Gap Year metrics: how to fit it all in

DEM_RAM_Aug2013Andy*, this one is for you, but you have to read to the end to get the rant.

It has been about two weeks since I returned to Maine from visiting my father in Milwaukee. This is peak summer vacation time and, indeed, that is what I have used it for.

A Gap Year principle that I am passing along is: do not over schedule; you will fail. That’s especially important when your body clock says “Maine! Vacation!”

As I have said before, if I could practice medicine, run the business of a private practice, serve on non-compensating boards and committees, maintain a family life as well as a Washington social life AND… write a book, reform health care and plan exotic trips, then I would not need a Gap Year.

But I cannot do all those things and so I need a break in August.

Reminder: why a Gap Year

Now that I have the time to enjoy an extended family visit in my favorite place on the planet, I still do not have the mental energy or strength to pay my day-to-day bills, play golf, sail, repair motor boats, babysit for two toddlers, prepare fresh seafood for island guests and in-laws AND research health care reform, research French lessons, research exotic travel (safe, yet outside the “tourist bubble”) and think about job opportunities for next year.

Something has got to go.

I have to remind myself that when I first began this year I knew that June would be a month of transition, July would be a combination of events and projects (finish the guest house, go to the World Domination Summit, visit my father) and August would be spent trying to have an extended summer vacation without the time pressure of past visits.

Measuring the perfect eight-hour day

The lesson I have learned is that while I had hoped to plan and research my Gap Year projects simultaneously, that is not going to happen.

My dream of a structured eight-hour day of research reading, personal growth reading, exercise, writing (touchy-feely blog posts, health care rants, personal notes), French exercises, etc. has not worked. I am unsettled over the fact that I cannot do it all and cannot decide what to do first.

Therefore, I am letting my grand plans wait a few more days until my grandbaby toddlers decamp and I can dial down in-law visits. Then, I promise I will get my schedule set and Debbie and I will start and end each day with briefings, progress reports and a review of Gap Year “metrics.” [Ed note: looking forward to this. – Debbie]

And now… a rant about healthcare metrics

Ok, let me rant about metrics for a minute. Does your business have metrics? Is it ruled by metrics? Do they work?

I suppose metrics have a role in terms of dollars and cents, time sensitive production issues and quality control of widgets. They may even have some role in the management of hospital systems and medical care.

I will grant that keeping the “post sternotomy blood sugar below 200 mg/dl” is associated with better outcomes and fewer wound infections (I’ll bet most of you don’t know what that means and never thought it would be measured) and is a laudable goal.

But is it a metric we should pursue? Everything can be turned into a metric. Should we do so?

Our rankings have slipped; what metric shall we improve?

I remember well a quality committee meeting at a WFMC (World Famous Medical Center, to the uninitiated) where the business people outnumbered the health care providers.

Three issues come up over the course of an hour. These were how many patients were dying of septic shock per month; how many patients dying of septic shock should be or were palliative care patients; and how much time elapsed between the first symptoms of septic shock, its diagnosis and the initiation of treatment.

Because of the high mortality of septic shock patients at this WFMC, its standings in the U.S. News and World Report rankings had slipped and the bean counters wanted to improve these metrics.

Conflating improved patient care with improved metrics

Suddenly these issues were conflated into a single management tool. It was proposed that a Septic Shock Rapid Response team could be created and the time from notification to treatment could be monitored.

Recognizing that much of the delay in treatment (and therefore the success of treatment) could be attributed to family discussions about appropriate care in a palliative care situation, it was proposed that diagnosis and treatment be instituted before a definitive family decision.

Well, if you have not seen the initiation of a septic shock work up you do not want to see one now. And, if you have you would not wish it on a family member in or near a palliative care status. It is brutal.

Fortunately, reason prevailed, at least briefly, and the metric managers looked elsewhere for something to monitor.

Patients are not widgets

People are not widgets. ER throughput of patients (another metric) should not be about filling beds to make more money but should be about getting the patient to the appropriate care level in the appropriate time period (a judgment, not a metric).

I am going to play golf, but I am so angry thinking about metrics that I am not going to keep score.

[Ed note: thanks to cousin Andy for being a loyal reader of this blog. As for golf, Sam reported back that he was six over par after six holes. Then he quit. – Debbie]

Embracing a new sense of time: slow but luxurious

iStock_clock_000003952454XSmallI recently returned from another week with my 92-year-old father. It was very pleasant and very quiet. The humidifier hums. The doors creak. The clocks tick. There is the occasional chime of the doorbell.

His world is shrinking around him and he knows it. It is hard to watch. It is frustrating. But people learn to put up with a lot of limitations. Life seems lesser and yet… it remains the life we have.

