Dr. Abelson Connects - a Park Nicollet CEO blog

Partnership and Reciprocity

Our mission, “to improve health and well-being in partnership with our members, patients and community” begs the question of why the word “partnership” appears in our mission. A mission states why we exist - an end, not a means. In contrast, “partnership” generally implies a means – how we do something. Additionally, partnership is one of our four shared values along with excellence, compassion and integrity.

Why is partnership so important? Would it not be sufficient to say we exist to “improve health and well-being with our members, patients and community” and focus on partnership as a value? Wouldn’t the word “with” in our mission statement imply partnership?

I don’t believe a single answer exists to the question of why we elevate the word “partnership.” Each of us needs to make the mission statement our own by answering that question for ourselves.

My own answer came to me as I wrote the blogs entitled Ghosts and The Gift of Speaking Up. As you might recall, the “ghosts” referred to about 10 patients who appeared to me over the years. I conjured them simultaneously to understand what they had in common. The answer surprised me - each ghost offered me the gift of healing a part of my own woundedness. The “gift of speaking up” described the gifts we give and receive as colleagues when we create an environment that invites speaking up.

How is the word partnership in our mission related to receiving gifts of healing from our patients? If I am being honest with myself, most of the time I employ the traditional clinical model when I consider the word “partnership” within healing relationships. It is my job as the professional healer to work with you as the patient to understand your needs and values, and together select an approach that fits you. This is our job. Yet the usual clinical model ends here and makes the relationship lopsided. As the professional healer, I am in the business of giving, while you, as the patient, are in the role of receiving. Asymmetrical relationships like this are not partnerships in the deepest sense, because the professional is in the dominant position.

Consider how “reciprocity” deepens the meaning of partnership. “Reciprocity” is defined as “a situation or relationship in which two people…agree to do something similar for each other.” I helped my 10 ghost patients heal, while simultaneously they did the same for me. The relationship was a reciprocal partnership between equal human beings - each one acted as the healer and the wounded.

Reciprocity also applies to our relationships with colleagues. In the blog The Gift of Speaking Up, I describe the gift that I received when a colleague spoke about an error that I made. This reciprocal gift between colleagues occurs throughout the organization and is not limited to care delivery.

Including the word “partnership” in the statement of why we exist makes sense to me if I consider “reciprocity” as the deepest form of partnership. Within our professional relationships with patients, members, and each other, what do we do similarly offer each other? I propose we all strive to give and receive. We are all wounded and we are all potential healers. We need to open ourselves to receive as we give.

Among other things, giving and receiving can make difficult and sometimes frustrating work more satisfying and sustainable. The pace of healthcare appears to accelerate endlessly. From the time our alarm clocks go off in the morning, we experience aspects of our day-to-day life that are intrinsically unsatisfying – screen time, paperwork, email, meetings, etc. Although we constantly try to minimize these dimensions, we know they will never disappear.

Are there small ways we can rise above our day-to-day lives by opening ourselves to receive as we give? I employ simple, ordinary practices during my day that make me more mindful and open to receive as well as give. Though simple and ordinary, these practices are difficult for me to remember moment to moment. I try to make myself aware of my personal boundaries by focusing on my physical foundation that plants me to the floor or chair. I attempt to acknowledge my internal state (am I crabby, is my mind churning with all of the other things I need to do, or am I still contemplating the previous interaction with another individual?). I try to bring myself back to the present relationship. Paradoxically, the more bounded I feel within myself, the more I expand and become open to both giving and receiving.

A colleague (now deceased) once described his practice for being mindful in his relationships with patients. Each time before he entered an examination room he paused for a moment and touched his right hand to his heart.

Please use comments below to describe your thoughts related to partnership, reciprocity, giving and receiving.

The Gift of Speaking Up

A single principle trumps all else in health care: first, do no harm. The word “first” implies that our foremost responsibility is the safety of patients who entrust us with their lives. National Patient Safety Awareness Week (March 2-8) is a symbolic reminder of what it means to be aware of safety each and every moment.

During Patient Safety Awareness Week, Methodist will strengthen our culture of safety by closing the operating rooms in order to convene around the topic of safety. One area we will discuss is the importance of each individual taking on the responsibility to speak up if safety is ever a concern. Healthcare is so complex that we cannot depend on one person, we need the vigilance of the entire team to promote and maintain safety. The aviation industry made great strides in reducing crashes by changing the culture of the cockpit. Key to their culture of safety is the expectation and ability of everyone in the cockpit to speak up, regardless of position or seniority.

Speaking up is a duty and best practice. A nurse during my internship year provided me an additional way to frame “speaking up.” It was late at night and I was on call. The first patient I admitted to the Intensive Care Unit had a pulmonary embolus (blood clot in the lung). I appropriately ordered 5,000 units of heparin (an intravenous blood thinner) followed by 1,000 units per hour. Then I moved on to the next admission, a young man with diabetic ketoacidosis. His treatment required fluids and intravenous insulin. I thought “insulin” as I wrote the orders, but my mind experienced a “slip” causing me to order insulin in the dosage that I just used for heparin—5,000 units of insulin followed by 1000 units/hour. This represents enough insulin to kill an entire herd of woolly mammoths.

