Classic Cars, Classic People – First Do No Harm

my favorite car at the show

Last Saturday I was excited to attend the 33rd Annual Winter Park All British Car Show. As you know, I’ve recently jumped into the old car hobby, purchasing a 1967 Triumph TR4A almost a year ago. Having little experience in auto mechanics, especially about the vehicles of 50 years ago, I’ve had a lot to learn. Fortunately, the members of the local Triumph and British car clubs have been welcoming and helpful. They encouraged me to enter the show.

I’m glad I did. The weather was fantastic, leading to a great turnout of cars and people. My car didn’t win any prizes but I made some new friends, had many nice conversations, and learned a lot more about my particular model and old cars in general. Or should I say “classic cars?” Most owners (certainly the ones showing their cars) cherish their vehicles and are very careful to treat and maintain them well. I’m trying to do the same.

twins!

Naturally, I had several conversations about best practices in maintenance and repair. Sharing a story of mine about a simple attempt to replace a light bulb – which led to a broken lens, disintegration of old rubber fittings, and a failed electrical connection – elicited knowing smiles.   The worst part was the light bulb had been working! These cars are fragile, and since then I’ve adopted a cautious attitude to any elective repairs.

Among the group, there seemed to be two schools of thought. One, like mine, was “be cautions;” just do the minimum for safety and reliability; don’t push the limit. Or in doctor language, first do no harm. The second is “make it perfect.” Any mechanical part that’s not quite right gets fixed or replaced. No job is too big. That works fine with classic cars (with enough money and expert help) and these are the ones that win the prizes.

It doesn’t work so well for “classic people.” Like cars, as we age, we often get more fragile. And things break or become blemished. But repair isn’t a simple mechanical matter. It depends on our innate biological mechanisms, mechanisms that degrade with advancing years. Sooner or later we die. It’s good to remember that.

a nice line up of MG TDs

Too often in healthcare we approach classic people as if they were easily repairable, or as if every issue should be fixed, made perfect. And it’s not just physicians; many patients think like that too. Let’s be more careful. Let’s keep the big picture in mind. Fragility and finiteness should be part of our calculation. What’s required for safety and reliability? What are the risks of any proposed “repair?” Like my light bulb story, we can always make things worse.

My car is 51 years old. I just turned 57. Does that make me a “classic person?” Regardless, I’m looking for doctors with philosophy number one. If you’re a classic person, I recommend you do the same.

Take care,

Pete

my car

B-17 hood ornament

 

 

 

 

 

 

 

Humbled by the Peanut Butter Jar

I love this stuff!

I love this stuff!

A few years ago I realized that I had the beginnings of generalized osteoarthritis – low back pain, neck pain and crepitus, creaky knees, and mild intermittent discomfort at the base of my thumbs. But, by my nature, I don’t quit and so nothing slowed me down really, until last summer when I tore the medial meniscus in my right knee (which can be a complication of arthritis). Since then I’ve stopped running.  The knee feels pretty good now and I’m enjoying walking with Sharon three times a week instead. And I’ve been pleasantly surprised by the improvement in my lumbar and cervical pain too. The new normal seemed to be okay.

But now my left thumb is acting up. I’ve been experiencing pain and tenderness at the base of my thumb for about a month, and it’s becoming increasingly troublesome.   It bothers me throughout the day, is a little worse at night, and hurts with direct pressure (like when doing pushups), gripping and turning motions, or if my thumb gets tugged or pulled away from my hand. So, as is my nature, I’ve been pressing on without limiting my activity or pursuing treatment. How serious could it be anyway?

Well… I had difficulty opening a fresh jar of peanut butter recently because it hurt too much. Whoa!  This is serious.   Without peanut butter (the crunchy kind of course) is life worth living? I love peanut butter! Fortunately I managed through the crisis, and my serum peanut butter levels have remained high.

All joking aside, it was humbling to have trouble with a simple jar. It was a wake up call of sorts; I can see the possibility of being seriously limited by arthritis in the future. Time to do something about it. I don’t think I need to see a doctor yet, but I’ve decided to try supplementing with glucosamine, and I’m thinking about a splint at night. We will see how it goes. If it continues to worsen it will be time to see a physician.

