I envy guitar players. I wish that I was decent plucker of strings. I have been trying to make progress in this area for forty years. Two of my greatest disappointments in life are that I have never become proficient enough with any musical instrument to feel comfortable playing for others, and that despite efforts to learn German, French, Spanish, and Mandarin, I remain monolingual. A few years ago I read in a book, Guitar Zero: The New Musician and the Science of Learning by Gary Marcus, an NYU neiroscientist, that there has never been a professional guitarist of note who began the instrument after age 17. I guess there is little hope that I might be the next Eric Clapton, although I can still learn a few new “licks” if I am willing to make a very focused effort. Old dogs can learn new tricks. It’s just a long and painful process.
Two of my favorite guitar players who can make their instruments talk are Mark Knopfler of the British band Dire Straits and the late Chet Atkins of Nashville and country music. I was delighted when years ago, actually in 1990, they put out an album together that was appropriately titled “Neck and Neck.” There is a lot of whimsy and banter on the album mixed with some great guitar playing. I think that in a few of the cuts from the album you can convince yourself that they are presenting some deep philosophical considerations. If they did not intend a deeper message in the neat, humorous piece, “There Will Be Some Changes Made,” I have gleaned a message for myself to go along with their catchy little tune. I hope that you will click on the link and listen to it before reading further. If time is an issue, here are the words to the first verse.
There’ll Be A Change In The Weather And A Change In The Scene
How Is That?
I’m Gonna Start Wearin’ Leather And Change My Routine
I’ll Wear Dark Glasses Maybe A Toupee
I’ll Get Down And Boogie And Become Risque
I’ll Start Wearin’ Make-Up Like Jackson And Prince
You’ll See Me Ridin’ In My Mercedes Benz
Nobody Wants You When You Just Play Guitar
There’ll Be Some Changes Made Tomorrow
There’ll Be Some Changes Made
The tune and the phrase, “There’lI be some changes made,” has reverberated. through my mind on a frequent basis over the decades since I first heard the tune. It is one of those tunes that become a “earworm” or as I call them “mind worms,” ditties that are triggered by events and become a soundtrack you can’t get out of your mind. With all the changes in healthcare and in my own life you can imagine that I am thinking about Knopfler and Atkins on a frequent basis.
From personal experience it is hard to escape the conclusion that change is a constant reality that we continually disregard or go to great lengths to deny. I am frequently surprised by the obvious physical changes that have occurred to some old friends when I unexpectedly see them after not seeing them for many years. It is hard to accept that in a reciprocal way they may be having the same thoughts about me. Paradoxically, despite our passive denial of change and our surprise when we see it, we frequently talk about making changes that we never make. We make a lot of unfulfilled promises to ourselves and others about getting ahead of the curve of the inevitable or making the changes that will improve some long standing deficiency that needs rectifying. “Transformation” is a word we use a lot as we wallow in the status quo. There seems to be a real connection between broken promises and an inability to initiate change. A recurrent theme in country music is the request for forgiveness with the promise of change and the fact that all will be well going forward.
Even harder than an individual being able to make the personal changes necessary to preserve a relationship during this time of transition in healthcare is for a group of clinicians acting as individuals protecting self interest to make the changes necessary to improve their practice or preserve the mission of their organization. On an almost daily basis I see reports form Becker’s Hospital Review and FierceHealthcare, the “throwaway” online healthcare media outlets, announcing yet another hospital or health system failure. The better alternative to failure for many physician practices and hospitals that could not come together to “transform” themselves in anticipation of change has been to give up autonomy and accept the protection of a for-profit entity like Optim or a larger non-profit system with a stronger market position.
The choice that has faced all healthcare organizations has been to transform themselves in anticipation of external changes in finance and performance requirements that are beyond their control, or to try to continue to do business as usual while cutting programs, looking for “low hanging” choices, for “one time only” savings, or revenue opportunities from selling assets that enable them to post a positive bottom line for another year while waiting for a miracle. In time most everyone learns that you can’t cut your way to success, and that the elusive growth necessary for continued success is not possible while staff is stressed by the sacrifice of critical programs and optimal staffing ratios. The change that they can’t avoid comes down as outright failure or the loss of autonomy.
