9 September 2016
Dear Interested Readers,
This Week’s Subjects
The opinions that define our personal world view often become the substance of disputes and misunderstandings. Mixing personal opinions about anything with political issues and political philosophies can be incendiary. Expressed opinions, especially about politics and about personal values and a touchy and personal term like “morality” have the power to motivate long time friends to “unfriend” one another on Facebook. Invitations to a wedding are not sent and one quickly turns down an aisle at the supermarket hoping not to be seen and thereby avoid an uncomfortable encounter with a person you once called a friend before they attacked you for your point of view.
This week’s letter has been difficult to conceptualize within the range of the variety of opinions that I know exists within a favorite population of mine, the group I call “Dear Interested Readers”. I know there is a spectrum of political philosophy among you. I also know that many, including me, at times have considered words like “values” and “morality” to be not only quaint but potentially dangerous subjects. I miss the era (if it ever existed) when we could easily acknowledge the differences in our points of view and amicably discuss solutions for commonly held problems without judging one another or having the conversation lead to the dissolution of long cherished relationships. My apprehension is even present within my family where I know there is a broad spectrum of political philosophy as well as a range of ideas about what constitutes virtue.
In recent years as the conversations and interactions between the leaders of the two major parties has become more strained in Washington, we have become accustomed to “gridlock” as a reality that is more broadly recognized and accepted as more inevitable than global warming. The same divide has become present in family gatherings. Most of the time when I am in conversation with friends and family who view the world through a red lense, I just steer clear of any subject that will touch on politics or public policy. Conversation is confined to “catch ups” and sharing on safer subjects like football, the recent weather, travel adventures or the celebration of the exploits of the toddler set within our circles.
Unfortunately, in the era of “Obamacare”, “Black lives matter” and Supreme Court nominees who can’t get a hearing, this strategy of avoiding sensitive and controversial subjects has led to me having a bloody tongue on some occasions. Even more unfortunate and regrettable is that on other occasions I have just “lost it” and submitted to the darker forces within me that want to fight for a principle that I cherish or position I have adopted even though it may test a relationship with someone I love and respect.
Let me give you the equivalent of a “spoiler alert” and suggest that if you are not interested in how I will examine “values”, both political and personal, and how those values impact our approach to better care, then perhaps you should just jump to the third section where I remember “9/11” or move on to the end of the letter. In the last section I draw some non controversial observations about persistence from what I see on the lake and make only minimally controversial (to sports fans) comments on the continuing soap operas we call baseball and football. Fall has arrived well before the autumnal equinox and I hope that you might enjoy reflecting with me on a summer of fabulous weather.
This week strategyhealthcare.com features a review of “Matt’s story” embellished with my thoughts that more directly attempt to connect Lean with Patient and Family Centered Care. If you somehow missed the original presentation, try this one. I like it better. I did appreciate the positive comments that I received from several readers who expressed genuine sympathy for Matt and saw the story as an expression of just how far we are from where we want to be, and how much work lies ahead before we can trust that when we need care, we will discover how good it is because we have achieved our goal of:
Care better than we’ve seen, health better than we’ve ever known, cost we can afford…for every person, every time.
Old Fashioned Values Applied to Complex Times
An “Interested Reader “ and friend recently sent me a eulogy that he delivered at his father-in-law’s funeral. It was a beautiful tribute and it triggered many thoughts beyond a sense of empathy and shared grief for the loss of such a person whose presence will be missed. Let me give it to you to read, abridged to cleanse it of identifying information.
I have been thinking about my nearly 50-year long relationship with Granddad, ...Charlie to work colleagues, friends and neighbors. He brings to mind Churchill’s snarky comment about Clement Attlee; “He was a modest man, with much to be modest about.” Granddad was a modest man with much to be proud of, though he was never boastful. As you all know, after leaving the University ...(where he met Grandmother, who was training to be a nurse), he served as a naval pilot in North Africa, Italy and France (Corsica) during WWII, when the Allies began at last to turn the tide on the until-then triumphant Nazi forces. He returned home to raise a family with Grandmother and work as a schoolteacher, coach and administrator in public schools in several Midwestern towns. He then returned to school in his 30s ….to earn an engineering degree, after which he worked at xxx and where Grandmother worked as the head nurse (no goldbricking in those factories!).
Granddad and Grandmother had a traditional understanding of their marriage (e.g., he told me that Grandmother’s salary was “the frosting on the cake,” though it was not in fact much less than his), but it was an unusual one for the time and place. She worked, mainly full time, and he supported her by helping at home to a far greater extent than most men of his generation or mine. He was active in his church and community, sang in a barbershop quartet, took endless numbers of photographs and slides, and raised roses. In retirement, he learned to make silver jewelry, (Mom wears one of his bracelets), became a volunteer tax-preparer for poor folks, and, with Grandmother, helped...[everyone in the family].
