My Day at a Free Clinic: The Truth Behind the Rhetoric

I just got back from a most remarkable experience: volunteering at a free clinic in Charlotte, NC.

Like many of you, each day I read my Daily Digest to be aware of the health care news of the day. The political rhetoric about the work ethic of the unemployed has been awfully harsh lately. Opinions about health policy and the tug of war between the two political parties that appear on the editorial pages of our nation’s newspapers seem very disconnected from the reality on the streets and country roads of the United States.

I had the opportunity to hear the stories of hard-working and proud Americans who have lost their jobs, and with the jobs, their health insurance. It’s these stories that make the policy issues come alive, and drive home the absolute necessity for clinicians to help create a system that is worthy and respectful of the character of these Americans.

Mary, 60, is a well-educated woman whose COBRA coverage expired two months ago. She lost her job as a loan evaluation specialist at a bank 20 months ago. She paid the full cost of coverage for her health insurance under COBRA because she knew the consequences if she developed a serious illness, and couldn’t pay for the costs of care.

With hypertension and thyroid disease, she’s familiar with generic drugs that keep her costs down. She’s not sure what she’ll do to cover the years until Medicare coverage becomes available, because she’s caring for her 87-year-old mother, and helping her son who moved back home when he lost his job. She’s also back in school re-training as a health care billing specialist, because even “dumbing down” her resume to not appear overqualified for many jobs hasn’t helped her land any interviews. She takes care of herself, and relies on her faith that she will make it through her difficult situation.

Susan, 45, is a wife and mother of two elementary school children who stayed behind in New York to continue working at her job when her husband got a new job in North Carolina. Though living apart as a family was difficult, as an accountant she knew it was necessary to get through the recession. She was the first to lose her job. A few months after moving to NC, her husband’s job disappeared. Neither has been successful in finding new work. She told me her children have health care coverage, and that her kids have been very supportive of her as a good mom, even though times are tough for the family.

Those were just two of the nearly 1,200 people who showed up for the free clinic. Not only was I privileged to be part of their lives for a few minutes, but it was an opportunity to work as a team with nurses, other physicians, and volunteers to help others in this season of hope and goodwill. The young physician (six months out of internal medicine residency) working in the cubicle next to me was my lifeline to high quality, current medical thinking. She thought my years of experience were equally as important. We made a good team yesterday. Thank you, Nicole.

Finally, on behalf of other ACPE members who served as volunteers yesterday, we thank Ed Weisbart, one of your ACPE colleagues who is a leader for the National Association of Free Clinics, for letting us know of this opportunity. Included with Ed in making this happen is our own Charisse Jimenez, who helped us get the word out.

Interested in volunteering or making a donation? Visit the National Association of Free Clinics to learn more. In addition to practicing physicians of all specialties, residents and medical students are welcomed to volunteer. The NAFC also needs mid-level practitioners, nurses and everyone else who can help, clinically or nonclinically.

A Good Death

My friends and family must be outliers from what many physicians tell me about patients’ demands for expensive, and often futile, care.

Several friends are facing terminal illnesses. Their concerns are about overtreatment and getting into situations that diminish the quality and dignity of their lives. They tell remarkably similar stories of listening to their oncologists’ recommendations for additional (but debilitating) chemotherapy. Then they decide to forgo the recommendations because it doesn’t fit with how they want to live. Their biggest concern is having a good death, because they already know life will not be long.

My Mom has a debilitating disease. She wanted enough diagnostics to know what the problem is, and then told her doctor that she’d come back when the symptoms got bad enough that she would consider medication. Not yet.

Grandma Winchester, my 93 year old mother-in-law, is another good example of health economist Michael Grossman’s theory of consumers’ demand for health and healthy days – not necessarily health care. Health and healthy days provide us opportunities to do what we love, whether it’s time with family, hobbies, or meaningful work. Time spent in doctor’s offices or hospitals is not a preferred way to spend her days.

Within the past year, she’s chased a bear out of her kitchen and been evacuated twice from her 600 square foot cabin in the Colorado Rockies because of nearby forest fires. She stays in shape by hiking, shoveling gravel on her mile long driveway and walking two miles round trip every day to get the local newspaper and her mail. She gave up driving a few years ago because she wasn’t as sharp as she wanted to be. But she still drives her snow plow truck in the winter to plow that driveway.

