Out of the Darkness

For my husband on his birthday...

Even though today marks eight years, I can remember it so clearly. It was just a few hours before the clock struck twelve and it would be my husband’s birthday. He loves presents, but always makes it difficult for me to get the right thing. He acts as if his birthday doesn’t matter to him, but I do think he likes a bit of a fuss.

The message on my phone wasn't very clear. There was a great deal of background noise. I could hardly hear him say, “Call me now, it’s an emergency!” I tried calling several times, but he wasn’t answering. Finally, I called my father-in-law and I could have never predicted what would come next. His voice was different; it was slow and soft as he calmly explained to me that my husband’s brother had just killed himself. He was 26 years old. It was incomprehensible. I couldn't make sense of it. Even after years of working in mental health, I could not even begin to grasp what I was hearing.

There isn’t a day that goes by that I don’t think of him. He and my husband were best friends. Al was always there. He did everything with us. I remember he would come out on the boat with us. He never got out on the ski or wake board. He never drove either. He just liked to come along for the ride. He liked to spend time with his brother. The feeling was mutual. They were very close. Where you found one, you would very likely find the other.

It only takes a momentary glance to see the sadness in my husband’s eyes. I have come to know this silent sorrow all too well, because it dwells in our family. I have experienced other family members dying. I have talked about my father's death, which had a profound effect on me but this is different; there is a silence that accompanies suicide. The silence is deafening. Each December we are quiet, our conversation subdued, as his birthday passes and the holidays come and go. Then there is today’s date, and even though we rarely speak of the night he killed himself, we are all thinking about it. I don’t really know how to say it other than directly. I miss Alfred. I really miss him. There is so much silence. I wish we could talk about him more.

With his permission, I decided this year I would give my husband a different sort of gift. On the night of June 27 -28, 2009, I will join thousands of other people on a 20-mile walk into the dawn in Chicago Illinois as part of the American Foundation for Suicide Prevention's, Out of the Darkness Overnight Walk. I have formed a team called 'Common Things' and I will walk for Alfred and our family. If you like, I will walk for you and your family too.

The goal of this journey, which will begin at dusk and finish at dawn, is to raise funds for suicide prevention. I would like to help end the silence and erase the stigma surrounding suicide and its causes, encourage those suffering from mental illness to seek treatment, and show support for the families and friends of the 30,000 Americans who die by suicide each year. Suicide is the third leading cause of death among teens and young adults and the second leading cause of death for college students.

If you would like to join my team or participate in any way you can go to my team webpage.

Please help save lives, reach out to those families who are devastated from losing a loved one to suicide and help create an outlet to help end the silence.

...Always

Medicine, Harm, and the Human Response

M. Scott Peck lead a three psychiatrist team appointed by the Army in 1972 to examine the "group evil" called the My Lai Massacre. His experience in this investigation lead him to develop a theory of "human evil" that appeared in his second book, "People of the Lie." After offering a psychology of love in, "The Road Less Traveled," he explored the psychology of evil in his second book. It is one of my favorite books--not because I agree with all of Peck's theories, but because he asks a simple question that troubles us all at some time in our lives, "How is it that normal people, individuals who may be upstanding citizens in many situations, end up doing unspeakably evil things to others--and even seem to have no recognition of the harm that they cause?"

It is a challenging and frightening question for us all. It is a question that points to the dark side of life and wonders. Can we understand more about good by understanding more about evil? It is a question that has been asked by many generations, in many ways. Lao-tzu framed it this way, "When the people of the world know beauty as beauty, there arises the recognition of ugliness. When they all know the good as good, there arises the recognition of evil."

In medicine, as a whole, we try ardently to do good. Although I have read about medical providers who try to hurt patients, in 29 years of practice I have never met such a person. However, medicine does cause great harm to patients (often without knowing it)--what used to be called iatrogenic harm. Iatro- meaning physician, -genic referring to causation, unintentional harm caused by the medical system--by the act of doctoring.

The wrong medicine is given and the patient has a side effect. The wrong diagnosis is made, and the correct one is missed. Care is delayed, and the disease gets worse. All of these, and other situations occur on a regular basis. So much so that the IOM estimated in 1999 that the US health system kills between 48,000 and 98,000 patients unnecessarily every year.

