Wednesday, August 15, 2012

Physicians, Humility and the Transformation of American Healthcare


“A disease and its treatment can be a series of humiliations, a chisel for humility”
                                                                                                                                           Laurel Lee
                                                                                                                                        
“Fullness of knowledge always means some understanding of the depths of our ignorance, and that is always conducive to humility and reverence.”                                 Robert Millikan

“Humility is nothing less but a right judgment of ourselves.”                                  William Law

“Early in life I had to choose between honest arrogance and hypocritical humility.  I chose the former and have seen no reason to change.”                                                Frank Lloyd Wright

“Humility is the foundation of all the other virtues hence, in the soul in which this virtue does not exist there cannot be any other virtue except in mere appearance.         Saint Augustine
                                                                                                                                 


Three physicians got me thinking about humility.

At the health care innovations summit in Washington, DC earlier this year, I heard Atul Gawande, MD call for medical schools to do a better job at training physicians in humility, discipline, and teamwork (http://careandcost.com/2012/02/03/notes-on-the-care-innovation-summit/).  In a 2010 Stanford School of Medicine Commencement speech, Dr. Gawande stated:

“And when you are a doctor or a medical scientist this is the work you want to do. It is work with a different set of values from the ones that medicine traditionally has had:  values of teamwork instead of individual autonomy, ambition for the right process rather than the right technology, and perhaps above all, humility – for we need humility to recognize that, under conditions of complexity, no technology will be infallible.  No individual will be, either.”

Eric Van De Graaff, MD wrote a blog titled “Why Are So Many Doctors Complete Jerks?” Dr. Van De Graaff was chagrined when his own mother was disappointed when he became a physician; she “had a deep-seated disdain for doctors.”  Dr. Van De Graaff answered his own question with two theories. His first theory was that some physicians “let the glory of their careers go to their heads and begin to treat patients and underlings like chewing gum on a movie theater floor.”  His second theory was that physicians act like jerks when emergencies occur and they feel overwhelmed and frightened.

Dr. Van De Graaff offers two simple rules, which he admits he sometimes does not follow:

“Rule #1:  It is simply not allowable to be impolite, mean, nasty, or snippy with staff or patients even when you are in a stressful situation.

Rule #2:  Whatever is stressing you is probably stressing those around you as much or more. Under those circumstances you have to go out of your way to be kinder and more understanding.  As a doctor, you control the mood in the clinic and operating room even if you can’t control the situation.” (http://www.kevinmd.com/blog/2012/08/doctors-complete-jerks.html)

A physician left the following comment on the above Van De Graaff blog post:

“Frustrations and stress mount, yes. I think in medicine we should be aware that continuing bad behavior is partially the responsibility of us all. We have social standards and maybe should ask ourselves how much have we allowed these actions to continue? None of us function in a vacuum.  We all have the ability to affect change and reward positive communication.”

How do we as a community of physicians respond to these three physicians who are clearly calling for physicians to exhibit more humility in our practice of medicine?  Do we know how to affect this change in behavior in our colleagues and ourselves?  T. S. Eliot once wrote, “Humility is the most difficult of all virtues; nothing dies harder than the desire to think well of oneself.” (‪Shakespeare and the Stoicism of Seneca.‬ ‪An address read before the Shakespeare Association 18th March, 1927)‬

The English words humility and humble are derived from the Latin noun humilitas and the adjective humilis which can be defined as grounded, from the earth, respectful, unassuming, modest, and low.  Humility is often contrasted with the terms pride, haughtiness, and arrogance (See the Frank Lloyd Wright quotation at the beginning of this post).  Humility has been held up as a virtue in both religious and ethical writings. 

Pride and arrogance are commonplace among physicians and provide the punch line for the famous New Yorker cartoon where a physician goes to the front of the line in heaven “because he thinks he is God.” In the Christian tradition, part of humility is self-knowledge about the limits of one’s own skills, knowledge, and authority.  (http://www.wikihow.com/Be-Humble)  When a professional like a physician or a teacher does have superior content knowledge when compared to the patient or the student, arrogance is an all too common attitude.  Bertrand Russell was talking about teaching, but his lesson applies to physicians as well:

“In the presence of a child [the teacher] feels an unaccountable humility – a humility not easily defensible on any rational ground, and yet somehow nearer to wisdom than the easy self-confidence of many parents and teachers.” (http://www.williamhare.org/assets/hare_humilityasvirtue.pdf)

The Harvard psychiatrist Robert Coles thought the greatest achievement of his mentor physician/poet William Carlos Williams “was to teach doctors honest self-scrutiny, to show how ‘we become full of ourselves, self-preoccupied, so caught up in either our importance or our own affairs that we can’t listen and pay attention to other people, even our patients at times.’”  (Carlin Romano. America the Philosophical, New York:  Knopf, 2012).

