Book review: The Art of Storytelling: from parents to professionals. The Great Courses

East Tennessee State University: Professor Hannah B Harvey

This is the first Great course that I have listened to. Yes, I’m like all of you. I’m proudest of those ‘important books’ on my bookshelf that I read during high school and college, and always aspire to buy and read more, but … there never seems to be enough time to CATCH UP ON THE LAST EPISODE OF BREAKING BAD or THE EXPANSE or THE MARVELOUS MRS. MAISEL (yes guilty as charged, your honor), much less break away to read a book (hello, audible.com for the commute) much less read the CLASSICS (unless of course your high school children start leaving their English lit or Russian lit or Holocaust books around and you pick them up an devour them, just to be annoying to the kids—try it, it’s fun).

So, it was with a mix of apprehension (will this be boring?) and pride (look at me! Taking another class for real! Kind of.) that I bought this and began listening. Thanks, ‘half-off audible.com sale.’ Turns out “on sale” Nudges do actually work (a future book review: I’m sitting here on the plane typing this review on my phone while the book Nudge presses against my knee in the seat-back pocket of this Economy seat).

Yes, yes I know. My wife often says: ‘it must be difficult to be you.’ Yes. Yes it is, honey. Thanks for noticing.

I’m listening to this first course. Professor Harvey has a bit of a southern accent, pleasant, well-spoken. A promising start. She’s explaining principles of good story telling, sure. Then she launches her first story, and I’M RIVETED. And then she dissects what just happened. AND I’M RIVETED. A big part of my job is: presentations, pitches for new ideas, new projects, talks to others about our successful work, speaking to laypersons, to programmers, doctors, students to convince them of something or another. I think I tell a pretty good story: some humor, some funny illustrative quotes, some quick lessons related to the story, and then a quick close.

But the professional storyteller? Watch this…

Wow.

Later in the course, the professor reveals that Little Red Riding Hood has hundreds of local culturally diverse versions. And many were not intended for children. In the version she tells, the wolf is a MAN. A handsome, vaguely dangerous, very attractive man. And darkness and blood and meat and ?string and ?white sheets in the river come into play. It only vaguely resembles the children’s story we all know. And the telling of the story is … transporting.

We learn about point of view, about developing characters and slight variations in voices, using head swivels, facial expressions, tone of voice, stepping around the stage to more clearly represent various characters.

We learn about accelerating time, expanding time to bring attention and create a short story from a longer narrative. We learn about the official role of the narrator, who, different from the heroine, or villain, or bystander, can be unreliable, or unlikeable, or have a complex and different point of view from you playing yourself. Hmm.

We learn about reading your audience, changing the story and presentation, engaging your audience in movements and shout-outs to bring them in.

And we learn about bringing it home. Remembering to tell a story THEY need and want to hear, not just a sorry YOU want to tell.

CMIO’s take? Give it a chance. I’m giving a thumbs up to Great Courses and to this Storytelling series in particular. I’m going to work on being a better storyteller in the service of improving patient lives. I’m also going to work on being a better storyteller to entertain friends and family and myself.

 

Talk to the Hand (11 seconds, seriously?) and 3 tools to FIX THIS PROBLEM.

Yes, talk to the hand.

Our smart colleagues have published in JGIM (Journal of General Internal Medicine) and have updated the classic study: how long does it take for a doctor to interrupt the patient at the beginning of the interview, when patients begin their opening statement about “why I am here today.”

https://www.springer.com/gp/about-springer/media/research-news/all-english-research-news/wait–just-a-second–is-your-doctor-listening-/15963052

In years past, we found that the time it takes for a doctor to interrupt the patient used to be …

18 seconds! Then 23 seconds (hey! we’re getting better!) and now … 11 seconds?!?! That is, IF the doctor asked an open-ended question AT ALL. Yikes.

Seriously disappointing. But, are we surprised? The time pressures on doctors have increased over time. More regulation. More required elements in the documentation. Meaningful Use requirements of Electronic Health Records. Decreasing reimbursement. Not sufficient time or effort dedicated to redesigning the exam room, or to redesigning teamwork so that doctors can be doctors and not clerical workers.

