Sabbatical 2014

July 2014
Sabbatical Notes

Between my Army retirement and before starting work as a medical school professor we have had the luxury of scheduling four or five months to focus on “pragmatism and principle.”  As to the former, the business and psychology of separating from something you’ve done for three decades takes time and introspection;  more than I would have expected.  We also had to find new work, a new place to live in addition to celebrating a college graduation, high school graduation and relocation of several children.  The time also included updating medical certification’s, studying pulmonology, reading Rick Atkinson’s “Liberation Trilogy” and a dozen other books.  From the standpoint of principle and philosophy, it is has been a reasonable time to rest and reflect. Sir William Osler recommended to all his medical colleagues that they take time away from medicine to rest, to “maintain mental freshness and plasticity” and to cultivate “a deep and enduring interest in the manifold problems of medicine, and a human interest in the affairs of our brotherhood.”

The first major event of this time of “rest” was a backpacking trip in the Grand Canyon with my daughters Bethany and Christine.  The second was three weeks working as a pediatrician in a mission hospital in rural Togo with my daughter Christine, who is entering her senior year of nursing.   There were leadership observations from both.

May 15, 2014
There’s a reason they call it “Grand.”

I last hiked the Grand Canyon twenty four years ago, the year before my twin daughters were born.  I suspect I will not be doing it twenty four years from now with my grandson or granddaughter.  Several brief reflections were made during the long hours of walking: twenty miles and ten thousand feet elevation in descent and ascent over three days in mid-May.

1)  It can be pretty hard.  My most quoted line may well be originally (and embarrassingly) from the movie “Stripes:” “How hard can it be?”  A Tripler PICU colleague and I bantered that line around as we cared for children from the South Pacific with rare tropical diseases most American doctors had never seen before.  When applied to a very challenging task like hiking in the Grand Canyon, I discovered: “Actually, it can be pretty hard.”  It is good to be optimistic and positive.  But balancing the tension between realism and optimism in leadership can be difficult.  We have to find the middle spot: optimistic about the outcome, but realistic about the resources and efforts it will take to get there, a concept Jim Collin’s calls the “Stockdale Paradox” in his 2000 book, Good to Great.

2) Physiology trumps.  Climbing back out of the Canyon in hot mid-afternoon sun was the hardest thing I had ever done physically.  I think I have reasonable aerobic conditioning, but with my heart pounding in my chest I could not understand why the climb was so difficult.  Somewhere short of the South Rim it dawned on me.  It was a combination of factors:  salt and water loss (despite efforts toward replacement), exhaustion, and insufficient caloric consumption (2000 Kcal burned on the hike out alone).  Most importantly it was something my daughter pointed out, something a pulmonologist should have thought of earlier:  we were ascending to an elevation above six thousand feet.  At six thousand feet, the percent of oxygen tension in the air is nearly one third less than sea level. We are limited by physiology.  Sometimes the source of challenges and difficulty may be natural and right beneath our noses (or in them!)  It may require listening to others to see them.

3) FOMO.  The hike was an invaluable time with my adult daughters.  It was three days without the of distraction digital devices.  I had the chance to really talk and listen (as best as I was able!) with representatives of a generation that we older baby-boomers sometimes lament about in the workplace: lack of focus, distractibility, etc. They really seem to live what has been called “FOMO (Fear of Missing Out), a form of social anxiety that Sherry Turkle writes about in her book Alone Together.  My daughters helped me to see that FOMO may be mislabeled and is more than the “fear of missing out.”  It is really the “Fear of Missing Others;” a deep and abiding need to be connected.  We can criticize and be skeptical but I suspect that we can also learn alongside these amazing young people how to leverage this need for connectedness into new ideas for industry, for service, for health care and for community.  It is going to take dialogue. And we may need to turn off our devices long enough to have the conversation.

June 15, 2014
I didn’t even know where Togo was…

When we thought of the idea of trying to serve somewhere together this year, my daughter asked me to look for a place on the coast of West Africa where she could use her French.  I looked on-line, found a need for a pediatrician and signed us up to serve in Ghana, the only English speaking country on the West African coast (!)  Six days before we were due to travel we were rerouted to Togo, the country immediately east of Ghana.  (This necessitated a border crossing which went well but was a story all by itself.)

