By Phyllis Kritek. Seems like a no-brainer question. Of course not! As the dust settles from the recent elections, however, it seems timely. Media coverage of the nation has obsessed for months over the dissatisfaction, anger, even depression of the nation’s citizens.  They might have been wiser and more productive to focus on greed and vengeance. They are costly indulgences with consequences.

If the often-evoked iconic Abraham Lincoln were alive today, I suspect he would not posit that greed and vengeance are manifestations of  “the better angels of our nature”.  Perhaps they provide a temporary sense of satisfaction. They do not, however, serve us well in the long haul toward the “pursuit of happiness”.

This observation flies in the face of assumptions that have increasingly been treated as inevitable. While individuals, minute to minute, myself among them, make choices about these two impulses, their manifestation as acceptable and inevitable national moral practices is treated as a given.  We argue that we wish to be moral beings while concurrently accepting moral choices for the collective likely to do harm to the collective.  Indeed, we insist that we MUST manifest greed and vengeance.  Much of the post-election analyses available will easily document this insistence.

There is for many a perceived quaintness, of course, in even raising the question. Once both were viewed as “deadly sins”, greed garnering its own status and vengeance posited as an expression of wrath. Now they are norms.

Our comfort with cynicism is enormous. We even confuse it with sophistication and knowledge.  And we confuse greed and vengeance with freedom, as if somehow I have a right to be greedy with a vengeance and be vengeful with insatiable intensity.

Both “health” and “healing” are rooted in the Old English word “haelen”, which means wholeness. It indicates that all dimensions of the human are in some way integrated, interrelated, a well-woven tapestry of completeness. We seem to grasp that this includes physical dimensions of humanness, and occasionally we give a nod to emotional dimensions. Less often do we address the human dimensions that acknowledge we are intellectual, social, moral and spiritual beings.  Even recording this thought is a bit countercultural. (more…)

By Phyllis Kritek. In my day job I function as a nurse who is also a health care conflict engagement specialist. Simply put, I work at improving our collective capacity in health care to discover alternatives to adversarial responses to conflict. As a student of conflict, early on I studied the arms race as an exemplar of irrational behavior. One cannot actually win the arms race without eventually cannibalizing oneself: every one is busy inventing the next iteration that requires that I do the same. Eventually, my investment in the arms race exhausts my resources. (Reference North Korea…)

I find this an instructive analog to the first fatal flaw in health care for profit. If I am engaged in such an enterprise, I am obligated to make a profit. Each year I am expected to meet or exceed last year’s profits. That requires that I continuously decrease expenses and expand my yield. If I fail to do so, I will go out of business or at least lose my stockholders and my stock value. I can never let up on profit expansion. My first best option in decreasing expenses is to cut back on major categories, such as personnel, the big budget item.

I then demand greater productivity. We did this in health care in the 90s when our national average for cutting nursing personnel in hospitals was 9%, while concurrently shortening length of stay with concomitant dramatic increases in patient acuity. Greater productivity not only evokes employee dissatisfaction; it also leads to stress, fatigue, and ERRORS. These errors are expensive. We begin to self-destruct. (I would suggest that this is the maze of horrors much of corporate America finds itself in today; most interestingly, they also now have eliminated so many workers that there is no one to buy their products because unemployed people cannot make purchases…see, it is irrational!)

The second fatal flaw that no one acknowledges is of course that another great way to make a profit is to withhold services. Insurance companies understand this. Hence, finding ways to game the system makes sense. They need to make a profit and delivering services costs money. No matter how dedicated they may be to quality health care, it is in their self-interest to deny services whenever they can. It is easiest to do this with the poor, powerless, and disadvantaged. They are less likely to raise a ruckus, and if they do, we can count on dominant groups to ignore them. After all, this profit making is our driving value, we need to serve our stockholders, and there will be acceptable collateral damage in our push to succeed. Besides, poor people might now even know they have received fewer services. (more…)

By Phyllis Kritek. As a registered nurse, I feel great pride in my profession. The list of reasons is long. One factor enjoys external validation, nurses have topped Gallup’s Honesty and Ethics ranking of different occupational groups every year but one since they were added in 1999. The exception is 2001, when firefighters were included on the list on a one-time basis, shortly after the September 11th terrorist attacks. I consider it an understandable outlier.  Apparently citizens think we are ethical and honest.