He was an exemplar of the strong values he learned growing up on …[a] farm in his staunch commitment to family, work, community and country.
So, for the lessons he taught me: these are what I have learned from watching him over the years. Granddad taught by example, not by speeches.
- Do not gossip, or say unkind things about anyone.
- In your family work and community, do what is expected of you and more, without complaint and without expectation of reward or praise.
- Be patient with those around you.
- Greet everyone you meet with a smile and a kind word.
- Find interests that give you and those around you pleasure, like his singing, roses, photography and jewelry making.
- Give unconditional love to your family, rejoicing in their happiness and success and offering support and encouragement during the hard times.
- Don’t complain. Granddad bore the discomforts and indignities of his last years with great courage and grace.
The best way to honor this kind, gentle and unassuming man is to try to live one’s life in accordance with these lessons that can be drawn from his. It’s much harder than it looks! In recent years, I have tried, and generally failed, to do so but I am a better person for making the effort.
With much love, [Interested Reader]
It was Charlie’s generation and the generation of my parents that survived the depression, and then brought World War II to a rather quick and decisive conclusion compared to the way subsequent conflicts in Korea, Vietnam, and the Middle East have persisted for two to three times longer. It was their generation that labored to produce the economic prosperity that we remember so fondly from the middle of the last century. Leaders of their day are seen as statesmen when observed in history in contrast to current occupants of the positions with the responsibility to govern and lead. It was from within this generation and a few before them that David Brooks found the examples of character that he celebrated in his book, The Road to Character.
To be sure, this is a generation that also struggled with equality and demonstrated some of the worst aspects of racism as it denied rights to minorities and women. Our international policies were full of distrust and at times seemed quite colonial and self serving as we propped up situationally convenient dictators around the world. All that said, there were many, many people like Charlie, my friend’s father-in-law, who had personal characteristics that deserve emphasis and must be the foundation for our continuing and future greatness as a tolerant, open and diverse society that offers more than any other society has ever offered its participants.
When I read the list and my friends confession that he had failed in his attempt to wear the suit of virtues that his father-in-law modeled, I too felt some shame as I remembered my mother who was Charlie’s contemporary. First on the list was:
Do not gossip, or say unkind things about anyone.
Right out of the blocks I was down. Mom’s phrase was, “Gene, if you can’t say anything good about someone, don’t say anything at all.” At my best I am often the master of what Alexander Pope described, “...damning by faint praise.” Many times in my life I have been capable of saying things about friends, family and colleagues, not to mention competitors, that I have regretted and would not want to say to their face. It is tough to flunk test one and realize that as you look down the list you are not even coming close to finding one that you can say, “Yep, I’ve got that one nailed. That’s me. I do it every time.”
As I reflected on Matt’s story from last week I realized that a revival of character as exemplified by role models like Charlie and Margaret Jane (my mother) may be a necessary prerequisite to achieving:
Care better than we’ve seen, health better than we’ve ever known, cost we can afford…for every person, every time.
Those virtues of Charlie are foundational for efficient, humane organizations where careers can thrive and where patients and families are treated with the professionalism and efficiency that we all deserve and expect but often find is lacking. These same virtues are necessary for any continued success in any attempt at continuous improvement or organizational transformation. The relational contracts upon which continued success in transformed organization depends are built on trust and nothing supports trust like virtue. As I contemplated my own failures and the Triple Aim, I was reminded of Don Berwick’s speech at the IHI last year, “The Moral Test”. I wrote about the speech last December and then expanded my “coverage” in January. For review click on the last link to read the speech in its entirety or click here to find my commentary, complete with YouTube links to the whole speech.
An easy Internet search reveals that many individuals and organizations beyond the IHI faithful have incorporated Don’s challenge into what they are saying. A good example is an excellent article from the Advisory Board consulting company entitled “Berwick: The 9 changes needed to make healthcare more ‘moral’”.
In their article they note:
A clash between health care's two eras of "professional dominance" and "accountability and market theory" is harming clinicians, communities, and patients—but there's a better way forward, former CMS administrator Donald Berwick writes in a JAMA viewpoint. [Unfortunately JAMA won’t give you the whole article without a purchase or subscription but read on for the same information]
They give a concise summary of Don’s 3 Eras of healthcare:
Era 1: 'the ascendancy'
Medicine's first era—dating "back to Hippocrates" in ancient Greece—"was the ascendency of the profession," Berwick writes....It was grounded in a belief that the profession "has special knowledge," is "inaccessible to laity," results in good, and "will self-regulate." As a result, society provided those who practiced medicine with a rare privilege, Berwick says: "the authority to judge the quality of its own work."
