I frequently reflect on my experiences with my parents. It’s ironic that long after they have gone, I am just catching on to some of the lessons that they tried to teach me. In retrospect, one lesson that I was particularly resistant to receiving seems very appropriate to me these days, and is succinctly expressed by St. Paul in his letter to the Philippians. I can still hear my mother quote scripture as advice that I should consider:
Philippians 4:8 King James Version (KJV)
8 Finally, brethren, whatsoever things are true, whatsoever things are honest, whatsoever things are just, whatsoever things are pure, whatsoever things are lovely, whatsoever things are of good report; if there be any virtue, and if there be any praise, think on these things.
She probably knew that as an adolescent I was frequently thinking about things that fell far from the definition of “pure” and “lovely.” I must admit that at times I have found it more interesting to think about what is not true, what is dishonest, what is not just, what is impure, what is unlovely, what is not of good report, and what lacks virtue. I would argue that there is more art and literature that explores the “dark side” or “R-rated” elements of human behavior than there is about the “G rated,” or upside of human existence. I do note that we love the conflict between the “dark side” and “the force.” It would be unrealistic to think only about sunny days and picnics and ignore the impact and influence of those things we are advised to avoid. Even on “Sesame Street” and “Mr. Rogers’ Neighborhood” the dark side is acknowledged in our attempts to give children the tools to deal with the injustice and cruelties that can even be encountered on the playground and in the classroom when the teacher isn’t looking.
I think my mother and St. Paul were saying that when there is a choice, recognize the negative and focus on the positive. Justice Stewart Potter’s comment on our inability to define or describe the negative in pornography became famous, and will probably be still quoted several hundred years from now. He said that though he could not define pornography, “I know it when I see it.” What is rarely quoted was his conclusion about the movie which was the focus of the lawsuit, “This is not it.”
These days we are bombarded with confusing images and observe circumstances where we even struggle to use Justice Potter’s definition of the unseemly. Ambiguity and complexity make it harder and harder to distinguish what is dishonest, unjust, or impure. Perhaps as a test that we can apply when we are faced with the dilemma of whom to follow or where to place our attention, we should think about the words of Hubert Humphrey that are carved into the walls of Health and Human Services and CMS. Humphrey said:
It was once said that the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped.
I sometimes wonder what is to become of us when I see stadiums and large halls filled by people who gather to cheer purveyors of confusion about what is true, and who owe their success to flaunting their attraction to what a “prude” like my mother might call impure, unlovely, and without virtue at any level. I am sure she would look away from an individual who suggests that progress depends on advancing our personal fortunes and the success of our nation by excluding the vulnerable and withdrawing much of the help we have provided to the less fortunate in our communities for the advantage of paying less on April 15.
My mother quoted scripture in her attempt to arm me to survive in a harsh environment. When I was younger I did not fully understand her intent. I am not sure that I realized that she was encouraging me to avoid as much as possible the darker elements of the world which seemed to be more expedient, and appeared very attractive on the surface, but had no durability, and would become toxic and potentially lethal in my life. From the perspective of almost 75 years, I think that she was really trying to get me to be aware of the world’s hazards and give me the understanding that I would always have a choice about how I would align myself in the world. I certainly see evidence of her wisdom around me all the time. Each of us has a menu of choices everyday. Do we choose the “facts” and try to understand the implications they support, or do we focus on a convenient questioning of evidence, and attempt to distort the evidence to support a more self serving alternative interpretation? How convenient is honesty? Is it impractical to be “honest?” Honesty is a quaint word. Perhaps it has been overemphasized, and is an impediment to the implementation of a desired objective. What are the implications of “just?” Is it a subjective term that must be considered in context? Does it apply to some of us, but becomes less applicable to an individual as they acquire more and more influence?
The King James translation of the Bible was completed in 1611, so it reads more like Shakespeare than a column by David Brooks in the New York Times. I would say that trying to be “of good report” does not translate well in these days of “influencers.” I take it to be about what was once valued as a “reputation.” The critical admonition in the scripture is to try to identify what is positive and sustaining, and focus there. Now as an old man who is no longer an active player, and who has fewer practical ways to apply my mother’s admonitions, I would like to think that she was advocating that I be focused on sustainability of what might be positive, and not a contributor to those things that undermine our collective experience.
Even though my father was the minister, he quoted less scripture than my mother. It’s a weird “origin” story, but my father said that he first noticed my mother in a seminary Bible class. He was attracted to her, and asked her for a date, because of the fact that she was the best student in a course in “Old Testament” scripture in the seminary that they both attended. My father’s forte was extracting stories from literature to emphasize the points he wanted to make in his sermons. I don’t think that he dismissed the importance of scripture, he just knew that the average person looks away and tunes out when Bible verses are thrown at them. We are attracted to stories.
