Saturday, November 27, 2010

Gratitude and Health, Happiness, and Well Being

Although Cicero identified gratitude as the chief virtue and religious traditions have long used specific prayers to nurture this practice, social science has only recently studied the effect of gratitude on wellness. “Scientists are latecomers to the concept of gratitude. Religions and philosophies have long embraced gratitude as an indispensable manifestation of virtue, and an integral component of health, wholeness, and well-being,” writes UC Davis’ Robert Emmons. (

Emmons defines gratitude as “a felt sense of wonder, thankfulness, and appreciation for life.” Cultivating gratitude involves concentrating on the present moment and recognizing others who have contributed to where you are today. (

Inspired by the Positive Psychology Movement which concentrates on developing human strengths rather than treating mental illness, Emmons and his colleague Michael McCullough at the University of Miami pioneered rigorous study of how gratitude can effect human health. Their landmark studies involved contrasting the psychological, physical, and social well being of subjects who wrote down five things that they were grateful for with subjects who kept track of five complaints about their lives. (

Adults who cultivate gratitude have more energy, more optimism, higher earnings, more social connections, more happiness, more sleep, more exercise, and more resistance to viral infections than those who do not. They are also less likely to be depressed, envious, greedy, or alcoholics. ( Although the first research subjects were university students, Emmons has now repeated similar experiments with several others including organ transplant recipients, adults with chronic neuromuscular disease, and healthy fifth-graders. (

Jeffrey J. Froh at Hofstra has extended this line of research by studying children. Grateful children are less materialistic, get better grades, set higher goals, complain of fewer headaches and stomach aches, and feel more satisfied with their friends, families, and schools than children who do not practice gratitude. (

Sonja Lyubomirsky of UC Riverside describes eight ways that gratitude can boost happiness. Grateful thinking promotes the savoring of positive life experiences; savoring is defined as behaviors capable of “generating, intensifying, and prolonging enjoyment.” Cultivating gratitude bolsters self-worth and self- esteem. People who are grateful cope better with stress and trauma. Expressing gratitude encourages moral behavior. Grateful thinking encourages and strengthens relationships with others. People who express thanks are less likely to make invidious comparisons with others. Expressing gratitude deters anger, bitterness, and greed. Gratitude counteracts hedonic adaptation, which explains why the happiness we experience after a positive event is so short-lived. (

Several leaders of the Positive Psychology Movement have developed scientifically based exercises to help us cultivate gratitude. Martin Seligman suggests writing a one-page testimonial to someone from your past who has made a major positive difference in your life. Meet with them in person to read out loud your essay and then reminisce together about your past history together. ( Lyubomirsky recommends keeping a gratitude journal where you regularly record your blessings. ( Emmons writes about watching your language because disparaging words reinforces negativity, and he also suggests learning prayers of gratitude if you are religious. ( A Buddhist exercise instructs people to ask themselves the following questions daily: “What have I received from…? What have I given to…? and What trouble have I caused…?” (

Emmons believes all can have a more grateful approach to life, but it requires hard work. One who practices gratitude cannot be a victim or entitled. In order to cultivate this practice one must be able to recognize one’s shortcomings and dependence on others. “Far from being a warm, fuzzy sentiment, gratitude is morally and intellectually demanding. It requires contemplation, reflection, and discipline. It can be hard and painful work,” writes Emmons. (

Anyone who knows me or has worked with me knows that my nature can be sarcastic and cynical. I have a lot of work to do in this area, but I am trying it out; it works. I am especially working on a better sieve mechanism to prevent the almost spontaneous generation of disparaging and sometimes accurate words to describe my world and fellow human beings.

Sunday, November 21, 2010

Hospitals Need To Focus On Culture In Order to Be Able to Survive in an Era of Accountable Care Organizations and Medicaid Reimbursement Rates

When a health system asked me to facilitate a Board discussion on physician alignment and integration on November 12, 2010, I was already committed to giving a keynote on the future of health care for the American Institute of CPAs in Las Vegas on November 11. Although I usually fly Delta or USAir where I have priority frequent flyer status, the only way I could get to the Board meeting was by flying from Las Vegas on Southwest Airlines.

My experience on Southwest reminded me of the importance of culture in navigating change in a rapidly evolving environment like we have in health care in the United States today. It is all too easy to focus on all the technical issues hospitals face in setting up Accountable Care Organizations to handle the inevitable global payments that will replace the current fee for service system. This blog is a plea for hospitals and doctors and consultants to pay attention to both the technical and the cultural or adaptive challenges we face in transforming a $2.5 trillion American industry.

