Doing Well By Doing Good

Like many home healthcare providers, throughout most of my tenure as a visiting nurse my compensation was fee-for-service. This meant that as business went up and down, so did my paychecks, and with the rocking and rolling that has characterized the industry, "down" often was more common than "up." As a result, most clinicians have had "side jobs," often with other home healthcare providers that needed flexible, part-time help. That way if their primary employers hit a rough patch or there was a downturn for any reason, they had another source of income to assure that mortgages would be paid, families fed, and other obligations met.

There came a point, though, where I accepted a salaried position with a large company, which also offered ample opportunity for paid overtime. The down side, as I later discovered, was extensive travel and excessive "on call" nights that put both my patients and me in jeopardy, because a chronically sleep-deprived nurse working long day after long day and then going out again at night is an accident or a serious mistake waiting to happen. While the money was good, it became clear that I needed to consider other options. What was less clear was what those might be.

At the very least, though, for almost a year I had not needed my side job, a part-time gig with a small, generally unremarkable home healthcare agency. Bottom line: I simply hadn't found time to stop by to resign.

One Friday afternoon my phone rang. It was the administrative assistant at that little agency, urgently seeking a nurse to manage some patients in my service area. At that point I happened to have the time but not the need for more work, with my primary employer offering all the overtime I wanted and at a higher pay rate. "Is the boss in?" I asked. "I'd like to speak with him."

"Sure," she said, and transferred me.

When he picked up the phone and after the usual pleasantries I got down to business: "'Barbara' needs help covering patients. My question is, why should I take any patients for you when I simply can take more with my primary employer, not have to deal with different paperwork or drop-off points, and make three dollars more per visit?"

His immediate response? "If they pay you three I'll pay you five!"

Now, five dollars above my current visit rate was a good deal. "That works," I said. "Transfer me back to Barbara, please, and I'll take some patients."

He did, and I did.

But it all had happened so quickly that I wanted to be sure he remembered and meant what he said. So a few days later while delivering some paperwork I popped into his office, and before I could raise the topic he produced the paperwork for my raise and handed me my copy. Point for him.

It only got better.

As we talked he said, "I want you to be a part of this company. Full-time, part-time, in the office, out in the field - you know I've offered you the Director position many times . . . " Indeed he had, and I acknowledged this with appreciation. It's not the kind of work I want to do any more, but that the opportunity was there certainly was clear. He continued, "In some capacity, I want you here!"

That was gratifying to hear, and I thanked him sincerely and left.

I like to say that it took me two weeks to realize that this was a human male saying, "Tell me what you want so I can give it to you," not a message I was accustomed to hearing!

"I wonder if he means it," I eventually thought. So I sat down, considered what I most would like to do in my work, thought about ways this might add value to that little company, and wrote a proposal.

Back to the boss I went, opening with, "What this company needs is a Home Healthcare Specialist - "

"Absolutely!" he exclaimed, cutting me off . . . and surprising me no end, because there's no such thing! I had made it up, taking my abilities and interests and crafting them into a job I'd like to do. Educated as a Clinical Specialist, I have the qualifications but cannot use that title because I graduated before Advanced Practive Nursing licenses existed and never bothered to grandfather myself. So I had made up a comparable title and tailored it to work I'd like to do in home healthcare.

Without even knowing exactly what it was, the boss signed on, and gave me a modest but not insignificant raise over what my primary employer had been paying me.

That little company was so small and, in my view, so precarious, that I actually kept my other job for awhile, cutting down to "as needed, registry" status, but still employed and so able to go back quickly should that be necessary. Indeed, I wondered if my paychecks for my new position would bounce. (They didn't.)

So there I was, with this new, undefined job and a title that was my own fiction and, as such, meaningless to everyone else. And the question became, How shall I earn my salary?

I considered what patients, doctors, and hospital discharge planners had told me over the years; what I had observed; who had stopped me on the street with what sorts of questions; what seemed to confound the efforts of others trying to do their jobs and what would make things better for them; what problems kept popping up over and over; what assumptions and rituals had been carried forward blindly whether or not they were effective, or as effective as they might be . . . and as ideas emerged I began to formulate a plan. A fanatic about people who are licensed to practice a profession actually doing so, whether or not they have non-clinical responsibilities as well, I continued to see patients while beginning to set other things in motion. That practice led to even more ideas.

