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.

WHERE IS THE CHECKLIST?


I have loved health care for as long as I can remember. I cannot imagine doing anything but providing care . What I have learned in the trenches is that the love of providing care is not enough. Over time i have realized that a fundamental problem with health care is not in the expensive of it but in the nature of the people in it. We want to provide care, but we bring into the system our biases. Those biases allow for less attention to be paid to some patients because of their language or skin color. We may say that we provide the same care to all patients, but as a black physician I see otherwise. My experience of the system at institutions where I am not known by members of staff is vastly different. The consequence of this uneven care is a system where those that can afford care and are the correction completion receive care that is more compassionate and timely.

How do we overcome the inherent bias in the system? The answer is not more training nor necessarily more diversity. The answer will be in the wide-spread use of evidence based payment structures. Our medical systems are complicated and expensive but are systems in name only. We have a complex string of components. All the parts are mostly well-trained and competent. However the results we obtain are not commensurate with the level of training nor the level of expense. The incongruity of expense and quality of results continues because those attempting to improve the system have not acknowledged or do not recognize the biases of the system. The gap in quality of outcome is most obvious in communities of color. The often given excuses are truly just that. Recognizing that there is a problem is the first step to a solution.

Paying for quality work is the only avenue to improved results. The question as to how we get better care for all patients is simple and complicated, but we have a great example in the aviation sector. My brother is an airline pilot and his training is extremity rigorous, but he starts his day with a checklist. He does not feel that his autonomy is being challenged, but that he is making sure that he does not kill himself. We in health care do not have any real skin in the game. Until the decision makers have some skin in the game we will not embrace what is necessary to make our constellation of components into a functioning system. Let us start delivering quality care by implementing checklists. Checklists are reminders of the quality in our options. The checklist is not for you it is for your parents and friends. That checklist is not for you, it is for that provider that is on her sixth surgery of the day. It is a nudge because she is tired. A checklist is for every one of us. It helps us by removing silly mistakes from our systems. For me the checklist is my hope that I will be treated like a patient deserving of care on the off-chance that I am a patient in a strange place where all that can be seen is the color of my skin.

LOVE ALL EQUALLY


There is a continuing fight all over the world today. It is mental, intellectual and physical. I’m not talking about terrorism in its State and Non-State forms. I’m talking about the continuing fight for equality and civil rights. This fight is getting simultaneously easier and harder. The right to embrace our individual sexual orientation is to me a basic human right that is worth defending. Although homosexuality has gained much wider acknowledgment and in many countries is no longer a sentence to death or deprivation, there is still much to do. The improved prospects have been won by hard intelligent work. As with any progress, only vigilance will maintain the momentum and keep our society honest. Many will disagree but I will continue to wholeheartedly support the equal rights of all in our society.

The deprivation of rights from any member of our Society makes us all less free. Fortunately the fight for the future is already won because a much maligned generation, generation Y, has fully embraced equality. The continuing battle is to define a clear and open future for those who are unfortunately living under less equitable systems. Many in our culture still have not gotten the “memo” but the momentum is not with them, this movement is irreversible. As irreversible as the general direction of progress is, there will be setbacks. These setbacks will be reminders of how far society as traveled.  I am proud to be living in an age where we are having the discussion about living up to the ideals of equality expressed in our constitutions. The march of progress is evident in the many same-sex couples that are out and open. I am proud and happy to take care of the same-sex couples in the hospital. Many are older and the acknowledgment of their decades old relationships is something that many wanted to see but never expected. They have all lived extraordinary lives because their love survived the ugliness of an intolerant society. Other groups can claim similar experiences and we should celebrate together the maturing of global culture.

As a young person growing up in a proudly homophobic society I saw many around that were different but never judged nor did I defend. I was confused by the incongruity that was religious society. On one hand extolling the love of Christ while also calling for the death and persecution of others. It was obvious to me that the love of Christ should extend to all his creatures, but that was not the a prevalent opinion. This divergence is still a puzzle to me. Older and not necessarily wiser I would not change the culture of my up bringing, but I say now with much confidence that we had it wrong. I never spoke openly about my opinion, but treated all around me equally. The truth is that there are people of varying orientations in the Church and our Father has directed us to love all equally.

