Tuesday, November 17, 2015

A rose, by any other name...

(The fact that this post is in different fonts, font sizes and colors is incredibly annoying. Despite many efforts to change it, Blogger seems to revert to the original post with all the irregularities. Sorry.)

This post is starting out as a bunch of random thoughts that I'm hopeful, when woven together, will make them feel far less random. I've been trying to sort out what happened at Flip the Clinic that caused a flip inside of me, a transformation, my breakthrough moment. It wasn't so much related to the project that we were working on, but rather the way I'm approaching the work that I'm doing in healthcare in general, the values that I hold, and what I view to be my role in this whole crazy system.

The last few posts have been about the process we went through and the steps that we were taking to figure out how to transform the notion of transition through the healthcare system at different points throughout the life cycle of a person living with a chronic illness. We had some amazing moments that gave us the ability to see the world the way we hadn't been seeing it previously, and I think we have the framework for a plan to take that work forward. But this post is going to be a little different. I'm going to start with today and work backward to see if I can figure out what changed inside of me and what it means for me going forward.

This weekend  my kids had to go to the doctor for a flu mist. I scheduled these appointments in September and the earliest that our pediatrician could get them in was yesterday. They called on Friday evening to confirm that they would be flu mists, and the kids anxiously asked, again and again, if they would be getting a shot at the doctor on Saturday morning or the nose spray. We reassured them that they would be receiving the mist. So when the time came on Saturday morning, my husband loaded up three willing kids (Drew had his shot at the pulmonologist in early October) and away they went. They returned a little different. When they arrived at the pediatrician's office, they were informed, not at check in but in the exam room, that they had run out of flu mist so they would be receiving the shot. The kids felt tricked, lied to, hurt. All of them in tears, one tried to take off and the others had to be restrained by several nurses and my husband for a quick and simple stick in the leg. And i'm not even really that mad that they had to get the shot. I'm mad that their trust in their parents, their little 3 and 5 and 7yr old trust in their healthcare providers was broken. I'm mad because we've experienced this shitty healthcare system in this way enough times that I know the implications of that simple and innocent change down the road. Next time they have to go to the doctor, it will be hard to get them to go. The ripples of this interaction with healthcare will not dissipate quickly. As an adult, I'm able to recall interactions I've had with the healthcare system that have had an impact on the ways that I behave and interact with healthcare providers today - not being totally forthcoming with information on how adherent I've been with a certain medication, for example, or not seeing my primary care doctor as often as I perhaps should. It's because it doesn't feel good to do that. 

Before the great flu shot fiasco of 2015, we tried to get Drew to take 3.5ml (thats about half a teaspoon) of a new medication that we are starting to treat a fungus that he has in his lungs. And he broke. We had pushed him too far. We were asking too much. But 3.5ml? Is that really what broke him? I had to reflect on why 3.5ml of a mediation that sort of tastes like oranges was the limit. And as I added up all that we asked this kid to do in a day, combined with a little disappointment he was feeling about a playdate he was excited about falling through, I realized something. A quote from "Being Mortal" struck me in this moment: “The terror of sickness and old age is not merely the terror of the losses one is forced to endure, but also the terror of isolation. As people become aware of the finitude of their life, they do not ask for much; they do not seek more riches; they do not seek more power; they only ask to be permitted, in as much as possible, to keep shaping the story of their life in the world. To make choices and sustain connections to others according to their own priorities. Society has dictated that debility and dependence rule out such autonomy, but it’s still very much possible to attain that.”

