An “Interested Reader “ and friend recently sent me a eulogy that he delivered at his father-in-law’s funeral. Let me give it to you to read, and then invite you to think with me about Don Berwick’s recent call for Era 3, the “Moral Era” of healthcare.
I have been thinking about my nearly 50-year long relationship with Granddad, …Charlie to work colleagues, friends and neighbors. He brings to mind Churchill’s snarky comment about Clement Attlee; “He was a modest man, with much to be modest about.” Granddad was a modest man with much to be proud of, though he was never boastful. As you all know, after leaving the University …(where he met Grandmother, who was training to be a nurse), he served as a naval pilot …He returned home to raise a family with Grandmother and work as a schoolteacher, coach and administrator in public schools in several Midwestern towns. He then returned to school in his 30s ….to earn an engineering degree, after which he worked at xxx and where Grandmother worked as the head nurse (no goldbricking in those factories!).
Granddad and Grandmother had a traditional understanding of their marriage (e.g., he told me that Grandmother’s salary was “the frosting on the cake,” though it was not in fact much less than his), but it was an unusual one for the time and place. She worked, mainly full time, and he supported her by helping at home to a far greater extent than most men of his generation or mine. He was active in his church and community, sang in a barbershop quartet, took endless numbers of photographs and slides, and raised roses. In retirement, he learned to make silver jewelry, (Mom wears one of his bracelets), became a volunteer tax-preparer for poor folks, and, with Grandmother, helped…[everyone in the family].
He was an exemplar of the strong values he learned growing up on …[a] farm in his staunch commitment to family, work, community and country.
So, for the lessons he taught me: these are what I have learned from watching him over the years. Granddad taught by example, not by speeches.
- Do not gossip, or say unkind things about anyone.
- In your family work and community, do what is expected of you and more, without complaint and without expectation of reward or praise.
- Be patient with those around you.
- Greet everyone you meet with a smile and a kind word.
- Find interests that give you and those around you pleasure, like his singing, roses, photography and jewelry making.
- Give unconditional love to your family, rejoicing in their happiness and success and offering support and encouragement during the hard times.
- Don’t complain. Granddad bore the discomforts and indignities of his last years with great courage and grace.
The best way to honor this kind, gentle and unassuming man is to try to live one’s life in accordance with these lessons that can be drawn from his. It’s much harder than it looks! In recent years, I have tried, and generally failed, to do so but I am a better person for making the effort.
With much love, [Interested Reader]
It was Charlie’s generation and the generation of my parents that survived the depression, and then brought World War II to a rather quick and decisive conclusion. It was their generation that labored to produce the economic prosperity that we remember so fondly from the middle of the last century. It was from within this generation and a few before them that David Brooks found the examples of character that he celebrated in his book, The Road to Character.
When I read the list and my friend’s confession that he had failed in his attempt to wear the suit of virtues that his father-in-law modeled, I remembered how I failed my mother who was Charlie’s contemporary. First on her list was:
Do not gossip, or say unkind things about anyone.
Right out of the blocks I was down. Mom’s phrase was, “Gene, if you can’t say anything good about someone, don’t say anything at all.” Many times in my life I have been capable of saying things about friends, family and colleagues, not to mention competitors, that I have regretted and would not want to say to their face.
As I reflect the issues of practice in our complex world, I realize that a revival of character as exemplified by role models like Charlie and Margaret Jane (my mother) may be a necessary prerequisite to achieving:
Care better than we’ve seen, health better than we’ve ever known, cost we can afford…for every person, every time.
Those virtues are foundational for efficient, humane organizations where careers can thrive and where patients and families are treated with the professionalism and efficiency that we all deserve. These same virtues are necessary for continuous improvement or organizational transformation. The relational contracts upon which continued success in transformed organization depends are built on trust and nothing supports trust like virtue. I was reminded of Don Berwick’s speech at the IHI last year, “The Moral Test”. Click here to find my commentary on the speech written last January.
The speech is analyzed in an excellent article from the Advisory Board consulting company entitled “Berwick: The 9 changes needed to make healthcare more ‘moral’”.
In their article they note:
A clash between health care’s two eras of “professional dominance” and “accountability and market theory” is harming clinicians, communities, and patients—but there’s a better way forward, [according to] former CMS administrator Donald Berwick…
Era 1: ‘the ascendancy’
Medicine’s first era—dating “back to Hippocrates” in ancient Greece—”was the ascendency of the profession,” …It was grounded in a belief that the profession “has special knowledge” [that] is “inaccessible to laity,” results in good, and “will self-regulate.” As a result, society provided those who practiced medicine with a rare privilege, …”the authority to judge the quality of its own work.”
