19 July 2019
Dear Interested Readers,
How Are You Doing in the Midst of The Swirl Around You? Are You Keeping Your Head [On]?
For a long time now I have been wondering how you are doing. I know that your days are full of challenges that often arise in the most unexpected ways, and at the most inopportune times. I well remember long days that did not end as scheduled. During the entire day you move from patient to patient with your eye on the target of the last moment that you can leave the office and still be on time for a long awaited event, like one of your children’s theatrical performances or athletic events. You can emerge from that last scheduled visit exactly on schedule to make the event only to learn that just before the office closed there was a patient that you know quite well who walked in and needs attention. Everyone else has gone home. You can address the issue, or you send the patient away at great inconvenience to them, and great expense to your practice. You have been building trust with this patient, and now all that effort is in the balance between your professional responsibilities and your own desire to be present at an important family event. It feels like a “lose/lose” moment.
Maybe you don’t spend your day seeing patients. Your day is full of meetings where the management team is trying to write a budget that the board will approve. You know that your cost structure is increasing at a staggering rate. Your organization is holding more “risk” than ever before. Your employees are expecting raises because they have not had one in a few years, and now the nursing contract must be renegotiated with their union. The payers are offering your group practice or hospital contracts that are virtually flat again for the second year in a row. There are internal and external “political” ramifications to cutting overhead and programs. Should your team hire a consultant to help figure out where management can “squeeze” yet again? How did you ever let yourself get into such a difficult position?
Maybe you are a pillar of the practice. You have always been focused on delivering exceptional care, not the politics or business of the practice. You are patient centered. You have left the business of the practice to others. You have trusted the leadership of your practice, and have done everything they have asked of you. You switch patients to less expensive generic equivalents. You make personal sacrifices to keep patients out of the emergency room and the hospital. You give close attention to the concerns your patients bring to you. You read what they print off of the Internet, and you work through their questions one by one even when the time required will mean that you are closing charts at home late at night. Now your “chief” has suggested that your “productivity needs to be increased.” What is going on? Suddenly, a line from a corny 19th century poem that you were forced to read and memorize in junior high school pops into your head, “If you can keep your head when all about you are losing theirs and blaming it on you…” You take a deep breath, try to subdue your anger, and keep going.
I apologize for the banality of the above paragraphs, but I have a sense that many of my former colleagues, as well as the majority of the professionals in all of healthcare, are living their lives from one challenge to another. We know that some give up, but I suspect that most persist. The vignettes above are snapshots from my own experience, or from the lives of my colleagues whose practices I have observed. I think that they are but a few examples of the experience of the majority of professionals who are trying to be faithful to their calling, or just feel, for undefined reasons, that they should just keep doing the work that they know needs to be done. They aren’t expecting much improvement. In fact they may expect that “things” will get worse, but they know that the need for what they do has never been greater, and will not diminish.
I have many wonderful memories from my childhood and adolescence. In retrospect, there were also a few moments that weren’t so good, but some of the worst were preparation for the challenges ahead that I would encounter in practice. Some of those “tough memories” that may have enabled later life resilience were so embarrassing that all I need to do is think about them, and I still cringe, or get a red face of embarrassment and feel again like crawling under the table. Rudyard Kipling’s poem “If–” is one of my favorite poems. I have even used the poem in these notes before, however,I don’t think that when I have used it that I have told the story of my first encounter with the poem. It goes like this:
Someone on the Board of Deacons at my father’s church, The First Baptist Church of Waco, Texas, decided that we should have a midwinter “Fathers and Sons” banquet. I was about 13 at the time, so it must have been in February 1959. The were to be speeches and other forms of entertainment, and I was invited, or assigned, the task of quoting Rudyard Kipling’s poem, “If-,” from memory. I was apprehensive from the get go although I was pretty good at memorizing poems and scriptures. I can’t remember whose idea the performance was, but it was clear to me that my dad thought it was a terrific idea.
I was offered the opportunity several weeks in advance, but I put it out of my mind until about a week before the event. My dad kept asking if I was getting ready, and I assured him that there was no problem, I would be ready. A few days before the banquet, I proved to him that I could recite the poem without a glitch. In retrospect I do not remember how it was decided that I was to recite the poem rather than just read it. I can assure you that going to the podium with nothing in hand was not my idea. Perhaps it was Dad’s idea. I never saw him take a note to his pulpit. He delivered his sermons with an easy flow that would have been the envy of a Shakespearian actor. There was a lot of theater in what he did. I remember him practicing his sermons, complete with gesticulations, in front of a big mirror over the dresser in my mother’s and his bedroom which also doubled as the family room where our black and white TV was located.
