Healthcare, Leadership, and Economics

Leadership when everything seems to be falling apart

It’s getting to be hard to sustain confidence. And specifically confidence in leadership. I get up every day and think about how to allocate scarce resources to the best use for improving the health of the communities we serve. It’s now harder than ever to sustain confidence that the interconnectedness of organizations, government, and individuals will work well. Have our elected officials, corporate executives, the SEC, all been paying attention and thinking about the security and welfare of average families?

There seems to be an awful lot of evidence of selfishness, focus on short-term gain, and unwillingness to warn of consequences. Just read this from the New York Times. 

We are all interdependent. Why is this such a surprise? For our health system to be successful, our patients need access to good insurance, they need to be able to afford to take their medications, and fill their car with gas, heat their home, and pay their mortgage. We are going through hard times. It appears they will get worse before they get better.

So what really matters in difficult times? I think the same things that matter during good times — core values, confidence in our ability to influence the future, and trust in each other to support doing the right thing. We will need our neighbors, friends, and leadership even more when times are difficult. Scarce resources just got much more scarce. We will be focusing more on basic needs and less on luxuries.

In health care, there will also be difficult times. As a leader in a local health system, I see several realities we will face in the next few years:

• Health care will become even more unaffordable, from the insurance premium to the cost of prescriptions.
• The pressure to reduce costs in health care will be extreme, and will lead to some unpopular decisions, such as closure of services, and even some institutions.
• People will forgo usual care and medications, leading to increased emergency room use and hospital admissions.
• Doctors and hospitals will have difficulty borrowing money to make capital investments, slowing the growth of technology and facilities in health care.

Here in Vermont, and at the health system in Bennington, we have “stayed the course” of focus on core values. The patchwork quilt - the interconnectedness of organizations works better in Vermont. Our health care leaders are running more cost effective organizations than most of the country.

We will be challenged to dramatically improve that in the short run, and we are starting from a better base. Our bankers did not get caught up in the “irrational exuberance” of risky lending practices, and foreclosure rates in Vermont are among the lowest in the nation. Our citizen legislature, and elected officials, are more connected with the needs of real people. Leaders in health care, business, and government, know each other, and care about the communities we live in.

Community hospitals are a precious resource. Preserving them will be hard work, and some things we have learned to count on will change. We are here for the long term, and we will be here to take care of our neighbors, even if we have fewer resources than we have learned to live with in the past. It’s the right thing to do.

Dr. Polifka in Nicaragua Part II

Last week I posted more from my friend Dr. Michael Polifka who spends his time providing medical care in developing countries as a volunteer. Here's the rest of his account of a recent trip to Nicaragua.

Mark

The next week I return to work in the small rural communities in the lowlands; the situation couldn’t be more different. First of all it’s hot and made oppressively so by the frequent heavy rain and humidity. My weekend in the city of Leon is hence uncomfortable and not restful. Here in the lowlands, unlike the prior week, the farmland is divided up into large fincas. Most people have but small plots for little more than their home and work day labor with machete in the large fields of sugarcane, corn or peanut for 50 Córdoba ($2.50) a day. 

We drove on dirt roads along miles of sugarcane to reach the mud trough filled cow path that was the road to San Agustin. The level of poverty was readily obvious from the appearance of the homes. The clinic was held in the two room school house. Most of the children were less than the 5th percentile for weight from a combination of poor nutrition and intestinal parasites. Virtually all of the adults had tendonitis in their shoulders and back aches from swinging a machete for 8-10 hours a day. Both adults and children suffered from intermittent asthma from the cook fire smoke in their homes. With the price of their staple beans and rice now quadrupled many were forced to eat one meal a day or less and hence none could possibly afford anti-parasite medicine or Tylenol let alone a ventilated cook stove or a water purification system for their homes. But we saw them all, and provided them with a temporary medical ‘band-aid’ for a few of their problems. As always the patients were effusively expressive with thanks and prayers for us.

The last patient I saw that day was 30 year old Petronilia. She had missed a day of work in the cane fields to see me about her shoulder pain and gastritis. Her examination revealed the typical overuse tendonitis, and I gave her the standard medicine I had for her problems. She hesitated as she was about to leave and asked if I would give her antibiotics for her husband’s leg infection as he was unable to come to our clinic. Rather than try to treat what I couldn’t examine, I asked her if we might go to their house. Surprised at my request she said, “Yes, of course.” After a 15 minute walk on a narrow path through fields, we came to the family dwelling, eight by sixteen feet, a damp dirt floor and a mixture of black plastic and collected old corrugated metal sheets for external walls and roof.

The main room had a small wood plank for the kitchen, a wood tripod held an old clay pot of drawn water and there was a tear in the plastic wall over the open cook fire to let out a small amount of the smoke. Between the heat from the fire, the metal roof and black plastic walls, the oppressive temperature inside made humble my seemly minimal complaints of my unventilated room in Leon. Their bedroom had a single double bed for the four person family. On the family’s single blue plastic chair sat 33 year old Luis, a left leg amputee.

Luis lost his right lower left 18 months ago while peddling his bicycle home after work along one of the narrow roads in the cane fields. As a cane carrier (the size of several semi-trailer trucks) came by, he had no way to avoid a large rock and was thrown under oversized wheel and lost his leg. The sugar company took no responsibility. Eight months ago he was able to get a prosthetic leg, but in the last several weeks had developed irritation and now early cellulitis on his stump. Being unable to work since his accident, the family was living on what Petronilia was able to make and they were simply unable to afford medicine.

And so I cleaned and bandaged the wound, gave him antibiotics and instructions about care for now and suggestions to help prevent a recurrence, knowing that my visit on that day was fortuitous; several more weeks untreated would have been disastrous. As I was to leave, he shook my hand and looking me square in the eyes said the most sincere thank you. Even without all the expressions of appreciation I have received from hundreds of patients I have seen this month, that one look from Luis would have made the entire trip worthwhile.

It’s why I do this.

Michael

 

Dr. Polifka's Travels cont.

Here is more from my friend Michael Polifka, who volunteers to provide medical care in developing countries. I hope you enjoy reading this. I'll post more later.

Mark

Sept 2008

San Agustin, Nicaragua

The rainy season starts here in late August and goes until November. Although I was here in Nicaragua last September, either related to global climate change or just pure luck, I didn’t have a clue what ‘rainy’ really meant; I do now.

Immediately after my arrival I, along with two Nicaraguan physician colleagues, went to the rural mountainous area in the central north of the country. Here at 4000 feet altitude it is blissfully cool, compared to the northwest lowland plain where I will spend most of the rest of the time. The small communities are connected by narrow dirt roads that often go through streams whose height will rise from six up to 24 inches from the twice daily two hour periods when it will rain, then pour, then rain harder.

Everything there is green. The rolling hills and low mountains have cultivated and livestock-grazing fields going up their sides and except for a few hours of blue sky in the morning there is a misty haze that covers everything.

Although medical care there is not readily accessible and the population has their share of regular medical problems, the general good nutritional status from raising their own food is apparent. The week passes quickly. The scenery is beautiful, our hosts are gracious, we are busy each day, and with the exception of momentary anxiety as we drive through the above mentioned rising streams, my time there is delightful.

The next week I return to work in the small rural communities in the lowlands; the situation couldn’t be more different.
 

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