The Togolese Republic is a small, French speaking country in tropical West Africa with a population of 6.7 million and a per capita income of $584/yr.  The Hôpital Baptiste Biblique (HBB) was opened as a 40 bed inpatient and ambulatory facility in 1985 by the Association of Baptists for World Evangelism to serve the people of rural southwest Togo around the city of Adéta, two hours north of the capital city Lomé.  We had the good fortune of working with a dedicated team of full-time and short-term missionary providers including two pediatricians, one of whom was a former naval officer and graduate of the military’s Uniformed Services University of the Health Sciences in Bethesda, Maryland.   We had the even greater fortune of caring for wonderful people from all walks of life, many of whom were ill with diseases I had never cared for before including malaria, amoebic dysentery, and typhoid.

I felt like the three weeks were a kaleidoscope of my thirty years in medicine: attending deliveries and practicing general pediatrics, consulting on complex pulmonary diseases, caring for critically ill children and thinking through the administrative challenges of running a hospital in a “lean” country (a term preferred to “developing” based on Dayo Olopade’s 2014 book The Bright Continent.  It is a refreshing view of the continent for anyone interested in Africa).

We are entering what we might be a potentially “lean” season in American Medicine.  (The term is almost ridiculously inappropriate in comparison to Africa.  Our leanest times will still leave us leagues ahead of any West African nation.)  Still, there are lessons from these brief three weeks that might apply to the journey we have before us in US health care.

Flexiblity.  The medical staff at HBB was flexible in providing what care was needed within the scope of their expertise.  Family practitioners delivered babies and those with the appropriate training and experience performed caesarian sections.  Visiting surgical and medical subspecialists als provided basic surgery and primary care.  In the military, pediatric subspecialists are expected to maintain expertise and supervise residents practicing general pediatrics.  Could American medical and surgical subspecialists adopt enough of a primary care mindset so that we could perceive and address the needs of patients whenever they touch the health care system?

Dedication and patient-focus.  I am not sure that I have met harder working health care professionals than those at HBB:  nurses, support personnel, administrators and providers.  Since many had raised their own support, or were paying to be able to travel and practice in West Africa, the personal incentives were different than one might encounter routinely in a U.S. practice.  But we clearly agree on one thing.  Many of us have been inspired by the motto of the Mayo Clinic: “The needs of the patient come first.”  This was the overriding principle behind the practice at HBB.  While we talk about this concept in American health care, how often are we willing to really ask and address what our patients need and want: Access to providers by text-messaging?  Appointments that fit the family’s schedule instead of our own?  Regular inter-disciplinary patient conferences for select, complex patients that include all the appropriate specialists, the patient and the patient’s family?

Innovation.  By necessity a number of adaptations had to be made to practice in this part of the world.  Premature babies with breathing difficulty were treated at HBB with a simple, locally-developed continuous positive airway pressure system that worked.  Equipment was routinely, effectively and safely used for a range of different purposes.  Intravenous fluid was made and sterilized in the hospital as were the gauze 2×2 and 4×4’s for surgery and dressing changes.  Our health care system seems at times to be almost addicted to buying the newest health care gadgets.  Perhaps we could learn to use the remarkable technology we already have in new ways.

Courage.  There were many gravely ill patients with complex medical and surgical diseases cared for by the staff at HBB while I was there.  In most cases these were patients for whom the providers at HBB were their only hope.  The list included children with cancer, infants with congenital defects, and adults with end-stage renal disease.   The providers consistently demonstrated the courage to attempt to care for these desperately ill patients.  They also had the courage to tell patients when there was nothing more that could be done. Some of us could learn from our colleagues (as well as from the Dartmouth Atlas of Health care, perhaps) and demonstrate the same courage to talk about outcomes before we recommend a diagnostic or therapeutic intervention that is likely to make no difference in the patient’s ultimate survival or quality of life.  The staff also had the courage to consistently address the needs of the whole patient: physical, emotional and spiritual.

In my view, the mission of the HBB hospital in Togo is to demonstrate the example of Jesus in caring for the people of that nation.  The New Testament writers consistently used the word θεραπεύω (therapeuō, the root of our word “therapy”) to describe Jesus’ healing: “I will come and heal him.” (Matthew 8:7).  The word θεραπεύω includes physical healing; the resolution of symptoms.  But it also implies a degree of well-being inconsistently found in American health care: to care for, to serve, and to restore.

We would do well as our own system evolves to recognize that we need all of these elements in the American health care.

Health is more than healing.  Well-being is more than merely feeling well.
I was reminded in Africa that we still have a long way to go.

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