This is what our EHR 2.0 Sprint and our Practice Redesign has been about.

Beyond that, we have an internal clinician retraining program at UCHealth to improve communication in healthcare encounters between patients and physicians, we call Excellence In Communication. Led by our inimitable Patrick Kneeland, executive for Patient and Provider Experience, and a team of a dozen physician coaches (myself included), we are teaching our docs highly effective communication strategies. In a four hour workshop, we can improve clinician experience, patient experience, and reduce physician burnout. Who doesn’t want that?

Of the many techniques and tips, here’s a trio that work particularly well:

  1. Open ended inquiry “How can I help you today?”, and then WAITING UNTIL the patient is done with their opening statement. The published data on this indicated that the vast majority of patients complete their opening statement in far less than a minute, and the exception will go up to maybe 3 minutes, if uninterrupted. The trouble is that docs feel like they’re under so much pressure that every second of listening is excruciating, and the other parts of their brain are already; categorizing, creating a list of possible diagnoses, worrying about completing checklists, wondering about quality metrics, and are too “full” to be present in the moment. We train docs to practice listening for up to 2 full minutes to a colleague’s statement and committing to trying this in an exam room with a patient. Simple, but the behavior change is IMMENSELY challenging and yet IMMENSELY rewarding when done well.
  2. The second technique is “What else?” That’s it. Just keep asking “what else” until the patient runs out of stuff. This, of course is the petrifying fear that docs have: “But that opens Pandora’s box and I’ll never get it shut ever again!” and “But then they’ll bring up stuff that I can’t help them with!” and “OMIGOD this will be 75 things and we’ll be here all day and night!” Yes well, we also know that the FIRST thing that patients bring up with their doctor is only 10% to 50% of the time, the most important thing they want to talk about. So, guess what, if we RUN with the first thing patients say, we’re going to be wrong 50 to 90% of the time. So there.
  3. Finally, and this is the piece-de-resistance, say: “Well, we have discussed quite a few things so far. Which of these topics would you like to cover today in the time that we have? I would like to discuss A, and sounds like B is also important to you. How does that sound?” Negotiating the agenda is a critical skill, and makes items 1 and 2 really useful, creates a win-win agreement between patient and physician, and EVEN SAVES TIME. Imagine: a tool that increases patient and physician satisfaction, and saves time.

Notice that this has NOTHING to do with the EHR being for good or for evil. This works regardless of what you have in the exam room, as long as you have the presence of mind to remember to practice and use the tools.

In this, the winter of our discontent, when everything seems to be going in the wrong direction, when all of our institutions are under attack, and public courtesy and discourse seems to have gone awry, and everyone has a complaint, it seems that so few have ideas to help us climb out of this morass.

These tools could be a glimmer of hope.

CMIO’s take? Use these three tools in the exam room (or the meeting room, the board room, any professional or personal setting where important conversations occur), see what transpires. They are EASY TO understand, but require discipline and hard work to make them work for you. Persist, and they will pay off in large ways for you and for your patients.

NYTimes: Power of Positive People

This is perfectly aligned with what I’ve been thinking recently. This combines ideas from a couple of books we’ve been reading: Nudge by Richard Thaler (a future book review), and another book on my to-read shelf: Connected, by Nicholas Christakis.

Nudge talks about how small changes in our environment, often something we can design or control, can subtly shift our behavior in either desirable or unintended directions, eg: a public school cafeteria can dramatically influence student food choices by the positioning of the food (eye level? early in the line, or late?).

Connected discusses in more detail, the idea that not only direct relationships (immediate family members, close friends), but friends of friends, AND EVEN friends of friends of friends, have some influence over our own health, eg: the NEJM research study that showed that YOUR likelihood of obesity is related to the obesity of those who are THREE relationships away from you. Wow.

And now, positive friend relationships (described as MOAI in this article, from Okinawa, Japan, with the longest-lived women, expectancy of about 90) have everything to do with long term health. I’ll leave you to read.

CMIO’s take? There are SO MANY THINGS outside of direct-healthcare that influence our health, our lives, and we are just beginning to explore them. How are you thinking about this in your healthcare organization?