Time moves slowly in my father’s apartment

Time moves slowly in his apartment. He has so much time but is physically unable to use it. He suffers from fatigue that limits his physical abilities, including the ability to read extensively as he used to. He can think clearly but he rests most of the day to marshal his strength. His mind is strong but his limited reading limits its expansion.

Time stood still for me for that week. I never had so much time. It was a great luxury to be with him – and also a burden to bear.

Of course, time is not a luxury available to the primary care physician. There is never enough of it. One goal of my Gap Year is to embrace that new luxury and experiment with it.

My first opportunity occurred on the flight out to his Midwest City when storms over Detroit diverted all flights and created a five-hour delay. Uncharacteristically, I was completely relaxed.

For the first time, a travel delay didn’t matter

Traveling alone and without a critical agenda, with a weeklong visit ahead, what did a delay or even an overnight stay short of my destination really matter?

While I was practicing medicine, every day off was precious and every trip a surgical strike. To lose a day to a travel delay on the outbound phase was to lose a day of vacation, of well-planned time off, of valuable relaxation or of time with an elderly relative (my dad, for example) whom I didn’t see enough. To lose a day on the return threatened my colonoscopy schedule.

Knowing that patients were starting their colonoscopy preps the day before their exams while I was returning from a trip, shuffling through the boarding gate with boarding pass in hand, was a time of real tension for me.

If the flight was delayed or cancelled due to weather or a mechanical delay, could we make alternative plans to get home to DC in time? Should I call each patient and ask him or her to stop the prep and reschedule?

Some patients embraced the prep as a day of fasting and cleansing. Others stumbled through it without complaint. Some tried to squeeze it in around an otherwise jam-packed schedule of meetings and travel.

But most felt that the prep was a significant burden. It was disruptive, unpleasant and the worst part of the procedure. To finish the prep and to be told to reschedule was not an option for them. They would not do it twice in a five-year time frame.

When I was practicing, I couldn’t let my patients down

Alternatively, in the scenario where I failed to get back for the morning exams I could have asked my partner to cancel his schedule and take over my procedures. This was anathema to me. These patients had chosen me. They trusted me. They were purging for me.

They believed in my expertise and my touch. To let them be treated by someone else (even my own partner, who was equal or better than me) was impossible for me to consider. It would mean that I had an acceptable substitute.

This was unacceptable.

I have just described the balance of the personal versus the professional in living one’s life. As a former practitioner, the professional commitment can be all consuming. To complicate this balance I have inserted a third factor, physical ability or well-being.

My father is retired and, clearly, at age 92, has time to spare. But his physical condition has shrunk so that he has little left to fill his days. My professional commitment weighed heavily on me for decades, leaching time from my personal space. Now I have time.

The luxury of enjoying time AND good health

I have shed the responsibility that only a treating physician can shoulder. I miss that trust. I miss the sense of self-importance, inflated though it was.

But I am enjoying the carefree freedom of time while I am physically able and before age or disease slows me.

Unmoored and learning to drift

red_buoyNow this is a bit of a surprise.

Sam is two weeks into our Gap Year and apparently enjoying his freedom. He has the normal worries (logistics of packing and travel) but he doesn’t seem particularly anxious about his yet-to-be-made-up future.

I, on the other hand, am feeling confused and discombobulated, set adrift. I seem to have lost my bearings.

This doesn’t make any sense.

Nothing about my work life has changed. I’ve been a creative entrepreneur, making up my own story as a writer, speaker and Web consultant, for a decade. My work and professional identity are location independent. It doesn’t matter if I am in Washington DC or Stonington, ME.

And in fact I have spent a good chunk of the past five summers working from Stonington while Sam has mostly remained in DC, taking care of patients.

So what’s up?

I’ve spent much of our 13-hour drive from DC to Maine sifting through my anxious brain for an answer. It finally came to me.

For the past three decades, Sam has been tied to his medical practice, the hospital and his patients. He had a permanent mooring while I bobbed around him doing different things at different times. Thirty years ago that meant being the hands-on parent for our three young children. After getting a late-in-life MBA and enduring a brief corporate career, I struck out on my own and have been an entrepreneur ever since, relishing – among other things – business travel on my own to China, Australia, Dubai, Canada and Europe.

In fact I railed against Sam’s inflexible career. We couldn’t take a three-month trip through Asia. We couldn’t take a six or 12-month break to live and work in another country. Sam was tethered. We could not leave.

But it turns out Sam’s being tied down provided stability for me to come back to while I wandered through the Interwebs and foreign airports. I depended on it as a way to define my life.

And now we are both untethered and it feels… different. It is a little scary.

I know the freedom of our Gap Year will make adventure possible. I wanted this. Sam’s stepping back from medicine to pursue a second act was as much my idea as his.

Now I must learn to be comfortable with a flood tide of freedom.