Gelukkig Nieuw Jaar van Nederland!
Today is Day II of my dutch expat experience.
My adventures in Europe began a week early...the husband has job-related training in Germany, so I'll begin the new year blogging from Deutschland.
I touched down in Rotterdam Saturday morning after a 7 hour nonstop from Dulles (IAD).
It was quite the adventure bringing my dachshund Oskar van der Whee along for the ride. Let's just say he was NOT thrilled with turbulence, fellow passengers crying, or our beef dinner selection.
Here's my creative problem solving, sanity-saving travel tip for those of you flying with dogs small enough to be brought on board as 'carry on' luggage: bring a familiar blanket and if your pet has anxiety issues on the plane, take brief break periods in the restroom, where you can give the pet 'stretch' breaks.
I won't say how long we spent in the restroom (ok, at LEAST half of the 7 hour flight) - but if it saves your fellow passengers from hours of continuous howling it's worth camping out in there.
I'd heard sometimes flight attendants will let you remove your pet from the carryon bag IF the flight is relatively empty (there wasn't a spare seat on our plane) once the lights are turned out; however, our flight attendants insisted Oskar not only stay in his carrier, but that his head be zipped in at all times.
Although not ideal, with a bit of distance (and time to forget the flight) I can say this was eminently reasonable as we had a seatmate from Georgia (former USSR), several toddler-aged children onboard, and the flight was packed - safety first!
Also, swallow any spare modicum of pride and bring doggie diapers and a spare change of clothes (at least one). Hope I don't have to explain the reasoning behind that one...
As for my new home country...
From what I've seen thus far (on foot and via auto) Rotterdam is a cosmopolitan city with wonderful architecture and amenities...the metro system is clean, safe, and efficient. At gas stations along the highways you can buy chocolate that beats Godiva and some of the most beautiful flower arrangements I've ever seen for under 10USD.
It's also extremely dog-friendly...I've seen well-behaved canine companions on the metro, in shops, supermarkets-all about town.
Our canal-side neighborhood of Delfshaven is picturesque (this B&B is right up the canal), with some older homes dating from the 17th century (including ours, which was once a blacksmiths shop), a historic windmill at the end of our haven, galleries, shoppettes, and small 'creative services' businesses (architects, decorators, antiques shops, etc).
I've begun a crash-course in Dutch, a beautiful language that melds some of the gutteral germanic sounds and some more fluent hooting long vowels. It is engaging to learn and a nice change from English/Spanish used in our system.
The people are warm, friendly, and extremely understanding of our linguistic limitations.
I've been grocery shopping, used public transit, shopped for home electronics, and eaten at a wonderful restaurant. The Dutch speak (for the most part) fluent English...as one friend who has lived in Zuid-Holland for a year puts it, "their English will always be better than your Dutch."
New Year's Eve is a holiday for many Dutch residents, who are spending time with their families, out shopping, or preparing for tonight's festivities.
Many of my new neighbors are already celebrating New Year's with fireworks that, from the sound of them, rival a 21-gun salute.
To those of you working this holiday, may the New Year bring health and happiness for you (and your patients and customers) - more from Nederlands in 2008!
I like to read on the rare occasions I eat alone. Although I had some work-related materials in my bag, I was interested in reading some local coverage.
On my way in, I picked up a new (to me) newsprint publication - The Washington Blade.
After I picked blackened catfish and collard greens (excellent choice) from the menu, I spread out the two publications I'd peruse during dinner:
1. A Harvard School of Public Health Center for Continuing Professional Education "Forces of Change" brochure (I'm considering attending the September 2008 Seminar for New and Emerging Leaders) = dry informative read.
2. The December 14, 2007 edition of The Washington Blade = juicy educational read.
I read the Harvard brochure through dinner, circling the seminars I'd find most valuable and writing notes in the margins.
After I ordered bananas foster, however, I dug in to The Blade, having no idea what to expect.
I was a few pages in, ruffling the pages and harrumphing at the commentary, deeply engrossed in a piece covering Dana Beyer's withdrawal from the race to replace a Maryland state legislator who passed away unexpectedly (Delegate Jane Lawton), when I realized The Blade is a WGSX (women/gender/sexuality) friendly-publication.
Beyer was among 7 candidates seeking support from Montgomery County Democratic Central Committee party officials. She was the only GLBT (gay, lesbian, bisexual, transgender) candidate in the running.
Beyer is a retired physician with policy experience; she currently works for Montgomery County Councilmember Duchy Trachtenberg. Last month she assisted in the passing of a measure preventing discrimination in bars against people who are transgendered.
We missed the chance for hearing the platform of a candidate with a unique skill set.
Beyer would have been "the nation's first transgender state lawmaker."
The MCDCC chose instead a candidate who placed 7th last year in the competition for 3 District 18 seats - Al Carr, a Kensington town Council member who garnered 8 percent of the votes. Beyer placed fifth, winning 12 percent of the 41,500 votes cast.
What does Beyer's story, and her withdrawal from the running (along with her continued commitment to "stay in the mix"), have to do with credibility and influence in the field of healthcare?
My immediate recognition of the Harvard brochure as a credible, worthwhile read is symbolic of how we treat "credible" and "influential" figures in the hospital/healthcare field.
Physicians, policy makers, administrators, lawyers - these are credible individuals, whom we trust to deliver 'important' news and influence the changing face of the healthcare marketplace.
Patients however, are personas non grata - especially consumers with chronic conditions.
Especially those with conditions we view with skepticism (sometimes rightly so), such as migraine headache disorders. Especially patients who present deep knowledge of their own healthcare issues, strong treatment preferences, and a long experience managing their personal wellness.
Patients, in short, are not viewed as 'credible' participants in designing our best-practice care processes. We currently lack the influence to push significant change in the healthcare field.
Even in the blogosphere, the democratic, "open-marketplace" forum for healthcare debate, this dichotomy exists...who are the most famous (or infamous) healthcare bloggers? Docs. Consultants. Hospital Administrators.
Whose blogs, although insightful in the extreme, revelatory in nature, and often painful to read, are most often left off the blogrolls (including mine)?
Those focusing entirely on a patient's perspective.
Do you view your patients as some of the most credible witnesses to your efficacy? Do you indoctrinate the wisdom of these witnesses at every level of your organization, including the Board of Directors?
Do your patients have influence?
College and university faculty members' review for tenured positions often involves student evaluations. How do you weight patient evaluations of physicians? Your facilities? Ease of use and comfort of care?
The blogosphere and the Health 2.0 movements offer a little-replicated, time-limited opportunity for broadening the debate around how to grow an efficient, effective healthcare system.
