Random Thoughts from a Restless Mind

Skyvision centers is a hybrid organization that brings together multiple, disparate skill sets in a medical environment. If you ask any of the staff or doctors who we are and what we do you will hear something along the lines of “we’re a customer service business; our product just happens to be eye care.” The founding principle for Skyvision was the creation of a truly patient-centered experience achieved by borrowing liberally from such customer service stalwarts as Nordstroms and the Canyon Ranch Spa organization. These practices were then layered on top of a flow process that was adopted from the Toyota manufacturing system in order to allow the doctors and staff to provide medical care that exceeded all industry standards for outcomes, safety and efficiency.

It became clear very early in the development of Skyvision that a traditional management structure would be counter-productive. Most small businesses, and essentially all medical businesses, are run using a steep pyramid set-up: doctor at the top, office manager next, and all kinds of middle management on top of the folks doing the real work of caring for patients. Command and control was exactly the wrong strategy for us. We adopted the ultimate flat organizational structure, the POND.

The Pond Theory of Management is best viewed from overhead. Unlike the pyramid of the traditional management flow chart, the Pond Structure is nearly invisible when you look from the side. Staff members “float” on the pond like overlapping lily pads. Tasks are determined initially by job description. Responsibility for seeing that larger projects are accomplished is determined by “mutual affirmation” in the overlapping individuals, and those who affirm a leader take on the responsibility of helping that task leader succeed.

With the appropriate systems in place and so much of what we think of as traditional staff management happening on something that looks like “cruise control”, what is the role of the “Boss” in a flat organization? Rising just above the lily pad-covered surface of the pond are the very few “flowers”, the leaders of the organization. If the “Tribe of Adults” is managing its own intra-staff personal relationships and taking responsibility for outcomes, what does the Boss do?

The common misperception of management in a flat organization (and in groups practicing TQM/CGI) is that there is no longer a leader or “Boss” role at all. This, of course, could not be further from the truth. The primary role of leadership in a flat organization is to make broad policy decisions and set major goals for the organization as a whole. The first of these is to choose to have a flat organizational structure! It is the few leaders who are charged with setting the general course of the business, from choosing the products or services to be offered, to determining the variables that will be measured to keep the organization on track.

Once the organization is up and going it’s important to identify the metrics necessary to maintain a tight focus on the goals that have been chosen. Monitoring these metrics and reacting to them is the responsibility of the “Boss”. From just above the Pond an effective leader is able to offer broad guidance without being involved in the minutiae of the day-to-day machinations of the business by reacting to these metrics. This also frees up the Boss’ time for critical planning, meeting with significant customers, and other larger picture tasks that will help the business grow and prosper.

It seems as if the flat organizational structure is designed to inoculate the Boss from any real staff management, doesn’t it? In reality, the only thing that the Boss might miss out on is any of the fun aspects of day-to-day interaction with employees. For better or for worse while the Boss may not do the hiring it is the Boss, and only the Boss, who must do the firing. At the end of the day, a business that chooses a flat organizational structure is not immune to any of the factors that make an individual employee an unsuitable member of the team. Remember, there are no managers, only a Boss, and no one else available to perform this (hopefully rare) task.

The role of the Boss in a Flat Organization is at once bigger and smaller than in a traditional hierarchical structure. Smaller in that the number of management tasks he is asked to perform is radically reduced. Bigger since the remaining tasks are more global and reach into every aspect of the business. Certain types of individuals are more geared to fulfilling this role (it helps to be a little more laid back and patient), and certain abilities are more helpful (delegation, data analysis, “blue-sky” planning). Indeed, the more of these characteristics one has in a leader, the fewer leaders you need!

The better the Boss, the flatter the organization.

I want Dick Lindsrom’s old job. Hell, DICK LINDSTROM  wants Dick Lindstrom’s old job! I mean, seriously, who WOULDN’T  want Dick Lindstrom’s old job? The  guy was the highest paid consultant for not one, not two, not even three, but something like FIVE ophthalmic manufacturing companies AT THE SAME TIME. Oh yeah…he was also the most famous ophthalmologist on the planet, and just happened to be a fantastic surgeon, too. He’s still got those last two things going on as far as I can tell.

Eventually someone is going to have to take up the mantle. Dick has been 59 years old for 10 or 11 years now, and he’s sure to turn the big 6-O at some point and decide to “retire early”. When he  does choose to do that, or if he is driven out of the consulting business by all of the petty new restrictions on physician relationships with industry (and vice versa) it will be a sad day, indeed. Not only for  the entrie ophthalmic community mind you, but also for the legions of patients-to-be who will NOT benefit from his influence and guidance.

Allow me to explain. Several years ago some folks in government and some consumer goody-twoshoey types all of a sudden “discovered” that doctors were consulting for companies that made medicines and things like implants and the like. They also “discovered” to their collective horror that these same companies not only paid these consulting doctors, but they also sometimes did “gifty” stuff for doctors and their staff members. Terrible stuff like, I dunno, buy lunch for the office or leave a bunch of logo pens or sticky notes around the nursing stations. Even more recently the startling discovery was made that these same pharmaceutical and medical device companies have been supporting post-graduate medical education.

The horror…the horror… (apologies to Conrad).

Dick Lindstrom has been one of the most influential clinical investigators in all of medicine for more than 25 years. By this I mean that he has suggested, launched, led, participated in, and reported on to his colleagues so many studies that led to ground-breaking clinical breakthroughs that his legacy must be considered not only in eyecare but in ALL of medicine. If you had a better medicine, or if you made a better cataract machine, chances are Dick not only had a hand in its development, but he also jumped to your better widget even if your competitors were paying him to consult on theirs. Patient first.

The guy just couldn’t be bought, in my opinion. Not only did he always choose whatever medicine or instrument was best at any given time, but his widespread, almost omnipresent involvement across the industry gave him a platform to push each competing company to outdo its competition. A continuous daisy-chain of technological advancement with Dick Lindstrom as ringleader. And now this small-minded, short-sighted movement would have Dick give up either his consulting or his clinical practice. Did I mention that he’s been among the most talented practicing eye surgeons for 25 years, too?

