I do not get invited to many baby showers. Before last month I do not think that I had ever been to a baby shower. Is it something about me, or is it just a cultural thing? Whatever, I was delighted when my wife announced that a couple of dear friends decided that the shower they were having for their daughter-in-law would be open for all genders and ages.
The father-to-be is an old friend of one of my sons. I have known him since his family moved to our town about the time the boys started middle school. He is one of those young entrepreneurial, good citizen types who give us hope that America will survive its recent identity crisis, and that its future greatness will be well worth the current confusion and struggles. Future Mom is a PCP/ internist who was trained at one of our best medical schools. After a vigorous training in internal medicine at a world famous hospital, she has chosen to contribute to the Triple Aim, and a better future for all, by working within a disadvantaged community. I was looking forward to seeing them again and was wondering if I would meet some new and interesting people at the gathering.
The party did not fit my preconception of a “shower.” It seemed more like a wedding reception with the guests naturally sorting themselves by family affiliation, generation, or prior acquaintance. The parents-to-be were gracious and circulated through all the groups trying to make introductions and create new connections. I had a great conversation with the father-in-waiting. His dad, the future grandfather, is a physician, educator, and an excellent “Words With Friends” foe who regularly beats me. Grandmother-in-waiting recently retired from a successful career in business. Now she devotes her time to gourmet cooking, decorating a new home, and frequently coming with her husband to see us in New Hampshire.
The baby will have physicians on both sides of its family tree, I was not surprised when I was introduced to a cousin who is a medical student at an Ivy League medical school. Making small talk, I asked her if she had taken a physiology course in her preclinical years taught by an old classmate of mine whom I thought was still teaching at her medical school. The answer was no, but she knew of him because her boyfriend and classmate, who was at the gathering with her, did have my old classmate, who just retired, as a professor. Then she surprised me with a question.
Like her cousin’s wife, the mom-to-be, she also feels drawn to primary care. She is looking forward to picking a few courses away from her school this next year, and was already looking past graduation toward her internship and eventually her practice. She has given much consideration to just where she should try to go for these next steps. It was clear to me that she was putting a lot of thought into her future and was not just going to hope that it all worked out. The question that she asked underlined how seriously she was thinking about the future, but our conversation that followed showed how ill prepared she had been so far by her medical school experience to understand the issues that will challenge her. I wondered whether any of the current issues in healthcare were discussed at her medical school. I also wondered just how typical her experience was.
A paraphrase of the question I heard that created all of these thoughts for me was, “What questions should I ask when I am interviewing at programs, and later when I am interviewing for a job, that will help me be sure that I am going to a place where I will be happy and will continue to grow professionally?”
Wow! I thought, “This young woman is asking a question that is very important for healthcare professionals at any point in their career.” In retrospect I realized that I had never considered the question for myself, but I had been lucky to have been in the places that I would have chosen if I had ever applied the same energy to the thought process about the future that she evidenced. In my era one just tried to get “the best” internship, residency, fellowship, or job possible. “Best” was either defined by some academic yardstick, location, or compensation scale. I do not think I ever asked myself, “Will I be happy there?” I never questioned, “Is there a sense of purpose or mission that draws me to this job?” I do remember some mentor suggesting that I try to imagine what I wanted to have accomplished in twenty years, and then plot a course in that direction, but my eyes were always on the traditional path, and my ambition was limited to: “I just want to be a good doctor.”
I decided to ask her some questions to help me answer her excellent question. I asked her if she was following the healthcare debate over access. Her answer was a little vague, so I asked her specifically if she knew what the “Triple Aim” was, and whether she had heard of the IHI or Don Berwick. The answer was “not really.” Then I asked if at any point she and her classmates were introduced to the concept of what constituted quality. Was Crossing The Quality Chasm ever mentioned in any class discussion? Her negative answers to my questions made me wonder more about the environment at her famous institution than about her abilities as a student.