Book Review: The Alchemist – Paulo Coelho

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Four stars.

I’m surprised of never hearing about this book, now in a 25th Anniversary edition. By Paulo Coelho, it is a well-told parable of the journey of a young man who loves to travel, and seeks his treasure, based on a recurring dream, at the pyramids of Egypt, a continent away.

I’m not an adherent of mysticism, and also not a scholar of the Koran. I did however enjoy the themes from these traditions that percolate up through the writing, the parables told as the boy undertook his adventures.

Each episode of his adventure: selling his flock of sheep and deciding to set out to pursue his Dream, meeting an old King who gives him two precious stones named Umim and Thummim, meeting an aging Merchant who himself realizes that striving for his goal was more important than reaching it, meeting the titular Alchemist, all become swirling threads, and messages of insight and hope.

It is reminiscent of The Little Prince by Antoine de St. Exupery. Also of ‘Tales of Power‘ by Carlos Castaneda.

CMIO’s take? ‘The world conspires to help those pursuing their Personal Legend.’ Perhaps I would not have said it in this way, but yes, I agree. In the world of human affairs, even in large academic medical centers and health systems, it is so easy to get caught up in ‘governance’ and too-rigidly respecting lines of authority and influence. As a result, it ‘makes us rather bear those ills we have than fly to others we know not of.’ (Shakespeares’ Macbeth) Sometimes we are too fearful to take a chance on our ideas. Worse yet, we don’t help encourage others to try new things and support them in their nascent efforts, especially when a kind word or slight nudge of support could make a world of difference. A good parable teaches us about ourselves. A great one entertains us as well, as this does.

Who could YOU support and encourage today? Let me know.

How can the Triple Aim help patients? Here’s how.

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Three amigos, with very different approaches to Aneurysm repair

My father (hi Dad!) recently was diagnosed with an incidentaloma. In medical speak, that is an “incidental” (or, unintended) finding on an imaging study conducted for an entirely different reason. His physician found an ascending aortic aneurysm of a certain size, on CT scan of the chest.

Dad was interested in finding a vascular surgeon in the Los Angeles area who was experienced in evaluating and if necessary, performing surgery for this condition. “So,” he asks me, “who’s good at vascular surgery in Los Angeles?”

I was completely stumped.

I went online, as all good internet-enabled adult children do, and found several dozen websites that purport to show and rate surgeons in the Los Angeles area. NONE of them were useful. Angie’s list, HealthGrades, lots of commercial and informal sites trying to meet an important need. Either there were no surgeons listed, or maybe there is a fragment of a listing and no data, or maybe there is a marketing blurb associated with that surgeon, or maybe someone ranting about a surgeon with whom they were unhappy. Nothing in terms of quality of care, operation case volumes, patient outcomes, very little of patient satisfaction…

And yet, we now are collecting such data in our massive EHR’s. WHAT IF we took the Triple Aim of improving healthcare:
-Improving health of populations
-Enhancing the experience of care
-Reducing costs

And gave a such tool to our patients? What if we could apply Amazon.com principles to searching for physicians and showed the screen above: how many operations of this type per year, the re-hospitalization rates; the complication rates, the patient satisfaction, the cost of that care, wrapped up with an overall star rating?

Yes, I can hear the outcry now. There are SO MANY REASONS that we can’t do this. As a former hospital CEO (Dennis Brimhall) said to me decades ago:

NO PATIENT SHALL WAIT. This is our vision. I know there are 300 reasons why patients HAVE to wait in our hospital. And yet, we ALL know that waiting is one thing patients hate about our care. So, NO PATIENT SHALL WAIT. And it will be ALL OF US working to solve the 300 things so that this can come true.

So it is, with this vision. It is hard, and nearly impossible with the sociopolitical structures we have now. The technology is just about able to do this, but the much harder work is convincing all the stakeholders in the healthcare industry (and in my own organization!) that this is valuable, this is important, and we must do it.

It is also possible, that by the time we achieve this, the 2 “surgeons” pictured above will have grown up and helped solve this problem. And that clearly irrelevant, untrustworthy guy on the right will have retired.