Honest self-scrutiny of physician limitations is particularly relevant now that medical group practices, hospitals, and integrated delivery systems are undergoing process work redesign in order to respond to federal health care and payment reform.  Socrates criticized craftsmen and poets for assuming that the knowledge and expertise they acquired in one area meant that they were experts in any area under discussion. (http://www.williamhare.org/assets/hare_humilityasvirtue.pdf)   Having sat in on many lean workgroups, there is a tendency for physicians to pontificate on subjects about which they know little. 

Another component of humility in Christian teachings is the recognition of the contributions and skills of others (http://www.wikihow.com/Be-Humble). Dr. Gawande has spoken eloquently about how traditionally medicine has emphasized   independence and autonomy (acting like cowboys) and how the complexity and need to decrease per-capita costs now require physicians to work effectively in interdisciplinary teams, even when they are not the designated leaders (acting like pit crews) (http://page2anesthesiology.org/2011/teamwork-humility-and-generosity-opening-session-with-atul-gawande-m-d/) In my experience consulting with physician groups, I have noticed that doctors are much more willing to listen to another physician, rather than a non-physician advisor who may have more content expertise relevant to the problem under discussion.  Developing more skill in this component of humility would help develop effective and efficient teams. 

If the physician does not maintain the correct balance between authority and humility, difficulties can arise in taking the patient’ s story and wishes seriously or in not critically assessing the patient’s wishes that may be unknowingly harmful to his health.  Dennis Gunning discusses this ideal balance in teaching history:

“It is hard for a teacher not to feel uneasy when faced with a fourteen-year-old giving an unorthodox interpretation of a piece of source material.  We really have to school ourselves not to ‘put him right’, not to sweep his interpretation aside (or, equally bad, apparently accept it, but in such a way that everybody knows that we are just humouring the student.)” (http://www.williamhare.org/assets/hare_humilityasvirtue.pdf)

One does not have to recall that the first definition of doctor in the Oxford English Dictionary is “teacher, instructor; one who gives instruction in some branch of knowledge” to see how Gunning’s advice might apply to the physician/patient relationship. 

How difficult and important this balancing act can be for physicians is highlighted by our need to continuously improve the care we give our patients.  Henry Sidgwick in 1874 commented on how strange it is for those who are experts to embrace a humility that requires a low opinion of one’s self. Would it make more sense to try for an accurate appraisal of one’s abilities? “Sidgwick suggested that the value of humility lay in its ability to temper the emotion of self-admiration, and to prevent appropriate self-esteem…from turning into self complacency.” (http://www.williamhare.org/assets/hare_humilityasvirtue.pdf) Sidgwick believes that those who lack humility will exhibit self-satisfaction and complacency that will prevent the recognition of the need for continuous improvement. 

When organizations need to change behavior, they rarely consult philosophers and theologians about humility; they usually look to rules with some sort of policing mechanism and incentives.  And we now have hospitals and payers instituting rules governing physician conduct, pay for performance incentives, and patient satisfaction surveys to encourage us to improve.  I have described elsewhere why physician report cards are fraught with difficulties (http://thehealthcareblog.com/blog/2010/08/21/trust-me-im-a-doctor-vs-physician-quality-report-cards/ and http://kentbottles.blogspot.com/2010/08/physician-quality-report-cards-part-ii.html) and why pay for performance programs often fail (http://www.kentbottles.com/pdfs/Pay-for-Performance-Why-It-Will-Not-Work.pdf). 

Barry Schwartz and Kenneth Sharpe in Practical Wisdom: The Right Way to Do the Right Thing (New York:  Riverhead Books, 2010) make a convincing argument that hospitals and medical groups should add training in practical wisdom in addition to their rules and incentives.  Drawing upon Aristotle’s Nicomachean Ethics, they think physicians need to be able, with humility, to choose between “right things that clash, or between better and best, or sometimes between bad and worse.”

