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FICTION
Jeff Collins, MD of Spokane, a past president of WSMA and widely read, offers the following reviews to members.
Imperfectionists
By Tom Rachman
One of my most cherished activities is to sit with a good paper and a cup of coffee before taking up the challenges of the day. Dating to my college days, Sundays have been special because I could lounge endlessly reading the substantial volume of the Chicago Tribune or later, as it became more available, the New York Times. The Imperfectionists is a novel written by a newspaperman for people who love newspapers. The writing is hip and funny with well-drawn characters, human and otherwise. I really enjoyed it.
The central "character" is an international English-language paper, never named, based in Rome. Cyrus Ott, a wealthy industrialist, founded the paper 50 years earlier, and subsequently, his family has run it, most recently his grandson Oliver.
Each chapter is like a short story-some better crafted than others-that describes the intersecting lives of the men and women who produce the paper, like the eccentric but absent owner, and the one woman who reads it religiously. Much of this seems a bit predictable, in that there are plenty of ready stereotypes to rely on. There is an obituary writer, a news editor, a copy editor, a CFO. Spouses cheat, though with greater frequency than I had previously imagined, dreams are lost, no one gets what he wants and those who seem to loathe their jobs become dramatically devoted when their positions are threatened.
Among the characters is Lloyd Burko who in the opening chapter is introduced as a burned-out Paris correspondent who can't produce, and attempts to use the only one of his four children who will speak to him to get a story. The corpulent copy editor, Herman Cohen, has a style guide the size of a small country, and compiles an internal newsletter of blunders from the paper. There is a truly hilarious chapter about Winston Cheung, a young stringer sent to Cairo, who is exploited by the older and more experienced but on-the-make war correspondent Rich Snyder with an over-the-top ego.
As the stories of these generally likeable characters unwind, so the paper and the newspaper industry spiral downward. The Ott family self destructs as well, until the Ott board forces Oliver to show up and tell the employees the end is at hand. "I'm totally useless at this sort of thing," is the best he can muster.
The novel is beautifully written, interesting, very funny at times, and very sad and touching at times. Louis Bayard had this to say in the Washington Post:
"The Imperfectionists is about what happens when professionals realize that their craft no longer has meaning in the world's eyes...and that the only people who really understand them are on the same foundering ship, and that, come to think of it, they really loved that damn ship for all it made their lives hell...."
Despite our general optimism in medicine, anyone paying attention these days must occasionally feel that we, too, are on a foundering ship. We should appreciate and empathize with those around us, even those who are not behaving well.
Far North
By Marcel Theroux
In a world grown crowded and awful, Makepeace Hatfield lives in a lawless ghost settlement in Siberia, one of five remote cities established by Americans who had opted out of global capitalism. They had lived a simple Quaker lifestyle in a conscious separation from the system choking the world to death, but then they had left or been killed so that Makepeace now appears to be the sole inhabitant.
Far North, a finalist for the 2009 National Book Award, has been widely characterized as "post-apocalyptic." The story begins as a sort of western with Makepeace telling us about life as a constable who rides a horse and carries a gun. Makepeace comes across and takes in a refugee by the name of Ping. Later, Makepeace sees an airplane overhead that makes her (yes her—I hate to spill the beans but the protagonist is a woman although that is not apparent initially) believe there may be other life outside the town.
When the plane crashes, Makepeace sets out in search of remnants of civilization. The remainder of the novel is the story of her journey, which takes her first to a strange cult encampment, Horeb, ostensibly a Christian settlement led by a Reverend Boathwaite who sells her to slave traders. Marched a thousand miles west to an old gulag, she is enslaved for five years but is eventually dispatched as a guard on a trip to a ravaged city known as The Zone, which contains untold wonders. She escapes, and with another slave they trek back for somewhat unclear reasons to Makepeace's town in Siberia.
The story of the journey and the landscape are stark but beautiful. The novel has been compared to Cormac McCarthy's The Road, and there are surely plot similarities, but differences as well. This is a first-person narrative of a small and dangerous world, intensely and intimately experienced. The writing lacks McCarthy's poetic beauty, The book is full of wonderful observations like this one: "Everyone expects to be at the end of something. What no one expects is to be at the end of everything." but the narrator's taciturn dryness is engaging. Although Makepeace is a world-weary cowboy of the old school, her philosophy and reflections on her circumstances seem if not feminine, not entirely characteristic of a hardened cowboy. By choosing a female protagonist, the author gives the entire novel a perspective it would not otherwise have had. "Try as I might, I haven't been able to give up on humanity wholly," she admits. She is witty, philosophical, worldly and acerbic.
As the journey progresses, there is some justice and ultimately redemption. The journey has the weight of 20th century history behind it, but this is no view from 30,000 feet. Everything is up close and personal, full of sensory detail, and all acts have significance and meaning. Personal revelations dominate. From the weathered skin on the faces of the inhabitants and the cruel way they treat each other, we learn more about the state of their world than the descriptions of the stark landscape. "Goodness only lives when time permits it," Makepeace says.