I had no doubt that she knew a lot of neuroanatomy, biochemistry, virology, and could go through the rote steps of a history and do a beginner’s physical exam. As we talked on it was clear that she was getting the bits and pieces of the basics that all medical students must master, but the basics were not being put into the context of the larger picture. Her school was failing to introduce her to the issues that would have a significant impact on the world in which she would try to practice. I interpreted her question to be an intuitive recognition that her work environment would matter, and so far no one had helped her understand how to locate where she would thrive.
I asked myself, “How aware of the big picture was I when I was venturing out from medical school?” Honestly, I was probably not that aware. I did have the benefit of the influence of classmates who were more socially active than I was. It was the time of social upheaval associated with the Civil Rights struggle and the national debate over Vietnam. I had gotten in line and joined the protest marches, but I was not really as informed or militant as many of my classmates were. Some of them were actually already talking about improving the delivery of care through better systems.
By luck, I fell into what she sensed she needed, the right environment for personal growth. In time I did come to understand how lucky I had been to apply to, and be accepted at Harvard Medical School while Robert Ebert was the dean. In retrospect, even as the dean he was challenged and often blocked from realizing his vision of using medical education to transform the delivery of care to meet the needs of the underserved in our society. He knew that the standard path of the times through medical school and the post graduate years could produce great scientists, but he also knew it was not designed to produce the socially responsible physicians that were capable of solving the problems as he saw them. He knew that the answers were elusive and contrary to conventional thought. If not why would he have said:
The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.
It seemed to me that she needed to explore the rich history of the quality movement of the last twenty five years and understand the thinking that had produced the ACA before she could identify the best places to work. I suggested that she read The Best Practice: How the New Quality Movement is Transforming Medicine by Charles Kenney. She did not need to read Crossing the Quality Chasm, but she should be familiar with the core principles it espoused and understand its definition of quality. The Best Practice could be a guide to an appreciation of Crossing the Quality Chasm. I told her that she needed to read An American Sickness: How Healthcare Became Big Business and How You Can Take It Back Back by Elisabeth Rosenthal, and finally she could get an appreciation of the moment by reading Robert Pearl’s Mistreated: Why We Think We Are Getting Good Healthcare and Why We’re Usually Wrong.
She had heard about the epidemic of burnout. I wondered if perhaps fear of becoming a victim might have been a motivation for her question. I suggested that she might also want to look at Preventing Physician Burnout: Curing the Chaos and Returning Joy to the Practice of Medicine, A Handbook for Physicians and Health Care Leaders, by Paul DeChant, MD, MBA, and Diane Shannon, MD, MPH. Then I suggested that she was right to assume that work environment, organizational culture, and the character of the local practice made a big difference in the environment in which we practice. I suggested that to the long list of books I had already suggested she should look at any of the books on Lean in healthcare written by John Toussaint or find Patty Gabow’s book on Lean transformation of a health system.
She listened and nodded at the right times. I tried to explain just why I thought she should do some reading to ground her understanding of the issues that would be facing her and her generation of caregivers. Our conversation was over before I really gave her a specific answer to her question because just as I was getting to the answer we were all called to enjoy a few toasts and the cutting of a cake.
Later I formulated my answer, and I will share it with you. Perhaps through some channel it will get back to her.
I should have told her that when she got to the part of an interview where they ask whether she had any questions that she would like them to answer, she could select a few questions from the list below being careful to ask only those questions that they did not cover when they were telling her about their organization:
- What is the mission of your organization?
- Do you have team based care?
- Do your teams utilize “huddles”?
- How do the various specialties work together to cover episodes of care?
- What are your Press Ganey/Quality scores?
- How do you approach improving quality ?
- Do you utilize some method of continuous improvement?
- How available to the practice is senior leadership?
- What are the turnover rates for clinicians?
- What is considered beyond RVU numbers in the compensation program?
- Do you have a leadership development program?
These and other questions will allow her to judge whether or not they are moving forward or clinging to the status quo. If she got a chance to walk around and visit with clinicians, she could ask them the same questions. If they didn’t talk about the “Triple Aim” and couldn’t describe their own participation in continuous improvement or efforts to improve quality, and couldn’t succinctly describe the mission that united their practice, move on. She wouldn’t want to train, practice or do an externship for a month in an organization where clinicians would not understand these questions, no matter how famous and prestigious the organization might be.