This amazing achievement is no accident. The ethos of nursing, since Nightingale, has gone well beyond the familiar “Do No Harm”. Ours has been an ethos of patient advocacy. We teach and enforce it with the same intensity of focus we give to medication administration. I think of it as a hybrid ethos, merging the principle-based ethics of Lawrence Kohlberg (read masculine) with the relationship-based ethics of Carol Gilligan (read feminine). Early on, as we became increasingly adept at articulating our “Code of Ethics”, the Hastings Center fretted with our fixation on patient advocacy.  We insisted and persisted. I am proud of that.

This persistence about patient advocacy shapes the daily lives of practicing nurses. It is achieved in health care settings where hierarchic structures are designed to protect the hegemonic power of physicians and health care administrators. It is perpetuated in civic discourse. It is rarely visible, often only made public in whistleblower lawsuits where a nurse was fired for being a patient advocate, i.e., challenging a practice or person that puts the patient at risk.  It is complex work, behind the scenes, often made exceedingly difficult and even career threatening.

When I was a very young nurse, a nurse leader advised me as follows: “If you haven’t been fired by the time you reach the age of 30, you probably have been co-opted”.  At the time I found this advice disturbing. Over time, through a number of experiences that pivoted on professional integrity and the cost of protecting it, I have learned the wisdom of her message. I agree with her. (more…)

I have always been a bit fascinated by people who make a living telling people what they want to hear.  To be perfectly honest, I actually think it is because I envy them. How nice is that for generating income: making people perky, reassuring them, telling them everything is fine, promising them they are right about everything, helping them keep their denial systems intact?

My envy stems from my irritation with myself for choosing a different path. I have spent most of my life telling people what they need to hear, hence often what they don’t want to hear. I try for balance, noting all the “good stuff”, then offering the counterbalance.  I find one unwelcome message can drown out all the affirmative messages. People home in on that “bad” stuff with an inerrant tenacity.

The differences between these two approaches are instructive.

Feeling good is quite popular. Creating the conditions for feeling good can lead to fame and fortune. We want to hear from these purveyors of endless good news and reassurance. There is all that amazing research on happiness, the blossoming theories and practices of appreciative inquiry, the neuroscience data on endorphins: you cannot ignore this compelling information.  The reassurance that one is right about everything can make for intense feelings of joy, hope, and optimism. The person who triggers the feelings is brilliant, constructive, right.

In contrast, mentioning the elephants in the room can lead to all manner of irritable behavior, judgments that are hard to absorb. I am too negative, a prig, a moralist, a mean person, a downer. I make people feel bad. Why do I have to bring all that stuff up?

It has taken me several decades to understand that wisdom lies in the middle ground, so I persist. It is in that spirit that I mention an important health care elephant.

• 27 to 30 percent of Medicare payments cover the cost of care for people in the last year of life.
• 40 percent of Medicare dollars cover care for people in the last month.
• 12 percent of Medicare spending covers people who are in the last two months.

We need to have a conversation pretty soon about longevity. Longer life spans are supposed to be the stuff of a success story, not a promise of immortality. We are going to die, eventually.

Exactly how long are we supposed to live, and how much money are we going to spend on dramatic efforts to extend the life of an elderly person for another month or week?  What are we going to do about all these studies that say that the lion’s share of health care costs occur in the last year of life?

How do we as a nation start a constructive discussion about death and how to let go of those we love without insisting that we spend a few large chunks of change on them while we struggle with their inevitable demise? How are we going to help families have this conversation without triggering the “death panel anxiety syndrome”?

Who will lead us in this effort? Theoretically, health care professionals would, however many are ill equipped to do so. They were educated to sustain life at any cost, literally. For many of them, success is not tied to a good death but the ability to not let death happen.  Their job is to save us. It is perhaps unrealistic to expect that they would be good at both warding off death and embracing it.

The antithesis of this worldview is found in the amazing work of the hospice community. They have been around for a while now. As someone who is willing to talk about death, I have had numerous conversations about hospice care, and have yet to hear a single person say this community’s work was anything but splendid. Quite a record, albeit anecdotal!

Maybe we need to make sure that their voice is heard more clearly in the health care “debate” about cost. Maybe we need to make sure experienced hospice workers are at every health care policy table. Maybe they have answers to our questions that would help us all grapple with death and dying a little more constructively.

They might even tell us what we want to hear.  More importantly, they might also tell us what we need to hear.