Ultimately, this is an adventure story, well written, evocative, intelligent and enjoyable, sad and sublime. Theroux is not really clear whether this story could be us, our children, or our grandchildren, but nothing in the book puts it too far in the future. Just as he is skeptical of the naïve optimism of Makepeace's father who fled a decaying world, it is clear that Theroux would think little of those who believe that growing a bit of produce and bicycling to work represent in some way a meaningful statement.
The book is full of wonderful quotes or observations by Makepeace. At one point, she says, "Everyone expects to be at the end of something. What no one expects is to be at the end of everything."
Cutting for Stone
By Abraham Verghese
This sprawling and poignant novel was first recommended to me by Samuel Joseph, DO of Spokane (thanks, Sam) and is one of the most enjoyable I have read in the last year. In addition, it's particularly relevant for those of us in medicine.
Cutting for Stone has been described as the epic story of conjoined twins fathered by a brilliant British surgeon and an Indian nun. It is so much more, a portrayal of life and love in all its cruelty and wonder.
The story begins with the illicit and secret years-in-the-making romance between Sister Mary Joseph Praise, a beautiful Indian nun, and Thomas Stone, a brash, brilliant British surgeon. Mary and Thomas meet on a boat out of Madras in 1947; she follows him to Ethiopia and to Addis Ababa's Missing Hospital (a mispronunciation of "Mission Hospital") where they are welcomed by the wise and pragmatic Mother Superior/General Manager Matron. They work side by side for seven years as nurse and doctor. After Mary dies while giving birth to twins—a harrowing, traumatic scene on the operating table—Thomas vanishes, and those twins, Marion and Shiva, quickly separated after birth, grow up with only a dim sense of who he was, and with a deep hostility toward him for what they see as an act of betrayal and cowardice in fleeing.
Hema and Ghosh, two Indian doctors who also work at Missing, raise Marion and Shiva, showering them with love and nurturing their interest in medicine-part of the deep, almost preternatural connection between the brothers. The twins are so close that Marion, the narrator of the story, as a boy, thinks of them as a single entity: ShivaMarion.
Marion and Shiva come of age as Ethiopia hovers on the brink of revolution, and their lives become intertwined with the nation's politics.
Yet it is not politics but love that tears the brothers apart. Shiva sleeps with Genet—the daughter of their housekeeper and the girl Marion has always loved. This second betrayal, now by the two people this sensitive young man loves most, sends Marion into a deep depression. And when Genet joins a radical political group fighting for the independence of neighboring Eritrea, Marion's connection to her forces him into exile. He sneaks out of Ethiopia and makes his way to America.
Marion interns at a hospital in the Bronx, an underfunded, chaotic place where the patients are nearly as poor and desperate as those he had seen at Missing. It is here that Marion comes to maturity as a doctor and as a man. It is here, too, that he finally meets his father and takes his first steps toward reconciling with him. We learn, perhaps a bit late, what made Thomas Stone the man he is, with all his strengths and deficits. Then, when the past catches up to Marion—nearly destroying him—he must entrust his life to the two men he thought he trusted least in the world: the father who abandoned him and the brother who betrayed him. The surprising, stunning denouement both arises from and reenacts the major themes of love and betrayal, compassion and redemption, forgiveness and self-sacrifice, exile and home and ultimately the inextricable union of life and death.
Hema and Ghosh, two of the key characters, are wonderful people, with warm and giving perspectives on life, which they share routinely with the growing twins.
As an example, when Ghosh is imprisoned in Kerchele during a coup in Ethiopia, he ultimately saves a general who can then be hanged. After he returns home, Ghosh relates an incident to Marion and Shiva that occurred in the prison:
In prison, lights were out by eight o'clock. We'd each tell a story. That was our entertainment. I told stories from the books we read to you in this room. One of my cell mates, a merchant Tawfiq — he would tell the Abu Kassem story.
It was a tale well known to children all over Africa: Abu Kassem, a miserly Bagdad merchant, had held onto his battered, much repaired pair of slippers, even though they were objects of derision. At last, even he couldn't stomach the sight of them. But his every attempt to get rid of his slippers ended in disaster. . . .
One night when Tawfiq finished, another prisoner, a quiet, dignified old man, said, "Abu Kassem might as well build a special room for his slippers. Why try to lose them? He'll never escape." The old man laughed, and he seemed happy when he said that. That night the old man died in his sleep. . . .
The following night, we couldn't wait to talk about Abu Kassem. We all saw it the same way. The old man was right. The slippers in the story mean that everything you see and do and touch, every seed you sow, or don't sow, becomes part of your destiny . . . I met Hema in the septic ward at Government Hospital in India, in Madras, and that brought me to this continent. Because of that, I got the biggest gift of my life — to be a father to you two. Because of that, I operated on General Mebratu, who became my friend. Because he was my friend, I went to prison. Because I was a doctor, I helped to save him, and they let me out. Because I saved him, they could hang him . . . You see what I am saying? . . .