Fortunately, a nurse spoke up and said: “Dr. Abelson, did you really mean to write for that much insulin?” I immediately changed the order and thanked her profusely. Her actions taught me that speaking up, besides being a duty, is a gift. She gave the patient a gift by protecting him from my error. And she gave me a gift by sparing me the agony of an error which would have harmed and likely killed a patient. I did not harm the patient that day, yet the “near miss” continues to echo within me nearly 40 years later. Imagine the impact on the patient and me had the nurse not spoken up. That night I was in the position of giving and receiving. I gave care to the patient and I received a gift from a colleague.

When I practiced as a physician I prided myself on not missing anything. That pride translated into an over-riding fear of missing something. Other physicians have shared with me their pet fears ranging from wrong sided surgery to inadvertently cutting an artery or nerve. These pet fears can make us better physicians. These fears can also open us to viewing the act of “speaking up” as a gift – a gift we should always be eager to give, and grateful to receive.

Speaking up as a gift applies throughout our organization beyond patient care. When you speak up or welcome others speaking up you create an environment that reduces waste (rework) and reputational risk by eliminating errors.

Please use comments below to describe how we can open ourselves to embracing the idea that a colleague who speaks up is giving us, as well as the patient, a gift.

Ghosts

Over the years, the memories of ten specific patients, many of whom appear in my blogs, move like ghosts through my mind. Nurses and other physicians tell me certain faces and encounters also haunt them. Recently, I conjured all of these ghosts in order for me to understand what they have in common. The answer surprised me.

The key to understanding the puzzle of why these 10 patients, and not others, haunt me came from two of them, Shirley and Bertha (names changed to protect privacy).

Let’s start with Shirley, as I described her in a previous blog:

Shirley, a 79-year-old patient at Methodist Hospital taught me the meaning of “healing” on a Saturday many years ago. On that particular weekend, I drove to the hospital resentful and feeling sorry for myself for being on call and missing family activities.

As her physician for the past few years, I recalled her history as I perused her chart outside the room. I remember her daughter committed suicide earlier in the year. Sometime after the suicide, Shirley underwent a hip replacement complicated by multiple admissions for dislocation of the prosthesis. She had a history of an artificial aortic valve and recently developed acute endocarditis of the valve seeding the prosthetic hip with an infection. During the current admission, the hip was splayed open enabling drainage and antibiotic irrigation of the hip as she received intravenous antibiotics to calm the heart valve infection. Her only chance for survival involved risky replacements of the infected valve and later the hip. I knew I needed to talk with her about the valve replacement. Given her condition, the surgery carried grave risk, but without surgery, she had little chance of leaving the hospital.

As I walked into the room, I saw she was covered with blisters, most likely a reaction to the antibiotics. She whispered one sentence: “I feel like Job.”

I held her hand and cried with her about the events of the last few months. My self- pity about being on weekend call evaporated. We talked about replacing the valve and the hip and she stated calmly she wanted to live despite her suffering.

Shirley taught me that healing is not the equivalent of cure. Healing occurs when we acknowledge life as it is and exercise personal choices in the face of reality. Healing may occur with the dying process. Healing may result from grieving.

On that Saturday in Shirley’s’ room two human beings healed.

I knew Bertha, a friend of my parents, from my childhood. I became her physician when she was quite old and I was in my thirties. During the specific visit that haunts me, I asked what her secret was for aging so gracefully. She said, “David, in order to age gracefully you have to live gracefully.” It was my first glimpse that aging gracefully could not be initiated when you are old. It begins with how you live now.

Shirley made me face my petty crankiness about being on call during a weekend. As I opened myself to her suffering my pettiness evaporated and on that day I became a better human being. Bertha gave me a life map to follow.
Gathering together my memories of the ten patients clarified what they have in common. They are not ghosts. They are guides who taught me important life lessons. They made me whole, and thus healed me.

Wounded Healers describes how Carl Jung used the term as an “archetype,” spanning cultures and millennia. As a psychoanalyst, Jung wrote about our “shadow side”- a part of each of us that is powerful, yet hidden. Jung thought patients were displaying woundedness, while their shadows represented healers. In contrast, the shadow of a healer is woundedness. At times, the visible woundedness of the patient may entangle the woundedness of the healer. This leads to an unhealthy dynamic in which the healer may feel anger, shame or other strong emotions out of proportion to the healer-patient interaction. As an example, a judgmental patient may remind the healer of a harsh parent. Dependent patients, unable to accept a lack of cure for their conditions, may push away the healer with a shadow of wanting the power and control to cure.

