You can't stay ahead of these errors.

Remember the story about my MD friend's elderly mother, the one who was suffering from falls because she was over-medicated for blood pressure issues? Once the doses were reduced, she did fine: "She has more stamina than ever before. She is happy."

Well, here's the next chapter:

So Mom is back in her original assisted living place, walking with a walker, to everyone's surprise. However, the medical errors are following her.

When she was being discharged, the rehab center sat me down and gave me a discharge summary and medication list, saying they had been faxed to the original nursing home. We went over and discussed every medication.

9 pm the night she went back, my phone rings; it's the nursing office of the original place saying they have her on Tramadol but the pharmacy says there is an allergy. I said, "What?" You see, Tramadol was not on her medication list. They said, "It wasn't on the list YOU gave us but it IS on the list that was faxed to us." So, I said, "There are 2 lists out there!" I said, "Take her off it," and hung up.

Today, two WEEKS later, the nurse practitioner calls and starts discussing clonidine, a BP medicine she was on. I said, "What?" You see, again, that wasn't on her medication list.  She said, "Oh, but the rehab center started her on that and I want to discontinue it." I told her there were at least 2 medication lists out there but she wasn't interested. So I said, "Fine, d/c the clonidine."

So . . . she's been on 2 BP drugs instead of 1 for two weeks, which was the original reason she was falling so much!

 

I'm ready to give up. You can't stay ahead of these errors.

Good news for C. diff patients: The "Poop Pill" arrives.

Way back in December 2013, I introduced my readers to OpenBiome, a start-up formed by a couple of MIT graduate students who had a new concept for Fecal microbiota transplant (FMT), which is now recognized as an effective cure for C. difficile patients.

In March of this year, I reported from one of the founders:

We've experienced rapid growth and are working with over 230 hospitals in 43 states and have provided treatments for over 2800 recurrent C. difficile patients at this point. 

We have also been testing and developing an encapsulated formulation that should reduce procedure related costs and risks for treatment of C. difficile, while enabling long term maintenance therapy for the investigation of chronic conditions where a single dose is unlikely to provide lasting benefit. 

Now it looks like that approach is going well. Gabrielle Emanuel at the Commonhealth blog reports:

Fecal transplants may have just gotten a lot easier to swallow.

OpenBiome, the nation’s first stool bank, is beginning large-scale production of a poop pill. This week marks the first time such a pill will be commercially available to hospitals and clinics.

Early tests suggest the pill is highly effective and comparable to traditional, more invasive delivery methods — for instance via colonoscopy, enema or a plastic tube through the nose and into the stomach or intestines.

Developing a pill that would not dissolve because of what it was delivering was the engineering task faced by the company.

After about a year and a half of work and testing, researchers at OpenBiome came up with something they’re calling the Microbial Emulsion Matrix (MEM).

Basically they’re taking the poop and suspending it in oil. The oil prevents the water from dissolving the capsule. Then, they freeze the capsule. This doesn’t kill the bacteria but it does make them inactive, stopping them from breaking down the capsule. Only once the pill is inside the gut does it break down — this time from bacteria on the outside, instead of on the inside.

I'll be looking forward to future chapters from this innovative group of folks, who are working on a very important health problem

A new concept: Acceptable preventable harm

Blogger Melissa Clarkson offers a wryly humorous take on a goal established by the CMS Partnership for Patients, to reduce preventable harm by 40% between 2010 and 2014.  She asks:

I was not aware that harm comes as a mix of acceptable harm and unacceptable harm and the concern is getting rid of the unacceptable portion.

But if hospitals are striving for such a goal, I simply ask that they fully explain this to patients and families. And to help, I would like to provide some ideas for facilitating this communication.

Here are some of the graphics she proposes for those hospitals who wish to be fully transparent.

For a hospital welcome sign:

For a marketing campaign:

For the front lobby:

More seriously, and perhaps not coincidentally, according to this Modern Healthcare article:

The Leapfrog Group has released the second round of its bi-annual hospital safety scores, which show “sluggish” improvement in patient safety among the nation's hospitals.

