It was a tough weekend for me. As usual, The Friday “Healthcare Musings” was posted on the Internet at 3 PM on Friday afternoon, but as the minutes, then hours, then days passed without the notice of it existence going out to you I became increasingly distraught. Based on recent delays with the “RSS feed” that I use with my letter, I am never relaxed for the weekend until I see that my RSS provider has sent you a notice that the post is “up” on the Internet. That usually occurs by 3:10 PM. Rarely, it is as late as 3:15, and once, even when there was not a demonstrable problem, it was a little after 3:30. I was told that the reason for the delay that day was “heavy traffic.” About two months ago there was a problem of a greater magnitude, and the notice did not go out until around 9 PM. By 9 PM I was bonkers with anxiety. What must people be thinking? I worried my friend who provides my site with technical support every 15 minutes or so with questions and concerns until the RSS feed went up that Friday evening.
You can imagine what was happening to me when the feed had not gone out by 4 PM or 11 PM on Friday. I was disappointed again when I awoke on Saturday hoping to see that it was up. On Sunday I was looking every few hours to see if the problem, whatever it was, had been resolved. I won’t tell you how many emails and texts went back and forth between me and my IT friend, Russ Morgan, over the weekend. I must have driven him nuts. He tried to reassure me by forwarding a letter showing that there was a work order, # 6624386, and that there was a customer service rep who was making sure that someone was busy trying to resolve my problem. But why, I wondered, was it taking so long?
If you can imagine my distress over the weekend, you can also imagine my relief when at 9:48 on Monday morning the feed magically appeared in my inbox, and in yours! So far, I have not gotten any explanations. I’ve been traumatized by systems before. I remembered the traumas experienced when our “Epic” system would crash, and the inconvenience and pain I suffered when American Airlines had a three day crash of its computers over a weekend that I was traveling last year. Often there is no satisfactory explanation for these things, and as a result I understand why our ancestors believed in curses and witches. Sometimes the paranormal seems like the only rational explanation for what is happening in our lives. In the end are, without an explanation, I am left with nothing more than the relief that things are working again, and the fear that in the near future I will be traumatized again. Are there parallels between my little IT problem and our healthcare delivery system in this process of recurrent disfunction without explanation or effective efforts at prevention?
Sometime during the weekend I decided that if things were working in time for this Tuesday post that I would move beyond my obviously narcissistic concerns and apologize for any confusion that the episode may have produced for you. I wish that other than a sincere apology for any confusion you might have experienced there was some sort of “service recovery” action that I could take. I also decided that if things ever worked again, I would let you know, to the extent that I understood, just what happened. So far, I do not know what did happen. It also occurred to me that since I can not guarantee it won’t happen again, I should remind you every post goes directly onto the Strategy Healthcare site at 3 PM “sharp” every Tuesday and Friday and that you can bypass the RSS reminder and go directly to the site to read the letter. If the letter is not there check the newspaper for my obituary.
The letter that you get from the RSS feed is a reminder for you to look and follow the direct link to the letter, but if in the future that RSS system breaks down again, and the notice doesn’t show up in your inbox shortly after 3 PM on some Tuesday or Friday, and you wonder where my post is, just go to the website where you will find it. If that happens, calm my anxiety about our “lost connection” by sending me a note that reassures me that you that you did see the letter. I will not ask you if you have read it!
If by now you have read some or all of last Friday’s post, you know that it was about “uncommon courage,” as described by Sister Joan Chittister in her book, The Time Is Now: A Call to Uncommon Courage. If the picture that heads this post puzzles you, let me present it as a metaphor for courage. Take a closer look. What you will see if you look closely is a huge block of New Hampshire granite deposited by a glacier 20 yards out into my lake from which a small tree is growing. I have passed by the rock with its little “bonsai” almost every time I have gone out on the lake in my kayak over the last eleven summers. I have no idea for how long the little tree was there before I arrived in the fall of 2008.
It is said that, “The purposes of bonsai are primarily contemplation for the viewer, and the pleasant exercise of effort and ingenuity for the grower.” This little tree definitely stimulates contemplation in me, “the viewer.” I don’t know how the “grower” feels since the questions stimulated by the little tree has never been answered in all of my conversations with nature. It just continues to sprout its leaves year after year. I am impressed by the persistence of the brave little tree, and its ability to withstand the winters on the lake, and the waves that surely wash over it when we have a big storm. I realize that even if I live another quarter century, it is unlikely that I will be able to measure any real growth, but with every summer that passes I will have another lesson in the courage it takes just to show up and persist without the hope of much change.
If you have read last Friday’s letter, you will remember that I finished with a promise to return frequently to the wisdom of Sister Chittister, and that I saw a connection between her principles and Don Berwick’s articulation of Era 3 in Medicine. If you feel the need for a brush up on “Era 3,” just click on the link and listen to Don give us a great seven minute explanation of his idea. I can remember the first time I heard Don talk about Era 3, it was clear to me that most of the other more than 5,000 who were present in the hall were shocked and surprised when Don got to the part about “decrease the focus on finance.” But, that response was nothing compared to the collective post gut punch expiratory sigh that was audible when he said “Reject greed.” It was if there was a shared fear, “He knows me for who I am on my worst days.” We are all sure that he is asking us to follow a camel through the eye of a needle.