And, Dad’s fine, by the way. Thanks for asking.

CMIO’s take? If you don’t like change, you’ll like irrelevance even less.

Book review: Spaceman – Mike Massamino

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Mike (his NASA colleagues call him ‘Mass’ and so will I) is an amazing storyteller. If you read this book, maybe consider getting it on Audible.com, as ‘Mass’ narrates his own words and journey.

Mass’s New York accent is working class-cool and fits right in with ‘The Right Stuff.’ But, instead of death-defying Air Force test pilots, we have PhD-wielding engineers and physicists competing to be the one-in-ten-thousand astronaut candidate.

I remember having watched Neil Armstrong in 1969. I was a 6-year old, and remembered some fuzzy black-and-white images, a big party of adults in our apartment, and being allowed to stay up late. I had been fascinated with space Science over the years.

I remember getting my own elementary-aged kids excited over watching the NASA channel during the landing of Spirit and Opportunity on Mars. Nothing visual interesting to see, just listening and watching the Command Center wait in hushed tones for the signal of a successful landing and the entire room of scientists and engineers erupting into tears of relief and shouts of joy. We raised our arms and hopped up and down in our own celebration. Mom walked in on us and shook her head in bemused consternation. Whew. We were such nerds. And so proud.

Mass’s story is riveting. He’s a kid from the Bronx, with childhood astronaut dreams, never straying far from home. But then a mentor suggests that if he was really passionate about Space, he would find a way. Spoiler alert: he does.

He brings as along as he barely survives a PhD at MIT, difficult post doctoral work on a Robot arm with improved human-factors feedback, vision so poor it would disqualify him, getting to fly on the Shuttle, losing close friends in both shuttle disasters, getting to work on the Hubble repair (don’t miss THAT story, OMG) doing many hours of space walks, Tweeting from space, getting to be on Big Bang Theory…

Whew! I feel like I was along for the whole ride. Mass tells us of action stories, cliffhangers, scientific breakthroughs, comedy routines, insurmountable engineering design problems, interpersonal conflicts, lifelong friendships and jaw-dropping space walks. And he is such a guy-next-door.

CMIO’s take? Lessons on how high powered individuals and teams work. And the stories are unforgettable. Get this book today. Give it a listen. You won’t regret it.

On Master Cleanse (or, is CT Lin crazy?)

image from Garciniacambogiacoloncleanse.com

Thanks to @ToddMeier, one of my IT colleagues at UCHealth.  He explained to me the benefits of periodic modified fasting.  This discussion put me on to watching a documentary about the Science of Fasting on YouTube, and then of course reading the book “Master Cleanser“.

Of course, I do not subscribe to non-medical claims about cayenne pepper boosting the blood circulation or “the only thing you lose during this, is mucus and clogged lymphatics”. But, look past all that.

If you know me and my writing, I like trying new things.  This certainly falls into the category of “something new.”  Perhaps the most powerful vision from my reading, is the idea that our Mastodon-hunting ancestors would have enormous protein meals and then perhaps not eat for weeks while the tribe looked for additional prey.  Fasting and starvation are a normal, expected physiology for our human bodies. We know that the human body can go weeks without nutrition.  Modern life, with 3 meals per day, and easy access to sugar and fat, and our tendency for overeating based on stress, eliminated the possibility of activating our fasting metabolism.  Various reports of improved energy, cognition, reduced inflammation and joint pain, and perhaps a resetting of our sugar cravings, were all attractive aspects of trying this. My colleague at University of Colorado has written extensively on this (The Fat Switch and The Sugar Fix).

This sounds somewhat reminiscent of the Paleo diet and perhaps pseudo-scientific hocus-pocus.  Nevertheless, with my underlying gout, and this desire to try something new, I broke through several weeks of ambivalence and decided to prepare the lemon drink proposed by this “master cleanse.”

The drink comprises half of a squeezed lemon, 2 tablespoons of pure maple syrup (200 cal), and a pinch of cayenne pepper.  This is added to an 8 ounce cup of water, and preferably consumed hot.  It is surprisingly tasty for what I considered a “deprivation” diet.