I hope one day you see this as clearly as I did in Kerchele. The key to your happiness is to own your slippers, own who you are, own how you look, own your family, own the talents you have, and own the ones you don't. If you keep saying your slippers aren't yours, then you'll die searching, you'll die bitter, always feeling you were promised more. Not only our actions, but also our omissions become our destiny.
There is much to enjoy here—the story, the writing and the wisdom of Matron, Hema and Ghosh. For me, although the ending brought a tremendous sense of loss it ultimately evoked a wonderful sense of unity, and optimism, saying that you live life forward but understand it looking back.
As Matron points out in defending a local minister at the hospital from the criticism of Mr. Harris, an American patron:
"When you look around Addis and see children barefoot and shivering in the rain, when you see the lepers begging for their next morsel, does any of that . . . [religious] nonsense matter the least bit?"
Matron leaned her head on the windowpane.
"God will judge us, Mr. Harris, by" — her voice broke as she thought of Sister Mary Joseph Praise — "by what we did to relieve the suffering of our fellow human beings. I don't think God cares what doctrine we embrace."
Parrot and Olivier in America
By Peter Carey
Did you hear the one about the Frenchman who walked in to a bar? No? Well, this book will help you supply one answer to that old joke. Parrot and Olivier in America has been described as an "improvisation on the life of Alexis de Tocqueville," the famed author of Democracy in America. It should be noted that humor is not one of the defining features of that seminal book, but Peter Carey deftly uses the events surrounding de Tocqueville's travels as the basis for a comic adventure.
De Tocqueville, in case you don't remember, was a French citizen who sailed to America in the 1830s and then travelled throughout the eastern portion of what is now the United States, penning observations of American culture, society and governance. He hailed from an old Norman aristocratic family that traced its ancestors back to participants in the Battle of Hastings in 1066. De Tocqueville's father, an officer in the Constitutional Guard of Louis XVI, and his mother avoided the guillotine only because Robespierre, that revolutionary enthusiast of beheadings, was driven from power in 1794. After an exile in England, de Tocqueville's parents returned to France during the reign of Napoleon. Under the Bourbon restoration, the father becomes a noble peer and prefect and de Tocqueville attended the Lycée Fabert in Metz.
De Tocqueville began his political career in about 1830, and in 1831 he secured a mission to examine prisons and penitentiaries in America. His travel companion was his life-long friend Gustave de Beaumont. He returned in less than two years with a report on the prisons, but his important contribution was Democracy in America, which first appeared in 1835.
"Parrot and Olivier in America" describes the escapades of Olivier-Jean-Baptiste de Clarel de Garmont, a snobbish, cosseted French aristocrat son of Norman nobility, sent across the Atlantic by his neurotic mother. Pompous, febrile, tantrum prone, he is supposed to be researching a report on American prisons, but in truth, his mother has had him kidnapped. France has become a dangerous place for young noblemen of idealistic sentiments. Sent along with him, unwillingly, is John "Parrot" Larritt, an Englishman twice Olivier's age, the orphaned son of a journeyman printer, with many more skills beyond Olivier's perception. He soon begins to refer to his boss as "Lord Migraine."
The novel is narrated not only by de Tocqueville's stand-in, Olivier, but also by his companion and protector, Parrot. Master and servant take turns advancing the narrative, so the reader is repeatedly tossed between hauteur and humility, naïveté and real-world experience. In addition, the author spends the first quarter of the book describing each of the main characters separately, so that by the time they meet each other, the reader has a good sense of each.
It is soon apparent that the two men detest each other. Olivier, who can trace his ancestors back to King Clovis, objects to Parrot's impertinence. Parrot marvels over "the general thoughtlessness of aristocrats. They never imagine a man has a life of his own."
They begin to meet Americans on the ship before they actually get to America, including a Jewish theatrical producer, a couple of sharpsters who've figured out how to use carrier pigeons to corner the stock market , and a draper's son who has lovingly amassed a magnificent personal library. As must be expected from a man of his age and temperament, Olivier falls passionately in love, while Parrot, a frustrated artist, suffers a crisis of purpose. Gradually, they warm to each other and form what Parrot calls the "most impossible of friendships, perhaps the only example of its type the world had ever seen."
This Felix-and-Oscar arrangement is really only the setup. During the course of their American sojourn, the mismatched pair will take turns being dazzled, appalled, bored and moved beyond imagination by the rough and tumble, dizzyingly alien democratic panorama, which includes pig stampedes in Manhattan, nascent displays of housing foreclosures, insurance fraud, an art market inflation, "the American autumn with all its drunken wildness," and the sellers on Broadway who "banged against one another like marbles in a lottery barrel."
The two bicker, separate, reunite, rescue each other, and even exchange roles as master and servant.
The writing is a bit stuffy at times, but generally very funny. And, while Olivier and Parrot are both prisoners of their stations and their pasts, and agree about nothing, they do manage gradually to feel some sympathy for each other. "A person like my servant was a foreign land," admits Olivier, "so although I might very sincerely wish to imagine him, how might I begin?" And they ultimately recognize that "the great lava flow of democracy" with all its vulgarity and potential misuse, is civilization's best way forward. In the New World, Parrot might never quite attain liberty, and Olivier might always distrust equality, yet by believing in America's possibilities, they lurch toward an unlikely fraternity.
