The Occasional Random Consideration - 5/1/19

Periodic thoughts that percolate forward while traveling about the world…

I’ve just returned from whirlwind visit to five cities in China – Xi’an, Zhuhai, Changsha, Beijing and Shenyang. Before I share some thought about health care in the context of the US-China relationship, I wanted to share a couple of observations: 

  1. The People – If you have the resources, you need to visit China. It is a wonderful country with even more wonderful people.  Unlike the uniformity of presentation and perspective that I originally experienced in 1978, there is massive diversity among the people. When you get them alone you learn about the very diverse thoughts they have which are creating an environment of intellectual diversity. It is evident by the adornment they wear which consists of multiple, bright colors (sometimes with matching hair color) and a variety of T-shirt statements that adorn their outerwear. I won’t repeat those T-shirt statements here. In fact, I’m not sure the Chinese actually know what their English statements on the front & back of their T-shirts are actually saying. Regardless – they are wonderful people. They are open. They are inquisitive.  They (the people) seem to love Americans…
  2. Air Pollution – Unfortunately, it seems that the presence of severe air pollution has become the new normal. Even with rain, the air did not clear in Xi’an.  It’s because of the reliance upon coal and wood-burning sources for heating and cooking.  There is a big national campaign to move toward less polluting resources but the latest report revealed that 337 cities in China had worse pollution this year than in 2018.  Not a good turn of events. When we think of global warming, we need to think international collaboration.
  3. Construction Everywhere – Oh, to be an architect in China at this time in history! The skyline of China in all of the major cities is adorned with high rises that challenge the traditional framework. While there are many, many (shall I say “many” again) high rises that are simple replications for housing – I mean row after row of 20 – 30 story buildings – the unique buildings are the ones that capture your attention.  There are a massive number of iconic buildings that are either under construction or already completed.  In fact, it is hard to take a picture of the skyline in any city without capturing at least a few construction cranes on the horizon.  They have become the national bird.
  4. Economic Development – The economy is clearly booming in China. In the US, we think of the Chinese taking over the manufacturing of all manner of goods.  And, in fact, they have done that in many instances because of their lower labor costs.  However, the “service” industry is the fastest growing component of the Chinese economy. Chinese manufacturing is moving from China to places with less costly production costs like Thailand, Bangladesh, Sri Lanka, major portions of Africa and other places in the world. So, the march of economic development continues its relentless pace.  It is a lesson for us, however.  We clearly need to redouble our efforts at investment in educating our work force for the next generation of economic development.  It will not be in repetitive manufacturing of widgets, vehicles or other similar products.  So, the question for the US is: what and how we deliver a work force prepared for the new economy.  From my perspective, too little debate and discussion has been held on this very important issue.
  5. The Cost of Living – We were told by our guides that the cost of housing in central Beijing is running about $15,000 a square meter. So, a 200 square meter apartment/condominium would run about $3M. It was clearly outside the range of our guides and the average Chinese resident.  The phenomenon is not just a central Beijing issue either.  So, inflationary concerns are top of mind for most Chinese.

Back in 1983, I applied for a Kellogg National Fellowship and was lucky enough to receive one of those coveted Fellowship experiences.  In my application, I noted that I wanted to study Chinese culture and language because I felt that “China will be the next great nation and the nation of the next century.” It’s becoming true.  I would encourage everyone to consider how we can embrace China rather than castigate it as a country.  There is much we can learn from one another.  The challenge for both sides will be in embracing a strategy of mutual respect, cooperation and collaboration. 

Finally, you might ask: Kevin, what’s this got to do with health care?  Everything!!  I believe we are moving toward a much smaller world where interaction, cooperation, collaboration, coopetition, co-learning are becoming the norm.  To survive in such a world means that rather than castigating countries and working to dismantle their efforts, we should be embracing those nations as learned relatives who over time become a part of us.  As the singular most diverse and accepting (even though it does not seem like it at times) country in the world, we have an opportunity to embrace such nations as partners in progress.  We need that because health care is going to continue absorbing more and more costs – despite our best efforts to control costs – due to the aging of our population. This is not just a US issue. It’s an EU issue.  It’s a China issue.  By working together; however, we can solve the problem.  The health care forum can actually serve as the petri dish for multi-national collaboration and development.  Economic development and sustenance is on the periphery of health care but, it’s central to health care.  Think about it…