This poor kid just wants some control over his life. The way that we have shaped our lives around this disease was according to the priorities of our family, not of Drew specifically. And quite frankly, having never lived with a chronic illness prior to Drew joining our family, we are making up our future out of our very imagination. We don't know what you're suppose to do and how you're suppose to act. I digress. While we need to realize that there is some control that he must relinquish due to the simple nature of cystic fibrosis, we cannot simply keep asking him to do more. We need to appreciate what he has and does and how this fits into the context of the rest of his life. He's being taught at school right now about all of the food and all of the life choices that are bad for your health - watching too much tv, eating too much junk food - important lessons, no doubt. But upon some self reflection, we have to appreciate how that might make him feel, hearing the message that what we've been asking him to do is wrong, and even more how him doing it in front of his peers - eating chips for lunch everyday, drinking gatorade, watching hours of tv as he sits doing breathing treatments - how he might feel. I can only imagine his 5yr old mind struggling to rectify this - how does it make him feel? who does he trust? He needs to be permitted, in as much as possible, to keep shaping the story on his life in the world. To make choices and sustain connections to others according to his own priorities. We recognized this and are going to be talking to his healthcare team about what we can change. 

Then I started to think about this in my own life. Feeling judged or even criticized at times for all that I do or don't do, how I choose to share my perspective and experiences, I realized that as the caregiver, I too was feeling the need to keep shaping the story of my life in the world, as that autonomy is something that chronic illness tries to take from you. I think we can separate it from healthcare even, saying that we all desire that autonomy in our lives. Turning into an advocate and a designer is my way of retaining that autonomy, designing for us the life that we need out of nothing more than my imagination. 

In my first post on Flip the Clinic, I had shared about being asked at the summit what we (individually) need to let go of in order for your team to make a breakthrough" and my response being "The fear that if I stop running (metaphorically) my son will die." On the plane on the way home, I realized that I had actually accepted that long ago. That wasn't what I was holding onto that was preventing our team from making a breakthrough. With the speed (or lack there of) at which change occurs in healthcare, I've accepted that much of what I'm doing in trying to change healthcare likely won't help Drew, and that's okay because Drew is alright. I'm able to do what I need to to help him. I was running for a different reason, for acceptance and understand of the way that I think, for who I am. 

I had shared with a different stranger at the summit how hard and uncomfortable and exhausting the work that I do can feel. And her response was that I was being courageous, and that my work is critical.  So on the way home I googled courage.

Courage (also called bravery and bravado) is the choice and willingness to confront agonypaindangeruncertainty or intimidation.Physical courage is courage in the face of physical pain, hardship, death or threat of death, while moral courage is the ability to act rightly in the face of popular opposition, shamescandal, discouragement, or personal loss.

Channeling my inner Brene Brown, I could finally declare that courage is a value that I hold. It is a choice that I make to show up and be seen, and I do so knowing that the only guarantee is that I will likely get my ass kicked. This is who I want to be

As if I hadn't received enough soul-filling inspiration from this summit, someone shared this with me, the recommendation  to watch this TED talk - https://www.youtube.com/watch?v=TaX5DUGC1CU. It's about how we, as a society, as people wanting to help, are trained to look at the problems - the lacks, gaps, needs, wants - the broken stuff. She suggests that perhaps instead of looking at all that people don't have, we should start to look at what they do.  I can give you the example of our doctor's appointment this morning. When we sat down in the office the nurse said, "So we have Andrew here, a 5yr old male with a history of cystic fibrosis, tracheomalacia, pancreatic insufficiency, more bronchoscopy's than I can count, chronic sinusitis, a bowel resection, ileostomy, and airway abnormalities. His medication list is 2 miles long but I've gotta go through it so here we go." My response was, "He's got a lot of really great qualities and successes in his life, too." She chuckled and we moved on. What if Angela Blanchard is exactly right and we can't build on broken. What if the answer lies in our ability as a team - patient and provider - to share what we have, and build what we can to find what we need. What if we can't see the solution by just looking at the problem. It is about partnership, but a different kind. A partnership focused on what we each have rather than what we each need. 

