The awesome work of my amazingly talented wife featured in USA Today’s College publication:

Susan Dawson, a training specialist from Genworth Financial gave a presentation that ran through the events each student had attended, goading them to spill what they had learned with tacky prizes of beer cozies and datebooks. She awarded points for connections made, cards received, coffee dates secured, and follow ups sent.

…

Before dinner, Macewan had called Q-Camp “life-changing.” When Dawson announced that Joe led all the top 120 business students at the university in points, Q-Camp really started to change his life. He had awoken, but was just beginning to emerge.

via Summer camp for business kids | USA TODAY College.

“You can’t tell people you ran nine miles and expect to ever be treated normally again.” At least, according to Marc Parent writing his Newbie Chronicles article in the February 2012 issue of Runners World Magazine. “In the minds of most everyone…instantly you are done for, a gone. You are an “other,” a “them.” You’ll never be one of the old again again…”

I know what he means. Not just because I’ve taken up running – I’ll let you know when I hit nine miles – but it’s a universal truth isn’t it? When you cross over from casual to extreme in anything, you run the risk of becoming a “them.” Parent suggests, at least in running, there is a invisible line where people can imagine themselves running the same distance, say two or three miles. Beyond that line, you are into the extreme category.

That’s the thing about extremes, they are hard to relate to. Extremes are what attract us to action movies. The idea of someone stowing away to Hong King, kicking a door down, two guns blazing, jumping over fire and rescuing the damsel works because it’s a fantasy most of us won’t ever live. Extremes can have a way of alienating people. If we can’t imagine doing it, sometimes our reaction is to just shut down, or even to become defensive.

Innovations, particularly in conservative industries like healthcare, often trigger the latter reaction. What do you mean ‘open a low cost self pay 24/7 clinic in a drug store‘? That’s not how we do things! And yet, Minute Clinics are popping up everywhere. Anyone remember when the iPhone first came out? The naysayers took to the blogs like…will… internet naysays are wont to do. It will never work, it doesn’t even have 3g, they cried.

I’ve had a similar experience with my diet change. If you tell people you don’t eat meat, they generally react favorably. Hey, good for you, that sounds healthy….I’m trying to eat better too. They can imagine themselves having a salad instead of a burger. When you tell someone you are vegan, a perceived extreme, they tend to take a step back and look at you funny. Why the hell would you do something like that? What do you eat, beans and rice? See what I mean about extremes?

Innovation has the same challenges. If you propose something small, iterative, then people can generally wrap their minds around it. Let’s extend the hours of our clinic so people can come in after work. That’s understandable, we can imagine working an hour later, or flexing staff times. Suggest virtualizing primary care through a series of Skype visits and smart phone apps and you are going to the the nine mile vegan reaction. Why the hell would we do something like that?

I’m increasingly of the opinion a lot of disruptive changes are happening outside of the healthcare industry, in the consumer space. I had an experience recently where I was showing off some consumer oriented health and fitness related apps – blood pressure monitoring, weight management, pulse, and personal health record solutions. All of these are free sites or smartphone apps. The response from industry insiders is usually something like not everyone is as geeky as you are Nick. Maybe, but then why have some of the apps been downloaded millions of times?

It’s a catch 22 for healthcare. We are likely past the point of being able to make small tweaks to the model here and there. Regardless if the future holds ACOs, bundled payments, personal mandates or insurance exchanges, someone is going to be the iPhone of healthcare. Someone is going to do that thing the rest of us think is too extreme. They’ll run 9 miles, in Parent’s terms. The question becomes how we help get traditional provider organizations get onboard? Because, the bottom line is, as an industry, we need to get comfortable with rapid, extreme innovation. If we don’t someone else will. Someone else will create the app that diagnoses your patients and allows them to Skype a primary care physician in India. Someone else will sell your patients a health monitoring service. Someone else is going to make money on your re-admissions. Someone else is going to offer a no wait urgent care clinic.

This week, Apple released their latest disruptive innovation, iBooks 2 and iBooks Author. iBooks 2 is a free update to the iBooks app for iPads. iBooks Author is a free mac desktop application which enables anyone with some basic typing and drag-and-drop skills to create pretty amazing eBooks. eBooks can contain pictures, links, audio, video, rotating graphics, self study questions and more. This is the future of patient education, shared decision aids and pre and post visit care.