“Rules can’t tell experienced practitioners how to do the constant interpretation and balancing that is part of their everyday work. Consider the doctor who has been well educated in the rules of how to practice medicine, but is constantly called on to make more complicated decisions.  How should such a doctor balance respect for the autonomy of her patients when it comes to making decisions with the knowledge that sometimes the patient is not the best judge of what is needed? How should the doctor balance empathetic involvement with each patient with the detachment needed to make sound judgments?... How should the doctor balance the desire to tell patients the truth, no matter how difficult, with the desire to be kind?”

Schwartz and Sharpe teach us that practical wisdom “depended on our ability to perceive the situation, to have the appropriate feelings or desires about it, to deliberate about what was appropriate in these circumstances, and to act.”

My favorite example of practical wisdom is their discussion of a hospital janitor who cleans the room of a comatose young man and then later is confronted by the patient’s father who claims the room has not been cleaned.  The janitor exhibits practical wisdom by remembering that his goal is to care and comfort patients and their families, and so he cleans the room again so the father can see him do it.

“And when the angry father confronted him, Luke also had to sort out conflicting aims.  There were other legitimate things he might have chosen to do.  Be honest:  tell the father he had cleaned the room already.  Be courageous:  stand up to the father’s anger and refuse the unfair demand to clean the room again.  But Luke had to determine how to balance these competing aims in this circumstance.”

It seems to me that a better and deeper understanding of humility by the physician community of the United States would serve all of us well in this time of rapid change and health care reform. 






Thursday, August 9, 2012

Does Luck Contribute to Personal Success?


Romney pouncing on Obama’s statement “you didn’t build that” got me thinking about success and luck and community.  Romney took Obama’s words out of context and contends that the President is hostile to successful small businesses and always looks to government for the answers. 

When the entire quotation is examined, it is clear that Obama is saying that successful people are helped “by personal mentors and government policies that support infrastructure and technology.”  Here is what the President said in Roanoke, Virginia on July 13, 2012:

“If you were successful, somebody along the line gave you some help. There was a great teacher somewhere in your life.  Somebody helped to create this unbelievable system that we have that allowed you to thrive.  Somebody invested in roads and bridges.  If you’ve got a business, you didn’t build that. Somebody else made that happen.” (http://www.washingtonpost.com/politics/as-romney-obama-spar-over-you-didnt-build-that-small-businesses-add-context/2012/07/25/gJQA6IN79W_story.html)

What interests me here is not the election speeches and ads; what interests me is the expression of two different views of American culture. 

“One narrative puts the big gamble at the center of American life:  from the earliest English settlements at Jamestown and Massachusetts Bay, risky ventures in real estate (and other less palpable commodities) power the progress of a fluid, mobile democracy…. The other narrative exalts a different sort of hero – a disciplined self-made man, whose success comes through careful cultivation of (implicitly Protestant) virtues in cooperation with a Providential plan.” (Jackson Lears, Something for Nothing. New York: Penguin Group, 2003)

In the first narrative, luck contributes to success or failure and net worth may not correlate with moral worth.  In the second, luck does not play a role in success and net worth in this world does reflect moral worth. 

Conservatives regard success in the marketplace as due to the individual’s hard work and skill.  Liberals believe that hardworking folks can fail because of bad luck and events beyond their control.  No wonder Romney and Obama are arguing over what causes success or failure. (http://www.nytimes.com/2012/08/05/business/of-luck-and-success-economic-view.html)

When I read Daniel Kahneman’s superb summary of behavioral economics, Thinking, Fast and Slow, (New York: Farrar, Straus & Giroux, 2011) I was surprised to find two formulas dealing with success.  Kahneman describes these two formulas as his favorites:  “Success = luck + talent; Great success = a little more talent + a lot of luck.”  He also states, “Luck plays a large role in every story of success; it is almost always easy to identify a small change in the story that would have turned a remarkable achievement into a mediocre outcome.”

Recent research on online markets concludes that the link between quality and success is uncertain.  The best products sometimes fail, and the worst products sometimes succeed.  Success in the marketplace for products that are not the best or the worst is mostly due to luck. 

In the research, a control group listened to music by obscure bands and rated them without knowing what others thought of the songs.  The researchers then compared the results of the control group with results from eight other versions of the study where participants could see how many times each song had been downloaded and its average rating.  The researchers concluded that if a few early listeners disliked the song it would fail.  If a few early listeners liked the same song it could go on to be a winner in the contest.  “The song ‘Lockdown,’ by the band 52 Metro, is a case in point. Ranked 26th out of 48 in the objective ratings, it finished at No. 1 in one of the eight groups, but at No. 40 in another.” (http://www.nytimes.com/2012/08/05/business/of-luck-and-success-economic-view.html)

Michael Lewis, the enormously successful writer of books like Liar’s Poker and Moneyball, gave the 2012 commencement speech at his alma mater, Princeton.  He described how an art history major ended up at 28 years old the author of a best selling business book with a little fame, a small fortune, and new life narrative.

