I only thought our society was lazy before. Now, I've discovered the new height of laziness.
We have lots of ideas about why Americans eat more and exercise less and the declining health that results. And there is no doubt that our habits are changing … and generally not toward healthy ones. Is one of the problems just plain laziness?
Think about the jumble of remote controls on your living room table. We don’t have to leave the couch (and the chips) to change the channel, switch to the DVD player, or adjust the volume. Now there are remotes for the gas fireplace and the air conditioner. I want one to refill my birdfeeders.
 |
| Healthy Las Vegas tourists rent mobility scooters to get around. |
My kids love to upgrade the stereos in their cars for more power, and all the aftermarket stereos now come with remotes! Tell me why a driver needs a remote to adjust the stereo in the dash? How lazy can we get?
Well, here’s a new height of lazy — perfectly healthy tourists going on vacation and avoiding the walking on the sidewalks by renting a “mobility scooter” intended for the disabled. In recent years a scooter company in Las Vegas has seen increasing numbers of healthy people renting their mobility scooters. You don’t have to walk and there’s even a cup holder for your high calorie drink!
Walking is good for us. Current recommendations for Americans' exercise is one hour a day! At first, that seems way too difficult to achieve. But if you break it out into smaller pieces, it can be done. One way to learn how many opportunities you have to walk is to buy a pedometer. Then compare your activity on a typical work day to one where you change your habits. Take the stairs instead of the elevator. Walk the dog for 20 minutes before work. I like to do this with my coffee from the kitchen brewer with the automatic timer that goes on while I’m in the shower. Maybe I could add some extra steps if I didn’t use that gadget! Go outside at lunch. Take a walk with your spouse instead of sitting on the couch. Take another walk after work (or a bike ride). Add it all up and you can really burn some calories and improve your health.
It’s making new habits that is so hard. But if you make it fun, and cut it into smaller bits — it’s not so hard. And please, when you go on vacation, leave the mobility scooters for the disabled folks who don’t have the opportunity to enjoy feeling their legs work for them.
Becoming a physician requires commitment. Commitment to hard work, study , becoming a lifelong learner. Commitment to do no harm, to place the needs of others as the highest priority. 
The opportunities to use a medical degree are as limitless as ones imagination. There are the obvious choices of office or hospital practice. There are small towns, big cities, academic opportunities to teach or do research. There are executive opportunities such as I have pursued, to make changes in the system to improve care for larger groups of patients than can be affected one at a time.
Dr. Michael Polifka, after leaving his primary care practice in Manchester due to medical disability, made a decision to make a difference by volunteering on international medical missions. Following is an excerpt of his words about this experience:
We are anchored several miles offshore here in Guatemala and travel to one of three different sites each day. There are surgeons (doing pre-op screening for elective surgeries on the ship in the up coming days), physicians of varied medical specialties, nurses, nurse practitioners, nurse educators, midwives, dentists. dental hygienists, optometrists, pharmacists and a batch of Navy Seabees (doing special construction projects). Each clinic site is packed, literally thousands of patients waiting to be seen each day; marginally organized chaos. I am doing general medicine, seeing pretty much anyone that comes in for a medical problem.
In the community clinics in Livingston and Morales, I am seeing the usual complement of poverty related illnesses, including intestinal parasites, asthma and aches and pains (from living a hard life). The clinic at the national hospital in Puerto Barrios is a bit different. Here patients have come from far and wide around the country to be seen for consultations for possible to medical treatments and technology not available to anyone outside of North America and Europe. There are lots of little successes, the simple medical interventions that will surely make patients better, albeit for a short time. And there are some of the impressive interventions; one of the surgeons, a fellow Project HOPE volunteer, saw a Mayan woman who walked 240 km over the prior 15 days to get here and arrange to repair her abdominal hernia on the ship (one of the seventy surgeries that will be done while the ship is in Guatemala).