The Occasional Random Consideration - 4/19/19

Weighing In On The Anti-Vaccine War – Activism is one thing.  Terrorism is another.  It’s time for doctors and all of our allied health colleagues to rally together for the purposes of stepping forward in the name of science and public health to demand an accounting.  Some of our colleagues have been dubbed “pharma vaccine whores”.  If they want to throw that charge at me – let them try.  I’m clean as a whistle.  And, I find the tactics and information used by the anti-vaxers to be demonstrably hollow.  As a young resident, I had the challenge of caring for a young man who we admitted to our city hospital with subacute sclerosing panencephalitis.  It’s a debilitating disease caused by the measles virus and, more importantly, it’s totally preventable by administering the measles vaccine.  It occurs in 1 of 10,000 cases but 1 in 100,000 or 1 in a million is too many.  And, the same goes for the mumps, rubella, polio and all the other interventions we implemented over the last century that precipitated a plummet in the death rate of children.  Now we are seeing a resurgence of diseases that should never be seen.  The situation is getting so dire that the World Health Organization (WHO) recently named “vaccine hesitancy” as one of the top 10 global health threats. And, there are other efforts as well.  Chad Hermann, the Communications Director and Todd Wolynn, MD, a pediatrician at Kids Plus Pediatrics in Pittsburgh, PA have taken up the mantle by speaking out at conferences and creating a pro-bono project – “Shots Heard Round the World” – a site for providers that provides tips on how to ban commenters, disable Facebook ratings and mobilize supporters who will support providers with pro-vaccine web information. It’s a laudable effort.  Now, we need to mobilize the professional societies and the rest of health care to support their effort.  The time has come to stand up and be counted.  Facts are facts.  It’s what drives good medicine and good practice. 

Remembering Mrs. Cary – I live a long distance from my Mom who has end stage Alzheimer’s disease.  Although I try to schedule regular visits, it’s quite difficult given the breadth of the country that separates us from one another. In the last couple of weeks there have been several hospitalizations for a variety of reasons but all related to the down turn in her daily existence.  In fact, her life has become an existence or, as my brother noted this past week, “She’s alive but not living.”  It’s sad to consider.  It’s painful to see.

But, all of this has brought to mind Mrs. Cary.  Working with her as a young lad was one of the seminal experiences in my early years as a health care provider.  My career in health care started on a very hot day in August at one of our local nursing homes in Bismarck, North Dakota where I worked as the “lawn boy”. One afternoon, the Chief Nurse walked out into the glazing sun and out of the blue offered me a job as an orderly.  She told me the job was an “inside the home” job where it was air conditioned.  She told me I’d have to wear a clean white smock. But, the cincher was when she offered me a pay raise of about $1 per hour – which back in the early 60’s was a tremendous amount.  My job was to help lift the patients into their wheelchairs, take the guests down to the dining hall for meals, assist with showers and personal hygiene, support the men patients, in particular; and, be the helper to all of the other aides for any and all manner of assistance. 

So, back to Mrs. Cary. She was a very slender, rather tall, distinguished looking lady with a patrician presence.  She wore her hair in a tight bun on the back of her head – just like her daughter had explained to the nurse’s aides.  She had an air of authority. In fact, she gave lectures nearly every day to the other guests in the nursing home as she sat in her wheelchair often before an audience of blank stares.  The lectures were about the proper use of English, spelling and papers that had obviously been written a long time ago.  She frequently quieted the room with rather loud statements like, “People, people – now, listen to me.  I have something to say!”  Then, she would clear her voice and begin a soliloquy.  And, her conversations or presentations were simply thrown out to the crowd of residents like a confetti of words that seemingly landed everywhere and nowhere.

We were told that Mrs. Cary was one of the very first woman graduates from the university in North Dakota where I grew up.  She had been a teacher of repute.  But, she suffered from dementia – most likely Alzheimer’s. I had a front row seat in her gradual decline with its weakened voice, increasingly incoherent “word salad” and physical descent.  It got to the point where she became a shadow of her former self.  She was “alive but not living.”  It was very sad to watch. For some reason, she always called me “Steven” – which was the name of her son that she had lost (I believe) in World War II – until the very end of her life.  I embraced her recognition and gave her all the care I could muster. 

