Old dogs can learn new tricks. My new resting habits are Exhibit A, and there are others as well. Thankfully, they’re not all tumor-related, and thinking about my new ways for maintaining energy levels has increased my awareness of other positive changes in daily habits. Please note that we’re conspicuously not thinking about how life will change next year when Shea starts college, though we’ve been laying foundations for an empty nest quite consciously for a few years. We’re enjoying life too much as it is to contemplate that upheaval just yet.
Here’s an example of the kind of change I am willing to think about now: for many years, I’ve read three newspapers every day. Like so many pieces of my life, it had a routine to it: headlines on all papers first, then a front-to-back reading. In the summer, when US papers aren’t available, we tried the International Herald Tribune and buying (once it started and was widely enough distributed that we found it around us) the European Wall Street Journal. Neither was very satisfactory, compared to the domestic editions. As on-line versions came into being, I switched some years ago to reading the New York Times exclusively on-line while we were away.
While there were oddities, it’s still possible to read the entire NYT, with some limitations imposed by their implementation. I submitted a range of suggestions to their customer service site, summer after summer, to a selection of which responses came back saying that my experiences were wrong and their way was right. This was emblematic of the lousy customer service attitude of so many large organizations that David and I were talking about the other day. While my suggestions might not be worth implementing, it’s brainless to write back and tell me my experience is “wrong.” It might not be useful to them, or worth a change, but that kind of response is beyond tone-deaf, especially when writing to a loyal, decades-long customer. That’s my assessment from my new mellow perspective. (It boggles the mind to think about likely reactions to such notes by New York City customers who are live with big-city stimuli and pacing and general Type A-ness.)
Anyway, leaving that rant alone, I still read the paper version at home—and sometimes the on-line edition, too. I frequently read the on-line version exclusively while traveling. (If you open and download all the stories you’re interested in while you have a connection, you can then read each story in succession on an airplane or in another location with no network access. The trick is to notice whether the story has a second page, and make sure you get the “single page” option selected so you have the whole story when you want it, not just the first chunk. It would be great to have the option to open stories only in the single page format so this last step wouldn’t be necessary. After my other experiences making suggestions to the on-line NYT, it seems impossible to imagine that anyone at the paper will listen, so I haven’t even tried to suggest it.)
What’s interesting to me, and what catalyzed this whole essay here, is that the unwritten “rules” in my head seem to be completely different for the paper version and the on-line version. In turn, over time, this has changed for the better the way I approach the paper version.
On-line, I usually read the NYT’s commentaries first; on paper, their placement on the op-ed page means they come after all they international and national news. Somehow, having read the on-line version in the way it arrives has given me permission now to read the physical paper out of order. Of course, Michael always reads the paper out of order according to my set of rules. Under his less rigid life view, which leaves him generally more relaxed, just about any approach works. (He also doesn’t have any rules about folding the sections back to what he’s reading and leaving them lying around that way, but the less said about that, the better.)
Another digression: the paper price of the WSJ in Europe is too high (2 euro a day) for regular consumption, especially when the dollar is in the toilet as it was last summer. The regular on-line subscription price is ridiculous, so we tried it on the Kindle this summer under a free offer choice. Take my word for it that it is completely maddening to read the Wall Street Journal on a Kindle. Together, these two organizations have made a combination of dumb-headed choices that leave even reasonable users (Michael is the metric for this) dumbfounded. “They did this on purpose?” is a common refrain. And the price after the free offers expire is disproportionate to the value. The upshot is that we’d rather go without the WSJ than read it electronically. This cannot augur well for the business model news organizations are going to have to find to survive in our changing world. (Unless, of course, we are so far out of the mainstream that their approach not working for us practically guarantees them success with the rest of the populace.)
Trying to come back to the topic, the short version of all of this is that a changed medium has changed my rules and habits. I still find the paper and electronic versions to be different experiences, differently satisfying. When home, I still read the paper version, though it’s much more frequently in what would have previously been a non-compliant, out-of-order, fashion. My inner rules czar has come to accept this gracefully. That seems like a harbinger of generally relaxed rules, especially the arbitrary ones, thoughtlessly adhered to at some cost even when not useful and constraining. That’s a positive change.