Berwick would definitely fit Sister Chittister’s description of a “prophet.” Listen to her words as she talks about “Prophecy,” the work of prophets. I added the bolding.
...What is the use of feeding the hungry without advocating for better social services? What is the use of demanding higher wages for physical labor while omitting the need for childcare for working mothers?
On the other hand, what is the use of prophetic vision while the living poor go hungry? As the world waits for the legislative insight it will take to reconstruct social services or raise wage levels, a family can starve. Intellectual concern is no substitute for the food a family cannot afford despite the fact that they work two jobs. The truth is that charity is laudable and seldom considered dangerous. It is the sign of a nice person, the one who unloads the trucks or sets up the temporary housing units.
Prophecy, on the other hand, has ragged edges. It sets out to deconstruct the present situation. It critiques social structures to which many have given their lives or in which many have status. They are invested in its continuance. They have something to lose if the world listens to the cries of the prophet for change.
While the hallmark of charity is it’s uncommon generosity, the ring of real prophesy lies in it’s uncommon courage.
As a prophet, Don Berwick is “deconstructing” the realities of medicine today. I heard him critique the social structures to which everyone in his audience, including me, had invested their lives and in which we found our status. It was hard for us to bear the thought of the individual or collective loss that might be associated with accepting his challenge. It took less than a second for the reality of his challenge to hit us in our guts, and cause us to internally express to ourselves something like , “Yes, but…”
Don has shown real courage as a prophet for over more than thirty years as he gently and patiently tells those of us in healthcare how we have failed our patients and our communities as we, our practices, and our institutions have prospered putting our interest before the concerns of patients, families, and communities. He has never come to the conclusion that we have passed the point where change is possible. But, how likely is it that the real change Don calls for is possible before we pass a point of failure that we never thought was possible, a point when we realize that the Triple Aim will never be a reality? Perhaps that moment has already been passed, but we just do not know it. It is true that for the past three years we have had a decline in life expectancy. What has passed us from the possible to the impossible without real notice?
I had a shocking experience last Sunday. My wife and I were entertaining our youngest son who had come up from his home in Brooklyn and friends from Massachusetts. We were enjoying a late lunch on the deck while gazing out at our beautiful lake. All of nature seemed aligned for our viewing pleasure. Inevitably, we broke the spell by beginning a conversation about the current political climate. Simultaneously, I could hear the Red Sox game going on in the background behind the open sliders on the deck. The Sox were impossibly behind the Blue Jays, a team they should be beating, and had lost to on Saturday after the bull pen blew a six run lead. My friend further killed the moment when he interjected into our casual conversation among like minded card carrying Democrats that we had already lost the battle to save the environment by combating climate change. He shocked us by saying that he was sure that we could not turn global warming around. He postulated that there was not now, and would never be, the “real will” to make the individual or collective changes that would be necessary to stop global warming before we suffered the reality of the worst predictions of environmental scientists. I was shocked, and a little frightened by the possible reality of his prediction. He continued by saying that the time had come when we should shift our efforts from how to prevent global warming to the development of strategies of how we would survive with it.
We have not listened to the “prophecies” of Al Gore, as delivered in all of his talks that were summarized in “An Inconvenient Truth.” Gore gave us prophecy by “PowerPoint.” Al laid it out in his show. It was good theater, some listened, a few acted, and a president now leads us in the opposite direction proclaiming the message as untrue, just more “fake news.” I will not recreate my friend’s analysis that supported his view that our chance for salvation has passed, and that the deniers have won a victory that will damage us all, but I will say that he got me thinking.
We have been hearing about the Triple Aim for almost as long as we have had the phrase “An Inconvenient Truth” (2006 v. 2007). We have been talking about quality and safety with vigor since the late eighties, and the rising cost of healthcare care since the sixties. Dr. Ebert gave us his formula for healthcare success and sustainability 54 years ago. We have never effectively acted to change our operating system or method of finance. Fee for Service payment lives on with its greed and dysfunction essentially unaltered, and continues to pay well while it undermines the future for all and the moment for some. It is hard to know where we would be without the conversations and actions that have occurred, but we do know that we have not made the progress we had hoped to make.
Could it be true that both the prophecies about global warming and the unsustainable status of healthcare share realities that preclude success?
It sets out to deconstruct the present situation. It critiques social structures to which many have given their lives or in which many have status. They are invested in its continuance. They have something to lose if the world listens to the cries of the prophet for change.
This conversation will continue, even if some may fear that it is too late to be certain of success. I disagree with my friend. It is not too late. We can’t afford to give up the hope for change. The road is steep, and the effort necessary will be great, but we can sustain the hope that exists if we believe in the reality that the arc of the moral universe is long, but it bends toward justice. Tomorrow night, and again on Thursday night, we all have the opportunity to listen to twenty wannabe prophets. They will give us their best thoughts about the way forward. They will all share the belief that we are currently going in the wrong direction in almost every area of our collective experience, and that they are the one that knows the best way forward. Their messages will be similar, but different. Our greatest hope lies in the fact that we can still have such an event. The challenge will be to try to see if there is real possibility in at least one of them. Democracy has taken some hits over the last few years, but like my little tree, it is still standing. Do your part to sustain hope. Be sure to watch and listen. As you listen try to entertain the “audacious hope” that someday we might move beyond a world that needs charity to a world of Shalom where every one has what they need to be a healthy, productive, fulfilled, and valued neighbor in our community.