I thought of Mrs. Cary because my family – like the 5.6 million other families in the USA who have a family member with Alzheimer’s – are often aghast at the services provided.  I often wonder if there is a young orderly at my Mom’s nursing home who provides the supportive care she needs.  My experience is that it is irregular and plus/minus.  And, an admission to the hospital is even more dreadful.  The focus is on scans, blood work, x-rays, lab tests and any manner of technical work that is far from the needs of the family and often done based on protocol rather than rationale.  Because of the overlaid demands we place on our health care workers from doctors through orderlies – the time available for holding a hand, listening to a family member, giving a hug and simply sitting with someone is simply shunted aside.  Too frequently our “care process” is broken and disjointed.  It seems to me that we – as health care providers – must as a first order of things provide support to not only the people who are “alive but not living” but also more holistically for their families as well. In fact, the Hippocratic Oath that many of us took in the mid-1960s said:

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

In the age of technology – of which I am an ardent advocate and supporter – we need to remember our entire role as health care practitioners.  Holding hands and simply listening are just as important as all the other accoutrements we offer are part of our armamentarium.

Random – But, Focused – Thoughts - 12/31/18

Thoughts needing your feedback…

Considering For A Moment The Realities Of Our Time – Sometimes as we deal with the daily burdens of our lives – both professional and personal – we tend to neglect the changes that are percolating across societies throughout the world.  I was really struck by an animated depiction of the GDPs of various countries throughout the world.  In particular, China has continued its rise as a major economic force throughout the world.  In fact, when I was selected as a Kellogg Fellow in 1985, one of my points of study was to learn more about China because I noted for the Kellogg Foundation that “China will most likely become the dominant economic force of the next century.”  Well – the next century is here and the prediction has become a reality.  Take a few minutes to watch this video.  It becomes clear that the economic changes are a marker for political and social changes as well.  We need to take note because even though the changes are outside of health care they will both directly and indirectly impact on health care.  Resources are what makes societies hum.  Embracing nations is how we’ve done it historically.  We should get back that approach.

Chasing Squirrels – About a week ago, I was upstairs in my office when I suddenly heard this horrible choking sound coming from the first floor.  It sounded as if my dog – Toto – was choking on something, although I’ve never heard him choking :-) .  He loves to chew on tennis balls so the fleeting thought was well deserved.  In a flash, I ran downstairs only to find Toto staring intently at the kitchen.  But, the sound continued.  I couldn’t figure it out but is was obvious that Toto was focused on something.  Then, I saw it.  Toto had cornered a squirrel that was screaming its head off atop a large painting hung on the wall.  He had cornered a squirrel!!  From simple observation around the squirrels outside the home, I knew that there was no way I was going to capture that squirrel by myself.  So, I calmly went downstairs and gathered up my son and his friend to assist me.  The next screen is directly from the Keystone Cops!  The three of us with coats and towels to protect us from the squirrel along with Toto gave hot pursuit to the wily little creature.  He gave us a run for the money.  We chased it back and forth and around the house.  He would occasionally stop and simply stare at us as if to say, “Are you kidding?  You think you’re going to catch me?”  But, then we thought wiser by opening the windows and the doors before restarting our hot pursuit.  Within a minute, he was out the door and we were staring at one another with laughter at how easy that had been – at the end.  So, what’s this got to do with health care?

As I was thinking about the squirrel incident when it came to me that much of activity in health care today is like chasing squirrels.  We’ve got the various parts of the system going in different directions.  Some are chasing the proverbial squirrel with large leather coats, others with towels and still others with open jaws in sheer intuitive instinct like Toto!  We’re not coordinated.  One part of the industry is trying to go in one direction, and another part is going in a different direction.  Meanwhile, the squirrel of health care costs and inefficiency is getting away with dart here and a dash there.  It is only by getting all of the parts to work in a coordinated fashion that we’ll solve the problem.  Fee-for-service providers working in isolation from public health programs who are not connected to social support initiatives that use emergency rooms as fail-safe support systems during off hours only results in more costs.  Then, there is the drug and medical device industry toddling along to their own drummer quite apart from the insurance industry to say nothing about the confusing role government now seems to play in the health care community of today.  We’re chasing squirrels!!  It’s time to stop and take thoughtful consideration of the situation before continuing the chase.  It seems to me that if we actually worked together – across the boundaries of the industry – we’d solve this squirrel problem that has captured the attention of the health care community.  What do you think?