The food and goodies part of this stuff is inconvenient (I bought pens for the first time in my adult life this year), but really not much more. It does make the jobs of the industry reps more difficult, and frankly just seems to be mean-spirited and  petty. I mean…come on…if Dick Lindstrom hasn’t been swayed by the massive sums he’s been paid by companies for whom he has consulted, how insulting is it that the prevailing opinion in Washington and elsewhere is that MY choices can be bought for a Subway foot-long?! Seriously?

The development of new technologies and new medicines is expensive. So, too, is the post-graduate continuing education of our nation’s physicians. They can’t occur in the vacuum of the laboratory, nor can they occur in the vacuum of the boardroom. The people who do this work need the assistance of doctors who not only take care of patients but who also understand both research and business. To prevent pharmaceutical and medical device companies from supporting programs for continuing education, while at the same time allowing these same companies to market directlty to patients, is simultaneously the most cynical and naive hypocracy imaginable.

To erect arbitrary and artificial barriers that prevent people like Dick Lindstrom from making the kinds of contributions for which he is justly famous (and for which he has been appropriately compensated) is pure folly. Folly which approaches madness.

Here’s the rub…I don’t think any doctors are going to quit what they’re doing because we have to buy our own pens, and I doubt that any of us will hang up our spurs just because we now have to make our own sandwiches for lunch. I AM concerned that participation in major medical meetings will decrease if it becomes more expensive because industry support is legislated away. I AM concerned that doctors of all types will do only the minimum continuing education necessary to mantain their licensure. I AM concerned that these foolish proposals that seek to prohibit clinical educators from also receiving compensation for consulting will dramatically reduce the quality of whatever education we might be receiving.

To do ANYTHING that might prevent Dick Lindstrom from being Dick Lindstrom is pure folly, and I AM concerned about that.

Wait…wait a minute. Could that be it? Could the whole problem simply be Dick? That it’s really just a Dick Lindstrom problem? Is it possible that all of these regulations, the no-pen/no-lunch rules, all of the nonsense about educators and leaders being prohibited from simultaneously having consulting agreements is all just a huge anti-Dick Lindstrom thing?

Well…why didn’t you say so? We can fix this thing right tidy-like. I want to make contributions to my field that will stand the test of time. I want to be known as a clinician/investigator/consultant who always put his patients first before any and all other considerations. I want colleagues to look at a new technology and have the first words out of their mouths be: “What do you think Darrell White thinks about this?” And not for nothing, I wouldn’t mind having those vintage consulting contracts. In a word, I want Dick Lindstrom’s old job. Who wouldn’t?

Because we all need SOMEONE who’s willing and capable of being Dick Lindstrom when he finally turns 60…

They got it half right. The jury that is. The jury in the malpractice case in which I just served as an expert witness got it exactly half right. Kind of like our whole medical malpractice court system if you think about it. A young woman had a bad outcome in one of her eyes following eye surgery, an outcome that has caused her quite a lot of unhappiness, quite a lot of difficulty. The jury was quite correct in recognizing this, and also quite correct in recognizing that this woman was going to need some financial help in order to make this difficult situation even a little bit better. In order to make this happen the jury found the doctor who performed the surgery guilty of medical malpractice.

Only one problem with that, though: no true malpractice actually occurred.

Herein lies the essential, fundamental problem with our medical malpractice tort system as it is presently constituted. Every single malpractice case is a “zero–some game” in which the only way that an individual who has been injured or otherwise suffered a bad outcome from some medical experience can receive financial help is for some doctor (or hospital) to lose a malpractice case. As an aside, the plaintiff’s attorneys, the lawyers who represent the victims of medical misadventure, must win the case in order to be paid. (The full–disclosure necessary here is that the only people who are guaranteed to be paid are the defense attorneys and the expert witnesses on both sides of the case.)

I’ve actually been up at night, literally losing sleep every night since the conclusion of this trial. That’s actually kind of odd, and doesn’t really make any sense at all because I received rave reviews for not only my testimony but also for the strategy suggestions I made over the four years it took to bring this case to its conclusion. Indeed, even the court reporter went out of her way to tell the defense team what a great job I had done. It’s kind of like getting all kinds of pats on the back for making 10 receptions for 200 yards in a football game your team goes on to lose–pretty empty feeling despite the fact that you did your part well.

What then, exactly, is medical malpractice? In the civil court system in the United States medical malpractice requires that two things have occurred. First, a doctor (or hospital) must commit an act of COMMISSION (do something) or an act of OMISSION (fail to do something) that falls below the Standard Of Care. This failure to meet the Standard Of Care must then result in some kind of harm to an individual. To be extremely technical and to–the–letter correct, the failure to meet the Standard Of Care is malpractice, and the resulting harm is malpractice liability. No need to get all tied up in that kind of detail; let’s just call the whole thing medical malpractice.

The Standard Of Care is a difficult concept. In effect, the Standard Of Care is defined as that care or medical decision-making that a preponderance of (most) similar practitioners would provide in similar circumstances at that time. Pretty nebulous, huh? Not a terribly rigid, hard, easy to put your hands around definition, and it’s a moving target on top of that. The Standard Of Care is an ever–evolving thing; new research findings, new technology, and new patterns of care will all combine to create a Standard Of Care that may be different today than it was even last year.

In this particular case there was never any question that it was a medical procedure that caused this patient to have such a bad outcome. There was never really even any question about the technical quality of the work performed by the doctor. No, what it all came down to was a question of whether or not the surgery should have been performed in the first place, and thus came into play that subtle little part of the Standard Of Care, the difficulty in describing to a jury of non-–physicians the difference between the Standard Of Care today and that of some years ago. The lawyers for the patient did a brilliant job of burying the jury with the details of HOW the complication arose, the difficulties that have arisen because of the complications, and the uncomfortable interactions that occurred between doctor and patient in the months following the surgery. They confused the jury about the difference between “could have done” (more than the Standard Of Care) and “should have done” (Standard Of Care). The lawyers were able to bury the fact that the Standard Of Care was followed by the doctor in question because at the time of surgery the PREPONDERANCE of similar physicians in similar circumstances at that time would have done the SAME THING.