So, exactly as its title promises, the book is about Parrot and Olivier in America, not really about America. It is entertaining, if a bit predictable. The language is vivid, forceful and at times poetic. It is very fun—and that is sufficient!
Lord of Misrule
By Jaimy Gordon
Jaimy Gordon won the National Book Award for fiction in 2010 for Lord of Misrule. This excerpt shows the book's flavor and style:
Inside the back gate of Indian Mound Downs, a hot walking machine creaked round and round. In the judgment of Medicine Ed, walking a horse himself on the shedrow of Barn Z, the going-nowhere contraption must be the lost soul of this cheap racetrack where he been ended up at. It was stuck there in the gate, so you couldn't get out. It filled up the whole road between a hill of horse manure against the backside fence, stubbled with pale dirty straw like a penitentiary haircut, and a long red puddle in the red dirt, a puddle that was almost a pond.
This book is not about the world of Secretariat or Seabiscuit, but about a run-down, second-rate racetrack and the desperation and determination of the down and dirty world of claiming races.
Before I read this story, I knew nothing about racing, although I did have an uncle who raised horses and ran them in harness races at Arlington, Maywood, Hawthorne and other tracks in the Midwest. It's all about the money, and specifically about the betting. And the center of that, it seems, is claiming races. According to Ainslie's Complete Guide to Thoroughbred Racing, without claiming races, there would be no racing at all. Owners would avoid the hazards of fair competition. Instead, they would enter their better animals in races against the sixth- and twelfth-raters that occupy most stalls at most tracks. This would leave little or no purse money for the owners of cheap horses. The game would perish.
The claiming race changes all that. When the owner enters his animal in a race for $5,000 claiming horses, he literally puts it up for sale at that price. Any other owner can file a claim before the race and lead the beast away after the running. The original owner collects the horse's share of the purse, if it earned any, but he loses the horse at a fair price.
That is, he loses the horse at a fair price if it is a $5,000 horse. If it were a $10,000 horse in a race for cheaper ones, the owner would get the purse and collect a large bet at odds of perhaps 1 to 10, but the horse would be bought by another barn at less than its true value.
Lord of Misrule follows five characters—damaged and solitary veterans of the horse racing world—through a year and four races at Indian Mound Downs, a declining racetrack downriver from Wheeling, West Virginia. The equilibrium of the life of the grooms, trainers, small-time owners and even the horses is disrupted by the arrival of horseman Tommy Hansel, who has a scheme to ship his four unknown horses to Indian Mound Downs, run them in cheap claiming races at long odds and get out fast before anyone notices. The problem is, everyone notices—veteran groom Medicine Ed, Kidstuff the blacksmith, old "gyp" Deucy Gifford, stall superintendant Suitcase Smithers, "financier" Two-Tie, and the ominous lead trainer, Joe Dale Biggs. In the center of all this is Tommy's frizzy-haired girlfriend, Maggie Koderer, a college-educated, intelligent if quirky groom for Tommy's horses, whose heart and spirit provide the glue for the somewhat sprawling narrative.
Gordon structures the story around four races, each named for a horse—Mr. Boll Weevil, Little Spinoza, Pelzer and the last best hope—Lord of Misrule. Mesmerizing prose captures the milieu of the racetrack, the physiology and the personality of the horses and the void and menace of the backstretch society. The dramatic momentum comes not from questions about which horse will run best in which race but matters much more sinister, and related to the rules of claiming races and the desperation of the characters all straining to keep their place in the downward spiral that is Indian Mound.
The book is stylishly written, in a striking colloquial voice that perfectly captures the time and place of the racetrack, but also includes a somewhat disorienting change in perspective from the second to third person, which the author uses primarily to reveal the very ominous domination of Maggie by Tommy. There is a kidnapping, blackmail, even a murder. There are no triumph-of-the-underdog moments, but the story ends, of course, with a race, a duel between darkness and light. Ultimately, none of the characters have quite what they want, but most get what they deserve.
With characters like Two Tie, Deucey, and Suitcase Smithers, the book has a film noir feel, sometimes a little over stylized and short on plot. Ultimately, the book is a beautiful story, which brilliantly underscores the unpredictability of life behind the racetrack, the origins and meaning of luck and the uncertainty principle, summarized by Medicine Ed when he first meets Maggie:
"Young woman, it is a price on everything. Every change make some other change that you can't see." Life and Lord of Misrule are a string of such changes.
So Much for That
By Lionel Shriver
Among the nominees for fiction for the National Book Award for 2010, this was my favorite, although it did not win. (That distinction went to Lord of Misrule, by Jaime Gordon, which I reviewed in the October 2011 WSMA Reports.)
I have just returned from a "destination" wedding in New Hampshire. The groom is from Spokane, the bride from San Diego, and they live and work in Baltimore. But they love New Hampshire and chose a beautiful site outside Franconia to be married during the height of the fall colors. At the reception were three couples from Spokane, all in our fifties, and all with the usual kids' commitments—music, soccer, basketball and then far-flung college placements. The joke went round: "When does life begin? At conception, says the priest. At birth, says the minister. When the kids leave home and the dog dies, says the rabbi."
