Minimizing

Sorry I missed posting on Monday - I've got a new work routine and it's throwing a wrench in my "usual and customary" schedule. Today's musing is all about the problem of minimizing. Psychologists and behavioral therapists know that the process of minimization is one of a set of disordered thought patterns that humans get into. Minimizations are those thoughts that do what the name implies - it takes a situation and falsely reduces the impact of it on others. One of the problems in healthcare, especially with physicians, is the common practice of minimizing the impact of procedures on the lives of those they are acting on. Case-in-point, I've had two conversations in the last week with folks about the benefit/burden of surgical procedures on loved ones who are nearing the end of their lives. In both cases, physicians have told the families that a given procedure is straight forward and easy to perform. In both cases, they are absolutely correct - the act of the procedure in both cases is quite easy for an experienced physician to accomplish. However, the burden of living with the procedure is never discussed. This is one of my main problems with the way that our healthcare system currently operates. There is no real informed consent - decision makers are only given one side of the story and are expected/led to make a decision without full disclosure of the likely long-term issues. Couple this with the fact that in both cases the patient in question had done no end-of-life planning or advanced directives and the situation quickly becomes a nightmare for an already stressed out family unit. The mantra of Medicine "first do no harm" has been co-opted into don't harm the patient with an intervention, but don't tell them the real burden of living with the intervention. For example, one of the people needed a tracheostomy to facilitate mechanical ventilation. This is an "easy" surgical procedure, but the burden is then living with long-term mechanical ventilation in a skilled nursing facility probably bedridden for the rest of the person's life - at significant societal and family cost. The alternative is no procedure, extubation without reintubation, being kept comfortable and pain free as the person breathes their last surrounded by family and friends. Which would you choose for yourself or a loved one? I urge all of you to make and Advanced Directive and Medical Power of Attorney soon. Discuss your wishes and make clear what you feel is important to being alive. If you don't the medical minimizers might just come calling. Peace for the journey, Dan

Generativity

Musing today on the ability of G-d to create things and to take those things already created (us in particular) and transform them/us to make them/us new. YHWH is THE Creator and as such has the unenviable task of putting up with all that the children are doing to that creation (and other creatures). I marvel these days at the endless patience and persistence it takes to continue to work against all the wrong-headed (and hearted) things that we do to each other and the world. Jehovah is keeping the promise made to Noah and not just throwing us all out with the bath water (again). Hard to believe that this isn't our fate...but it's not. We're at the beginning of the Jewish New Year, year 5300+; G-d is nothing if not faithful. I was talking with a friend just a short while ago about a critical illness and the realities that lie ahead for the loved one in question. The ill person is a life-long Catholic and believer, yet that person did nothing to plan for the end of their life. One could argue that believers are taken care of by our loving Creator and thus don't need to plan (that's a Calvinistic predestination approach), or that G-d will miraculously intervene, or that heaven is as good as we're told and we can't wait to get there.... More likely it is that we avoided the decision as long as we could and now we have to pay the piper. After all, all of us will die at some point in the future - life is 100% fatal. Difficult decisions present us with opportunities to discern what's important and what's real. How do I really feel about the choice between long-term mechanical ventilation through a tracheostomy (hole in my throat) versus extubation and being treated comfortably while I breathe my last breaths in this life? How does my view of YHWH influence this decision? Granted, I've seen this scenario played out thousands of times in the last 25 years so I know something about the suffering associated with the former choice. Spiritually, it comes down to whom do I trust? Do I trust my generative Creator who "knows what plans I have for you" or do I trust a fallible human physician who can't know the future? In G-d all things are possible, even the very hardest of things. Hope comes when we look to G-d to do the things that we can't and to create the outcomes that we most need. This week, look to G-d to generate new things in your life. Take a moment to think about what you'd like at the end of it as well. Some planning and advanced directive creating will be invaluable to you (and your decision makers) down the road. It will generate conversation and a new thing for you and your family - thanks be to G-d! Peace for your journey, Dan