An example of superb medical training

I have made a serious commitment on this blog to promulgate the best in medical education, with a strong emphasis on programs that focus on clinical quality and safety improvement. It was with a delighted gasp of approval, therefore, that I read this recent bit of feedback posted on the residents' bulletin board of the anaesthesia department at a major academic medical center. This is truly superb pedagogy, well worth emulating in other training programs.

In case you are not familiar with Wu-Tang Clan, you can enhance your cultural competence by viewing this video.

Riding the Cancer Coaster

Several months ago, through a virtual friendship with her father, I got to know a young lady named Clarissa Schilstra.  She is a lovely and thoughtful person who has been through double doses of cancer in her short life.  She is now a member of the class of 2016 at Duke University. We first met in person (all three of us) in August of 2014.  Clarissa felt that she learned a lot from the passages of her life and wanted to share what she had learned with others, and so she wrote me back in July:

"I am really excited to tell you that I have written a book this summer, to help teens and young adults with cancer through the social and emotional challenges of treatment."

The book is now out, and it is very, very good.  My review is as follows:

Clarissa Schilstra offers knowledge, wisdom, and advice to teenagers and young adults who are facing the travails of a cancer diagnosis. Drawing from her own experience, employing plain talk and empathy, she offers helpful suggestions for the entire family. This is an essential book for anyone you know who is going through this life-changing chapter in his or her life.

If you can't change people, change people.

My friend and colleague Michael Wheeler, in his excellent book The Art of Negotiation, notes:

"Negotiation is never about us alone. What ultimately unfolds is a function of each party's attitudes and decisions, not just our own. Asking ourselves, 'How did I do?' is the wrong question.  It's a one-hand-clapping exercise.  Instead our starting point should be, where did we end up and how did we get there?"

I was reminded of this advice by a New York Times article about Justice Ruth Bader Ginsburg by Irin Carmon. Excerpts:

“My advice is fight for the things that you care about,” Justice Ginsburg said. Fair enough — banal enough, really. Then she added, “But do it in a way that will lead others to join you.”

Justice Ginsburg [has] no patience for confrontation just for the sake of it. “Anger, resentment, envy and self-pity are wasteful reactions,” she has written. “They greatly drain one’s time. They sap energy better devoted to productive endeavors.”

As Ginsburg notes, one way in which the opposite approach is often evidenced is through self-pity and self-victimization.  I've run across this often in the health care world, and, sadly, it is a technique often used by the most prominent in the field.  As CEO of a hospital, I saw it when there were disputes between a particularly assertive chief of one service and two other, more passive, chiefs of service.  Each of the latter would come in to me with an aura of self-victimization, complaining about the colleague and asking me to solve their problems with him. This, even though they were just as senior, experienced, and famous in their fields as he was in his.

Their self-victimization was their way of avoiding responsibility.  Meanwhile, other chiefs figured out how to deal with the bully--through humor, redirection, or otherwise--knowing that pursuing the shared goals of the hospital was the overriding objective.

Look how Ginsburg deals with an angry and bullying member of the Court whose views are often widely at variance with her own:

“I’ve been known on occasion to suggest that Justice Scalia tone down his dissenting opinions … because he’ll be more effective if he is not so polemical.”

Imagine, giving advice to your philosophical adversary so that he will be more effective!  Ginsburg understands that in a court of nine members, today's negotiation is but one of many to come. But her thoughtful approach offers lesson beyond the Court.

Over the last several years, I have been teaching negotiation to corporate executives and advising corporations on complex and interesting business negotiations.  As is evident to many in the business world, the most important part of a negotiation with another party is first achieving an alignment within your own organization.  Indeed, many deals fail to be brought to fruition because of internal failures, rather than substantive business issues with the external counterparty.  As I've analyzed those internal problems, I've seen that a significant percentage of the failures occur because some division chief engages in a kind of self-victimization:

"No one cares about my point of view, so:"

"...I'll just be quiet about flaws I see in the deal;" or
"...I'll withhold important information from my division;"
"...I'll quietly do my part to undo the deal later."