People noticed. One of the most talented Physical Therapists I've ever known had signed on with this little company on a part-time basis, it being his "side job" as it once had been mine. Knowing his vision, his insatiable curiosity, his openness to new possibilities, and his phenomenal clinical acumen, I created a "Rehabilitation Specialist" position that was as undefined as my own role, and he came on board full time, too. On a very small scale we began putting specialty service lines and programs in place, and people began noticing even more. Stellar clinicians we had known in our various previous positions began coming on board, and when I realized that many had put their eggs in this basket because of their confidence in me I scrambled particularly hard to create a positive work environment for them, with challenging patients, solid support and respect, and as few dissatisfiers as possible. In this information age there is little need to pull practicing clinicians away from their patients to drive for miles and sit in meetings. "On call" can be managed safely and with minimal imposition. Efforts above and beyond the usual can be recognized and rewarded, and the need for sleep, family time, and simple down time honored and defended. We did all of this, and more.

After decades of working alongside them, my team and I knew some things about what physicians need and what presents problems for them. The same is true for hospital and extended care providers. So we solved some of those problems. We introduced people to clinicians with whom they had worked in the past and assured them that their commitment to being and doing the best had only increased, and had only more support. We had photographs of demonstrated results, and evidence from the literature explaining the scientific bases of our approaches.

And we had fun. The Rehab Specialist, who later became the Director of Rehabilitation Services, and I worked seven days a week . . . because we so chose, because we wouldn't let that patient in the hinterlands go without a nurse or therapist on the weekend, because we took care of our people, because we wanted to deliver a compelling presentation the next day or week or month or all of those, because new ideas and new possibilities had a way of popping into our heads in the wee hours of the morning . . . because we loved our work and knew we were making a positive difference in many, many lives.

That little agency went from being a virtual unknown to being one of the major players in the metropolitan area. We established affiliations with all of the university medical centers in the city and put liaisons on site at each one. And our liaisons were there to serve, not to sell. We focused on making things easier for referring providers and on securing the best possible clinical outcomes for patients. And our agency took off. We chuckled when from time to time we heard our competitors exclaiming the likes of, "What are they doing over there? That place is on fire!"

And it all happened because one day the owner had said to a part-time employee who hadn't even worked for him for the better part of a year, "I want you here in some capacity," allowed me to write my own ticket, and supported what followed, whether actively or simply by getting out of the way.

There's a lesson here.

Deepak Chopra says the best motivation is inspiration. What would happen if we began asking our people what they would like to do to earn their salaries? Truly, that's where it began for me. I needed to go from "in some capacity" to defining what that capacity would be, with an eye to professional satisfaction for myself, to serving in a way that mattered, and to adding sufficient value to my employer to justify my salary.

If instead of writing detailed job descriptions including pages of required qualifications, tasks, and "other duties as assigned" and then forcing people into those roles, what would happen if more people had more opportunities to offer service as they uniquely could, and we watched and we cheered and, when requested or needed, we helped? What would happen if even in an endeavor as serious as healthcare people were free to be a little crazy, and we encouraged rather than stifled that?

WE'D LOSE MONEY! I can hear it now.

But I don't think so. Highly educated, licensed clinicians who have demonstrated skillful execution of their professions for years and who have managed even basic household budgets can be trusted to carry our their work responsibly, including fiscally responsibly. And with freedom to practice and a modicum of sense, there's no need to game the system or manipulate. Imagine the energy that this alone can free up!

Let me tell you about "Camella."

Camella lived with her daughter in a high-rise in Chicago's Cabrini-Green public housing development, and truth be told I don't remember exactly what problem precipitated her hospital stay and subsequent referral to home healthcare. But I do remember the first day I walked into that home. After the usual climb up several flights of dark, smelly stairs, having passed the cadre of drug dealers out front, I entered Camella's apartment and stuck to the floor. Yep, every step I took turned the bottoms of my shoes into suction cups; the floor was that dirty, that sticky. There were flies and probably rodents, and definitely no safe places to set my bag or coat. I piled anything I didn't immediately need onto my police escort, who stood stiffly in the middle of the floor, "stuck" himself and surely not wanting to move too close to any furniture or walls.

Camella was lying on a sagging, urine-soaked mattress, curled tightly in a fetal position, and frail as she appeared, able to let out an ear-splitting cry of "AAAAAAAAA," with the "A" sounding like the "a" in "cat," when anyone so much as approached, much less attempted to touch or move her. She was blind and utterly immobile in that bed, and I quickly discovered that her arms and legs were "frozen" in their curled position. The connective tissue that links muscles and bones and holds them together shortens and becomes very stiff if a person doesn't move, and after awhile it won't move at all, causing joints to become contracted, immobile. This is what had happened to Camella. And when despite her "AAAAAAAA" I moved her enough to examine her I found eighteen pressure ulcers, also known as bedsores, on her body. Some were large and deep enough to encompass my entire hand; some were small and crusted with God-knows-what under those hard and dark covers, and others were at various points in between. In over forty years of practice I never before and never since saw eighteen pressure ulcers on one body at one time. But Camella had them.