Beyond the thumb, the episode also has me reflecting on my “nature.” An internal drive and intensity makes it hard for me to slow down or accept weakness. Perhaps it’s a “man thing” or maybe it’s just me. I’m also generally conservative and skeptical of healthcare and I tend to avoid medicines and doctors even when they might be helpful. It’s a form of pride no doubt, and I need to work on that. Perhaps you do too. Illness and death will humble us all eventually. Better to get humble in advance.

Workplace Wellness Programs and Respect for Our Humanity

file0001229562991Workplace wellness is a big issue these days. Employers large and small are designing wellness programs to (hopefully) produce healthier employees. I wish I could say that it’s because the top leaders love and care for their employees as people, and in some cases that is certainly true, but what’s motivating most is a desire to maintain or increase profitability by decreasing absenteeism and presenteeism, increasing productivity, and lowering the cost of the employee healthcare benefit.

Increasing profit is a worthy goal as long as it doesn’t come at the expense of treating people humanely; that’s worth a little thought as we business leaders design our wellness programs. In my mind there are three main categories of wellness programs which I’ll term: a) the Public Health approach, b) Carrots & Sticks, and c) Inspire & Invite. In practice, employers typically blend these styles into their own unique program. I believe it’s important to understand each of these methods in order to design an integrated and human-honoring plan.

Public Health

The Public Health approach involves making changes to the physical environment or culture (emotional and behavioral environment) that affect all employees. These broad programs or policies can be either positive (or additions) or negative (or removals). An example might be eliminating candy machines and fried or high-calorie food from the cafeteria. Many firms also have instituted non-smoking campuses. Creating a positive and vibrant “culture of health” is a goal for some employers. In my view these examples are reasonable approaches that can positively shape employee behavior at least while they’re at work.

The counter argument is that such policies suppress or reduce “choices” and that choice is a good thing. This is a valid argument, but we know that people are not always able to make good choices. The Christian worldview suggests that human beings find it nearly impossible to make good choices most of the time; our national problem with lifestyle illness supports that view. Yes, people do need to be protected from themselves (at least a little bit), and it’s not wrong to be somewhat paternalistic in our designing our wellness programs if it comes from our love of and respect for people.

Naturally one can go too far in this direction and restrict liberty in the name of wellness. Banning all possession of candy or fast food on the campus might be an example.   “Food police” are not humane. Similarly a policy of not hiring smokers or creation of a workplace culture where athletics or fitness is glorified and unfit or overweight individuals are shamed does not reflect love and concern for people.

Carrots & Sticks

In a Carrots & Sticks model the employer provides incentives or penalties for certain health behaviors or outcomes. You’ve probably seen many of these. An insurance surcharge for employees who smoke; payments or deductible reductions for employees hitting body mass index targets or completing a health risk assessment are examples. In my view these are also reasonable steps as long as they are accompanied practical tools and help (say health coaching) to enable employees to change, that is, to get the carrot and avoid the stick.

As with the Public Health approach, Carrots & Sticks can be taken too far. Employers may design many-step or many-outcome plans integrated with their insurance benefit and triggering various copayment reductions and other benefit enhancements or penalties. These may continue to increase in complexity or materially change from year to year. Beyond a certain point, I think programs of this type can become attempts to micromanage employees’ lives. Micromanagement does not honor our nature as individual agents. People hate it at work, how much more do they hate it when it involves their personal lives?

Used sparingly, Carrots & Sticks can be good as a stimulus for people to try something new. Sometimes people could use a little help getting ”unstuck” from bad habits. Perhaps that one-time incentive to run a 5K turns a couple of participants into dedicated runners afterwards, or that mandatory health and wellness class gives an individual a nudge towards healthy eating that grows over time. In my case, it was only after joining the Navy (which uses a very big stick approach) that I began to run and found that I actually enjoyed running.

Inspire & Invite

This is pretty simple; people need inspiration, and are inspired by the stories of others and visions for themselves. Business leaders get this as it relates to their business; they create a compelling company vision, and they tell inspirational stories of customer service, overcoming operational challenges, or other business success. They’re trying to inspire and invite employees to contribute to achieving the corporate vision.