Like similar pivotal points in history (the rising power of employer unions and 'organized' labor resulting from the industrial revolution), we have a short time to harness the wisdom of crowds and recognize the growing collective power of an increasingly vocal and involved user-base.
All we have to do is open ourselves to perspectives of populations the market currently derides as 'the others.'
And then incorporate their recommendations into strategic planning...small-order tasks for an industry that has built gospel on the basis of expert influence.
Let's give some weight, finally, to those who actually have credibility gained via their use of healthcare and hospital services.
I'm posting it as an example of excellent customer service.
These emails also show why, if Lijit ever goes corporate commando and requires a fee for usage, I will pay such a fee without question - because I know people like Tara will be there to help convey my suggestions to improve the system.Is the deeper point coming through? Systems improvement requires internal catalysts who hunt & gather feedback from users and then integrate suggestions into the corporate process to change systems.
Who are your internal catalysts? Patient registrars? Greeters/patient advocates? Nurses? Who integrates suggestions into the corporate process and facilitates system change? The BOD? Your unit directors/managers? The executive team?
Lesson: You can't buy loyalty like this, but you can certainly earn it, as Lijit has done. I recommend Lijit to all my fellow bloggers.
Thanks Tara! And keep reaching out. The organizations who grow too big to reach out to individual customers grow too big to hold my interest (and business) as a consumer.
Your devoted fan,
Health Mgmt Rx
Thanks for taking the time to send your thoughts. We appreciate it. To answer your stats question, we recently added the geo-location information that you are asking about. If you go to your stats page (log into your Lijit account and click on “my stats” up top), you’ll see a chart that shows what countries your searchers are coming from. It’s a neat addition to our stats and I never realized that I had so many readers in Romania .
You can most definitely use any of this in a blog entry. It proves to my bosses that I’m actually working. J We’ve been reaching out personally to new users who sign up for about a year now. However, with our growth, I’m not sure how much longer we can do it. It’s the kind of personal touch that I love but once we start getting 50 new users signing up every day, it becomes very time-intensive. I’m currently struggling with how to scale the process and keep that personal feel.
Thanks again for your support. Please send any questions my way. Hope your Tuesday is going well…
lijit networks, inc.
1050 Walnut St., Suite 340
Boulder, Co 80302
303.493.5490 x496 direct
We've moved! Please note our new address. Our phone/fax numbers remain the same.
From: Jennifer McCabe Gorman [mailto: email@example.com ]
Sent: Tuesday, December 11, 2007 1:26 PM
To: Tara Anderson
Subject: Re: Some Lijit feedback...
Hi Tara -
Thanks so much for the email - I've been using the lijit wijit (that's a tongue twister) with great success.
It's fascinating to see which searches have brought visitors to Health Management Rx - using Lijit stats I've been able to see an upward tick in both political search terms (universal healthcare) and searches for individuals/facilities.
My Statcounter allows me to see percentage of searches that are international/domestic - does the lijit functionality have this capability? If so I've just been too lazy to unearth it!
I'll keep your message and continue to evaluate the lijit service; if I come up with additional suggestions I'll most certainly pass them along.
Happy holidays -
Jen McCabe Gorman
PS - this is impressive customer service and a great way to build the lijit community! Mind if I use it in a future Health 2.0 blog entry? And do you touch bases with all users?
Tara Anderson <firstname.lastname@example.org> wrote:
Hey there Jen. I noticed that you signed up for an account with us and wanted to thank you for installing our wijit on your blog. As the daughter of a public health nurse, I saw firsthand some of the struggles my mom went through in the field of health management. She opened my eyes to the complex workings of the health care system and I feel that your blog has the potential for doing the same.
In the interest of insuring a positive Lijit experience, I was wondering if you had any feedback for us concerning the installation or functionality of the wijit. We are a growing company and user comments are helpful in guiding our development team. Also, in case you hadn’t yet, I wanted to encourage you to take a look at your stats when you get the chance. Our goal is to offer detailed stats to help you get a better sense of your audience; we welcome any suggestions you may have for enhancing our stats offerings.
If you have any questions, don’t hesitate to contact me. Thanks again for taking the time to install our wijit and I hope you’re having a great Monday!
lijit networks, inc.
1050 Walnut St., Suite 340
Boulder, Co 80302
303.493.5490 x496 direct
We've moved! Please note our new address. Our phone/fax numbers remain the same.
In preparation for my move to Rotterdam, I'm staying in a very good friend's home. A very good friend's empty, echoing, 3 bedroom, 1920's era rowhome.
Our buddy (my husband's coworker Rich, who hails from Jamaica), owns a house in the Columbia Heights section of DC.
Rich is making the move to Rotterdam along with my husband Brandon - the two of them left just over 14 days ago. Rich's things have all been shipped and are on their way (along with the sum and total of our worldly goods) across the ocean. Rich's rowhome is almost monastic in its bareness.
In the face of almost hysterical holiday overconsumption, my current lifestyle is an exercise in holiday ascetism.
I'm spending the majority of my time at 'home' in one small bedroom on my sleeping roll.
Supplies includes a camping bag rated to 0 degrees (F), a large down comforter, and two pillows. No pad, no air mattress - just me, the bedding, and the hardwood floor. I roll this up tatami-style before leaving every morning for work.
A suitcase's worth of clothing hangs in the bedroom closet, and my laptop is stored next to my bedroll. Other than the bathroom, I'm living in a space smaller than most people's offices. And here's the really interesting part - I'm loving it.
I've lived out of a suitcase before - traveling for former employer HRC, I did stints from 2 to 5.5 weeks on the West Coast. I actually enjoy the spartan nature of this type of living.
Ruthlessly requiring yourself to cut down on possessions is a great exercise...an increasingly busy lifestyle (Health 2.0 internship, interview with a Dutch medical center three days after I touch down in Rotterdam, recruiting/training my replacement, etc.) absolutely necessitates such a tradeoff.
This also is not the first time, as a family, that my husband and I have decided to pare down. (We are blessed and privileged enough that our sloughing of goods has always been voluntary rather than necessitated by hardship or disaster).
Last year we moved from a two-story, 3 BR (with deck) single-family home in Southern Maryland to a 1 BR, single floor English basement apartment in DC.
At a yard sale (and via frequent donations to local thrift stores) we jettisoned about 75% of our furnishings and home goods. (I could only bring myself to eliminate 50% of my clothing though....nobody's perfect).
When the movers arrived last month to pack us up for Holland, we eliminated even more goods.
