GONE, BUT NEVER TO BE FORGOTTEN.


When was the last time you looked up at the night sky? The beauty of the natural world seems well hidden from us. This weekend I had the opportunity to send my auntie off to the land of painless rest. The sadness and joy of the occasion was not lost on us. Her relief had come. I love my extended family for how we show up for each other in times of difficulties. We came from near and far. I am proud to be a member of the extended James family. I continue to be amazed by the strength of the children of Wilhel and Clarence James. They are my heroes. What does the traditions of a funeral have to do with the night sky? It is about the beauty of the universe and the short time we have to enjoy it.

The night before the funeral is ‘set up’. It is a festive party send off before the day of mourning. As we drove to the setup at the home of my deceased auntie I noticed how dark the roads were. The darkness was intensive and reassuring. No light pollution to distract. It was a wonderful contrast to the intense sunshine of the daytime. Once we arrived at the destination we parked about a third of a mile from the home and walked. As my practice I looked up at the sky and noticed the depth of the darkness. as far as I could see there were stars and the their brightness seemed many fold brighter than the night sky I had grown used to in Florida. I looked up at the Pleiades and counted 8 sisters as opposed to the 6 I usually see in the Florida night sky. I felt an excitement to be under a truly dark sky. As I arrived at her home I hugged many family members and got introduced to some new arrivals. I love my family, because at times like these we are pillars of strength for each other.

The band arrived after 10 PM and the party went into full effect. The street was blocked off and the music rang loudly through the valley. All joined in the dancing, old and young danced. The elders seemed most enthusiastic and I noticed many in their 70’s who danced all night while the youngster exchanged social media details. This was a time of cheer and remembrance. It was a celebration of life. It was the celebration of a wonderful mother, auntie, cousin, grandmother, wife and child of God. The melodic voices of the male and female lead of the band kept us all engaged. The key board player and drummer were excellent compliments. The band played until well after 1 am and we all danced and enjoy the company of family and friends.

A wonderful night and festive remembrance came to a close and we all need some rest before the continuation of auntie’s send off. As I walked back to the car I looked up and again and there it was, an awe-inspiring star filled sky. It reminded me of how often we take life and the people who share it with us for granted. The older I get the more I understand my mortality. The older I get the more I appreciate the wisdom of my elders. The older I get the more I love my family. The older I get the more I realize that my family is not perfect, but that we make up for that with commitment to each other. The older I get the closer I get to the end of my time and the more time I want with my family.

Another one gone but never to be forgotten. I love you auntie Peggy.

COMPETENCE ABOVE ALL


The first principle of health care is to “first do no harm”. In the complex system that we live we seem to have forgotten to whom we are responsible. The duty of care and the equitable distribution of such has taken a back seat.  The comfort of the staff is vital but their competence is far more important to our patients. Many seem to believe that our staff members being “nice” is the key to care. ThIs misguided notion is taking us into the weeds and missing the real problem in many institutions. Our real problem is competence and consistency. If the goal of our system is to provide consistent and dependable care we must first stand up for equity. The equity I mean is equity of care standard.

The care delivered varies wildly and the reason for such disparity is as varied. Fortunately many institutions have noticed the problem but their solutions seem worse than the problem. The government has stepped in because we have not consistent applied the care we know to be best. The government has used the same consumerist benchmark of satisfaction that is used in retail sales as a proxy for care delivered. This approach is sub-optimal at best. It is not likely to be the best measure. However, our opposition to these measures will not improve patient care. What we need to recognize is that patient satisfaction can be a good proxy if we work in a system where competence is priority number one.

Patient satisfaction is a complex fickle beast. We cannot practice from the point of providing a ‘satisfying’ experience. Our care should be directed at proving the best outcome to all. The only way to provide such care is if our systems are focused on designing best in class care systems and staffing such systems with competent staff. In recent years our systems has fallen into the sad and despairing state were we have lost focus on care and the competence of our staff. The misguided first basis focus on the social behaviour of the staff is driving the best out of the system and putting out patients at the mercy of the less competent, but ” nice”.  If our purpose is best in class care and superior outcomes there is only one matrix that matters. We must provide our patients with the best trained staff. Our efforts must be evidence bases and physician driven.

EXAMINE YOUR LIFESTYLE.


The new year is here and I still cannot believe it. 2014 came and went at a seemly quicker pace. The truth is that the speed of time as not changed. What has changed is how we experience it. We continue to allowed procrastination to decrease how much we achieve. We over think and neglect to take the actions that would allow us to attain more of our goals. As we second guess our decisions the universe continues forward at the same pace we found it. We are achieving less and the feeling that time is going by faster is just a reflection of our lack of focus on the important things.