How about doing the same for them as individuals? Help them see that they can be well. Find employees to share stories of personal health problems and success in overcoming them. Invite employees to tackle their own health challenges and provide the resources to do so. That’s Inspire & Invite. Personally, and even though at any given time most employees may not be ready to change, this is my favorite approach because it’s about connecting with others on a deep emotional, and even spiritual, level.

Can you take Inspire & Invite too far? Maybe. If it becomes overbearing and creates a culture where people feel hassled, that’s too far. But I haven’t seen that yet. My perception is that employers tend to overdo the Public Health approach and Carrots & Sticks while limiting Inspire & Invite which seems by comparison too “soft” and perhaps less measurable.  Yet it’s exactly this “softness” that people require to truly change on the inside.

Let’s remember what it means to be human while we develop workplace wellness programs for the other humans that we call our employees.

Finding Rest in the Work

Want to stay on top of the food chain? Better get your rest.

Want to stay on top of the food chain? Better get your rest.

I’ve been invited to speak for a few minutes on the topic of rest at an internal leadership meeting later this week. This is a little more challenging than it may seem, because at Florida Hospital, rest is integral to our whole-person philosophy of health and wellness, and the weekly Sabbath day of rest and worship is a key feature of Seventh Day Adventism. So pretty much everyone there will be well versed in the necessity and importance of resting from our labor. But of course, knowing isn’t doing.

How many business leaders actually get the rest they need? It’s pretty common for leaders at all levels to work long hours (or “around the clock” via technology) and use very few vacation days. I think it’s a combination of our personalities; often we’re overachievers, and the importance of our job roles. Job wise, leaders have business-critical responsibilities – that’s what it means to be a leader.

The healthcare leaders to whom I’ll be speaking, whether over a department, campus or other business unit, are all responsible for achieving certain clinical and financial goals. These outcomes matter to patients and to the organization. Although we all need to sleep, as leaders, our business responsibilities are 24/7. None of us will be able to negotiate a 25% reduction in our goals because we plan to take a week’s vacation this month. Rest or no rest, we own our results.

Together, an overachiever-type personality and a weighty, outcomes-based job responsibility can lead to a pretty stressful life. We may feel constant pressure to produce, becoming micromanagers or control freaks trying to guarantee results. We may find ourselves unable to truly relax, stressing out about work even when we’re off. Consequently we work longer and harder and ignore our need for rest. We simply don’t have the luxury.

And we won’t get the luxury either – unless we change our attitude. A mental shift has to come first. In order to rest from our work, we need to be able to rest in our work. We need a little less intensity, less pressure and a lighter feeling to our responsibility. I don’t mean less actual responsibility or a reduced job role, but rather a different feeling in the role. Here’s how we can get it.

First, we need to remember that healthcare is a “team sport.” Lets’ invest in our peer team and the teams we manage to build their capabilities and trust them with our responsibilities. We, as individuals, don’t have to have all the answers as long as the team can produce them. And we don’t have to do all the work ourselves either. We can ask for help from peers and delegate appropriately to subordinates. The better our teams, the more we can rest in the work.

Even more importantly, let’s remember that we are quite small and that God is big. We can trust in God’s provision. Despite our illusions of importance, we’re not in control of much of anything, but God controls everything. And God provides, and he provides generously. Let’s seek God’s will in our work, and rest in his provision. Our labor is important, but it’s not all-important. The more confidence we have in God, the less worry we’ll have about making everything happen ourselves, allowing us to find rest in the work.

I confess to be a work in progress here, and this post and the talk are as much for me as anyone. Nevertheless, I’m convinced that by trusting God and trusting the team, we can find rest in even the weightiest of responsibilities.   (And perhaps we can use all of our vacation days too.)

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Unless the Lord builds the house, the builders labor in vain.
Unless the Lord watches over the city, the guards stand watch in vain.
In vain you rise early and stay up late, toiling for food to eat – for he grants sleep to those he loves.
   Psalm 127:1-2

No Business is an Island

m1The healthcare business grows increasingly complex with each new law, regulation, and rule – not to mention advances in actual healthcare. There is so much happening, so many moving parts, that it’s hard to apprehend the whole. In a large provider system like the one in which I work, no single individual can really grasp the overall business operations in any significant detail, and no one organization can manage without relying on many others for specialized assistance.