Deciding to take only one vase, a cut-glass heirloom from my great grandmother, was one of the first painful steps in paring down. After a few opportunities to eliminate stuff, however, giving things away starts to feel surprisingly refreshing.
With today's weighty lives (and waistlines) and even heavier expectations (of success, of sharing time and self), we do ourselves a disservice by weighing ourselves down with 'goods.'
It's the holidays.
Your home may be decorated. Traditions abound. You're dragging out a tree, or a menora, or whatever else symbolizes a celebration relevant to your lifestyle and faith - you're baking cookies, shopping, arranging family meals.
Mountains more stuff is about to make its way into your home.
Why not take an evening this week to personally pare down?
Look through your closet and put anything you haven't worn in 6 months to a 'donate' pile. I recommend Goodwill, the Salvation Army, or your local shelter. Same goes for things that have been collecting dust unaltered, or you've allowed to hang around in disrepair.
This is an easy way to gradually transition yourself into a more streamlined mindset for living.
We have, after all, begun to live for stuff, and the ability to accumulate more stuff.
This holiday season, consider "Celebration by Decluttering."
My family is taking up the gauntlet - my mother no longer uses a microwave. My sister has done away with paper towels.
These are extreme examples, but I look to them as amazing instances of what is actually possible when you consider eliminating unnecessary stuff - you end up finding out very few 'things' are as vital to your way of life as you thought.
We decided last year that instead of giving gifts, we would either donate to each others desired charities or spend time/money used for shopping to travel - spending that time instead with each other.
Along with fellow bloggers Lisa Haneberg (Management Craft) and John Halamka (Life as a Healthcare CIO), I want to recommit myself to decluttering - to only having stuff around that augments a greater quality of daily life.
Shed old sports equipment, kitchen items and electronics you don't use regularly.
And while you're at it, shed the albatross.
Too often quantities of stuff shield us from the fact that we're not living in a way that measures up to our desired quality of life.
The happiest, healthiest, and sparest of holidays to you all, dear readers.
May you have an abundance of friends, family, success, and support, and time to share not worrying about the pursuit of stuff, but rather the pursuit of selflessness.
Although I tend to steer clear of quoting futurists' reports in general, I can't resist sharing a few coming 'megatrends' as conceptualized by Dr. Stephen Schimpff.
I'm also sharing Schimpff's work due to a bit of hometown pride; University of Maryland Medical Center is the site of my first ankle and knee ortho surgeries post MVA, and they did a bang-up job.
Schimpff is a former CEO of UMMC in Baltimore (published in The Examiner 12.10.07). It's encouraging to note he isn't settling down to long days golfing or fishing - he stays busy with research and other gigs including Lead Consultant to the Army on the "OR of the Future."
I'm also adding Schimpff's new book, "The Future of Medicine -- Megatrends in Healthcare That Will Improve Your Quality of Life," to my holiday reading list.
Here's a taste of what's to come over the longer term (15+ years), according to the good doctor:
- "The century-old model of 'diagnose and treat' will become 'predict and prevent.'"
- "Repairing or replacing organs will be routine" (not without some kind of incentive for more people to donate).
- "Personal medical information will be instantly available no matter where we are" (thumb drive PHRs/EHRs anyone?)
- "The entire practice of medicine will be much safer" (continued performance and quality improvements, transparency in quality and outcomes data, etc. will push this through).
- "Designer drugs individualized for a patient's specific molecular makeup" (think this may be an overly enthusiastic estimate).
- "New vaccines for diabetes, multiple sclerosis, shingles, and to prevent hardening of the arteries, cervical cancer in younger women, Alzheimer's disease, and possibly even drug addiction" (apparently we'll be able to cure destructive behavioral patterns as well).
- "Robots will assist surgeons in complex operations" (ok, already there).
- advances in the lab/genomics
- infectious disease tracking
- computational power
- entrepreneurial focus
- patent and trademark law (i.e. the ability to patent intellectual property)
"Policy changes by government officials to make medical care more available, more affordable, safer and better distributed are moving at a glacial pace. But medical care as outlined above is changing rapidly."
"The megatrends above are inevitable — albeit the time frame for each will certainly vary. Unfortunately, we cannot be nearly so confident that health policy will keep up with our medical knowledge and abilities."
As healthcare and hospital bloggers, the more visible of us have the unique opportunity to educate others on advances in care practices and processes.
Let's make sure we don't ignore the responsibility to educate ourselves about relevant changes in public policy.
This is just the first sortie however - a final vote is slated for January 8th.
In The Washington Post:
"The D.C. Council voted 7 to 6 yesterday to give initial approval to legislation that would make the District the first jurisdiction in the country to license pharmaceutical sales representatives, a major blow to the prescription drug industry and one that could have national implications if states follow the District's lead."
Council member David A. Catania (SafeRx lead sponsor and leader of the Council's Health Committee) is making a name for himself with this move.
""For too long, we have allowed profit and paternalism to be our guide for patient safety," Catania said in an interview after the narrow vote."
""Councilwoman Muriel Bowser, D-Ward 4, said she worried that the SafeRx bill would set D.C. down the same path as the FDA: too few employees and too small of a budget to combat a far bigger problem. "It promises exactly what the FDA can't accomplish," said Bowser, who voted against the measure, but said she would have supported pieces if they were carved out separately. "It's also incumbent upon us to go down that road and to make sure we're putting in place legislation that is sufficient to a problem.""
"Any lawyer can tell you that this is going to be very difficult to enforce," said Councilman Marion Barry, D-Ward 8, who voted against the bill. "It's a waste of time to try to do this. ... It does nothing to protect patients or enhance their quality of life."
One of the most interesting provisions of the bill bans pharmaceutical manufacturers from using doctors' prescription data for marketing purposes without their consent.
Even the AMA has weighed in:
"It is the AMA's position that an opt-in system would have substantially the same effect as an outright ban on the commercial use of these data, which would result in a major setback for the medical research community and the health outcomes that they are trying to improve," AMA Chief Executive Michael D. Maves wrote in a letter to the council" (Washington Post).
Should SafeRx legislation pass on January 8th, we may see a lengthy court battle before the bill goes into action - Maine, New Hampshire and Vermont have passed similar data mining legislation and are tussling with various firms and special interest groups.
Certainly something to keep an eye on...and will hospital administrators be next?
Many patients have been repeatedly told that they have very little say in their healthcare process, since they have very little ability to pay.
Some folks at the US Agency for Healthcare Research and Quality agree we need to be doing more to involve patients in their own care processes.
View a brief Medscape webcast here.