If I was asked about my priority at our visit today, my answer would have been, "To get to school before 11am so that he doesn't miss his favorite part of the day." I'm here for a sinus polyp consult, but my actual priority is to get this disease to a place that doesn't interfere with school, because that's his favorite thing right now and I think that finding a way to include his priorities into the story of his life is importat.  Channeling more from Angela, we've all been in situations,
 as humans, raw and painful and excruciating moments, and it's hard in those moments to think about asking people what they have, talking about their strengths, what they're good at. But much like so many of us feel compelled to help, these people, the patients/caregivers, we want to contribute too. Our stories matter. We want to tell you what we can do and what we do know and that's the first step on my path to a new story. This gives us hope, meaning, a sense of belonging. Think about how that might contribute to successful transitions, adherence, sustainability, success. We all have the capacity to imagine a future different from the life we live. The job of those who want to help us is stand beside us - not in front of us, but beside us. When chronic illness shows up in our lives and takes away some of our freedom, we truly are left trying to create a life out of only our imagination. It's a little bit like stone soup - if we all give what we can, we all have a little more, not a little less. 

So what does this all mean to our work and the project we were focused on at Flip the Clinic? Well, we discovered that perhaps instead of trying to change the system, we needed to change ourselves and the way we interact with it. Rather than focusing on transition as a point in time and trying to identify which transitions throughout the life cycle of a person with a chronic illness have the greatest impact on the other aspects of life and health, we shifted our focus to the core components of a transition point, any transition point, and the parts that we want to take to 100 and the parts that we want to take to 0 - what do we need to start doing and what do we need to stop doing in order to achieve transformation. In our 100 column we thought about things like partnership, preparedness, empowerment, shares goals and ideal communication. In our 0 column we put things like wasted time, feelings of abandonment, falling through the cracks, preventable illness and "the yuck", defined as anxiety, helplessness, hopelessness. We are living with a reality that will not go away, at least not in our lifetime, but we know that things could be better. So we moved from these temporal transitions into the realization that every interaction is a transition and we need to change the way that we interact with one another. As a team we haven't yet come up with a physical prototype, but we did set goals for ourselves. In a year, we hope to have active experimentation and a way to capture our learning, leading to pattern emergence to identify new and better ways of interacting with one another (patients and clinicians) on a personal level to achieve better health outcomes.  We changed our team name from Lost in Transition to Navigating Transition Together. We have plans to connect with one another soon to map out a path to move forward. We've also nominated one of our team members, a med student with the most beautiful soul you've ever seen, to help write our narrative, organize our learning in the form of a story and help us to share it with the world. I'm really excited to see what we can do!

I took so much more from Flip the Clinic than I had expected to. It went so far beyond the work on our actual transition flip. Some of it can't be shared, not because it's private but it was personal, and it wouldn't mean the same thing to you that it meant to me. Words truly cannot express my gratitude for this gift that was given to me through Flip the Clinic. It was transformative for me to have so many breakthrough moments, to have a better understanding of who I am and what I want and am trying to do in the world. I came home feeling like 1000 bricks had been lifted off my shoulders, with a clear eyes and a full heart for my purpose and passion, and I'm going forward 100mph, only now, in the right direction. 

Wednesday, November 11, 2015

"...at least he fails while daring greatly"

"Its not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does the actual strive to do the deeds; who knows great enthusiasm and great devotions; who spends himself in a worthy cause; who at the best knows in the end triumph of high achievement, and who at the worst, if he fails, at least he fails while daring greatly." ~Teddy Roosevelt

I received this quote last night from a friend and the only other thing this email said was. "This is you, my friend. Vulnerability is the best measure of courage. Show your vulnerability today." And I needed that more that I realized. When yesterday ended, well, the conference proper, I had a hard night. I had to reflect on the reactions to some of my vulnerability and it hurt, a lot. And through both the receiving of this information and the processing of this information, I was reflecting on 1 thing that was said to me here that has had the biggest impact on my decision to keep pushing the train, and that was "This is critical." Darcy Winslow said it to me and its exactly what I needed to hear that no one else has taken me by the shoulders and stared me in the eye and told me to be the truth. 

I'm constantly considering whether feeling the yuck is worth it in my current role. I know there is a lot of yuck in chronic illness, but that's not the yuck I'm talking about. Its the yuck of frustration, of disappointment, and stress. It feels good to connect with other people like me, to take on fun projects that are short and easy and have tremendous impact, not on my life directly, but so little of what I do actually does. I like that feeling. Who wouldn't? I like seeing what good is going on around me and connecting with it, partnering to learn and grow and take pieces back into my life. But the yuck is necessary, in fact critical. I think need to think less about staying in the yuck or leaving the yuck or changing the yuck, and more about how I can make the yuck feel less yucky. 