But those foundations were shaken when researchers began to examine the field and found "enormous unexplained variation in practice, rates of injury from errors in care high enough to make health care a public health menace, indignities, injustice related to race and social class, ... profiteering," and wasteful spending…
Era 2: 'the present'
[the ultimate failures of era1]... helped spawn medicine's second era, whose backers "believe in accountability, scrutiny, measurement, incentives, and markets" through "the manipulation of contingencies: rewards, punishments, and pay for performance," ...But the conflict between the first era's "romance of professional autonomy" and the second era's accountability tools have put the morale of clinicians in jeopardy, Berwick argues.
"Physicians, other clinicians, and many health care managers feel angry, misunderstood, and overcontrolled. Payers, governments, and consumer groups feel suspicious, resisted, and often helpless." Both sides, Berwick says, dig in further, resulting in "immense resources [being] diverted from the crucial and difficult enterprise of re-creating care."
[I should add that it is not a far leap from that reality to the complaints about regulation, the loss of clinical autonomy, and the ubiquitous “burnout” that fills the pages of “throwaway” journals and healthcare blogs.]
Era 3: 'the moral era'
Berwick says it is time for medicine's third era—which he calls "the moral era"—"guided by updated beliefs that reject both the protectionism of era 1 and the reductionism of era 2."
The new era will require at least nine changes to medicine, he says:
1. Reducing mandatory measurement. Much of the current era's mandatory measurement is "useless," ... wasting valuable time and money for providers....payers should work with the National Quality Forum to reduce the volume and total cost of mandatory measurement by 50 percent within three years and by 75 percent within six years. "The aim should be to measure only what matters, and mainly for learning,"...
2. Stopping complex individual incentives. For most, "if not all," clinicians,...the best form of compensation to promote value-based care is "salaried practice in patient-focused organizations." ....payers and healthcare organizations should halt complicated incentive programs for individual clinicians and ...CMS "should confine value-based payment models for clinicians to large groups."
3. Shifting the business strategy from revenue to quality. Improving quality is "a better, more sustainable route to financial success" than focusing on maximizing revenue... To that end, ...health care leaders need to view "mastering the theory and methods of improvement as a core competence," while payers need to delink reimbursement rates from input metrics that "are not associated with quality and drive volume constantly upward." [For me this is the core strategy. Unfortunately it seems to be the industry equivalent of a moon shoot or using another metaphor, teaching a dog to walk on it hind legs.]
4. Giving up 'professional prerogative' when it harms the team. "The most important question a modern professional can ask," ..."is not 'What do I do?' but 'What am I part of?'" ... young doctors should be trained to value citizenship over professional prerogative, and "physician guilds should reconsider their self-protective rhetoric and policies." [For me this represents the great challenge to clinicians of adaptive change]
5. Using improvement science. "Four decades into the quality movement," ..."few in health care have studied the work of Deming, can recognize a process control chart, or have mastered the power of tests ('plan-do-study-act' cycles) as tools for substantial improvement." Improvement science, ...must become a core part of preparing clinicians and managers. [If the core strategy is moving from a finance to a quality focus, this is the core tactic to achieve that strategy.]
6. Ensuring complete transparency. The rule for transparency,...should be, "Anything professionals know about their work, the people and communities they serve can know, too, without delay, cost, or smokescreens." ...Congress, insurers, and regulators should take steps to ease data sharing, and that states should adapt all-payer claims databases.
7. Protecting civility. "The rhetoric of era 1 can slide into self-importance; that of era 2, into the tone of a sports arena," ..."Neither supports authentic dialogue. Medicine should not ... substitute accusation for conversation." [Mother and Charlie would cast several votes for this one.]
8. Hearing the voices of patients and families. Further empowering patients and families to shape their care will improve care and lower costs,... "Clinicians, and those who train them, should learn how to ask less, 'What is the matter with you?' and more, 'What matters to you?' [Dr. Anthony DiGioia and my friend and her partner Matt (from last week’s letter) vote enthusiastically for this one.]
9. Rejecting greed. ...the industry has "slipped into tolerance of greed," from high drug costs to "profiteering physicians." ...stakeholders need to "define and promulgate a new set of forceful principles for 'fair profit and fair pricing,' with severe consequences for violators." ... professional organizations and academic medical centers…[must] "articulate, model, and fiercely protect moral values intolerant of individual or institutional greed in healthcare" [I can remember cringing when I heard Don say this one. There was a sense of unease across the five thousand in the audience who were with him up till this moment. Perhaps, sadly, it is a bridge too far for many to consider. At a minimum, it was jarring and uncomfortable as it hit home to all of us in a very personal way.]