The long and short of it is this: our system is not sustainable unless we create an environment that integrally involves patients in their care and encourages an atmosphere that harnesses the 'wisdom of crowds.'
We are beginning to see cracks in the system, and will see fault lines deepen as our use of overburdened, understaffed facilities increases.
We must encourage patients to consider themselves consumers of healthcare goods and services, but we must also teach them to become self-advocates for their own health and well-being.
Of course, as providers, practitioners, and policy advocates, we must remember some patients will not wish to be involved and will prefer to rely on practitioners as primary 'guides' and decision-makers.
Policy makers and administrators must acknowledge that involvement levels will vary significantly...for example, in any given 100-person patient population, we'll average 10 hyperinvolved consumers, 20 semi-involved consumers, 40 simply engaged consumers, 20 disintererested consumers, and 10 patients who 'opt out' of decision-making.
At the most basic level, supporting an atmosphere of self-advocacy requires:
1. Transparency: we must be able to access pricing and quality data.
2. Access: resources will be entrpreneurially designed that enhance consumers' ability to moniter, manage, and share wellness goals, data, information, recommendations, and experiences.
3. Infrastructure for disadvantaged consumers: funded support for those who cannot advocate for themselves (social services, case management assistance, federal/state/municipal funds, nonprofit involvement).
4. OPTIONS: an open market system where consumer are able to select from a greater variety of healthcare plans, goods, and services, and share information about their experiences.
One of the primary tenets of the Health 2.0 movement, guided by the next generation of H/HC leaders, is that our healthcare system is fractured.
Participants, practitioners, and patients alike view 'healthcare' as a series of disjointed, episodic occurances.
Get sick, see your PCP. Break your arm playing Thanksgiving football, head to the ER. Need a flu shot, head to the local retail/minute clinic.
All care, patient education, and support has been based concretely in a physical location (hospital, docs office, clinic, etc).
Health management, and the Health 2.0 movement however, dispense with the idea that patients are best healed by unrelated, disconnected provider occurances.
Health 2.0 is more accurately represented by a curve or contiguous timeline that spans a consumer's life and integrates all varied wellness/illness experiences, according to Matthew Holt of The Health Care Blog. *Blogger's note: Matthew is also one of my new bosses - more on that later.
Health 2.0 embraces the conceptualization of a longer term environment where consumers cycle repeatedly into and out of the healthcare contiuum.
Graphically, this contiuum would be drawn as a timeline. Each consumer would appear repeatedly along the H/HC contiuum represented by a series of 'hits' on the H/HC system, (hospital stays, doc visits, PT appointments) located along a horizontal axis - someday soon I'll figure out how to draw this and post the Health Management lifeline, unless somebody beats me to the punch.
Holt describes the movement in further detail in this Modern Healthcare article (first part of a series):
""The other thing that's going on that's contemporaneous is a societal shift in which there is an understanding that medical care is an ongoing process rather than a series of episodic events," Holt says. "The relationship between physicians and patients is becoming more of a team rather than a priest-supplicant relationship." "
This holiday season, I'm giving thanks for the quality healthcare I've 'consumed.' I'm giving thanks for the fact that there's work yet to be done, and people interested in improving the industry. I'm also giving thanks that there are Health 2.0 prophets carrying the gospel of consumer-directed healthcare to policy-makers.
This holiday season, ask yourself what your organization is doing to bridge gaps in access/advocacy and establish services that provide health management along the ENTIRE length of a consumer's lifeline.
If this question is difficult to answer, there's no better time of year to strengthen your resolve and prepare your organization for the challenges ahead.
Attending the next Health 2.0 event, "Connecting Consumers and Providers" (March 3-4th in San Diego) is an excellent way to break out of your comfort zone and jumpstart your strategic planning. Click here for more info.
You may have noticed the new icon at left. Follow it to find an amazing group of women taking their respective workplaces by storm.
I'll have more to share after the retreat, but for now, think about what ceilings are holding you back.
In your organization, which barriers are viewed as insurmountable? In a perfect world, what would it take for you to break on through to the other side?
"Reining in the Reps"
Legislation introduced by Councilmember David Catania
"Pharmaceutical representatives, also called "detailers," make up the largest unregulated segment of the health care industry today. There are currently more than 100,000 detailers in the U.S., equal to one for every nine physicians.
Detailers exert enormous influence over the prescribing decisions of our doctors. And they do so without any real rules or regulations.
The result is a system that promotes the use of the latest, most expensive drugs at the expense of the best, most effective ones. It also encourages false and misleading claims about how well certain medicines perform, what uses they're approved for, and what the true side effects are.
Around the country, governments are waking up to the reality that the current "anything goes" system of pharmaceutical detailing places their citizens at risk.
Catania introduced SafeRx in the District to treat detailers for what they are -- medical professionals who directly affect the health care of our residents.
Like other health professionals in DC, detailers will be required to obtain a license, meet certain educational requirements, and be held to a code of ethical conduct developed by our Board of Pharmacy.
SafeRx represents a common sense way of ensuring that the profits of the pharmaceutical marketers don't come at the expense of our health care or safety."
SafeRx is on the Council's agenda for tomorrow, Dec. 11th.
It's not surprising that a critical "vote no" editorial was published in today's Washington Post (we do have a few pharma lobbyists in these here parts...).
The major takeaway point I got from the op-ed piece was this: we've got bigger things to worry about in DC - why waste our time and money trying to fight Big Pharma on this (since they have even more time and money and really are just trying to save lives with safer meds?)
Here's an interesting editorial on the unmeasured influence drug reps and detailers have on our current medication landscape.
Before you judge my bias, let me relate that I'm quite familiar with the functions (both good and maybe not so good) that drug reps serve.
My sister's father-in-law was a pharma man for years. On my way into meetings as an H/HC consultant, I was often asked if I was a drug rep (guess it was the black suit and heels). In high school, my husband's mom, an LPN in a small PC practice, often brought home leftovers from drug rep lunches. She told me her office learns about most new drugs when the drug reps visit.
Here's some more coverage from FierceHealthcare.
So what do you think? Has your organization banned unscheduled pharma visits? Are the 'gifts' or benefits your office will accept from reps limited to samples?
Final food for thought - we license the people who cut our hair. I'm very interested to see whether or not the DC Council will seriously consider licensing the people who teach some of our doctors about the drugs we take.
Sometimes a systemic sea change is planned carefully, utilizing insights gleaned through months of evaluation, pages of data, and shepherded step-by-step through the implementation phase by multiple internal stakeholders guiding an organization to the next phase of evolution.