The jury got it half right.

There, in a nutshell, is everything that’s wrong with our present medical malpractice tort system. In order for this woman, obviously harmed by this procedure, to receive some award so that she can do certain things that will make her life easier, she and her team had to “beat” a doctor and win in court. And oh yeah, she’ll also have to give 40% of whatever her award might have been to her lawyers. I think that’s a big part of why I’ve been having trouble sleeping. Not the lawyer payment thing, but the fact that a doctor who (in my opinion) practiced within the standard of care must now have a black mark against his name so that a patient can get some money that I frankly think she deserves.

Maybe a better analogy of my role in this “competition” would be something more like this: I was the consulting coach brought in to suggest an additional element to a figure skater’s program. Assuming that everyone in the competition was as conversant with the subtleties of the rules involved I suggested that the skater add an elegant, understated movement that would be obvious to any experts on the panel of judges, the jury as it were. Unfortunately, in our American system of medical malpractice, that’s not the case, and the opponents eschewed subtle elegance in favor of multiple quad jumps. The skater I assisted performed totally within the letter of the rules, but was penalized because the jury, the panel of judges, was not really an expert panel and missed the added element. And so he lost.

I DO wonder though what my reaction would have been if the opposing skater who landed all those quads had been the one who lost. Would I be up at night over that, too?

Among the many things that I have called over the course of my lifetime, none has been more meaningful than “Coach”. I spent time on the sidelines and on the bench for about 10 years coaching junior high school sports.  When my own children moved on to high school sports I retired to the committee rooms and the grandstands where adults who don’t coach play their role in youth sports.

There are three roles that adults can and should play in youth sports. First and foremost, all adults who are involved in youth sports should have as their primary goal the safety of the children playing the games. Secondly, kids who play sports should be guided by the adults around those games, taught by their elders not only about the games but also taught the life lessons that one can glean from playing sports. Finally, we ARE talking about kids here; the last important role that adults have in youth sports is to make them FUN!

Let’s start by talking about safety.

I suppose we should probably define youth, huh? There’s not much to debate the inclusion of grade school or junior high school kids. Sure, reasonable people can disagree about the importance of playing time and, when to start cutting kids and when to start playing to win, but through eighth grade there is simply no question that these kids would be considered in the “youth” category. In some quarters it might be a little more dicey with high school athletics, but when it comes to safety I don’t see how you can separate high school kids from their younger brothers and sisters. Protecting ALL of these kids is job number one for every adult involved in youth sports.

A quick word about college sports: the brightest, clearest dividing line between youth sports and sports as commerce, or job, is clearly the line that separates college and other athletic programs aimed at very young adults, and professional sports. But even here that line might be a little fuzzy. There are reasonable people who would say that Division I athletes on scholarship are de facto professional athletes. I suppose I’d feel a little more comfortable with this if a larger percentage of these young men and women went on to earn a living from their sport after college. Certainly we can agree that divisions II and III in the NCAA would still constitute youth sports, don’t you think? For my mind only the most cynical among us would draw a line between divisions I and II when thinking about the safety of the athletes.

So, how do we ensure the safety of our children when they are playing sports? It starts at the very top with league commissioners and athletic directors. Every organization that sponsors athletic competition with youth participants, be it a league or a school or some other organization needs to be clear from the outset that job number one is keeping children safe. Commissioners need to set clear guidelines, rules that will be enforced that put safety first. No spearing in football. Elbows in on the basketball court. No head shots–not a SINGLE headshot–in hockey or lacrosse.

Each one of these directives needs to be clearly communicated to the athletic directors or program directors responsible for individual schools or teams. These men and women in turn need to hire or appoint coaches who will make it their primary mission to teach the children in their charge how to play the game safely. Not only must the coaches do this on the practice field, but as they roam the sidelines and pace in front of the bench they must bring this to the games as well. How many times have you been in the stands and cringed when a defensive coordinator screamed at his players, exhorting them to “take someone’s head off?” I can’t count the number of times I’ve been sick to my stomach watching a coach dance with glee as a long pole defenseman stands over the attackman he cross-checked in the back of the head. No amount of teaching in practice can withstand this type of “coaching”.

During games coaches need to look first to the well-being of their players; only after assuring that they are okay can winning and losing enter the equation. I’m certainly not proud to admit this, but I remember one clear instance where I probably should have kept a star athlete on the sidelines during a football game. I actually had my very favorite coaching job–I was the assistant to the assistant to the assistant backfield coach, responsible only for catching the kids doing something right and praising them for when they did. But I was the quasi-team doctor as well, and when our star halfback limped off the field with a sprained ankle, I really probably should have overruled the head coach, the offense coordinator, and the young man’s father and kept him on the sidelines, at least a little bit longer. Coaches need to allow themselves to be trumped by trainers and doctors.

The ultimate arbiters of safety, however, are the officials on the field. Whether it’s grade school, junior high school, high school, or even college sports, the officials who enforce the rules must make the safety of the participants their primary concern. Oh, I know, I know, the officials are supposed to be invisible, doing everything they can possibly do not to impose themselves on the game, not to affect the outcome of the game. The players should win or lose; the officials should not take a role. Blah, blah, balh. All well and good, until the retaliation for the retaliation for the initial hard tackle from behind results in a three ligament knee tear for that girl who was just about to get that shot off in soccer. All well and good, until they’re wheeling the center off on a stretcher, unconscious from the elbow he took to the jaw as he skated through mid-ice. All well and good, because the officials lost control of the game, allowing dangerous plays earlier for fear that they might “affect the outcome.”

Bullshit.

As far as I’m concerned the greatest responsibility for protecting our children on the various courts and fields of play lies with the officials. The referees and umpires who are right there in the middle of the game MUST protect the children playing the games. Dangerous play just cannot be allowed. Officials have lots of latitude, and every sport has rules, penalties for dangerous behavior. Blow the whistle! Throw the flag! Pull out that red card! Set the tone early and let it be known that dangerous play will not be tolerated.