I reject the idea that one successful businessman can give us greatness. Greatness is not a gift that can be given to a passive nation that one man protects. One man never has and never will make everything “wonderful”, “impressive” or “fantastic”, and you can “believe me” on that one. History reminds us that we have come this far with many great leaders. As a nation of many leaders and many willing participants, we are great. We have responded to leaders who demonstrate character and call on our character as they challenge us to virtuously engage. Some of those who teach us and call us to service, like a Jack Kennedy or a Don Berwick, are known in history or are well known in the moment, but many more are unknown except to family members of those like Margaret Jane (my mom) and Charlie. As a nation we have survived because of our ability to sacrifice and to work virtuously together both with those we know and with those we meet who come from afar to join our effort to achieve and maintain greatness. Greatness is a product of working together while exercising love, generosity and cooperation as the core competencies that complement our energy and ingenuity.
Together we have made progress toward the shared objectives of health, happiness, safety and prosperity for all. Together we will be more successful in our effort to manage the complexity of our crowded and challenged world. I paraphrase from a song I had learned by the time I was three, “Red and Yellow, Black and White, we are all precious…” The path to the continued national greatness and expanded successes that we want, including the Triple Aim, will be easier to travel together, if we rededicate ourselves to renewed and redefined virtues and agree on a new set of shared moral objectives. The Triple Aim is quite possible, if we personally work hard to develop within ourselves the virtues that Charlie demonstrated, and then together seek to move into the third era of healthcare that Don envisions.
9/11 Remembered
I downloaded the Globe and the New York Times to my iPad early Wednesday morning for reading during that period when they make you stop writing and close your computer until the plane is above 10,000 feet. We were flying to California for a business meeting and a family celebration of my wife’s birthday that corresponds to the usual expectation for longevity that you can read in Psalms 90:10. As what I was about to write was rolling around in my head and the plane was taking off, I happened to see a piece on the editorial page of the Globe written by Sandro Galea, the Dean of Boston University’s School of Public Health. His words resonated with me and my own remembrance of 9/11. His observation of the fact that 9/11 was the origin of depression and PTSD for many who were not present at the site rings true to me.
Every 9/11 seems to return us immediately to the pain of those days. Everyone who saw the towers fall in person or on television was changed. The events since 9/11 and the perspective available from the widening distance of the years underlines its importance to our collective sense of security and national identity. This anniversary helps us remember how effectively we can respond when things suddenly change and it reinforces our sense of vulnerability in a complex world. We mourn the loss of those who died and the change in all of us who were witnesses to the horror of their departure. We cherish the bravery of those who resisted and surely saved others and those who with no thought for their own safety entered falling buildings on a missions of mercy. Virtue was on display as a force against evil in ways that should not be forgotten.
Dr. Galea’s insight seemed a partial explanation for why there has been something of a persistent dystopian world view over the last fifteen years and explains perhaps some small piece of the allure of “Make America Great Again”. It would explain the attractiveness to many of someone who proclaims to be the insurer of protection. Can anyone forget Rudy Giuliani's shrill set up, complete with references to 9/11, a night or two before Trump's acceptance speech?
There are other ways to face the future than to rely on a strong protector. I have lifted several of Dr. Galea’s thoughts which attempt to look at 9/11 as an ongoing concern for public health from which we should extract lessons learned and apply that knowledge in preparation for future concerns.
- For millions of people, Sept. 11, 2001, was the first mass disaster experienced in real time. Many who watched the event unfold on television can still remember with great clarity, as the 15th anniversary approaches, where they were, and how they felt, on that terrible day.
- Stunned by the destruction, our research team quickly became concerned with the potential long-term mental health consequences of the attacks.
- We estimated that about 7.5 percent of Manhattan residents had post-traumatic stress disorder, and 9.7 percent had depression that first month, for a total of about 67,000 people with PTSD and 87,000 with depression in Manhattan alone. We then studied residents in the entire New York City metropolitan area and found a substantial burden of PTSD and depression throughout the region.
- ...the seemingly interminable string of terrorist attacks worldwide remains a sad and insistent reminder of the need for more work in this area.
- ...we must expect that the consequences of these events will be pervasive, threatening that large-scale terrorist attacks or disasters can change the trajectory of population health for decades after the initial catastrophe.