And sometimes, a small, almost unnoticed system change germinates when you put a Sharpie to a legal pad and try to write something amusing.
When I pasted this sign on my door, I was (literally) in the middle of two coworkers contentedly engaging in some good natured ribbing.
When voices started to rise a half-octave and the comments became a bit more pointed, I grabbed a legal pad, scribbled this sign, ripped off a piece of Scotch tape, and thumped it up with my palm.
Facetiously, I said something along the lines of "There. New rule. This is a place of UNIVERSAL RESPECT."
You wouldn't think a low-tech, handwritten sign that started out as a half-joking response to situational discomfort would actually influence a change in organizational behavior.
But in the weeks since I smacked up that sign (where it hangs to this day), I can't tell you how many times I've stopped comments in their tracks by pointing to the sign. I can't tell you how many times I've reevaluated my own comments, even my own internal thought processes, as a result of that yellow piece of paper.
Here's why something this simple works to change behaviors within a system.
I DO want to respect everyone who comes within feet of my office door. This text reminds me daily that when you enter, your concerns are my concerns. Your priorities are more valuable than my own. It is my job to treat you and your comments, ideas, questions, and challenges with the utmost respect by giving you my total and complete attention.
I think a coworker put it best when we were discussing the strange ripple effect of the sign (less teasing in my office, even less in our area of the hallway - coworkers who wanted to say something sarcastic literally delivered witty remarks feet from the office entrance).
He said: "Jen, you're in a constant daily battle not to be selfish."
All of us in healthcare today are fighting this same battle.
Systemic change, in some respects, is easier to influence (or easier to convince ourselves we are influencing). When we research change that we hope will create grand and sweeping improvement at the systemic level, it's easier to divorce our individual efforts and foibles from the actual daily success and/or failure of the plan.
But when we implement change on the micro level, when we make a ripple that spreads at the personal level and influences behavior within a small microcosmic system, it's nearly impossible to separate our hourly successes and failures from the goal.
I've had this photo of that sign for weeks now.
I'm writing about it tonight because today included one of those hours when I failed.
I made a sarcastic comment to a coworker that many would most likely shrug off as meaningless. But here's the rub: that sign is the first thing I see in the morning as I unlock my door. It's one of last things I see in the workplace at night before I head home.
That sign means I'll walk into work tomorrow, take off my winter gear, and go find my colleague. That sign means a "good morning" will be closely followed by an apology for not showing the level of respect I want to convey, the level of respect she deserves.
That text reminds me that nothing is more important than trying to change a faulty system within your own daily work.
If you can accomplish that, perhaps it's time to step up and pick a system within your organization that needs improvement (handwashing procedures, emergency preparedness, physician recruitment, employee recognition).
You can't realistically influence systemic change if you don't start at the level of an individual system. Grand plans are good, but small signs that generate results are even better.
Sometimes to improve people's health we must stop. thinking. of. healthcare.
Who they are. Where they live. What services they buy.
Click here to read about how neighborhood barbershops in DC are reducing the impact of heart disease in the District.
Author Delphine Schrank of The Washington Post has single-handedly revived my faith in traditional journalism with chestnuts like this opening line:
"In the annals of beauty, the pompadour, the beehive and the Afro all had their day. Now comes the lifesaving haircut."
Schrank's great article begs the question of what's more important in innovative approaches to healthcare - the methodologies or finding means to employ intervention techniques that meet people where they are?
My only question after reading the article is this: Why did it take two decades for the Hair Heart and Health Program to spread virally to the District, just about 1.5 hours away from the program's birthplace in Baltimore?
Here's a summary from DCPA:
In southeast, one barber dispatched two freshly trimmed customers with hypertension straight to the emergency room. At the Divine Transformation Beauty Salon, a beautician cajoled a 300+ lb. patron into trying a fiber-rich diet. And in northeast, the owner of Fresh Cut II All About You opened her hair salon on a Sunday night to check the blood pressure of a client who had nearly fainted after learning that her daughter died in a car crash.
These three are among African American barbers and beauticians in five DC shops with blood pressure machines and digital scales tucked between hair-drying bonnets and bottles of shampoo.
They were enlisted in a program underwritten by CareFirst BlueCross BlueShield and the MedStar Research Institute to combat coronary heart disease. Modeled after a Baltimore program coordinated by U.Md.'s Department of Medicine, the DC program trains stylists how to screen clients for obesity and high blood pressure and when to urge them to follow up with a doctor. The plan is to be implemented in 12 shops by year's end.
Launched last month, the Hair Heart and Health program joins a groundswell of similar efforts across the country. All expand on the unique cultural role that barbershops and hair salons play in the African American community to raise awareness about health issues -- particularly those that disproportionately affect black Americans.
Barbershops and beauty salons are one place where African Americans meet across socioeconomic lines. They're the nerve centers where gossip is traded and racial politics is dissected. The idea to marry health care and hair styling arose in Towson, Md., in the early 1980s, when U.Md. doctors began checking blood pressure in churches, but sought to capture a wider audience.
Also read: "Barbershops, Bibles and BET: Everyday Talk and Black Political Thought" by Melissa Harris-Lacewell, an associate professor at Princeton University. For more info, read: Hair Salons, Barber Shops Become Centers of New Cardiac Care Effort in District of Columbia; Hair, Heart & Health Addresses Coronary Health Risks for African-Americans, CareFirst BlueCross BlueShield, News Release, October 1, 2007.
Amazing. If DC can encourage barbershops in cash-strapped neighborhoods to take part in community-based, consumer-centric healthcare, what can you and your organization do to address each customer where they are?
Normally I'm not a big movie buff.
In fact, we don't own a television, a stereo, or any other large, entertainment-oriented electronics. We're pretty geekmo and highly portable when it comes to tech stuff (Blackberrys various Apple music devices abound). When I want to watch a movie, I either pack it up and head to the theater or pack it in and download something from ITunes onto my laptop.
When I took a trip to the Twin Cities this weekend, I lugged my trusty laptop Raphaella (yes, I name my computers - wanna make something of it?). I didn't plan to spend quality time with my dad watching a rental Indie flick, but we were snowed in...plus 2003's The Barbarian Invasions (a Canadian film in French with subtitles) turned out to be a sharp and touching healthcare hit.
It's got wine, drug-seeking behavior, unique *ahem* methods of combating chronic pain related to terminal cancer, end of life care debates, pasta with truffles (mmmm), healing pastoral scenery by a beautiful lakeside cabin, and enough quirky, painfully 'real' interpersonal dialogue for an Oprah's Book Club novel.