So Much for That is about a 50-something couple, Shep and Glynis Knacker, on the cusp of that phase in their life, although Shep has been planning his "Afterlife" for years. A successful businessman believes his life will only begin in earnest when he quits the rat race and moves to a third-world paradise. He's chosen Pemba, an island off the coast of Tanzania, after years of sampling trips all over the world that Glynis has rejected in succession. Shep has three (one adolescent still lives at home) one-way tickets in hand. But he and Glynis have grown apart, and he has bought the tickets without telling her, prepared to go alone if she declines. The book's opening sentence reads:
What do you pack for the rest of your life?
But Glynis has a secret of her own—she is mortally ill. "Constitutionally obedient" Shep hunkers down in his odious job working for the nasty boss to whom he had sold his business eight years earlier, and dedicates himself to his wife's care.
Shep is the straight man to his easily riled best friend and colleague, Jackson Burdina, whose "emotional default setting" is disgust. Jackson, a libertarian anarchist whose teenage daughter suffers horribly from a rare degenerative disease, is no stranger to the inadequacies of the American health care system. Jackson rants about bloated administrative costs, "bloodsucking greedy" insurance companies, taxes, "Patsies and Parasites," and "Mugs and Mooches."
Shep observes early in the book,
. . . even if he accepted Jackson's cartoonish categories, he'd still rather be a Mug than a Mooch. Someone on whom others depended, a man as he understood the word. Although he believed in an implicit social contract-that you agreed to take care of other people so that when the time came, they would take care of you-he didn't keep up his end of things in order to incur a debt he'd any intention of calling in. He would remain a resource rather than a drain to the end of his days if he could help it, if only because being reliable, self sufficient and capable felt good.
Glynis, on the other hand, seems not a very nice person.
Glynis not only worked with metal (or used to); she was metal. Stiff, uncooperative, and inflexible. Hard, refractive and shiny with defiance. Her body long, attenuated, and angular like the jewelry and flatware she once crafted in art school, Glynis had not chosen her medium by accident. She naturally identified with any material that so fiercely refused to do what you wanted it to, whose form was so resistant to change it responded only to violent manhandling.
The trajectory of the story follows the awful downward spiral that Glynis's life becomes over the next year. At the same time, the book chronicles a ghastly parade of other physical ailments and inadequate responses involving Shep's aging father, his friend Jackson who submits to gruesome penile enhancement surgery, and Jackson's daughter who has familial dysautonomia.
In addition, the cost of her catastrophic illness is detailed at the top of each chapter. After a year of grueling treatment, which generates $700,000 in costs above and beyond her insurance, Shep asks the New York City specialist Dr. Goldman what he thinks his wife has gained. "Oh, I bet we've probably extended her life a good three months," Dr. Goldman replies. "No, I am sorry, Dr. Goldman," Shep responds. "They were not a good three months."
Shriver (the author is a woman) writes in a sharp, clever, witty style. She also well describes Glynis's pain and suffering, graphically at times, but not in a way that the message is sensationalized or romanticized. In addition, she has a keen eye for dysfunction in these families. Shep's sister is unbelievably self centered and immature in the face of multiple problems, and Jackson's family is stretched and strained under the weight of their daughter's illness. Shriver captures in an accurate and insightful way how well-intentioned friends falter and disappear in the face of a terminal illness.
Despite what might seem like a dreadfully depressing story, Glynis's acerbic wit and Jackson's bitterness are balanced by Shep's goodness and Carol's (Jackson's wife) resilience and common sense. I found myself thoroughly engaged. Shriver manages to create at times a very funny story interlaced with serious and timely messages about medical care and the ethics of disparity.
The ending is unexpectedly jubilant and an unexpected gift.
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NON-FICTION
Leadership on the Line
By Ronald A. Heifetz and Marty Linsky
About a year ago, Thomas Friedman wrote a column for the New York Times entitled "The Fat Lady Has Sung" in which he described how the last 70 years of American history have been about building the bounty of freedom and prosperity. American leadership and government have been pretty much all about giving things away, building things from scratch, lowering taxes, making grants and creating entitlements.
Now we are in a different place, and the task of leadership will be to help those with whom we work do more with less. The assignment is about taking things away, trimming programs or personnel. We have, Friedman notes, gone from the age of government handouts to the age of citizen give-backs, from companions fly free to pay for each bag.
So it was timely that I recently re-read "Leadership on the Line," written in 2002, about the perils of leadership in any number of arenas, not just health care. The largesse of medicine has largely followed the trajectory of post-war economic expansion in our country. At the same time, as our consumption of medical services and the expansion of resources to meet that demand have come to exceed in absolute and relative amounts those of all other industrialized economies, our fat lady has sung, too. The work of creating value for the resources we devote to medical care will require major and difficult changes in the way we organize and deliver health care. We're going for the triple aim—better health, better care, lower cost.