On the verge of reporting her daughter to adult protective services for elder abuse, I asked in, the most measured and professional way I could muster, some version of the question, "What the !$%#÷¿%@! have you been doing?!"

And she told me. In a word, her answer came down to, "Trying." And gradually understanding the larger scenario, I couldn't fault that.

There was no place other than that urine-soaked mattress for Camella to sleep. "Jane," her daughter, didn't have enough sheets to change the linens every time Camella urinated, and because the mattress was so wet clean sheets didn't make much difference anyway. Camella couldn't move and wouldn't try, so there was no place to put her even temporarily. Any time Jane attempted to move her, even to change wet clothing, Camella let out that ear-splitting "AAAAAAAAA," so both not wanting to hear that and fearing she somehow was hurting her mother, as much as possible Jane left her alone. Jane had small children in her care as well as her mother, and both her good heart and her frayed nerves clearly were visible.

I put my hackles back down and set to work.

A hospital bed was delivered that day, and diapers and disposable underpads ordered. Steeling myself against the "AAAAAAAAs," I cleaned, measured, and dressed Camella's wounds. I began teaching Jane how to care for them, as well as about Camella's need for good nutrition and to be turned and repositioned frequently, regardless of the sounds such efforts generated. Once clean and repositioned Camella magically was still . . . and content. She admitted that she felt much better, and acknowledged understanding that we needed to continue to do what I just had done.

For reasons I don't understand, the Physical and Occupational Therapists I sent into that home still talk to me today, and boy do they have stories! Shortening the tale, I'll say that Camella learned to sit up and feed herself. We ordered a bedside commode for her, and she learned to move from the bed to the commode by herself, at which point we discovered that she hadn't been uncontrollably incontinent of urine and feces but rather simply had been unable to get to a location where she could eliminate properly. Jane mopped the floor and we stopped sticking to it, and as she cleaned more and more I even came to be able to set down my belongings. The greatest achievement of all, though, was when Camella started walking, after weeks and weeks of screaming "AAAAAAAA" at the therapist from the moment he hit the apartment door through careful efforts to loosen and straighten those contracted extremities, to building enough strength that Camella could bear her own weight. Oh, her posture was bent and she needed help, but indeed, she walked! Eventually she decided that walking was more trouble than it was worth. Being blind she couldn't see where she was going and felt vulnerable, so she opted to stay in her wheelchair, which she learned to wheel around the apartment herself.

It took months, but those eighteen pressure ulcers healed. They were quite a project, as there was no way Camella could sit or lie that her body's weight wasn't on at least some of them, and because the various ulcers were of different sizes, depth, and tissue types, and they had different amounts of drainage, I needed a variety of dressings and bandages to manage them. Day after day after day I made my way past the gangbangers dealing drugs, up the dark and smelly stairs, and into that apartment to tend those wounds, teach Jane how to change bandages when I wasn't there, and manage Camella's care overall. Eventually she healed.

As our time together was coming to an end Christmas also was approaching. Rarely at a loss for words I was struck dumb when Jane presented me with a gift: A beautiful "angel" doll bearing a banner that read, "Peace on Earth." Jane had barely two nickels to rub together, but she had seen that doll in a catalog and knew it was for me. She said that she learned later that there was a "nurse" doll as well and had she known she would have chosen that one. If only I'd had the words to tell her that there is no greater possible honor than being perceived an angel of peace, particularly for someone who looks like me working in a setting that. "Nurse" pales in comparison . . . and in my book "nurse" doesn't pale in the face of much!

Here's the reason for this story: Somewhere along the line my manager said, not unkindly and not telling me to stop what I was doing, "I want to show you something. I know you're saving her life, but look how much money we're losing on this patient!" She handed me pages of the statement from Camella's account.

Medicare reimburses home healthcare by allocating a sum of money to cover up to sixty days of service. There is a lengthy assessment form that the clinician, usually a nurse, admitting a patient to home healthcare must complete, and this determines how much the agency will be paid for serving that patient for the two month period. Diagnoses are considered, of course, with some carrying higher reimbursement than others. Other considerations include how much patients can do for themselves and how much they need help, whether they are blind, short of breath, incontinent, or have ostomies or infusions, and whether they can manage their medications. There are many variables, and once assessed all combined result in a specific payment to the home healthcare agency.

