I love solving problems and helping people. My greatest satisfactions and moments of joy in practice came when I made a positive difference in someone’s life or helped solve a problem as a manager that made the system better for everyone. That joy was greatly multiplied when my efforts were harmonized with the efforts of colleagues, and we functioned as a “winning” team for our patients and our practice.
I am saddened when I think that the joy of practice has been diminished by our growing focus on finance and its dependence on RVU based calculations of compensation. The effort required of professionals to provide documentation of how every erg of effort was utilized has created an unacceptable environment for everyone. I will not be the first to emphasize that caring for patients is not the same as generating a bill that will be paid by a third party. When I think about how colleagues have struggled with electronic medical records I am saddened as I realize that as often as not their struggle is driven by the need to document their activities for billing or for payment enhancement by compensation driven quality programs.
The heuristic joy of autonomous problem solving seems in conflict with the algorithmic processes that have evolved as we seek to meet quality objectives, but it does not need to be so. Algorithms and quality metrics can guide us to improvement and clinical engineering could free up the valuable time we need to consider the unique concerns of patients. We could engineer our work flows and mechanisms of team based care in ways that would create more time to give to patients and to increased the joy and the mutual satisfaction that is the natural outcome of the patient/ provider experience that everyone values.
I am very happy that we are examining what is important to joy in practice. Even though it may vary from individual to individual based on their own personal history and preference, I believe that our growing knowledge of systems, our expanding capabilities in continuous improvement, coupled with our growing understanding of what motivates and demotivates us, will allow us to slowly move forward. Bobby Kennedy was right:
Each time a man stands up for an ideal, or acts to improve the lot of others, or strikes out against injustice, he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring those ripples build a current which can sweep down the mightiest walls of oppression and resistance.
Applying that principle to medicine gives us direction in these complex times and should restore belief in the idea that the Triple Aim and joy in practice are not ideas in conflict, but rather they are mutually reinforcing concepts and the best way forward. We are deep into collective efforts for mastery. We can have autonomy to solve problems in practice as individuals for unique patients if we recognize it is appropriate to stand on the knowledge that we have buttressed with continually evolving algorithms of standard care and practice that we have negotiated while we keep our eyes on the collective objective of the Triple Aim. We can have it all, if we realized that the challenge is for all to have it. At this moment in time we have the knowledge and resources to make quality healthcare something that is available to everyone. It is my belief that if we keep our eyes on that prize, and the justice it entails, we will all have more joy from our efforts and find the energy and strength to solve the problems that frustrate and fatigue us now.
Walking in Another Maple Leaf LandI am back home in New Hampshire now where I walk on back roads and byways that are lined by majestic sugar maples. The sugar taps and buckets are down. It's still four months until the maples will be sporting their majestic fall colors. It is a lovely time of year to enjoy walking in the shade of the greenery of such lovely trees. There are plenty of maple leaves along my walks to remind me of a very pleasant few days in Vancouver at the end of our trip to Alaska.
We last visited Vancouver exactly twenty years ago. It is scary how the years go by in chunks of twenties. As we anticipated this Vancouver trip we had great memories of jogging and riding bikes in Stanley Park. Twenty years ago my wife enjoyed shopping on Granville Island where she had bought a funky doll that reminded her of one of her best friends. We were eager to see what had changed on Granville Island. We had hopes of finding another doll or some other unique treasure to remind us of our trip. As it turned out Granville Island is a little less bohemian and much more like most tourist areas than it was twenty years ago. We did not find the artist/doll maker. On the other hand, Stanley Park looked even better than I remembered it. The park has both wild areas of old growth groves and very formal garden areas. The park is the tip of the peninsula upon which the downtown and oldest parts of the city sits. The shore line is the boundary of the park on three sides. The park is crisscrossed by trails through the gardens and wooded areas, but the most exciting route is the Seawall path that follows the perimetry of the park and continues along an almost twenty mile course around the entire harbor. The header for this week gives you a glimpse of the Seawall path.
Canadiens are our just “too nice” neighbors. They look fitter. They sound happier. They are very accomodating. They take their turn and do not break into lines or shove their way to the front. They seem less worried about the state of the world. One Canadian told me that they really only have two things on their mind: hockey and whatever is going on south of the border. They just do not seem to understand how we could turn over so much power to someone who seems so careless and disrespecting of the rights and privileges of others. I wanted to tell them that it was a very long story. It’s sort of an inside joke that only family members can understand. In fact, many of us still do not understand what happened after millions of lines of newsprint and hours and hours of listening to talking heads in the broadcast media.
Our national worries seemed far away as I took a walk in Stanley Park with one of my traveling companions. Twenty years ago I enjoyed running the Seawall path that skirts the perimeter of the park. Now I am very happy to stroll the path and watch others jog by, skate by, or ride their bikes by me. I stay to the right in the “just happy to be here” slow lane.
Uber has not yet invaded Vancouver, but it’s easy to get about town on the “Hop On, Hop Off” buses for tourists. AirBnB is in Vancouver and we enjoyed sharing a great 35th floor condo sporting spectacular views with two other couples with whom we traveled. It was well located at the end of “False Creek” near Chinatown and the Rogers Arena where the Canucks play. I was delighted to discover that the Seawall path extends up the West End past Stanley Park and on around to False Creek. The condo was just a short walk from the shops and restaurants of “Gastown.” Vancouver is a great “walking city.”
Now that summertime is in full swing, I hope that there will be shady maples for you to walk under this weekend. The truth is that almost anyplace is a good place to walk, especially if you take a friend along. Walking is a great time to think and talk about why things are the way they are.
Most travelers like to bring home souvenirs. I have decided that the souvenir that I am bringing home is a little bit of emulated Canadian attitude. I wonder how long I will be able to sustain my new Canadian mood.