My youngest child, in ways too many to count an athletic clone of his father, finished his high school lacrosse career sitting on a bucket on the sidelines, sobbing as he vomited. He was vomiting because he had just suffered a concussion, his third, this one the result of a vicious crosscheck to the back of his head. The play occurred just feet from the sidelines, yards from the referee looking directly at the play. Unbelievably, he hesitated. He HESITATED! He actually gave thought to not even pulling his flag. Eventually, out came the flag and the verdict was rendered: one minute for unnecessary roughness. Almost the smallest infraction in the game of lacrosse. One minute for a blatant headshot, right in front of the referee, right in front of Randy’s coach.

The trainer on duty, a lovely young woman, very empathetic… very concerned, hovered over him. Was he crying because his head hurt so much, she asked? No, he sobbed, he was crying because he knew he had a concussion, and he knew that that his playing role in youth sports was now over, his days as a lacrosse player now officially done because it was no longer safe for him to play. How many more, I asked.  How many more children would be hurt before that referee said enough? How many more, I asked him out loud in a silent stadium, my voice the only sound, clearly heard by every ear in the stadium. Everyone turned to look at the father escorting his injured child off the field. Everyone, that is, save one, the coward who couldn’t look at the child he had just failed to protect.

Officials, indeed any adult, who will not protect the children who are playing have NO role in youth sports.

Little did I know how hard it was going to be to help my Bellevue target, Jean. He didn’t know he was being mugged when the gangbanger asked him for his jacket. How could he? He only spoke French. He couldn’t tell the police officer who came to the scene that it was HE who had been assaulted. How could he? He only spoke French! At Riker’s Island he had no idea that the gangbanger sharing his cell was demanding his fancy, leather sneakers. How could he? He, well, you know…

So what could I do? How could I help? What could I possibly do to help make the end of this very bad day a little bit better? Well, first off, I clearly needed to make sure that Jean did not go back to Riker’s Island any sooner than was absolutely necessary. The prison guards, who had now become quite a bit more interested in Jean knowing  his story, agreed that nothing but very bad things were likely to happen to this young, skinny, soft boy from France if he ended back at Riker’s. We decided to keep him at Bellevue as long as we could.

What else? Well, the theme that runs through Jean’s very bad first day in America was his total inability to tell HIS side of whatever story he was in because he spoke only French. I decided that what he really needed was to be able to tell his story, and to do so we needed someone to translate for him once he left Bellevue. No problem, right? I mean, we were in New York City, the biggest, most cosmopolitan city in all of America. Should be a snap.

It turns out that there’s actually quite a bit of France in New York. I called the French Consulate hoping to have someone from France take charge of my French target. It was pretty late at night, around midnight if I recall, and the consulate was closed. “Please leave a message…” No problem. Bellevue is on 1st Ave. at 27th St., and United Nations is only a couple dozen blocks north on the same Avenue. I rang up the French delegation to the UN. They, too were closed. “Please leave a message…”

I imagined out loud what it must be like to call France itself. You know, just ring up the country and talk with whoever answers the phone. This was back in the days of answering machines, not those ubiquitous “for thus and such press one” messages. At midnight midweek I told the guards it would certainly go something like this: “Thank you for calling France. Our business hours are Monday through Friday, nine o’clock in the morning until five o’clock in the afternoon. If you would like to negotiate a trade agreement, sign a peace treaty, or seek political asylum, please call back during normal business hours.”

Okay then, plan B. Lots of other folks speak Parisian French in New York City. I thought the next logical place to look for Francophones would be at a French restaurant. Good thinking, right? At this time in the mid-1980s the most famous French restaurant in the United States was Le Cirque, so I gave them a call. A  little after midnight the restaurant was still open and still busy. I asked the woman who answered the phone if anyone there spoke French. Yes, indeed, there were lots of folks who spoke French. In fact, there were more than a dozen French citizens who worked at Le Cirque! Great, I said, I have this young man from France who has been assaulted and he needs someone to help him tell his story to the police and to the judge. (I was getting visibly psyched; the prison guards were smiling). Oh no, Monsieur, we are MUCH too busy to do any such thing. We could not POSSIBLY have anyone available to provide that type of service. Have a pleasant evening Monsieur.

Wow. Made me think of that Robin Williams routine where he describes a conversation with a Frenchman. “(Puffs on a Galoise) We are French (sneers)… we don’t care.”

Now I’m stuck. It’s almost 1 o’clock in the morning and I can’t think of any other way to get someone to translate for Jean. Think! Think… think… think. What would I do if it was ME? Who would I call if I was in a foreign country and needed a translator, needed help with the language and the authorities? And then it hit me: American Express Global Assist! Remember those commercials? Any help you could ever need any time anywhere, as long as you were a cardholder, American Express would be there. I reached into my pocket, pulled out my wallet, and took out my own American Express card (which I had never actually used). I dialed the number on the back of the card and the very helpful operator connected me to American Express Global Assist, and the equally helpful operator there put me on with the head of their French translation department, right there and then. I told her the sad story of Jean the target and then handed him the phone.

BINGO!

The only thing left to do now was to keep Jean at Bellevue through the night so that he wouldn’t have to go back to Rikers; my friendly pair of prison guards pointed out that if we did, indeed, do this, Jean would miss the bus taking him to court, and would end up spending an extra day at Rikers. The guards were now fully into the project, however, and they agreed to ride the bus with Jean back to Rikers, and to sit with him in a duty room so that he did not have to go back into the prison population. Not only that, they personally escorted him into court (off the clock, on their own time) and delivered him to a French speaking attorney whose assistance had been arranged  by American Express Global Assist. Upon hearing the story the judge threw out all charges, and the city of New York and American Express put Jean on a plane home to France that very afternoon.

There’s a very nice epilogue to this story as well. Many months later I received a letter in that same consultation room at Bellevue Hospital. There was a brief type written note from American Express. Dear Dr. White, we apologize for the delay in delivering this note. In the excitement of helping Jean we failed to obtain any of your contact information. Please accept our apologies. Please let us know if we can ever be of any assistance to you, or your patients, in the future. Sincerely. The note was wrapped around a postcard, the message written in French.

Thank you for saving my son’s life.