Camella did not have an ostomy or an infusion; beyond that I can't think of many "payment variables" that she didn't have. But I had a sinking feeling that the numbers on that financial statement I was about to review wouldn't be pretty, because there is nothing on the assessment form that takes into consideration the presence of eighteen ulcers that need to be treated. In fact, the form asks if the patient has one ulcer, two, three, or four or more, implying that the money pot is the same for four ulcers as it would be for seven or twelve . . . or eighteen. I couldn't fault the feds, or any of the researchers who did the background work to develop this tool. Who on earth would anticipate that a human being needing care at home would have eighteen pressure ulcers?

So I looked at the first page of that financial statement and saw a nice amount of money that the agency indeed had received for Camella's care. But then I saw all my visits, and all the therapists' visits, all the supplies we had ordered, and all the time that had gone by. Page after page, I looked. And indeed, ultimately the number at the bottom of the "expense" column was far greater than the one at the bottom of the "revenue" column.

But then I looked more closely. The assessment form that determines payment to the agency must be completed every sixty days, and every sixty days a new payment amount is generated. The financial statement in my hands noted only the revenue for the first sixty day period, but expenses were listed for six or eight months. There should have been three to four times the amount of revenue stated, but nothing after the initial payment was noted. This was a working document and not an official record; my guess would be that it was generated for analysis of the very substantial expenses Camella's care had required rather than to evaluate profit vs loss.

I did some quick math. Camella stopped being incontinent and needed less help bathing and dressing, but she still needed some help with everything, she still was blind, and she still had a lot of wounds, not eighteen over time, but always "four or more." The payments to the home healthcare agency following the first sixty day period still would have been substantial, and as Jane learned to change bandages and manage her mother's care the therapists and I visited less frequently. So while revenue may have decreased somewhat, expenses did even more.

On the basis of my quick calculations it was apparent that even with this patient's extreme needs, the home healthcare agency had turned a modest but significant profit. This was possible because the therapists and I managed her care well. We did not make unnecessary visits, we taught her daughter how to care for her, and we ordered only what was needed.

In life one does well by doing good. In business, and in healthcare, that's true, too. If an agency doesn't lose money on the likes of a patient such as Camella, then there aren't too many risks than an inspired clinician might take that would materially jeopardize the financial position of the company. This doesn't give license to being foolish or to failing to think through an idea and its potential consequences, but it does mean that there's room to be a little unconventional, to break out of old molds, to release some control, and to have faith in one's staff, managing from that faith rather than from fear.

There is room for fraud and abuse in the system, and, sadly, those happen every day. But Camella taught me that doing the right thing pays off: After I had picked my way through the dirt and the dangers, providing the needed services, teaching and supporting the family, and trusting enough to ease off and eventually go away when the job is done, the home healthcare agency made money, and I somehow had to reconcile my imperfect self with an image of an angel of peace in a time and a place where peace perhaps was needed most of all.

Coupling the experience with such patients as Camella with later being given the chance to write my own ticket and report to a business owner who didn't even know where I was or what I was doing most of the time but trusted me anyway and had my back, and seeing astoundingly positive outcomes of both types of endeavors I am more convinced every day that we don't need to live in a world where those who serve say, perhaps daring to do so only to themselves, "I love my work but hate my job." Even with seemingly hopeless clinical cases and with seemingly stifling regulatory red tape, health can happen: Healthy patients, healthy organizations, healthy, satisfied, and productive workers.

What would happen if we stopped scheming, cheating, manipulating, and justifying, and instead put one foot in front of the other and took the next right step, and the next one, and the one after that? If we managed patients rightly and well, and if in our organizations we set our people free, delighted in their flight, and assured them a soft landing? What if we stopped being afraid to take risks, whether this meant no longer gaming the system for more money for oneself or one's business, or trusting one another to define what working "in some capacity" best could be for them? What would happen if instead of directing and controlling we asked and listened? What would happen if workers didn't need to do an end run around their employing organizations in order to survive, feel safe, and thrive? What would happen if workers could try out their ideas instead of having them referred to committees, councils, and layers of administrative bureaucracy guaranteed to suck every drop of creativity and life out of them? What would happen if we stopped focusing on "marketing" and started focusing on developing extraordinary products and services? In short, what would happen if we all discovered the reality of

Doing Well By Doing Good?

We Can Do Better

We can do better for our seniors, it isn't hard, it would make a tremendous positive difference in their lives and health, and the savings in healthcare costs would be substantial. Consider this:

"Pablo" had a heart attack. Again.

