Having this day reached my “three score and ten,” I am drawn to think about things which define who we are and how we will be remembered.  Having possibly entered the last decade of my professional life, and maybe being further along than even that - no one knows - I think about what I have learned about excellence in the practice of medicine and excellence in being a patient.  These thoughts have reminded me of a tree and of the lessons which I learned from that tree.

Lessons from a Tree

Let me tell you a story about a tree.  It was an ugly tree actually, which is remarkable as I have rarely seen what I judged to be an ugly tree.   It stood to the right side as you faced toward our house.  It had been there for many years and grass had been allowed to grow up under and around the tree.  Junk had been discarded and thrown under the tree, allowing it to become an eyesore in the neighborhood.  I know this tree well because it was on the north side of the first house my wife and I bought in San Antonio. 

It was a beautiful house in a very nice neighborhood.  I worked every weekend I was off during my internship and residency in order to supplement my residency salary of $500 a month in order to provide this home for my family.  During my second year of post graduate training, I would leave San Antonio on Friday afternoon and drive to Bryan, Texas, where I worked in the ER until Monday AM.  I then drove back to Beaumont at 4:00 AM to start at the hospital by 7:00 AM.

After living in this house for a couple of weeks, “in my spare time,” I decided to get rid of this junk heap and this ugly tree.  I discarded all of the junk, mowed the grass and began cutting the tree down.  Realizing that cutting out the roots was the only way to “get rid” of the tree permanently, I dug down to the tap root.  I cut off the root four feet under the ground.  I then planted a flower garden on the spot.  All of our neighbors began stopping by and commenting about what a beautiful spot that eyesore had become.  One of my medical school professors lived across the street and he and his wife often commented about how this effort had improved the neighborhood.

Several years after that, we moved to Beaumont.  We reluctantly sold that house.  I had put a sculptured patio of my own design at the back of our large back yard, put lighting in the beautiful Spanish oaks, planted dozens of roses and made other improvements.  We still talk about the “Green House” with pleasant memories.  It was almost twelve years before we returned for a visit to San Antonio.  The first thing we did was drive by Spanish Oaks, the street on which our house stood. As we drove by, I was shocked.  There stood the tree I had cut down, only now it was at least 7 feet taller than it had been when I cut it down. 

I learned a life principle from this tree.  We can beautify our lives and make them look pretty by removing the obvious clutter but if we don’t root out the problems, they will re-grow until they are bigger and “bad-er” than they were in the beginning.  Our lives require constant attention in order to be the best we can be.  Excellence requires relentlessness in its pursuit.  Procrastination, compromise, and slothfulness will all destroy our best intentions.

Application to Medicine:  Provider and Patient

In medicine, the incessant “routine-ness” and recurrence of those routines are such that it is easy to “fall behind.”  And, when we are behind, we become despondent, or forlorn, giving up on any idea of “doing it right,” and just wanting to “get it done.”    It is not unlike the person who finds themselves morbidly obese with all of the health problems associated.  They did not set out to become obese; it just happened.  When the weight gain started, the patient thought, “Well, I’ll stop next week,” but two years and 60 pounds later, “next week” never came, and the patient rationalizes, “this isn’t so bad.”  Before long, 60 pounds has turned into 200 and there is no reason to stop.  It takes no imagination, using our weight-gain metaphor to see what happens when a person gets themselves in hand and loses 70 pounds, only to lose their focus and like this tree reach a larger size when their attention and energy are focused on something else.

Relentlessness

Excellence in medicine is not practiced by the person who knows the most or even by the person who is the brightest.  Excellent medicine is practiced by the person who relentlessly pays attention to details and who consistently completes the mundane, routine tasks which cumulatively result in excellence. 

Interestingly, like our tree, when a health-care provider is “doing it right,” it becomes easier to continue doing it right.  As a person stays current with reviewing lab, x-rays, telephone messages, correspondence, procedure reports, orders, information and referral requests and a myriad other routine, ordinary and mundane tasks, staying current becomes easier and easier.  Conversely, when lab review stacks up; when x-rays accumulate unread; when telephone messages go unanswered; when correspondence, procedures and information requests are not dealt with, like the morbidly obese person who “gives up,” it is easy to rationalize that:

• I just don’t have the time
• I am too busy
• I have more important things to do
• I am so tired
• This is overwhelming, etc.

Involutional

Done routinely, routine tasks become our friends; ignored too long, they become tyrants which oppress us.  In medicine, the word “involutional” means, “The gradual and progressive decreased function of organs and tissues as a result of the natural aging process.”   In the practice of medicine, the term means “the deterioration in performance by a provider.”  The more we neglect doing things right; the easier it is to justify not doing them right.  I am trying to apply the lessons learned from this tree to the practice of medicine, as I experience how much easier it is to keep up when you stay up than it is to catch up with you stay behind.  Recently, I have coined a new phase which has become my excellence in healthcare management mantra:  I want it done right and I want it done right now. 

Patients

And, for patients - which means all of us, for even healthcare providers are, also, at one time or another, patients - the principles are the same.  Procrastination - putting things off which we don’t enjoy doing - can result in worse conditions developing, or in treatable and even curable conditions progressing beyond a point of recovery.
The reality is that we are all going to die.  The inevitability of that reality, however, does not mean that we “give up,” or that we don’t do all that we can to maintain, or to regain our health.  But, health is like our tree; left unattended our health will by nature deteriorate. Without intentional acts of health - losing weight, exercising, stopping smoking, getting preventive health such as immunizations and screening examinations - habits of procrastination, neglect or slothfulness, which had been “rooted” out of our lives, will re-grow and become bigger problems than they were before.

Inertia and the 2x4 Room

In physics, “inertia” refers to the principle that a body in motion tends to stay in motion until acted upon by an opposing force and a body at rest tends to stay at rest until acted upon by an external force.  What we must overcome is the natural inclination to do nothing, which often is easier than taking positive actions.  In medicine, we call that “treatment inertia,” referring to the fact that studies have shown that even in the most sophisticated care settings there is a bias toward not making a change, i.e., to do nothing.

In patient choices, the “treatment inertia,” means that it is easier to keep on not doing what we are not doing, or actually to neglect doing what we need to do, than it is to start doing the right thing.  The key to success is for healthcare providers to find effective motivators to make us uncomfortable enough with our present state so that change is less painful or less stressful than doing nothing.  At SETMA, we humorously tell our patients who smoke that we have a “two-by-four room.”  If you don’t quit smoking, we’ll give you an appointment to this special room, where we’ll “beat” you until you quit smoking, i.e., we’ll make you uncomfortable until you find it easier to change than not to change.  In reality, we would never intentional harm a patient but it does give us a reference point to encourage patients to quit smoking.

Whether you are a healthcare provider, or a healthcare provider who is a patient, the need is the same; it is imperative that we make changes and that we sustain those changes. The former is difficult; the latter is where most of us fail.