These relationships have become critically important to many organizations. When a vendor doesn’t deliver a quality product or service on time and on budget, the organization’s business is at risk, perhaps serious risk. Naturally, managers track their vendor’s performance closely and insist on improvement when appropriate. But just how does one go about getting improvement from a vendor? It’s not that easy.

If you’re like me, you’re used to fixing things. When performance improvement is needed in your own operations, you do what’s required to make it right. You have the responsibility, and you have the authority. Not so when it comes to your vendors. Often, they’re a black box to you. You’re not sure how they work, why things are going wrong, and if they can fix it. You stand by, feeling helpless, asking or pleading for better performance, maybe even threatening contract termination and/or a suit for damages. Sometimes they come through, sometimes they don’t. Either way, it leaves a bad taste in your mouth. Been there, done that.

Now you have problem. Perhaps you discuss the situation with your colleagues, “This vendor’s not reliable. Let’s ditch them and find another.” It happens a lot. A firm may contract with vendor after vendor, looking for a perfect one who won’t “let us down.” The truth is there is no such vendor, and “vendor” isn’t always a helpful term. Behind the term “vendor” are people. Ultimately your business relationships depend on your human relationships.

I believe it’s most helpful to consider any critical business relationship like a marriage. First, have a few dates while asking yourself, do we want to be married to this firm? Get to know the leaders, their values, skills and their capacity for commitment. Eventually you need go all in (or not). Then, together, you’ve got to make the marriage work, and “keep the romance alive.” That means no black boxes, no blaming, and no name-calling, but rather mutual openness, honesty, caring and forgiveness.

Yes, of course there will be issues, but when you’re committed to your marriage you don’t have the divorce lawyer on speed dial. Mistakes will be made. Your side will make them too. Similarly, conflicts are natural, they will come up. Resolving even serious conflicts respectfully is possible when both parties have the right attitude. And like a marriage, the business relationship will grow stronger each time you work together in a spirit of cooperation, and grow weaker with each episode of blame and recrimination. Like a spouse, the “vendor” should become a “partner.”

Start by getting to know the people behind the business.  Like the dating scene, not every firm you meet is marriage material. Leadership makes the difference. Be on a first name basis with the top executives at any business partnership you lead. Spend time understanding their business and their lives. Make the investment, and let human relationships drive your business relationships.

A Primary Care Therapeutic Alliance? Love in the Doctor-Patient Relationship

file1141234819793Recently I had the opportunity to have a conversation with Dr. Marc Braman, a national leader in “lifestyle medicine.” Marc’s an integrative, out-of-the-box thinker. He’s dedicated to serving his patients well and has decades of experience in helping patients to change for the better. Naturally, I asked him to tell me how he goes about it. So how do you help people give up bad habits and adopt new health behaviors? Marc, what’s your secret to that?

Of course, there is no secret knowledge, but Marc replied that it was critically important to form a strong and committed relationship with the patient. He likened it to the “therapeutic alliance” concept used in psychotherapy. Marc tells his patients plainly that he won’t judge or condemn them for their habits (say smoking) and won’t harangue or badger them to change. From the first appointment, he seeks to create a relationship of mutual trust and commitment where it’s safe for patients to be honest with him, and he can, over time, help them make positive changes.

We went on to share more of our ideas and experiences, but this particular idea of a “primary care therapeutic alliance” struck a chord with me, and I’ve been thinking about it a lot since then. My first thoughts went to Dr. Scott Peck’s description of the therapeutic alliance in his best-selling book The Road Less Traveled. He had this to say:

Genuine love, on the other hand, implies commitment and the exercise of wisdom. When we are concerned for someone’s spiritual growth, we know that a lack of commitment is likely to be harmful and that commitment to that person is probably necessary for us to manifest our concern effectively. It is for this reason that commitment is the cornerstone of the psychotherapeutic relationship. It is almost impossible for a patient to experience significant personality growth without a “therapeutic alliance” with the therapist. In other words, before the patient can risk major change he or she must feel the strength and security that come from believing that the therapist is the patient’s constant and stable ally. For this alliance to occur the therapist must demonstrate to the patient, usually over a considerable length of time, the consistent and steadfast caring that can arise only from a capacity for commitment. [emphasis mine]

I believe Dr. Braman has identified a very significant issue. How committed and non-judgmental is the average doctor with respect to the average patient these days? It seems to me, that if we’re not careful to guard against it, we’re pretty likely to find ourselves blaming and shaming the patient. What does the term “noncompliant” imply about the patient and the nature of the doctor-patient relationship? Should we ever dismiss patients for “noncompliance” or missing appointments?