Two or three years ago he found himself in the ER with excruciating chest pain and shortness of breath, did a lap through the cardiac catheterization lab and ICU, then went to the general cardiac floor and ultimately home and back to his normal life. That's too bad, that latter part, because "normal" for Pablo was a diet of the likes of McDonald's and KFC together with a general disregard for medicine, exercise, and doctors. So now he's had another heart attack and repeated the same process all over again, except, we hope, for the return to his previous "normal" life. Combined, Pablo now has eight stents in his heart, and one foot on the proverbial banana peel.

But this time it seems he was scared straight. Well coached while in the hospital, he could recite his medication regimen almost completely correctly from the first day I saw him at home, he had an overall good sense of what a "heart healthy" diet was, and he knew exactly when he needed to see each of his doctors. He wanted a medication list written in a particular way that made sense to him and would help him manage his pills; I can take direction, and carefully complied with his request. He's done beautifully with his medications ever since. He showed me the cans of vegetables that he had purchased, and with raised eyebrows asked if he had made good choices. Frozen would be better than canned, I explained, but if he carefully rinses the canned products before preparing or eating them he should do fine. He agreed, and has followed through. He has kept his appointments . . . except for the one with me that his missed today, however, I found a tidy note taped to his door telling me that he had needed to go to the hospital to see his cardiologist, whose name he amusingly misspelled. Yes indeed, this time Pablo is making an effort. "I didn't take care of myself before," he has told me, "I eat all the grease."

Looking out the window of his small apartment I understand the temptation. There are not more than five or six feet of clear walking space in his home, but as Pablo shows me where to hang my coat and rolls an old desk chair over to the table so I can sit down he is noticeably short of breath. He feels fine when he's resting, he says, but when he tries to "do anything" he feels "not so good" and needs to rest again. I tell him that this is normal in the early period after a heart attack, and that he should "listen" to his body, resting as soon as he begins to feel tired, and then resuming activity when he feels better. In this way he gradually will be able to do more and more, and won't overtax his healing heart in the process. I tell him he is taking medication that slows his heart and decreases its workload so it can heal, and while this, too, can make him tired, he won't need it forever.

I don't know how Pablo obtained those canned vegetables, as the nearest grocery store is six blocks away. Given that Pablo becomes tired and winded just walking around his little apartment it's hard to imagine him somehow making his way downstairs, outside, and to the store, and then carrying groceries home. But from his apartment I can see McDonald's right across the street, Burger King around the adjacent corner, a fried chicken place, and a number of pizza joints. The heart of a strong Asian community is just a few blocks away, complete with many restaurants that deliver (sodium laden) traditional foods.

And today while I was waiting for the elevator in Pablo's building I glanced over my shoulder and saw these:

Yep, two vending machines full of sugar, salt, and fat. The beverage machine does have one offering of bottled water, which probably is that last thing that the low-income residents of this subsidized senior housing building need, having both little money and running water in their apartments. Otherwise the only options here are nutrient-poor, high risk selections.

It's little wonder Pablo was "noncompliant" after his first heart attack.

"Zelda" is another of my patients who lives in the building. A diabetic with high blood pressure and diseased arteries, she developed a leg wound that wouldn't heal. It became infected, and by the time Zelda went to the ER she had developed gangrene and her leg needed to be amputated above the knee. Now she crashes into walls and furniture just trying to learn to maneuver her wheelchair around her apartment; I can't imagine her managing on the street. Yet, like Pablo, if she is hungry in the middle of the night, or her daughter is delayed bringing groceries, Zelda's only option is to wheel herself to the elevator and ride down to those vending machines.

Sugar, salt, and fat: All addictive, and all exactly what someone with diabetes, high blood pressure, and vascular disease doesn't need.

And there's "Dolly," a somewhat confused little dynamo of a woman who went to the hospital last fall with some gut issues. Those now have resolved, but in the course of her workup a Vitamin B12 deficiency was discovered, and I see Dolly regularly for vitamin injections. These are stored in her refrigerator, and every time I remove the vial I notice that there is precious little food there. There is a lunch program in the building where residents can buy hot lunches five days a week for little more than pocket change, and not only does Dolly like those, but also she seems to have gamed the system such that she often is able to take home "extra food." Her son is attentive and often there; I don't believe he will let her starve. But my sense is strongly that his resources are limited, too, and that Dolly, who needs written reminders posted in order to remember to turn off the water, is unlikely to be able to hop on the bus to go shopping.

Of course, neither are Pablo or Zelda, and, very probably, many of their neighbors.

But there's always those vending machines . . . full of nothing that nourishes, ingredients that heighten health risks, and untold preservatives and other additives and chemicals.