There are only two kinds of people in New York City, targets and people who hit targets. At Bellevue Hospital we took care of the targets.

There are only two kinds of people in New York City: targets, and people who hit targets. At Bellevue Hospital we took care of the targets.

I’m not sure if they still use these terms, but I take full credit for the original use of “target” to describe the victims of violence who came to the Bellevue Hospital emergency room. As an ophthalmology resident I was on call every fifth night, and because I lived outside of the city I actually have to spend each on-call night in the hospital. The bad news, of course, is that I didn’t get to sleep in my own bed. The good news was that I developed a more friendly relationship with the ER attendings, fellows, and residents, as well as the nursing and clerical staff. I also developed a very easy relationship with the prison guards from Riker’s Island. The term was coined, and the game was set when I sauntered into the ER in the wee hours of some morning and asked out loud to no one in particular: “okay, where’s the target?!”

Whether it was primary care or specialty care clinics like our ophthalmology division, Bellevue Hospital was where people who fell through the holes in the safety net went for their medical care. Pretty much everyone received care that they couldn’t receive anywhere else, so it was easy to feel good about the contribution that you were making, even as a resident. It would be difficult to pick out the person I helped the most over my three years in New York except for young Jean, the target from France who I saved one night while covering the ER.

It was around midnight and I was seeing an older woman who was complaining of flashes and floaters. A Latina, my patient spoke not a word of English, so I was delighted to make the acquaintance of her daughter, a lovely woman roughly my age who accompanied her mom and acted as translator. I excused myself when the phone rang. “We gotta target from Rikers for ya Darrell. Not a word of English.” Send ’em right up was my response, pretty confident that my new friend the patient’s daughter would be able to translate for what I expected to be a Riker’s Island prisoner who spoke nothing but Spanish. Imagine my surprise when a rather thin, soft, artsy looking boy of 20 or so from France shuffled into our waiting room, his right eye black and blue and swollen tight.

The target part was pretty much standard fare, punched in the eye, but everything else was totally out of place. The visual was just wrong on more levels than I could describe. My new best friend said she knew little bit of French so I sent her out to chat with Jean while I examined her mother’s retina. Our French lad was clearly not much of a threat; the unwritten communication between the doctors and the writers Island guards told us as much, the guards chatting between themselves at the other end of the room. These two particular guards, a man and a woman who were not part of the normal Bellevue Hospital crew, would actually become a pretty important part of saving this target.

I finished up with my older woman, reassuring both her and her daughter that the flashes and floaters were nothing to be alarmed by, and that they would eventually go away. I asked her daughter what she had discovered, and with a sad, slow shake of the head she started to tell the story.

Jean, our target, had been in the United States for less than 24 hours. He was to visit friends, and had arrived a day earlier than a bilingual friend, another young Frenchman who would be the tour guide and connector for a group of kids in New York City. Rather naïve and not the least bit street–savvy, Jean decided that he would go on a walking tour of the city around Penn Station. This was back in the mid-1980s, and Jean came from a very fashion conscious family. It was cold in the city and he was wearing a fancy, team logo jacket, the kind the gangbangers in the city were wearing at the time. Sure enough, he happened upon a group of gangbangers very early in his travels.

The leader of this street corner group told Jean that he admired his jacket. He admired it so much, in fact, that he thought Jean should give him the jacket. Jean, of course, had absolutely no idea what the gangbanger was saying;  he only spoke French. The gangbanger pulled a knife and threatened Jean. Amazingly, Jeann took away the knife and stabbed the gang banger! When the police arrived and asked what had happened Jeann stood mute while the gangbanger screamed that John had tried to kill him. Unable to tell his side of the story–the street cops didn’t speak French– he was arrested for attempted murder and sent to Riker’s Island.

Now jacketless but still otherwise fully clothed, our target found himself in a holding cell at Rikers. It turns out that he was also rather fashionably shod, wearing brand-new leather sneakers that were all the rage at the time. You know, the kind of sneakers the gangbangers wore. Not too surprisingly his cell mates, at least some of them, were gangbangers. One of them approached Jean and proclaimed his admiration for these brand-new sneakers. Jean, of course, had no idea what he was talking about, seeing as he still didn’t speak a word of English. When it became clear that the gang banger was demanding his shoes Jean refused. The gangbanger cold-cocked him in the right eye and another target was off to the Bellevue Hospital emergency room.

With the exception of this fascinating story taking care of Jean was otherwise standard target fare. After prying open his swollen eyelids I was able to determine that his eye was intact and that no damage to his vision would ensue. But now what? What do I do with this thin, soft, French speaking 21-year-old all alone in New York City. I decided that I would help this one. If I ever made a difference, I would make a difference for this one.  This target, the recipient of violence he neither deserved nor sought, this was the one target, that one patient I would help outside of the professional help I gave everyone else.

How? What could I do? What did this young man need? There it was! What this young man needed was help telling his story. I was in the middle of the biggest hospital in the biggest city in America. Surely I could do this. Little did I know…

I had an apple for lunch today. A MacIntosh Apple. Remember them? Remember when “apple” was the SECOND word in a phrase, when it was a “something” apple, not an Apple “something”? All alone at home, save for the pet menagerie, I had a MacIntosh apple for lunch and I was transported back in time, born aloft on the wings of tiny memories.

We always talk about the big things when we talk about memories, don’t we? We just assume that the bigger the event the bigger the memory, and the bigger the memory the more it must resonate. Beth and I just celebrated our 25th wedding anniversary, and this of course prompted us to reminisce about our wedding day. We had an absolutely spectacular wedding, one that our friends and family still talk about, still compare with other weddings. It’s funny, though, when I look back on that magnificent day all of the really big things that you’d think I would remember are really kind of running “fast forward” and filmed through a slightly out of focus lens. I remember them, I really do, the bigness is just kind of… big! What I DO remember though is every tiny detail about my first date with Beth. I burned the scallops! And yet many’s the night when I sit down to dine with my “netty empster” partner, just the two of us, and a tiny memory of that first date alights.