- ... we must invest in strong community infrastructures and in responsive, flexible health systems that can manage these long-term effects in the months and years after disasters occur.
- When disaster strikes, the highest price is often paid by marginalized groups already at a disadvantage.
- The best way to honor the victims of the attacks is to resolve to build on what we have learned over the past 15 years about the consequences of mass trauma, and devise strategies to mitigate these consequences.
The Lonely Little Tree and Other Reflections As Fall Arrives
My wife and I purchased the home where we have retired eight years ago and began to enjoy weekends and vacations there in September of 2008 about the time Lehman Brothers proved that they were not too big to fail. I immediately began to explore the lake in my canoe and the next spring switched to my now beloved “pedal kayak”. If ever I was to do an advertisement for a product that I value, and the service that I have received from an innovative manufacturer, it would be for my Hobie Outback kayak.
Not long after I began to get to know my lake I discovered a little tree trying to grow out of a large boulder that pokes its head up out of the water about twenty yards offshore from an area of shoreline that is “under conservation”. The big rock may be an erratic from somewhere in the North left by the glacier that created the lake and sculptured the surrounding countryside more than 10,000 years ago. All around the lake there are “rock piles” that make great habitat for the fish that I catch and release almost every evening of the spring, summer and fall. These stones are like landmines for careless boaters and serve the purpose of keeping a lot of fast boat joyriders from interrupting my solitude. Hardly an evening on the water in my kayak goes by that I do not encounter the loon family or try to check out the bald eagle who uses a tall white pine on Colby Point as his home. One of the most important stops on my evening tour of my watery domain is the rock with the little tree that you can see in today’s header.
I am not sure when I first noticed the little tree trying to get a foothold on the rock but I feel sure that it was probably in the fall of 2008. It seemed like a little bonsai plant destined to struggle to survive, always in jeopardy out in the wind and the cold of our long winter. One of my first observations this year, when the ice thawed and I was back on the water, was that the top of the little tree had been broken. It was a traumatic moment that seemed to emphasize some sort of universal vulnerability that all living things share. If you look closely, you can see that the the top hangs like a wounded limb. I assumed that the little tree would probably “give up the ghost”, as the older members of my family have frequently said, and then fade in memory as well as in reality. I wondered whether if it was the first little tree to try to make it in this crack or whether others had tried and failed. Would a new little tree try to take its place? By June my questions were answered. This little tree was no quitter. It had new branches and more leaves than ever. What a joy!
On Tuesday evening I was out on the water near sunset. I was pedaling along thinking about “virtues” and how to cast this letter. The lake belonged only to me and the loons. It was the day after summer. The sky was gorgeous as the cloud cover reflected the light from the setting sun. Then, just as I was approaching the rock with the little tree, I experienced the sudden electric shudder that I feel when a little bass hits my fly (green wooly booger) and then begins to frantically tug on the line that I am trolling behind me. Simultaneous, the sun found a window in the cloud cover and the little tree and everything in its world was suddenly bathed in a golden light. I was so overcome by the sudden beauty that I let the fish swim around tugging on the line while I tried to capture the moment with a picture. It was not necessarily a “burning bush”, but for a moment the only thing that would have made it better would have been to hear the voice of God. Until the clouds closed the window of light and the sun faded again toward its departure in a few minutes, it was definitely a mountain top experience.
If you are a Sox fan you go day to day from a mountain top like today when the Sox are in first place and everyone is hitting like a future “Hall of Famer” to the pits a few games later when they might fall out of first place by losing a couple of games to basement dwelling teams in dramatically creative ways that you could never have imagined, as they did earlier in the week. The only thing that gives me hope is that the other contenders in the American League East, the Blue Jays and the Orioles, seem to be equally inconsistent as each team rises to the top and then slides down again. I am sure that there must be people in Baltimore and Toronto who are just as nauseous from this up and down ride as I am. One thing is sure; there will be interesting baseball for at least another month to hold us until Brady returns and to counter the daily fatigue of the world’s longest election process. By November 8 (if there is no “hanging chad redo” of the uncertainty of the 2000 election) there will have been almost 600 days between when Ted Cruz was the first announced candidate and when it ends, sort of. My guess is that the race for 2020 will start by Thanksgiving.
This was the best summer for weather that I can remember in a long time. The only downside was the continuing reality that we are in a drought of sorts. Since rain was rare, the garden needed more watering. I am hoping that the fall is a glorious run up to what the Farmer’s Almanac suggests will be a very snowy, cold winter for many. Take every opportunity you can to be outdoors in nature this fall. You never know when you may be the recipient of a glorious shaft of light from the late afternoon sun. |