The Importance of Listening…

Observations and thoughts about the world we live in…

I’ve been working on a new book which I hope to release sometime in early 2019 – although that timeline may slip a bit given the other pressing demands of life. It seems that the many projects, making sure that Toto – the wonder dog and constant companion – goes for a walk every day when I’m at home as well as watching to make sure that the tides continue to go up and down ten feet at least twice a day at our home in Kittery, Maine :-) among the many other requirements of daily living.  These diversions sometimes pull me away from the petitions of my editor to cut out the wordy segments, reduce the number of metaphors and synthesize my thoughts more effectively so that readers will actually learn something about the lessons of leadership on persistence derived through focus, tenacity, failure, learning, understanding and reflecting – but emanating from the power of listening.  

The following thoughts are an adaptation from one of the chapters, “On Listening”.  As we step away from the travails and torment of our current political dialogue and offer tribute to our veterans, it seemed like a good time to step back and consider the need for listening to one another.  In reading the above bipartisan quotes, I’m particularly drawn to the notion that in honoring our veterans we are honoring the principles upon which our nation has been sustained.  It is through our diversity of cultural background, our diversity of ideas, our diversity of industry and our diversity of perspective that we have been allowed  and encouraged to hold diverse viewpoints across the whole of society.  But, all of this diversity cannot – will not – be sustained if we don’t listen.  So, I offer the following thoughts on

Learning the Art of Listening.

The Persistent Leader must acquire one characteristic above all others and that is the art of listening.  It is perhaps the most difficult but the most treasured of art forms for any leader.  In fact, it is the one area where I continue to diligently focus ongoing effort toward refining my skills in hopes of doing better over time. I must say that the recent debates, discussions and dialogues have challenged me in this regard.  Some of the discussions have been heated.  Others have been abruptly terminated because of the heat.  Some have even had the door closed on them before the discussion began.  And, still others have resulted in both sides simply shaking their heads and wondering – what the hell is he or she thinking?  The most productive; however, have been those where both sides persevered and listened carefully to the other to gain an understanding, to discover a core nugget of truth, to obtain an appreciation of the other’s ideas.  When we support such an approach in our dialogues, debates and discussions and don’t cut off our communications from one another – that’s when we have learned the art of listening. 

Now, please note that I am a student on the art of listening – not an expert.  I view listening as a continuing education skill.  I first learned the art of listening from a college friend’s father.  Her name was Sally and her Dad was Butch.  I met Sally through my best friend in college who eventually became her spouse.  She grew up on a farm not far from our university town so we would frequently “…go out to the farm” as a retreat from the rigors of university learning for a bit of reality learning.  When we arrived – often in a caravan of cars – we were always greeted by Butch (her Dad) and Ellen Ann (her Mom) with open arms.  It’s as if we had become part of the extended family which in many respects we were.  

When we arrived at the farm, we often sat around the kitchen table simply talking about university life and the latest events that seemingly swirled around us.  It was the early 1970’s and there was always a swirling “event” of some sort – much like today’s world except that the swirl came with the evening news with Walter Cronkite or Huntley and Brinkley rather than the 24x7 news cycle and the assault of Twitter from every political and social dimension you can think of. The important part of the conversations with Butch was that up until that time, he was the most conservative person I had ever had the opportunity to meet, debate and discuss the issues of the day.  My Dad often debated me and he was quite conservative but Butch made him look centrist.  Butch was an ardent – but extremely thoughtful – advocate for the conservative perspective in society.