For the few days that remained before the banquet, I stood in front of the mirror in my room several times a day, and delivered the poem flawlessly. Since it was winter, I knew that I would be wearing my itchy brown wool suit. The pants legs had no lining, and if it was not pretty cold, just wearing the suit was torture, but I had no other option. “Looking the part” you are to play was also something Dad stressed. On the evening of the dinner, I began to get a little nervous as we headed out from home for “Fellowship Hall.”
Fellowship Hall was a large building on the other side of the parking lot of the church. The church sanctuary was huge. The complex of the main sanctuary, the educational buildings, church offices, and the chapel which was larger than most churches, filled an entire city block. The sanctuary was completed in 1907, and was built to be large enough to accommodate the annual meeting of the Texas Baptist Convention. The church is not quite as big as Symphony Hall in Boston, but it can seat more than a thousand people on its main level and several hundred more in its balconies. In the fifties the church had more than 3,000 members with two services every Sunday morning. The second service was televised on the local TV station starting about 1956. The Fellowship Hall was a gym, a skating rink, and a venue for church suppers and youth activities, or any other scheduled celebration. Several hundred fathers and sons showed up for the big event. In February, in Central Texas, the temp can vary from frigid a 20 degrees to an occasional sweltering 90 degree day. I can’t remember what the temperature was that day, but I think it was one of those days when you did not need a jacket. My legs were itching, and I was sweating even before we got to Fellowship Hall.
Since my dad and I were part of the program, we were at the head table. As soon as we arrived, I began to sweat even more, and was suddenly envious of my younger brother. I can’t remember if my brother had a part on the program, but if he did, it was not to quote a long poem from memory.
If you have ever attended a church supper, you know the menu usually contains mashed potatoes, green beans, some kind of jello salad, a bland white meat of some sort, and plenty of dinner rolls. I usually ate with great gusto since I liked all those things, but I was hot, beginning to get nervous, and suddenly because of some vague nausea, had no appetite. As the moment of my presentation got closer, the whole room seemed to be moving away from me. When my moment came, and the emcee read my name, and as I stood and moved toward the podium, I felt a little lightheaded. My white shirt was sopping wet under my brown wool suit coat. My wool pants made my legs itch like I had been rolling in poison ivy. I gripped the podium and looked out at the faces of my friends and their fathers. Their faces looked fuzzy and far away. I could hear myself saying thank you to the master of ceremonies and hello to the audience, just like I had practiced. I think the first verse of the poem went fine.
If you can keep your head when all about you
Are losing theirs and blaming it on you,
If you can trust yourself when all men doubt you,
But make allowance for their doubting too;
If you can wait and not be tired by waiting,
Or being lied about, don’t deal in lies,
Or being hated, don’t give way to hating,
And yet don’t look too good, nor talk too wise:
I am not sure what I said after that. I think that I came up with a combination of random lines from the poem that popped into my head like bits and pieces of flotsam floating to the service after a shipwreck. I felt like I was drowning. I was also vaguely wondering what everybody was thinking. I knew that I was in trouble, and was pretty sure that my distress was obvious to everyone else in the room. Then I grabbed onto a big piece of flotsam that popped up much too early than it would have occurred if I had remembered the poem. It was the last stanza, or some fragment of it.
If you can talk with crowds and keep your virtue,
‘ Or walk with Kings – nor lose the common touch,
if neither foes nor loving friends can hurt you,
If all men count [on you,] with you, but none too much;
If you can fill the unforgiving minute
With sixty seconds’ worth of distance run,
Yours is the Earth and everything that’s in it,
And – which is more – you’ll be a Man, my son!
I know that at the minimum I said,
And – which is more – you’ll be a Man, my son!
That last line was probably why someone had chosen to have “If-” recited at the First Annual Fathers and Sons Banquet. Having “finished,” I stood there for a few seconds, although it seemed longer. Someone in the audience realized I had finished, or more accurately, that I was cooked and began to clap softly. I remember hearing a ripple of polite applause as I walked, or staggered the few yards back to my seat at the head table wishing all the while that I could crawl under the table, or rush out the door away from all the inquiring looks of those who wondered if I was OK.
If you have never read Kipling’s “If-” which is probably unlikely if you attended high school and college anywhere in America during the last half of the twentieth century, it is hard to go through any educational portals without encountering Kipling, or if you need a refresher, here it is in its entirety. If you prefer, click here to hear Joni Mitchell sing her slightly modified version.