These folks are actually more comfortable with having stopped an initiative that could be of broad corporate value because of the way they perceive their treatment.

It might--or might not--surprise my readers to learn that such things occur, even in highly profit-driven organizations.  What's the remedy?

It's easy to say that we should want to run organizations so that each person feels empowered, entitled, and encouraged to call out problems and state his or her objections.  But, even in those places, there are some people who will tend to engage in self-victimization and act as anchors on joint progress.  In the Supreme Court, where there is lifetime tenure, it comes to a teacher like Ginsburg to try to help her colleagues learn and grow.  In other organizations, things turn to the leaders to recognize the syndrome and deal with it directly.

You as a leader have a responsibility to create a true culture of engagement, substantive support to encourage full participation by all in your organization, and a commitment to your staff's personal and professional growth. In so doing, your key attribute as a leader must be empathy, to understand where the people in your place are in their own learning process.

But, here's where I offer what might seem to be self-contradictory advice--but it is advice informed by years of experience.  If, in the presence of that culture, support, and commitment, you are still facing key staff members who are characterological and persistent self-victimizers, it's time to cauterize the wound.  In such cases, revert to the old adage:  If you can't change people, change people.

Only certain people

A person who has over 3000 friends on Facebook saw no irony in posting the picture above in her status bar.

Being less alone together

Above, seen on a table at the back of a conference room during a staff all-day negotiation, team-building, and communication workshop.  It is a great enforcement mechanism to enhance interactions and the learning process, imposed by the conference organizer. I think Sherry Turkle would be pleased.

She has said:

What I've found is that our little devices, those little devices in our pockets, are so psychologically powerful that they don't only change what we do, they change who we are. Some of the things we do now with our devices are things that, only a few years ago, we would have found odd or disturbing, but they've quickly come to seem familiar, just how we do things.

So just to take some quick examples: People text or do email during corporate board meetings. They text and shop and go on Facebook during classes, during presentations, actually during all meetings. People talk to me about the important new skill of making eye contact while you're texting.

Why does this matter? It matters to me because I think we're setting ourselves up for trouble -- trouble certainly in how we relate to each other, but also trouble in how we relate to ourselves and our capacity for self-reflection.  

So you want to go to that board meeting, but you only want to pay attention to the bits that interest you.

The story from Consorci Sanitari del Garraf

"In 2009, three medical facilities in the comarca del Garraf, near Barcelona, merged into one organization, the Consorci Sanitari del Garraf. Faced with a 17% budget cut, a result of the financial crisis, the newly created hospital had to find a way to improve its processes and become more efficient."

This is a really sweet story from Spain that illustrates how you don't need lots of money and extra resources to apply Lean thinking.  Read the text, but really watch the videos to get a feel for how it happened.

The vestigial newspaper

It isn't often that I take someone's comment on a story and use it as the heart of a post, but someone named Greg Lee nailed it and summarized what I've been watching, too.  The context is this latest story about layoffs and buy-outs at the Boston Globe.  Like Mr. Lee, I read the comments of the editor and said, "Nice try."  Here's what Mr. Lee said:

I understand the financial realities that drive the recent moves by the Boston Globe. It is now, however, a lesser paper than it was, before this current process. 

What was touted to subscribers as redesign and layout changes, has actually been evidence of a slow retreat in journalism, at the Globe. The layout changes feature bigger type sections, more graphics and white space, and much less news coverage and op-ed pieces. 

It's depressing, as a life-long subscriber of over 45 years, to see this current decline in the Boston Globe. The new bottom line is less news coverage and less in-depth journalism, in the daily edition. Economic reality dictates these changes. I understand that point. But please don't call process an improvement or a new birth of possibility. Call it what it is, which is slow, strategic retreat.

