A colleague of mine asked me a while back a simple question: "What's the best advice you ever got?" Navigating through choices in life is hard. Uncertainty seems everywhere. The pace of change is dramatic. How to stay on top? How can I correct after an error? How do I maximize the chance of success?
While I can’t claim any core wisdom on these issues, I have received some good advice along the way. I also pay attention to what others who are successful do and say. I can summarize the best advice I ever got in three phrases:
- Be prepared
- Pass going uphill
- Ask for feedback
“Be prepared” is a bit out of favor in our instant messaging, ultra short attention span era. I’d guess I first experienced "be prepared" in the Boy Scouts — yes, I really did do that. The staff that works for me now once confided in me that they call me ‘the boy scout’ behind my back. I can think of lots more worrisome images for the ‘boss.’ Being prepared is doing your homework. And not just the Cliff's Notes the night before. Read the articles, digest the material, and think. These days it often means “Google it!” — see what else I can learn. Being prepared means making better decisions with some data, examples, or history to guide me. And I still have my backpacking list, honed over 40 years of hiking, with reminders of all the stuff I need to take along to be prepared for wilderness contingencies. And that list does not include a GPS unit or a cell phone. It does include wool layers and waterproof matches.
“Pass going uphill” came from my high school cross country ski coach. We practiced it every fall when we were running. We’d do “wind sprints” on our long runs. The guy in the back of the line had to sprint around the rest of us to the front. Coach made us do it going uphill to practice for the real races in the upcoming winter. His idea was twofold. First, you can dig deep and find an extra reserve to push even when you think it's tough going up this hill. Second, the guy you just passed is likely to drop back faster if you pass him when he thinks he’s working as hard as he can. It’s about winning.
“Ask for feedback” is about managing myself. I wish I had learned this one earlier in my career. I’m sure there were mentors and coaches who tried, but I didn’t really get this one till I had assumed some management and leadership roles. Comically, I remember talking with my close friend and partner Michael Polifka about perceptions of myself over the years. I would sometimes lament to him that others didn’t understand me or my intent. His advice was very pragmatic: “get over it; just do the right thing.” It was good advice, and I used it.
Then later I hired a career coach as I entered several leadership roles. Howard’s advice has been clear and consistent. The only way you can understand how others perceive you is to ask. And you have to do so frequently, in real time, and of different constituents. Perception is, in fact, reality. I have to get over my internal compass. I know my intent. It doesn’t matter that I meant well. If others perceive my actions or behaviors as insensitive, wrongheaded, or worse, then I need to know that. And the only way to learn, and get better, is to ask. So I ask 2 questions about whatever the topic is: 1) what am I doing well? And 2) what can I do better?
I still don’t do this often enough. I still get caught up in my agendas, projects, timelines and bull forward. Then I bump up against some negative perception and think “wow, I did it again…didn’t ask for feedback often enough, and hit a wall”. So, like the rest of you, I am still learning.
So readers, tell me, what is the best advice you ever got?
In this second installment of Dr. Polifka’s Africa journal, he describes his participation in medical education for the medical students and interns in the rudimentary training program at the John F Kennedy Medical Center in Liberia. For the entire country with a population of 3.4 million, there are only 52 physicians. Michael describes his personal transformation to a view that “all health care is local.” That’s how he feels change will happen and it’s how he’s decided to spend his time. See what you think.
Mark
Dr. Michael Polifka’s medical journal from Monrovia Liberia- March 2008
The medical ward had about seventy beds divided up into six bed wards. It was but 75% filled, not for lack of patients in the country but rather because of lack of any public funding or health insurance. With the profound lack of virtually all standard daily medical supplies the hospital had to resort to having most patients pay an upfront deposit for medicine before they could be admitted and then pay for every lab or x-ray test prior to it being done.
Some of the patients lived in or near the capital but many of the patients had been to other medical facilities in the country recently and had come to ‘the JFK’ for more advanced treatment; all were very sick. In one ward were mostly patients in their 40s and 50s, too young for the significant stroke, kidney disease or heart failure they had resulting from severe uncontrolled hypertension. The next was a room with older patients often with cancer presenting too late for effective treatment even if there were oncologists or surgeons available; there weren’t. The one starkly furnished room where there was up to date treatment available (from international sources) was the female AIDS ward; it was always full.The afternoon outpatient clinics were more of the same illnesses, severe hypertension, heart disease, pneumonia, and diabetes along with the more common intestinal parasites, typhoid fever and malaria (lots and lots of malaria). There are remarkably few patients with just aches and pains. My days are always full and satisfying, feeling that I have added a bit to the care of the patients being that day and to seen in the future.