I stood outside the building this afternoon, counted its floors, and did a little quick arithmetic: I'm sure there are over 200 apartments there, each occupied by a low-income senior or couple, most of whom probably have health issues, and all of whom would benefit immeasurably from decent nutrition. Yet apart from the five weekly lunches, a bus or taxi ride to a grocery store, and/or the benevolence of friends or relatives, these seniors' option for meeting a most fundamental need is vending machines full of, to put it kindly, junk.

We can do better.

After visiting Zelda today I stopped by my house to pick up my own lunch and let my dogs out for a few minutes, and in the short time I was there noticed in my own kitchen many options that would be vending machine friendly, nutrient rich, and consistent with most therapeutic diets. Things like these:

In that photo are instant organic oatmeal packets with such additions as nuts, dried fruit, flax, and pumpkin seeds, with no sodium or added sugar. There are small packets of dried fruit and whole grains, the latter having some sodium but reasonable amounts when portioned out correctly. The cans contain sparkling fruit juice.

I can drive, shop, cook, and emerge unscathed from dietary indiscretions more or less unharmed, so I've not made an effort to stock my kitchen with easily prepared nutritious foods. Imagine the collection I could gather if I did!

If vending machines can dispense cold pop and sweetened iced tea, then they can dispense juice, yogurt, cheeses, healthy milks (I prefer almond milk to cow's milk for many reasons, but any milk is better than pop!), and other nutritious selections. Instead of candy and chips they can offer whole, dried, or single-served canned fruits, low sodium single-serve soups, nuts, even small amounts of dark chocolate, and more. If a vending machine can dispense ice cream bars, then it also can hold single-serve packages of frozen vegetables and lean meats. And so forth.

But there's more. Here's the space around the building where Pablo, Zelda, and Dolly live:

There has been maintenance work on the exterior of the building, hence the damaged lawn and remaining construction fences and equipment. But what I see is massive space for residents to plant gardens. Imagine raised beds, with seating among them, both for tired gardeners and for other neighbors who might stop by to chat while enjoying the sunshine.

And look at this:

This is the side of the building, and those long balconies have a direct southern exposure. Picture pots of tomatoes, peppers, herbs,and other crops, with beans and other vines growing on the railings.

In short, the answer to Pablo's, Zelda's, and Dolly's nutrition problems is right where they live: Replace the "junk" in the vending machines with nutritious alternatives, turn much of the lawn into a garden, and put pots on the balconies.

Many years ago I visited "Theda," who suffered from "cardiodiabesity," that is, the combined ill effects of cardiovascular disease, diabetes, and obesity. One day she was thrilled to have three or four large bags of groceries sitting on her table when I arrived, delivered by volunteers from a local charity. However, she asked me to go through them and remove anything she shouldn't eat, explaining that she could give those things to neighbors and wanted to be sure she was having the right things herself. From all those bags I was able to select only a handful of items that would be safe for Theda, and sadly had to advise her to give the rest away. She agreed far more readily than one might have expected, being serious about not doing anything more that could damage her health.

Over the years I've wondered about those volunteers, who no doubt believed they were doing something helpful and good when they delivered those groceries. How helpful it would be if the public health department provided guidelines for food pantries and other charitable organizations and their donors so that better selections could be offered to their clientele, with less waste and fewer health problems down the road.

And what if instead of delivering unhealthy items, some of those volunteers helped people like Pablo, with his fatigue and shortness of breath; Zelda, with only one leg; and Dolly, with a diagnosed nutritional deficit and cognitive limitations as well; what if those volunteers helped such seniors plant and tend their gardens? Churches that collect donations for food pantries might also collect commitments to donate hours for weeding plots and staking tomatoes, and students who need community service hours could pitch in as well, helping with shopping as well as gardening. Of course many residents are robust and would be able to tend their own gardens and help their neighbors, too.

To some extent after his first heart attack Pablo probably didn't fully believe that whether he had a burger at McDonald's or troubled to make his way to the store to buy lean meat and prepare it at home himself made much difference, and McDonald's certainly was easier. Zelda likes her "regular pop, not diet" and is an admitted junk food junkie, but no matter her preferences those nutrient-poor, chemical-rich options are all that's readily available to her. And I wonder if Dolly's nutritional deficit would be as severe if she had regular access to the makings of a well balanced diet.

Everything necessary to effect positive change is right in the neighborhood, and mostly is in that building and on its grounds. Contracts with suppliers for the vending machines would need to be renegotiated, but otherwise much reduces simply to repurposing space and redirecting the efforts of well intended people. This isn't rocket science; it's little more than a matter of awareness, organizing, and enlightening.

We can do this. Solutions to this problem and so many others, or at least ways to make bad situations better, often are contained in the problems and situations themselves. And therein lies the key to how

We Can Do Better.