At strategic retreats and staff meetings we hear bold statements about our positive missions and our commitment to change, but then the work of the next day sucks us dry of the energy necessary to affect those changes. We speak positively about what we will do to prepare, but the status quo is hard to overcome and in the end we rationalize why delay is prudent. We hear speeches about avoiding unintended consequences, and fall victim to the fearmongers. Before we settle the question of what to do, and come to a consensus about what needs to change, and what must be inviolate, the moment of opportunity to direct change or prepare for change passes, and then change does occur, and we have little or no control over the outcome. If we do recognize the inevitability of change then the fall back position is that we will do it later; mañana will be soon enough, or that others will do it for us.
I have a mixed record with change. I see the need for it in others much more clearly than I see it in myself. Not only do I see the need for change in others, including the need for institutional changes, but I can clearly see what the outcome is likely to be if change does not occur. I became a CEO with a clarity in mind of the changes that needed to occur in our practice, and over five and a half years many changes did occur. Some of the moves we made stuck and continue to be an asset to the organization. Other moves did not yield the desired result or faded when I retired and turned over my leadership responsibilities to others. The sum total of the analysis five years after the fact is that just knowing that change is necessary and vigorously trying to affect change is not a guarantee of success. Shakespeare had Cassius say to Brutus,
“The fault, dear Brutus, is not in our stars,
But in ourselves, that we are underlings.”
My experience suggests that Cassius is almost right. External events and forces largely out of our control do create the majority of the challenges that we face. Our responsibility to prepare for those changes that are inevitable does lie within ourselves. My observation, I am sorry to report, is that many healthcare organizations have delayed the transformations that they needed to make to insure their ability to protect their mission, or even the commercial success of their private practices or entrepreneurial concerns. Having rationalized the reasons to delay, or in the aftermath of being unable to sustain the energy to complete the work of transformation, they are now imminent “road kill” in the very competitive and stressed world of healthcare in America in 2018.
What is sad for me is not that individuals will move on from failed organizations to other opportunities. I have no worry about unemployed orthopods or cardiologists. Empty buildings do not worry me. I expect that assets will be purchased, and new owners will redefine the business objectives and decide whether the old concepts of mission will fit the new paradigm dictated by the realities of 2018 and what follows. What I am not so sure about is how those who were still underserved, despite a sense of mission of many fading organizations, will fair in the reorganization of care that will follow the relative reduction of resources from public support that now seems inevitable.
I do not know how the looming changes in the Supreme Court will play out going forward for the underserved. Will a Court with a guaranteed conservative majority for decades to come ever consider access to care as an entitlement? It seems possible that we will discover that the right to determine their own future that women have enjoyed since Roe v. Wade came down 45 years ago will prove to be a passing aberration. Will more and more of the briefly enjoyed benefits of the ACA be deemed an overreach? Our future is uncertain. The gains of the last twenty years in the extension of coverage to children and the underprivileged may become interesting history and not continuing realities.
Perhaps it is just an old man’s reaction to events beyond my control, but as I contemplate what might lie ahead based on the outcome of recent events, a cloud seems to pass between me and my sense of continuing hope in a near term realization of the Triple Aim. I do not see a majority of clinicians or medical institutions looking beyond their short term concerns with a willingness to prepare for better care for everyone at a cost that we can all afford. Those of us who do desire a day when all our citizens can be assured of the healthcare they need, as well as the education and employment opportunities that will allow them to realize their full potential, are swimming against a strong current of resistance that has been created by the fear that any privilege or help offered to someone in need will come at their expense. In that circumstance we may all become the victims of the fate determined by the stars since we have failed to take advantage of the changes we could have made when we had the time and opportunity, and should have known the challenge was coming.
