In most of my writing and speaking I am talking about what we can do working together at all levels within organizations to achieve the Triple Aim. Opportunities exist at every level of healthcare for the innovation, improvement and transformation that will be required if we are ever going to experience…
Care better than we have ever seen, health better than we have ever known, cost we can all afford, …for every person, every time.
I have passionately advocated for the “I” to “We” transformation as a necessary primary change. At the start of any change process when faced with a vexing problem, one should ask the question, “What part of the problem am I? This may seem paradoxical, but even as future efficiency and effectiveness of care will be dependent on our ability to work together, it is also important to realize that there is a critical interplay between personal and group transformation.
Many of the issues in healthcare that will determine our future seem to be far beyond the control of the individual. As healthcare professionals it is right for us to be informed even about things we can’t change alone. It is right for us to have opinions. And, it is most important for us to ask, “What can I do right here and right now?”.
As TIp O’Neill famously said, “All politics is local”. Don Berwick has advised us that if we want to see true reform in healthcare that achieves the Triple Aim we must think globally but act locally.
Don also has said:
Leaders must emerge who regard themselves as defenders not of organizations but of the underlying purposes that have temporarily created those organizations in their current forms. Leaders will have to be willing to unmake the very organizations they hold in trust. That’s a big job. It requires the kind of courage that is rare among human beings, including organizational leaders.
I am taking Don’s “leader” and expanding the definition to include everyone who cares enough about the future of healthcare to ask themselves, “What can I do?”. Such a person would also realize, as Don implies, that practices and institutions exist for a purpose, and if that purpose is in jeopardy or if it is not being achieved, then change must occur, even if it means individual and institutional transformation.
One of the most frequent complaints that I hear as I move from conversation to conversation with physicians who are friends and colleagues is that they have lost the joy of practice. Burnout is indeed a huge concern. The usual complaint is “This is not what I signed up for!”. George Bernard Shaw had a balanced but rather blunt response that could be applied to such complaints. He advised us that to find true joy in life we must expect to be “used up” by a mighty purpose and not be focused on grievances.
There is the true joy of life; to be used by a purpose recognized by yourself as a mighty one; to be thoroughly worn out before being thrown on the scrap heap; to be a force of nature instead of a feverish, selfish little clod of ailments and grievances complaining that life will not devote itself to making you happy.
I see harmony between the admonitions of O’Neill, Berwick and Shaw. We all have the opportunity to be involved in improving things where we live and work. Leadership is much more about being an example that others notice and follow than about titles and institutional powers. A focus on self almost never leads to anything that has enduring satisfaction. There has never been a better time than this moment in healthcare for those who felt compelled to work in healthcare to have an opportunity to make a difference.
One of my favorite lines from pop music comes from Paul Simon’s brilliant song “Kodachrome”: “When I think back on all the crap I learned in high school, it’s a wonder I can think at all.“. That song came out in 1973 when I was in the middle of my postgraduate “training”. Even then I was aware of the incomplete nature of my preparation for practice. In my head the line became “When I think back on all the crap I learned in medical school, it’s a wonder I can think at all.” When I joined Harvard Community Health Plan in 1975 as a PCP and its cardiologist, the line morphed further into “When I think back on all the crap I learned in medical school, internship, residency and fellowship training, it’s a wonder I can think at all.”
Just as I was ill prepared from my training for the challenges of office practice in an innovative capitated practice of the mid seventies, I hear and see that most physicians and other medical professionals question their preparation for the demanding fast paced and poorly supported realities of practice today where there is never adequate time for the ideal patient interaction. The time that they once had, or always imaged that they should have, to give to their patients is now consumed by time spent on compliance with regulations and doing the documentation of their every action that seems to add little value for anyone other than those in finance.
It is easy to understand their anger, depression and burnout that is associated with such a reality. It may seem preachy and insensitive for me to reference a moralistic quote from Shaw that outlines a path to “true joy” and seems insensitive to pain when it admonishes one “…to be a force of nature instead of a feverish, selfish little clod of ailments and grievances complaining that life will not devote itself to making you happy.” But, your mindset and sense of purpose are your own choice. Your attitude as you face your daily challenges is the only factor over which you have complete control.