I've come to see the difference between a routine that simplifies life, reducing the need to expend thought on repetitive tasks (how to load and unload the dishwasher, for example) and one that is constraining. My new-found habits catalyzed by the change in the newspaper-content delivery mechanism have been freeing, and are leading to a re-examination of other routines. Some survive the examination, like having a set path to frequent destinations. I hate to have to think about navigation, and knowing in advance a way that works is, for me, value-added. Michael, on the other hand, loves variety and drives a different way as often as possible, even to places he goes all the time. When riding with him to a place for which I have a set route, it takes a real act of will not to tell him that his way is “wrong.” (Sadly, this effort is not always successful, as even riding, it’s less wearing for me if the familiar route is followed. I’m working on this.) Differences are illuminating and world-expanding.
So is letting loose of rules and routines that do not make life better.
That’s a lot of writing on a little topic. Or, maybe a big one, if all the implications are examined. Whatever. I hope the sun is shining wherever you are, at least inside, if the outdoor sun isn’t cooperating or didn't get the memo today.
Showing posts with label Transition to Next Stage. Show all posts
Showing posts with label Transition to Next Stage. Show all posts
Wednesday, November 19, 2008
Tuesday, September 23, 2008
Still Learning to Take the Tortoise-Approach
Tortoise. Tortoise. Tortoise. Yesterday was a great day and I overdid it.
We restarted our strength training and it felt fantastic. I was comfortably able to do twelve minutes on the treadmill at incline (we climbed steep hills this summer in France and have been trying to keep that gain) for a cardio warm-up and then I was able to do most—but not all—of what I have been doing all along. We were warmly welcomed back and being at the gym again was great.
Michael and I started strength training together for our birthdays almost two years ago, in large part because of how often I was falling down at the time, not to mention general aging and health issues. Since my mother died so young (47), we don’t have much health history for her, and we’d watched Michael’s mother shrink over the years, so all the way around, strength training seemed like a good idea. It’s been something we do together as we move closer to our empty-nest years. While I’m not big on the actual exercise part of it, it has been an unexpectedly positive experience. One completely unanticipated aspect of it that I’ve particularly enjoyed is the part where I just do whatever the trainer says to do: if she (our first trainer) or he (now) says “you should be able to do 15 of these,” I just do them. I don’t have to make any decisions or think about it, just do it. Letting go in that way—and clearly getting stronger throughout—has been great. And, the difference it’s made in my balance has been remarkable. Except for stepping in a pothole and twisting my ankle while carrying a tray of food (my excuse for not seeing the pothole), I hadn’t fallen down since we’d started the training. Even then, I was able to catch myself and save the tray of food, which felt like, and was, a great victory at the time. I was steadier on my feet than I’ve been in years. Of course, now we’re beginning to understand that I wasn’t just a clumsy oaf (my self-image), but that my balance had probably been tumor-affected for some time. I’m still working through this part of what’s been central to my self-image for so many years. It’s unlikely that it’s just been the tumor, as I’ve never been all that well coordinated and my hand-eye coordination, in particular, are terrible, as I am profoundly near-sighted, with eyes that don’t match, which affects my depth perception. Plus, my preference would always be to read a book before I’d go exercise.
Here’s the perfect illustration of my point: when Michael and I first took up many years ago, he and his friends played pick-up softball on a field across the street from the Meadows off Race in Urbana, near the old Bliss Drive housing area. (Where my parents, as so many faculty of their generation, first lived when arriving on campus.) I’d never played softball, and his friends were a particularly generous group (then and now—nice knows nice, it turns out) who encouraged me to join in, even though I didn’t know what I was doing and wasn’t ever an asset to the team that ended up stuck with me. I still remember as an epiphany the moment in which it became clear that when other players said “heads up,” it wasn’t a sports euphemism for “close your eyes and duck” as I’d always understood it. They really meant that I should look up and try to catch the ball! They laughed until they fell down, in the nicest possible way, when they grasped the extent of the insight I was experiencing. I’ve heard about it on and off for years.
Anyway, the strength training has been positive for us in many ways including providing a strong foundation for this recovery of mine. There are motions I cannot yet produce, especially with my right arm, and we experimented to discover what I can and cannot do. Since we’re doing all the training and therapy at Mettler, the physical and occupational therapy will all be coordinated with the strength training. It felt great to be back there and while I’m not as strong as I was before surgery, the number of things I could do that weren’t much worse was encouraging.