I wonder if it would be useful for us in the field of medicine to explore Peck's experiences and concepts? Could it help us to understand the harm that we cause and find ways to avoid it? Not because we as individuals intend any harm to our patients, not because medicine is evil, not because what we do is similar to My Lai; but because we, as a system, do cause harm to our patients--harm that happens despite our best intentions.

Some background is needed for me to ask the right questions.

On March 16, 1968, Charlie Company murdered between 300 and 500 unarmed civilians in the town of My Lai, South Viet Nam. The civilians included many women and children. The murders were horrific--individuals were tortured, mutilated, raped, signatures of the killers carved in the flesh of some of the deceased. Hundreds of soldiers witnessed the event, scores participated in the murders. Only one officer, Hugh Thompson, Jr., tried to stop the killing, and after he subsequently filed a formal complaint the facts of the event were covered up by scores of upper echelon officers in the Army.

How could that possibly happen? There is no evidence that these soldiers were inherently "bad" people. It is statistically impossible that all of the hundreds of soldiers involved both directly and indirectly could possibly be a random conglomeration of evil, peculiar, or sociopathic individuals. There is no evidence that the soldiers planned this attack days in advance. Yet, they all participated in a serious wrong doing. A wrong doing that is not unique. In every war throughout history, similar episodes have occurred. Indeed, episodes similar to My Lai occur today in parts of the world that practice genocide. In many ways, it would seem that this behavior is "hard wired" into the human behavior system--triggered in certain extreme ways.

How is it that one individual, apparently no different than the rest, was able and willing to stand up to his colleagues and attempt to stop them in My Lai? What is different about Hugh Thompson that made him approach the massacre differently than all of the others? And, more relevant to us who have made a career from the study and treatment of the human situation, "What does this sad episode say about the human process of 'group think' and 'group morality?'

Peck developed a psychological theory of "human evil" in order to explain the sad facts before him. He noted that when individuals see themselves as part of a group under stress, they tend to abdicate their ethical decision making to the "others" in the group. "Others" can mean one person in the group or many people; but often means the "lowest level of common assessment" in the group. That is, when all members of a group take action based upon an assessment that the group is "responsible" for the actions--then no one is really responsible and the only limitation of group behavior comes from the most "base" levels of our humanity. Furthermore, Peck observed in this case, and in others, that denial of reality is a prevalent coping "skill" that humans use to deal with stress and uncertainty--a "skill" that he calls "evil" when it is used constantly by individuals.

This is not the typical form of denial (i.e., the initial response to loss, or the childlike response to making a mistake). The type of denial that Peck talks about is a pervasive personality structure that constantly and persistently causes the individual to frame all experiences so narcissistically that the reality of the outside world becomes secondary to the internal fantasy world of the individual. DSM might call this a form of narcissistic personality disorder or some form of sociopathy when it is happens to one individual, but Peck wasn't trying to talk about diagnoses of one individual. Rather, he was concerned about how humans do "evil" as a group.

He observed in his discussions with involved soldiers that each one individually believed that the massacre had been sanctioned by "someone higher in the chain of command." The individuals claimed that they felt justified by that belief. In addition, they did not see the dead as innocent victims. They felt like they were "the enemies" even though they were mostly women, children and elders. The episode seemed "unreal" to the individuals involved. And, since they had been trying to kill as part of the war, the killing did not seem "real."

In the end of his analysis--he reasoned that, when "group dynamics" are active, the simultaneous (1) abdication of responsibility and (2) individual "denial of reality" enables the group to cause harm without limitations--almost without recognition of the harm.

"What does this have to do with medicine," you ask. "Has Jeff 'gone off the deep end?" Does he believe that medical mishaps are like mass murder. NO! But I do wonder if the extreme case of My Lai gives us an insight into human behavior that can help us in our own "group function." Let me ask the questions that challenge me when I think of all of this. Your answers will determine whether it is relevant to medicine or not. I do not have any answers, just questions.

