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Eat Dessert First

Nothing is certain, especially in health care.

by Emily Friedman

I've never figured out how, when, or where being certain about things became a positive human trait. Perhaps it goes back to the time when human beings (or their primate predecessors) were challenged daily by volcanic eruptions, eclipses, attacks by both human and reptilian foes, and the occasional earthquake. Living in a world of such dire uncertainty would make it quite easy for a tribe to ascribe superior or even spiritual powers to someone who always seemed sure about what was going on. In fact, that certitude may well have been so seductive that people didn't mind when it didn't pan out. When we want to believe something, we always have an explanation for whatever challenges our beliefs.

Today, eons later, we are still confronted with certainty of belief. Shortly after September 11, two Protestant fundamentalist leaders announced that they knew for sure that the United States had brought the terrorist attacks on itself by "tolerating" feminism and homosexuality. The Al Qaeda and Taliban fringes of Islam apparently have an absolute conviction--one that they are willing to die for--that Allah approves of mass murder and the brutal subjugation of women. Religious extremists in India assassinated both Prime Minister Indira Gandhi and, years later, her son Rajiv, in the name of their faith. And the Israelis and Palestinians have now passed the half-century mark in what seems likely to be a modern Hundred Years' War.

But the notion of absolute certainty goes far beyond religion. In the Declaration of Independence, the creators of the United States of America stated, "We hold these truths to be self-evident, that all men [italics mine] are created equal. . . ." Women, of course, did not count, nor did African-American men, male indentured servants, or men who were not landowners. To the founding fathers, this was the self-evident truth. Marx and Lenin believed that socialism, which was supposed to evolve into pure communism, was the only way to organize society; Americans believe that capitalism is the only way to go, and sometimes we insist that other societies accept this notion, even if the result, such as the mess unfolding in Russia, is catastrophic. We state on an unfortunately regular basis that ours is the best health care system in the world, despite the fact that most of the people who announce this "truth" know precious little about other nations' systems and seem oblivious to the fact that one in six Americans has no financial access to our system. And in a display of amazing hubris, a television station in the San Francisco Bay Area describes its region as "the best place on Earth"--earthquakes, economic disasters, and unaffordable housing notwithstanding. Apparently they have never been to Hawaii.

Yet we continue to follow those who seem sure of themselves and of their environment, perhaps because we are so unsure of these things ourselves.

Healthy Uncertainty

On the other hand, we are also drawn to those who challenge claims of certainty. Galileo suggested that maybe the universe wasn't constructed with the earth at the center of it all. Christopher Columbus--whose main goal was not to make history, but rather to find an easier route to the East Indies--didn't think the earth was flat, despite the fact that nearly everyone else at the time did. Darwin challenged some of the most basic tenets of Christian theology. Sojourner Truth taught the slave owners a thing or two about the skills and strength of African-American women. Gandhi proved that large numbers of committed nonviolent resisters could defeat a wealthy and extremely well-armed occupation force. Florence Nightingale offered the astounding idea that maybe we shouldn't just take physicians' word on the quality of their care, but should rather try to quantify the results. Simone de Beauvoir and Betty Friedan argued that women are not, in fact, a lower form of life.

These mavericks and rebels, who challenged the certainties of their times at enormous risk to themselves, changed the world. They reshaped the prevailing notion of what was thought to be true.

Not surprisingly, this conflicting view of certainty--that it is comforting on the one hand and a barrier to productive change and creativity on the other--can cause an enormous amount of anxiety in the world of health care. Why? Because health care's environment is even more uncertain than that of society as a whole.

Just think about the last decade. Managed care, which had been seen as some kind of hippie boutique oddity in California and Minnesota and Massachusetts and a few other places, became the dominant form of employment-based insurance--only to run head-on into protests, hostile press coverage, litigation, regulation, and restrictive statutes. Former president Clinton announced a universal access program that dominated the headlines for 18 months, then faded in complete failure. Ten years ago, we thought we had health care inflation licked; in January of this year, the federal government reported the highest cost increase in a decade. Pharmaceutical manufacturers were the good guys whose products could replace invasive and labor-intensive services; now they're the villains, accused of profiteering, greed, and illegal hoarding of patents. In a wave of "efficiency," hospitals laid off thousands of nurses; now, for some funny reason, they can't seem to find enough of them. Highly touted mergers of hospitals and systems have disintegrated into name-calling and fragmentation. High-flying health care organizations, for-profit and nonprofit alike, turned out to be making their money by engaging in unethical and, in many cases, illegal activities. And managed care turned around one day to find that provider systems had gained enough market leverage to be calling a few shots of their own.

Within individual health care organizations, those at the top were busy tossing out the five-year plan as virtually everything in their environment changed. Those in the middle and at the bottom were asking questions, with an increasing sense of dread: "Is this place going to stay open?" "Are we going to be bought?" "What do you mean, I have to learn an entirely new information system?" "Why are the policies different every week?" "Am I still going to have a job?" "How can I do my job, plus the work of the two people they just laid off?" "How much more of this do they expect me to take?"

The answer, for the most part, was a resounding silence.

You Never Know

At the risk of sounding certain myself (and as a trend analyst and historian, I am not a great friend of certainty), I would make two observations. The first is that health care is never a static entity; it is in a constant state of change, and those who want it to stand still are not only dreaming, but also present a grave danger to patients and to the organizations with which they work. It was only 150 years ago that a few courageous American physicians were castigated for insisting that obstetricians wash their hands between births once it had been demonstrated that childbed fever was being transmitted by those who were delivering the babies. And the tepid and largely paranoid response of many health care providers to the patient safety issue shows that we have not come all that far since.