Then I went home and slept for an hour before a nice visit from C, the source of the information on crabbiness in the index of her Brain Tumor Recovery Manual. While we visited, she edited flowers to refresh them all and told us that lime seltzer water will help prolong flowers—nice to know. We found a stray staple on my head, which Michael removed using tools not quite as cool as the surgeon’s but equally effective. Then I slept for another three hours.
Because I felt strong and good, I ate something and went to the second half of my law class. That was a terrific experience. This class has one of those great group personalities that happen now and again and are so special when they do. The second half of yesterday's class plan is a particularly fun and illuminating group negotiation. Both sides want the same thing, but because they’re so afraid of losing leverage by being the first to put their goals on the table, it comes to impasse a remarkable percentage of the time, which is a great teaching/learning moment. Being there for this negotiation was fun, as this group did two or three novel and skillful things in the way they approached it, though it did get messy in the end. They settled, though, which is more than many classes ever manage to do. I was very happy to see them, and they were welcoming and warm. It was a real spirit-booster.
It’s pretty clear that I’m not going to have the stamina to teach this class alone for a while, so wonder-woman friend who has been handling it for me says she’ll keep coming and will be there with me as long as I need. That’s a real friend. It’s also pretty clear that I’m not going to be writing on a blackboard with my right hand anytime soon. Michael thinks maybe I could write on an overhead projector in lieu of the blackboard, since if my elbow is supported, I can write more often than not. Plus, wonder-woman says she’ll be there and SHE can write on the board… brushing off completely the cost in her life for adding this in this chunk of time and effort to an already-full load.
Anyway, I’m working up to admitting to having overdone it. Even though I was testing as I went and making sure at each point that I felt ok and even though I sat down through most of the class (they were negotiating, and we were watching, after all)… ok, I wasn’t as clued in as I should have been to my energy level. Another bad night with the return of headaches/pain resulted. I’ll learn from this. Really. It’s just going to take me time to learn my new energy rhythms and limits, because it’s just not the way I’m used to living. This is the new me, though, so I’ll get the hang of it.
Wasn’t Kearney’s post yesterday wonderful? What a terrific human being she is. We are so proud, and of course we need her—just not in the same way we did when she was here, filling in all the gaps and taking care of me and us. She was here for us when we did need her and we know she will be again, should the situation change. So what we need for her to do now is have a fulfilling and productive life in Madison doing her research and making progress on becoming who she is going to be. She’s right, of course, about how our questions and worries were misdirected. It’s worth thinking about, as we gleaned many of our questions from our research and still never hit some of the really important ones. One area dawning on us now to ask about, for example, are hormonal effects. Either we have some massive coincidences going on or we’re seeing some. Time to go back and do some more research.
We mailed off our full document with both the counting results and our suggestions/reviews to the hospital and clinic CEOs as well as our two main physicians, and it occurs to me that it would be polite to let them get it before we post our suggestions for improvement in this quasi-public place. Plus, I’ve blathered on today, so we’ll postpone our more personal, qualitative review of the medical adventure for a day or so.
At least in central Illinois, we have on tap another beautiful autumn day. The leaves are just beginning to turn and the quality of light filtered through the green and gold is stunning. Take a walk at lunch if you have nice weather where you are.
We restarted our strength training and it felt fantastic. I was comfortably able to do twelve minutes on the treadmill at incline (we climbed steep hills this summer in France and have been trying to keep that gain) for a cardio warm-up and then I was able to do most—but not all—of what I have been doing all along. We were warmly welcomed back and being at the gym again was great.
