During the week after I had given a very positive review of the 27th IHI Forum in my weekly “Healthcare Musings” I received an email comment from one of the regular readers who wrote to me saying that he admired my optimism, but he just did not feel it.
The comment caught me by surprise because although I thoroughly enjoyed the Forum and was energized by the speakers and excellent sessions, I remain painfully aware of the huge problems facing patients, providers, and payers. At times when I survey all that lies ahead in healthcare and experience the sense of loss, anger and frustration that characterizes the emotions of so many who feel like healthcare is getting worse with each passing day, I am reminded of the old saying that I would hear sometimes from my father, “The harder we try, the behinder we get”. It seemed important for me to let my reader know that our expectations were not dissimilar even though our emotional responses to the hard work that lay ahead were perhaps different.
..You read me wrong. I am not optimistic. I am hopeful. Optimism is about false certainty and frequently leads to huge doses of disappointment. It’s like being sure that the Patriots would beat the Giants a few years ago and then have them loose on a fluke catch.
I am hopeful…A hopeful person is looking for small indicators of possible progress. I think that there is a high likelihood of significant short-term disappointment in healthcare and even some possibility of a reversal of the little bit that has been accomplished.
My life’s experience as a kid growing up in a segregated and racist South encourages me. We are still racist but we are not as segregated… Change has occurred, but not perfection. That gives me hope. I do not despair. At the end of the piece I tried to indicate with my comments about McGovern in ‘72 that a collection of healthcare enthusiasts in Orlando who can point to a few small successes does not mean the game has been won…
A friend and former colleague, Diane Gilworth, NP, brought the nuanced difference between optimism and hope to my attention several years ago. In a nutshell, she would always say that she was hopeful about the future, which to her did not mean that what she desired was likely; but it was possible, if she could keep the idea alive. Diane was always reluctant to say that she was optimistic because to her optimism assumes that what is desired is very likely to become a reality. She believes that a hopeful person accepts that there are many bridges to cross, hearts and minds to win, and battles to be survived, if not won, between this moment and the dream. A person with hope is less likely to be deterred by a loss or a setback. The opposite of optimism may be pessimism but there is another choice, hope.
Hopeful people orient themselves to the future as they work in the moment. They live and work for their dreams and hopes as they continue to struggle with how to make the dreams come true. They live a life that is one big heuristic exercise. The spirit and reverence in the song, “We Shall Overcome” and the spirit and expectation in Dr. Martin Luther King’s famous “I Have A Dream” speech come to mind as embodiments of Diane’s concept of hope. In the 1963 “I Have a Dream Speech” Dr. King taught us that we should realize that “Out of a Mountain of Despair, a Stone of Hope“ was possible. Dr. King and his father, Dr. Martin Luther King, Sr., were the co-pastors of the Ebenezer Baptist Church in Atlanta. “Ebenezer” is Hebrew for “stone of hope”. The quote about a mountain of despair becoming the origin of hope is carved into the pedestal of the Martin Luther King, Jr. monument on the National Mall.
Hope endures even in defeat or when it faces obstacles. The desired outcome may be a long shot or perhaps a theoretical impossibility but the dream lives. Hope has patience and expects delays. Hope takes a long view. Dreams plus hope suggests an “audacity” that defies conventional thinking as the title of Barack Obama’s book, The Audacity of Hope, implies.
Whenever the unexpected occurs, the optimistic person who is expecting success that suddenly has evaporated is likely to be devastated by the surprise. The emotional work of processing the grief associated with the loss when victory was expected puts everything that has been accomplished at even greater risk or prevents extraction of any good from the shambles after the disappointment. The hopeful person rolls with the punches and quickly incorporates the lessons of the defeat into the strategy for the next attempt at the summit.
I can list plenty of reasons to be apprehensive about the future. I know that the ACA is constantly under attack. Marco Rubio has successfully created legislation that prevents subsidies to insurers who are facing big losses. I know that consumers and providers are bearing more and more risk even as some insurers and many pharmaceutical companies are enjoying big profits. I know that the the cost of care is rising again. In know that last year we spent over three trillion dollars or over $9500 for every person in the country. I read that hospitals and health systems continue to invest in expensive robotic surgery and other machinery as they continue to compete for volume-based revenue. I know there are a large number of physicians and other clinicians who remain angry or have such a sense of loss that they show up in dissatisfaction surveys as depressed or burned out. These few factors plus a host of others give the continued path of healthcare reform an uncertain future, but I am hopeful.
Perhaps on the list the biggest barrier to the Triple Aim is the emotional state of the professionals that provide care. “Burnout” is a popular topic but it is a symptom and not a disease. We need to fix the root cause issues. As a symptom burnout requires deep reflection and deserves immediate action. Unless we fix the root causes of burnout, it has the potential to undermine much of what has been achieved. The achievements we have experienced could be undermined by a disaffected workforce. These and other concerns were directly addressed by Don Berwick in his Keynote address that closed the 27th Forum.
My belief is that Don ’s speech was as much a call for understanding where we are as it was a call for moving forward. My excitement that was interpreted as optimism was actually a sigh of relief that Don was suggesting a dual process analysis. The first step toward understanding why the “joy of practice” is vulnerable is to look at what has been the basis of the status quo, or a review of from where we have come and why we have not gotten to our goals. We also need to understand why what he called “Era1” and “Era 2” were positive at one moment in time and then their competencies and attitudes became inadequate for these times. After describing where we have been he creates a compelling vision of “Era 3”, the way forward. For those who missed Don’s speech at the IHI let me recommend that you listen to it in its entirety. Within the speech you will hear him call for a renewed movement toward a rearticulated Triple Aim. His speech was a very inspiring potion capable of sustaining a lot of hope as we face the challenges in 2016 to find the way to
Care better than we have ever seen, health better than we have ever known, cost we can all afford, …for every person, every time.
