Henry V 4.3

“The vein rolled.”

This is how the medical student summarized his efforts to place one of his very first intravenous lines in an elderly hospitalized patient. He was successful on the second attempt, but reached for this classic explanation for the first failure. We learn early how easy it is to blame patients when things don’t go the way we expect.  Perhaps it’s how we cope with work in such a high-stakes business. And lest you think we have crested the hill and are on the downhill of this particular thinking, consider the following language recently heard from a resident physician:

“The patient was non-compliant.”

Medicine began the general migration from this term more than a decade ago, but you still hear it frequently when a patient’s response to his or her treatment regimen differs from the provider’s instructions. “Compliance” suggests a matching of patient behavior to provider recommendations.  “Adherence” is the preferred term and implies a match between patient behavior and the agreed upon regimen developed by both the patient and the provider. Adherence suggests that a dialogue has taken place and a set of behaviors (e.g. exercise, diet-modifications, medication) were agreed upon. Even of the patent fails to follow the regimen, at least he was a part of the decision.

There are other ways we reveal the same bias in our thinking. Patients who do not come to their appointments are called “no-shows.”  If they go to the emergency room for care instead, and do so frequently they are called “frequent flyers” or even as I heard recently, “PAUers” (PAU = Potentially Avoidable Utilization).  Interestingly we also tend to villainize the emergency rooms where they get care and the providers who care for them in the ER instead of recognizing their key role in providing patients access to care.

When we objectify patients language like this becomes acceptable. We forget that these are people with stories and refer to them instead as “teaching material” or “fascinomas.” From a business perspective we talk about “market-share” when we really mean people; people who need surgery or hospice, women who deliver babies prematurely, men suffering from prostate cancer. When we agree to see a patient who has come to the appointment late we are “rewarding bad behavior,” with no particular insight into why they might be late.

“They just don’t care” is something I heard recently from a provider. It is a troubling value judgment. And it may be the thought that is most concerning because it reveals how disconnected we have become from our patients’ lives.

American medicine in the mid nineteenth century was provided by practitioners who lived in the community with their patients. Healthcare was delivered in the home. In 1873 there were fewer than 400 hundred hospitals in the entire nation.  The transition to twentieth century medicine was fueled by gasoline. The introduction of the automobile allowed the physician to dramatically increase his productivity and efficiency. The transition was also accelerated by the invention and proliferation of the telephone. According to Professor Paul Starr (The Social Transformation of American Medicine, 1982) the first telephone exchange in the United States was established in 1877 to connect the Capital Area Drugstore  in Hartford Connecticut with 21 local doctors, so patients could contact the doctors and coordinate their visits. Provider efficiency increased but so did revenue, driving an even greater need for efficiency.

The transition has come at a cost and we continue to experience the repercussions.  Again from Professor Starr:

“The doctor of the nineteenth century was a local traveler who knew the interior of his patients’ homes and private lives more deeply than did others in the community. By the early twentieth century, many physicians went to work at hospitals or offices and had little contact with the homes or living conditions of the patients they treated. This radical change in the ecology of medical practice enabled physician to squeeze unproductive time out of their day.”

Unfortunately it also created a distance between patients, providers and health care systems that exists to this day. When patients in our inner city community talk about what they are looking for from their health care system they talk about trust.

The economy of medicine is ultimately relationship, and the currency of that economy is trust.

The vein may well have rolled. But the operator on the other end of the IV catheter is the one with the responsibility to explain why and then to attempt it again. If we can’t get the line we will find someone else who can.

There is a person and a people at the end of the IV needle.

And I suspect they are getting tired of being stuck.

Chuck Callahan Henry V 4.3 – Lead from the Front https://henryv43.wordpress.com/

Tumid.

I stumbled across this gem of a word recently while I was looking at an old translation of the Hebrew word for “proud” (`aphal) from a passage in the biblical writings of the prophet Habakkuk (2:4). When used anatomically, tumid means “swollen, distended, of a bulging shape or protuberant” from the Latin word “tumidus” derived from ”tumēre,” “to swell.” The Latin root is also the source of our word “tumor.” When used to refer to speech the word means inflated, pompous, or bombastic. How about “orotund” for another related beauty from the Latin word “ore,” or “mouth,” and “rotundo”  “to make round.”  It’s a good facial expression if you’re singing. Probably a bit pretentious if you’re not. These words have become illustrative of the current state of American politics.

Faith is one of the cardinal principles of leadership. The leader must be able to cast a vision and believe in something he or she cannot see; something that’s bigger than self or an organization. In addition to believing, the leader must also be believable so that others will see and believe the vision as well. This is where truth comes in.

Vision requires a balance between faith and the senses; between hope and the stark reality of the way things really are. One of the earliest lessons I learned in the practice of medicine was the tension between realism and optimism. It was reinforced repeatedly over decades in the practice of pediatric intensive care. The job of the clinician is to find the balance between hope and reality; to be honest about the risks and potential negative outcomes in a patient’s course but at the same time to recognize that there are almost always reasons for hope. Both are true and both are needed.

Leaders face the same dilemma, a tension that author Jim Collins called “The Stockdale Paradox,” based on lessons Medal of Honor awardee Admiral James Stockdale learned as a prisoner of war in Vietnam.  “This is a very important lesson.” Stockdale told Collins in an interview for the book Good to Great. “You must never confuse faith that you will prevail in the end—which you can never afford to lose—with the discipline to confront the most brutal facts of your current reality, whatever they might be.“ He told Collins, “I never lost faith in the end of the story. I never doubted not only that I would get out, but also that I would prevail in the end and turn the experience into the defining event of my life, which, in retrospect, I would not trade.”

The leader must seek and believe truth while balancing optimism and realism. As an example, when I helped lead a federal medical facility during the 2013 Sequestration our message was to acknowledge the awful betrayal these public servants felt toward the government and the potential impact on their lives of losing 20% of their income.  At the same time we tried in every meeting to recognize the incredible sacrifices they made for our patients. We told them we believed the crisis would see a prompt end because of their commitment and the relationship they shared with the families they served . We were right. It ended quickly.

But what if I had lied? What if I had told them something that I knew was untrue or something that they could easily ave confirmed as disingenuous? How would my words of praise or promise have been interpreted then? I suppose that out of loyalty they might have ignored the lies, or convinced themselves of the truth of something that any objective person could confirm was untrue. But thinking people would have seen through it. They would have known that what I was saying in my weekly town hall gatherings and frequent emails was tumid: bombast, hot air, empty promises without substance.

We must be thinking people; sensitive to the difference tumid and true when evaluating our leaders or when considering those whom we would chose to lead us, just as we do in our own leadership practice.

For the leader, neither volume nor verbosity can replace veracity.

Chuck Callahan Henry V 4.3 – Lead from the Front https://henryv43.wordpress.com/