Michael and I started strength training together for our birthdays almost two years ago, in large part because of how often I was falling down at the time, not to mention general aging and health issues. Since my mother died so young (47), we don’t have much health history for her, and we’d watched Michael’s mother shrink over the years, so all the way around, strength training seemed like a good idea. It’s been something we do together as we move closer to our empty-nest years. While I’m not big on the actual exercise part of it, it has been an unexpectedly positive experience. One completely unanticipated aspect of it that I’ve particularly enjoyed is the part where I just do whatever the trainer says to do: if she (our first trainer) or he (now) says “you should be able to do 15 of these,” I just do them. I don’t have to make any decisions or think about it, just do it. Letting go in that way—and clearly getting stronger throughout—has been great. And, the difference it’s made in my balance has been remarkable. Except for stepping in a pothole and twisting my ankle while carrying a tray of food (my excuse for not seeing the pothole), I hadn’t fallen down since we’d started the training. Even then, I was able to catch myself and save the tray of food, which felt like, and was, a great victory at the time. I was steadier on my feet than I’ve been in years. Of course, now we’re beginning to understand that I wasn’t just a clumsy oaf (my self-image), but that my balance had probably been tumor-affected for some time. I’m still working through this part of what’s been central to my self-image for so many years. It’s unlikely that it’s just been the tumor, as I’ve never been all that well coordinated and my hand-eye coordination, in particular, are terrible, as I am profoundly near-sighted, with eyes that don’t match, which affects my depth perception. Plus, my preference would always be to read a book before I’d go exercise.
Here’s the perfect illustration of my point: when Michael and I first took up many years ago, he and his friends played pick-up softball on a field across the street from the Meadows off Race in Urbana, near the old Bliss Drive housing area. (Where my parents, as so many faculty of their generation, first lived when arriving on campus.) I’d never played softball, and his friends were a particularly generous group (then and now—nice knows nice, it turns out) who encouraged me to join in, even though I didn’t know what I was doing and wasn’t ever an asset to the team that ended up stuck with me. I still remember as an epiphany the moment in which it became clear that when other players said “heads up,” it wasn’t a sports euphemism for “close your eyes and duck” as I’d always understood it. They really meant that I should look up and try to catch the ball! They laughed until they fell down, in the nicest possible way, when they grasped the extent of the insight I was experiencing. I’ve heard about it on and off for years.
Anyway, the strength training has been positive for us in many ways including providing a strong foundation for this recovery of mine. There are motions I cannot yet produce, especially with my right arm, and we experimented to discover what I can and cannot do. Since we’re doing all the training and therapy at Mettler, the physical and occupational therapy will all be coordinated with the strength training. It felt great to be back there and while I’m not as strong as I was before surgery, the number of things I could do that weren’t much worse was encouraging.
Then I went home and slept for an hour before a nice visit from C, the source of the information on crabbiness in the index of her Brain Tumor Recovery Manual. While we visited, she edited flowers to refresh them all and told us that lime seltzer water will help prolong flowers—nice to know. We found a stray staple on my head, which Michael removed using tools not quite as cool as the surgeon’s but equally effective. Then I slept for another three hours.
Because I felt strong and good, I ate something and went to the second half of my law class. That was a terrific experience. This class has one of those great group personalities that happen now and again and are so special when they do. The second half of yesterday's class plan is a particularly fun and illuminating group negotiation. Both sides want the same thing, but because they’re so afraid of losing leverage by being the first to put their goals on the table, it comes to impasse a remarkable percentage of the time, which is a great teaching/learning moment. Being there for this negotiation was fun, as this group did two or three novel and skillful things in the way they approached it, though it did get messy in the end. They settled, though, which is more than many classes ever manage to do. I was very happy to see them, and they were welcoming and warm. It was a real spirit-booster.
It’s pretty clear that I’m not going to have the stamina to teach this class alone for a while, so wonder-woman friend who has been handling it for me says she’ll keep coming and will be there with me as long as I need. That’s a real friend. It’s also pretty clear that I’m not going to be writing on a blackboard with my right hand anytime soon. Michael thinks maybe I could write on an overhead projector in lieu of the blackboard, since if my elbow is supported, I can write more often than not. Plus, wonder-woman says she’ll be there and SHE can write on the board… brushing off completely the cost in her life for adding this in this chunk of time and effort to an already-full load.
Anyway, I’m working up to admitting to having overdone it. Even though I was testing as I went and making sure at each point that I felt ok and even though I sat down through most of the class (they were negotiating, and we were watching, after all)… ok, I wasn’t as clued in as I should have been to my energy level. Another bad night with the return of headaches/pain resulted. I’ll learn from this. Really. It’s just going to take me time to learn my new energy rhythms and limits, because it’s just not the way I’m used to living. This is the new me, though, so I’ll get the hang of it.