Just an Ounce

My professional world is healthcare. I have worked in it steadily since the mid-1980's and have seen much change. However, much of the change has been in the form of new technologies and therapies for diseases that are a direct result of the life choices we as Americans make. Stuffing down endless amounts of junk food and red meat, washed down by sodas and/or juice and/or alcohol, all while living an increasingly sedentary life. Really, what do we expect our bodies to do with that kind of mistreatment? This week as I cared for the next in a long line of physiologically broken people, a couple of old adages came screaming back into my mind. "An ounce of prevention equals a pound of cure." Very similar to "a stitch in time saves nine". The sayings contain great wisdom that was hard won. By getting out ahead of the issue, one can prevent in large measure (9 to 16 times from these sayings respectively) future misery. This is not to suggest in anyway that everything can be cured through prevention and planning, however, there is a compelling amount of rigorous scientific data to show that vaccinations, good dental care, controlled use of alcohol, not smoking, modest and consistent exercise and seatbelts save a tremendous amount of lives and money. Since none of the medicines that we currently have actually cure any of the most common ailments (asthma, high blood pressure, high cholesterol, heart disease and stroke) it appears that the only cost-effective approach to these diseases is to do everything we can to prevent them in the first place! The main poblem is that we lack the self-discipline to do what it takes to become healthier. The other problem is that our healthcare system and insurance carriers do not value prevention as highly as they should. In fact, many plans do not incent or often cover the very basics of prevention and promotion of communal health. Couple that with the mythology surrounding vaccinations and the relative risk associated with them, and there is a perfect storm that wrecks prevention before it can even get started. Morally and ethically this is wrong - both at an indivdual level and communally. When we don't care for ourselves we show a uge lack of gratitude for the lives that have been given us. We should be ashamed! This weekend, think about all the prevention that you've let slide. Make an action plan to get the information that you need and implement one new healthy activity or preventative act. You'll be very glad you did - and so will all the rest of us who ultimately have to pay your healthcare bill. Peace for the journey, Dan

Seven Words

I was grabbed by a provocative and challenging article in the most recent Christian Century journal (September 5, 2012) entitled, "The Gospel in Seven Words". The CC asked 15 theologians, academics and spiritual writers to explain the Gospel in no more than seven words. Not surprisingly, each of the fifteen had a slightly different take on their descriptions, but all are powerful, insightful and blessed. I've dedicated myself to using one each week in my daily devotional time to see what "pearls of wisdom" I might receive. Additionally, it got me thinking about how I would answer the same question, and more broadly, how I would answer a question of describing my faith in just seven words. Musing on this topic I was also struck by a question of how I might describe my work, my life, all the things that I feel are important and illustrative of who I am as a member of the human family. Over the years I have been on groups that have created mission statements. These statements of purpose are at best supposed to be no more than 9 words in length. Each of those was challenging as one tries to distill down to the essence what it is that the organization is put on earth to accomplish. My own organization, Possibilities Journey Inc, has a mission statement that is 17 words long: "To co-create a model of health care that fully engages faith communities to optimize health, wellness and wholeness." It's probably time to revisit that and see if it truly reflects who we are and who we want to become (or are becoming). This week, I invite you to take the challenge to describe your faith, the Gospel, your spiritual beliefs, the meaning of your life, or another important piece of who you are in seven words or less. It will be challenging, but I know that you will find it a blessing as well. Peace for the journey, Dan

Learning Impaired

Two days from now a new report will be released by the Institute of Medicine (IOM) on creating learning organizations in healthcare. The wag in me says that this is an oxymoron. One of the main lessons I've learned in being in hospitals over the last 25 years is that they rarely learn anything and if they do, they learn painfully slowly. Thus, I've come to regard the whole system as "learning impaired" from the standpoint of being able to realistically change its behavior or learn from itself. Case-in-point, we have talked endlessly about making decisions on the basis of empirical evidence (evidence-based medicine), yet day in and day out in practice I interact with prescribers who do not know and/or follow guidelines from the late 1990's! The learning impairment comes from many places in my humble opinion - I'll highlight my top 3. The first is the overall focus on dollars rather than outcomes. When the obvious focus is on running a business, then everything else is secondary. Until this is redefined, the system will not change it's focus. Secondly, physicians have always practiced autonomously - even though their decisions drive the costs in healthcare. I had a pulmonologist (lung doctor) tell me honeslty a few years ago that he knew he was supposed to treat asthma a certain way, but though he might see 6 persons with this disease a day, he would probably treat them at least 3 different ways. Until all physicians (and other prescribers) are held to strict treatment protocols, there will be no functional learning (it will just be personal bias). Finally, physicians always treat lawyers first prior to treating patients. Decisions are based on risk mitigation for litigation, not necessarily on what is best for the person. Learning can not happen until tort reform is enacted (not going to happen when approximately 2 out of 3 legislators are lawyers). I applaud and agree with the IOM's conviction that healthcare needs to become a learning environment. However, the forces aligned against this are formidable, and a think-tank like the IOM can not change this. ACA (aka Obama-care) takes us a number of steps in the right direction - and while certainly not a panacea, it will move us a bit towards the goals we'd all like to see healthcare learn to achieve. Peace for the journey, Dan