Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Archive for October, 2017

Cost + Quality + Convenience = Value

My wife Beth and I had a rather spirited discussion about how we in the U.S. might be able to pay for the healthcare of our citizens. Being ever practical, and also owning the job of writing the checks that pay for the “health insurance” our company offers its associates (including us), Beth in effect is arguing for a national consensus on something we might describe as a baseline ‘value’ for healthcare. Others would label her concept a ‘floor’, but you get the idea.

What Beth intuitively understands is the tension between cost, quality, and convenience. You pick a baseline or a floor level of value and offer that to everyone. With training as a nurse and 15 years in healthcare administration, her idea of what constitutes the sum of cost, quality, and convenience naturally overweights the integers for cost and quality: outcomes should be essentially equal across the board at the baseline or floor level, and the costs of achieving that should be in some way equitably shouldered by something we could describe as “society”. Very practical. A strategy that lends itself to being observable and measurable.

What’s the rub? Well, only two of the three elements that make up value are covered. To obtain an agreed upon level of medical outcomes (mortality, morbidity, longevity, etc.) the cost is covered. Ah, but HOW you obtain those outcomes is still a variable. It is the FLOOR of value that is guaranteed. Our family is experienced a bit of this recently with Beth’s Mom. After a hospitalization she was living in a setting that ws providing excellent care at a reasonable cost, but it was a setting that did not provide any extras; it was old, not very pretty, and she could  have had a roommate. Her (and her daughters’) experience, what we might call “convenience” or  in our formula, was found to be lacking. The girls opted to move her to a nicer setting, one that will eventually involve a higher cost because of the enhancements to the experience, with no change in the already best possible outcome, or quality.

Therein lies the problem with any discussion about literally anything that we might discuss as a “right”. Is everyone entitled to anything other than the minimal amount of convenience/experience necessary to obtain the best outcome at an affordable cost?

If we examine food, we find something quite similar. No one among us would say that X Million people should go without food. Indeed, we don’t even really talk about true hunger in the U.S. anymore, we talk about “food insecurity”, the concern that we may become hungry. By the same token, though, no one asserts that everyone is entitled to the same quality of food. Not even a little bit. No, quite the contrary, all that is discussed is cost and convenience (access).

Now, of course, we in the CrossFit world (and to a degree in the medical world) argue that quality is an ineluctable part of nutrition, that one must extend the equation outside of food alone so that an explicit choice is made that prioritizes quality calories over other purchases (cell phone, cable, fancy car, etc.). While this is accurate and proper I believe that we can reasonably quarantine nutrition and keep it separate from other needs, at least for the purpose of our discussion. The universal concept of the interplay between cost, quality, and convenience holds true in nutrition/food on a global, grand policy making level:

You can pick any two, but only two, when you are declaring what is the minimally acceptable level.

My formulaic approach to the coverage of needs has a little wrinkle that should be mentioned: quality cannot be increased ad infinitum. In all examples we might evaluate there is a practical limit to the ability to improve quality or outcomes. The law of diminishing returns arrives in the form of the asymptote as quality rises. On the other hand, cost and convenience are unbound and can rise almost infinitely. It is the alcohol in a drink that confers the health benefit; the same outcome occurs no matter what you drink. One person’s jug wine from Costco is another person’s Chateau Lafite served in the Gulfstream V. You get the picture.

What will become of our conversations about issues such as healthcare? Will we arrive at a similar juncture to the one we have now in food, clothing, and shelter? Where quality (outcomes) and cost issues are addressed and everyone is left to make their own call on convenience/experience? Beth can’t see how it can be any other way. Me? I’m much less optimistic. That old “want vs. need” thing just keeps popping up. Confusion arises when a truly generous people confuse what people want with what they need. Need is measurable and therefore finite, whereas want is neither. We can, and should, all work to pick up the check for the needs of each. “Want”, on the other hand, is the proverbial “free lunch”, and we as a society will need to agree on that before we can even begin to discuss begin to talk about the mechanics of paying the bill.

TANSTAAFL. Heinlein was right.


Succeeding Through Effective Failure

The secret to success just might be failure. Not abject failure, of course (although it’s always cool to use the word ‘abject’), nor consistent failure. But failure while pushing one’s limits or while exploring the new and the unknown might be the magic ingredient in the success recipe.

Why? Success is not simply the absence of failure, it is the defeat of failure. Success is over-coming failure. Indeed, without having failed at something some time, how do you know what success is? How do you know what it’s supposed to feel like?

Neither success nor failure need be any particular size. Small successes build confidence, and smallish failures teach. It’s important to qualify acceptable failures, though. Failure caused by sloppiness or laziness is ALWAYS bad. On the other hand, failure encountered while stretching beyond one’s limits, while reaching for something new, large, important…well…that’s the type of failure from which lessons are learned.

It takes a certain chutzpa to put one’s self at risk to fail while in the act of reaching further. I like Churchill’s take on it: “Success is never final. Failure is never fatal. It’s courage that counts.”

Be a little brave while failing.


“It’s better to full-ass one something than to half-ass a bunch of things.” Anonymous

At the moment I am living day seven of another week of on-call coverage for one of the largest hospitals in Ohio. When asked recently by colleagues why I still do hospital coverage I had to admit that I really didn’t have an answer. I don’t really have to do it, and yet it doesn’t really seem like it feels right not to. There’s a kind of “pay it forward” debt to the giants who came before me that still lingers, I suppose. That debt’s been paid, with a bundle of interest, many times over, and it may be time to close the ledger.