How much more so when we watch the paper's owner invest in a new on-line "vertical" called STAT.  Here's the promo:

People at the Globe have told me that 40 people have been recruited for this venture.  That's a hefty annual budget.  Time will tell whether STAT rises to the level of the other big producers in the health care news arena--Pro Publica, Kaiser Health News, and the New York Times.  Time will tell, too, whether--even with great reporting and presentation--STAT will succeed as a business venture.

But I return to Mr. Lee's comment.  For several years, the management has shed as much as possible in costs and journalistic assets, hoping that enough remained to look and feel like the Globe.  Now, it must be difficult to sit in the shrinking Globe newsroom while millions of dollars are allocated to a new enterprise.  The investment in STAT is the strongest indication that the newspaper is now a vestigial organ in the minds of the owners.

In appreciation: Maureen Bisognano and Jim Roosevelt

It's a big day for transitions in health care here in Massachusetts. Maureen Bisognano has announced that she will step down as head of the Institute for Healthcare Improvement, and Jim Roosevelt announced his retirement as CEO of Tufts Health Plan.

Others will surely offer their thoughts on the notable accomplishments of these two folks, and so I prefer to spend a bit of time talking about them as people.  Oddly, I can apply almost the same descriptors and adjectives to the two of them--with one pertinent exception, as you shall see.

First, both are driven by a sense of public purpose.  Guided to do what is right for their community or the broader world, they have never left a doubt as to their underlying dedication to make the place work better--safer, higher quality, and with extreme attention to the dignity of individuals.

Second, both are unfailingly polite, measured, and respectful in their communications and relationships with people of all persuasions and backgrounds.

Third, both are good humored, taking their work seriously but never taking themselves too seriously.

Fourth, both are devoted to their families, and their families are devoted to them.

Fifth, I am hard pressed to think of anyone in the community who doesn't respect them.  They are truly admirable people.

The major difference?  Well, let's just say that Jim doesn't have much of a Boston accent, whereas Mo, well . . . .

I join thousands in wishing them well for the next chapter of their lives.

Madaket is not just a beach on Nantucket

To understand corporate nimbleness and creativity, read this story and then compare it to my previous one about IBM.

As I've noted in the past, there are lots of companies seeking to find one or another Holy Grail in the health care world.  After all, when this sector comprises almost 20% of the US economy, who wouldn't want a piece of it?  But to be successful, you need to offer a product or service that actually enhances the day-to-day lives of clinicians or others in the sector.

This brings us to Madaket, founded by my buddy Jim Dougherty and friends.  (Note: I have no financial interest in the venture.) They noticed a very serious hole in the health care marketplace--the enrollment of doctors with the variety of insurance companies with which they must deal--and have developed an elegant solution to fix it.  Short version:

The average healthcare provider works with 25 payers. Providers must be enrolled with payers to receive payments. Each payer requires a unique set of forms, procedures, and data to be submitted in order to enroll for Electronic Funds Transfer (EFT), Electronic Remittance Advice (ERA), Electronic Data Interchange for Claims (EDI) and other common provider-payer transactions. When providers make minor changes to their enrollment information, they must submit these forms again.

It takes months for payers to fully process provider enrollments – and months before providers start receiving correct payments. Time is wasted dealing with paper forms, correcting manual errors, and tracking down the status of enrollments. Madaket automates the enrollment process.  Providers fill out a simple online form once, and Madaket sends the right information each applicable payer. The result? Less paperwork, faster payment.

Here's the video:

Note the design: All web-based, user friendly, and infinitely scalable. In addition, the existence of Madaket will pull those insurers who currently rely on paper and faxes into the same web-based environment, further enhancing its (Madaket's) deliverablity and efficiency over time.

This is a winner.  Let's go back to that beach on Nantucket and contemplate the good that will come from this!

Big data, big deal

Cousin Dave hamming it up in the 1960s

The joke goes like this:

Sherlock Holmes and Dr. Watson decide to go on a camping trip. After dinner and a bottle of wine, they lay down for the night, and go to sleep.

Some hours later, Holmes awoke and nudged his faithful friend.
"Watson, look up at the sky and tell me what you see."