Perspective is so critical, because while some see my C3N work as "head in the clouds", that's often the way I feel about the work that's happening inside of the clinic or at the Foundation, so far from the actual reality of my day to day. But we don't know that about one another until we can share that. And that's important information to know, understanding where you're starting from, and then considering how might be find ways to communicate better to allow for this? 

Something so simple has helped me to reframe the way that I need to think about this. I know it's what I need to be doing, even though sometimes it feels so yucky, because it is critical. And I will carry on, daring greatly. 

"What do you need to let go of in order for your team to make a breakthrough"

There is so much new and useful information in my notebook that I wrote in the front of it my name and cell phone number, and then in a big box with stars around it "Reward if Found", just in case I lose it.

Holy shit. My thinking has been bent. I haven't tweeted all day because I could not turn an ear away from the conversation that are happening even for a moment. Our day started with a reflection on what we accomplished yesterday, revisiting our Lego display's and continuing to think about the problem. If you want to create a transformational solution, you have to accept that you cannot see the solution to your problem from where you are starting (depicted beautifully below, where the dot on the left represents the problem and the dot on the right represents the solution(s)). We are in the process of climbing the mountain and are close to reaching the summit.

The other thing we did this morning was start to turn insights into "how might we" style questions. Here's a couple of the things that our group came up with:

We've done a lot of diverging as a group, spending time with other groups and learning from their expertise and then bringing it back to our own group. The session I attended this morning was lead by Thomas Goetz discussing how we translate data into action. Right now there is so much latent data, data that could be useful to patients or clinicians but we can't get it or can't get it in a useful form. It's just stuff that already exists that says something to you (lab results were used as an example - I can see my cholesterol number, but so what, what does that mean to me?) 

So what do we do about this? Well Thomas shared about the 4 phases of data: evidence, relevance, consequence and action. An example of this outside of healthcare could be one of those electronic speed monitoring signs that tells you your speed as you pass by. "Your speed is" is the evidence, it is what is. "You need to slow down" is the relevance. "The decision to take the risk and keep going that speed and perhaps get a ticket, or slow down" is the consequence. And "What I choose to do" is the action. So if we think about this in healthcare, test results are designed for, at best, doctors, and at least for the patient, the person who needs to act upon it. How might a better design enable a build on that, adding to verses taking away (yes, and). 

Also related to data we talked about The Principle of Progressive Disclosure, where you get to see the highest level of the data and then can drill down into whatever level you desire. An example used here was around the weather. I can see what the temperature is today, right now. Then I can drill into that and see hour by hour, the rest of the day. I can go further and see the forecast for the rest of the week. And we started talking about how might we have access to healthcare information in a similar way, where all of the information exists but I'm able to access it at my pace and comfort level. I was a particularly huge fan of this idea and even more the opportunity for folks to self-identify their learning style and start to receive information in the way and at the pace that is most comfortable to them. I think it could have a transformation impact on patient engagement. 

Organization of data is another issue altogether, with the current trend and tendency to be the creation of a dashboard. Dashboards can be counter productive because it can be so pervasive that you can't understand change. We shouldn't give people a dashboard without giving them a steering wheel. 

So this hour (I know!! It was a LOT for 1hr!) was really just getting input and information from someone who has expertise in a different but perhaps complimentary space to help you think about your problem differently and overcome obstacles. We had to take this knowledge (my new knowledge was from the Thomas Goetz group while my teammates all split and went to other sessions) and bring it all back together to think about our prototype for a transition tool/program/system/we don't know. Some of the questions that we had at this point were how will this integrate with all that we are already doing? How do different transition points build on the next transition point? How might we turn a linear transition plan into a circular one, to identify critical relationships and key levers? We decided (or thought about) how if we could pick 1 point that has the biggest leverage then that's where we should start because it could help to carry several things forward and have telescoping impact with one thing building onto the next. We were considering things like diagnosis as a major and important transition point, and transition to school (preschool and/or college), transition from pediatric to adult care, transition from being a CF patient to being a transplant patient, just as some examples. Then we had lunch and everything changed. 