By Phyllis Kritek. When I hear a story repeated in different parts of the country by persons who differ, one from another, in striking ways, I pay attention: This is no longer a story, it is a pattern. The stories preoccupying me these days are ones where parents of recent college graduates tell me that their son or daughter successfully completed college but was unable to find a job, and thus became a waitperson, the politically correct term for one who serves food in a restaurant. Usually waitpersons do not have health care coverage through their employer.  We can find these same young people in the health care insurance reform legislation: they can now stay covered by their parents’ insurance policies until the age of 26. I think this is supposed to be good news.

Watching the unfolding drama of the health care insurance reform legislative process and the citizen responses, I kept looking for the young people. They were virtually invisible, perhaps busy serving food, and their unique plight went unexplored by virtually everyone. I wondered if their concerns were embedded in the endless polls, or even if they were being polled. The mandate for individual coverage, it is anticipated, will uniquely burden these young people. The anticipated challenge of a rapidly expanding aging population with extensive health care needs is their responsibility to assume, we assume.

As a group that has been fairly well researched, the baby boomers have some descriptors they do not like, no matter what the evidence. Along with a whole raft of wonderful qualities, it is often noted that they are self-centered and self-absorbed. They tend to reject this descriptor out of hand. Their elders, in the early studies on generational characteristics, were interestingly not called the “greatest generation” but the “entitlement generation”.  I watched Tom Brokaw’s recent report on the boomers, waiting for him to ask a young person what he or she thought about the boomers. It did not happen. I watched the obsessive air time given to angry, often vitriolic people reacting to the impending health care legislation: none of them looked very young to me.

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Probably the thousands of nurses who have been following this case were encouraged to read the press report of its outcome:

“Texas jury finds nurse not guilty for reporting a physician for unsafe practices.

It took the jury less than an hour on February 11, 2010, to return a not guilty verdict for the nurse, Anne Mitchell, of felony charges of “misuse of official information,” for reporting a physician to the Texas Medical Board for what she believed was unsafe patient care.

Since news of the criminal indictment – and Mitchell’s being fired from her job – first spread through the nursing community, nurses across the country have followed developments. Labeling the criminal indictments “outrageous,” an outpouring of support – and financial contributions to the Texas Nurses Association Legal Defense Fund – has continued.

According to a New York Times article on February 9, the prosecutors claimed that Mitchell intended to damage the physician’s reputation when she reported him to the Texas Medical Board, which licenses and disciplines doctors. Mitchell explained that she felt an obligation to protect patients from what she saw as a pattern of improper prescribing and surgical procedures – including a failed skin graft that was performed in the emergency room, without surgical privileges.

Conflicts of interest seemed to be part of this case with allegations that this case was, in part, a result of the local sheriff being good friends with, and a former patient of the physician, and bending the rules to protect his reputation.

A number of nurses who had previous worked at the same Winkle County Rural Health Clinic testified in court that they left the clinic because of their concern about the care provided by the same physician that had never been addressed. The case is no less perplexing as to why Mitchell was even indicted – all witnesses (even the state’s) have agreed nurses have a duty to report unsafe care.

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Last night I saw a sobering statistic, reporting audience numbers for Fox News, CNN, and MSNBC. It was instructive. Put in overly simplified terms, if 5 people are watching cable news, three of them are watching Fox News, one is watching MSNBC, and one is watching CNN. It seems to me that there is some embedded information here. Three people are being scared to death, while only two might be getting a somewhat more nuanced picture of the nation’s response to health care reform.

I have to admit that I was heartened to see MSNBC edge ahead of CNN. Rachel Maddow is doing the closest thing to investigative reporting I can find on cable, though I think her colleagues at MSNBC, with a few exceptions, are not noticing this, even though her rankings keep swelling. She is also the “young” and “very intelligent” player in this drama. She consistently references the successes of her colleagues, though they rarely return the favor. She understands the role of the internet as no other commentator. There is probably some embedded information in all these facts too.

One of the most bizarre aspects of watching our collective response to the potential of a real change in health care is the fixation by cable news on the political gamesmanship of the process, likening these games to games of the past in a rather nostalgic tone of voice. There is thus an overt neglect of the issues. Hence, I have an excess of information about who thinks who is doing stuff behind the scenes (reference Ronald Reagan and Bill Clinton here) and almost no factual information on the realities of the health care world. The rare exceptions are noteworthy because they are rare.