“Even I could see there was another, truer narrative, with luck as its theme.  What were the odds of being seated at that dinner next to that Salomon Brothers lady? Of landing inside the best Wall Street firm from which to write the story of an age? Of landing in the seat with the best view of the business? Of having parents who didn’t disinherit me but instead sighed and said, ‘do it if you must?’ Of having had that sense of must kindled inside me by a professor of art history at Princeton?  Of having been let into Princeton in the first place?”

Later in the speech, he observes that the true narrative of his successful career makes many in America uncomfortable.

“People really don’t like to hear success explained away as luck – especially successful people. As they age, and succeed, people feel their success was somehow inevitable.  They don’t want to acknowledge the role played by accident in their lives.  There is a reason for this:  the world does not want to acknowledge it either.” (http://blogs.ajc.com/get-schooled-blog/2012/06/09/author-michael-lewis-commencement-speech-lucky-you/)

It is hard to imagine Mitt Romney giving a similar commencement speech. It is easy to identify Romney with the narrative that has no place for luck in the story of his personal success. Romney clearly believes in the dominant culture of control where everything from universities to medicine is valued by the marketplace.

“The new rhetoricians of progress believed that their success was the product of a meritocratic process, that they were the type who took chances successfully, that their superior skill and drive allowed them to make their own luck – and that history was on their side.  This is a fair summary of the dominant mood within managerial professional elites, amid the triumphalist atmosphere of the American fin de si├Ęcle.  (Jackson Lears, Something for Nothing. New York:  Penguin Group, 2003)

Contrast that point of view with Tim Berners-Lee who invented the world wide web without cashing in to become a millionaire.

“People have sometimes asked me whether I am upset that I have not made a lot of money from the Web.  In fact, I made some quite conscious decisions about which way to take my life. These I would not change…. What does distress me, though, is how important a question it seems to be maddening is the terrible notion that a person’s value depends on how important and financially successful they are, and that that is measured in terms of money.  That suggests disrespect for the researchers across the globe developing ideas for the next leaps in science and technology.  Core in my upbringing was a value system that put monetary gain well in its place, behind things like doing what I really want to do.  To use net worth as a criterion by which to judge people is to set our children’s sights on cash rather than on things that will actually make them happy.”
(Tim Berners-Lee, Weaving the Web:  The Original Design and Ultimate Destiny of the World Wide Web by Its Inventor. San Francisco:  Harper, 1999)

In the afterword to the 25th Anniversary Edition of The Gift:  Creativity and the Artist in the Modern World (New York: Vintage, 2007), Lewis Hyde describes why he wrote his book about the parts of the world that do not work well under the marketplace theory:

“The first is simply that there are categories of human enterprise that are not well organized or supported by market forces.  Family life, religious life, public service, pure science, and of course much artistic practice:  none of these operates very well when framed simply in terms of exchange value.  The second assumption follows:  any community that values these things will find nonmarket ways to organize them.  It will develop gift-exchange institutions dedicated to their support.”

The Gift is a great place to start thinking about the tension between the two narratives described in the beginning of this blog post.  The current tension in the medical scientific community between knowledge being a gift or a commodity is nicely summarized in this quotation by MIT Geneticist Jonathan Kind:

            “’In the past one of the strengths of American bio-medical science was the
free exchange of materials, strains of organisms and information…But now, if you sanction and institutionalize private gain and parenting of microorganisms, then you don’t send out your strains because you don’t want them in the public sector.  That’s already happening now. People are no longer sharing their strains of bacteria and their results as freely as they did in the past.’”

