Month: October 2019

There is an old saying in health care: “no margin, no mission”. The perspective was not originally meant to be harsh. Instead, it was intended to remind employees within many non-profit systems that mission cannot be pursued unless adequate finances keep the doors open. Money must be considered. A positive “margin” (i.e. revenue exceeds costs) must be achieved. If not, the organization cannot survive very long.

I’ve never much liked the expression, I must admit. Sure, there is truth behind it. But so is there truth to “no food, no life” and you don’t hear too many people saying the obvious about food in countries that aren’t experiencing a famine. It is simply understood. It’s an inherent part of the basic rules of sustainability.

And yet I’ve heard the margin mantra all too often in my career, especially in the past decade. Usually it’s mentioned by a finance person, or a new health system administrator. Typically it’s spoken to physicians, nurses, and other clinicians when a new administration is planning on making some cuts, offered soberly as if the people taking direct care of patients never themselves had to balance their own checkbook or bank statement. There are a lot of health care MBAs out there who seem to think that clinical staff don’t understand the necessity of budgets, operating margins, and cost containment. It must be something those folks are taught in business school. “Doctors don’t care about spending,” they must hear. “Careful or they’ll break the bank whenever they can.” Why else would a non-clinician sigh, hold his hands as if standing in a pulpit, and prophetically declare “No margin, no mission” in response to questions from clinicians about spending?

Please. The person making the most money in the health system is preaching about the importance of margin to staff who are about to be told that their nurse-to-patient ratios are too high? This isn’t about margin at all. It’s about how much margin. Which is a different thing entirely.

Not all hospital administrators or health organization chief finance officers are like this; I’ve met some good ones, people who don’t think about the “bottom line” as a set of spreadsheet numbers or financial goals. However, it’s scary how many actually do. The percentage of people running health care in this country that sit in offices separated from where people get care and pass judgment on waste and cost-effectiveness is frightening.

“What does he do out there?”

That was the question that a CEO once asked about me when, as chief medical officer, I used to walk through the hospital once or twice a day, often before the sun was up or well after it had set. This person didn’t ask me. No, he asked my retiring predecessor.

“What did you tell him?”

My friend shook his head. His eyes looked sad. “You should keep your options open,” he told me.

Ah, my options. Yes. Indeed, I kept them open. A few months later, after tolerating more than a few childish outbursts and lectures about the importance of budget cuts in a system that had operating margins well above the norm, I exercised the one that made the most sense: I left. Any place that wanted me to “choose which side I was on” (i.e. doctors or administration) was not a place that understood why it was there.

No margin, no mission? How about this: no mission, no meaning.

It is seductive, the margin argument, as it is – to a degree – logical, practical, and pragmatic. Margin pays bills. Margin replaces equipment. But who decides in the margin world what count as funding priorities? Who gets to say how much margin is needed to feed savings and investment portfolios rather than after-hour and weekend nurse-patient ratios? It can be shocking, even shameful, how quickly perspective can be lost on what matters when the view to meaning is distorted by the thick and opaque lens of margin.

Mission gets forgotten. Morale sinks. People suffer.

It’s no wonder that there is surging interest in something better, something that makes more sense. ‘Medicare for All’ isn’t some communist plot to destroy health care companies. It is a rational response to the lunacy of what we get when margin motivation goes unchecked. It is a reasonable request for balance in a so-called ‘health care system’ that seems uncertain why it exists in the first place.

Does ‘Medicare for All’ really have a chance in our current political climate? Is it even the right solution? I don’t know. But maybe the debate will help clear some cobwebs from our collective thinking. Why is it we have even developed a system of care delivery in the first place? Do we deliver care in order that it can be financially sustainable or do we do so because we actually want to help each other heal?

No margin, no mission? Left unchecked, that pithy maxim is a Faustian bargain, in disguise. Because, when it comes to health care, margin without mission can be meaningless.

It’s that time again, in the northern hemisphere, when trees shed their leaves, flowers release their blooms, and the winds of fall sweep us through another cycle of change. There is something about the blush of color covering the season, the quiver of yellow, orange and red across nature’s outstretched hands, that makes my skin tingle. I am drawn to surrender myself into the embrace of such inviting wonder.

We talk sometimes about autumnal color as if it is painted atop our environment forms. It is not, of course. The richness of a maple tree’s crimson brilliance or an aspen grove’s golden shaking comes from within. There is a complex chemistry at work, an interplay of light, temperature and moisture with the nutritional sugars running through arboreal veins that generates the unique palette of pigment that we experience every September and October. The magnificence of nature is not something applied by an external artist.

The beauty of the fall springs from the internal.

All living things have an aura, an energy field that surrounds each form of life. Whether plant or animal, the energy radiating from every organism is real. It can be measured – as heat or electromagnetic wave. It can be experienced – as color, vibration, or frequency. It can be visualized, through special photographic techniques. We and the world around us resonate. We exude life.

There are people who report that they can perceive the color of a person’s aura. I’ve never been able to do that; no matter how much I try to soften my gaze, color fields surrounding others, if they exist, are not visible to my naked eye. I can, however, feel when someone’s energy is open, hesitant, or hostile. That sensation doesn’t need my eyes. It is accessible through other channels.

I can also feel when my own energy changes. And, if I pay attention, I can watch how those around me react to that change. For better or for worse, my thoughts and feelings can be sometimes exposed by the flow of energy inside me that, like a tree’s sap, reaches the surface of my physical being in surprising and not always helpful ways.

Have you ever closed your eyes and turned your awareness into your center? This is accessible through various relaxation and mindfulness techniques. For me, I sometimes shut my eyes to see, with my internal vision, what sort of energy is within. The experience can be powerful. First, there may be nothing; my vision peers into an emptiness. What follows may be a series of hazy, almost imperceptible pulsations, as if the images that my retina last received from the external world are dissembling, the nerve cells still twitchy and responsive to that input. Then there is nothing, an inky yet un-inky stillness. I might call it black but it is really emptiness. The retina receives no stimulation. There is nothing to see. There is no light or form to process.

If I open my eyes, right at that moment, the outside world seems fresh. But, if I keep my eyes closed, if I bring no thought or intent, and if I let my vision relax while maintaining something I can only describe as an internal viewfinder, sometimes, from somewhere deep within the optical emptiness, color stirs.

At first, it isn’t really color; there is only a sense of a swirl, of a probing, a release. I am not reaching in, like some painter with a brush. Instead, what is within seems to be shimmering outward. I can almost feel a force within me feeling itself freed to open, to expand. There aren’t thoughts associated with this. There isn’t emotion. It is almost a non-physical energy. It isn’t a memory. It isn’t some sort of sheltered consciousness. It is uniquely itself.

And then, sometimes, if I just allow the experience to be, like a flower in the sun, it opens. Streams of essence enter. Like a non-physical well that spontaneously gushes from depths beneath my physical form, a sense of expansion swells and, with it, color. Orange, green, blue, magenta and a range of the rainbow rushes up and out, as if a celestial fireworks is fired from the most internal place that this form I call “me” can experience. I cannot and do not ask for color. I simply experience color. In the strangest and yet most wondrous of ways, I am color. Or, in an odd yet magical way, color becomes me.

I am light; I am dense. I am expanded beyond my skin; I am life contained within the semi-porous boundary of my physical form.

Is this how a tree feels when it vibrates majestically in the autumnal sun?

There is so much beauty in the world. In the seasons we are blessed to have, may we all continue to learn how to share as much of that beauty as possible.