One story that I remember my father using as a literary expression of St. Paul’s advice to “focus on the positive” was Nathaniel Hawthorne’s short story, “The Great Stone Face.” I probably first heard the story as a young child while living in Oklahoma long before I ever lived in New Hampshire, or had ever visited Franconia Notch to see the “great stone face” while it still existed. I am sure that Hawthorne knew of the rock formation, now gone, that is our state symbol, but he does not set the story in a specific location. Click here to read about the collapse of the face in 2003, along with other facts about the ‘face,” and speculations about Hawthorne’s use of the image. Better yet, you can read the story. I will lift a few words from Hawthorne. The story begins:
One afternoon, when the sun was going down, a mother and her little boy sat at the door of their cottage, talking about the Great Stone Face. They had but to lift their eyes, and there it was plainly to be seen, though miles away, with the sunshine brightening all its features.
And what was the Great Stone Face?
Embosomed amongst a family of lofty mountains, there was a valley so spacious that it contained many thousand inhabitants. Some of these good people dwelt in log-huts, with the black forest all around them, on the steep and difficult hill-sides. Others had their homes in comfortable farm-houses, and cultivated the rich soil on the gentle slopes or level surfaces of the valley. Others, again, were congregated into populous villages, where some wild, highland rivulet, tumbling down from its birthplace in the upper mountain region, had been caught and tamed by human cunning, and compelled to turn the machinery of cotton-factories. The inhabitants of this valley, in short, were numerous, and of many modes of life. But all of them, grown people and children, had a kind of familiarity with the Great Stone Face, although some possessed the gift of distinguishing this grand natural phenomenon more perfectly than many of their neighbors.
That sets the scene. A little later in the story Hawthorne tells us about the legend associated with the face.
…[the little boy’s] mother told him a story that her own mother had told to her, when she herself was younger than little Ernest; a story, not of things that were past, but of what was yet to come; a story, nevertheless, so very old, that even the Indians, who formerly inhabited this valley, had heard it from their forefathers, to whom, as they affirmed, it had been murmured by the mountain streams, and whispered by the wind among the tree-tops. The purport was, that, at some future day, a child should be born hereabouts, who was destined to become the greatest and noblest personage of his time, and whose countenance, in manhood, should bear an exact resemblance to the Great Stone Face.
Ernest, a good name for a diligent little boy, was obsessed with the face, and we can presume with the legend. Hawthorne continues:
And Ernest never forgot the story that his mother told him. It was always in his mind, whenever he looked upon the Great Stone Face…In this manner, from a happy yet often pensive child, he grew up to be a mild, quiet, unobtrusive boy, and sun-browned with labor in the fields, but with more intelligence brightening his aspect than is seen in many lads who have been taught at famous schools. Yet Ernest had had no teacher, save only that the Great Stone Face became one to him.
Ernest was not the only one who believed the story. It was a common reality that when someone new and interesting came to the valley, there would be speculation about whether or not the new person was the exceptional individual that would come to them that the legend predicted. There were rich men, famous soldiers, and important politicians who came to the valley. With the arrival of each new impressive visitor, the people asked the same question, is this the person predicted by the Great Stone Face? Meanwhile Ernest was growing up and becoming a valued and respected member of the community. He was disappointed each time the new arrival failed to be the one they all anticipated. As he grew older, people who respected Ernest would ask him, “Is this the one?” At times it seemed as if the new person was a good fit, but on every occasion the final call was, “This is not the one.” Hawthorne describes the man Ernest had come as he pondered the Great Face and the promise it predicted.
By imperceptible degrees, he had become known among the people. Now, as heretofore, he labored for his bread, and was the same simple-hearted man that he had always been. But he had thought and felt so much, he had given so many of the best hours of his life to unworldly hopes for some great good to mankind, that it seemed as though he had been talking with the angels, and had imbibed a portion of their wisdom unawares. It was visible in the calm and well-considered beneficence of his daily life, the quiet stream of which had made a wide green margin all along its course. Not a day passed by, that the world was not the better because this man, humble as he was, had lived. He never stepped aside from his own path, yet would always reach a blessing to his neighbor.
