The Occasional Consideration or Perspective - 9/24/20

Periodic Meanderings and Ideas Deemed Important by the Author…

The American Trifecta - by Kevin Fickenscher 

We all seem to be either glued to the tube for the latest evolution of commentary and inside information or we have totally turned off what is happening in the world and diverted our attention to other interests. I must admit that I am part of the former crowd and hanging on the words of Fauci along with other experts to ascertain the facts. As I’ve considered our dilemma here in the United States, I’ve recently come to the conclusion that we are experiencing a series of events that hold the prospect for dramatically altering the course of history – not just for our nation but, for the world, not just now but, for far into the future!

At a minimum, we are facing what I describe as The American Trifecta. Trifecta?  Isn’t that about horse racing? Yes, originally that’s where the idea started but over the years, the definition of trifecta has shifted to mean: a bet in which the person betting forecasts the first three finishers in a race in the correct order. So, the question becomes what are the three forces that are affecting the American spirit? My thinking on the topic started when I realized that Covid-19 has become the news item de jour much like the winner of the Kentucky Derby! We wake up every morning to a plethora of statistics and stories – all Covid-19 related. The pandemic is dominating the news cycle on all channels both domestically and internationally across the spectrum from right to left. As I considered the ongoing events which are swirling about us across the world; however, it occurred to me that there are actually three dominant and simultaneous pandemics – not just one – occurring at the moment.

To begin, let’s outline the notion of pandemic which is defined as: an epidemic occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people. Epidemics, on the other hand, are simply outbreaks that occur across limited geographic areas within a single country. I am anticipating that most will agree with the first bet I am placing in the race of a lifetime for The American Trifecta. It is that we are facing a Medical Pandemic that has been precipitated by the spread of the Covid-19 virus across the entire globe. The evidence in support of its position as the #1 problem facing America and the world seems fairly clear. So far, the Covid-19 virus has spread to all the continents of the world except Antarctica and, who knows how long it will take before the spread of the virus occurs there as well? The Medical Pandemic has changed everything in our life’s experiences…

  • from how we do our work to where we do our work,
  • from how we engage with people and to when; and,
  • from our approach toward interacting, engaging and meeting friends, neighbors and associates of all types to if we will even see them at some point.

In fact, the Medical Pandemic has overtaken virtually every other event occurring across the globe to the premier pole position as the dominant consideration in our discussions, discourse, and debates. It seems that every minute of hour in every day is consumed by a focus on the Medical Pandemic of our lifetime – as it should be. Our lives depend on those exchanges! The rank of #1 in The American Trifecta seems well deserved.

The #2 slot goes to the slowly evolving Sociocultural Pandemic of racism which has accelerated over the last year to some degree in part because of the Medical Pandemic’s tragic unfolding. But it has also been accelerating due to other factors extending beyond the medical side of the equation. What do I mean when describing a Sociocultural Pandemic? It is clear that different societies host different cultures. America is different than India is different than China is different than France, and so on. While it is important not to confuse the idea of culture with society, it is equally important to understand that these elements – society and culture – are inextricably intertwined.

A culture represents the beliefs and practices of a group – not just a national entity. Society on the other hand represents the people who share those beliefs and practices. The long and short is that neither society nor culture can exist without the other. Furthermore, different cultures and societies can co-exist within the confines of the same geography, government, or nationality. The result is exemplified by the “mask-wearing” society versus the “not-wearing-masks” society – two groups of constituents that live within the greater cultural background of the United States.

Furthermore, the social elements of culture and society have evolved in contemporary societies to include references to the redistributive policies of the government which – through consensus of the community – applies policies and resources determined to be in the public interest. One of the best examples of this concept is the American Social Security program which provides protection against the loss of earnings due to retirement, death, or disability. Other examples would be requirements by state governments for a mandatory driver’s license by all people driving cars or other motor vehicles or, the Medicare-for-All policy – a hot debate across the country.