Though she loves her doctor and has gotten excellent care, she hates going for a visit because it means she has to impose on one of her children or grandchildren to drive her to town. Instead, she appreciates that her physician answers her questions by email. She’s talking about getting “DNR” tattooed on her chest.

About two years ago, her husband of sixty-seven years died in their cabin – just as he always wanted, sitting by his favorite fireplace. Despite being paraplegic for almost sixty years from the polio epidemic, he never developed a pressure ulcer – even in his final days. His family made sure of that.

Grandma will die in that cabin someday. Her family will make sure of that.

I read somewhere that 80% of Americans say they don’t want to die in a hospital or nursing home. But 80% of Americans do die there. The reasons are undoubtedly complex.

Think about your own wishes and what members of your family want. Lots of expensive care, waiting for the next test result, cooped up in a hospital? Maybe some do, but many other people just want to have healthy days, and realistically know they won’t live forever.

What is a good death for your patients? Have you asked?

Arrogance

The word came up in two separate conversations, from two very different people. Every two weeks, we ask someone associated with ACPE to spend 45 minutes sharing his/her insight on the trends occurring in health care. Both people are nationally known, one a recruiter, the other a physician leader. With the number of physician leadership roles growing rapidly in the past few months, I want to share their comments because they’re important for both job seekers and leaders who plan on staying in their current organizations.

The recruiter said physicians seeking a new position for all the wrong reasons are spotted very quickly in the process. These physicians often say they’ve discovered how talented they are in management and know they would be successful in their first full time management role. They haven’t invested in management training because they possess “natural talent”, are highly critical of the leadership of their current organization and say they no longer enjoy clinical work. The term the recruiter used to describe their demeanor? Arrogant. Further, these doctors are quickly dropped from candidacy.

What does arrogant mean? Here are a few definitions – none of them conducive to effective leadership! “Overbearing pride evidenced by a superior manner toward inferiors.” “Haughtiness.” “Contemptuousness – the manifestation of scorn and contempt: every subordinate sensed his contemptuousness and hated him in return.” “The trait of being imperious and overbearing.”

The other guest, a health system physician CEO, said over the years he had to fire several excellent clinicians who had very poor communication skills and lacked self-awareness. They often had very good analytic abilities, great insight into problems and solutions, but could not manage a civil word with peers, subordinates or superiors. Some were friends. Again, the term arrogant was used to describe their behavior.

With teamwork replacing autonomy and independence, arrogance is a trait that will derail you and your career. It’s OK to be proud of your achievements as a physician, but it should come across as quiet confidence to others on the health care team. Some physicians DO have a natural talent for leadership and business. Most of us, however, must learn new concepts and behaviors we weren’t taught in our medical training. I’ve heard stories from coaches and mentors about successful behavior change in arrogant physicians who recognized how they were being perceived, and sought to change. Some of my most valuable experiences have been helping smart, talented physicians change their behaviors.

If you’re one of the hundreds of physicians who are looking for a rewarding role in leadership or management, be sure your first interview puts you in the best possible light. We want you to be successful. Many people are watching and curious about the impact of more physician leadership in the health care industry.

Notes from the road: An optimistic view of the future

Physicians are preparing to lead health care change across the country. This is perceived by some entrenched interests to be a threat. To patients and their families, and to physicians’ co-workers, this is a very positive development. I think whoever is closest to patients and consumers will be in the best position to impact change.

Crisscrossing the country over the past few weeks, here’s what I’ve seen and heard to justify my optimism. In Iowa, a large predominately rural health system has launched its Physician Leadership Academy. Each of the thirty-seven physicians were enthusiastic about learning how to improve dysfunctional work processes, develop innovative strategies, and find ways to improve patient outcomes of care. The initial class was nearly 50 percent larger than anticipated, and next year’s new class is equally committed and talented.