Tiny memories are different like that. Take that Apple I had for lunch. A McIntosh apple, the kind of apple that pretty much everyone I know thinks of when they think of an apple from childhood. I just started buying them again; I have no idea why. I don’t think I’ve bought any real Macintosh apples for some 15 years or so. Do you remember the apples of your childhood? I sure do. My mom wasn’t really a great cook, if you define greatness by complexity or the use of fresh ingredients plucked from some farm stand or specialty shop somewhere. My Mom was an expert at foods that created tiny memories, though.

We only ever had MacIntosh apples in the house. All by themselves they were something better than good. Every now and then there would be something a little bit special. Maybe Mom put the salt shaker out and we remembered to shake a little bit of Morton’s goodness on our Apple. Perhaps she whipped up a little bit of cinnamon sugar to sprinkle on the apples. This was usually REALLY special because cinnamon sugar apples were almost always sliced in a bowl! When she made apple crisp… even without ice cream apple crisp was an event.

I find that tiny memories can be triggered by equally tiny things, and those tiny memories always seemed to transport me back in time to to a warm and happy place. It’s not always a trip to childhood, although the first stop on the trip may indeed a be a place I knew as a child. It’s not that these places or that these memories evoke a better time or anything like that. I’m truly convinced that the best day of my life so far was today. No, it’s something else, something a little less and something a little more. The best of the tiny memories seem to be crystal clear in their details, kinda viewed in HD.  Tiny portraits or little scenes whose details are surrounded and framed by happiness. Perhaps even by love.

Do you have these? These tiny memories that flit and fly across your consciousness like so many tiny sprites, floating aloft on wings so delicate they can’t be seen? No matter how hard your life might have been, I’ve yet to meet anyone who doesn’t have at least of few of these tiny memories. I can’t land at O’Hare or Midway without at least a little smile. Going to Chicago! That’s what I chanted when I traveled through the kitchen in the turkey basting pot. Who knows why Chicago. Every successful landing in Chicago comes with one of my tiny memories.

I wonder, as I get older, what will become of my tiny memories. Will they be the ones that will remain? Will they be the ones I’ll hang onto, call upon, resurrect as I plow on? I sure hope so. I sure hope that the first barefoot step on a beach, new or old, will still make me hear the screen door slam at the beach house in Manasquan. I hope I have to climb over someone on my way to the “way back” of some great big SUV, so that I can remember the epic climb over my brother and sisters to the back of that Chevy wagon my Mom drove. I hope I’m standing on the tee at some golf course watching some guy wiggle and waggle and generally make a fool of himself as he gyrates through his pre–shot routine, and I hope a tiny memory of my Dad barking at me or my brother floats in for a landing. “Quit farting around!”

Dad said FART!

Yup, I was home today for lunch, just me, the dogs, and Thug, the world’s biggest rabbit. I had a MacIntosh apple for lunch. Not sure which was sweeter, that wonderful, nearly perfect apple, or that tiny memory of a time long ago, the details in HD, so vivid. The details–the memories–surrounded by love.

I smiled. Someone had left the salt out.

Former Budget Director Peter Orszag wrote an Op-Ed piece in the New York Times titled “Health Care’s Lost Weekend” in which he offers several reasons why healthcare in general, and doctors in particular, should be open for business 7 days a week. “Doctors, like most people, don’t love to work on the weekends…” is his first shot across the bow. He cites a study in the New England Journal of Medicine (the only medical journal to which God subscribes) which is actually a pretty darned good study, one that shows an increase in cardiac mortality of 0.9% (decimal point is correct) for people admitted to the hospital with a heart attack on the weekend in comparison with those admitted during the week.

I’m willing to buy this conjecture, even willing to say that Mr. Orszag’s conclusion, that medical services should be available 7 days a week with expanded hours of business to boot, is a desirable and necessary goal for American Healthcare. The difference between the two of us is that I will openly state what it will take to make such a thing happen, whereas Mr. Orszag has taken the cowardly politician’s route but simply saying “this isn’t right…this isn’t fair…this must be changed,” without offering anything about how.

Someone, or some someones, will pay something somewhere to make this happen. There, I said it.

There are actually a couple of really good examples of this phenomenon right now in my community,  Cleveland. The vaunted Cleveland Clinic is downgrading the trauma service at one of its hospitals, ostensibly because the city of Cleveland is “oversupplied” with trauma centers,  and because it is becoming increasingly difficult to find trauma surgeons to staff these emergency rooms. All true, but in reality it’s because the Cleveland Clinic has decided that the operating loss associated with keeping this trauma center open is more charity than the institution wishes to give to the city, especially in light of a palpable lack of civic gratitude. Similarly, all of the emergency rooms in town are finding it difficult to provide specialty coverage as specialists are declining to make themselves available. Insufficient compensation for the inconvenience associated with that availability, as well as the significant exposure to a litigious patient population are the culprits.

The funny thing is, once upon a time we actually had the equivalent of a 24/7 medical service economy. Back in the day, when Mr. Orszag and I were children, physicians were held in high esteem because they put their patients and their medical practice first, in front of every other aspect of their lives, 24/7.  They were incentivized to do this in two very specific ways: they were paid, and paid very well to perform their services, and they were afforded out–sized doses of respect, occupying a place of honor in every community. In return for this combination of handsome concrete and social compensation medical care was provided when medical care was needed, 7 days a week.

My first real job was caddying for wealthy golfers at the local country club. Not surprisingly, a significant percentage of the country club members were local physicians. Mind you, this was back in the day when only doctors carried beepers. I can’t begin to count the number of times I had a fantastic loop toting the bag for a doctor in the middle of a career round only to see some easy shot go careening into the woods when his beeper went off at the top of his backswing. I vividly remember seeing the assistant pro speeding down the fairway coming directly toward us in a golf cart to retrieve a doctor who was needed at the hospital. Saturday afternoon, Sunday morning, Wednesday evening… no matter.

What was the cost? Well, certainly the doctors didn’t do this for free. They asked for, and received, handsome compensation for this 24/7 availability. Society readily made this investment, in part because the best technology available was actually the technology available only between the ears of the physician. This is somewhat different today given all of our fantastic technological innovations and advancements, but not so different, really, because the stuff between the doctors ears is still what drives all that new technology.