Beyond the attitudes and behavior of the individual physician or other healthcare provider, how is the system working to foster such therapeutic alliances? Not very well. An individual’s insurance coverage often changes from year to year, necessitating a change in their doctors. Or the insurance company drops a physician from their panel. Or, in reverse, the physician drops the insurer. Or the doctor joins a new practice across town. Provider networks are not stable these days.

Clinic practice methods are not stable either. Financial pressures in healthcare are forcing a trend for providers to operate at “the top of their licenses.” This means, doctors only do what only a doctor can do. Let someone of lesser training and scope of licensure do the other things. Sounds nice in concept, but it certainly doesn’t make for strong doctor-patient relationships. Taken to its logical extreme, why ask doctors to talk with patients about their lifestyles at all? Let the health coach do it. It doesn’t take a medical license to help someone change his or her lifestyle.

So what do we do? I don’t know. Some of the structural shifts in healthcare (like “top of license”) that interfere with relationships aren’t going away. I do think that provider networks will become much more stable over time. Maybe the design of the system will not allow for the typical patient to have a therapeutic alliance with his or her doctor. But patients need a therapeutic alliance with someone! The patient needs a constant, stable, loving ally from within the healthcare system. It may not have to be the doctor, but if not the doctor, then who? Could it be a health coach, ARNP or social worker? Possibly. I think it depends on the individual person as much as the degree or training.

As a healthcare leader, I’m asking myself some questions – How do we design therapeutic relationships into our healthcare system? Where will healing happen in the future system we’re building? How do we love our patients like Jesus loves us? If you’ve got ideas, I’d love to hear them.

Thoughts on Helping 5: “MTV” – Myself, the Team, the Victim

MountainSomething, perhaps my recent vacation experience (see last post), got me thinking about being in the mountains of northern California over 25 years ago. Back then I was attending the U.S Navy Cold Weather Medicine Course given at the Marine Corps Mountain Warfare Training Center. It wasn’t all fun and games, but it was interesting and very different for a Florida boy like me. Overall, I enjoyed it.

Honestly, I can’t remember too much about the experience, and even less of the actual medical/survival information. But one thing I do remember is learning about a general approach to rescue situations expressed in the easy-to-remember acronym “MTV” – Myself, the Team, the Victim. That little nugget of wisdom has stuck with me all these years.

The basic idea is that, when a rescue becomes necessary, say a buddy drops through surface ice into a freezing lake, you don’t want to just charge into action potentially placing yourself or others at risk. Stop. Think for a second. “Myself” – Am I secure? “The Team” – Are the other members of my team secure? What actions are necessary to assure their, and my, security? After taking steps to assure the safety of the rescuers, then go after “the Victim.” – MTV

I think that learning goes beyond the mountains and wilderness. We’ve all seen family caregivers harm their own health through well-meaning devotion to a sick relative. Job-related stress leading to burnout, depression and even a heart attack or stroke is not uncommon among physicians and other intensely committed healthcare providers. Most people in healthcare (and maybe in ministry too) have at least a few stories of helping professionals who helped themselves into an illness from a lack of attention to their own physical, emotional and spiritual needs.

If you’re in a helping profession, or serving as a caregiver, make sure you’re taking care of yourself. Like the airplane flight attendant says, “In the event of an emergency, place your own oxygen mask on first before assisting others.” After yourself, consider your personal “team” – which might be your family and/or your staff. How are they doing? Are you supporting their health and wellbeing or placing it at risk? Get your life in balance. Support your family. Now you’re ready to help others.

Other posts in this series:
Thoughts on Helping 1: What Do People Need?
Thoughts on Helping 2: Who Wants To Be Well?

Thoughts on Helping 3:  Like Helps Like
Thoughts on Helping 4: Gods Grace