But social is not simply about policies and programs. Societies, in general, also hold certain expectations of behavior as social norms that we as individuals and organizations are expected to internalize. In essence, these elements represent the cultural component of the ideas, customs and social behavior we encourage as a society. Therefore, these cultural components include language, allowable interactions, religious practices, social habits, music preferences and the like. In other words, the norms we create function as the requirements for acceptable behavior for our mutual interactions with one another within our society. These expectations create the general societal climate where the intent of our social norms is to impact, affect or control those behaviors through acceptable conduct as members of the society. These norms then serve as the guidelines for defining our behavior, dress, language, interactions, and demeanor in any given situation.

The various societies that dominate our nation are derived from activities relating to our communal experiences, our community identity or collective experience or group affiliation. It represents the interaction of the individual with social institutions that we have created as part of our community such as schools, churches and clubs or groups within which we are affiliated. And it’s not just professional or political interactions. It can also include other types of interactions we share as common experiences such as commuters on transportation systems. I can assure you that the travel experience of commuters on the DC Metro is quite different than the MTA (Metropolitan Transportation Authority) experience of New York City. And it affects our behavior and the commonly accepted attributes of commuters on those different lines. These differences evolve from the social or tribal behaviors promulgated over time by the norms of the participants in the society which drive our experiences within these groups.

Another example comes from the professional world. Physicians are a good example – a group of which I am a member. We interact with one another in certain ways. We hold expectations of one another and when physicians do not adhere to those principles the society reacts. It’s part of the reason that the medical community has reacted so strongly to the misinformation provided by the Centers for Disease Control as a result of the Medical Pandemic. The principle of adherence to the facts has not been maintained at the forefront of information dissemination. The application of similar principles can be applied to most professions like accountants and police as well as to other social groupings or associations such as the National Rifle Association versus Moms Demand Action. Similar organizational principles are pervasive across the organizations.

Unlike the Medical Pandemic which has been with us for just under a year, the Sociocultural Pandemic of racism has been percolating in the background of the American experience for centuries. Over the last half century the issue of racism has been evolving and morphing as a recognized societal sickness among the American people. Unlike the Medical Pandemic which may ultimately be managed with a vaccine; however, the Sociocultural Pandemic will most likely will only be resolved through the metaphor of herd immunity – when all of us get it!! And, by get it, I mean “understand” or, “believe” or, “embrace” or, similar words that describe our acceptance of new social norms best exemplified by racism – a societal norm that we not only “say” is unacceptable but where we also root out the subterranean behavioral tentacles that exist across society and must be resolved!

Since there is no vaccine for racism – how will our norms be changed permanently? First and foremost, the dynamics of a Sociocultural Pandemic require a different approach that includes the application of certain “social skills”. These skills must be adopted and used regularly by all members of the society to change the norm. The literature describes these six skills as: 1) engaging in effective communication, 2) engaging in conflict resolution, 3) actively listening and not just hearing one another, 4) exhibiting empathy, 5) supporting relationship management; and, 6) holding respect for one another. A cursory review of these six skills would suggest that as a society we are failing on all six fronts. Thus, the Sociocultural Pandemic of racism has been allowed to percolate rather than be resolved.

Furthermore, the Sociocultural Pandemic of racism has been thrust to the forefront of societal debates because of new technologies and information sharing that allow for immediate and direct scrutiny of racism by all of us – simultaneously. It is because of the simultaneity of our experiences and ensuing abhorrence at what we see that a new norm is being forged that is declaring racism an unacceptable behavior that cannot and will not be tolerated. Once the pandemic is recognized, the vectors of racism inherent to the Sociocultural Pandemic – like the insidious Covid-19 virus in the Medical Pandemic – need to be proactively managed by society in a unified, cohesive manner. In essence, that is how pandemics are controlled! And, in fact, that is the task before us as a society in The American Trifecta.