But the most interesting part was a satirical (I hope) depiction of a Canadian hospital stay. Never having gone this far north for medical care, I can't verify whether a whiff of it's accurate. On Amazon, a reviewer named Francois Tremblay from Montreal, QC Canada, calls it a "dingy and corrupt (but unfortunately realistic) portrayal of the health care system in Québec." When the father in the picture, played masterfully by Remy Girard, cannot secure a private room or advanced treatments for cancer, he and his son argue about heading down to the good ole' US of A for treatment.
Particularly amusing (depending on your point of view) are depictions of hardworking nurses, fellow patients, unsympathetic hospital administrators, and union reps. There's something for everyone - academics and B-school financial types don't escape the picture's scathing wit.
In case I haven't convinced you to spend 99 minutes of your time checking out the film, written/directed by Denys Arcand, won the Academy Award(R) winner for Best Foreign Language Film in 2003.
These cards are big bucks. Click here to read about how the alternative giftcard market is making a lot more than chunk change for Safeway.
I can think of one very interesting application for the H/HC market.
Colleges and universities are using "onecards," cards with magnetic strips linked to a student's account. You can use the cards to pay for a meal, a triple venti skinny mocha, a CD from the campus bookstore, or a scoop of gelato from a neighborhood shop.
The cards usually have the users photo, a logo, and other information encoded or 'linked' (such as the students account including course enrollment data, demographics, etc.) via the magnetic data, a barcode or RFID tag.
In my idealized future hospital, patients (and patients' families) could charge a reusable onecard and use it at locations around the hospital to pay for things in the cafeteria, coffee shop, gift shop, perhaps even surrounding area restaurants and other local businesses (check out the model used by Virginia Tech).
Here's how you could push the card concept several steps further by linking it to an EMR system. *And if no one's doing this yet, who'll be the first hospital to implement and build on the concept?!
If your hospital employs RFID tagging, you could issue every patient 2 cards upon admission, one for their use and one that care providers use (stored in the chart). If you're using EMRs, you could swipe the patient's card before each treatment, medication administration, vitals check, procedure, when calling up records/results from radiology, etc.
Of course, this type of integrated system is useful for billing and reconciliation in current systems, but it would REALLY generate some burning ROI only if your charges are transparent and patients can compare what they're paying to a listed menu of services and corresponding costs.
To get this going, I'd take the following steps:
1. Visit a few colleges/universities in your area and view the onecard systems in action. Take notes. Ask questions. Think of challenges you might have in translating this system to your organization. Ask one of the administrators for a reference - who was their sales rep? How did they decide which vendor to select? What advantages 'sealed the deal?' How often has the system gone down (if ever)? What backup does the school have in place?
2. Contact a few onecard vendors (or get your Administrative Fellow to do it). Work through the chain until you find a salesrep that really knows their stuff. Ask them all your tough questions. They should be hopping to come onsite and show you how things might work. Walk them through your facility. If they don't ask questions, don't call them back.
3. Put out RFPs. Do your homework. Proceed with your normal vetting process. Do the CBA. Ask other hospital administrators and your personal brain trust for thoughts. Does this make sense? Will it create undue complexity AFTER the painful trial and implementation phase?
4. Pull someone you don't know well from every department, an environmental services worker, night float pool nurse, greeter, dining services representative, etc. Form an action team, not a committee. Tell them they'll be mystery shopping systems. Ask them what they think about the idea. Better yet, see Step 1. Take this delegation on the college tour with you and record their opinions. And finally, don't make the mistake of using this team in all the planning stages and then leaving them out of the decision-making process. One person on the team = one vote when winnowing down the vendors.
5. Take a deep breath and pull the trigger. If you've done due diligence, you're making the right choice.
PA-based insurer Highmark launched a healthcare giftcard in parnership with Visa. It looks like Visa is taking the program national.
The card was created to "encourage the use of medical services among certain cash-averse populations." Now, does this mean the card was designed for those who don't like to use cash, or those who don't have enough cash to pay for medical services? Apparently both.
Highmark feels seniors who pay for health services (not in cash) and cash-strapped college students are perfect market segments to target (hmmmm). They're also suggesting the card can be used to supplement high deductible plan coverage for costs incurred before the CDHP kicks in.
Customers could also use the card to foot the bill on copays in times of 'situational' need, such as when a child breaks an arm and needs multiple follow-up visits with an ortho doc.
Kim Bellard, Highmark's vice president of e-marketing and consumer relations, would "love to get a phone call from the AARP."
Visa also thinks the card is a perfect gift for friends making 'get healthy' New Years resolutions, for baby showers, and for getting back in touch.
"After all, what could be more thoughtful than the gift of health?" (from givewell.com).
If you want to give someone the gift of healthcare dollars, the Highmark card can be yours for the low cost of $4.95 (plus s/h of course). Then load the card with any amount from $25 to $5,000. (It would be interesting to see some stats on the average amount loaded...). Visa will also charge you a $1.50 maintenance fee per month.
The card can be used at any health-related business that accepts credit/debit cards bearing the Visa logo. Designated health-related businesses where the card can be used include docs, ambulance services, counselors, dentists, pharmacies, spas and gyms.
Prescriptions at Target, Wal-Mart, CVS, RiteAid, Kroger, Safeway, Sam's Club, and Costco are also covered. Not sure if you can use the card to purchase 'other' healthcare 'related' supplies at these locations. For instance, gum is essential to my daily mental health and wellbeing, so would the purchase of Orbit be covered?
You can get more info about the cards (and purchase one if you're so inclined) at www.givewell.com. You can also enter to win a $100 Healthcare Visa gift card (which I did not do, but I have to admit I was tempted...).
Click here to read the Kaiser Daily Health Policy report, or click here to read the original Pittsburgh Post-Gazette piece by Bill Toland.
- Remember K.I.S.S.: We want hospitals that talk to us like we're more than bodies for cutting and keep us up to date on treatments, wait times, etc.
- A slim 20% of a patient's hospital choice is based on clinical reputation (transparency, transparency, quality outcomes, error data, and more transparency)...While just under half (41%) is based on softer, 'nonclinical' experiences (accomodations, design, patient satisfaction, etc). Still feel like laughing at Cleveland Clinic's other CEO Dr. Duffy or United Airlines new Managing Director for Customer Experience?
- As an industry, we've got bigger problems than arguing over whether concierge care is a passing fad or the next hospital best practice - few hospitals have "the marketing skills, the organizational structure, or the operating approach needed to deliver a distinctive experience in the way that retailing and hospitality companies do." Start looking at which hotel/hospitality chain hire you want to recruit for your next VP opening. And why they would want to come to your hospital.