Wasn’t Kearney’s post yesterday wonderful? What a terrific human being she is. We are so proud, and of course we need her—just not in the same way we did when she was here, filling in all the gaps and taking care of me and us. She was here for us when we did need her and we know she will be again, should the situation change. So what we need for her to do now is have a fulfilling and productive life in Madison doing her research and making progress on becoming who she is going to be. She’s right, of course, about how our questions and worries were misdirected. It’s worth thinking about, as we gleaned many of our questions from our research and still never hit some of the really important ones. One area dawning on us now to ask about, for example, are hormonal effects. Either we have some massive coincidences going on or we’re seeing some. Time to go back and do some more research.
We mailed off our full document with both the counting results and our suggestions/reviews to the hospital and clinic CEOs as well as our two main physicians, and it occurs to me that it would be polite to let them get it before we post our suggestions for improvement in this quasi-public place. Plus, I’ve blathered on today, so we’ll postpone our more personal, qualitative review of the medical adventure for a day or so.
At least in central Illinois, we have on tap another beautiful autumn day. The leaves are just beginning to turn and the quality of light filtered through the green and gold is stunning. Take a walk at lunch if you have nice weather where you are.
Monday, September 22, 2008
Counting for Positive Deviance
In a change of pace from recent posts, today brings a summary of the counting exercise that Kearney and I (with back-up from Michael and Shea) did during our medical adventure. We’ve written up our experiences and will be sharing them with the hospital/clinic folks, as well as posting some extracts of them here. We have two sets of observations: our counting results and then our thoughts on the systems we saw in operation. Today is counting and tomorrow, I hope, will be some of our systemic comments. As background in that area, Bob Sutton from Stanford (author of the No Asshole Rule, which I use as a text in my MBA ethics and leadership class) has a terrific article in the McKinsley Quarterly on “The Ergonomics of Innovation” about the campaign of the Institute for Healthcare Improvement’s campaign to reduce by 100,000 the number of patients who die in hospitals from preventable errors. You can download the article from his website (bobsutton.typepad.com) if this topic is of any interest… it’s a short, well-written and interesting piece.
Otherwise, we generally had two days of slight slippage this weekend: neither days nor nights went very well as we lost the pain-control rhythm for a while. We think we’re back in a good groove today and the night went pretty well. Plus, thankfully, we’re closing in on the end of the steroids.
This week represents another new phase in recovery: I’m restarting my strength training today, occupational therapy begins on Wednesday and physical therapy on Thursday. Following the good advice of friend L, I’m working on internalizing the tortoise-mindset (as opposed to that of the hare) for this process: slow and sure, with my eyes firmly fixed on the long-term goal of full recovery. The tortoise slow-and-sure approach doesn’t come naturally to me, but now is surely the moment. Social psychology research emphasizes the importance of making a public commitment using the consistency principle, so now all of you have seen me commit to this goal. I know you'll hold my feet to the fire.
And now, for some of our counting results:
Kearney and Tina decide to count
In the epilogue of his book Better, Atul Gawande advises doctors to become "positive deviants," with suggestions for making a worthy difference in the world. Among his suggestions for achieving this, he says "If you count something you find interesting, you will learn something interesting." (Afterword, page 255). This rang a bell for us as we were entering our medical adventure, so the two of us set up a rubric for tracking our interactions with the staff members we were going to encounter. We created a spreadsheet and printed blank sheets that we taped to the back of our hospital notebook. Our methodology was simple: we logged every person we encountered, giving ratings of five simple factors on a 1-5 Likert scale. (We later modified one of the elements to a simple yes/no.) We were sufficiently diligent that we found only a few entries that were incomplete when we began this summary.
Summary of Counting
From Thursday, September 4, the date on which the meningioma tumor was first diagnosed via a CAT scan, through the craniotomy Wednesday, September 10, and until discharge from the hospital on Saturday, September 13, we logged interactions with more than 60 staff members at Carle clinic and hospital. This included staff during:
• the initial diagnostic CAT scan (Thurdsay, September 4)
• an appointment with the surgeon to consult and schedule the surgery (Friday, September 5)
• an outpatient MRI scan preparatory to surgery (Monday, September 8)
• a pre-op insurance clearance (Tuesday, September 9)
• a pre-op medical record session (Tuesday, September 9)
• a pre-op physical and a consultation with an anesthesiologist (Tuesday, September 9)
• check-in and preparation for surgery (Wednesday, September 10)
• a pre-op MRI and the surgery (Wednesday, September 10)
• time in the recovery room (Wednesday, September 10)
• time in the surgical intensive care unit (two nights, Wednesday and Thursday, September 10 and 11)
• recovery time on the surgical floor (one night, Friday, September 12)
For each staff member we encountered, we rated five items on a 5-point scale:
5 completely top-notch
4 pretty good
3 neutral
2 not so good
1 terrible or non-existent
Items rated were:
• did the staff member introduce him or herself to us?