If that were not enough, there is a third pandemic lurking in the background to round out the trifecta that will likely take center stage in the not-too-distant future. While we are primarily focused as a society on the first two dominant pandemics of the day – the Medical and the Sociocultural Pandemics – the Environmental Pandemic has day-by-day extended its reach around the world. Unlike recent proclamations by some in leadership positions – I, for one, am absolutely clear: Science knows! Any observer of facts will readily accept the fact that climate change is precipitating an Environmental Pandemic. There are many scholarly reviews related to climate change that clearly defines the role of human activity – based on facts and data! Here are just a few nuggets for your consideration:

  1. The concentration of carbon dioxide (CO2)​​​​​​​ in our atmosphere, as of May 2020, is the highest it has been in human history or, 416 parts per million,
  2. Since 1880 when weather records were started on a global basis, the five warmest years on record have all occurred since 2015.
  3. 11% of all global greenhouse gas emissions are due to deforestation which is equivalent to the emissions from all the passenger vehicles on the planet,
  4. The most effective and efficient method for storing carbon is to sustain the tropical forests,
  5. The data shows very clearly that the USA – with 5% of the world’s population – is responsible for 25% of global emissions, more than any other country; and,
  6. There are more facts out there – just look for them!

Rather than engaging in a prolonged diatribe, however, it seems more appropriate to point the reader toward additional facts that are recognized as major causes which are precipitating the Environmental Pandemic. We tend to think the Medical and Sociocultural Pandemics are upending our culture and economy. However, the strife we are experiencing from them pales in comparison to what will be occurring because of the Environmental Pandemic. It will readily overtake the other two in short order – making our current problems seem quaint by comparison. And, if the race were a bit longer – which it ultimately is – the Environmental Pandemic would ultimately reach the #1 spot of The American Trifecta.

While there are many issues on our national horizon, The American Trifecta must be positioned as our North Star! If, in fact, we maintain our focus on it, the nation will be able to make the required changes for resolving these three pandemics that are haunting our society. We have the means to accomplish this objective. We hold the pre-existing culture to hold the debates and move forward toward solving the problems these pandemics have presented. Now is the time…

I always thought that entering the senior years would be a period of greater tranquility and peace. But, now – more than ever – it is evident to me that all of us must stay engaged by maintaining our focus and energy on The American Trifecta. All of us must stand up and be counted by maintaining our vigilance. In addition to The American Trifecta, there are many, many other issues that require our focus and energy. Mark my word, there are other pandemics lurking on the horizon among those issues we face. Vigilance and persistence are the watchwords we need to consider in keeping the pandemics at bay.

Considerations

Thoughts pulled from readings over the last several weeks…. 

Holding The Line – I’m obviously behind in my reading (if you only knew how far behind or, perhaps I should not subscribe to so many periodicals?). The recent editorial from the May, 2020 issue of Wired Magazine was all about pandemics and how we handle them. One of the closing paragraphs offered the following advice:

“We can do this. In the 1950s a sociologist named Charles Fritz jump-started the academic study of disaster with a single, vivid insight: People in crisis help each other. Elites panic about riots and looting, but most of us just try to help the people nearest us. And then we help the ones a little farther out, and then farther again. The center holds; the gyre widens. A government can do things to make all that happen, and in a better timeline, it would. Sadly, we don’t get to choose a timeline. Luckily, we do get to choose a government.”

We’ll get through this! Hang in there and listen to what the scientists are saying – whether you like it not. Their advice is based on facts, not conjectures, not opinions, not hypotheticals – but facts! And facts are what we need when everything seems to be going to hell in a hand basket (it’s my Mom’s declaration to me when things didn’t seem to be going right and I was making mistakes  :-)

The Occasional Consideration - 7/29/20

Periodic Meanderings and Ideas Deemed Important by the Author…

An Initial Thought – For twelve years (yes, I’ve been at this for that many years), I’ve assiduously maintained a central political perspective with the occasional barb thrown in both directions. However, in recent months I’ve been accused of being “partisan”. Let me clear, I have many fewer arguments with the Republicans than I do their current leader of state. That being said, I still have problems with my Democrat colleagues as well and point out the errors on that front. If the lens of partisanship is “Trump” then I guess you could, in fact, accuse me of partisanship. If the issue is whether I’m supportive of left or right, I tend towards the middle. Why? Because that’s where problems are solved. My left of center colleagues will think of me as one who gives in. My right of center colleagues will think of me with the same perspective. I think of myself as a practical person who desires a long-term, sustainable solution to the most vexing problems facing our nation. That requires a sense of what’s needed, how to achieve it and over what time frame.