(The WSMA is promoting physician leadership in a variety of ways, including sponsoring the annual Physician Leadership Conference, May 13-14 at Lake Chelan. For details, see page 1 of this WSMA Reports. This highly regarded annual conference is reliably topical and relevant for leaders in medicine, and delivered in a relaxed setting deliberately separated in time and geography from the pressures of the work week. The WSMA is also offering physicians, in partnership with the University of Washington Graduate Programs in Health Administration and UW Professional and Continuing Education, a 40+ hour online and in-person course that will focus on leadership and conflict management, strategic planning and management, safety and quality management, finance, and communication and advocacy. The initial pilot course will coincide with the UW spring quarter and will begin on April 8. Contact Jennifer Hanscom at jen@wsma.org for more information.)
This book presents the observations of two Harvard professors (one a psychiatrist, the other with a background in media and politics, and both with long tenures at Harvard business school), about how those willing to undertake leadership roles in tough situations can manage the potholes along the way and protect themselves.
The book has three sections. The first describes the dangers to leaders during time of change. Leaders need to be aware of, they say, the nature of resistance to change and be alert to manifestations of opposition in ways that may not be apparent or obvious.
They make the distinction between the technical aspects of change (using technology or operating procedures to get more done) and the adaptive aspects of change (those not amenable to technical or procedure modification).
In health care, we need to create more connected, better coordinated care and use a longer horizon to measure results rather than simply create more efficient but fragmented services. These are adaptive problems, not solvable through expertise or standard operating procedures; they require more than hiring the right expert and pointing her at the problem. Their solutions require experiments, discoveries and adjustments from many people in many settings. Often the benefit will not be obvious at the beginning, and the fear—or the reality—of loss will cause people to make efforts to postpone, or shift responsibility for, any change.
Those leading change will be subject to opposition that may take many forms, including marginalization, diversion, outright attack or seduction. Nothing radical here, just politics, but perhaps they can be anticipated and managed. Many medical managers have been marginalized by their colleagues at times that really count, made to function as apologists for corporate decisions, and physicians can be relentless critics of those with whom they disagree.
The middle portion of the book focuses on appreciating conflict, achieving productive perspective, and managing the process of conflict toward positive resolution. The particularly useful chapter entitled "Getting to the Balcony," describes the need to view a situation and participants from a "mental balcony" from which one can see patterns, minimize one's own emotional responses, and react (or not) in ways that will help the community engage in the adaptive challenge.
The third portion of the book deals primarily with maintenance of personal perspective and balance, certainly a challenge for anyone up to their eyeballs in change and conflict, and it reminds me of Stephen Covey's admonishment in "The 7 Habits of Highly Effective People" to leaders to "sharpen the saw." Covey describes a lumberman who is sawing a tree, but is having difficulty because his saw is dull. Asked why he could not stop to sharpen the saw, he replies that he is too busy. The point is that cumulative stresses dull our effectiveness and we all need to take care of our instruments-in this case, our intellect and thinking—to remain effective.
The final couple of chapters address the question of WHY? Why would anyone put themselves on the line like this? We are collectively at an auspicious moment in medicine although the challenges we face are substantial. If leadership were about giving people good news, the job would be easy. Leadership cannot be just about personal hungers; those leaders for whom it is often suffer very public falls from grace. It is about concern for others. And in return for their willingness to expose themselves to risks, leaders gain the possibility of meaning and significance.
The hope of leadership lies in the capacity to deliver disturbing news and raise difficult questions in a way that people can absorb, prodding them to take up the message, rather than ignore it or kill the messenger. I think doctors do this all the time with our patients. But our rules, organizational cultures and norms—and economic incentives—regularly discourage physicians from facing the hardest questions and making the most difficult choices. Our communities, organizations and our profession need people, wherever they work and live, to take up the challenges within reach, rather than complain about that lack of leadership from on high, or wait until they receive a "call to action" or wait for their turn as committee chair.
This is an uplifting and practical book that addresses many seldom-talked-about aspects of leadership. It could help any one of us to lead courageously and effectively in whatever environment we find ourselves in.
The Power of Half
By Kevin Salwen and Hanah Salwen
Back in 1970 in my European literature class Miss Miriam Nyman introduced us to a number of European authors. Miss Nyman was, as far as we could tell, the NICEST person on the face of the earth, and one reason was that we did not have to read "War and Peace," like they did in Miss Britain's class.
We did read Tolstoy's great short story "How Much Land Does a Man Need?" that I've never forgotten. It's a morality play in which the protagonist, a peasant by the name of Pahom, is initially heard complaining that he does not own enough land to satisfy him. He declares that with plenty of land, "I shouldn't fear the Devil himself!" Unbeknownst to him, Satan is sitting behind the stove and listening. Shortly thereafter, a landlady in the village decides to sell her estate, and the peasants in the village buy as much as they can. Pahom himself purchases some of the land to farm and is able to repay his debts and live a more comfortable life.
However, Pahom becomes very possessive of his land, leading to arguments with his neighbors. "Threats to burn his building began to be uttered." Later, he moves to a larger farm that is part of a commune. Here, he can grow even more crops and amass a small fortune, but he has to grow his crops on rented land, which irritates him.