• did the person don gloves or wash hands before touching the patient?
• the listening skills of the staff member
• the clarity of the staff member’s communications/instructions to us
• the helpfulness of the interaction as we perceived it
Given the items, some of the ratings were really yes/no while others were qualitative assessments of our responses. We converted the “washed hands/wore gloves” from the five-point scale to a yes/no scale after the fact, but left the “introduced self” on the five-point scale, as there were qualitative differences in the nature of the interactions.
The staff we encountered and on whom we kept records fell into the following categories:
• 4 physicians (2 surgeons, 1 pre-op physician; 1 pre-op anesthesiologist); we did not meet any of the hospitalists who presumably were around and about during my stay; the surgeon was present every day, sometimes twice a day (and during the first night as well)
• 23 nurses
• 4 health technicians
• 3 scan technicians
• 5 blood lab techs/EKG tech
• 6 therapists (2 PT, 3 OT, 1 vocal)
• 3 food deliverers
• 10 receptionists/schedulers/managers
• 2 uncategorized/unknown
Numerical findings.
Scores at the highest levels across the interactions:
69% (36/52) interactions in which an introduction was appropriate occurred at a “5” level
59% ( 19/32) individuals visibly cleaned hands or donned gloves before touching patient (where appropriate)
66% (31/47) had listening skills that we rated at the highest level, “5”
52% (25/48) interactions in which information was conveyed were ranked at the “5” level
60% (30/50) interactions were rated at the highest level of helpfulness
Aggregating the two highest scores (4 and 5):
69% (36/52) interactions in which an introduction was appropriate
59% [(19/32) individuals visibly cleaned hands or donned gloves before touching patient]
77% ( 36/47) listening skills were rated at a high level
71% (34/48) interactions in which information was conveyed were effective
72% (36/50) interactions were rated at a high level of helpfulness
Eight of the 60 staff members (13%) we encountered scored at the lowest level across all interactions.
By Role
Three of four doctors received the highest ratings for every interaction.
One doctor (the pre-op anesthesiologist) was hands-down the worst interaction across the entire time period, in every dimension.
19 of 23 nurses received the highest ratings for every interaction. There were four nurses whose names we never learned; who simply appeared, did things to the patient and then left. This was disconcerting when it occurred, especially compared to the quality and consistency of care otherwise.
Two of the three radiology technicians rated at the highest levels. The third was more ancillary to the process, though an introduction here would also have been nice.
The five lab techs did not consistently introduce themselves, but received the highest ratings on every other aspect of the interactions.
The six therapists from the different services had a mixed record: two were superlative, two were fine and two we never learned their names. They just appeared, took actions, and disappeared.
The three surgical floor Health Care Techs did not wear gloves for taking vitals (probably not necessary?) and otherwise received the highest ratings on every interaction. They added considerable humanity and gentleness to the experience.
Ten office staff members (receptionists, schedulers, etc) were generally effective and rated well. They were more mixed than other categories and also had a lower rate of interaction.
Three different people delivered food ordered from the menu. None introduced themselves (not really required) and each was gloved, personable, helpful and pleasant. Each had a nice manner in getting things established well for being able to eat.
There were two items we didn't track that, in retrospect, we wish we had, especially after reading Sutton & Rao's article.
Patient Identification. We didn’t tally the consistency of patient identification before treatment interactions, and in retrospect wish we had been alert enough to the systemic issues to have done so. Our sense is that this was done at a very high level of consistency. Our collective sense is that date of birth was asked as a matter of course by most, if not all, staff members, before any interaction began.