Some Final Thoughts – The other night CNN hosted one of its “Town Hall” meetings with Sanjay Gupta, MD and Anderson Cooper. Their guest was Bill Gates – a person I would describe as prescient, obviously smart and beholden to no one! He clearly knows and has studied pandemics. He knows and has studied vaccines.

  • First Thought – As the discussion between the three of them continued, it occurred to me that the USA is absolutely filled to the brim with various experts on most fields of endeavor. In fact, I could argue that the USA is brimming with talent and knowledge – far above the usual nation. BTW – this is not nationalistic thinking but rather just facts. It’s not to say that experts don’t exist elsewhere. They do. It’s just that we are lucky enough to have more than our fair share.
  • Second Thought – These experts are no doubt incredibly busy. Getting on their schedules is not an easy task but, if we could, we could tap into a wealth of knowledge and expertise that could likely help us solve the pandemic problems.
  • Third Thought – There is one person who holds enough sway that with a simple call to these experts, they could be mobilized to work together. Something like this could occur: “Hey, Bill. This is XXX. I know it’s already Tuesday but I need you to be at a meeting on Friday with a group of folks I’m pulling together to discuss how we best manage the pandemic. I’m sure you’ll know a number of these folks. I’m looking for advice. In fact, I’ve also hired someone to facilitate our conversation so we get the most out of it. I hope you can be there. Thanks”. There’s only one person in the entire world that could make such a call and, that’s the President of the United States. Have we done this? It doesn’t seem so. Could it still be done? You bet.
  • Final Thought – Besides Bill Gates and Anthony Fauci, MD – who should be invited? How about this list as a starter kit:
    • Governor Larry Hogan (R-MD) – Chair, National Governors Association
    • Tim Storey, Executive Director – National Conference of State Legislatures
    • Delos Gosgrove, MD – Former President/CEO, The Cleveland Clinic Foundation
    • Ron Williams, Former Chairman/CEO, Aetna
    • Mary Wakefield, RN, Ph.D. – Past Deputy Secretary, US-DHHS
    • Senator Bill Frist, MD (R-TN) – Physician and Former Senator, the State of Tennessee
    • Richard Besser, MD – President/CEO, Robert Wood Johnson Foundation
    • Karen Daley, RN, Ph.D. – Past President, American Nurses Association
    • Derrick Johnson, President, NAACP
    • Catalina Experanza Garcia, MD – Physician and Founder, Dallas Women’s Foundation
    • Leanna Wen, MD – Health Commissioner, City of Baltimore
    • Maura Healy (R-MA) – Attorney General, State of Massachusetts
    • BUT, THESE ARE JUST SOME INITIAL THOUGHTS. I’m absolutely positive there are others that should be added to the list AND, I’m confident that these leaders would be responsive to a call for “help”. After all – it would be the President of the United States calling :-)  . Who would not want to receive such a call – from any President…regardless of your political perspective! It’s our duty as American citizens.
    • And, finally – don’t be offended if you’re not on the above list. More later…as always!

The Occasional Consideration - 6/24/20

Periodic Meanderings and Ideas Deemed Important by the Author… 

From Listening to Hearing to Learn and Act – So much has happened since my last report in May – so much so that it’s a bit difficult to figure out where to start.  This blog is about health and healthcare so it makes sense that the “health” of everyone should be a concern for all of us in the health care field. So, here goes…

First, it appears to me that we are moving to a new era. Father Richard Rohr from the Center for Action and Contemplation refers to it a “liminal” time derived from the Latin word “Limen”, meaning “threshold” where we pass from one era to another – and, as we enter a period of protracted uncertainty. We’ve had other periods like this in history. Consider the shift from living as hunter-gatherers to living in tribes or small groups. Having been involved in the formation of many groups over the years, I’m sure that for many such groups there was lots of consternation and struggles when it came time to figure out who was going to be the leader. Another example is the Industrial Revolution which extended over a period of about 90+ years. And, now, we are at the formative stages of the Digital Revolution. We are going from a world where societies have placed artificial lines in the sand and dirt to an interconnected world where boundaries are not so clear at all.  And, given the connectivity that exists as a result of the Digital Revolution – it seems to me that as a people, as a society, as a global community we are moving from an all-about-me mentality slowly toward an all-about-us way of thinking. Now, if that is the case, we clearly need to be thinking about the needs of all of us – not just some of us – as we move through this passage to a new state of being.