Watson replied, "I see millions of stars."

"What does that tell you?"

Watson pondered for a minute.
"Astronomically, it tells me that there are millions of galaxies and potentially billions of planets."
"Astrologically, I observe that Saturn is in Leo."
"Horologically, I deduce that the time is approximately a quarter past three."
"Theologically, I can see that God is all powerful and that we are small and insignificant."
"Meteorologically, I suspect that we will have a beautiful day tomorrow."

"What does it tell you, Holmes?"
Holmes was silent for a minute, then spoke: "Watson, you idiot. Someone has stolen our tent!"

Last week, I found this eight page insert in the New York Times, and I was left wondering if this IBM ad was inadvertently another form of the joke.

IBM, you see, is trying (again) to transform itself.  Once the industry leader in whatever it wanted to do, it has now spent years slowly decapitalizing as it tries to find a commercial niche.

Now, it is offering services based on Watson, noting that "Watson is designed to understand, reason and learn.  In a sense, to think."

In a sense?

Here's a quick summary from Wikipedia:

Watson is a question answering (QA) computing system that IBM built to apply advanced natural language processing, information retrieval, knowledge representation, automated reasoning, and machine learning technologies to the field of open domain question answering.

The key difference between QA technology and document search is that document search takes a keyword query and returns a list of documents, ranked in order of relevance to the query (often based on popularity and page ranking), while QA technology takes a question expressed in natural language, seeks to understand it in much greater detail, and returns a precise answer to the question.

According to IBM, "more than 100 different techniques are used to analyze natural language, identify sources, find and generate hypotheses, find and score evidence, and merge and rank hypotheses."

Is that thinking? Stanley Fish offered this view:

Far from being the paradigm of intelligence, therefore, mere matching with no sense of mattering or relevance is barely any kind of intelligence at all. As beings for whom the world already matters, our central human ability is to be able to see what matters when.

So, in short, IBM is offering an expensive tool that might help corporate executives troll through lots of data and try to divine commercially relevant strategies. It suggests that, "When your business thinks, you can outthink" the competition.

IBM five-year stock price summary

I guess the proof of the pudding is whether this approach can be applied to IBM itself.  What I see instead is a behemoth of a corporation, with tens of thousands of employees spread across the world unfocused in purpose and execution, stagnant in the capital markets--with thirteen straight quarters of decline in revenues.  The company is an exemplar of brute force decision-making, being outflanked left and right by more nimble players in the marketplace.  The additional value offered by Watson is unlikely to be attractive to industry leaders in other fields.  The millions of dollars spent on the Times insert is, in my mind, just another example of ineffective corporate thinking.  What's the audience, and how is the ad persuasive?

Back in the 1960's, you could drop by the IBM building in New York City and pick up the iconic blue think desk sign seen above.  I still have mine.  I'm saving it for my daughters to take to Antiques Roadshow someday, where it might have some value as an a piece of industrial archeology.

Shared baselines as a guide to protocols

There have been some interesting and important discussions flying across the web in recent days on the issue of protocols in helping to reduce variation and reduce the incidence of harm to patients.  My mistake in the debate was assuming that medical leaders would be reasonable about how protocols should and should not be used.

A doctor friend, highly committed to patient safety, notes:

My point about the protocols is that I have been chastised for not following them in situations where it was blatantly obvious that they did not apply. ("The protocol is there for a reason.")

The chastisement comes not from hospital administrators, but from clinician leaders in the doctor's own department:

We just got another email scolding us for not following the "colorectal pathway" sufficiently. One of the provisions of that pathway, for example, is strict limitation of iv fluids, sometimes difficult to "comply" when patients are severely dehydrated from their bowel preps, particularly the elderly.

The initial goals were to decrease opiate use and decrease PACU LOS, both worthy goals, but we're all annoyed at being beaten over the head with them and getting our hands slapped if we deviate, even with good reason.