I hope that you are blessed with local leadership that understands their responsibility as described in the quote from Don Berwick. I hope that where you work there is enthusiasm for positive change and the work to provide new workflows and a redistribution of responsibilities that will ameliorate burnout and improve your ability to serve patients is well underway. But, if you are in an environment that is still struggling, what can you do?
It may be simple minded and easier to say than to do, but we must hold on to our original sense of mission and purpose. The old children’s song, “This Little Light of Mine”, describes the determination to be a positive force in difficult moments.
This little light of mine, I’m gonna let it shine…
I’m gonna take this light around the world…
I won’t let anyone blow it out, I’m gonna let it shine…
Every day, every day, I’m going to let my little light shine.
To sustain a purpose over the long haul of a career we need a methodology as well as ritual, comradery, and a sense of community to support us. Robert Fulghum postulated in his little book, All I Really Need To Know I Learned in Kindergarten, things do not have to be that hard if we stick to basics that a five year old can understand or sing about. In over forty years of practice I had many difficult days. I am sure that many times I failed to give my patient was needed, but I can say that at some moment before most sessions I paused long enough to think about what was ahead and tried to focus my mind on the challenge ahead and my responsibility. In my reflection I tried to be grateful that I had the opportunity to be of help to someone. I distinctly remember being aware of the joy of working with people I loved and respected. I remember conceptualizing that I needed to try to realize that for the last patient of the day I had the professional responsibility to focus on their need with the same intensity as I brought to the first patient.
My first responsibility was to be present for every patient and to try to understand their concern free of my own issues and fatigue. I was grateful for the support of all my colleagues, no matter their title or responsibility. I was mindful that I had assets that were given to me to use for others and in coordination with my colleagues. I learned that a bad day, a day that I regretted, was not a day when I was asked to do too much, but a day when I failed to keep my needs secondary to the needs of the patient. When I lost sight of the patient’s needs and succumbed to my own self serving strategies I was more likely to provide care that seemed expedient for me but in the long run was neither safe, timely for the patient, an efficient use of resources, or equitable or fair to the patient. In the end I was invariably the looser. When I prepared myself to focus and serve and had the self control to follow my professional instincts, even if it cost me time or required me to triage my day, things were better for everyone, including me.
Looking back I learned some simple rules that unfortunately I did not always follow and those failures are the source of many “do over” desires in retirement:
- Do not hide in the office under the pretense that you are overburdened. Be an active part of what is happening around you.
- “Rely on the kindness of others”. When you do not know an answer or have a task that seems to be more than you can do well for your patient, reach out to colleagues for help.
- Thank people for the help that sustains you.
- Realize that in the end “cutting corners” leads to defects and is ultimately inefficient. Look for what Lean calls “the best least waste way” to get the job done. At a minimum be analytical about what you can control in your own work and practice, what TQM called “quality in daily work life”, even if everyone else seems distracted.
- Listen closely to your patient and try to understand their question or concern in the context of their worldview or perspective and not your own.
- Respectfully bring your concerns to your supervisors and if possible endeavor to be part of the solution and not part of the problem for others.
- Be truthful about everything and to everyone including yourself. Do not attempt to hide your inadequacies, especially from yourself. Be able to say “I do not know, but I will try to find out”.
- Try to understand how you are perceived by others. If they misunderstand you, ask yourself why and what in your presentation or performance leads them to the wrong opinion of you.
The list could be much longer but I will leave it there. My objective in creating my list is to suggest and encourage you to create your own list. My enthusiasm for Lean is because its philosophy and methods carry the spirit of this list from the acts of an individual to a process that can be shared by everyone in the organization. Being an agent of change, making a difference, is not easy work. Being a self interested source of disharmony may be transiently satisfying, but as professionals we should realize that we have chosen to accept the responsibility to try to solve the problems that face us and our patients. Just complaining about how tough the job is will never do anybody any good.
[Note about the picture: The late Dr. Roy Rubin was a beloved colleague. He was a great example of the informal physician leader. In this picture I am sure that Roy is attempting to “sell” an idea to Barry Small who is a talented and devoted administrator.]