- The biggest "duh" finding: "Hospitals can segment customer groups in the same way that marketers segment them in retailing." Gee, really? And don't forget to segment w/in service line structures as well. There are multiple 'archetypes' among 'cardiac' patients...how are you appealing to your top 2-5?
- And finally, whose job is it anyway? Hospital C-levels can't forget it's our calling to germinate a cultural and operational model that grows and nurtures a "distinctive patient experience."
Health Reform 2.0: What Should Happen PRIOR to Policy Design, and Why Consumer-Centric Innovation Will Drive Change
This blog edition will NOT be a particularly eloquent piece with tons of quotes and sources (I haven't had any coffee yet, so we'll all be lucky if I can string together graphs with some semblance of grace).
Plenty of commentators with higher IQs and many more years of involvement in various aspects of the system are providing heavy-hitting commentary (just check out a few of the writers in my blog rolls at left).
I'm not the sharpest tool in the shed, but I do have a significant personal investment in how the system evolves. Here's my simplistic, blunt-instrument look at where I think we're headed.
Plenty of us are quoting facts and figures, but my purpose this beautiful gray morning, typing from Natural Sound Studio in Minneapolis/St. Paul, is to take a step back and gut-check some basic assumptions driving the political end of the health reform debate. (For your reference, dear readers, I tend to identify with consumer/market competition-centric portions of Huckabee, Hunter, Romney, Thompson, and Dodd's proposals).
Last weekend, two uncles and I were standing around the kitchen talking some business. As we are wont to do in my family (thanks Uncle Tim), we moved the discussion from a relatively friendly overview of the market ("Cash is king until mid 08 ") to a deep and visceral healthcare debate, with comments ranging from "healthcare spending will bankrupt the system" to "it'll be a tsunami."
Talk got hot and heavy ("is the healthcare industry more interested in defeating death or maintaining quality of life?") until we backtracked; there are a few fundamental questions we had to answer before we could hypothetically design the next cocktail-napkin generation of H/HC reform.
I'm going to play devil's advocate this weekend and ask you to consider the debate in terms of broad, sweeping generalizations.
Chew things over and give me your detailed, down-to-the-nitty-gritty responses in the comments.
So here we go:
Before we design policy, we must answer two fundamental questions:
Is healthcare for US citizens a right or a privilege? Does the game change if we modify "US citizens" to read "US residents?"
Who should pay? Employers? Employees? The government? Non-profits?
I believe healthcare is a right, but as with many other rights, citizens bear some level of responsibility for the system and their place within it. Those who can economically afford to be 'responsible' for some level of their care should be (e.g. we need an individual pay system designed using models including Sweden and Nederland as examples).
Second, the contributions of those who can pay combined with certain resources redistributed into the collective civic service bank of our government (via income taxes and other funding models) should help support those who cannot pay for care (e.g. we need a socialized or 'universal' system where everyone has access to more than emergency care provided via government funding, a la the systems in Canada and France). These funds should be redistributed through a program that provides basic services to those consumer populations who need them most, like WIC.
In addition, I expect our nonprofit sector will continue to provide some level of care for those who cannot otherwise afford to pay, creating a third slice of the H/HC reform pie.
None of the suggestions above are shockingly new. None of them are impossible to administer. The hybridization and collective efforts of these systems, however, is failing to deliver care in a sustainable, cost-effective, wellness-maintaining manner. I believe some of this failure may be attributed to of a lack of incentivization.
If consumers are largely divorced from the real costs of care in the current marketplace, what incentives are we providing for people to manage their personal health and wellbeing?
Very few. Give us more market transparency. Let us see the real prices for care versus what our insurance companies are paying. Let us purchase insurance plans across state lines. Let us select healthcare services from a menu of options that includes cost and quality data.
If healthcare providers continue to provide services for patients indulging in excessive use of care and they continue to be adversely impacted personally, professionally, and economically by these experiences, what incentives do they have to continue practicing?
Very few. Let's plug the holes jettisoning docs from the system. Combat decreasing interest in primary care and other service lines/specialties that don't offer incentives to practice, such as work-life balance, timely payment for services, ability to operate in a transparent, competitive marketplace, etc. with more training in design, implementation, and care delivery.
Let's provide docs with realistic ways to set up and manage businesses (step it up entrepreneurs - we need many more firms like Athena Health to smash H/HC silos of inefficacy). Let's increase training in areas that are increasingly important in healthcare, and augment clinical coursework with patient-centric communications and general management knowledge.
Why will some aspects of a federally-funded, 'socialized' or 'citizen'-centric system work?
We pay a certain percentage of our incomes into the larger federal pot - those funds are redistributed based on the needs of the nation as a whole (or they should be).
Another working example of this model is present in many of our municipal services; in cities and states a portion of our taxes are used to pay for (subsidize) services like trash collection, the public school system, fire departments, police departments, water and other utilities, etc.
So what type of system will ACTUALLY work in the US with all of our big-gun lobbies heavily investing in candidates and thus influencing outcomes?
Do we move to an individual payer system, where the responsibility to pay for our healthcare transfers completely from employers to workers? Or do we move to a federally-funded, government-paid, socialistic, 'universal' system, where the government funds and administers healthcare at a national level?
My answer: A hybrid system is the only type that will ACTUALLY have a chance of working in the US.
A unified move to a socialized, government-paid, supposedly government administered* national or 'universal' healthcare system would collapse under the lobbying power of the HMOs, or these same firms would put so much time and money into the legislative process that the design that emerges would be advantageous to corporations rather than consumers (Exhibit A: Medicare Part D). *Portions of Medicare/Medicaid enrollment, processing, and administration are outsourced, creating a shadow industry whose operations are partially hidden behind the exposed profile of the governmental plans.
Plus, a unified move to an individual payer system would provide untenable pressures on HMOS and other insurers - these behemoths would not be able to adapt fast enough to respond competitively to the variety of demands that would be placed on the system by consumers seeking services significantly more a la carte in nature than the current employer based, broad-spectrum package deals. This means they'd put up significant dukes to stop such a move.
In addition, our consumers just aren't ready to consider healthcare options within a competitive marketplace.
We aren't teaching healthcare providers and healthcare consumers to communicate on a level that partners providers' knowledge with patients' goals for quality of life. We aren't fostering game-changing, market-morphing, Health 2.0 style movement towards innovative, user-influenced care modalities.