Those of us who have won Warren Buffett’s “ovarian lottery” and have experienced a modicum of worldly success might living in the United States of America should constantly remind ourselves that we are indeed lucky.  We should heed the conclusion of Lewis’ commencement speech:

“You are the lucky few.  Lucky in your parents, lucky in your country, lucky that a place like Princeton exists that can take in lucky people, introduce them to other lucky people, and increase their chances of becoming even luckier. Lucky that you live in the richest society the world has ever seen, in a time when no one actually expects you to sacrifice your interests to anything.” (http://blogs.ajc.com/get-schooled-blog/2012/06/09/author-michael-lewis-commencement-speech-lucky-you/)


           






Monday, August 6, 2012

Activated, Empowered Patients Are Not New


One of the most inspiring athletes of the 2012 London Olympics is American swimmer Dana Vollmer who won the gold medal in the 100 meter butterfly by being the first woman to finish that event in less than 56 seconds.  Vollmer exemplifies the engaged, empowered patient, and her story reminded me of three such patients who took charge of their health long before there was a formal participatory patient movement.  These three pioneers were President Franklin Delano Roosevelt, writer Norman Cousins, and actress Patricia Neal.

When Vollmer at the age of 15 was diagnosed with long QT syndrome, it most likely meant the end of her competitive swimming career.  The usual treatment for this genetic cardiac electrical disorder that can cause sudden death due to supraventricular tachycardia is to implant a defibrillator in the heart.  The risk of sudden death in competitive athletes with this syndrome is up to three times greater than in sedentary patients. 

However in a dramatic example of how treatment must be tailored to the individual patient, Vollmer and her family decided to continue competitive swimming training and to always have an external defibrillator available should the need arise.  It never did, but still the diagnosis weighed on Vollmer’s mind:

“’I could die, my heart could just stop…There were definitely times it was scary, as much as I tried to block it out. If I got lightheaded, I would associate it with long QT,’ she says.  Part of Olympic training involves underwater work, and for Dana, having to hold her breath to the point of feeling lightheaded was one of the hardest things to do. ‘Slowly but surely I never fainted and never had symptoms.  It just got further and further from my mind.’”  (http://well.blogs.nytimes.com/2012/07/31/overcoming-a-heart-condition-to-win-olympic-gold/)

After being told by Boston Children’s Hospital expert Dr. Robert Lovett that there was nothing he could do for the patient’s polio, Franklin Delano Roosevelt created his own rigorous exercise rehabilitation program. When he purchased a hotel and pool facilities in Warm Springs, Georgia, other polio victims came to participate in his unique exercise program that took place in the warm springs pools. Roosevelt even published his clinical experience in the Journal of the South Carolina Medical Association and proposed that he present his work at the 1926 American Orthopedic Association annual meeting.  When the meeting planners rejected his proposal, FDR went to the meeting anyway and “secured a commitment from the orthopedists to evaluate the Warm Springs program.  The association made good on its promise and confirmed the program’s positive effects.”

“’During that first year, I was doctor and physiotherapist rolled into one,” FDR would later boost.  David Blumenthal and James A. Morone in The Heart of Power:  Health and Politics in the Oval Office (Berkeley:  University of California Press, 2009) concluded their discussion of this most empowered patient by writing, “No president has ever come closer to practicing medicine without a license than Franklin Delano Roosevelt did in the 1920s in rural Georgia.”

Norman Cousins, the editor of the Saturday Review for 35 years and the author of 15 books, described in Anatomy of An Illness as Perceived by the Patient (New York: WW Norton, 1979) how he decided to treat his ankylosing spondylitis by checking out of the hospital and into a hotel to watch Marx Brothers movies.  He stated, “Medical treatment is a 20-point partnership – the physician has 10 points, the patient has 10 points.  If patients are given the idea that they can do something, they take the treatment better.” (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2154152/) After the publication of his book, Cousins joined the faculty of UCLA School of Medicine where he examined the usefulness of patient engagement and “’found myself being pushed into the role of ombudsman for patients who were complaining about their treatment.’” ((http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2154152/)

In 1965 the 39-year-old film actress Patricia Neal suffered a severe stroke that resulted in a coma that lasted two weeks.  When she woke up unable to speak, unable to walk, and paralyzed, her neurosurgeon said, “’I don’t know if I’ve done you a favor’” by keeping you alive.  Neal’s husband, novelist Roald Dahl, improvised “a rigorous program of confronting her with tricks, games, and puzzles to improve her memory and speech.” (http://www.nytimes.com/1981/12/08/arts/tv-patricia-neal-s-victory-over-crippling-stroke.html) By not giving up and by not listening to the advice of their physicians, Dahl and Neal changed the way stroke patients are treated and eventually supported a special rehabilitation department in her hometown of Knoxville, Tennessee. Two years after her stroke, Neal starred in the movie The Subject Was Roses.

Vollmer, FDR, Cousins, and Neal all remind us that activated, engaged patients do better clinically and often can surprise themselves and their doctors by their efforts.