More is Magic

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I travel through daily life protected by a veil masking the unforeseen that might befall me and my loved ones. Several years ago, the veil temporarily lifted during a single week in December when I experienced a vision problem in my lone good eye, my wife underwent surgery and my daughter, an avid cyclist, sustained a concussion (yes, she was wearing a helmet) requiring a two day hospitalization.

Unprotected, I longed to prevent and control the occurrence of harmful circumstances for me and my loved ones. Throughout history, humans felt this same desire expressed through incantations, prayer, sacrifices, ritual dances, magic and superstitions to ward off the “evil eye.” In healthcare today, this universal need emerges as magical beliefs that “more is better” and “knowledge is power.”

Examples include:

Knowledge is power; uncertainty can be eliminated. Surely more tests lead to greater certainty

Often, multiple testing generates even more uncertainty through “false positives” (an abnormal result when no abnormality exists) or “false negatives” (a normal result despite an abnormality).

An explanation exists as to why I feel this way.

Sometimes with a medical evaluation, uncertainty reins supreme. The probability of developing conditions such as specific cancers, diabetes and heart disease increases with risk factors related to family history, smoking or obesity. Yet, people may succumb to illness for completely unknown reasons. Additionally, symptoms and suffering may exist that modern medicine cannot explain.

Early detection of problems leads to cures.

Although sometimes true, early detection provides no guarantee of improved prognosis.

Don’t just stand there, do something!

Treatments can be ineffective or produce deleterious side effects eroding the quality of life. “Watchful waiting” may at times remain the best course.

As health care tackles reducing unnecessary services (medical services without obvious benefit and with the potential to do more harm than good) we must begin with compassion toward ourselves, patients and their families who, in an attempt to ward off harm, cling to the deep seated magical illusion that “more is better.”

Please use comments below to discuss how you personally and professionally deal with the longing to prevent the occurrence of harmful events.

Health Care is Different

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During a family health crisis I noticed we were  hypersensitive to every interaction. We hung on each word and reacted to tone of voice or averted eyes. Would we have reacted this way in a non‐health care setting such as Target or the grocery store? Of course not, as we would not be feeling anxious or vulnerable in a checkout line. Essentially, as patient and family member, we needed compassion and caring with every single human interaction‐ from clinicians to nurses to check‐in to phone calls to nurse’s aides to lab technicians to environmental services team members.

Sitting at a hospital bedside, I reflected on our longing for compassion and caring as I watched team members perform myriad essential tasks (e.g. validating  identity, bar code medication administration, checking drug sensitivities, handling blood products, documenting in the computer) within the urgent multi‐tasking environment of modern health care. As a physician and CEO, I knew these tasks involve life and death decisions and drive safety and great clinical outcomes.

As a family member and CEO, I marveled at how health care is distinct from other service sector operations. In health care, patients/families, CEO’s and each of us as team members expect a two dimensional approach to care. We ask team members to provide compassionate human connection as well as reliable expertise in managing life and death decisions. I wondered whether another industry held the same simultaneous expectations within both dimensions. I could not think of one.

The airline industry involves life and death tasks. But pilots barricade themselves behind locked doors, avoiding requests from passengers. Flight attendants play a role in managing safety during a crisis but averting disaster does not directly hinge on their performance. And we expect courtesy of flight attendants, not compassion. The role of air traffic control and maintenance are also outside the scope of passenger interaction.

Personnel on the flight deck of aircraft carriers manage life and death decisions but expect crisp, task oriented communication from each other‐ not compassion.

The auto industry involves life and death tasks but these take place in the design and manufacturing phase far away from consumers. And we don’t expect compassion from auto engineers and assembly line workers.

Police interact with us in life and death situations, but we expect courtesy, not compassion. (Perhaps crime victims expect compassion but unlike patients/families they can’t take their business elsewhere if they are not satisfied with the level of compassion)

The nuclear energy industry entails the performance of life and death tasks. Yet, consumers sit comfortably in their homes separated from the technicians performing these tasks.

I know of trends to run hospitals like Disney or Ritz-Carlton. But customers don’t feel vulnerable when visiting Disney or sleeping in a Ritz-Carlton bed. We expect courtesy, not deep compassion at Disney and the Ritz. And Disney and the Ritz do not involve life and death decisions in a highly complex, ever changing and uncertain environment.

While health care can learn from all sectors, it is different. We expect  safe, reliable, outstanding professional care in the performance of life and death tasks and compassionate human connections.

Use comments below to describe your views about the difference between health care and other industries or how you approach simultaneously performing life and death tasks while interacting with compassion and caring.

Seeing Inside

inside of tree

In the welcome page to my blog site, I write the following: “moving from youthful illusions of invulnerability to embracing the fullness of loss and love, I realized when I could be still, medicine and leadership brought me back to my starting point- the shared human condition”.