In contrast, as healers we sometimes might heal alongside our patients when we open ourselves to the possibility of our woundedness connecting with the shadow healer of the patient. This entails vulnerability – to our own woundedness, but not necessarily vulnerability to the patient. As an example, by being in touch with our own core human wound of feeling the finiteness of our own lives and the potential loss of loved ones and losses associated with aging, we open ourselves to receiving the gift of healing from our patients as we stand witness to their courage and wisdom facing the same ultimate human wound.

Please use comments below to describe how you have been made more whole by interacting with patients, members or others that you serve.

Glimpsing the world through the eyes of another

Working in healthcare grants us the privilege of glimpsing the world through the eyes of others. I use the word “glimpse” to avoid the arrogance of “seeing” the world through the eyes of others. I don’t believe we can ever truly view and understand the world of another person, particularly since all of our worlds change moment to moment. The word “glimpse” implies a fleeting peek, which is the most we can hope to see.
 
David Homans recently circulated a short passage from a patient that gave me a “glimpse” through the eyes of another person. Kevin allowed us to use his true first name. Kevin received a kidney transplant several years ago and wrote this last year. Although he does not get his care within Park Nicollet and HealthPartners, his insights feel universal.
 
As you read his words consider how you feel as you glimpse the world through the eyes of another person.
 
In a scene of The Great Gatsby, Nick Carraway mentions how ill George, another character, looks. Fitzgerald then gives him one of the many profound lines of the novel: “It occurred to me that there was no difference between men, in intelligence or race, so profound as the difference between the sick and the well.”
 
I have struggled with this distinction.  Foucault and queer theory have struggled with any distinction. I am not what I experience, nor a tidy sum of my actions or beliefs.  Sometimes I am sick, sometimes I am well.  Much more frequently I am both.
 
The more clear distinctions happen rarely - though they have both happened recently.
 
I was in the hospital a few weeks ago with a UTI.  This simple little SOB landed me in the hospital for three days.  Some people, god knows why, talk their way into a hospital.  I generally resist going in and spend most of my time in trying to get out.  I’ve thought about being that guy who sneaks out, but I respect most of my doctors and nurses.  Besides, this time, I was sick.  Like, sick sick.
 
This has happened to me a few times; I go from feeling fine - you and me fine - to asking for a ride to the ER because I can’t hold anything down and I’ve got a climbing fever of 103 or 104.  This typically takes six to eight hours.  I undergo a profound transformation from the time I walk in the door, clothed in my clothes, my wrists free from hospital plastic wrist bands, looking and feeling like a healthy person.  This is when I feel awful, but am still my own person - sick but not hospital sick.  Not naked in the gown.  I might lean on a wall for support but I am leaning with my shirt sleeves, with my phone in my pocket, with my shoes on.
 
An hour later I am in the gown, toting an IV pole.  And I am seen anew.  The hospital is the place where I am home.  Think about that.  Where are you ‘home?’  When I walk through a hospital for some other reason I am a visitor - passing through this land of the sick, this quarantine of disease and infirmity.  I think of the hospital as hallways, doorways and elevators.  Transience.  A place to pass through. When I am ‘sick,’ the hospital is a room, a bed from which I move reluctantly and with caution.  It is the space between my bed and the bathroom.  Asking for another blanket.  Asking for a glass of water. Asking for a drug to make me feel less nauseous.  Being asked to take four deep breaths.  Listening to the ragged breath of the guy sharing my room.  I’m pretty sure he never left.  In the hospital I am attended to.  I can ask for things.  I give up something to gain access to this treatment.  Perhaps this is what Fitzgerald was talking about when describing George Wilson, desperate with jealousy - a person loses a piece of themselves to sickness or death when the hospital is the place from where they exist.
 
I imagine a struggle for nurses as well, working with dozens of partial people every day, humans at a valley of dignity.  On the one hand there is so much suffering in the humanity of these people, of me in a bed, dirty, unshowered, weak and emasculated - how could a nurse remain open to such suffering while administering care within the confines of a hospital.  There are only so many kinds of nurses, and at the heart of it just two - those who see patients as humans and those who cannot.  I do not fault those who cannot - I cannot.  What an awful place to be; sick.
 
Being well is much more familiar to us - to you, really.  Biking to work on a crisp morning, passing cars at a stop light, dodging potholes, having cold thighs taut with blood.  Powering up a hill with some leg left at the top.  This is being well.  It is miraculous, and the gift of being so often sick is to have ready access to that miracle.  Feeling the cold wind on my face is sometimes everything.  The unmitigated world is a miracle, but the condition of this experience is wellness.
 
Most of the time I live between sick and well.  I’m like a spy, surveying the country of the well, passing as not-sick.  I don’t make a habit of talking about why I missed school, or how I spent my weekend trying to catch up on sleep and work.  But I do those things - miss school and sleep a lot.  I struggle to carry my share along with my guilt for not always carrying it.  I navigate the collateral damage my health inflicts on the people who love me.
 