To Be a Beginner

To be a beginner must be among the most fundamental experiences that a being, human or otherwise, has. To talk, to walk, to ride a bike or ice skate, to drive a car or dance the cha cha, to change a diaper or put a band-aid on a boo-boo, to perform surgery or find and repair a leak in a car's transmission; the things great and small that we learn over the course of a lifetime are myriad beyond counting, and we embark on each as rank beginners. That being the case, one would think we'd become darned good at it, this business of "beginnerhood," of starting anew with something or other and going through variations of the process over and over and over for decade after decade.

Not so, I learned, powerfully, thanks to "Carmen" and the wholly unintended and unrecognized kick in the pants she served up that both shamed and inspired.

As a youngster I'd been part of an experiment to learn what would happen if Spanish was introduced in elementary schools, and from age ten or eleven on memorized dialogs in Spanish, addressed my lily-white midwestern classmates by Spanish names, and wondered what it was about this language that so enchanted my teacher. This was enough to land me in accelerated Spanish classes in high school, but these, too, consisted of little more than slogging through boring text and trying not to be embarrassed by my decidedly uncool instructor. After my sophomore year I opted not to continue, and had no further dealings with the language for the next thirty years.

Then I met "Carmen." A tiny Mexican woman in her mid-nineties, Carmen had been hospitalized with heart disease and diabetes, and while still medically precarious returned to the home she shared with generations of kinfolk. Carmen didn't speak a word of English, but her family was happy to translate. Over time she began offering more and more English words, beginning with "Hello," "'Bye," and Thank you," and progressing to asking about my health, the weather, and other basic small talk. I enjoyed her smiling efforts but otherwise thought little of it, and her family gladly translated my responses.

But one day Carmen was home alone. Her daughter had explained earlier that because of converging needs to deliver children to school, be at work, and meet various other responsibilities no one would be with Carmen that day, but by then Carmen was much improved medically, comfortable with my being in her home, and able to cooperate with an exam even if we couldn't communicate verbally. So Carmen and I went through our ritual of simple small talk, and by then she understood enough English to answer my basic questions, saying she felt "fine" and had "no pain" and was "breathing good." Then I reached for the meter to test her blood sugar level, pricked her finger and ran the test, and happily noted the perfectly normal "104" reading. In so many respects, Carmen had come a long way!

But Carmen pointed to the meter with a questioning look, so I told her it was "good, normal!"

"What number?" she asked, in English!

And I was stymied. Staring at the reading on that screen I struggled to blow thirty year-old cobwebs from my brain and elicit "104" in Spanish. "Cien . . . " I said, the word for "!00" coming to me, " . . . y . . . cuatro," I finished, hesitatingly offering an arithmetic problem in lieu of a direct answer, "one hundred plus four," as my full response.

Carmen broke into a huge smile and she exclaimed, "Cientocuatro!," the correct Spanish word for "104."

"YES!" I exclaimed. And we beamed at one another for both her medical progress and our feat of communication.

It wasn't long, though, before I felt about two inches tall. Here was an exceptionally elderly woman who had been critically ill and was far from stable when first we met, and in the weeks I visited besides accomplishing the substantial task of recovering medically she had learned many English words and phrases, whereas I, who served a city with a huge Hispanic population and once graduated from eighth grade with a medal for excellence in Spanish, remained unable to extract even "cientrocuatro" from my brain.

I enrolled in Beginning I Spanish class the next month, the first of what then was a three-year curriculum (now four). Those were great times. I met people from around the world, some of whom are friends to this day. We went to class on Saturday mornings, weekday evenings, and, ultimately, twice weekly at 6:45 AM, and had a ball. But that Beginning I experience was . . . traumatic.

It was a Saturday morning class, and I fell into a habit of seeing one or two patients in "the projects" early, after which my security escort police officer would drop me off at school. After class I walked back to my car, which was about a mile and a half away where I'd initially met up with the officer, knowing a bus or taxi was an option if necessary, but quite enjoying the walk. And as I walked, I thought. And week after week, without fail, once finally to my car, I unlocked the door, settled into the seat, and burst into tears. "I can't do this. I don't understand it, I'm not learning, I don't get it, it's hopeless, what's wrong with me . . ." You know the routine. Once calm enough to start the engine I'd hear the Spanish station to which I kept the radio tuned, and waves of despair would wash over me once more. "It's just noise, it's all gibberish, I'm stupid." Oh, my, but those were difficult moments!