My other thought is that contemporary life is not a sure bet, no matter how much you try to make it so. You can live in a gated community and drive a bullet-proof car and own a gun, and some drunk in a truck can still end your life at a nondescript intersection. You can eschew tobacco, alcohol, and other drugs, and eat your vegetables, and exercise responsibly, and die of food poisoning from the sprouts on your sandwich. There are entire industries in this country, from alarm-system firms to total-body-scan peddlers, who promise you a greater degree of certainty, a protection from the basic fact of life that goes back to the folks who did not understand eclipses or dinosaurs: You never know. One of my favorite proverbs is known as Holten's Homily. It tells us, "The only time you can be positive is when you are positive you are wrong."

So think for a moment about what it would be like if we were really, truly sure about everything. You would know that you would have the same job for the rest of your life, that you would never have to learn new skills, that things would always be the same. You could do the same thing, be with the same people, and think the same thoughts forever. Now, come on; how appetizing does that sound? Being laid off or driven out of your job isn't fun; having to strike out on your own is terrifying; trying to learn new things, especially if they have anything to do with Microsoft, can almost guarantee you a migraine, if not an ulcer. But it also keeps things interesting, and in my opinion, much as I hate being broadsided by change, it keeps us engaged, alert, and feisty.

Uncertain Suggestions

So, if not in praise of uncertainty but more in acceptance of its inevitability (the inevitability of uncertainty? Now, there's a concept!), I would like to offer a few suggestions for coping in a world that will continue to smack you in the face with the unexpected.

First, separate the serious from the trivial. Whether your team is going to make the play-offs is not worth an anxiety attack. Whether your organization's policies are going to cause harm to patients is worth investigating. Many angst-producing situations, such as a football game or a minor tiff at work, are highly transitory and won't matter the next day. Don't give yourself indigestion worrying about the inconsequential.

Second, try to get information, if you can. Many times, our uncertainties and fear are simply the product of lack of information. Often, that information is not being intentionally withheld (Enron aside); the person with the information, usually a manager, supervisor, or executive, does not realize that the information is important to the staff. I have had several situations in my life in which events that I considered to be key to my future were announced on the news or in some anonymous memo or in some other impersonal form, and I had to live in Panic City until I could find someone who could tell me what I really wanted to know: What are the consequences of this? What will happen short-term? Long-term? What becomes of me?

One of the down sides (and there are many) of the increasing cultural, financial, and social gap between those who work in the lower 90 percent of health care and those who work in the top 10 percent are that those at the top assume the rest of the employees know what the implications are of a given event. Most of the time, they don't. And they're scared.

Third, avoid gossip and rumor. In a country where tabloid thrills like The Weekly World Globe, Inside Edition, and Maury Povich are the daily bread of millions, this may sound a bit unrealistic. But professionals in any line of work should be able to discern between totally unsubstantiated claims for which there is no source and no documentation and information that sounds reasonable and probable. Gossip and innuendo are so common in this society--such-and-such a celebrity did this or that, such-and-such a politician is guilty of that or this--that we expect them. We have become used to claims of Martians in New Mexico and two-headed women in Tierra del Fuego--and if you hear these assertions often enough, you start to wonder.

In the privacy of your home, you can fret about rumors, if you like. But spreading them, or, even worse, starting them, does no one any good. I have, in my life, been both victim and victimizer when it comes to rumor mongering, and I try not to fall prey to it now.

Fourth, try to be prepared, within reason. I have friends who have worked for the same firm since college, and are perfectly happy with that choice. I know folks who have lived in the same place for decades, and have no plans to move. I have clothes that are older than my goddaughters.

But I also know, from traumatic personal experience, that the world in general and my world in particular can turn on a dime. As much as continuity, long-time relationships, and familiar employment are a part of life, so are discontinuity, sudden severance of relationships through death or other forces, and the unforeseen end of employment.

Keep your resumé up to date. Back up your hard drive. Keep a flashlight handy. Save some money. Do not dwell on the possibility of apocalypse, but do not deny it, either. As they say in the earthquake preparedness ads, plan an escape route. Then, if the worst happens, you will not be overwhelmed by panic; you will know that there are things you can do, whether it is taking the flashlight to check on patients or looking for a new job.

Fifth, enjoy the ride. I do not recall who it was who said that the real poverty is the absence of possibility, but it was a brilliant thought. Think of all the people who were born into feudal and other societies where their future was determined before they were born, just because of who their parents were. Think of all the people who have had no choices in their lives--bound to slavery, bound to a particular piece of land, bound to a job, bound to a certainty. Those of us who have choices are lucky--extremely lucky. And choice is enhanced by uncertainty. If we knew, absolutely knew, what was going to happen, and what the consequences of our decisions would be, our choices would have no more meaning than selecting grapefruit at the grocery. Nothing in this life comes without a price, and uncertainty is the price we pay for having the opportunity to choose.

So in the end, despite the fact that I often hate it, I think uncertainty is better than the alternative. It is worrisome at best and frightening at worst, and it can lead us to seek shelter when we should be out exploring. But I do not think that we learn and grow at the hands of the expected; rather, we do so at the hands of what we did not expect, and perhaps do not even welcome.

So, if life has taken a left or right turn on you, and you realize that you are being sent in an entirely different direction than what you had in mind, enjoy the ride. And learn. Be grateful that you have the chance to experience something you might not have chosen, in your safety and contentment. And heed the words that are emblazoned on many a pastry chef's apron: "Life is uncertain. Eat dessert first."

This article first appeared in the March/April 2002 issue of Health Forum Journal

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