It's ironic that on the one hand we are extolling the virtues of gene-based individualized therapies, but on the other hand we are trying to pigeonhole every patient into a standardized protocol. 

This is disappointing in so many ways, but especially because the solution is in the hands of the profession.  Brent James discussed the sensible application of protocols to clinical process improvement, as employed in the Intermountain Health system, several years ago:

The concept of “shared baselines” came to rule:

1 -- Select a high priority clinical process;
2 -- Create evidence-based best practice guidelines;
3 -- Build the guidelines into the flow of clinical work;
4 -- Use the guidelines as a shared baseline, with doctors free to vary them based on individual patient needs;
5 -- Meanwhile, learn from and (over time) eliminate variation arising from the professionals, while retain variation arising from patients.

Note that this approach demands [my emphasis] that doctors modify shared protocols on the basis of patient needs.  The aim is not to step between doctors and their patients.  This is very different from the free form of patient care that exists generally in medicine.  Notes Brent, “We pay for our personal autonomy with the lives of our patients.  This is indefensible.”  The approach used at Intermountain values variation based on the patient, not the physician.

I guess my friend's experience is one example of the Law of Unintended Consequences.  I think the rigid approach being employed in that doctor's hospital and elsewhere is the result of little or no training in clinical process improvement in medical schools and in graduate medical education. We have often been told by residents, during our Telluride patient safety workshops, that they get more exposure to matters of clinical process improvement and high reliability systems in four days than in their seven previous years of medical training.

Brent expressed hope back in 2011:

Brent is optimistic because he has seen this philosophy of learning how to improve patient care extend to more and more doctors and hospitals around the country.  He views it as providing the answer to the rising cost of care, and he is excited about the potential.  He concludes that this is a “glorious time” to be in medicine because it is the “first time in 100 years” that doctors have a chance to institute fundamental change in the practice of medicine.

Thus far, such change only exists in certain islands of excellence, and it clearly takes energy and thoughtfulness to sustain it even in those places.

An error about mistakes

There are few neurologists I admire more than Martin Samuels, chief of service at Brigham and Women's Hospital in Boston.  So it truly pains me to see him engaging in a convoluted approach to the issue of mistakes.  Read the whole thing and then come back and see what you think about the excerpts I've chosen:

The current medical culture is obsessed with perfect replication and avoidance of error. This stemmed from the 1999 alarmist report of the National Academy of Medicine, entitled “To Err is Human,” in which the absurd conclusion was propagated that more patients died from medical errors than from breast cancer, heart disease and stroke combined; now updated by The National Academy of Medicine’s (formerly the IOM) new white paper on the epidemic of diagnostic error.

No, the obsession, if there is an obsession, is not about perfect replication and avoidance of error.  The focus is on determining the causes of preventable harm and applying the scientific method to design experiments to obviate the causes.  The plan is, to the extent practicable, implement strategies to help avoid such harm.

[T]here is actually no convincing evidence that studying these mistakes and using various contrivances to focus on them, reduces their frequency whatsoever.

Yes, there is convincing evidence (from Peter Pronovost's work on central line protocols, for example) that the frequency of errors that lead to preventable harm can be dramatically, and sustainably, reduced.

For example, there is absolutely no reason to believe that a comprehensive medical record will reduce the frequency of cognitive errors, whereas it is evident that efforts to populate this type of record can remove the doctor’s focus from the patient and place it on the device.  

Well, here's one place we agree! EHRs might actually increase the chance of cognitive errors. But why would you pick that one example, Martin?

We all try to avoid errors but none of us will succeed. This is fortunate as errors are the only road to progress. Focusing on the evil of errors takes our attention away from the real enemy, which is illness. We should relax and enjoy the fact that we are lucky enough to be doctors. 