Why now? Well, it has very little to do with the work itself because that hasn’t really changed all that too very much over the years. No, it’s more about the work that’s NOT being done by others, work that they own and are responsible for and don’t do, that will ultimately drive me away from this part of my day job. It’s really no different than any other job or workplace anywhere. The lazy and the shiftless, the incompetent and the entitled all see it as just fine to kick the can downstream to whomever they can get away with kicking it to.

I’ll bet you just had a dozen images of this from your own life flash by, right?

Boy, there are a thousand reasons you will hear to explain and rationalize why they feel it’s perfectly reasonable to get you to do their work. After awhile it gets really old. The first thing you should do when you encounter this is to look within and make sure that YOU aren’t doing this anywhere to anyone else. Gotta make sure that your virtue is intact before you saddle up the high horse! Once you’ve ascertained that all is right and proper with your own work ethic you then have a bit of a choice to make: rock the boat or sail along. Sadly, though you know the consequences of the latter (you continue to do that slacker’s work), be prepared for the possibility of not being thanked for pointing out reality to bosses and co-workers. It’s entirely possible that you will be the one criticized. Totally fair, right?

In the end there is no best answer to this dilemma. All you can do is use the feelings generated in you by being on the receiving end of this work-shifting to make yourself a better worker, no matter who it is you do that work for. If you do, indeed, reach that point where you just can’t look at yourself in the mirror any more because the injustice is simply too much to accept, it’s OK to call it as you see it. That’s where I am today, and that’s what I’ll be doing this week. To be sure, all of that “pay it forward” I’ve done will get me an audience, though it may not mean I will be able to effect change. Other than workload, that is. As of tomorrow, in this tiny part of my day job, I will be doing the very best job I possibly can, as I always do, for each of my patients each time I see them.

What I won’t be doing is picking up the other half an ass that someone else missed before I full-ass my part of the job.

Sunday Protests

One of my all-time, never fails thrills is a pre-game flyover. I get serious chills and a full coat of goosebumps every single time. Doesn’t matter what event follows, or why I’m watching. Unexpected, surprise fly-overs are an even more special treat, that “oh, you’re kidding…I get to see this even AND I get a fly-over?” It’s like getting dessert first at a Michelin starred restaurant. Never having served in any of the branches of our military I have no special call to feel this way. Yet goosebumps arrive on cue whenever a particularly moving rendition of our National Anthem is played, or if I hear Kate Smith or Ray Charles singing one of our other patriotic anthems.

It should come as no surprise, then, that I am quite completely conflicted about the recent protesting of professional athletes done during these tiny interludes of observing our shared nation. I do get, as should all thinking individuals, that the protests themselves are not directed at either the anthem or the flag, and certainly not toward the men and women who have served in the defense of the historical values that these symbols represent. I truly love these tiny moments of patriotic sentimentality. They are, for me, similar to saying “Grace” before our evening meal: a tiny vestige of a once much larger experience.

Sporting events of all kinds used to be a much bigger presence in my life than they are today. Whether playing or watching, it was weird to not have some sort of game front and center. Once I hung up my various sporting implements, and even when I moved away both literally and figuratively from the teams of my youth, I could usually find some sort of sporting event to have on as background noise on a given day. The fact that I watch fewer games, and almost no football, at a time of unprecedented activism on the field is therefore purely coincidental.

Still, I do think about sports, and major sporting events are still a rallying point (or at least a conversation starter) in most walks of my life. To say that this next statement has me conflicted doesn’t really measure up to the truth: the on the field activism of athletes makes me avoid the discussion of sports entirely. It’s not that I feel the athletes have no place expressing their opinions, nor that I necessarily disagree with the opinions they are expressing. The heartfelt conviction that a particular group has been singled out for mistreatment is a righteous cause to which very public individuals could lend their support. By choosing the venue of a sporting event they have removed my ability to choose whether or when I will engage the topic.

By choosing to do it in the manner that they have chosen prevents me from experiencing a tiny thrill that used to at least feel like it was free.

So what? Isn’t that the point of protest, to make the safe and the secure a little bit uncomfortable? Sure, I get that. I really do. It makes little difference to those protesting to learn that people like me really do set aside time to consider the merits of their grievance; creating discomfort is part of the point. Having twice scrubbed my own workplace of all political activity, making it clear that our team is to avoid the creation of similar discomfort in our clients, I sort of feel like my patronage is being abused I guess. Kind of like that old joke “I went to a fight and a hockey game broke out”, except it’s a political expression upending my expectation. Certain jobs just don’t mesh with political action in the workplace. Who wants to see their local police officers in uniform and protesting anything at all? Can you imagine listening to your surgeon expound on some controversial topic just as you slip under anesthesia?

You could very well read this and say that my bleating is nothing but one more example of “White privilege” (funny, given my name), the smug mutterings of someone safe and secure and as close to immune from the dangers being discussed. I would understand your position. I would disagree, but I would understand, and more than that I would inherently realize that no amount of discussion on our mutual parts would change your mind. All good. I’m uncomfortable, and a little bit unhappy, and maybe that was always the point.

The risk is that my discomfort may make me stop listening. That’s probably not what the protesters are aiming for.

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