I am now on day 3 of my master cleanse and feeling good.  I am experiencing no hunger, I went to my usual 90 minute karate workout, I did 4 hours of yard work, cutting down innumerable branches to appease my home-owners association “warning letter”, and now I have done a couple 5-mile bike-to-work rides.

f962a9cc-5970-419c-9120-88c1acae8860.jpg     af395773-fdca-4e26-8543-7ab262400edb.jpg

Despite my wife’s misgivings, I did not “bonk” or hit the wall on my rides. Maybe my ketogenic diet was actually promoting my fat cells to convert stored fat into ketone bodies for nutrition (the normal non-glucose pathway, I vaguely recall, as I clear the cobwebs from my medical school physiology days). My sustenance has been about 3-4 cups of master cleanse lemonade. I could not convince my wife to smell me to check if my breath was actually fruity (as patients with diabetes who are in severe ketoacidosis exhibit).

Some observations:

Within about 2 or 3 minutes of consuming a master cleanse glass, the hunger disappears rapidly. Hunger is suppressed for 4-6 hours.  Then taking another glass rapidly suppresses appetite again.  I find no decrease in energy.  I find that the hour spent preparing for a regular meal, eating the meal, and cleaning up from the meal becomes just 2 minutes of drinking my lemonade and cleaning a glass (… and then an hour writing a blog about it).  I no longer experience post-meal fatigue and drowsiness.  I think that my mental clarity is actually better throughout the day, and I am forgetting to drink tea as an energy boost because I find I do not need it.

Unlike my perception that fasting would be a miserable starvation experience, this method, that does provide 200 cal in maple syrup 3-4 times per day, is a comfortable, minimal impact to my day.  I am finding that it does not impair my exercise or activity at all.  In fact I am somewhat motivated to stay physically active to prevent any muscle breakdown during this “cleanse.”

It is unclear to me how many days I will persist in this trial.  Each day I find there are challenges as I either smell my wife’s aromatic cooking or observe various family members crunching their way through a delicious meal.  I find interesting moments when I crave a bagel or a piece of cheese, or some takeout Chinese food.

One time, I did consume a ginger candy midway through this cleanse and about 30 minutes after felt somewhat drowsy.  I am wondering if this is a burst of insulin in response to an oral glucose load, causing post-meal sleepiness (see: Post-prandial somnolence on Wikipedia).  Hard to say if it was a coincidence.

Last night in a moment of weakness I rationalized having a bowl of miso soup from a concentrate that I bought at a local Japanese store.  Reading the label carefully, I find that it is only an additional 30 cal of protein and a little bit of carbohydrate.  This was perhaps the most delicious bowl of miso I have ever had in my life.  There is no umami flavor in lemonade.  https://en.wikipedia.org/wiki/Umami

UPDATE end of day 4. Having braved 4 days of “cleanse”, my cravings betrayed me at last: chips, salsa, miso soup and some cheese and crackers. Oh well, not the end of the world. After four days of consuming only 600-800 calories by way of lemon drink, I figure that’s about 1200 calories net negative each day. My scale did show a drop of 5 pounds over this period of time, with really very little effort. Not sure I noticed any difference in my knee pain (probably a non-inflammatory degenerative arthritis anyway), and my gout is so stable, can’t tell the difference. I did my usual activities, sipped 3-4 glasses of “cleanser” each day, found a surprisingly peaceful, evenly-balanced energy day, felt clear-headed and at least somewhat virtuous. If I was a data geek (ok, I am) I would ask my doc for some lab tests on my uric acid (breakdown product from muscle) and a serum creatinine and electrolytes, to see what is going on inside. Maybe another time, if I end up doing a more extended version someday.

Surprisingly, I found that the first meal after 4 days of a liquid-only diet was an incredible sensory experience.  The luxury of just CHEWING and using my tongue and tasting flavors is a surprising joy when it is no longer a routine.  Maybe that is one good reason to do a periodic fast, the ability to re-discover such simple joys. Oh, the crunch, the flavor, the aroma…

CMIO’s take?  A little bit of fasting may do you good.
Have you fasted before? Let me know!