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As the health care reform dialog speeds up and the possibility of a single payer system wanes, I find myself more fascinated by the subtle back-story than the predictable dialog. History informs. The last forty years or so, with the center piece of the end of the Cold War, we relegated the communist threat to pockets about the globe while the triumph of capitalism flourished. We had a great need to show that the free enterprise system, both politically and economically, was triumphant. We in the United States often called this democracy.

One expression of that process was the insistence that health care could be a commodity, a product one could market and sell, a service that would enter the hurly burly of competition and that this would make it a better product. Somewhat like lemmings to the sea, we in health care complied, introducing corporate refinements to our system of operations and governance, calling patients consumers and ourselves providers. We attempted to create appropriate metrics to demonstrate our engagement in the models of industrialized businesses. We got aboard.

Every few years I have an opportunity to seek health care services, happily for nothing life threatening, nonetheless experiences that take me into the “consumer” role of health care agencies, one who is purchasing a “product”. My most recent one was instructive. I was scheduled for an MRI and an MRA at a brand new community-sited imaging center.

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“A new public plan — to offer consumers greater choice, keep the private plans honest and, one can hope, restrain the relentless growth in health care premiums and underlying medical costs — seems worth trying.” New York Times Editorial, April 7, 2009

And thus, the New York Times adds its comments to the chorus of voices noting that indeed we might want to try a new way of financing health care in the United States. I focus on financing deliberately, since the conversation about health care reform is primarily one that tinkers with the model of health care financing, not health care itself. What we really are stumbling toward is some new way of grappling with third party payers, expanding our options, we posit, and rendering these payers more honest, and competitive among themselves.

What worries me is not the reform but the mindset underlying the proposed changes. At the risk of sounding ancient and retrograde, I actually can remember when insurance companies thought their mission was to decrease the fiscal risk for all of us by group contributions that would help pay for some of us at any given moment. That mindset focused on the patient; over time, we learned to focus on the shareholder. The latter was engaged in the search for profit. Hence, success for insurers shifted to shareholder profit. The best way to be profitable was to simply not have to pay out for health care. That is the mindset we gradually convinced ourselves was a good one.

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I just finished reading Matt Taibbi’s analysis of the state of the union, so to speak, called The Great Derangement: A Terrifying True Story of War, Politics & Religion at the Twilight of the American Empire. It is a great read, one I recommend, and forewarned, like most great reads, both unsettling and haunting. Among other analyses he provides is his descriptive narrative about how Congress “works”. Decisions are controlled by a small group of “leaders” in Congress who cut deals with interest groups so current members have enough cash (and influence) on hand, through grateful donations and reciprocated influence, to be reelected, so they can continue to do what they do. This incestuous circle, embraced by both parties, does not appear to have (as yet) been disrupted, from what I can gather.

Enter health care reform, which not surprisingly, is really health care financing reform with a nod to access. Health care as a human right does not appear to be the overriding focus so far, albeit an acknowledged catalyst for the discussion. And the arena of discourse will be the Congress. Here the confluence between Taibbi’s observations and the charge to our legislators creates a deep misgiving.

One of the most interesting first “worries” getting airtime as the process unfolds is what to do about all those young people who refuse to buy coverage, as if this were our most fundamental challenge. It reminds me of the good old days when Aid to Dependent Children was attacked because of the massive “abuse” of the system: we don’t want to pay for these folks who are not bearing their part of the great burden. In nearly all the discussions about change since the rather startling activity emerging from the Obama Presidency (it seeming a rather stark contrast with the last 6-8 months of the last administration who seemed to be silently watching Rome burn), one of the persistent themes is the irresponsibility and threat of abuse from the least powerful players in the game: folks facing foreclosure, elderly people buying medication, union members with healthcare coverage.

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Seismic shifts are inherently discomforting. I think we are in one, and the health care system seems a little Cro-Magnon in its response to this discomfort. We seem uniquely able to slog along, business as usual, without innovately entering into the dialog. The demise of Tom Daschle simply intensifies this sensation, as “our” anointed “leader” at the White House table is removed from the dialog. The problems that created his demise look a bit dated too. We seem stuck in trying to create a future while hanging on for dear life to the past.

People mention us a good deal, of course, largely noting that we are alternately broken, inefficient, dysfunctional, too expensive, held hostage by insurance companies, unfair, unsuccessful…there is a long list here. We apparently need to change. This occurs in a larger context, both nationally and globally, and there we find what Yeats described so well: “Things fall apart; the center cannot hold”. The poem was called “The Second Coming”.