I standardize my answers; I rarely know how to talk about myself, or about my weekend.  I lie outright sometimes, which comforts me as much as it does them.  I sometimes enjoy the secret, that I am secretly sick and most people would never know.  Other times I feel alienated and alone in the middle of a crowd - that people do not know my reality.
 
Of course these experiences are not uniquely mine, but I may experience them more profoundly than most.  We all attend to the various unfolding crises of our lives.  And many of us exist in the space between things.
 
As I glimpsed Kevin’s world I sensed my own world expand. It felt like he gave me the gift of better understanding life. I experienced wonder at our privilege in healthcare to learn from other human beings, as long as we  open ourselves to receiving as we give.
 
How did you feel glimpsing Kevin’s world? What are your experiences related to being open to receiving as you give?

Wounded Healer

Given the changes in healthcare, what remains unchanged, that should never change?

As I ponder this question, I begin with the enormous changes my father, age 90, has witnessed. During his childhood, infections remained the “big killer” just as they had for thousands of years. My father was 11 years old when the discovery of sulfa, the first antimicrobial drug, changed the course of meningitis and other scourges.  The first lifesaving treatment for a chronic disease started a mere 2 years before he was born when Banting and his associates injected insulin into a 14-year old with diabetes who lay dying in the Toronto General Hospital. At the time, children dying from diabetic ketoacidosis were kept in large wards with 50 or more generally comatose patients.  In one of the most dramatic moments in medicine, Banting and his associates circulated through one of these wards injecting each child with insulin. By the time they finished the last injection the first few children to receive the injections regained consciousness. The responses surely felt miraculous to grieving parents who had been waiting for their children to die.

Compared to the miraculous response of these children to insulin, it is easy to take for granted the everyday miracles of modern medicine that have occurred during my father’s lifetime: adults leading normal lives because of cures for childhood leukemia and lymphoma; seniors walking regularly because of sight restored with cataract surgery and enhanced mobility from joint replacement; kids running on playgrounds who started their lives as premature infants unable to survive before the onset of modern neonatal intensive care units; lives restored through kidney, heart, lung and liver transplantation.  And let’s not forget the everyday miracles of modern diagnostic tools like endoscopes, C-T scans and MRI scans that spare patients from painful procedures and most exploratory surgeries.

The number of peer reviewed articles published each year serve as a marker of the rate of change in health care knowledge. Approximately 30,000 articles were published the year that my father was born compared to 1.9 million in 2012, a 60-fold increase.

The pace of societal changes in medicine rivals the rate of clinical change. A few years before my father was born, physicians competed for status and control with naturopaths, chiropractors and “eclectics.” My father’s generation saw the ascendency of physicians, the era of solo private practice with hospitals as the free “workshop” of physicians followed by an increasing role of government and large organizations in health care.

Between aging baby boomers, health care reform, genomics, nanotechnology, “big data” and other technological advances, the future of health care promises ever quickening change.

With all of the change in healthcare what has not changed? With the certainty of ongoing changes, what should never change?

From the dawn of recorded history we know that human beings long for healing.  The word “healing” implies a return to wholeness. Humans feel a fundamental need to be in harmony with themselves and with their worlds. In response to the deep need, formal healers occur in every culture across the vast expanse of time.

With all of the change in healthcare, the deep human need for healing-for wholeness and harmony- has not changed. With the certainty of ongoing changes in health care, what should never change is our role within modern medicine as healers.

Carl Jung, a famous early psychoanalyst, described “archetypes” – constantly recurring themes and symbols in individuals (often in dreams), literature, paintings and mythology. These archetypes, etched in prehistoric cave paintings and embedded in Greek Mythology, appear in disparate and completely separate cultures and today in movies like Star Wars (hero archetype). Jung wrote about the healer as an archetype evident from prehistoric times across dispersed cultures. Interestingly, he called this archetype the “wounded healer” implying that the archetypical healer needs to be in touch with his/her own woundedness in order to be effective. Thus, the typical initiation of a shaman healer involves the shaman embarking on an internal (and sometimes external) journey to experience and come to terms with their pain- their woundedness.

Jung described the centaur Chiron from Greek mythology as a “wounded healer.” Chiron became a healer after sustaining an incurable wound from one of Hercule’s arrows. Chiron mentored the orphan Asclepius who became a famous wounded healer. The picture below shows Asclepius with bare chest suggesting vulnerability and carrying a rod with a single serpent. This rod became the “rod of the physician” though some organizations inadvertently replaced it with the Caduceus (a rod with 2 serpents and wings on top). Thus the rod as a symbol of medicine is the wounded healer.

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Karolyi Kerenyi, a colleague of Jung, elucidated the wounded healer archetype as the capacity “to be at home in the darkness of suffering and there to find germs of light and recovery, with which, as though by enchantment, to bring forth Asclepius, the sunlike healer.”