On the outset, the idea of combining text and video and pictures isn’t really that new. It’s been around since…well… the start of the web. But in the context of a book, there is something really strangely compelling about seeing a moving video in the middle of static text. I can’t quite describe it. After about an hour of tinkering with the app and pasting some images and text in from a keynote presentation, I had a nice little proof of concept. You can download it and see for yourself here.

There is something which draws you in when you see live action video playing within a frame of text. Adult education experts call this blended learning. We absorb more when we engage more of our senses.

So imagine this, your doctor tells you that you are going to need surgery. What’s that process going to be like? What do I do before hand to prep? What should I do when I get home, you ask?

“Well, you can just download my free eBook,” he says.

The book walks you through the pros and cons of surgery. It plays a video of the doctor outlining the procedure. A moving picture gallery shows you where to arrive, and what to expect the day of surgery. Another video shows you how to use the pre-surgical antimicrobial wash the doctor sent you home with. There are links to online communities from other patients who have been through the same process. There is even an embedded twitter search showing a real time discussion about your condition. Wow!

A few days after the procedure, you fire up chapter two. It shows a diagram of some basic stretching. The next page talks about nutrition. To make sure you understand the concepts, there is a short self test, don’t worry, it’s open book.

These tools are simple to create. They are easy to publish (for free). And, they are a tremendous value-add to patients. Apple has done it again. By disintermediating author from the publisher, they’ve given us all the ability to make robust patient aids. For that matter, patients could make them for other patients, and publish them on their blogs, or via the iTunes book store.

What are you waiting for, go publish your first eBook!

You can download my demo/work-in-progress book, Innovation in Healthcare: A Requirement For Success here. I’ll continue to update it after this post is live, however the point is not to provide a serious book about health reform and innovation tactics. Rather, the point is to demonstrate how the technology can be used in a healthcare setting (this book is more geared to the administrative types than patients).

The gallery below includes images and descriptions of features in eBooks. 

In 1984 my aunt, Phyllis, was the best female equestrienne in the world. That summer, she represented the U.S. in the Olympics in Seoul Korea. Phyllis has all the motivation in the world to ride. It’s her passion, it’s her profession and her reputation. Clearly, she also has the ability. And, she has Grandma Grace. When it comes to support, Grandma Grace, her mother, my grandmother, is a tour de force. What ever you are into, you’d be so lucky as to have her in your court. Grandma broke out her chain saw and tractor and built a cross country course on the family farm – jumps, water obstacles, galloping paths – so Phyllis could train. Where other U.S. riders had million dollar facilities and sponsors, Phyllis had Grandma Grace. She built a barn. Herself. Nuff said.

In 1984, Phyllis finished better than any other rider on the U.S. team. Support clearly matters.

It goes to 11

Lambs neck tortellini, see what I mean?

On a scale of one to ten, my carnorvosim went to eleven. If it had blood coursing through it, there’s a good chance I tried to cook it, or would have. And I’m not talking about being a steak and potatoes guy either. I was a fried pancreas, brains and eggs, deviled kidney kinda carnivore. I always thought I had a pretty decent diet, all things cosidered. We buy mostly whole foods and I ate veggies with just as much enthussim as I did a side of beef. But you know the punch line already, in September of 2011, Susan and I made some dramatic changes to our diet – we switched to a (mostly) vegan diet. It started as a four day expirement, then a week, and a month. In December I converted a wine refrigerator dedicated to dry curing sausages and other salty porcine parts back into, well, a wine fridge. It’s prominent place in our kitchen should give you an idea of how much meat was a part of our lives.

The costs of healthcare in the US are increasing at an unsustainable rate.(Although interestingly, the rate has slowed over the last two years). The problem, though, is cost means something different to each constituent. To the consumer (hint: that’s us, the patients) costs are co-pays, deductibles, and pay check deductions (premiums) for insurance plans. If you get insurance through your employer, then they are, in fact, the ones really footing the bill. If you are a provider – hospital, doctor’s office, clinic, etc, and you read about the “cost curve”, your thoughts turn to fixed and variable costs. Implants, food, meds, gauze, overtime, the CEO’s salary, debt financing, consultants….it’s all part of what goes int the infamous $15 aspirin.