It is within this context as we move through “Our Liminal Time” that essential requirements will necessarily percolate to the top.  The first requirement is for us to LISTEN to one another – all reasonable perspectives, all reasonable considerations and all reasonable solutions. Embedded within that notion is a very robust conversation around what is “reasonable”. From my perspective “reasonable” will percolate up and be distilled through societal conversation. The second requirement is for all of us to HEAR what we are saying. Essentially, I’m arguing that we need to be TALKING TOGETHER so that we can create an environment or culture of togetherness. Once we accomplish this objective, there are two more essential requirements. We need to LEARN from the moment. In fact, the argument can be made that we will have no “learning” if we will have no “finding”.  Then, the final requirement comes into play – and, that is ACTION

These thoughts need to be at the forefront of our conversations in the healthcare community as we grapple with racism, disparities, police violence and other considerations that impact the health of the people.  For example, there have been many editorial pieces and scholarly articles on racism over the years which highlight the intolerable differences in care delivery, access, treatment and a host of other considerations. I raise the issue of racism because it is clearly front of mind for many of us AND, most importantly, the requirements I’ve outlined above have not occurred in a sufficiently robust manner by those of us in leadership roles in the healthcare community. We’ve listened – sometimes. We’ve heard – on occasion. We’ve learned and documented but the final requirement has not been front and center. ACTION has not occurred. 

And, ACTION will not occur by simply reading this editorial consideration. It will require all of us to “do” something. So, I encourage all of you to be on the alert to potential avenues for how you can make a difference. Whether it’s in your department, across your organization, in your community, throughout society or by making changes in attitude, in programs, in policy, in funding – we each need to do our part for creating and fostering ACTION to solve the problem of racism. You will not be alone if you decide to pick up the mantle of change. Think about it.

Our new evolving society requires this conversation if we are going to be successful in creating an “all-about-us” mentality. And, it’s clear that our society does not end at the edge of the Rio Grande River, the Atlantic or Pacific Ocean, or the Great Lakes region or the vast prairie line in North America. If we want to retain our position as the shining beacon on a hill (NOTE the change from “city” to “beacon” in my reference) – now is the time to step forward by cleaning our own house and showing the world what “us” is all about.  Health care is not a sideline consideration. It is central to the question and the resolution of the issues we’ve allowed to fester for far too many decades…

Mark My Word – When Congress passed the $1.8 trillion package as a stimulus to help the economy stay afloat as a result of the current pandemic crisis, I was truly amazed.  It was more than double the size of the stimulus package passed when the economy collapsed in 2009 and almost as large as the entire 2019 Federal revenue generated by the nation (= $3.5 trillion). Where did all of the new money come from?  You guessed it – we borrowed it!  Now, I’ll be the first to say that this was a good decision on the part of Congress. Without their intervention, the nation would have gone into total hibernation which would have been bad not only for the nation but also the global community. So, the critical question that the Heritage Foundation recently asked is: Where do we go from here?

If one takes a hard look at the federal budget there are not a lot of places that politicians – who are prone to think of getting elected – can turn. The proverbial cookie jar is empty and only crumbs are available for distribution. We will clearly need a broader solution in the coming months and years. My prediction is: HEALTH CARE WILL BE FRONT AND CENTER AS THE MAJOR TARGET FOR FINDING REVENUE THAT CAN BE REUSED TO PAY FOR THE LOOMING DEFICITS. Health spending in the U.S. has continued to increase at a rate far faster than the economy or, about 4.6% (2018) to an unprecedented level of $3.6 trillion which is equivalent to $11,172 per person. There is no other broad area of the U.S. economy that has experienced such growth with much of it at the expense of the federal, state and local governments.