The “wounded healer” archetype implies that we need to be in touch with our woundedness in order to effectively support other humans in healing- moving to wholeness. What does it mean to be a wounded healer in modern medicine?

Although we each have our unique wounds, the universal wound is that life is impermanent and changing- we are born, we live and then die. And we have limited control of what happens in our lives. I know I carry a veil over the fragility of life- I can’t constantly face the reality that my life may change in an instant and my loved ones may suddenly suffer and even die. I did not wake up to my woundedness until my mid-thirties when I went through a divorce. Until that time I carried a quiet illusion that somehow I was different from other human beings in that I was fully in charge of my life and magically protected from suffering.  Even though my mother died a few years before my divorce, her death felt like the natural course of life and failed to alter my magical thinking. My divorce, however, shattered the illusion of special protection from suffering. I lifted the veil covering life’s reality and saw I had the same fundamental challenges as all humans—how to make sense and find joy in a world I could not control. After a while I accepted the only thing I could control was the kind of person I chose to be (and even that is not always easy).

I know I became a more effective healer after facing my illusions. I moved from being a doctor who was good at diagnosing and occasionally curing, to a physician who embraced the role of healer. And my practice became more satisfying as I opened myself to the privilege of being healed by my patients as I stood witness to their courage, grace and integrity.

I believe the challenge for modern healers in healthcare is greater than ever. We have the same challenges as healers throughout the ages—to help other humans find some sense of wholeness and harmony in the face of loss and eventual death. But additionally we have the challenge of helping people come to harmony and make decisions based on the scientific model of what is effective.

Whether we look back or ahead in medicine we find enormous change. How much of our woundedness relates to our desire for things (including healthcare) to hold still for a time? Can we embrace the paradox that what should remain unchanged, given all the change, is our role as healers while the pace of change in healthcare is deepening our wounds? Can we use these deepening wounds to become even more effective wounded healers?

Please use comments below to provide your thoughts about changes in healthcare and wounded healers.

Health vs. Well-being

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Our mission at HealthPartners and Park Nicollet is to improve health and well-being in partnership with our members, patients and community- begs the question, “what is the difference between health and well-being?” Recently, I attended a panel discussion at St. Thomas with my wife and daughter that elucidated the differences between the two.

The conversation, described as “living well in broken bodies,” featured Matthew Sanford, director of Mind-Body Solutions and Dr. Bruce Kramer, the former dean of education at St. Thomas. While driving home from a Thanksgiving gathering in Iowa, Matthew, age 13 along with his family slid off an icy highway. His older sister and father were immediately killed and Matthew shattered his thoracic spine resulting in complete paralysis below his chest. In his book, Waking, a Memoir of Trauma and Transcendence, Sanford describes how his treatment team, allied to the usual medical model, encouraged him to overcome and compensate for the paralysis by teaching him to ignore his lower body while focusing all of his efforts on developing upper body strength. Although this approach improved his functioning, it failed to promote his healing. Many years after the accident, he began a journey toward healing his emotional and spiritual wounds by practicing adaptive yoga in an attempt to reconnect with his lower body. Through Matthew’s Mind-Body Solutions he now teaches yoga to the “temporarily able-bodied,” referring to those of us without visible disabilities, but for whom aging will cause a loss of functionality,” and adaptive yoga to individuals with disabilities.

Matthew is Bruce Kramer’s teacher. For the past few years, Dr. Kramer has been living with Amyotropic Lateral Sclerosis (ALS). He describes ALS as “death by a thousand paper cuts” as it involves small but progressive loss of muscle functioning until only eye movements remain. Dr. Kramer movingly talks about dealing with ALS in his blog entitled Dis Ease Diary.

Bruce and Matthew, each situated in their own wheel chair, discussed living well within the confines of their bodies. They harbored no illusions of ideal health, yet they both exuded an impish well-being. The following excerpt from Bruce’s October 18th blog entitled “Endgames” telegraphs well-being as it flows from the pain of an individual who views life as it is:

I cannot help but feel robbed, not of immortality, but of the 30 years of healthy old age that I honestly thought was my future. ALS provides the perfect corrective to the best of plans. She grants knowledge that our imperfect physical envelopes in which we place so much importance, given to us for such a short time, always fulfill their design destiny and break down utterly and completely. There are so many ways to shorten our lives, and when you consider how many ways you could go, how easy it is to experience catastrophe, how unremarkable is death, then dying before one’s so-called time should probably be seen as more the norm than the exception. The 30 or so years that I like to believe would have been mine were it not for ALS are so minuscule in the scheme of the universe, that it is tempting to diminish their importance, to believe they are meaningless.

But they are my 30 years, and I had dreams and plans.