Recent articles on companies outside of health care have highlighted how important culture has been to the success or failure of Southwest Airlines (, QVC (, and Zagat ( to respond to changing business conditions. Southwest’s COO states “our culture is our biggest competitive strength,” and the flight attendant and pilots’ union worry about how the recent purchase of AirTran will affect their unique culture. I have seen Southwest pilots help clean up the cabin, and the flight attendant on my recent trip told me she was giving up her day off because the company needed her help. QVC is trying to use the same methods and culture that made selling on TV popular with Internet customers. And Zagat, which had cultural troubles moving from book format to online, is now hoping that smart phone applications will reinvigorate their business model.

Harvard’s Ron Heifetz differentiates between technical and adaptive work (, and I have found this concept useful in working with health systems responding to payment reform. Everyone involved in hospital physician integration efforts will need to undergo a cultural (adaptive) shift because the healthcare reform law and the transition from fee for service to global payments mean the old ways of doing things are not sustainable. Even if all the technical tasks are superbly done, difficulties will arise if the leadership, management, care teams, and physicians still have the old mindset and culture.

In attending conferences and working with hospital CEOs, I have found that there is more emphasis on the technical tasks that need to be accomplished in order to form an Accountable Care Organization than on the culture such a change will require. I have heard a lot of keynotes filled with power point slides on defining the role and reporting structures for newly formed physician leadership teams; creating system-wide operational councils; and specific legal structures of ACOs so they can accept and distribute global payments. These are all important technical tasks, but they will fail if the culture does not change too.

Two concrete example may help make this point. Sony engineers came up with the equivalent of the iPod long before Apple. However, Sony ran into internal obstacles because of its culture. Sony’s leadership and organization was designed to come up with improvements to the next generation of CD players, but the new iPod technology threatened how Sony’s leaders and engineers thought about their product line. They could not overcome the cultural barriers to marketing such a revolutionary product. Sony’s failure was not one of technical expertise; it was and adaptive failure of cultural mindset.

My travels found me in Savannah, Georgia recently having lunch with Joe Scodari who sits on three Boards of Directors in the health care space. Scodari related a similar story of cultural failure to adapt when Kodak engineers invented the digital camera; the film culture at Kodak did not approve marketing such a transformational product that would cut into Kodachrome film sales. Kodak missed out on digital cameras, and film sales plummeted anyway.

So how do hospital system CEOs avoid the fate of Sony and Kodak as they respond to the sweeping changes in the new federal health care reform law? They must focus on both technical and cultural issues. Jane Kornacki and Jack Silversin ( who pioneered the physician/hospital compact model and Bob Kegan and Lisa Laskow Lahey ( who developed the immunity to change model for transformation have much to teach all of us. Physician leadership academies are another essential ingredient in transforming culture among newly employed physicians who are not used to being employees.

Southwest Airlines made money when other airlines floundered; they attribute this success to culture. Hospitals that focus on culture and technical tasks will have a better chance of survival in an environment that is increasingly saying you better get ready to survive on Medicaid rates, not private insurance rates.

Saturday, November 13, 2010

Top 10 Things I Appreciate After Crazy Week Spent in 5 Different Cities

1. I really like reading by the roaring fire in the fireplace.

2. Walking on a Fall Day by the Wissahickon with leaves coming down.

3. Brut champagne.

4. Talking to my daughter Reva who is visiting from NYC.

5. Catching up on twitter because I was too busy traveling last week.

6. Eating a great lunch at home and not in a restaurant.

7. Not answering the telephone at all.

8. Going out to dinner tonight with friends.

9. My good health.

10. How lucky I have been in my life to have the family, the friends, the jobs I have had.

Wednesday, November 10, 2010

Top 10 Developments That Give Me Hope About Future of Health Care

Tomorrow I will be giving a keynote address for the American Institute of CPAs conference in Las Vegas ( At first they wanted an overview of federal health care reform and what the future holds for US hospitals and doctors. Latter, they called back and said we want a more hopeful message about the future of American medicine and health care. Do you have any hope?

So I got to thinking about what makes me hopeful about our industry's future? I came up with 10 developments I am very excited about.

1. Shared Decision Making and Slow Medicine

2. Computer Simulation (Think David Eddy's Archimedes)

3. Video games for professional instruction, lifestyle changes, drug adherence

4. Patient social networking sites (Think PatientsLikeMe and DiabetesMine)

5. Smart phones and health care apps including EMRs

6. Patient generated research (Think CureTogether)

7. Reverse innovation (Think GE)

8. PHRs

9. Doctors being replaced by online information from a patient like me for health information

10. Twitter and Facebook.

The AICPA folks would only give me an hour for the keynote so I am going to talk mostly about numbers 1 and 2, but all of these developments give me hope for the future.