Monday, January 26, 2015

Against the grain

There was a session at the Jaipur Literature Festival that I found surprisingly close to home in the health care world.  It was titled “Against the Grain” and was summarized as follows:

Voices of individual courage and conviction examine strategies of steadfast truth telling in the face of social pressure and mass opinion.

The panelists comprised a Who’s Who of writers who have taken a stand and engaged in acts of conscience in their work.

Swapan Dasgupta, an Indian conservative columnist, says he is labeled as “contrary because I betray my class, “ a group that has “a self-image of being progressive” but are actually condescending towards those with other views.

“I have lost a lot of friends” by taking positions, he notes. He bemoans this result.  “I don’t think political positions should be viewed as so polarizing as to preclude normal social relationships.”  He proclaimed, “Can’t we let this closed mind attitude disappear?”

Salima Hashmi’s father was jailed in Pakistan for his political views decades ago. This episode and the isolation from her previous friends and neighbors provided lessons for her:  “You learn about value, friendships, and loyalty in these situations.”

These memories, along with her own work, prompted her to elaborate on the themes mentioned by Dasgupta.  “People accept self-censorship.  They accept dictatorial behavior.”  Such attitudes become socialized as the norm.

And then, Gideon Levy, an Israeli whose very life has been threatened because of his views about his country’s occupation of Palestinian territory, went further.  He described many of his countrymen as being in “a pathological denial.  No one wants to know.  No one wants to say.”  They are “ignorant, blind, apathetic, without any moral doubts.”

He went on to explain the role of the journalist: “We are there to give a message that is not convenient.”

I don’t put myself in the category of these great writers.  But I have to say that I have found similar patterns of behavior from many in the health care field when I have raised concerns about the actions of doctors and hospitals that tread on medical ethics, that fail to address ongoing problems of quality and safety in patient care, or that employ overly greedy approaches to corporate acquisitions, mergers, and management.  Several other writers I know have faced the same patterns.

In short, instead of arguing the merits of those issues we raise, those who disagree often adopt the kind of unsocial behavior noted by Dasgupta.  Some simply do not respond, favoring a passive aggressive approach.  Some respond by personal attacks.  Sadly, in the words of Levy, they often present symptoms of being “ignorant, blind, apathetic, without any moral doubts.”

Imagine another world.  Imagine one in which, when challenged about an issue, health care people would listen modestly and carefully, engage in civil discourse, and try their best to think of what approach would best serve their communities—as opposed to what would best serve their individual or corporate interests.

I believe that health care folks can get away with bad social behavior because many media outlets and journalists fear being put in the outcast role described by the JLF panelists.  It is a problem for the public good when journalists accept the unstated and do not probe behind the scenes and expose the inefficiencies, the harm, and the injustices that are endemic to our health care system.  The media simply become outlets for the press releases and pablum produced by vested interests in the field. Were it not for people like Charles Ornstein and his colleagues at Pro Publica, John Fauber at the Milwaukee Sentinel Journel, Elisabeth Rosenthal at the New York Times, many of the major issues facing US health care would receive no attention at all.

I wish my health care journalist colleagues could have been present for this session in Jaipur.  Maybe they would have been stimulated to take on Gideon Levy’s advice: “We are there to shake.”


Anonymous said...

Yet another way of understanding what is required of us in "going against the grain": (on being a changemaker)...people will:
1. Ignore you
2. Pretend to agree, but actually do nothing
3. Resist, delay, obstruct
4. Openly attack you (the dangerous phase, but also a sign that change is starting)
5. Absorb
6. Utilize
7. Take credit
8. Proselytize

What people say in the process of accepting the change:
1. "That might work for your population but not for mine." (absorbing)
2. "I can use it, but not for anything important." (absorbing and utilizing)
3. "Some of my people can use it if they feel they need to." (utilizing)
4. "Oh yes, we've been doing that for years, it's quite good." (utilizing and taking credit)
5. "We've come up with a really incredible program; you should try it." (taking credit and proselytizing)

How the changemaker can react effectively
1. When they ignore you, find allies and persist.
2. Don't be misled by lip service. Find allies and persist.
3. Meet resistance with persistence. Move around the resistance; try other avenues.
4. The stage of open attack is a touchy time. People can get fired, for example. Keep your head down, but persist. Don't take the attack personally, even if it is a personal attack. Attack is information; it tells you:
a) You're getting somewhere: change IS happening, causing extinction-induced aggression.
b) Your attacker is frightened. Empathize.
c) Your attacker still believes in the efficacy of aversives.
5. Absorbing and utilizing: this stage can last a year or more. Maintain generous schedules of reinforcement.
6. They're taking credit for your idea? By all means let them; your goal is the change. Credit is a low-cost reinforcer and people who want it don't satiate. Give it away in buckets.
7. Are they pitching the change? Good. If you want to change something else, you now have new allies.

Initial Truth said...

This morning, with the HHS announcement that it was moving ambitiously to "value-based care" payment models, I went and looked at some of what I wrote as a journalist in the late 1980s and early 1990s. It anticipated much of what we see today and gave specific examples of the issues.

I was not an outcast. But, since I was writing for the Chicago Tribune, neither was I particularly influential in changing the national conversation. I don't think the "outcast" model works for health care policy journalists the same way as it does for someone covering politics. Or, for that matter, for more conventional beats.

Rather, the issues are much more conventional. My editors let me write what I did because they trusted me and had a budget. Generally, reporters have to write what's in the news. Ornstein, at ProPublica, is untethered from that problem and has the freedom (and trust) to be a leader. The Times is not always a leader, but is incredibly influential. However, investigating "doctors" is nowhere near as dangerous to a community newspaper as, say, accusing a specific major academic medical center of wrongdoing (an experience I'll never forget) or targeting a major corporation (ditto).

Remember: most ordinary people don't care about health care. They care about medicine; hence, the "medical miracle" stories. (Robots, anyone?) Even for those publications that cover health care, popularity rules. HHS announced 50,000 lives and $12 billion saved from improved patient safety over 3 years; the NYT didn't write one word!

Many journalists sincerely want to "afflict the comfortable and comfort the afflicted." (Others want to cover celebrities.) But they are limited by what they see, what others tell them and what the interest of their readers/viewers are.

One recent exception proves the rule: Brill's piece for Time. The reason it was so good is that it took many facts other journalists knew and put them together in a cogent, passionate argument. It deliberately did not do "he said/she said," and was, deliberately, not "fair" in one sense -- although very fair overall. But it was 25,000 words, written by an independently wealthy, well-connected publisher who went back to his roots as a writer and had the clout to pull his piece from The New Republic when it planned to put President Obama on the cover of its redesign as opposed to him. Brill said he wasn't going to wait an extra issue and pulled the piece.

Having said all of that, and having been in the health care field as a non-journalist for many years, the social pressure on true change makers in health care is exactly as portrayed above. Journalists can help. The real heroes come from within.

Bob said...

Most people are not brave. Most people are not independent thinkers. That is why you need to keep writing the way you do.