Do doctor's constitute a group that functions based upon "group dynamics?" What about the entire therapeutic team? Is the practice of medicine akin to "group think?" Do we take for granted that the system of care, as it currently exists, is necessary to the health and well being of our patients? Do we, as a whole, take individual responsibility for the actions of the group? Do I think of myself as responsible for the medical errors made at CCRMC? Do you think of yourself as being individually responsible for those episodes of harm? Are we individually responsible for the harm caused when mistakes are made at some hospital in Florida (or anywhere else)? Does medicine freely admit its mistakes? Do we see bad outcomes as "necessary evils" of the process? Do we challenge bad or useless research? Do we accept clinical practices merely because "experts" tell us it is the "standard?' Does US medicine accept that the public thinks that we provide a mediocre product that costs double what other health systems cost? Do we acknowledge that the standard measures of health care quality in the US are far below where they should be? Is it all the insurance company's fault? or the lawyers'? or the administrators'? or the drug companies'? Do we accept the reality that we are fallible? Do we tell patients that we have harmed them? When we do make a mistake, do we blame someone else--a colleague or a nurse or the patient? Do we acknowledge that it is impossible to practice medicine, as it is currently practiced, without mistakes? Does that mean we try to change the current style of practice, or that we are satisfied with the incidence of harm? Do we acknowledge the fact that many of our "interventions" are not proven to be effective (we do not have an evidence basis for many treatments)? Do we truly weigh the risks and benefits of intervention in each case? Do we challenge the "system" when "new technologies" cost more and bring no really significant benefit to the health of the patient? Do we challenge the medical schools who produce many more specialists than primary care physicians?

In essence, do we in health care have a risk buried deep in our profession...the risk that we may function as a group that abdicates individual responsibility for the harm that we do and relies upon a false sense of beneficence that we have as a group to comfort us when mistakes do occur? If so, is it possible to change this structure? How can we be more like Hugh Thompson--unwilling to buy into the (1) abdication of responsibly and (2) the individual denial of reality? What characteristics make us different from the military men who acted at My Lai? How are we similar? Do we need to create systems that will modify "hard wired" behavior that is problematic? Do we need to change the entire belief system of health care?

Do we face the risk of being good people who cause bad things to happen without really being aware of the extent of injury? And, most importantly, can we, as a group, change our system of care so that harm does not occur?

My final question, "Can we learn from Peck about the human condition, and take steps to improve our systems of health care?

Lots of questions....no answers from me. The answers are yours.

Magic Monday

I am posting this for Maxine Power PhD, Director of Quality Improvement, Salford Royal NHS Foundation Trust (a hospital in the UK), Salford, England.

It is a heartfelt note to you all and coming from such an esteemed improver, quite humbling to read.

Maxine's comments are as follows:

On Monday 23rd February 2009 I had the pleasure of spending a day with the staff of Contra Costa. This experience was truly transformational and I wanted to take the opportunity to ‘blog’ to describe why that is the case. First, I must confess – I am a blog novice – never done it before so please excuse my stilted efforts…….

Here’s how the day went, I arrived at 8.00am walked straight in to an extremely warm reception in the CEO’s office. I had met Jeff a couple of times at conference events but actually felt as though I had been part of the organisation for years. Next I went to a scheduled clinical meeting, a meeting of the peri-operative committee and walked the floors with Anna Roth. In the afternoon I attended senior management meetings with Anna before returning to the hospital to take a second walk of the floors where I had the opportunity to take some photos to share with my team back at the hospital I work in.

The sense of openness and warmth I had felt in Jeff’s office followed me the whole day. In fact, if anything it intensified the closer I got to the patients and the teams delivering the care. Everywhere I looked there were examples of dedication and excellence. I was blown away by how much improvement work was embedded into daily work and how eloquently teams described making changes based on data and testing. It was evident everywhere, almost like it sat within the DNA of the organisation. I took photos, but even then didn’t capture the depth and breadth of the improvement work.

I had the opportunity to talk in detail to only a small number of staff – I wish I could have stayed longer and talked more. The overwhelming sense I got at Contra Costa was of a group of staff who were working with a shared mission and vision. Despite having seen exemplary outcomes already, they had not slowed or faltered in their improvement efforts. There was a constancy of purpose around never stopping with improvements in care.