Finally, he is introduced to the Bashkirs. He is told that they are simple people who own a huge amount of land, which Pahom is determined to acquire at the lowest price he can negotiate. The Bashkirs make him a very unusual offer: For a sum of one thousand rubles Pahom can walk around as large an area as he wants, starting at daybreak, marking his route with a spade along the way. If he reaches his starting point by sunset that day, the entire area of land his route encloses will be his. He is delighted as he believes that he can cover a great distance and has chanced upon the bargain of a lifetime. That night, however, Pahom dreams he sees himself lying dead by the feet of the Devil who is laughing.
He stays out as late as possible, marking out land until just before the sun sets. Toward the end, he realizes he is far from the starting point and runs back as fast as he can to the waiting Bashkirs. He finally arrives at the starting point just as the sun sets. The Bashkirs cheer his good fortune, but exhausted from the run, Pahom drops dead. His servant buries him in an ordinary grave only six feet long, providing at least one answer to the riddle posed in the title of the story.
"The Power of Half" is a short and wonderful contemporary twist on the fable of Pahom. In the introduction Joan and Kevin Salwen write:
Our family is a fairly typical Atlanta foursome: two baby boomers (Joan and Kevin) and two teenagers (Hannah and Joseph). Our days consist of the standard American life—school, work, and youth sports. For more than a decade we aspired to the usual: new cars, a spacious home, nice vacations. Sure, we took on the occasional volunteer activity, feeding the homeless and building Habitat for Humanity houses, but largely we were consumed by our careers and enhancing our lifestyle through bigger, newer, better. We were focused on us. We moved into a huge "Dream House," large enough for us to scatter in different directions. As we drove from activity to activity, the TV in the back seat kept the kids entertained-and our family from connecting. At dinner, conversations began to center on to-do lists instead of meaningful dialogue. Our sense of togetherness was beginning to erode. I can't pinpoint the moment it happened because, after all, erosion is so much harder to recognize than earthquake damage. Still, when we stopped to take a hard look, it was clear that we were drifting apart. We were losing our core.
Then our life took an amazing turn.
While waiting at a traffic light, fourteen-year-old Hannah and her father saw a black Mercedes on one side and a homeless man begging for food on the other. "Dad, if that man had a less nice car, that man there could have a meal," Hannah protested. The light changed, but Hannah persisted, as teens will do, about the inequity of the situation. "What do you want to do," her mom ultimately responded, "sell our house?"
Any parent should know better. Hannah seized on the idea of selling their luxurious home and persisted relentlessly that they should do somthing. The remainder of the book is a warm and engaging story of the journey of this privileged Atlanta family, with a writer/entrepreneur father, social activist mother, idealistic teenage daughter and reassuringly normal son, initially reluctant to relinquish the comforts of solid middle-class American life. They decide to sell their pricey Atlanta home and move into a more modest replacement home. After a year's study of the options, they elect to use half the proceeds from the sale to leverage the good deeds of a charity.
Along the way, they become more fully aware of the traps of what they call the treadmill of consumption in contemporary life. They also reap the rewards of escape from the thoughtless and empty accumulation of stuff, and they contribute in a real and personal way to the greater good of the planet.
Mixing humor, inspiration and self-reflection, this is a story of generosity realized. The Salwens seem to set a new standard for families and individuals looking to inject meaning into their lives. "What does your family stand for?" they repeatedly asked themselves as they seek to find a way to make a difference. But they are clearly privileged, and one could contend, completely unrealistic. They would respond, I think, that it is not important how much you give but that you are part of the solution. In a world where three billion people live on less than a dollar a day, everyone, they say, has three T's: Time, Talent and Treasures, some of which they can donate to help even the score.
Although the family donated money to a good cause, they wanted to be involved in a more direct way. They researched extensively the history of failed attempts to provide "aid" to the Third World. For example, despite $2.3 trillion (yes with a t, as in trillion) in foreign aid since 1958, a recent United Nations study shows that the average poor person in sub-Saharan Africa now lives on a meager 73 cents a day, less than 1973. All that aid and people are actually worse off. There is some interesting discussion about the multiple reasons for this well-intended failure.
Ultimately the family decides to fund two community centers in Ghana to house medical and school facilities, which would help the people of the region help themselves in an ongoing fashion. They travel to Africa to see the project and the villages they support, and there they learn from the villagers even greater lessons about generosity.
Their aim is not to get everyone to sell their houses, although this one act sets off the chain reaction that leads the Salwens down a new path where they open themselves to new experiences and come together as a family. They acknowledge that few people are really that nutty. Rather, their goal is to encourage people to step off the treadmill of accumulation, to define themselves by what they give as well as what they possess.
Finally, there is a lot here about leadership. No need for graduate degrees, or corporate structure or legislation. We all have more than we need, and as one of our great contemporary minds said, "Unless someone like you cares a whole awful lot, nothing is going to get better. It's not."—Dr. Seuss, The Lorax.