As the years passed, Ernest’s reputation as a good and wise man gained some momentum that went beyond the valley. He had grown old living a life of hard work and charity for those around him. Hawthorne writes:
And Ernest had ceased to be obscure. Unsought for, undesired, had come the fame which so many seek, and made him known in the great world, beyond the limits of the valley in which he had dwelt so quietly. College professors, and even the active men of cities, came from far to see and converse with Ernest; for the report had gone abroad that this simple husbandman had ideas unlike those of other men, not gained from books, but of a higher tone,–a tranquil and familiar majesty, as if he had been talking with the angels as his daily friends. Whether it were sage, statesman, or philanthropist, Ernest received these visitors with the gentle sincerity that had characterized him from boyhood, and spoke freely with them of whatever came uppermost, or lay deepest in his heart or their own. While they talked together, his face would kindle, unawares, and shine upon them, as with a mild evening light. Pensive with the fulness of such discourse, his guests took leave and went their way; and passing up the valley, paused to look at the Great Stone Face, imagining that they had seen its likeness in a human countenance, but could not remember where.
The story of the Stone face spread beyond the vale and a poet wrote an “ode” about the virtues of the Face that Ernest read. He was inspired and said referring to the poet:
“O majestic friend,” he murmured, addressing the Great Stone Face, “is not this man worthy to resemble thee?”
The Face seemed to smile, but answered not a word.
Hawthorne switches the search from Ernest to the poet:
Now it happened that the poet, though he dwelt so far away, had not only heard of Ernest, but had meditated much upon his character, until he deemed nothing so desirable as to meet this man, whose untaught wisdom walked hand in hand with the noble simplicity of his life. One summer morning, therefore, he took passage by the railroad, and, in the decline of the afternoon, alighted from the cars at no great distance from Ernest’s cottage.
The great hotel, which had formerly been the palace of Mr. Gathergold [the rich man who was not the face], was close at hand, but the poet, with his carpet-bag on his arm, inquired at once where Ernest dwelt, and was resolved to be accepted as his guest.
Approaching the door, he there found the good old man, holding a volume in his hand, which alternately he read, and then, with a finger between the leaves, looked lovingly at the Great Stone Face.
“Good evening,” said the poet. “Can you give a traveller a night’s lodging?”
“Willingly,” answered Ernest; and then he added, smiling, “Methinks I never saw the Great Stone Face look so hospitably at a stranger.”
That’s when the tables turned. The poet and Ernest talk. The poet reveals that his poems describe the virtues of a man like Ernest images to be associated with the Face, but assures Ernest that he is not the one. There is to be a town meeting that evening and Ernest invites the poet to join him at the gathering. During the gathering, Ernest speaks. I’ll let Hawthorne finish his story:
At that moment, in sympathy with a thought which he was about to utter, the face of Ernest assumed a grandeur of expression, so imbued with benevolence, that the poet, by an irresistible impulse, threw his arms aloft and shouted,”Behold! Behold! Ernest is himself the likeness of the Great Stone Face!”
Then all the people looked, and saw that what the deep-sighted poet said was true. The prophecy was fulfilled. But Ernest, having finished what he had to say, took the poet’s arm, and walked slowly homeward, still hoping that some wiser and better man than himself would by and by appear, bearing a resemblance to the GREAT STONE FACE.
To state the obvious, my father used Hawthorne’s story to give us a hook on which to hang St. Paul’s advice. We are affected and our lives are influenced by what we admire, what we anticipate, and what we think and do. I think this story and its philosophy is very important at several levels at this moment in our shared experience. I will let you draw your own conclusions about the political implications, and what it might imply for the the goal of how best to make America great. I will just say we are impacted by those whom we follow and emulate. A little bit of the positive or the negative is passed on to us from every encounter.
I used this story several years ago when I was writing primarily to my colleagues. What we think about does impact our outcomes. If we are trying to emulate the spirit of a Frances Peabody or apply the principles offered by Don Berwick, the results will be different from what we might expect if we are focused solely on the onerous aspects of our professional responsibilities. When we think about our professional opportunities there is much to ponder that is true, honest, just, pure, and lovely. Patients desire care from those who are of good report. As we develop our responses to the challenges that constitute the substance of the healthcare debate, I am sure there is merit in a focus on what has virtue and is worthy of praise.
I have facetiously said that Crossing the Quality Chasm has value for our instruction about what we should emulate that is like scripture. The spirit of the principles of the ACA were modeled on principles enunciated in Crossing the Quality Chasm. The Triple Aim brings an image of heavenly justice and health to earth. How do we look past our personal frustrations and put the patient first? Is it possible that if we could come together in a way that reduces the cost of care would that make universal coverage more feasible?
I think our challenges can be reduced to just how effectively we bring quality to the care we provide everyone. We need to speak vigorously to the virtues of care that are patient centered, safe, timely, efficient, effect, and equitable. Those qualities are true, honest, just, pure, and lovely. They define healthcare virtue, and the effort to live up to the clinical realities they describe are definitely worthy of praise. Like Ernest, we will become like what we think about, and what concerns us. In my heart of hearts, I always knew Momma was right, even though I had to test the boundaries.