So what’s all this got to do with meat? 

Yours truly, clocking in at 215 on Jan 1, 2011

In January of 2011 I weighed 215 lbs. I’m 5’8 (on a good day…with shoes… leave me alone). You don’t need a BMI chart to know that’s too much Nick to be healthy. I was active. I’ve had a life-long obsession with extreme skiing and, in order to maintain some semblance of ability, I’ve tried to keep in reasonable shape. I have a trainer at the gym – going 3 days a week – and could probably have run a mile. Who knows, I hadn’t tried in a long time.

If any of this sounds dire, let’s recalibrate. I’ve always liked the term bon vivant, it says it all about someone who loves the good things in life. Sure, I was carrying around some extra pounds, but I was still skiing double blacks; and if I could do that on a diet of veal tongue, brussels sprouts, and red wine, what’s not to love? The side effects are always in the fine print.

In 2004 my doctor diagnosed me with mild hypertension, high blood pressure. I freaked out a bit, I’m way to young for that! So he ordered a stress echocardiogram. A stress echo is a test that involves, at least my my case, shaving your chest, sticking some electrodes on and running on a treadmill while the cardiologist plays the name game to see if you work with any of the other docs he went to school with. The pronouncement: hereditary hypertension, there’s nothing I can do about it but take my meds. “You’ll be fine,” he said, “just take the pill and it’s nothing to worry about.”

The pill costs me $20 a month. Not bad, right? My insurance covers the remaining $30, which comes directly out of my employer’s coffers. Still, not a huge price to pay, all things considered. But, something in the back of my mind told me I was too young to be on BP meds; at this rate, what’s next?

The case for support

The last meaty thing I ate was an extremely large – and, I’ll add, quite tasty – pulled pork sandwich from a food cart outside the Petaluma Market in Petaluma, California. I remember it vividly, including my sauce covered fingers working to stuff the thing into my pie hole. It was damn good! I was on my way to pick up a vegan coworker at the airport and intended to adopt his diet as an experiment for the next few days. What was I going to do to stash the evidence?

That night we ate at white table cloth, rather high end vegetarian restaurant in the Mission district of San Francisco. “What do I order?”

“I’m having the tamales, they are totally vegan”

“That’s what I’ll have too then….”

I had the ability, we were in the birthplace of the fresh food revolution in America. I also had the motivation, I was excited to try a four-day experiment. Four days of eating in the Bay Area with an established vegan might be the best way to recalibrate your diet ever. It’s also all about support: the restaurants, the menu, the coaching, the lack of pressure since we were both on the same page food-wise…

When I got home, I told Susan about the trip and diet. “Here, let me cook dinner tonight, I’ll show you the kinds of things we ate…” And with that, I had one more day under my belt. And, more importantly, I had another notch in my support belt. Susan was eager to try her own experiment with diet change and together we could be mutually accountable. We could also cook for each other and not worry about having two separate menus.

There are also other, less obvious forms of support. The privilege of eating a plant-based diet of whole foods hasn’t been lost on me. It’s sadly more expensive to buy a grocery cart full of veggies, grains and legumes in this country than a cart full of subsidized corn-based processed foods. Having the financial support to make substantial diet change is not something I take lightly.

See what I mean? Support, particularly in any behavior change, makes a world of difference.

In part 2…

• Self Tracking
• Data
• My cost curve
• And the big reveal

It was the best of times, it was the worst of times.” Dickens wasn’t exactly talking about graduate school, but he might as well have been. After two long years, Susan graduated top of her class in 2010 from The American University with a Master’s of Science in Organization Development. In 2011 she was invited to become faculty in the program, giving her more opportunities to visit Toni and George (Susan’s parents).  In January 2011, Nick started an Executive Master’s of Hospital Administration through the University of Minnesota. Somehow, we’ve still found time to have some fun.

Susan traveled for work: England, Ireland and Spain. Nick was asked to speak a few times: Colorado, Las Vegas, Palo Alto, Chicago. Together we skied everywhere that had snow and a hill.

The early cold months of 2011 gave Susan time to perfect her passion for brewing. In January, she began Suze Brews – a very limited release of some seriously premium beers.