LEADERSHIP CANNOT BE TAUGHT.


Leadership cannot be taught, it has to be encouraged. That is my view of the world and nothing I have seen in my very short lifetime has shown me otherwise. The problem of leadership in American culture is a complex challenge. We have bought into the idea that leaders are created in business school with ever more specialized management degrees. This philosophy could not be further from the truth. Leadership is about getting those around you to perform above their own expectations and to feel included and empowered. Leaders are great managers, unfortunately great managers are not necessarily great leaders. Business school can turn poor managers into great managers, but cannot create leaders.

The education that creates leaders starts in early childhood. It starts in the home at play. Creating leaders is about allowing your toddler to make decisions. It is about allowing her to be her own change agent. It is about explaining why. It is about explaining your yes and no answers equally. It is about recognizing that our toddlers learn from us. They are sponges and their best and worst habits are learned long before they can explain their decisions. Early training prevents later correction.

As the father of the two smartest daughters in the world I can attest to the strength of character of toddlers. My girls are now 3 and 5 and it is clear that they have very different personalities. In spite of their differences they both are confident and insist on making their own choices. They don’t readily follow the crowd. They, like little girls everywhere have been infected with the princess bug, but I smile when they choose the “boy” toys or face paint patterns. I am happy that they have been allowed to make their own choices and will not follow the other girls to the dolls but more often than not want both the doll and the truck. Having a community that supports our  girls is vital for the development of future female leaders.

For me, growing up around equally strong men and women instilled a powerful sense of place and robust confidence. This is what I want for my daughters and all our daughters. However, there is a noticeable lack of strong female leadership in our country. I would consider myself a feminist and believe that my girls are capable of doing and achieving anything they desire. Because there are physical limitation does not mean that she is not capable. The question is, are we willing to design and improve so she can express her full potential? This is the key question that needs answering. I know what my answer to that is. My daughters will never be told by me that they cannot. No one in my presence will go unchallenged if they suggest that my daughters cannot. I will lovingly push and challenge them, because they are just as capable as their male peers. It is time for us to use technology to level the playing field and allow all who would to be challenged by all this worlds has to offer.

WHAT IS YOUR AMERICAN DREAM?


Every July 4th I remind myself of the courage of the founders of my country. The beauty of the declaration of independence is in the broad inclusiveness of the sentiments expressed. The global equality of mankind as expressed is at the root of the American dream. However, the history of our country is littered with the carcasses of failed policies and leaders who have not lived up to the lofty expectations of that celebrated document. The 4th should be used as a time to refocus on the sentiments expressed. This land of immigrants is not about where you were born, but about what you believe in. It is about fairness, equity and the continuous match toward a more perfect union.

The dream of America is alive and prospering despite all the attempts to distract. Some have lost hope in the self-evident greatest of the American experiment. I am not one. For people of color the American experience is that of continued heart-break, but there runs a determined strain of hope that as continued to improve our lot in this union. I read the declaration of independence on the 4th to be reminded of the promise and the progress. This is a marathon not a sprint, and we dream of true equality as we march toward that goal. This is my American dream.

I have hope because I have to be hopeful. I have young children and I know that the world has changed for the better and that change will continue. Most importantly I know that the growth in American society is irreversible because my generation and the following have made it so. As the country ages those who express the old prejudices have been out numbered and embarrassed into submission. There will always be a few stubborn ones. There will always be some expressions of darkness, but the light of equity is here to say. Progress has been slow and inconsistent but it is here to stay.

The continuous expression of hope and growth is why I continue to love my America. American greatness is derived from the philosophy of her people. If you were born in this land or emigrated the dream is the same. We are a people buoyed by hope and the understanding that we can be the best and always expect to be.

What is your American dream?