Crabbit Old Woman, an initially anonymous poem later attributed to Phyllis McCormack, paints a poignant image of our shared human condition. I inserted my name, David, where the word “nurse” appears in the original text. This facilitates the old woman speaking directly to me but more importantly it transforms the old woman into me. I encourage you to substitute your name as you read the poem. The poem touches on the person inside each patient; more importantly, it connects us with our shared human condition—the person inside experiencing joy, change and loss.


An Old Lady’s Poem

What do you see, David, what do you see?
What are you thinking when you’re looking at me?
A crabby old woman, not very wise,
Uncertain of habit, with faraway eyes?
Who dribbles her food and makes no reply
When you say in a loud voice, “I do wish you’d try!”
Who seems not to notice the things that you do,
And forever is losing a stocking or shoe…..
Who, resisting or not, lets you do as you will,
With bathing and feeding, the long day to fill….
Is that what you’re thinking? Is that what you see?
Then open your eyes, David; you’re not looking at me.

I’ll tell you who I am as I sit here so still,
As I do at your bidding, as I eat at your will.
I’m a small child of ten …with a father and mother,
Brothers and sisters, who love one another.
A young girl of sixteen, with wings on her feet,
Dreaming that soon now a lover she’ll meet.
A bride soon at twenty — my heart gives a leap,
Remembering the vows that I promised to keep.
At twenty-five now, I have young of my own,
Who need me to guide and a secure happy home.
A woman of thirty, my young now grown fast,
Bound to each other with ties that should last.
At forty, my young sons have grown and are gone,
But my man’s beside me to see I don’t mourn.
At fifty once more, babies play round my knee,
Again we know children, my loved one and me.
Dark days are upon me, my husband is dead;
I look at the future, I shudder with dread.
For my young are all rearing young of their own,
And I think of the years and the love that I’ve known.

I’m now an old woman …and nature is cruel;
‘Tis jest to make old age look like a fool.
The body, it crumbles, grace and vigor depart,
There is now a stone where I once had a heart.
But inside this old carcass a young girl still dwells,
And now and again my battered heart swells.
I remember the joys, I remember the pain,
And I’m loving and living life over again.
I think of the years ….all too few, gone too fast,
And accept the stark fact that nothing can last.

So open your eyes, David, open and see,
…Not a crabby old woman; look closer …see ME!

Use comments below to describe how this poem helps you connect with our shared humanity.

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Anything Worth Doing is Worth Overdoing

“ Anything (huff) worth (puff) doing (heavy breath) is worth (wheeze) overdoing (gasp).” I heard these words for the first time at the Chequamegon Fat Tire Festival, an off­road bicycle race in Wisconsin. A cyclist, a man in his 60’s, uttered the phrase as he passed me. I was in my late thirties, and felt humbled and inspired as the older rider overtook me. The words captured what I was unintentionally doing with my riding and running.

If running a 10k was admirable, then a marathon was superior. If riding 50 miles was good, then certainly a century ride (100 miles) was better. If exercising at a heart rate of 145 was recommended, then 155 was preferred. If eating oat bran for breakfast (a 1980’s fad) lowered cholesterol, then a diet consisting of nothing but oat bran would really do the trick (it did—my total cholesterol went to 120 without the use of medications).

If Nordic walking 2 miles a day was healthy, then increasing to 6 miles a day over the course of a few weeks had to be better. I assumed the instructions to increase mileage over a minimum of 8 weeks applied to other people, but certainly not to me. This arrogant assumption resulted in a stress fracture of my hip.

The fracture forced me to slow down and ponder the “more is better” story that I told myself, and that contributed to the “overuse” injury. I realized over the years I used exercise to attempt to out ­run, out­ bike, and, most recently, out­ walk the reality that I was not immune to the passage of time and the randomness of events. Like many of us, I felt restless discomfort and a lack of control in simply living with this reality. Instead, I preferred constant movement, compared to the sublime but frightening stillness of seeing life as it is. I used exercise to avoid the unavoidable: life is uncertain and change, aging and death are inevitable. I know other people who use frantic schedules or acquire possessions to avoid sitting with this truth.

And how often do we use prevention and treatment narratives to try to outrun the reality that we cannot make our lives and the lives of our loved ones completely safe? How often do physicians try to avoid the necessary pain of diagnostic uncertainty by ordering more and more tests that at times generate additional uncertainty of incidental abnormalities or false positives?

I overhear the “more is better” illusion in the snippets of healthcare conversations that permeate restaurants, coffee shops and walking trails. Recent examples include the following:

“There must be a reason I am tired. I only sleep 5 hours per night, but other people do fine with 4 hours. I am going to ask my doctor for another battery of tests.”

“Food labels contain only the minimum daily requirements of vitamins. I take megadoses to be healthy.”

“I know my cholesterol is normal, but I like to get it checked every 6 months—just in case. You know, you can’t be too careful.”

And in my case, the “more is better” approach to exercising created the illusion of control over my health but the reality of a stress fracture.

What do you do to outrun life as it is?