Summer gave us an opportunity to come together. George (Nick’s dad) was diagnosed with a tumor on his common bile duct. After a complicated surgery,  with his strength and your thoughts and well wishes, he’s doing great!

Between papers, dog training, and half marathon training, we’ve also found time to keep our 1973 Series III Land Rover on the road. This summer, we tackled the Mid-Atlantic Land Rover Rally with our friends, the Thews. It was four days of mud, Rovers and fun in the wilds of central Virginia. Ippa had a blast!

In the fall, Susan and Rosemary (Nick’s Mom) finished the Richmond half marathon with record times. Nick is training for the Monument 10K in 2012. Together, we started this vegan thing in September. Collectively, our belts are looser, steps lighter and hearts happier. What a year!

Thank you for being a part of our life. Here’s to seeing you more in 2012!

Nick ,          Susan,                Ippa,       Turley        &       Sydney

The following is a guest post from my father, hero and best friend George Dawson. 

“Illness is the night-side of life, a more onerous citizenship.  Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use only the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place.”  ( American author and activist, Susan Sontag Illness As Metaphor (1978)).

My citizenship in that other place began on August 4, 2011.  It came without much time to get ready. The week started with a routine visit to my primary care physician and ended with a diagnosis of cholangiocarcinoma (cancer of the common bile duct) at Johns Hopkins.

For the past 30 years I have been a hospital CEO.  Cancer caught up with me two months before my scheduled retirement as President and CEO of Centra, a 6000 employee health system serving central and Southside Virginia. Aside from several outpatient procedures,  I had never experienced a significant illness or injury.  In some ways my professional career prepared me to be a patient.  I am still learning about the gaps in that readiness.

Throughout my career I have been very interested in what we have come to call ” the patient experience.” Centra, like many health care systems, has focused intently on patient satisfaction and the various related topics and measures of how our patients feel about their care.  We have been students of Quint Studer and his ideas about how to better serve.  We have listened to Fred Lee tell us how Disney would do it.  And we have benchmarked our performance against other healthcare systems using metrics from Press Ganey and the CMS HCAPHS reports.

As a patient,  I am learning new perspectives.  One of these has to do with the loss of personal identify I felt as I entered Sontag’s Kingdom of the Sick.  In the Land of the Well, people know who I am.  Certainly this fact relates, in part, to my role as the chief executive of a large organization in our community.  But it’s more than that.  People also know me as a husband, a father, a skier and a guy who grows heirloom tomatoes.  My friendships and associations go back 30 years. Just as each of us has a distinct fingerprint, every one of us has an identity that is unique and personalized.

When I became a patient, I felt this identity slipping away.  Immediately the focus was on my illness and treatment.  There seemed to be little time to understand or consider the person who was hosting this particular cancer.  I found myself trying to engage my nurses and doctors in conversation to establish some identity as an individual.

In one sense, my feeling of personal anonymity is the product of a good thing.  I chose my doctor and Hopkins as the place for my surgery because of their expertise and the large number of surgeries they perform on cases like mine.  Some 300 patients a year receive Whipple procedures at Hopkins.  It is a long and complex procedure and involves significant post-op care. I was an inpatient for nearly two weeks.  At Hopkins the clinical pathway for this procedure is well established.  Everybody on the treatment team knows each step of  the process and his or her role.  This is one reason why Hopkins has excellent outcomes for Whipple surgery patients.

At Centra we don’t perform Whipple procedures,  but we do plenty of high volume procedures with excellent outcomes. Examples include cardiac cathertizations, total joint replacements and breast surgeries.   Each has a well established clinical pathway and a clearly defined process.  My time as a patient makes me wonder how well we understand  and accommodate the uniqueness of each of our patients. How often do our patients feel the same loss of individual identity that I have felt?