Administration of Medications. Similarly, we didn’t log the administration of medications and wish we had. Again, our sense is that this was also a very deeply routinized process executed with great discipline: the hospital ID bracelet was scanned before any medication was provided and each and every administration checked in advance on the computer and then entered on the bedside computer afterwards.
Overall, this is an impressive track record of a lot of people in a large and complex undertaking.
The counting we did along the way gave us a joint mission, let us feel that we were not totally helpless/being acted upon as we careened through this most peculiar experience (a brain tumor??) and grounded us. Feeling that we were still us, capable of observing and assessing helped all of us, we think. A side-effect we didn’t expect was that, eventually, the aggregating numbers began to reinforce how well this system in which we were caught up was working on a moment-to-moment basis. As the positive numbers continued to pile up, that realization affected our attitudes in helpful ways. We hadn’t anticipated that—actually, we hadn’t really anticipated anything other than just having an activity—and it was an interesting effect that probably made us easier to deal with for the staff we encountered, too. Finally, the whole mission gave us a handle on being less completely self-absorbed than would have been easy to become.
We’d do this again. Here’s hoping the need never arises.
Otherwise, we generally had two days of slight slippage this weekend: neither days nor nights went very well as we lost the pain-control rhythm for a while. We think we’re back in a good groove today and the night went pretty well. Plus, thankfully, we’re closing in on the end of the steroids.
This week represents another new phase in recovery: I’m restarting my strength training today, occupational therapy begins on Wednesday and physical therapy on Thursday. Following the good advice of friend L, I’m working on internalizing the tortoise-mindset (as opposed to that of the hare) for this process: slow and sure, with my eyes firmly fixed on the long-term goal of full recovery. The tortoise slow-and-sure approach doesn’t come naturally to me, but now is surely the moment. Social psychology research emphasizes the importance of making a public commitment using the consistency principle, so now all of you have seen me commit to this goal. I know you'll hold my feet to the fire.
And now, for some of our counting results:
Kearney and Tina decide to count
In the epilogue of his book Better, Atul Gawande advises doctors to become "positive deviants," with suggestions for making a worthy difference in the world. Among his suggestions for achieving this, he says "If you count something you find interesting, you will learn something interesting." (Afterword, page 255). This rang a bell for us as we were entering our medical adventure, so the two of us set up a rubric for tracking our interactions with the staff members we were going to encounter. We created a spreadsheet and printed blank sheets that we taped to the back of our hospital notebook. Our methodology was simple: we logged every person we encountered, giving ratings of five simple factors on a 1-5 Likert scale. (We later modified one of the elements to a simple yes/no.) We were sufficiently diligent that we found only a few entries that were incomplete when we began this summary.
Summary of Counting
From Thursday, September 4, the date on which the meningioma tumor was first diagnosed via a CAT scan, through the craniotomy Wednesday, September 10, and until discharge from the hospital on Saturday, September 13, we logged interactions with more than 60 staff members at Carle clinic and hospital. This included staff during:
• the initial diagnostic CAT scan (Thurdsay, September 4)
• an appointment with the surgeon to consult and schedule the surgery (Friday, September 5)
• an outpatient MRI scan preparatory to surgery (Monday, September 8)
• a pre-op insurance clearance (Tuesday, September 9)
• a pre-op medical record session (Tuesday, September 9)
• a pre-op physical and a consultation with an anesthesiologist (Tuesday, September 9)
• check-in and preparation for surgery (Wednesday, September 10)
• a pre-op MRI and the surgery (Wednesday, September 10)
• time in the recovery room (Wednesday, September 10)
• time in the surgical intensive care unit (two nights, Wednesday and Thursday, September 10 and 11)
• recovery time on the surgical floor (one night, Friday, September 12)
For each staff member we encountered, we rated five items on a 5-point scale:
5 completely top-notch
4 pretty good
3 neutral
2 not so good
1 terrible or non-existent
Items rated were:
• did the staff member introduce him or herself to us?
• did the person don gloves or wash hands before touching the patient?
• the listening skills of the staff member
• the clarity of the staff member’s communications/instructions to us
• the helpfulness of the interaction as we perceived it
Given the items, some of the ratings were really yes/no while others were qualitative assessments of our responses. We converted the “washed hands/wore gloves” from the five-point scale to a yes/no scale after the fact, but left the “introduced self” on the five-point scale, as there were qualitative differences in the nature of the interactions.