If you can keep your head when all about you
Are losing theirs and blaming it on you,
If you can trust yourself when all men doubt you,
But make allowance for their doubting too;
If you can wait and not be tired by waiting,
Or being lied about, don’t deal in lies,
Or being hated, don’t give way to hating,
And yet don’t look too good, nor talk too wise:
If you can dream – and not make dreams your master;
If you can think – and not make thoughts your aim;
If you can meet with Triumph and Disaster
And treat those two impostors just the same;
If you can bear to hear the truth you’ve spoken
Twisted by knaves to make a trap for fools,
Or watch the things you gave your life to, broken,
And stoop and build ’em up with worn-out tools:
If you can make one heap of all your winnings
And risk it on one turn of pitch-and-toss,
And lose, and start again at your beginnings
And never breathe a word about your loss[ess];
If you can force your heart and nerve and sinew
To serve your [or our] turn long after they are gone,
And so hold on [to it] when there is nothing in you
Except the Will which says to them: ‘Hold on!’
If you can talk with crowds and keep your virtue,
‘ Or walk with Kings – nor lose the common touch,
if neither foes nor loving friends can hurt you,
If all men count [on you,] with you, but none too much;
If you can fill the unforgiving minute
With sixty seconds’ worth of distance run,
Yours is the Earth and everything that’s in it,
And – which is more – you’ll be a Man, my son!
There are many great lines in this poem that I have returned to on occasions of stress and failure during years of practice. Perhaps that fact is connected to the history of the poem. Kipling wrote it as a tribute to Dr. Leander Starr Jameson. Dr. Jameson knew both triumph and defeat in his life. He was trained at the University College Hospital in London in the 1870s, and was on a trajectory to be an important academic figure of his day when his health failed from “overwork.” Did he burnout? What he did do was to move to South Africa where he practiced medicine in the North Cape city of Kimberley, a center of diamond mining. His patients and social circle included the most influential people of the colony including President Krueger, the Zulu king and leader, as well as Cecil Rhodes, business man and the donor of the resources that support “Rhodes Scholars” at Oxford. Jameson was trusted by the British who ruled the colony as well as by the indigenous leaders, and became the leader of a daring military engagement against the Boers that was a crushing defeat, but he persisted and became a shining example of British virtues. Wikipedia reports that one biographer described him as a man of great character:
His whole life seems to illustrate the truth of the saying that in self-regard and self-centredness there is no profit, and that only in sacrificing himself for impersonal aims can a man save his soul and benefit his fellow men.
Dr. Jameson may be a better example for these times than Kipling realized when he wrote his poem in1896 (though it was not published until 1910.) Dr. Jameson got involved in the communIty. He had successes and defeats, but there was never any doubt that he cared, and that he was committed to the cause. No one will ever criticize the healthcare professional who presses on to meet the demands of the day while keeping their head in the midst of change and political cacophony. Our work will never go away, and we are reminded every day that there are those whose needs our extended efforts will not touch. Do we leave that larger problem of what will happen to those who have no access to our care, or any reliable care, for politician and others with vested interests to solve?
If I was a poet and was presumptuous enough to add a line or verse to Kipling’s poem, I would write an acknowledgement of those who do today’s work, and then still try to be engaged in some way in making today’s problems become part of tomorrow’s history of problems solved. “If” you can do all that you are asked to do today, and then still be dedicated to, and work for, the hope of a better tomorrow for everyone through realization of the Triple Aim, then we may someday wake up to discover that we live in a much better world. “If” is a short word with a very big potential outcome. “If” often follows a problem that is looking for a response.
Make Earth Cool Again.
This weekend is predicted to be a scorcher across the country. I do not have air conditioning. It makes little economic sense when you live where most days are cool, and you can jump in the lake if you feel a little warm and sweaty.
This time of year we are delighted to have friends and family drop by to enjoy the breeze, and feel the shiver of diving into water that will be about thirty degrees cooler than the air in the breeze. When there is a little movement to the air, I am ready with my old sailboats, a 60s vintage O’Day Javelin, and a 70s vintage Sunfish. I also enjoy “sailing” my Hobie Outback kayak. It has a small sail that turns using it into something like windsurfing sitting down.
Wherever you might be this weekend, I hope there is water to keep you cool, and friends or family to help you document and survive what may be record temps. I will make the weekend political by wearing my green baseball cap with the words “Make Earth Cool Again.”
Stay cool, be well, take good care of yourself, let me hear from you often, and get active in the efforts around you to make things better. Don’t let anything keep you from doing the good that you can do every day,
Gene