We had lunch with a different adviser named Ed Porter and he challenged us to think about the piece of this that, if removed, our system would crumble. And all of us sort of went "ah-ha!" because we realized that it wasn't a specific transition that we needed to focus on but rather the key components that make up any transition point and came up with a list that included things like it must have information (we haven't defined what kind yet), it must have collaborative communication, it must solicit perspective from both (or all) parties it impacts, it must include experience and support, it must include empathy and it must include mindful presence. We didn't define these things further at this point, but we started to think more about how we could create a new way to communicate (patients and clinicians) through these transitions points that are disease agnostic, and less about which transition is actually the most important. And after we created this list, then we were rethinking which of these is critical to the success of the interaction, which is our key lever. While they all perhaps "lift", which ones lift 25lbs and which lift 250lbs. The advice we got was to start there. To choose the lever that could have the biggest impact and then test it.

So following lunch, we as a team were to present our new thinking - where are we now - to a group of other teams and advisers. We were also asked to share the questions that we still had, and talk about where we were stuck. We got INCREDIBLE feedback from the rest of the group, questions like "What do you envision this idea to actually be? Is is an online tool? A face to face encounter? Both, and? How are you thinking about whose needs must be met? There is more than 1 person in this service relationship so do you need 3 tools (patient, caregiver, provider) rather than 1 tool? And how might the other stakeholders fill the toolboxes of the groups that they're not a part of (how do I (caregiver) give the provider the tools they need to help me transition successfully and how do they fill the patients box?) This specific example was coming from the concept of groups like Sisters by Heart that send a new diagnosis package to parents of kids diagnosed with congenital heart defects to help them get started on this journey. What a crazy good idea!! We were challenged to think about how what we create now has to be responsive to the fact that time is changing simultaneously - is the creation of this going to be ongoing and dynamic, will there be a feedback loop for continual improvement? Are the solutions we are creating going to be additive or integrative - we have to make sure that we're not creating more work for anyone, and perhaps even think about what already exists that we could derive valuable information from, re-purpose something and see it through a different lens. It was suggested that we focus on impact versus intent, that whatever we create doesn't necessarily have to be measurable, but it must be communicable.

I think that one of the greatest questions posed was what does the community already have to solve the issues of that community, and how do you build on those strengths instead of trying to fix problems. (((drops the mic, exits the room)))). Wow. We had to take all of these new great thoughts and new ways of looking at this back to our smaller working group and identify what it is time for right now, thinking about how our world will organize around what we focus on, and how do we change our focus. How do we choose that starting point? We run experiments, trying more than one option so that we have the opportunity to compare and contrast, to learn. How do we stack the deck in our favor without artificially creating an outcome? We talked about these things for a while as a group, and then ended our day by talking about all of the things that we want to take to 100% (partnership, joy, just for example), and all of the things that we want to take to 0 (fear, frustration, etc). Tomorrow we get more specific with our actual plan, it my mind doesn't explode before then!

The part I glazed over in the middle was the mid-afternoon walk where we paired up with someone that we didn't know. We were asked to find someone in the room (approx 100 people) and pair up and take a 30min walk with them, getting to know them a little bit, and to come back prepared to answer the question "What do you need to let go of in order for your team to make a breakthrough". And through the conversation that we've had over the past few days on the importance of appreciating perspective, I recognized what I need to let go of in order to better collaborate with the team and on the project in order for it to be successful is the mindset I have that if I stop running (metaphorically) that my son will die.

More tomorrow on how this all comes together and where we go from here.

Monday, November 9, 2015

Flip the Clinic

Its not really fair that I'm writing about this event that I'm at after just day 1 as there are still 2 days left of this experience, but I'm having a really amazing time here and I needed to share these thoughts so that there was room for more tomorrow.