For the new year we all should stop thinking and start doing. I am a parent and want to leave a better planet for my children. What are you planing to leave to your children? The discussion about climate change is just one of those issues where we could improve the world for our children. The facts are not in dispute, the climate of earth is changing. I do not dispute that human activity is the cause. If you dispute that I hope we can at least agree that the climate is changing.

With that in mind I would ask you, how do you think climate change will affect your children or grand children? I would suggest that the most likely direct effect will be on the quality and quantity of food and water available. The current estimate of people around the world going hungry is about one billion annually. Concurrent with that is the fact that some of the most productive agricultural areas are in regions whose water supply is dependent on seasonal rain and snow falls. It is already evident from current objective measurable data that these regions are close to breaking point in their water balance. The drought in California, which is the current bread basket of the United States is worrying. The gravity of the danger is not being addressed. But if the level of the water in Lake Mead Nevada is any example we should all be much more concerned.

Our water usage patterns are unsustainable and more forthrightly has led us to a very dangerous place. Agriculture is the primary user of water both for plant and animal production. Animal production is an especially egregious drain on our every decreasing available water sources. The continuing willful deafness of many of our leaders to the coming and already present crisis is criminal. The low intelligence of many of the people on mass media discussing the topic is genocidal in their effect. As we continue to neglect the obvious the problem worsens and the solutions become evermore burdensome. The unfortunate consequence is that the poor all around the world are already experiencing the trauma of food and water insecurity. Even the wealthier among us are being affected. The difference is that most of us can afford the increasing cost of our basic supplies. The larger question needs to be asked, what will happen when the squeeze truly gets to the richer among us?

I am of the scientific persuasion and believe that all the evidence points to mans central impact in leading to climate change. However, I will acquiesce to those who have not attain that clarity. I need only you agree that no matter the cause climate change is occurring and that we need to act to protect our global society.

I would suggest that we start by examining our consumption patterns. Change your lifestyle and change the world. We are all apart of the change that we need.

AMERICAN SWEAT SHOP.


There is a curse that inhabits the American work place. We have become slaves to profitability and not to best outcomes. The primacy of profits has led us to misunderstand the nature of work and the importance of worker satisfaction. Making ever-increasing profits is the goal but how we get there makes a difference. Some employers have lost their focus. Sustained profitability is about worker satisfaction. In many fields lip service is paid to the worker, while they are trapped under inhumane work conditions. Fortunately work conditions in the developed world are better than they were. However, we still have a way to go before we can claim victory over poor working conditions. The severity of the impact of poor conditions is dependent on your industry. In health care the impact can be life threatening.

Our culture for too long as valued hard work over smart work. We seem to believe that the worker that workers longer hours is more noble and deserving of praise. This misplaced praise has led to continued poor choices and has led to the misery and burn out of the American middle class. The depth of the problem continues to go unnoticed and unacknowledged. Poor outcomes continue to be placed at the feet of poor training and individuals are blamed. I too have a tendency to blame the individual. The truth is that sometimes the individual is to be blamed, but we too often neglect to evaluated the conditions under which mistakes are made. The systems under which most of us work are archaic, inefficient and are undermining our ability to be the best we can be.

I will be attacked for my stand but the truth needs be told. I love my work because it gives me the opportunity to help my fellow humans at a time when they are most in need. From my limited experience that help is best delivered when I am well rested. Some may consider me weak for insisting that adequate rest is required for best productivity and patient safety. I, however, would rather follow the evidence that suggests that efficiency and safety are best attained with a well rested and optimally trained work force. The conditions of many operating rooms where staff can work full daytime shift and take overnight call then work a full day shift is putting our patients at risk.

The unfortunate problem is that when a staff member makes a mistake that harms a patient she alone is blamed. The idea that she needs to take personal responsibility for her mistake is commendable , but essentially is a cop-out. Her bosses are just as culpable, because they have put in place a system that does not allow her to work at her best. The continued scapegoating of individuals is a sickness in our system that needs to be driven into the grave. Our success is dependent on the balance and efficiency of the systems we construct. Spending money on technology is commendable and necessary but alone will not improve patient outcomes.

Better pay is a great place to start, but is a poor quality band-aid when one works under mentally oppressive conditions. Improving the system starts by focusing on the best assets of the system. Our human capital is our best asset and must be treated as such. We are not robots, we are better. We may not be able to work as long hours and we get bored easily; but until robots can think intuitively and problem solve on the fly we will continue to be the best part of the workflow equation. Functioning at maximum efficiency must be out foremost goal. For humans to be focused and efficient we must have adequate rest and distraction. If we would focus on those areas many of our problems would be resolved without the need for expensive investments in equipment.

Let us invest in our best and most productive assets, our people.