We aren't teaching these things yet, but some entrepreneurial types aren't waiting for the 08 election outcomes to seize opportunities. Startups following in the footsteps of consumer-centric success stories like Starbucks, Google, and Apple, will innovate ways to avert the coming coverage crisis, and change the way the industry offers care.
Oh, and they'll probably make lots of money in the process. The transformation of the healthcare marketplace may provide the next leg-up in national productivity, GDP growth, and booming small business sector employment. The space is of increasing interest to venture capitalists as well...and why not? The more users are involved in their health management, the more users there are to utilize web-based services and a plethora of other new products.
A hybrid system, driven by competitive pressures from an exploding Big Bang of market-based innovation, is the way I hope we'll go - who's with me?
Somehow a majority of the vocal population also manages to become miraculously glued to their easy chairs on election night, rather than getting out to rock the vote.
But healthcare administrators and practitioners are not that type of person - right?
I sure hope not...if so...get off the proverbial couch.
Here's your chance to get involved - at the policy generation level no less - on an issue of concern to all H/HC professionals - electronic health record (EHR) certification.
The Certification Commission for Healthcare Information Technology (CCHIT) has posted its 2008 draft of certification criteria for EHRs.
A 30 day comment period is open until December 22nd.
You need to do some significant homework before commenting though; read the detailed, thorough proposals from 6 service-line specific workgroups (Ambulatory - 67 page PDF, Child Health - 5 page PDF, Cardiovascular - 13 page PDF, Emergency Dept - 30 page PDF, Inpatient - 66 pages, Network - 27 page PDF) and then register/login to leave your opinions.
Here's a bit about CCHIT, an independent nonprof (verbatim from cchit.org):
"The Certification Commission is a recognized certification body for electronic health records and their networks, and a private, nonprofit initiative.
Our mission is to accelerate the adoption of health information technology by creating an efficient, credible and sustainable certification program."Founded in 2004 by the American Health Information Management Association (AHIMA), The National Alliance for Health Information Technology (Alliance), and the Healthcare Information and Management Systems Society (HIMSS), the CCIHT was later funded (2005) by the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), HCA (the Hospital Corporation of America), McKesson, United Health Foundation, the California HealthCare Foundation, and WellPoint.
Two years ago, the US Dept. of Health and Human Services awarded CCHIT with a contract to quote "develop, create prototypes for, and evaluate the certification criteria and INSPECTION PROCESS for electronic health records (EHRs)."
Before DHHS funding dries up, CCHIT must move to create a sustainable model and continue its work based on a feasible business ops platform.
CCHIT must engage multiple stakeholders to accomplish its mission, including:
- Clinicians and provider organizations who purchase health IT products;
- Safety net providers who purchase or receive health IT products;
- Vendors who develop, market, install and support health IT products;
- Payers or purchasers who are prepared to offer incentives for health IT adoption;
- Health care consumers;
- Quality organizations;
- Public health agencies;
- Clinical and health-services researchers;
- Standards development organizations;
- Federal agencies and coordinating bodies representing various Federal agencies as identified by the National Coordinator.
Here's the deal - as both a healthcare consumer and a healthcare administrator, I want to see EHRs in full swing by 2015. I want to use them, and I want to offer them to clients/patients.
Can this be done? Perhaps - but only with all of our input.
I'll be working on my response next weekend.
The point? Good organization, great goal, good pedigree = well worth your time to read and respond.
Click here to comment.
Close friends, constructive colleagues.
The fact that I have experienced both an excellent education (which is ongoing) and excellent healthcare (also ongoing, although I may wait a bit longer to receive it).
I am thankful for a family that tolerates my rough patches and celebrates my achievements.
This afternoon I received a letter of acceptance from Georgetown's Master of Health Systems Administration program. I sure as #$%^ am thankful for that.
I am thankful that patient-centric, user-generated health management gives me a forum to express all this wonderful gratitude, and channel it.
And tonight (this morning) a special thank you to my husband.
Here's something a little different to digest on Turkey Day:
How to Live - By Charles Harper Webb, from Amplified Dog. © Red Hen Press
"I don't know how to live."
Eat lots of steak and salmon and Thai curry and mu shu
pork and fresh green beans and baked potatoes
and fresh strawberries with vanilla ice cream.
Kick-box three days a week. Stay strong and lean.
Go fly-fishing every chance you get, with friends
who'll teach you secrets of the stream. Play guitar
in a rock band. Read Dostoyevsky, Whitman, Kafka,
Shakespeare, Twain. Collect Uncle Scrooge comics.
See Peckinpah's Straw Dogs, and everything Monty Python made.
Love freely. Treat ex-partners as kindly
as you can. Wish them as well as you're able.
Snorkel with moray eels and yellow tangs. Watch
spinner dolphins earn their name as your panga slam-
bams over glittering seas. Try not to lie; it sours
the soul. But being a patsy sours it too. If you cause
a car wreck, and aren't hurt, but someone is, apologize
silently. Learn from your mistake. Walk gratefully
away. Let your insurance handle it. Never drive drunk.
Don't be a drunk, or any kind of "aholic." It's bad
English, and bad news. Don't berate yourself. If you lose
a game or prize you've earned, remember the winners
history forgets. Remember them if you do win. Enjoy
success. Have kids if you want and can afford them,
but don't make them your reason-to-be. Spare them that
misery. Take them to the beach. Mail order sea
monkeys once in your life. Give someone the full-on
ass-kicking he (or she) has earned. Keep a box turtle
in good heath for twenty years. If you get sick, don't thrive
on suffering. There's nothing noble about pain. Die
if you need to, the best way you can. (You define best.)
Go to church if it helps you. Grow tomatoes to put store-
bought in perspective. Listen to Elvis and Bach. Unless
you're tone deaf, own Perlman's "Meditation from Thais."
Don't look for hidden meanings in a cardinal's song.
Don't think TV characters talk to you; that's crazy.
Don't be too sane. Work hard. Loaf easily. Have good
friends, and be good to them. Be immoderate
in moderation. Spend little time anesthetized. Dive
the Great Barrier Reef. Don't touch the coral. Watch
for sea snakes. Smile for the camera. Don't say "Cheese."
Climbing - By Yours Truly (give me a break, I'm rusty...)
I have never enjoyed
on a Wednesday night and
the size of a pencil point
in the spotlight
over the dining table,
its web falling
on the axis of rays
beaming down on the centerpiece
I carefully arranged -
An antique glove mold,
seed pod picked up
from the park
walking the dogs.
You wouldn’t notice
The time spent -
they will not reach.
And the spider
its way to
Sleep well dear.
Dream and stir
as I sit
contemplating things that climb