Frustratingly, there are too many that we are unable to help either because of lack of technology, time in the country, or hours in a day; but never for lack of caring or personal effort by virtually everyone on the Comfort. There is a 45 year old mother of 5 children with a damaged heart valve that is beyond the surgical capacity of the ship; an 8 year old boy unable to walk from congenital contractures of the tendons in his legs that won’t be repaired as the operating room schedule for the time we are here is over filled. There is the 51 year-old father of three with the uncontrollable shaking and stiffness to the point of near immobility of Parkinson’s disease who needs a life time of medicines readily available in the U.S. but we don’t have with us. There is the 32 year old agricultural engineer, who has been treated for leukemia; he flies across the country from the capital to ask me to arrange a bone marrow transplant in the U.S. And there are the hundreds who will receive only a small or partial supply of medicine as we run out by the middle of each afternoon being overwhelmed by the number of people who come to each of the clinics.
I remain incredibly touched by the individual expressions of thanks; the smiles, the hugs, the prayers given. But I experienced something new on this trip. On the first day in Morales, I happened to be the first one off the bus and the first to reach the wall of people, a couple of thousand at least. As I said “Buenas dias” to those in earshot, there was a simultaneous chorus greeting back. At the back edge of the crowd, the wall quietly opened for us to pass, and then they spontaneously started to applaud. The lump in my throat was heavy as I fought back tears. And it was immediately apparent to me for all the people that we saw and even the thousands that we didn’t, we, from the wealthiest country in the world, came and showed them, the poor people of the world, that we cared. So perhaps sometimes the most important thing you can do is just to show up ... And the world will be a little better for it.
It’s hard not to be aware of the shortages of physicians in Bennington. Our recent struggles to sustain pediatric call coverage and the consequent problems in delivering obstetric care highlight how the physician shortage has affected us dramatically in our hometown. So what’s the deal? Why don’t doctors want to come to such a beautiful place as Vermont to practice?
There are a number of reasons. Vermont is a beautiful place, with a sense of community, superb education, abundant recreational opportunities, and a health-care system that is both low cost and high quality. While I am biased, I believe the quality of life in small communities in Vermont offers much of what many Americans think of as core values.
The problems for physicians are largely economic. This is a hard topic for doctors to talk about, because in comparison we remain affluent members of society. However, the actual earning capacity of doctors has been declining for over a decade. At the same time, the indebtedness of graduating physicians has climbed to an average over $180,000. Physicians also do not begin earning any income until they are 30-35 years of age.
We are now in an era of physician shortage. That means doctors can choose an area to work where they can repay their debt quickly and practice in a supportive environment of colleagues and hospitals that are up-to-date and have modern technology to support the practice of medicine. Vermont has lost its competitiveness on the national scene. Government payments in Vermont for Medicare and Medicaid are extremely low, making the practice environment here much less appealing than in other states. New physicians can settle in most other states and repay their debt more rapidly, enjoying a better lifestyle than they could obtain in Vermont.
The national shortage of physicians is due to extremely poor planning in the 1990s. The baby boomers ironically contain the bulk of practicing physicians, and will shortly be the source of retiring physicians, and a huge group of patients needing care. Current estimates state that America will be 200,000 doctors short by 2020.
Hospitals, health systems, and communities in Vermont cannot survive without a steady supply of new and well-trained doctors. In many communities, the local hospital has begun employing physicians so they can keep critical local services available. Small hospitals are also struggling economically, but they will reorganize their economic priorities because they will fail faster without an adequate doctor supply to use their facilities. In the long run, rural communities like those in Vermont will only see this problem resolved when payment methodologies driven by the federal government change.