There are errors that lead to progress and there are errors that lead to death and other harm. The flaw in Martin's article is not so much what he says, as the extrapolation he makes from what he says.  A friend sent me a note summarizing the case nicely:

While I agree that we’ll probably never achieve zero errors in healthcare for a number of valid reasons, there is ample evidence that a systematic approach based on the scientific method can significantly reduce harm to patients.  Yet, there is no reference to the great work done by so many of his colleagues, e.g., Peter Pronovost, Lucian Leape, Donald Berwick, John Toussaint, Robert Wachter and Gary Kaplan, just to name a few.  Nor is there any empathy toward the patient and the impact of avoidable harm on his or her life. 

"Protocols are for nurses."

Every now and then you hear something so dramatically stupid that you have to wonder.

One such example was a couple years back, when someone said: "I only text on the highway."

The latest example comes from a resident who was being "trained" by an attending doctor.  The resident was about to administer a drug using the protocol developed by that hospital's clinical department--one based on evidence produced as a result of systematic clinical evaluations.

The attending doctor interrupted the trainee and said, "Don't do it that way. I've been a doing this for over 20 years, and that way is stupid."

The resident replied, "But I've been told that this is the protocol."

The rejoinder, "Protocols are for nurses. Do it the way I say."

Which is worse, the pedagogy that has been employed or the practice of medicine that is being carried out?

After several years of participating in resident quality and safety workshops, I can report that we hear stories about this kind of thing quite often. Each time, the resident is put in an untenable position. Each time, a patient is put in jeopardy.

Marty teaches about mathematics and learning

My buddy Sam came home from back-to-school night at Wellesley Middle School inspired by his son's math teacher, Marty Wagner.  He related Marty's message to the parents, that mathematics is about taking risks and making mistakes.  He said, "If your kids aren't frustrated when they come home, I'm not doing my job."

In my undergraduate days at MIT, an esteemed mathematician named Gian Carlo Rota taught freshman calculus and put it this way when we were having trouble grasping a new concept: “Learning is overcoming your prejudices.” He understood that people are not really good at getting past their old frameworks of viewing things and in so doing have to work through the discomfort of adopting a new view of a topic.

Afterwards, you experience the joy and satisfaction of having learned the new item and find yourself on a new plane. At that point, as noted by Cynthia Copeland Lewis, "As soon as you understand 2 x 4 you can't believe there was a time when you didn't understand it."

A key attribute of a good teacher is to have sufficient empathy with his or her students to understand where they are in the learning cycle--the initial interest, the distress of overcoming prior conceptions, and the pleasure of success.  In an email Marty sent to parents many years ago, he displayed that empathy and helped the parents understand how he was trying to teach their children.

We did do a lot of cross-country skiing this vacation, but having two pre-adolescent boys means that we also did a lot of downhill skiing. At this point it is clear that my two boys (9 and 11) are definitely better skiers than I. They kept going through the glades on ungroomed and extremely bumpy trails, in and out of trees, and kept pushing me to do the same thing. I would have been perfectly happy to stay on nice, groomed, cruising trails.

 Frankly, it's hard for me to get over the fear of falling. I don't like to put myself in a position where I might fall.

I think that many 7th graders are in a similar position. They are being asked to accomplish more than they think they can. There is more content, more homework, more tests, more new thinking than they feel comfortable with. As a teacher, my job is to push students to go down the hill, support them when they fall, and tell them that they need to go right back and do it again.

After skiing this week, I can really appreciate how scary that is. I have extra respect for the courage of students who do fall-- who can't quite figure out the homework, or maybe even get failing scores on tests, but then come right back, get help when needed, and figure out what they need to know to do well on their next test or quiz. 

We can expand on Marty's construct to the corporate and institutional environment.  If a key job of a leader is to help his or her place become a learning organization, a full understanding of the stages of learning is essential.  The key attribute of the leader, then, is to have sufficient empathy to understand where his charges are in the learning cycle. He or she can then adopt strategies that will help them move to the next stage, both individually and collectively.

Two books

I'm often asked to read books and post reviews here, and I thus find my bookshelf overly full.  I just can't get to them all.  (Indeed, I just donated a few dozen books--some read and some never opened--to one of our local hospital management degree programs!)