Some specific ideas:

• It is about taking time to ask and listen to patients.  In our daily rush to complete the social history screen in the Electronic Medical Record,  do we really ask our patients who they are and listen to their  response?
• It is about the symbols and customs we adopt.  I have developed a adverse reaction to hospital gowns –  the kind that are split up the back.  For me the gown has become the symbol that I am in the Kingdom of the Sick.  When I put one on,  it’s a little like surrendering my passport.  I wonder what other unnecessary symbols and props we have adopted in healthcare.  And I wonder how often they serve to protect our status and control  rather than serve our patients interests.
• It is about the fragmentation in healthcare.  Specialized intensive care units, hospitalists and multiple consultants  have lead to greater clinical quality and efficiency.  At the same time they are barriers to really knowing our patients.
• It is about information.  The better we understand  the clinical pathway,  the greater our opportunity and responsibility to explain it to our patients.  If we listen as we do so,  we have the opportunity to understand what alterations or modifications are needed to meet each patient’s unique needs. In doing so, we have a chance to increase patient ownership and responsibility for recovery.  If we leave the patient out of the information loop the best we can hope for is a passive partner in the process.

I understand the difficulties those of us in healthcare face.  Short length of stays, pressures on productivity,  the complexities of our professions are real challenges. My lifelong  experience in healthcare management tells me pressures like these make it hard.

So I will leave  you with just one  question,  how well do you really know your patients?

Steve Jobs
1955-2011

I’m sticking with my ambiguous language here. While I have been a passenger on this journey, it has not been principally mine. Of course, that also begs the question: why am I writing about me then? Its my blog. Ok, its also because that’s the part of the story I can tell.

I was talking to my next door neighbor, T, recently. They have their house on the market and brought in a stager (an expert on arranging the house to make it attractive to buyers). The stager had them put a lot of their stuff into storage, de-cluttering the house. T told me: “I may just not unpack any of it from storage, we haven’t really missed that stuff at all.”

The last few weeks has been life changing. Many of my deepest beliefs have been affirmed and some challenged. There’s this idea about crisis compelling change. Often, great leaders emerge, or find their real strengths or a sense of clarity, from a crisis. The same is true for organizations. And, the same has been true for me.

When you are forced to drop everything and focus solely, singularly on something unexpected, it really helps you figure out what matters. I put most things in my life on hold over the last two weeks. As it turns out, some of those things on hold really weren’t that important. Some of those things, like friendships, were the reason I could just step away for a while.

More than anything, I hope this clarity, the little bit of magic which comes from a fast of daily life sustained only by a cocktail of difficulty and support, remains. I wouldn’t want to lose this. The feeling developed over a few days of lingering in the stale air of a hospital ward. It culminated as we sat together one morning on a balcony overlooking the hospital grounds – a setting and moment entirely pleasant enough as to be disarming considering the circumstances. We were opening cards, literally hundreds of them, some from people we didn’t even know personally. That mattered. Those cards mattered. Friendships, relationships, love, compassion, kindness, strength, encouragement, positivity, empathy….those things matter. Care matters, as do caregivers – those people who are drawn to giving a part of themselves to someone else, as a choice of profession – they matter.

Family,  perhaps above all else, matters.

First, a note sincere gratitude for the many notes, tweets, comments, emails, texts and calls over the last week. Please know they are greatly appreciated. Posting here is cathartic and I’ll continue to share while respecting the privacy of those involved. I kindly ask readers to do the same. Finally, I’ll offer a preface to this post – its an update pure and simple. No style. Nothing profound. 

If there is such thing as an intensive masters education in critical care experience, then  consider me a graduate. We’ve had an intense twenty-four hours, punctuated by optimisim and encouragement. Most importantly, I’m utterly floored by the strength and courage of what I’ve witnessed. While some of the weight comes off of our shoulders, I’ve been thinking about the idea of pressure relief valves, in a metaphorical sense.

First, my previous post was pretty raw. I offer no apologies for the language or the content. Although, I’ll admit a few tinges of embarrassment… Fortunately, you have all countered with gracious sympathy. Thank you for that.

Writing that post was a pressure relief valve for a lot of emotion. It was a way to express fear, anger and a loss of control. It was also a way come to grips with the reality that not all healthcare experiences are the same. A no brainer, right? There will be plenty of time to write more about that later.