Yesterday was eye opening to say the least. A 16 year old girl who had slipped into a coma the previous night was presented to me on morning hospital rounds. She had been slowly deteriorating for the past five days (she had walked into the hospital) and the cause unrecognized by all the nurses, med students, and interns that had seen her over that time. As I was about to begin a Socratic questioning of the medical students about the causes of coma, I noticed the IV fluid the patient was obtaining was dextrose water, apparently only that since admission and was certainly the cause of her condition.
My comments were direct but restrained, aimed at education during the last minute change in treatment that of course did nothing to change the expected outcome. She died in front of us. Through the day I found myself perseverating about the case, trying to grasp the magnitude of the problem. Where do you start? The immediate lesson to be taught about the IV fluid management was easy to present, but what about the bigger picture? Certainly being accusatory is useless at best; for the med students have all taken nine years to get to the 4th year of med school, with little in the way of textbooks, school closed every couple of months for undetermined amounts of time and no real clinical training. The interns all in their 40s have taken even more time to get to where they are, trying to learn without even the most basic clinical equipment to support them, and with few attending physicians to supervise and teach them. And there are but 52 physicians in the entire country, many of whom are elderly, hanging on hoping there will be someone soon to replace them.
Worldwide it is increasingly being recognized that real improvement in the developing world comes not from large grandiose plans (more often than not from those outside) but from those working locally. The task of returning this medical center to its prestigious level of two decades ago is a very large barrel to fill. Dr. Dennis and his small attending staff certainly have made major contributions in the past two years adding to the barrel, but there is still is so much to do. What we accomplished here is but a ladle-full added to that barrel, but I am impressed by the belief of my new friends here that this is a pail that can be filled. I have been privileged to add a few drops to it.
Michael
My friend and medical partner Dr. Polifka has sent another journal entry. This time he’s in Africa. In addition to his adventures in practicing medicine in difficult circumstances, he’s finding a voice as a writer. Now he’s also ‘practicing ‘ by teaching others. “teach a man to fish….”
Dr. Michael Polifka’s medical journal from:
Monrovia, Liberia
March, 2008
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Michal Polifka on medical mission
in Nicaragua
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Our Project HOPE team of 12 was transported from Ghana to Liberia on the stealth-looking U.S. Navy ship, appropriately named the Swift (actually it’s a modified inter-coastal ferry). The rusted, gutted, semi-sunken ship at the wharf in Monrovia that prevented us from docking was premonitory of the difference in the condition between the two countries. The drive to the city from the dock area made it absolutely clear.
The four lane thoroughfare was more pot hole than road and managed to fit seemingly three lanes of traffic in each direction, a large majority of which were aged yellow taxis. At each window a passenger hung out head and arm trying to get a bit of relief from the 95 degree heat. The snail’s pace traffic allowed me to see that each taxi typically had seven to eight passengers within, and occasionally with two more sitting in the back, legs covered with the partially closed trunk as if it was a lap blanket. The shops along this commercial street selling hardware and building materials were open, but the hand painted signs suggested that this relatively recent. But the real commerce was on the sidewalk in front. Small tables with local vegetables shaded by bright colored crooked umbrellas, women in colorful patterned lapas with matching head scarves squatting next to the fish they are selling while fanning away the flies, a rusty wire mesh hangs shirts and pants dusty from the road’s proximity, there are wheelbarrows filled with brassieres, a wood plank is lined with shoes all are but minimal obstacles to the hundreds of people, bundles in their arms baskets on their heads, weaving about them in their own pursuit of the day’s buying or selling. As we enter the city center the fact that civil war ended but three years ago is even more apparent. The ground floor storefronts with hand painted signs suggest the short duration of the current enterprise, but hanging laundry and small cooking fires in the bombed out charred concrete shell in the second and third floors open to the sky tell the real story of the chaos just ending.
The following day we go to our work site, the John F Kennedy Medical Center, for orientation and a tour. Literally and figuratively a shadow of its former self, once the medical state-of-the-art, shining star of Western Africa, a third of the buildings on the campus are more bombed out concrete remnants from senseless destruction during the fourteen year civil war. The rest are all in bad need of lots more than cosmetic repair. Poorly lit, at times dark, hallways lined with over filled benches served as waiting areas for various outpatient departments. As typical for the third world, patients came very early in the morning and waited all day for the possibly of being seen. Some areas of the hospital seemed and adequately supplied and staffed. The physical therapy department was staffed with well trained therapists who had adequate equipment, either older things in good repair or ingeniously things made for locally available material, as well as supplies for their very busy prosthetic limb clinic. The emergency room, the intensive care unit and the general medical floor were quite the opposite. Typically out of daily supplies like gloves, and with medical equipment both in short supply and often non-functional, the quality of care was certainly affected. I didn’t see one heart monitor in the six bed open ward optimistically called the ICU; of the two oxygen concentrators in the entire place, the one I witnessed didn’t function when needed; there are but two ECG machines; the lab results were often delayed for lack of reagents; the one x-ray machine in the hospital was a portable one and gave poor quality films, and on and on.
