Thank You

To the patient who said with wide-eyed astonishment and awe, “I thought I just had a bad cold, but you found a problem in my lung and took care of it,” thank you.

To the daughter who said after her mother died, “You kept her alive all those years! She never would have survived without you,” yes, I did, and thank you for realizing it.

To the countless patients who have said, “Now I understand!” or “That makes what I need to do so much easier!” or “This chart you made is so helpful,” thank you.

To the family that texted from time to time for years with “Mom’s doing this now; what should we do?” messages that never failed to end with “Thank you for your time/we’re so sorry to bother you at night/on a weekend/on the holiday,” thank you. Together we kept her home and out of the hospital for the last year and a half of her life despite multiple chronic and progressive problems and a doctor who never came to the phone and whose after-hours calls went to strangers who didn’t know her. I’m glad to accept those texts and to stand by while you carry out my instructions, even though they are nonbillable interruptions of my personal time, because I can do what the stranger in the doctor’s practice cannot, because it makes an important difference, and because you as a family are grateful and non-abusive collaborators.

To the bystander who asked as the ambulance pulled away, “How’d you know what to do? He looked fine to me!” thank you for recognizing that my seemingly unlikely knack for knowing that something wasn’t “normal” just saved a life.

To the myriad of patients who have thanked me just for showing up and being there, thank you for underscoring the loss suffered when “attending physicians” stopped attending and for recognizing what a steady presence with a sharp eye, educated mind, and keen and skilled intuition is worth.

And as we embark on another “Nurses Week,” thank you for understanding my imperfect efforts to be gracious when you describe my colleagues and me as “caring,” “compassionate,” and “hard-working.” A child often is caring and compassionate, and a window washer is hard-working; indeed, most human beings are caring and compassionate in their own ways and most work hard in the endeavors they have chosen or that have fallen to them. Nurses are human beings; ergo those traits pertain to us. But there's more, and it's the "more" that defines us and matters most.

We know that patients and those important to them rarely understand what’s going through our minds as we seem just to chat about the weather or a television program. And we know that the extra warm blanket or the steadying touch or the reassuring smile when life seems most uncertain and scary, these are tangible things people can understand as comforting and so they comment about compassion. So when you recognize our “caring” we hope that’s code for a silent nod to years of rigorous education, finely honed skill, experience and understanding beyond the pale of most people’s imagination, and a great deal of responsibility borne daily for decades that is the glue that holds together all of healthcare.

Thank you for paying attention. And to anyone who has a sense of nurses’ compassion entailing something different from that of a faithful old dog and of their hard work being substantively different from what goes on in an ant colony, a shout out to politicians, regulators, and CEOs about safe nurse staffing, safe workplace environments, reasonable workloads, and compensation commensurate with expertise would be most appreciated.

Another tote bag or tulip won’t make much difference. Recognizing, respecting, and rewarding what nurses actually know and do will, for nurses, patients, and anyone who cares about either. . . . And

Thank You.

Too Many Pills!

Too many pills! The intensity of my visceral reaction to my pill boxes still stops me in my tracks, now five days and ten "doses taken" after I upgraded to a larger size that more easily accommodates their contents. And the kicker is that apart from a generic, over-the-counter tiny tablet that controls any reflux that might pop up from time to time, there is no actual "medicine" in them. My eye doctor once recommended a vitamin, so I take that, but nothing else in there ever has been endorsed by a physician, much less prescribed by one. Instead, everything is a supplement I take to offset any deficiencies my occasionally careless habits might create, or to augment something positive. With pitches for Medicare-related insurance products arriving with my mail almost every day now, I should be glad that at this point in life I have no prescribed medications, no diagnoses, and no pain or other symptoms to be managed. And I am. But the sight of those "jumbo" pill boxes in my cupboard nonetheless momentarily leaves me feeling old and sick the minute I open the door and see them, never mind that I'm about to go out and hop on a bicycle or shovel snow. The small pill boxes were fine, just a convenience. But the exact same supplements I'd been taking all along prompt an entirely different reaction once placed in different containers. I shake off the feeling, down my supplements, and go on my way, only to repeat the experience later, morning and night, every day.