I'm at the Flip the Clinic Summit in Denver working with a team of patients, caregivers, and clinicians on a Flip called Lost in Transition. The actual problem that we are trying to solve is yet to be fully fleshed out, but basically we are working to design strategies to strengthen communication between health centers and children who have chronic conditions, looking to improve a child's understanding of their chronic condition while they're so young so that they can better manage it when they're on their own. For me its about the power of empowerment. As for Flip the Clinic, it's is a community-driven open experiment to transform the patient-clinician experience (their words that explain it way better than mine ever could). I feel like I need to pinch myself to confirm that this is reality and that I'm actually here!

We started off the day talking about how we would be working together - how most of us know many things but that none of us know as much as all of us know. We talked about the elements of a "flipped clinic" - how it would be joyful, people-centered, nourishing, expansive and transparent. Flip the Clinic wants to be (and is, in my opinion) the Petri dish where new culture grows. I seriously couldn't think of a better analogy if I tried. We were challenged to think, be ambitious, and stretch possibility, to be open and challenge assumptions. Founder of Flip the Clinic, Tom Goetz said that he believes in the capacity of ordinary people to make good decisions, and all day long that's what we were doing.

One of the most interesting parts of the morning for me was a discussion about how we need to evolve the way we communicate. It often feels like we are downloading (just saying the things we always say) and debating. This feels like we are both projecting our opinions onto others and judging. It's very hard to be innovative when things feel confrontational. The opportunity that we have is to move into reflective and generative dialogue, which invites innovation and empathy. In the first two we are focused on the past, and in the latter two we are focused on the possibility.

After lunch we had the great opportunity to work in smaller groups with different influential folks from all different industries, and I chose to join a group lead by Darcy Winslow focused on massive complex change in the corporate world and in smaller organizations. And WOW. My mind was just spinning. I'll give you three key takeaways from our discussion. The first was that if we are serious about making changes in the world, we need to do it first from within. Take a risk. Step outside of your comfort zone. And think about how you show up as a leader. This is critical. (((((long pause so that sinks in)))))) I could have left after that insight alone, but I'm glad I didn't because the next key learning was around how we really need 20% buy in in order to create the momentum to move the change forward and make it unstoppable. I need to think about my 20%. Is it 20% of the pulmonary team? 20% of the CF community? 20% of the hospital? And to buy in to what? What's the goal I'm trying to achieve? And then while I'm thinking really hard about my 20%, we started to talk about getting the right people, and how we identify who those right people are. They're not always the people at the top, but they have to be influencers. The third key thing was the need to be multi-lingual; I need to be able to both understand and speak the language of the people that I want to engage. The fourth key takeaway and  a motto that I will live by is to proceed until apprehended. Thats more than 3, and I could go on and on, but I've more to share. 

The rest of the afternoon involved one of the more creative activities that I"ve been part of. We used Legos to build our own individual representation of part of the current healthcare system. I did our home. Then we had to explain our model to our teammates, and combine our models using the best parts of each to represent the current problem that we are trying to address. It was so fun and insightful to see how we came together to literally build the problem together, with our varying perspectives, out of Legos. 

This is our house with all of the orange representing medication and Drew doing treatments and some kids with him and others protesting in another corner of the house, and the strewn legos were representative of the other chaos in our life. Healthcare doesn't just happen inside of the hospital. 

Then this was what we all put together to represent transition. What you can't see that is one of my favorite parts was at the top of that ivory tower an executive that was representative of hospital administration or pharma or insurance sitting above all of us who are trapped in this disconnected system full of barriers trying to navigate these slippery slopes of transitions throughout the life cycle of a chronic illness. The "rest of my life" is on the periphery with my family and friends, and the folks who don't make it across those bridges don't make it. 

Today was about identifying the problem that we want to solve, not yet creating a solution for it. Tomorrow we are going to roll up our sleeves and get to work on that. And if I have to a chance tomorrow night, or if I'm up again at 4am because time zones are evil, I will continue to reflect out loud because I think that this is both important for others to see and I want your feedback on how we can make it all work better. 

Now I'm off to our progressive dinner! Cheers!