In South Carolina, the hospital association and medical association held a joint meeting to discuss what health care reform means for their communities. I talked with several ACPE members during that meeting. I learned that South Carolina has been collaborating with Atul Gawande on the surgical checklist project and with IHI on quality initiatives. The sense of common purpose and respectful disagreement on issues (not people or motives) between the medical society and the hospital association was very impressive. When it comes to interdisciplinary teamwork and measuring health care outcomes, I think South Carolina is a special place.

In Nevada, a large physician group has been managing financial risk for a few years, and doing very well. I listened to a sophisticated conversation at breakfast between two of the attendees about the clinical and financial management of heart failure patients across the continuum. I assumed both were physicians. Wrong. One was the CFO. I believe these kinds of conversations will become commonplace in integrated systems, ACOs, and medical homes if health care change continues in that direction.

In Nebraska, a rural community is beginning an important dialogue with its hospital board, independent and employed medical staff, and hospital staff about how to become a “physician led system, managed by business professionals”. Everyone will have to imagine how their roles will change, and what it means for relationships with large tertiary care centers in nearby cities.

In San Antonio, Texas several dynamic young physician leaders from different branches of the military remind me that some of the best teamwork training and practice occurs in our armed forces. When an individual fails, the whole team fails. They hold both individuals and teams accountable for serious safety events. They correct the problems that lead to the adverse outcomes.

If you see a system around you that frustrates you, or isn’t good for safe and reliable patient care, start now to learn what you can do to change it. Your satisfaction in helping to lead change, and see your role as a physician in a new perspective, will give you exciting new options in your career.

Dog Sleds and Teamwork -- Or How a Team of Huskies Made Me a Better Manager

Years ago, before beginning my management career in health care, I trained our four Siberian/Alaskan huskies to pull a dog sled. My motivation was to allow our toddlers to enjoy the winter wilderness with a smile on their faces. Kids love dogs, and a down sleeping bag wrapped around them makes for a nice trip in the back country.

Now this is going to be dangerous: I’m going to share some insights on working with a team of dogs and how that might have some relevance to working with people when you and your team have a goal in mind. We love our dogs, but we should have at least that same love and respect for the people we work with, don’t you think?

There’s always a first time when you and the team get together to try something new. Each one of the huskies individually would instinctively pull on my ski-joring rope when I went cross country skiing. I thought getting each of them to work together would be a piece of cake. But the first time I hooked up the four dogs in their harnesses it was a disaster! The dog I chose for the leader was Junior, the oldest and alpha male of the group. Strong beyond belief, he was always the aggressor in the yard. I assumed that the others would follow his lead. Wrong. Junior would stop pulling to turn around and snap at or fight with the others. Harnesses were tangled, none of the others wanted to pull.

I was quickly growing frustrated -- and so were the dogs. I decided to “punish” Junior by putting him at the back, in the “wheel position” – the first dog immediately in front of the sled. I chose the youngest dog (Togo) with the mellowest personality of the group for the lead. Lo and behold, much to my surprise and delight, the team ran with the characteristic excitement and enthusiasm of a high performing sled dog team! Junior loved being in the wheel position because he could keep an eye on the others, and it was the best position for the strongest dog. The others (Wiley and Lupe) appreciated being able to run faster. The dynamics changed very quickly among the four of them.

Over the years, you learn valuable lessons about teamwork. Don’t expect your team to do something that you wouldn’t do yourself. Got a hill to climb? Get off the runners and run up the hill with them. Lost and unsure about which trail to take in a whiteout? Trust your team. Their instinct is correct and deserves your trust and faith. Praise them for a job well done. Keep the momentum going. Don’t slam on the brake suddenly and stop the forward movement until you’ve crossed the finish line.

I noticed that every time I stood up to use the footbrake to slow the team down, I’d lose my balance, and sometimes fall, bringing the team to a complete stop. “What’s your problem?” they seemed to be saying when they looked back to see why we weren’t moving. One day I asked a veteran sled dog driver how he managed to avoid falling when using his brake.

“I never use it until the race is over. I stay low like the dogs, dragging my feet or knees. Standing up on one leg, and raising the other to stomp on the brake, elevates your center of gravity, and makes you unstable.” I have no idea how that relates to our teams at work, but I thought it was interesting.