Now imagine what a long-haired, university-based, student liberal who always wore a peace symbol around his neck from the early 1970s might be like when he sat down for coffee with Butch. Well, that was me!  The formative years of my life at university contained the rich experiences of the Vietnam War in a far off land, Kent State shootings in Ohio, the Watergate scandals in DC, the Stonewall Riots in New York City, and a host of other experiences that pushed me toward the more liberal perspective.  If you don’t know about these events, follow the hyperlinks.  You’ll get a sense of the discord that exuded America in the late 60’s and early 70’s.  It was a period where a distraught society boiled over in anger – until we finally sat down and listened, for a while, to one another.  The time for listening has returned…

But, back to my story.  Despite my political leanings, I was quite taken by Butch.  He was not only the most conservative person I had ever interacted with, he was also one of the most learned.  Here we were, out on the prairie in North Dakota sitting around a kitchen table, debating the tenor of the times and Butch was quoting John Locke, Edmund Burke, Alexander Hamilton and other conservative thought leaders.  He was awesome!  He never raised his voice.  He always looked you in the eye.  He often would smile in an exchange where he disagreed and point out that he disagreed, very politely. 

What I learned from Butch, in addition to the ideology of conservativism, was the beginning skills of listening.  We would sip our coffee, I would pontificate about some burning (often in a very real sense) issue of the day and Butch would listen.  He would then listen some more.  Finally, he would offer his thoughts in a very reasoned fashion and often with a fleck of humor.  Through our dialogue I learned that I needed to be prepared.  I needed to think my position through.  I needed to more fully understand alternative viewpoints to make sure that my viewpoint could stand the test of time.  I learned to listen (NOTE:  I’m still learning – just ask my wife :-)  ).

Butch was not only intelligent but he was able to lay out a perspective on an issue we were debating by cementing his ideas together with perspectives that made sense. His listening was disarming.  His reasoning was clear and often data filled.  The important lesson in the art of listening I learned was that it was important for those of us sitting around the table to be equally clear with similar precision as we articulated our rebuttal positions.  With Butch you didn’t simply flame out.  You did not pontificate – which is something we hear from both sides of the aisle far too much these days.  You didn’t yell or call people names.  In order to respond effectively as an artful listener, we learned that the same degree of clarity on thought, distillation of information and formation of perspective that Butch offered must be constructed for our arguments if we were going to withstand the thoughtful responses of Butch’s positions and perspectives.  By listening, he often gained the upper hand in our discussions and for some, he even carried the day.  I admired Butch.  He embodied what my good friend, Senator David Durenberger (R-MN) once offered to me in a conversation at my home when he said, “We need to listen to the other side to make a difference.” I must say that I have diligently attempted to adopt Dave’s philosophy as my working mantra over the years as part of my foundation for learning the art of listening.

To this day, I count Butch – and, Dave by the way – as a couple of the most influential people in my life – along with Tommy Joe, which is whole other story.  By virtue of demonstration, Butch revealed an important skill that is woefully undeveloped among too many leaders and missing from today’s societal dialogue.  Too many leaders are not listening very well.  Yet, to gain the respect and gratitude of those who sit around our proverbial kitchen tables, listening is one of the most important skills that has been shunted aside among the diatribes we often hear in today’s political debates. Listening is a skill that requires honing every day of your life as a leader.  It is a skill that you must always monitor to assure it is on full alert and omnipresent in your life so that it can be called upon at a moment’s notice. 

So, on this Veteran’s Day 2018, I encourage all of us to ponder the most wonderful gift we have been given by our forefathers  and the veterans who have served our nation – the ability to listen and figure out for ourselves what we believe and where we want our communities and nation to stand.  Unlike so many societies both present and past, we in the United States of America are so very gifted to have the right of freedom of expression.  Let’s not destroy it by not listening to one another.  In fact, sometimes the best lessons in life come from sitting around the kitchen table.  I encourage all of us to take time on Veteran’s Day to not only honor our veterans but to reflect on what they have given us.