I’ve been engaged in some healthy conversation with members of our Quality/Safety Department recently about how organizational change occurs at the level of the individual worker. Health care organizations have recently been looking outside ourselves to other industries for performance improvement ideas. The “Toyota model” of performance improvement is based on the teachings of Deming since the 1940s and has transformed auto manufacturing. The same principles have been used in a number of healthcare organizations in the United States to dramatically improve processes, standardizing, becoming more reliable, and reducing waste. Examples include Virginia Mason Medical Center in Seattle, and Bellin Healthcare in Green Bay Wisconsin. Our own efforts in Lean Six Sigma training and process improvement here at SVHC have improved the outcomes for care at end-of-life, with cost savings; reduced “bedsores” at Centers for Living and Rehab, and a number of other hospital processes.
When this team shows up to work on me, I want them to have a flawless execution of their process, and enjoy their work. |
So the debate is: must we change the culture (attitudes, willingness to change, engagement in process improvement, trust, team behavior) before people can participate in performance improvement and change in their work? Or whether the experience of improved work leads to the changing culture. Our health system is currently engaged in accountability training, one component of which teaches that in order to change culture, peoples beliefs need to change. And beliefs are based on experiences. so if you really wants someone to change their beliefs, they must experience something new that tells them that their previous beliefs about the organization are no longer true.
Brent James, MD, teaches that an organizational culture of safety includes an organizational commitment to detecting and analyzing patient injuries and near misses, and is a "just" culture. A "just" culture has also been described as a learning culture. He distinguishes this from cultures that are "pathologic" (shoot the messenger), and those that are" bureaucratic"(write a new rule). A learning culture understands the broader implications of patient injuries or near misses and generalizes. To generalize requires standardizing a process and improving it.
So the dialogue I have been having (and I will upload a couple comments from my colleagues) surrounds where to focus the energy. Can one "teach" a new culture? Or does one experience a new culture because processes and behaviors have changed? I think one has to "teach" that there are behaviors that are more effective (like asking for feedback and really listening), but that in the end it is the experience of the improved process in the workplace and improved behaviors in the workplace that changes the culture. Our health system is on that journey, and has experienced dramatic improvements in infection rates, complicaiton rates, and mortality. Now we need to unleash the energy of every person who works here to be able to help the organization standardize and improve their own work process, just as Toyota has done with cars.
Read No Satisfaction, the complete article on the Toyota method that appeared in Fast Company Magazine.
Is there a health care system? In a word, no. I find myself chuckling internally whenever I hear politicians talk about reforming our health care system. In the United States, we have a patchwork quilt that is barely stitched together with an incredible variety of rich resources, absent resources, good insurance, lousy insurance, no insurance, and providers of care that provide good quality and poor quality. In fact, for the price we pay, we have the most expensive health care in the world with performance that is only fair.
For $5,700 per person per year, the performance of our health care “system” scored 66 out of a 100 on international review of health care outcomes. click for reference 14 countries perform better than the United States in death rates for diseases considered treatable by healthcare, and all at lower-cost than we do. We spend an enormous amount of money on end-of-life care and elective procedures that provide small benefits to people, while not adequately using preventive strategies and effective care for the chronically ill. 
Doctors are frustrated with lack of payment for things that could make a big difference, like effective systems to care for chronic illness. Employers are fed up with the high cost of health insurance, and their subsidy of government underpayment for the cost of health care services. Yet this issue has not reached the top of the list of topics that Americans consider important politically. And it’s a very hard topic to discuss in a “sound bite.”
But there is absolutely no system. The quality and availability of healthcare varies by family, employer, city, state, health care facility, physician group, and a variety of other factors that are not applied according to need. In my view it’s really unethical, and screams for standardization and the building of a real system. Is it fair that if you’re a child of a family that’s unemployed you have a different health system than that a child of a family that has employment? Fortunately, here in Vermont, it’s very hard to be a child without insurance. But that’s not at all true in all states.
Building a system won’t be easy. But neither was building an Interstate Highway system, or sending humans to the moon. First it takes leadership and political will, and then it takes reorganization of the healthcare resources and a more even and fair application of those resources to the interventions that will help the most people.