The staff we encountered and on whom we kept records fell into the following categories:
• 4 physicians (2 surgeons, 1 pre-op physician; 1 pre-op anesthesiologist); we did not meet any of the hospitalists who presumably were around and about during my stay; the surgeon was present every day, sometimes twice a day (and during the first night as well)
• 23 nurses
• 4 health technicians
• 3 scan technicians
• 5 blood lab techs/EKG tech
• 6 therapists (2 PT, 3 OT, 1 vocal)
• 3 food deliverers
• 10 receptionists/schedulers/managers
• 2 uncategorized/unknown
Numerical findings.
Scores at the highest levels across the interactions:
69% (36/52) interactions in which an introduction was appropriate occurred at a “5” level
59% ( 19/32) individuals visibly cleaned hands or donned gloves before touching patient (where appropriate)
66% (31/47) had listening skills that we rated at the highest level, “5”
52% (25/48) interactions in which information was conveyed were ranked at the “5” level
60% (30/50) interactions were rated at the highest level of helpfulness
Aggregating the two highest scores (4 and 5):
69% (36/52) interactions in which an introduction was appropriate
59% [(19/32) individuals visibly cleaned hands or donned gloves before touching patient]
77% ( 36/47) listening skills were rated at a high level
71% (34/48) interactions in which information was conveyed were effective
72% (36/50) interactions were rated at a high level of helpfulness
Eight of the 60 staff members (13%) we encountered scored at the lowest level across all interactions.
By Role
Three of four doctors received the highest ratings for every interaction.
One doctor (the pre-op anesthesiologist) was hands-down the worst interaction across the entire time period, in every dimension.
19 of 23 nurses received the highest ratings for every interaction. There were four nurses whose names we never learned; who simply appeared, did things to the patient and then left. This was disconcerting when it occurred, especially compared to the quality and consistency of care otherwise.
Two of the three radiology technicians rated at the highest levels. The third was more ancillary to the process, though an introduction here would also have been nice.
The five lab techs did not consistently introduce themselves, but received the highest ratings on every other aspect of the interactions.
The six therapists from the different services had a mixed record: two were superlative, two were fine and two we never learned their names. They just appeared, took actions, and disappeared.
The three surgical floor Health Care Techs did not wear gloves for taking vitals (probably not necessary?) and otherwise received the highest ratings on every interaction. They added considerable humanity and gentleness to the experience.
Ten office staff members (receptionists, schedulers, etc) were generally effective and rated well. They were more mixed than other categories and also had a lower rate of interaction.
Three different people delivered food ordered from the menu. None introduced themselves (not really required) and each was gloved, personable, helpful and pleasant. Each had a nice manner in getting things established well for being able to eat.
There were two items we didn't track that, in retrospect, we wish we had, especially after reading Sutton & Rao's article.
Patient Identification. We didn’t tally the consistency of patient identification before treatment interactions, and in retrospect wish we had been alert enough to the systemic issues to have done so. Our sense is that this was done at a very high level of consistency. Our collective sense is that date of birth was asked as a matter of course by most, if not all, staff members, before any interaction began.
Administration of Medications. Similarly, we didn’t log the administration of medications and wish we had. Again, our sense is that this was also a very deeply routinized process executed with great discipline: the hospital ID bracelet was scanned before any medication was provided and each and every administration checked in advance on the computer and then entered on the bedside computer afterwards.
Overall, this is an impressive track record of a lot of people in a large and complex undertaking.
The counting we did along the way gave us a joint mission, let us feel that we were not totally helpless/being acted upon as we careened through this most peculiar experience (a brain tumor??) and grounded us. Feeling that we were still us, capable of observing and assessing helped all of us, we think. A side-effect we didn’t expect was that, eventually, the aggregating numbers began to reinforce how well this system in which we were caught up was working on a moment-to-moment basis. As the positive numbers continued to pile up, that realization affected our attitudes in helpful ways. We hadn’t anticipated that—actually, we hadn’t really anticipated anything other than just having an activity—and it was an interesting effect that probably made us easier to deal with for the staff we encountered, too. Finally, the whole mission gave us a handle on being less completely self-absorbed than would have been easy to become.
We’d do this again. Here’s hoping the need never arises.
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