Finally, I would like to salute my Uncle Gary and one of my life long friends, Ralph for their service to our country.  Uncle Gary rose to the level of Master Sargent which is the very highest rank for an enlisted person who enters the military.  He served in many locations throughout the world during the course of his career – including in Vietnam, a war I opposed.  And, also to Ralph who enlisted midway through college after receiving a low lottery number in the draft during the Vietnam War.  He did the practical thing and enlisted. Irony of ironies, Uncle Gary and Ralph ended up working directly together in Vietnam.  It is, in fact, a very small world.  And, that is yet another story for another day…

Now, to close out – please note that I frequently disagree with Uncle Gary and Ralph on any number of issues but, I always listen – just like I did with Butch. It is important to listen and to understand because it is only by understanding that we learn to use our knowledge for making a difference.  Again, thank you to all of the vets – of all perspectives, all    persuasions, and from all cultures – who have served on the front lines of democracy so that we can have our debates, engage in our discussions, and hold our dialogues.  But, we need to remember that we will only move forward by also engaging in the opportunity to listen as part of our assembly as families, as communities, as a nation…

Thoughts Beyond Health Care…10/11/18

In an era of considerable name calling and ugliness – there are some very good things happening…  

womenWitnessing The Revolution: Building The Foundation Through #MeToo – The #MeToo movement has been top of mind for most of us over the last month.  In a world where every day brings a flurry of new news as the life of our national soap opera unfolds, the Kavanaugh hearings were perhaps a seminal turning point in our nation’s dialogue.  The hearings brought to the forefront the #MeToo movement.  Witness the sign we saw in the window of a shop as we strolled to dinner the day of the Kavanaugh vote in the US Senate.  It speaks about all women and the role of all people and all families.  I suspect that Tarana Burke – the Founder of #MeToo in 2006 – never anticipated that the community initiative she created for connecting survivors of sexual violence would have such national and international ramifications.  Although I can point to incredible gains that have been made for women over the course  of my lifetime – we have a long way to go…and, I’ll leave it at that!  So, while the issue of sexual violence, let alone sexual disrespect, is an extremely important one for society to address, I believe the movement is extending beyond the too frequently disempowered, one-half of our nation’s and world’s population – women!  In fact, when we look back in a couple of decades, my prediction is that the #MeToo movement will be as much about bringing into the fold the diversity of the whole human populace rather than just half of it – or, at least that is my prediction for the United States.  We are seeing the last hurrah of domination by old white men (I am one of them by happenstance of birth) in America.  Women AND people of other cultures, perspectives, preferences and colors are coming to the forefront of society – AND, THAT IS A VERY, VERY GOOD OUTCOME!!  The #MeToo movement is highlighting the acceptance of diversity across the nation.  It’s about time.  It’s about women but, it’s more than just about women.  In fact, I believe the #MeToo movement is the cornerstone of the diversity movement which is finally coming to America.  We’ve been struggling with it since the Civil War.  I suspect we will continue to struggle with it in the years ahead.  But, hopefully, the new generations will take the lead and move acceptance to a higher plane – a calling, if you will – for what the United States of American stands for…  To all women – thank you for changing our society for the better.  Yes, we’ve come a long way but we have so much further to go!  The Kavanaugh hearings have helped the nation extend a dialogue that is only just now beginning to reshape society.  Don’t be disheartened.  The picture in the window caught the spirit of the changes we are experiencing.  We all need to continue the quest for making the spirit a reality for women and everyone. 

Crossing The Boundaries – To my point above, I recently read a news story about a young women who won the homecoming queen vote at her school and saved the day for her school’s football team – all on the same night.  She’s a student at Ocean Springs MS High School in Florida.  Senior Kaylee Foster had the double honor of being named homecoming queen and serving up the winning points as the kicker for the football team.  The younger generation are crossing all sorts of boundaries.  I look forward to their leadership as they take the reins of society and guide us into the new millennia.  In a similar vein, our youngest was arrested for demonstrating while in Washington, DC.  When Senator Susan Collins gave her speech (apologia) on the US Senate floor last week, there was an outburst in the gallery.  The outburst was a statement of angst about all of the events over the preceding weeks.  But, even though the protest did not stop the speech, the arrest awakened within her the desire to “make a difference” just as the protests of the 60s did the same for my generation.  The flame of change to make a difference is bright and alive. It will change society.  Let’s also hope and pray that some of that energy, that desire, that focus for change will be invested in making health care better! 

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