There were hidden costs back then, too. Hidden costs are the ones that are actually the most expensive when we really drill down to see what the ramifications would be if Mr. Orszag had his way. Countless physician families were roadkill, collateral damage to the single-minded emphasis doctors placed on practicing medicine. Troubled children, troubled marriages, broken marriages, broken people all littered the landscape of the medical community, silent testimony to the cost of 24/7 availability. So, too, the nurses and technicians and orderlies who worked the swing shift and the graveyard shift. The social and physical pathologies of shift work are now quite well known. How does Mr. Orszag intend to handle THIS cost? Surely he’s not willing to ignore the well–documented evidence of the social and psychological harm that befalls workers and their families when they are forced to to work weekends and nights?

Behavioral economics is based on the simple concept that people will act in a manner consistent with rational self–interest. Most of the time this is EXACTLY how people behave. Over the course of the last several decades, as physician incomes have declined and as the doctors’ societal esteem has plummeted, physicians have been notably less willing to put their families in jeopardy by putting their profession first and foremost. By the same token, the vast majority of non-–physician workers in healthcare are loath to do the same, hence the difficulty filling nighttime and weekend shifts in hospitals, clinics, and the like. No one likes to work on the weekend when their family is home, when their friends are not working.

So, a  24 seven medical service economy? Sure. Who wouldn’t want THAT? Even without the data from that NEJM study it would be very convenient to have that colonoscopy I’ve been putting off on a Saturday instead of a workday, maybe even a Sunday with Saturday for the prep (prep…yuck). Heck, I found it pretty inconvenient that I couldn’t get a sandwich at one o’clock in the morning at a big convention hotel in Chicago last weekend. I was even willing to pay a premium, not only for my sandwich, but also to the person who made that sandwich appear. I would have given effusive thanks as well.

Therein lies the beginning of the solution. If you wish to have high technology medical care available seven days a week you must provide a significant incentive to those people who provide the care. Simple. I will offer as well that it probably doesn’t make a whole lot of sense to bash those very same people you are trying to convince to put aside some part of their self-interest (or the interest of their families) to work weekends; who is going to do something nice for someone when their reward is to have that same someone turn around and show nothing but disdain for not only the service provided, but also for the provider of the service?

So Mr. Herzog if you want me and my colleagues to be available on Sunday afternoon to take care of people exactly the same way we might on a Tuesday morning you  have to be willing to do two things which thus far you and others of your ilk have demonstrated no inclination to do: you must pay us what those services are worth, and you must be thankful that we are willing to provide them. It’s not enough to declare the “what”, you also have to declare the “how”. Isn’t that what REAL economist do, Mr. Orszag?

Heinlein was right. It doesn’t matter what time you serve it, There Ain’t No Such Thing As A Free Lunch.

We’ve had lots of new people around Skyvision Centers recently. Two sets of consultants have come through at our invitation, our hope being that they would help us improve our patient education process. While they certainly had lots of really good ideas, systems and protocols that have been tested and found to be quite helpful in typical eye care practices, we found that they didn’t really translate terribly well “off-the-shelf” at Skyvision.

Why? It turns out that we have a very different culture at Skyvision, and that the management structure we use to foster that culture is so foreign to traditional medical care that we had to eat up some of our consulting time teaching the consultants who we are and how we work. Oddly enough, the question that set this process off was one that probably seems to be ridiculously basic to these two groups of consultants, but one that turned out to be nearly impossible for us to answer. “Who is your office manager?” Um… well… Gee., we don’t really HAVE an office manager. “Well, who should we talk to , then?” The answer to this question turned out to be just as difficult for them to understand: “everybody.”

I should start, I guess, with a word about our culture. I described the Skyvision culture to a new employee yesterday as a group of adults behaving like adults and treating each other like… adults. I told her to think of us as a Tribe of Adults! This is all I really wanted from my staff five years ago when I founded Skyvision. My most enjoyable part of management has been “blue-sky thinking”, setting priorities, charting a course, and allowing my people to work to the absolute limits of their capacity and ability in order to bring us home. Employee relationship monitoring and management is beyond boring and only barely tolerable. Hence, a Tribe of Adults.

Unfortunately, the typical management structure in small businesses in general and medical businesses in particular is not really conducive to fostering this kind of culture. Pretty much every other medical practice that I’ve ever been involved with, either as a physician, a patient, or a consultant has been set up as a steep management pyramid. Very strict top–down management in a command and control environment. Lots and lots of rules and regulations with an equally dense layer of middle management whose prime objective appears to be applying discipline to everyone who falls below it on the pyramid. Individual initiative is totally suppressed, and even the task of managing your relationship with a coworker is given over to a manager. Yuck.

But a Tribe of Adults clearly needs to be managed in a totally different way. A group of people who are willing to take responsibility, not only for the outcomes of their work product but also for their own personal behavior and relationships within the organization is best managed with as flat a management structure as possible. The ultimate flat organizational chart would be one in which literally no management existed. This is impossible, of course, because at some point someone has to chart the course, lay out priorities, and designate goals. After that  a Tribe of Adults shouldn’t need much management!

Enter the “Pond Theory of Management.”  Unlike the top–down management of a pyramid, if you look at an organizational chart set up according to Pond Theory from the side, what you will see he is a very thin layer on the surface of the pond and a few tiny flowers sticking up a bit above the surface. The magic, though, is looking at this organizational chart from above. If you look down on the pond what you see are a number of lily pads which flow on the surface of the pond, one for each employee in the business. The flowers above the lily pads represent a small number of individuals responsible for big picture issues and those very few instances where the Tribe of Adults cannot work through an issue on its own.

How does this Pond Theory of Management really work? The key, critical difference between a business run based on Pond Theory and one that is run on traditional command-and-control principles is in the allocation of tasks. In command-and-control theory some manager assigns a worker to a task, and might even assign that worker responsibility to direct other fellow workers in the accomplishment of that task. In the Pond there are areas where lily pads overlap, tasks that could be performed and responsibilities that can be shared among two or several workers with similar skills or job descriptions. Where these lily pads overlap the responsibility and the accountability for completing this task or achieving this goal is determined by mutual affirmation of all the workers whose lily pads overlap.