I am responding to Anna’s blog today because I shared your story with my team back at my hospital in England today. I wanted you to know how I described Contra Costa Regional Medical Centre – your place, your creation. Here’s what I said……

‘ I have never been anywhere like this hospital, they serve the most needy population, the under and uninsured with a fraction of the regional healthcare spend they deliver more patient episodes than their neighbors combined. In any other system the sheer volume of patients being treated would strain the system to create intolerant and angry staff. I saw staff under pressure but they were caring, warm and excellent. Never once did they waiver from their values and mission. They were proud of the service they deliver and dedicated to providing excellent care to their patients. I have never seen so much come from so little………….. Make no doubt this is a system with considerable challenge, but what I observed was leadership who, despite having to make heartbreaking and impossible decisions, were transparent and unwavering in their desires to stay on mission, unify and bring forward workable solutions to challenging issues’

I sat on the plane on my way home to England reading ‘Chasing the Rabbit’ by Stephen Spear and realized – I just visited a rabbit……………….Contra Costa, stay firm, stay together and trust in yourselves and your mission. You are an inspiration.

Maxine Power

Choose a path.....if you dare.

Every time that we are faced with budgetary reductions, the entire organization buzzes with frustration and angst. No one ever likes this part of the life-cycle of governmental service organizations. We all spend many months in a very unhappy "place." Having been a visitor to this "place" many times before, I totally understand the anger and frustration that I sense in the organization now.

The facts before us are brutal, and very sad to say the least. To reiterate:

1. For the current fiscal year (2008-09), the Contra Costa County budget is very much in the red--revenues from property taxes, state programs, and sales tax are way down because of the national recession.

2. Demand for services is way up--also because of the recession and job loss.

3. And, even if #1 and #2 could be changed with the "wave of a wand," Contra Costa still has a built in ongoing financial deficit because the employee costs will escalate geometrically over the next 10 years.

So, what are the options? Frankly, nothing in the short run that anyone would like to see. Very stark paths are in front of us indeed. Unless new money arrives unexpectedly (which it won't), there are only three options for CCRMC:

1. Reduce access to health care services,
2. Reduce the level of services offered,
3. Or reduce the cost per unit of service provided (fundamentally change the way that we provide service in order to be more efficient and effective).

All of these options are easy to say, but very difficult to do. And, we will probably need to exercise all of these options in many different ways as we move on. A daunting task set with very important questions presented constantly before us.

Are any, or all, of these options consistent with our mission as a county health care system?

How should access to services be limited, if it is to be limited? Who should get less? How do we make the choice? Who makes the choice? How do we implement the choice? At what point does reduction of access mean that there is no longer a good reason for the system to exist?

If the level of services are to be reduced, which services? Can patients get these services elsewhere? What are the critical services that must be preserved? What is safe? What about new standards in health care? When is the service no longer "worth" the effort?

It sounds more attractive to lower the cost per unit of service and to keep all of the access and the services the same. However, can that approach address the magnitude of the deficit? Short term "efficiency" changes usually can only save, at the most, 5 to 10%. More fundamental, and more important system change, can save much more--but usually takes a number of years to accomplish effectively. And, in the current public health system, there are very few resources available to support fundamental system redesign. How do we move ahead with redesign efforts when we anticipate ever fewer supportive resources?

In the end, the choices are all seem like Hobson's choices--options that are not really options at all! Nothing that we really "want" to do. "Forks in the road" that are not what we expected or wanted.

However, no matter what, we move on--not necessarily forward, but onward. Whether or not a conscious and thoughtful choice is made, time makes choices for us. No matter what choice is made, there will be new challenges and new pressures in the future. And, despite our desire to find an outside "savior," there will be none.

Gautama Siddharta, the founder of Buddhism many years ago, framed the reality well with simplicity and strength, "No one saves us but ourselves. No one can and no one may. We ourselves must walk the path." We take that path that seems the best to us, we learn from the mistakes that are inevitably made, and we hope that we can face the next challenge with more skill and more wisdom.

There are many things about the future of health care that will not be "pretty," however, despite the Hobson's choices, we can make progress. For, as Thoreau pointed out, " The constant abrasion and decay of our lives makes the soil of our future growth."

We choose a path in uncertainty, confident that it will make sense in the end and that we will grow enough to make the next decision more wisely.

He called it "The message you hope never to send"

On July 5th, I read a message from a leader whom I greatly admire. He said hoped he would never need to send such a message. It was in the form of an email that was sent to the Beth Israel Deaconess Medical Center Community by their CEO, Paul Levy, about a medical error that had occurred.