Secondly, I want to tell you about someone I met here and her unique role. K is a care coordinator. I had watched K most of the morning, interacting with family members in the waiting area – I couldn’t quite figure out her role. Translator perhaps? Every time she went over to a family, she got down on one knee, to be the same height as a seated person. She leaned in when she listened with a smile which wasn’t forced and instead conveyed “give me some of your burdon, I can take it.”  K has what some call the X factor, that difficult-to-describe trait where service isn’t something she learned, its a natural skill; she was born with it the same way some athletes are just gifted.

I hope I’m not becoming jaded…well, more jaded than I was before… but I’ve started to question if you can truly teach service. Of course we can teach expressions like “please allow me to find out for you,” or “its my pleasure.” You can even teach someone to get down on a knee to be closer to eye level. But can you really teach someone empathy?

When it was our turn, K came over to talk to me, taking a knee. She introduced herself as a care coordinator. “Its my job to help you and the patient with whatever you need, starting with a bed. Here’s what we have arranged for you… here is how the next few hours will go. Is there anything I can help with – do you need a hotel, or something to drink or eat?” It wasn’t scripted.

I told K about my role in our health system and about my interest in experience and service. I asked her how they trained her. “It all starts at hiring. We have to hire the right people, not everyone can do this job.” K went on to tell me she had worked for Disney. For those who haven’t read Fred Lee’s If Disney Ran your Hospital, every job title at Disney is performer. If you sweep the streets, you are hired to play the role of a janitor. In patient care, we have to play the role of caregivers. K gets it.

In addition to customer service and family support, care coordinators help arrange rooms and transportation. As another care coordinator, on a patient floor, told me: “we can do anything that’s not clinical.” This is a special kind of role, different than a unit secretary and every bit as integral in patient care as a nurse.

I asked K how she felt about her role. “I provide the customer service support for patients and families. I get to help take care of things so nurses can focus on what they do best. I’m the pressure relief.”

This post is a deviation from my normal demeanor in both subject and language. It may upset some readers. If the language offends you, then I hope you never find your self in a similar situation. I’ve intentionally been ambiguous about identity and relationship. It’s not my information to give away. Please respect that and do not ask. I just ask that you send your positive thoughts, prayers and love. 

I’ve spent my whole life with a front row seat to the healthcare industry. I grew up in it. I don’t talk about that much, it’s important to be my own man. Here I am, apple fallen next to the tree, in my front row seat isolated and insulated like a surgeon’s hand in a latex glove.

I write about patient experience, idiotically thinking two busted knees and an annual physical qualifies me as a real patient. That’s bullshit. The smug sense of pride I feel when I walk a family to a patient’s room, putting on my best customer service show for a family who’s only thought is, “dear God make him wipe that smile off his face, he doesn’t know what scared is,” … Who do I think I am?

I’ve watched all the medical shows, with their perverted dramatizations and absurd scripts. I know how we are supposed to react to news Some will-be-soon indie band plays us out to commercial.  That’s when the lump in your throat is supposed to swell up. But the truth is when you get the call, it is nothing like TV. Music doesn’t play, you aren’t standing in the rain in some pensive repose. The truth is you are in some shitty place running some shitty errand. Except now that shitty place and shitty errand will always be the place where you found out someone you love very much has cancer.

That’s when it all changes. The prophylactic glove is punctured, the front row seat exposed.

Today is different than yesterday. It looks the same, and smells the same but it’s not the same. There is less air. We’re suddenly part of those TV dramas, only there’s no script for this. No one tells you how to comfort your heroes. No one tells you what do to do with the anger.

The nurse, doing her best job to be best care giver she knows how to be – when she refuses to look up from her monitor to look me in the eye, I want to scream. The countless, faceless staff walking with their heads down to avoid eye contact, least they have to show me how to get somewhere, I hate them too. Where is their smug sense of customer service job well done? I hate everything about this sterile, cold, insensitive, plastic, sanitized environment. Want to hear what I think about the doctor who thinks more Latin than English is an appropriate way to update a family?

And yet, I’m tied to this place, all my faith is in it. I’m as emotionally invested as it gets. When I its logo on the wall, my brain retrieves my opinion, filled in my vault of prestige somewhere between NASA and the presidential seal. It’s that kind of place. I need it to be.

I don’t pick sissy heroes. This is a minor set back in an otherwise kick-ass existence. We’ll win at this and that will be that. So hear the earnestly, determination and convection when I say loudly: Fuck Cancer.