I then met with the Chief Medical Officer of the hospital to find out how we could best help. Dr. Robert Dennis, a plastic surgeon practicing in the U.S. for the past 20 years had been recruited by Mde. Sirlief, the country’s recently elected president, to return to country of birth and head up the hospital’s effort to return to its former state of prestige. I told him that with medicine we had with us, I was prepared to supplement the hospital’s general outpatient clinic by seeing patients as we had done in Ghana or help in anyway else. “Education” is what his professional staff of interns, medical students and physician assistants most needed he said. Therefore, I would spend my time running teaching rounds on the medical floor in the mornings and mentoring them as they attend patients in the outpatient clinic in the afternoons.
Pharmaceuticals have been a core of the dramatic medical advances available to patients in the past decade. In particular, cancer chemotherapies, drugs to control symptoms of chemotherapy, cardiac agents, diabetes medications, and amazing new anti-inflammatory immunosuppressant drugs for rheumatologic diseases are but a few examples of enormous advances in pharmaceuticals.
But there is trouble for all of us in the pharmaceutical industry, and its regulation. Several recent examples raise issues with the pharmaceutical firms and their addiction to greed. It's been a long-standing truth that the pharmaceutical industry spends more on marketing than it does on research and development. So when an industry that has profit margins rivaling and exceeding the oil industry justifies its profits on the basis of the quality of the products it is producing, I wince. Between direct to consumer advertising, and the incredible attention the pharmaceutical industry pays to physicians, they are wasting dollars that could be spent on more research, or less costly drugs.
And now we have some very troubling news. The Washington Post article Maker of Vioxx Is Accused of Deception cites the journal of the American Medical Associaton indicating that pharmaceutical firms write their papers for publication before finding an author!
And the FDA is overwhelmed and incapable of effectively reviewing the science brought to them says this Federal Times article. And the NY Times reports that the FDA is under fire for a new plan to relax rules on drug promotion. For physicians and consumers, these trends should prompt demands for reform. Pharmaceutical agents are very important to all of us. However, they should be introduced after effective review of the science, and when risks have been adequately evaluated, and at lower cost.
And how addicted to greed can a pharmaceutical firm be? To actually write a paper regarding their research and then seek an author who is willing to attach their name to something written by others with a self-serving agenda is incredible.
I am no fan of excessive regulation. The healthcare industry is already the most regulated industry on the planet. But these egregious behaviors will cause a response. Those of us who occupy board rooms must constantly remember who we are serving. I am glad that the board rooms I sit in seek to manage most effectively a nonprofit community resource-a community hospital. The board rooms of the pharmaceutical firms need to remember that they serve the same ultimate goal-patients with illnesses. How they do so while satisfying their shareholders, is an agenda that needs better thought than is currently being applied.
and another from Dr. Luloff
Mark
Depending on who you talk to, ADHD (Attention deficit hyperactivity Disorder) is either the most common neurodevelopmental disorder affecting our children (10% of all Children in School) or the most overdiagnosed and abused label put on our children...and the most common reason for overmedicating kids, sometimes as young as 3 years of age.
In order to eliminate any abuse or excess/inappropriate medication parents need to first be sure that the diagnosis of ADHD is accurate and appropriate. When is an overactive or impulsive child stepping over the line of normal into one of dysfunction? The only way to be sure is to have a complete evaluation that includes feedback from adults who regularly interact with the child (parents, teachers, coaches, child care workers etc), a full medical evaluation by the child's health care provider and a neurological exam either by the child's regular provider or by a specialist.
An MRI or CTscan is not necessary, nor are the many expensive (and poorly predictive) "ADD" computer tests. Once a diagnosis is made, and confirmed, the next step is to assess the level of dysfunction/lack of success the diagnosis imposes on the child. In most studies only about 20-30% of children with the diagnosis of ADHD required chronic medications, and medication should never be the first strategy employed for any child.
Behavioral and educational management plans coordinated between parent, school and behavioral therapist should always be the first step in any treatment plan. Only when these plans fail or where the level of dysfunction is so severe that medication should come into play.
So, what to do? Be an informed consumer (or provider) and ask the right questions and if you don't have all the answers seek the advice of a specialist in ADHD Medications are appropriate for some children but not for all and should never be used as the sole therapy. Their role in the treatment of ADHD needs to be re evaluated at regular intervals to determine their effectiveness and to identify any possible side effects.
Marty
Marty Luloff MD FAAP
SVHC Pediatrics