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Among the barrage of strange events assaulting even the most durable citizen watching the transition of federal power these days, one of the most interesting is the long line of pundits and purported experts queuing up to give the Obama administration lengthy and often preachy doses of advice. I don’t remember us doing this for George Bush…hmmm. While chagrined, here I am getting in line. My intent is to balance the discourse a little.

My advice is about the undertow. The often unacknowledged subtext of much of the advice now being offered is an enormous expectation that somehow Obama will magically restore our collective capacity for ethical choice and conduct. The undertow, of course, is that we all participated in a frenzy of unethical behaviors of one kind or another to get us into the mess we are in. Many seem to me more passive than active: things fell apart and we did nothing or very little. One does not see the whistleblowers receiving Medals of Honor. Yet somehow we want Obama to single-handedly reverse this collapse of communal values and moral conduct. It seems kind of unrealistic to me. I took seriously his contention that all of us were going to have to do our share.

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Like many Americans, I am still trying to wrap my mind around the shifts and changes wrought in our country on November 4, 2008. We will all be at it a while, I think. One dimension haunts me as a nurse: we elected a president who calmly stated “I think health care is a right”.

As a young nurse I repeatedly tried to understand why education, fundamental K-12, was considered a given in this country, yet health care was something one not only had to negotiate for but indeed was being systematically subjected to the vagaries of markets, profit motives, shareholder demands, and the overt “rankism” of our society. (more…)

The current state of health care systems in the United States is not accidental. It has a history and that history counts. Though there are many dimensions to that history, some that fly under the public discourse radar are worth exploring. I want to share my thoughts about a few of these “elephants in the room” that haunt me. This is not an exhaustive report; it simply highlights one of many processes that set the stage for the current conditions in health care today. I will be writing about other ones…

Some social commentators called the 1980s the decade of greed in the United States. I thought it was more accurately a cultural drift where greed was confused with success, embraced as a worthy motive. It was not the Baby Boomers finest hour, or decade for that matter. Just ask their offspring who are inheriting the inevitable results of this greed.

This drift was in part shaped by a conviction held by many that the free market could and would correct itself, even in the context of a complex emerging global economy. (It seems self-evident to note that the last few weeks beg to differ). This worldview created the conditions for the 90s where health care systems, seeing health care reform deep-sixed early in the Clinton administration, drifted toward a cost-containment marketplace mentality. (more…)

Amidst the frenzy of critiques of the US health care systems (yes, there are several), what is still working are the workers, the health care providers - from community health aides and orderlies to chief nursing officers and medical staff leaders – who continue to slog through the detritus of the systems’ dysfunctions, get up every day and try to figure out how to care for patients, their families, and their communities despite the incessant shifting obstacles to meeting that goal. The vast majority of health care providers made their occupational choices with one thing in common: they thought it would be a way to help people suffering from disease and its consequences. Most keep trying to do this.

Reluctantly, I am going to use a war metaphor to amplify. The national discussion on wars often emphasizes the “troops on the ground” and their perceptions of their situation. I try to imagine all those soldiers being asked to divert themselves from their primary responsibilities to collect “performance metrics” so we can find out where they are failing to do their job or making errors. I picture us posting these shortcomings so we can prove that we are transparent. I try to imagine literally hundreds of external experts creating elaborate documents and initiatives designed to ignore the larger enterprise of war and instead creating bureaucratic monsters eating time, resources and even lives in an effort to tinker with the system. I try to imagine soldiers incessantly being blamed in the media for the obvious human errors that wars create. I try to imagine benchmarking this war against other wars so we can see which war is more wonderful. Enough!

I like to think that my analogy is germane because the two groups share a common goal: keeping Americans safe.

In the next cycle of change, I would hope we might get back to the overriding mission in health care: to take care of people faced with challenging health experiences. Quality care and cost containment are polar forces to be balanced. Using the tools of cost containment to assess quality care is at best naïve. Try measuring compassion or the tears of a child watching her mother die of cancer. “Not everything that can be counted counts and not everything that counts can be counted.” (A. Einstein) A bit more emphasis on the mission might change the dialog.

I would recommend the President, his cabinet members, and all the members of Congress try an anonymous three-day hospitalization. They could go through the admissions process stating they have no health care coverage, for starters. The “boots on the ground” might inform the discourse, unveil the impact of provider shortages, demonstrate the nuanced nature of giving good individualized health care, reveal the cost of cost control measures, and introduce them to some providers who are trying to give quality care despite all the disturbances swirling around them.