Today I read another message from a leader I greatly admire, Dr. William Walker. With his permission, I have posted it below. It is a message I know he and all of us at the Medical Center wish never had to be sent.

I am confident that we will get through this time and eventually emerge stronger, but there is no mistaking that it is a painful time for our system and many others across the state and nation. In our planning and actions, we will follow the example set by systems like Beth Israel Deaconess Medical Center: in the face of adversity, they remained transparent and pushed to discover and improve. We will face this challenge, meeting it with innovation and creativity. Our mission will guide us.

Tomorrow morning, the Operations Leads of Contra Costa Regional Medical Center (CCRMC) will meet to discuss the challenges that lie ahead. We recognize the immediate need to review and revise our saturation plan and we have begun that process. We will continue to provide care for all who are in need at CCRMC and we will open the doors wider if we must. We will look for innovative ways to utilize the public's precious, limited, resources while improving quality for those whom we serve.

I can only imagine how difficult it was to send this message, and I intend to stand with Dr. Walker, the Board of Supervisors and all of you while we find our way forward.

Although it may be difficult to see, each day will offer us a new opportunity. We are not alone. We are a part of a much larger community; we are the nation's safety net. A frayed net, perhaps, as Dr. Walker described it, but it is our calling. For far too many, there is no one else.

We must draw on the strength of others and the determination of the many. We can learn new ways. Isolation, fear and anger will not serve us. Now, more than ever, we need effective communication. We must not forget that we need to talk, we need each other. The science of improvement, ingenuity, constancy of purpose and our mission are the tools and the guides we need to build our future.

Please, let us stand together.

Anna

Dr. Walker's message is as follows...

Tomorrow, the Board of Supervisors will discuss policies related to how to address the county deficit. As I told you in the Director's Report last week, the proposal I submitted was a very difficult one - $13.5 million with significant cuts in Public Health, Mental Health and the Medical Center. (A calendar of the upcoming Board actions is online at cchealth.org)

It is never easy to cut expenses because those cuts generally mean a reduction of services and lay-offs of employees. This round of budget cuts is especially difficult because it contains both. Today we are posting the list of positions proposed for elimination. Some of you in the positions listed for elimination will have the right to "bump" to another position in the same classification or perhaps to a position you held previously. Our Personnel staff will begin meeting with impacted employees and their labor organizations shortly. Regardless of who ultimately will be laid off, the list represents cuts that will negatively impact a great many lives in our Department and in our community, and I wish that were not so.

Among the very painful decisions I've had to propose to the Board of Supervisors this year is to restrict eligibility to our services. Assuming the Board approves that plan, Contra Costa residents who are undocumented non-citizens will no longer be eligible for non-emergency outpatient services at our Health Centers. We will begin phasing in that policy shortly after Board approval. We will continue to provide services to pregnant women and children.

Along with all hospitals, we will continue, as required by law, to provide emergency services and related inpatient care to everyone. I will be working in the coming weeks to encourage our community partners to work with us to help all those who need care.

Restricting eligibility will save an estimated $6 million a year - county funds we spend for undocumented Contra Costans with no federal or state reimbursement. It will also free up critically needed appointment slots for Medi-Cal and Health Plan members and the newly unemployed who have lost their health insurance.

No one who has chosen to work in the public sector - for many of us, like me, who have devoted their entire careers in service to the people of Contra Costa - thinks this is good public policy or that rationing health care makes sense.

But this is a public agency and we have been directed to balance our budget. Across California, other counties are regrettably taking similar steps. In Sacramento last week, two Health Centers were approved for closure. The banks and car industry have been bailed out by Washington and I hope with all my heart that the health care system is next.

You can hear more of my thoughts about restricting eligibility in the Podcast on our website at cchealth.org. Information about specific cuts and other material will be posted there also.

There will be public hearings about the proposal. The Board of Supervisors is responsible for making the final decision about each of the reductions we have proposed.

I can only ask that in the coming weeks as we move ahead with whatever they approve that we remain committed to our mission and to protecting the safety net - frayed though it may be. I ask you to treat our community with compassion, our partners with respect and understand how difficult these times are for those of us who are forced to choose between conflicting demands and distasteful strategies.

William B. Walker, M.D., Director and Health Officer, Contra Costa Health Services