I recently received two requests, and frankly, I was hesitant.  For one thing, I am friendly (in the internet virtual kind of way) with the authors, and when friendship is involved little good can come of an honest review. For another, the topics were troublesome and likely to be a bit timeworn--yet another book styled as a guide to personal health and yet another autobiography about the trials and tribulations of being a doctor.

Well, what a relief!  They are both very good, and I am pleased to recommend them to you.

An Illustrated Guide to Personal Health

Tom Emerick and Robert Woods, with some important help from illustrator Madi Schmidt, offer 40 common sense steps to improving your health.  Don't worry.  You don't have to adopt all 40, but you might like to.  As the authors note:

Alas, medical care can really only deal with about 20 to 25 percent of the things that cause you to die before your time.  The remaining 75 to 80 percent [other than genetics] of health risks come from . . . factors . . . you alone can control.

With good humor the authors warn:

As you read this book, you will see a lot of repetitive redundancy, over and over.  Why? We are trying to inculcate you with certain principles.

Much of what we have written here is documented science.

Some of what we wrote here is less science than a merger of philosophy and personal observations.

And then the final disclosure:

Some people do almost everything wrong their entire lives, and we mean everything, and live to be age ninety. 

I'll let some of the chapter headings titillate your interest. To find out more, buy the book. Don't worry.  It's short.

Avoid Hand Dryers in Public Restrooms

Avoid Antibacterial Soaps and Gels

Let Kids Play in Dirt

Don't Take Multivitamins

Envy is a Killer

Brush and Floss Your Teeth Regularly

Retirement Can be Bad for Your Health

Medicine Man, Memoir of a Cancer Physician

As first glance, Peter Kennedy is the stereotypical overly intelligent young man who dives into his medical school textbooks to learn everything so he will never face the possibility of not knowing something important that he might face in the classroom or the clinic.  There not much hint of emotional intelligence as we read that chapter.  Later, too, we see his impatience with colleagues, administrators, and regulations, and we are set on believing that he is overly hard-driving and arrogant.

Why on earth would we consider his life to be interesting? Simply, because we watch him grow as a human being and as a doctor.

It turns out that this fellow is deeply dedicated to his patients. We like to talk about patient-centeredness today, as though it is a new concept.  Decades ago, Peter walked the walk, sometimes literally.  Here are some excerpts from his fellowship period:

The work [of taking care of indigent patient's in the Ben Taub cancer service] was long and rarely exciting.  On those occasions where I couldn't quite understand a patient's difficulty with immediate family or home issues, I ventured into the Fifth Ward (Houston's ghetto district) to visit patients at night in their homes. It was plain stupid to go alone. I had seen hundreds of the wounded from that region, more than enough to make me wary, but I was never approached or threatened on those visits.  It was at those times that the total impact of a patient's journey to improvement or death upon his family became reality to me.

As I talked with patient and family . . . I felt something in the room change. And as I explained a mother's medical status, her husband, her children, and any extended family present would calm down and give me all their attention.  Some of the free-floating anxiety, and the suspicion and wariness about a physician in their home at nine p.m. began to dissipate.

I pushed past my own hesitation a little further.  Patient and family were presented with a gentle reboot of sorts, a statement of data rather than information mixed with hysteria or bias. . . . They became active participants in their own disease and its treatment.

[He'd say:]

"When I am sure you understand all of this, and you must try very hard to do so, we'll talk about what can be done to reverse, stop, or cure this cancer.  I'll tell you about treatment, warts and all.  Nothing will be held back"

"Then we'll use this information to decide what we as a team think is best."

And then Peter offers this confession to the reader:

As I became more deeply involved in it, I began to impart a quality I did not know I had--true empathy.

I had been trained originally to use evasion and misdirection as tools to maintain hope. 

It is unusual for an author to display the vulnerability that Peter offers, not just on these clinical matters, but with regard to his personal life.  (I'll leave those sections to you.)  His story is a compelling one. It is a privilege to be asked to read it. I am pleased to recommend the book to medical students, clinicians, administrators, and patients.