The individual who now has accountability and responsibility for this task retains them as long as he or she is able to deliver the desired outcome; all of the other workers whose lily pads overlap accept this individual as their leader for this particular task. In a similar and related manner, those workers who have affirmed this individual give up any “right” to criticize how this outcome is achieved. There are certain rules and regulations that might apply, of course. In our medical world HIPPA and other government regulations are unavoidable. National, state, and local laws apply, too! Beyond this what we achieve in “The Pond” is outcomes with minimal managerial oversight,  interference, or necessity.

After two full days with us I’m still not sure the consultants really got what I was talking about, and if they did I’m pretty sure they didn’t really believe me. How about my new hire? She came from an extremely rigid practice with rules and regulations to account for pretty much every minute of her day, and a manager who monitored each one of those minutes to make sure that there was 100% compliance with all of those rules and regs. What was her reaction when I explained to her the culture of a Tribe of Adults working in an extremely flat organization, working on the Pond?

“Wow! We’re all BIG girls here!”

Uncle. I give up. Full surrender. Total capitulation. I cannot beat the takers.

It’s funny because my first three drafts of this missive started out “stop the madness”, but I can’t. It won’t stop. The “Do-Gooders” and “We Shoulders” who make the decisions because “they think” or “we feel” have beaten me. Beaten everyone like me. The white flag is up. Turns out the windmill is really a dragon, and contrary to what it says in all the fairy tales the dragon always wins.

You see I, Dr. Quixote as it turns out, thought that being right made a difference. I thought that data, precedent, FACTS would rule the day. Silly me. Silly, sorry sad little me. I thought it was about patients, patient outcomes, statistics, but all along it’s been about the system and protecting the system, protecting it from the very possibility of theoretic risk, protecting it from…patients.

Here I was looking at yet another cost being added to the experience of my surgical patients and asking why a change was being made. Why were we opening a new bottle of $13.00 eye drops for each laser patient, when each bottle held enough medicine for 100 patients? Why were we using a new vial of antibiotic to be injected into the infusion bottle of each case, when each vial held enough medicine for 5 cases? Why, indeed, when there had never…not once…been a reported case of acquired infection, ever, from using one bottle or one vial. Ever. When eye doctors in their offices use and have used, bottles of eyedrops until they can’t squeeze our a single extra molecule. Why?

I blanched at the waste. Plastic baggies of bottles full of drops carted to the trash. Vials of man’s best antibiotics less the microliters used for one surgery crowding the sharps buckets. It was unconscionable, an insult to Puritan and non-adherent alike. The amount of waste nothing short of vulgar.Did no one else see this? I mean, here we are in the supposed throes of a healthcare crisis born of excess and waste, and yet I, Dr. Quixote, flailed alone?

Data…surely data would prevail. Look at the cost, I cried. Never mind the insult to the Puritan ethic, simply look at the cost! You can’t bill the patient, though Lord knows you’ve “mistakenly” done so innumerable times. It’s a cost. It decreases “revenue in excess of expenses” (you’re a non-profit…I get it…we can’t call it profit). I even understand why you’ve spurned my entreaties about Pre-Admission Testing even though there was an article in the New England Journal of Medicine that said PAT is unnecessary. The NEJM is the only medical journal that God reads, and even SHE knew I wouldn’t win THAT one because you can get PAID for PAT. I get that one.

You’ve beaten me. Today I see it. You sent in the REAL decision maker, one of the people who make the decisions in this new age of medicine. I was still under the illusion that maybe I, a doctor, was a decision maker. That I, a doctor who looked at and liked real data, had a vote, some skin in the game. No, today you sent in The One From Pharmacy. I have seen the One With Power and now I know that I am beaten.

The One From Pharmacy has all the words. He has all the weapons. “It’s only fair that each patient receive the same freshly opened bottle/vial.” “What if we have an infection and we re-used a bottle? How could we ever face that patient?” “Here’s an article by a pharmacist that says you could possible have contamination of an open bottle.” “Should we ignore this article that discusses the theoretic possibility of infection?” I also know from prior conversations with The Hospital Administrator that The One From Pharmacy cannot abide not knowing the destination of each drop, cannot abide not having the option of charging each individual patient (if only he could) for each medicine, and that a new bottle must be opened and assigned to each patient for this purpose. This I know.

Oh, I tried. I really did. I tried to point out that each of the articles the The One From Pharmacy shared with me were nothing more than opinion pieces, essays that were little more than editorials sharing one author’s thoughts. His or her feelings. “I think,” therefore it must be. But…but…but…there’s no DATA. No evidence. Nothing to refute decades of experience in the operating room. No results or reviews showing that the status quo is dangerous, only some somebody who managed to get what “they think” into some non-peer reviewed journal.

“Doctor, are you saying that we should just IGNORE these articles? You would have us simply continue with business as usual? The governing bodies ALL say this COULD happen. Are you saying that we should ignore what they THINK?” I confess, I had no answer. I was paralyzed, caught between my horror at the thought that decades of success, as well as common sense so obvious it made stomach hurt, were to be tossed aside because of some someone’s feelings, and my fascination at the sheer revulsion registering on the face of The One From Pharmacy. Funny, he wasn’t anything at all like what I thought the dragon would look like.

I stood there for a moment, bleeding, as the realization slowly came to me that I was defeated. Vanquished. It’s a shame, really, because doctors of my generation are the last, best hope for all of us. We bridge the divide between the ancients who lived through the Golden Age of Medicine–the Giants who cured polio, discovered antibiotics, replaced joints–and the moderns, the nextgen who will live through the silicon age of medicine–Dwarfs who will serve a system, cure the economics, replace care.

I felt small, diminished, inconsequential, a failure, a disappointment. It was hard, frankly, to haul my carcass to the operating room to begin my work day. Yet that’s exactly what I did. I mounted my steed and raised my lance; slowly, ever so slowly, we rode alone to the operating theater.

A white flag, attached to my lance, waving in the breeze.