This silly little jolt morning and evening reminds me in a new way that when patients complain about taking "too many pills" or having or doing too much, or too little, of anything, we would do well to listen instead of "teaching the problem away." You know, the very rational, "Actually, Ms. Jones, you don't have much at all. There are just some vitamins, some iron because you're a bit anemic and a stool softener so the iron doesn't constipate you, a couple pills for your blood pressure that are very low doses, and the pill you take at night to lower your cholesterol. It may look like a lot, but it's almost nothing and many people take much, much more."

While it's important that "Ms. Jones" know that, this information does nothing to help her cope with the reaction she has to seeing eight or ten pill bottles lined up on her dresser or alongside the kitchen sink. "Medicine" means "sick," and lots of medicine means "old, frail, failing." Even when it doesn't. Because perceptions matter, and often decisions are made on the basis of perception rather than "facts." Indeed, for the past year or so there has been buzz in the political winds about "alternative facts," the substance of which are not factual at all, but the beliefs about them are very real and often drive action.

Perceptions matter. Often if perceptions can be modified the underlying facts matter less or take care of themselves.

Interviewing for what would become my first Vice President position, years ago I met with the physician "movers and shakers" at the hospital where I was a candidate, i.e., the department heads, medical staff officers, and "big admitters" who brought large numbers of patients, and therefore revenue, to the hospital. They asked me about my background, experience, and interest in the position, and then I asked them what concerns they had about patient care that they would want the new VP to address. Like most of us, I suppose, sometimes doctors are better at complaining than at teasing out a problem and naming it, and there were a few moments of shuffling and awkward silence before one of them chimed in with, "My patients' call lights aren't answered. They have to wait and wait before anyone responds." Heads bobbed and affirming grunts issued forth from around the table, and everyone seemed to agree that this indeed was a significant problem that the new VP should tackle right away.

So, once selected, hired, and settled into my new office, I met with the clinical department heads and shared what the doctors had told me. "That's not true," was the response in one way or another from every one of them. "Our staff is conscientious and our patients' needs attended promptly and well. This is not a problem, absolutely not."

"Well," I said, "Truth is we do have a problem. The question is just which problem we have. Either call lights are not being answered promptly, or our doctors perceive that to be the case even though nurses, technicians, and assistants are swift to respond. Whichever problem we have needs to be solved. So let's figure out which it is and get on it."

I never again brought up the topic with those managers, never had the need.

One day, just one day, I stepped out of my office and glanced down the hall where I could see one long corridor of a general medical unit, and noted that call lights were ablaze as though people had been decorating for holidays. So I walked over and answered the first light I saw, where a patient in an embarrassingly gaping hospital gown was struggling to move her overbed table to reach something. That was easy to fix. After helping her I stepped back into the hallway ready to answer the next light, but all were off. A walk around the unit confirmed that the patients were settled and comfortable, and not that all the lights had been turned off centrally because the VP had been spotted on the floor.

In the remainder of my tenure at that hospital I never again saw a corridor of a patient care area that looked like it had been decorated for holidays, except when holidays indeed were at hand and actual decorating had been done. And a month or so after that meeting with the clinical department heads I sought out the physicians who had reported the problem of unanswered call lights and asked how that situation was now. To a man (and they all were men), there were no concerns.

To this day I don't know what the problem actually was. Were call lights unanswered and an unacceptable status quo shaken up by a new VP who called out the situation, cited unhappy doctors, and once was seen taking matters into her own hands, or was there a new level of attention to physicians' (mis)perceptions and energy given to correcting them and to demonstrating more clearly excellence that had been there all along? Or some of both? Or something else entirely?

What I do know is that without ever knowing the "facts," the problem, whatever it was, was solved.

And in that is a lesson about moving forward and achieving goals.

Too often clinical practice is about the facts of pathology and the teaching of health management, when the need is for reframing a problem and managing emotions. Too often management is about blame-fixing, marching through a punitive personnel process, and making numbers look right, when the need is for light to be shone in dark corners, problems reframed, and people closest to the issues empowered and set free to innovate.

Facts matter, of course, and must not be confused with "alternative facts" and misperceptions. But much of the time the focus needs to be on objectives, i.e., the question, "What needs to happen here?" rather than on arguing, setting straight, or being "right." When we listen hard, widen our perspectives and shrink our egos, and remember that however the mess of the moment came to be we now are looking forward rather than back and that people are energized by the positive and recoil from the negative, we're likely to find that behaviors improve and new avenues open as creativity and vision thrive, whether the problem is bickering neighbors or politicians, call lights that may or may not be answered promptly, or a patient needing to deal with

Too Many Pills.