I planned to sleep in the arms of my one true love, to be awake, so very awake to her presence in my life. I planned to be there for my boys and their true loves and the children that they would have. I planned to cook birthdays and anniversaries, Thanksgiving and Christmas, three-day weekends and one night chili cookoff’s, holidays and holy days. I planned to be the husband and father and grandfather of legend. I planned to bring a rational voice and compassionate love to the education of children, the emotional healing of people, the design of systems. I planned to be the best friend anyone could ever have. Before ALS, I could see those plans opening into limitless vistas.

I am cured of planning, at least for the moment. Now, I pay attention to the losing – hand dexterity, back strength, neck strength, vocal presence – all of these to go along with the legs and arms and torso already gone. And with the losses, I have struggled to play catch-up and turn to new ways and old ways that I now realize are just barely ahead as the losses pile up behind. And yet, I am not cured. I still have plans – final words, time spent, memories, music.

I plan to end in a better space, always a better space.

If there is anything that I have learned from ALS, it is that the bad times are like changeable weather. If you have patience, things will begin to turn around. There is no big event, no one thing that turns me away from feeling sorry for myself toward that person I want to be. In spite of my whining, I work hard for spaces devoid of soul-killing feelings – deep resentment, crushing bitterness, prolonged anger. It isn’t that I don’t own major reserves of these feelings, but grim feelings have no payoff, they depress colors, muffle sounds, numb the touch and leave me hopeless in dis ease. So I do my best to acknowledge them, communicate them, concentrating on things that bring me back into the here and now space where the beauty of living is so much clearer, even if it feels shortened by circumstance.

And the endgame is just one end, opening new beginnings.

Dr. Kramer’s words prompted me to recall individuals I have encountered who appeared healthy but clearly did not convey a sense of well-being. These individuals ruminated about past regrets, coveted more and more tangible gains or lived for some future state which was already in the past once it arrived. Matthew ended the session with a wish for the audience that clearly flowed from a sense of well- being: “may you have the strength and courage to allow your life to change you.”

Please use comments below to describe your thoughts about health and well-being.

The Other Side of the Bed

In early June, life smacked me in the face with a deeper understanding of the “patient and family experience.”

The usual clinical summary of my “case” would read something like the following:

 This 62-year-old male noticed the sudden onset of imbalance while browsing in front of the refrigerator. Despite being a physician and knowing better, he asked his brother to drive him to Methodist Hospital instead of calling 911. On arrival he displayed staggering gait and mildly slurred speech. A code 99 (possible stroke) was called. Tests showed no hemorrhage or stroke. The symptoms improved greatly during the first 3 hours and completely resolved within 12 hours. He was discharged home with aspirin therapy and probable Transient Ischemic Attack(TIA).

My background remains different than most patients who are hospitalized at Methodist. I have spent nearly every working day of the last 20 years there – it feels warm and familiar.  However, once I arrived at the Methodist Emergency Department “on the other side of the bed,” the warm and familiar transformed into scary, uncertain and foreign. Code 99 for a possible stroke involves an elegantly choreographed and standardized dance of simultaneous evaluation and treatment. These codes save brains and lives. From the other side of the bed I experienced the code 99 as a hazy throng surrounding and touching me. I was scared before the code 99 and the emergency activities increased my fear.

Minutes later the ceiling became a moving blur as I was wheeled to radiology for a CT scan. (I had never considered moving ceilings as part of the patient experience, but when else do we lie on our backs gazing up at ceilings as transporters navigate carts through halls and elevators?) I started to transfer myself from the cart to the XR table but was immediately told that the team would put a transfer board under me and all I needed to do was cross my hands over my chest. I knew I was capable of transferring on my own but I had entered the strange and foreign land on the other side of the bed in my beloved hospital and the team was appropriately following a transfer protocol to keep me safe.

Back in the Emergency Department, my neurologist explained the findings and discussed the proposed treatment options. I simply basked in the warm glow of Ativan - I could not navigate the foreign territory of decision-making on the other side of the bed.  I was admitted for observation and additional tests and went home the next day feeling fine, though changed.

How I felt supported

Although my experience was sobering, I felt wonderfully supported throughout my hospital stay. Everyone I interacted with combined an air of professional competency with warm compassion and empathy. I sensed that the care was centered on me as the patient. I felt secure and confident in my care as I watched individuals from different areas assist each other.

I received constant updates about what to expect and people routinely asked me whether I needed anything. And perhaps most importantly, within the limits of being safely tethered to a bed that sounded an alarm if I tried to get up on my own, I was given choices. Even small choices, such as the ability to select foods from the room service menu and who in the family I wanted updated, acted as an antidote to my sense of vulnerability.

The essence of the patient and family experience

The patient and family experience is not about scores, better business, or scripts.  It is about how we as human beings support our fellow human beings during scary, uncertain and foreign times. It is about healing relationships for patients and families, and at times, for healers. It is about seeing the world through the eyes of those we serve and helping to make that world less foreboding and foreign.  It is about understanding the story of patients and with them changing their stories as we compose our own.