But those foundations were shaken when researchers began to examine the field and found “enormous unexplained variation in practice, rates of injury from errors in care high enough to make health care a public health menace, indignities, injustice related to race and social class, … profiteering,” and wasteful spending…
Era 2: ‘the present’
[the ultimate failures of era1]… helped spawn medicine’s second era, whose backers “believe in accountability, scrutiny, measurement, incentives, and markets” through “the manipulation of contingencies: rewards, punishments, and pay for performance,” …But the conflict between the first era’s “romance of professional autonomy” and the second era’s accountability tools have put the morale of clinicians in jeopardy…”Physicians, other clinicians, and many health care managers feel angry, misunderstood, and over controlled. Payers, governments, and consumer groups feel suspicious, resisted, and often helpless.” Both sides, … dig in further, resulting in “immense resources [being] diverted from the crucial and difficult enterprise of re-creating care.”
Era 3: ‘the moral era’
… it is time for medicine’s third era—… “the moral era”—”guided by updated beliefs that reject both the protectionism of era 1 and the reductionism of era 2.”
The new era will require at least nine changes to medicine:
- Reducing mandatory measurement. Much of the current era’s mandatory measurement is “useless,” … wasting valuable time and money for providers….payers should work with the National Quality Forum to reduce the volume and total cost of mandatory measurement by 50 percent within three years and by 75 percent within six years. “The aim should be to measure only what matters, and mainly for learning,”…
- Stopping complex individual incentives. For most, “if not all,” clinicians,…the best form of compensation to promote value-based care is “salaried practice in patient-focused organizations.” ….payers and healthcare organizations should halt complicated incentive programs for individual clinicians and …CMS “should confine value-based payment models for clinicians to large groups.”
- Shifting the business strategy from revenue to quality. Improving quality is “a better, more sustainable route to financial success” than focusing on maximizing revenue… To that end, …health care leaders need to view “mastering the theory and methods of improvement as a core competence,” while payers need to delink reimbursement rates from input metrics that “are not associated with quality and drive volume constantly upward.” [For me this is the core strategy. It is the industry equivalent of a moon shoot.]
- Giving up ‘professional prerogative’ when it harms the team. “The most important question a modern professional can ask,” …”is not ‘What do I do?’ but ‘What am I part of?'” … young doctors should be trained to value citizenship over professional prerogative, and “physician guilds should reconsider their self-protective rhetoric and policies.” [For me this represents the great challenge to clinicians of adaptive change]
- Using improvement science. “Four decades into the quality movement,” …”few in health care have studied the work of Deming, can recognize a process control chart, or have mastered the power of tests (‘plan-do-study-act’ cycles) as tools for substantial improvement.” Improvement science, …must become a core part of preparing clinicians and managers. [If the core strategy is moving from a finance to a quality focus, this is the core tactic to achieve that strategy.]
- Ensuring complete transparency. The rule for transparency,…should be, “Anything professionals know about their work, the people and communities they serve can know, too, without delay, cost, or smokescreens.” …Congress, insurers, and regulators should take steps to ease data sharing, and that states should adapt all-payer claims databases.
- Protecting civility. “The rhetoric of era 1 can slide into self-importance; that of era 2, into the tone of a sports arena,” …”Neither supports authentic dialogue. Medicine should not … substitute accusation for conversation.” [Mother and Charlie would cast several votes for this one.]
- Hearing the voices of patients and families. Further empowering patients and families to shape their care will improve care and lower costs,… “Clinicians, and those who train them, should learn how to ask less, ‘What is the matter with you?’ and more, ‘What matters to you?’ [Dr. Anthony DiGioia votes enthusiastically for this one.]
- Rejecting greed. …the industry has “slipped into tolerance of greed,” from high drug costs to “profiteering physicians.” …stakeholders need to “define and promulgate a new set of forceful principles for ‘fair profit and fair pricing,’ with severe consequences for violators.” … professional organizations and academic medical centers…[must] “articulate, model, and fiercely protect moral values intolerant of individual or institutional greed in healthcare” [I can remember cringing when I heard Don say this one. There was a sense of unease across the five thousand in the audience who were with him up till this moment. Perhaps, sadly, it is a bridge too far for many to consider. At a minimum, it was jarring and uncomfortable as it hit home to all of us in a very personal way.]
We have responded to leaders who demonstrate character and call on our character as they challenge us to virtuously engage. Some of those who teach us and call us to service, like a Jack Kennedy or a Don Berwick, are known in history or are well known in the moment, but many more who work hard to deliver their best in practice every day are unknown except to their patients, colleagues and family members. As a nation we have survived because of our ability to sacrifice and to work virtuously together both with those we know and with those we meet who come from afar to join our effort to achieve and maintain greatness.
Together we have made progress toward the shared objectives of health, happiness, safety and prosperity for all. The path to the Triple Aim, will be easier to travel together, if we rededicate ourselves to renewed and redefined virtues and agree on a new set of shared moral objectives. The Triple Aim is quite possible, if we personally work hard to develop within ourselves the virtues that Charlie demonstrated, and then together seek to move into the third era of healthcare that Don envisions.