Fast forward to say I did complete that three year curriculum and more "enrichment" classes as well, loved it all, and learned to speak, read, and write fluently in Spanish. In fact, native speakers tell me I have no accent, which is silly because everyone has an accent of some sort, but I think they mean that I manage not to sound like a gringo. Indeed, one of my most satisfying moments was the sudden realization one day as I sat at her kitchen table bantering in Spanish with a Mexican patient that the conversation felt perfectly natural, without my groping for words, hesitating in conjugating a verb, or feeling self-conscious in the presence of a native speaker. We were just talking, normally, the way people do.

But those sob-fests in my car during my Beginning I Spanish class days proved to be a gift, as I came to realize that what had shaken me to the core was the difficulty of being, and accepting myself as, a beginner. At forty-five years old I had a good measure of experience under my belt and had developed substantial expertise. I was the teacher, the nurse, the resource for colleagues, the idea person who could see ways to solve problems and bridge differences. I could travel all over by myself, buy and sell property, invest money, lecture to audiences of esteemed professionals and leaders across the country, and serve as president, whether by design or default, of seemingly every organization I ever joined. While certainly no paragon of wisdom and virtue, I was accustomed to holding my own in the world quite well, and to a tendency to emerge as a leader whether or not that was something to which I aspired.

That did not sit well with suddenly being unable to say, "My name is Sue, I'm from the United States, and I work as a nurse," . . . in Spanish. Indeed, it probably took me two years to learn to pronounce, "Soy estadounidense" ("I'm from the United States"). But I sure can say it now!

I learned, from my tears and despair, that despite years of unconscious practice, it can be hard, very, agonizingly hard, to be a rank beginner when one is an accomplished middle-aged adult. And that has served me well. Colleagues who take new positions and suddenly find themselves undertaking very different work than they did in the past, new parents, brand-new college graduates thrust abruptly into full adulthood, the newly widowed, even just a new neighbor who has moved into a new home in a strange neighborhood and needs to carve out a new daily routine and find new friends, all of these may find their equilibrium and self-confidence more than a little disrupted by the phenomenon of suddenly becoming a beginner.

A well known career coach in my field noted recently that it can be humbling when everyone around seems to know more than one does oneself. Certainly this is true. We all have looked at others deftly overhauling an engine or flying a plane or manipulating lines and monitors in an Intensive Care Unit . . . or speaking a second language . . . and thought, "Wow!" and felt a little small in their presence. However, I wonder if much of the resistance even to such changes as going to the gym to begin an exercise regimen or learning to cook more "healthy" foods is less about feeling self-conscious around in-shape, athletic sorts strutting about or sophisticated shoppers who move among the exotic offerings at Whole Foods and seem to know exactly what to do with them, and more about the raw discomfort simply of being a beginner, that is, of carrying the Beginning I book or not knowing how to use the machines in the gym or where on earth in the store to find ingredients whose names one can't even pronounce. The discomfort may not be about other people or one's surroundings; instead, it may be a consequence of needing to be an adult starting over, being a beginner.

A few years ago bright and early on New Year's Day I came up behind this gentleman, and his four-legged companion, as we all were doing (not necessarily "running") a 5K. I passed him, but I'll never pass what he represents: Getting out there, starting where one is, and moving forward.

But there's more to it. Even if everyone around is a beginner, too, or one is just as lost as another, as surely we all were in that Beginning I Spanish class so many years ago, the experience of starting over, of being an utter beginner at something brand new, can impact the confidence and self-worth of even the most capable, strong, and accomplished individuals. And but for that Spanish class I don't know that I'd ever have realized it.

So now I put a label on the experience for my students, for colleagues and friends branching out into new endeavors, and, especially, for patients. Indeed, patients may have the roughest gig of all, because their health and capacities are compromised just when they need to learn to do new things (manage a colostomy?! give myself shots?! keep track of all those pills?! change the way I eat, after eating the same way for seventy years?!), and the consequences of their efforts literally could be life or death, and certainly are good versus not-so-good quality of life. It can be important to say, "You're a beginner with this, perhaps the first time you've been such for many, many years. It's a process; be gentle with yourself. (Not lazy and excuse-making; gentle and forward-moving, please!) I'm here to help and guide you; your job is to reach the point of not needing me anymore. But it is a process, and it's normal and ok not to feel on top of it, to feel overwhelmed and incapable, to make mistakes, and even to despair a bit from time to time. You're forty-five or sixty-five or eight-five years old and may not have been a beginner for a many years; give yourself permission to be one now."

No doubt Carmen long since has gone to her Reward; were she still alive she'd be about one hundred fifteen years old today. But her spirit and energy yet live in me, and I remember with gratitude that tiny old woman who helped me to say "cientocuatro" and ultimately to recognize, name, and appreciate what it means simply

To Be a Beginner