I was fortunate that after my time spent in the strange and foreign land on the other side of the bed, I am fine. We may not all have the same outcomes, but we all desire and deserve the same great experience.

What do you view as the essence of the patient and family experience?

Standing for better outcomes

The wonders of modern medicine amaze me.

The picture below shows a patient in the Intensive Care Unit walking while on a ventilator! During my medical training I considered this feat as impossible as flying a manned spacecraft to the sun and back. Though I could picture space travel eventually covering the 93 million miles from sun to earth, I knew the sun’s heat would consume a metal vessel. Similarly, I assumed if a patient walked while on ventilator, this activity would consume an already excessively heated and stressed body. I made this assumption without a shred of evidence.

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The evidence is now in.

First, being on a ventilator in an Intensive Care Unit takes a toll on brain function. One out of four individuals surviving a stay in an Intensive Care Unit show significant cognitive impairment one year after discharge. Second, early mobilization while intubated improves outcomes, including fewer days in the Intensive Care Unit and better cognitive function. The mind and body are one, not split. We can improve outcomes with innovations as simple as helping patients walk while on a respirator.

While medical innovations continue to astound, certain basics remain the same. I had the privilege of spending time with the patient before her breathing tube was removed. She listed what she wanted to eat once the tube was out—hot hardboiled eggs, 1% milk on buttered toast and Cold Stone vanilla ice cream with fresh strawberries.

What simple innovations amaze you?

Consumer or patient?

Patients. Families. Members. Consumers. Customers. Employers. Clients. Communities. Citizens. Students. Government. As a combined health care, dental, financing (insurance), research and educational organization, we use many words to describe those we serve. We also use various terms such as experience, healing relationships, service excellence, satisfaction, reputation, brand and top-of-mind awareness to describe the perceptions of those we serve. How do we make sense of this word salad?

Words evoke emotions and frame thinking. In the past, I bristled when I heard “consumer” or “customer” used in place of “patient.” The terms “consumer” and “customer” felt corporate and seemed to demean the near sacred nature of healing relationships conveyed to me by the term “patient.”

Over time I lost my emotional response to “consumer” when I realized in my own health care experiences I often viewed myself as a patient, consumer or both depending on circumstances.

Imagine examples outside of health care in which you consider yourself a consumer. You stroll into Caribou for a cup of coffee, order a book from Amazon or buy milk from a grocery store. You pay for the transaction with some combination of time and money, and expect hassle-free service or an item that performs as advertised. The hallmark of your consumer role is a sense of your own power as you feel in charge of your time and money. And as a consumer, you think about service excellence, rather than trusted empathic relationships and a healing experience.

In contrast, the hallmark of being a “patient” is your feeling of fear and vulnerability. You want trusting and empathic relationships to provide guidance and comfort in a strange and foreign land. Being a patient involves interactions between human beings, rather than consumer transactions. You likely think about healing and empathic experiences, rather than service excellence.

The day I lost my vision I felt afraid and vulnerable. During my recent transient ischemic attack (TIA), I sensed I was in a strange and foreign land “on other side of the bed.” In both instances, I could not possibly feel in charge, and I desperately needed the empathic trusting relationships that come with being a patient. I did not want to feel like a consumer and did not think about “service excellence.”

Over time, these events have shifted into periodic visits to physicians to check my blood pressure, eye pressures and receive medication refills. During these encounters, I feel in charge and want hassle-free service. I appreciate the relationships, but I don’t have the same need for them as I did during the first few days of the acute episodes. In both instances, healing involves my transformation from a vulnerable and frightened patient to feeling like an empowered and in-charge consumer. Additionally, I feel like a consumer in health care when I receive a flu shot or when my children needed a strep screen. In these examples, my time trumps an empathic relationship, and I think about service excellence rather than a healing experience.

Similarly, I encountered a variety of needs and roles in my involvement with the legal profession. When I was sued for malpractice, I felt very vulnerable in the strange and foreign land known as the courtroom. I didn’t feel much like a consumer and preferred to be called “client” by my attorneys. However, years later when I was working on my will, I actively shopped around for an attorney, felt in charge of the process, and returned to the comfortable “consumer” role.

The in-charge role of “consumer” and the vulnerable role of “patient” are not on opposite ends of a spectrum; we can experience both roles simultaneously and the balance may shift in the blink of an eye.

The graphic below depicts a useful way to think about the roles of patient and consumer.

The y-axis represents the empowered and in-charge consumer seeking hassle-free service and value, while the x-axis marks the fearful and vulnerable patient needing empathic, healing relationships. An individual can be in any of the four quadrants one moment and shift to another quadrant in the blink of the eye.