Aftershock: The Next Economy and America's Future
By Robert B. Reich
Robert Reich, the diminutive Secretary of Labor in the Clinton administration, has written a compact but insightful book presenting a unifying theory of our current economic woes: that the "basic bargain"—working and middle-class Americans would share with the wealthy in the prosperity created by their own increases in productivity—has been broken. The bargain has been steadily eroded over the past few decades, and that erosion is not only at the heart of our economic failure but will ultimately threaten (think Wisconsin) our political stability.
Reich opens the book by quoting Treasury Secretary Timothy Geitner. "For too long," Geitner starts, referring to the period leading up to the financial bust, "Americans were buying too much and saving too little." Oh oh, seems like a snoozer. But then, somewhat surprisingly, Reich's purpose becomes clearer. He doesn't agree with that sentiment.
Reich contends that American consumers, and particularly the middle class, have been buying too little. Yes, for years, the United States has consumed more than it has produced and goods from abroad have met that demand and created a sustained trade deficit. The explanation: our culture has expanded its expectations driving up that consumption. Americans have found it hard to resist increasing their consumption of goods and services when those around them are spending lavishly. He notes, in an example that resonates with us aging boomers, that the average cost of a wedding had risen to nearly $30,000 by 2007.
Caught between rising aspirations and stagnant wages that began in the 1970s, middle-class Americans developed a series of coping mechanisms—women joining the workforce to provide a second income, employees working longer hours and taking shorter vacations and finally, families and individuals accumulating debt to maintain their consumption.
In the same years, productivity has actually grown remarkably and Wall Street and the wealthy have profited greatly. But the economic benefit of the increase in productivity has accrued largely to the very wealthy (about 90% to the top 2% income bracket). In this setting, the inequality helped to stoke the credit bubble as the middle class struggled to keep up.
The stagnation of middle-class buying power had been a drag on growth. "If earnings are inadequate," Reich asserts, "an economy produces more goods and services than its people are capable of purchasing." More low-paying jobs alone will not be sufficient. Even though prices might drop, those with low-paying jobs don't have enough left over after buying essential goods to buy the stuff that drives economic expansion.
Now that the bubble has burst, the old coping mechanisms are exhausted. Americans are not going to increase their working hours even more. Ever notice the ads on the evening news? Erectile dysfunction drugs and sleep aids. Americans sleep one or two fewer hours per night than their parents in the 1960s; in 2007 they spent an incredible $24 billion on sleep aids. More credit is a thing of the past: even if it were available, recent memory serves as a governor of sorts and Americans have in fact, paid down their credit card bills.
Americans will now, writes Reich, "face a necessity they have managed to avoid for decades: they have to make do with less." This belt tightening will not be popular, and Reich then goes on to describe potential political disruption. People will resent material losses if they are not broadly—and fairly—shared. In the wake of the financial crisis it seems that fairness has gone by the wayside. Millions of Americans have lost their jobs, but the financial sector has bounced back, attention-getting bonuses are back and in 2009, the top 25 hedge fund managers bagged a combined $25 billion. Current budget battles, in both Washingtons, are at a fever pitch. The concept of fairness, and shared sacrifice, however, does not get much air time.
Over and over throughout the book, Reich returns to the underlying problem of the current financial structure: the wide, glaring disparity of income between the rich and the rest of us. While Wall Street wants to blame a reckless, overspending working class (and the poor) for bringing on the recession, the responsibility is more widely dispersed. Here's what Reich says:
The problem was not that Americans spent beyond their means but that their means had not kept up with what the larger economy could and should have been able to provide them. The American economy had been growing briskly, and America's middle class naturally expected to share in that growth. But it didn't. A larger and larger proportion of the economy's winnings had gone to people at the top.
This is the heart of America's ongoing economic predicament. We cannot have a sustained recovery until we address it. It is also our social and political predicament. We risk upheaval and reactionary politics unless we solve it. The central challenge is not to rebalance the global economy so that Americans save more and borrow less from the rest of the world. It is to rebalance the American economy so that its benefits are shared more widely in America, as they were decades ago. Until this transformation is made, our economy will continue to experience phantom recoveries and speculative bubbles, each more distressing that the one before.
Reich then proposes some tools for economic restructuring, some traditional and familiar, others more provocative, including getting money out of politics, sizable increases in investment in public works, a reverse income tax, increased marginal tax rates for the wealthy, and a re-employment system rather than an unemployment system.
Whether any or all of these are practical or achievable given our current polarized political climate is far from certain. Still, this is an important book, relevant at this time of genuine need for economic stewardship. Reich is optimistic that we—Americans—will come around, embrace common sense and fairness, and in the end do the right thing by the middle class and working classes.
For a great photo essay of the history behind this story, see www.huffingtonpost.com/robert-reich/aftershock-economy-middleclass_ b_716920.html#s140110&title=
1930s_and_40s.
For more information
www.350.org, an organization coordinated by an international team of organizers, including author Bill McKibben and young climate leaders from around the world. The number 350 refers to the parts per million CO2 that scientists say is needed to retard global warming.
www.pachamama.org, an organization working for balanced global energy conservation and environmental preservation.
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