Now, I’m not advocating a slash and burn approach to health care. Far from it. We need a robust Medicare program. Medicaid is essential – especially given the magnitude of stress we are seeing with state budgets which makes the federal budget deficit pale in comparison in some states. Social Security is a benefit that is an expectation by society – among all age groups. Right there you have one-half of the federal budget.  Reducing funds for highways, bridges and infrastructure does not make sense based on many studies which show that the aging of our infrastructure will incapacitate the U.S. economy if something is not done soon. We could turn to the Pentagon but in the scope of things we are looking at nickels and dimes not dollars. Education is an absolute requirement if we want to be a leading nation (some of us would like to reclaim that title). And, that pretty much does it for areas where funds might be available. Which takes us back to health care…

I predict that we are moving toward a robust, spirited and radical conversation about moving health care from a fee-for-service (If-I-do-something-to-you-I-get-paid-for-doing-it) mentality to a value-based care delivery model (If-I-keep-you-healthy-and-prove-it-I-get-paid-for-doing-it). We’ve been tinkering around the edges and some regions of the country are moving more rapidly in this direction. But, just like the COVID-19 pandemic changed everything about how and where we eat, transportation requirements, what we wear and the like – so the deficit will push our policymakers in the direction of rapid change. The most reasonable solution on the horizon is value-based care. It’s a game changer and while it has been slow in coming – I predict that within five (5) years, the nation will have either radically moved toward value-based care or we will have nationalized the care delivery approach. There will be resistance on both sides but I believe many players will clearly be inclined to move toward such a model.  Medicare-for-All has been touted at the approach by some. It proposes placing the care delivery financing into the Medicare model. My approach is a CARE-for-All model which fully embraces value-based care delivery. For a copy of the white paper outlining this approach – send a note to This email address is being protected from spambots. You need JavaScript enabled to view it..  To bring closure on this perspective, I’ll quote the Heritage Foundation who stated unequivocally in their analysis mentioned above, the following point: “The stakes are high, with the prosperity of current and future generations hanging in the balance.”

The Occasional Consideration - 5/26/20

Periodic Meanderings and Ideas Deemed Worthy of Some Consideration… 

Kudos to Governor Doug Burgum – Some folks think I’ve become too partisan. The current times seem to bring that out in my considerations.  But, as a physician, I’m basically driven by facts and the current times don’t seem to place much weight on facts.  However, my friend – Governor Doug Burgum (R-ND) recently gave a speech making a plea the public that we should not tolerate any shaming of those who are wearing masks.  I want to express my public appreciation to him for stepping up to the plate, showing integrity for the kind of person he is (I know him) AND, most importantly, showing the public that the current pandemic and our response to it is NOT A PARTISAN ISSUE.  Go Doug!!!

The Teacher’s Song – If you have not seen "The Teacher's Song”, you should check it out.  It will lighten your day and help you to understand how many of us are managing the current situation :-) . I even saved it for those times when it seems I can’t take much more from the strains of the pandemic. You might even what to join in with the song.  It’s easy to learn. Enjoy!!

Planetary Health – Pope Francis declared May 16 – 24 “Laudato Si’ Week” as a note of remembrance during the current pandemic so that we would not forget about planetary health. This month is the 5th anniversary of his encyclical “Laudato Si: On Care for Our Common Home”. While we are currently focused on dealing with the short-term disruptions of the pandemic, we should not forget the longer term. Did you hear – Siberia (next to the Arctic Circle) was in the 80s this week! Argh!! Both events require a communal commitment and focus if we are going to be successful in helping and protecting our fellow humans across all nations.  In essence, to solve both problems, we need to work together rather than apart. Consider it. Working together will solve the pandemic. Working together will create planetary health. To this end, you might want to consider One Shared World – a site that is asking each of us to commit in whatever ways we can to sustaining planetary health.

Speaking of Longer Term – I wanted to pass along a very thoughtful piece from the March 25, 2020 issue in The Atlantic by Ed Yong on “How the Pandemic Will End”.  It’s a bit long but definitely worth the read. He provides an overview of the current state, how we are managing it and shares his thoughts on the longer term implications for us as individuals, as a society and as a nation. 

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