When I lost the vision in my left eye, I started in the lower-right quadrant (vulnerable and fearful patient), and over several weeks as I adjusted to the change in my life, I shifted to the upper-right quadrant (I wanted regular follow-up visits that fit my busy schedule, yet lingering fears remained). Now, more than 12 years later, I am solidly in the upper-left quadrant as I fully accept my loss and want follow-up eye checks to be as convenient as possible.
 
Consider some illustrative vignettes which demonstrate movement within the quadrants. A young woman named Rita is visiting her dentist for a routine check-up and cleaning. She senses no vulnerability, feels in charge and wants to get in and out of the office as quickly as possible. She decides to ride her bike to the appointment. She feels like a consumer. Unfortunately, on the way home, she falls off her bike and shatters four teeth. She is worried about the damage to her mouth and wonders when she can return to work and how she will tolerate the pain. In the blink of an eye she has changed from in-charge consumer to a vulnerable patient needing an empathic caring relationship.
 
Kathy is 35, married and has two young children. She is in charge of the health care decisions for her family. She feels like a consumer when she chooses her family’s health plan and takes the kids to their well visits. The evening after she selects the health plan through her employer, her youngest daughter is hospitalized with respiratory failure from influenza. She and her husband find themselves in a strange and foreign called the Intensive Care Unit. They need guidance and empathic relationships to navigate the world of ventilators, heart failure and kidney failure. In a blink of the eye Kathy shifts from an in-charge consumer to a scared and vulnerable family member.
 
Many individuals with chronic disease are in the upper-right quadrant, similar to where I was a few months after my vision loss. They live every day with their chronic disease, and as a result, feel empowered and in charge, yet also may harbor lingering fears about complications.
 
Our work requires understanding the needs of those we serve at any given moment and understanding that those needs may change in the blink of an eye. The work of healing relationships includes supporting individuals to move from fear and vulnerability to feeling empowered and in charge.Paradoxically, healing relationships support the process of patients becoming consumers.
 
Please use comments below to describe your thinking about the role of patient and the role of consumer.

Healing Wounds

As a young physician I focused on curing patients and assumed “healing” was just another word for curing. I reveled in making the right diagnosis and “snatching patients from the jaws of death.”  However, over time my patients taught me the difference between healing and curing. I learned how some individuals who were cured were not healed while others who were healed were not cured.
 
Consider a woman I encountered 10 years after her diagnosis of breast cancer. Based on the type of cancer she had, I explained to her she was most likely cured.  Although cured of the cancer, she felt bitter about her disfigurement created by the initial treatment and fearful of a recurrence. She was cured but not healed.
 
In contrast, another woman with terminal breast cancer taught me how someone who is dying can also feel healed. She accepted she would die soon from advanced breast cancer and appreciated every remaining moment of her life. She was healing though she was far from cured.
 
Similarly, patients taught me how some individuals with no definable disease felt disabled while others with severe chronic illness did not.  A man with advanced congestive heart failure (ejection fraction of 15) fished and hunted (albeit slowly) with his sons and grandchildren. Although he had severe disease, he did not consider himself disabled. In contrast, another man with chronic low back pain (with no obvious cause) severely restricted his activities and spent much of his time consumed by pain. He viewed himself as severely disabled despite the absence of a definable medical disease.
 
Wound healing provides insight into the difference between healed and cured. A wound represents a loss in the wholeness of our tissue. We do not say that health care cures or heals a wound. A wound heals itself by calling on the regenerative powers of the body. Wound treatment consists of removing barriers to healing such as infection and debris thus enabling the body’s natural ability to heal wounds.
 
The word “healing” means to return to wholeness. The body heals wounds from the inside out restoring tissue to wholeness though a scar remains. At times the scar may be tougher than the initial tissue.
 
The word “cure” means to “take care of.” Grammatically, we assume that a treatment (Or role such as “physician”) cures “an object”, the patient. In contrast, “the subject” (the patient, body or wound) heals itself. “Healing relationships” support patients to become whole by marshaling their own healing resources.
 
Wounds go well beyond loss of tissue. A diagnosis of cancer entails the “wound” of fearing pain, anguish and death. A diagnosis of congestive heart failure involves the implications of reduced activity and premature death. Patients heal their various wounds through a process of acknowledging what they have lost and embracing what remains. Simply, the healing process involves grieving.
 
12 years ago I suddenly lost the vision in my left eye. Modern medicine provided no cures. My initial “wound” went far beyond my eyesight. I lost my sense of invincibility and had to face the fragility of life. Although my visual loss was permanent, I healed during the first year by accepting my loss and facing my own the vulnerability. I vacillated through phases of grief (denial, anger, bargaining, sadness and acceptance). The “anger” phase culminated in my throwing bottles of eye drops at a wall. As I accepted my loss, I found that like the scar covering a tissue wound, the healing resulted in my discovering new strengths and embracing life because of its fragility.
 
Please use comments below to give your thoughts about the differences between healing and curing.

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