Dishes

There are some ads that just speak to you. For me, it’s the Finish ad that has a montage of images of dirty dishes that monotonously says dishes…dishes…DISHES. It speaks to my dread and long standing hatred of this daily chore. The challenge for me is that I equally can’t stand dirty dishes accumulating next to the sink, so it’s a chore that fits in the non-negotiable list.

When I met my partner, this issue seemed to resolve itself. I cooked, he cleaned up. He even kind of enjoyed it. This was something I found bizarre, but I was more than happy to leverage. Then kids happened.

Kids bring with them evening rituals, one of which is bath time after dinner. The supervision of this seemed to fit neatly in the Dad category, leaving me with the dishes. Urgh.

For a good few years I loathed this time. It was like it triggered the memory of my Dad insisting that the cleaning up occur immediately after dinner and that no, I could not let it wait until the ad breaks so I didn’t miss Neighbours. Clearly I have some unresolved issues.

Then one day I woke up in the present and discovered podcasts and audiobooks. To say it changed my life may be overstated, but it certainly had a positive impact. I started to look forward to cleaning up after dinner. Dare I say it, I even started to stretch it out to try and make it last longer.

Reflecting on this, I can see what James Clear was talking about in his book Atomic Habits was true (which incidentally, I listened to while doing the dishes). One of the ways to make an unpleasant habit stick is to link it to something that you want to do. Something that contributes to you becoming the identity you want to create for yourself. It worked. I now have a cleaner kitchen and a broader mind.

The Right Stuff

This morning at school drop off one of the kids mum’s told me how she had to get her son to rewrite his Christmas card to my daughter because he couldn’t decide if he was saying ‘to’ or ‘dear’. I laughed and responded, ‘well I don’t have a clue what my daughter wrote in the card because she wouldn’t let me look at it’. Later my overthinking brain kicked in and I wondered if I came across as being a disinterested parent, leaving my daughter to her own devices like this.

I’m not really in to writing Christmas cards, but for my daughter they still have novelty. She’s almost six and nearing the end of her first year of school, so writing in itself has still got novelty. Our Elf on the shelf isn’t a spy for Santa, he helps us do the jobs to get ready for Christmas. So when he arrived this year he came via Big W with a packet of Christmas cards and a note to my daughter advising her to be generous to her friends. (There were also some Christmassy erasers but they seem to have mysteriously gone missing).

On the weekend she set herself up on the kitchen table and got to work. She got out her class photo to spell the names correctly and she was off. I wasn’t allowed to read them, only to double check that she hadn’t missed anybody. And to find her a suitable Christmas themed bag to carry them in.

Yesterday she excitedly delivered them to all her classmates (still sans Christmassy erasers). I was with one of the other mum’s when her son got his, so I was able to sneak a look at one of the messages. “Dear Zac C. You must call me a name and it must start with a C”.

I don’t care if people judge me as being a disinterested parent for not overseeing the Christmas card messages. I don’t think there’s a right or a wrong way to write a Christmas card. Scratch that, I do think there’s a right way – to write a message that means something to you, with the recipient in mind.

Participation Award

This year my daughter participated in her first ever school sports day. The final event was the sprint. All the kids lined up in their age groups and (most of them) ran their little hearts out.  The top three got the blue, green and yellow ribbons as they crossed the finish line and everyone else got a red one that said ‘competitor’.

Situations like this almost always spark discussions amongst parents and grandparents (or more accurately, broadcast of opinions) like “kids these days need to learn how to lose!” and “what’s the point of playing if no one wins?”

You see evidence of this attitude everywhere. Reducing everything is a zero sum game – designed for one person to win, and another to lose. Supposing that your individual worth is determined by bettering an opponent. Maybe in some circumstances, perhaps this is valid. But I kind of doubt it. I’m not really one to use sporting anecdotes, but I’m pretty sure there are plenty of AFL footballers who had very fulfilling careers and never won a premiership. I would even dare to say that some of their most memorable and satisfying games were ones that they may have ended up losing, but were a well fought out match.

A guy named James Carse refers to these as finite games. These are games where there is a winner and a loser, the rules are defined, and there are a specified number of players. The game usually goes for a specified amount of time and it’s based upon a model of scarcity. But he also talks about another type of game – infinite games. In an infinite game the aim isn’t to win, it’s to keep the game going. To enjoy the experience. You are reliant on other players to keep the game going. You want the people you are playing with to be capable players, otherwise the game will end prematurely or it will all fall in a heap.

This is the subject of Simon Sinek’s latest book The Infinite Game. It’s still on my ever growing to read list, but I’ve listened to him talk about it and I like what he has to say. He places this game theory in the context of businesses, and suggests that it’s the business who have an infinite approach that will lead us into the future. And I tend to agree with him.

If we take Pharmacy as an example, I think its fair to say that the reason we are in this position a profession is because for so many years we have been positioned within a scarcity model protecting community pharmacy. And it has failed us. It has not led to a profession striving for quality standards, it has led us to a race to the bottom. I don’t think it’s too late to turn it around, but it going to require some pretty strong leadership. And by leadership, I’m talking about the genuine type of leadership demonstrated by individuals taking action. Not the other kind.

My daughter got a red ribbon and she couldn’t have cared less where she finished in the race. Well, that’s not entirely true. There were a few super slow runners and I’m pretty sure she would have felt disappointed if she finished behind them! What mattered to her was that she went out there, ran as hard as she could and there was a crowd cheering her (and everybody else) on. It was fun! With the school’s encouragement, she was able to have the mindset of an infinite game, and felt much happier for it. And she went to bed that night with her tokenistic red ribbon pinned to her PJs and a big smile on her face.

 

 

Feedback

On Friday I got some feedback and it got me a bit riled up. Before I knew it I reverted to my traditional behaviour of venting my fury. Picking it apart. In that moment I was pissed.

You see, I’ve been making an effort in recent years to put myself in positions where I can receive feedback on my work. This blog is a prime example. I’d use the old line “it never gets any easier” but I’m not sure that accurately depicts the situation. I have found that it very much depends on the circumstances. And interestingly , the circumstances aren’t related to the positive or negative nature of the feedback itself. It relates to who is giving said feedback.

I’ve found that when the feedback is from people who are known and identifiable, they can be as critical as they like and I’m cool with it. Because in these circumstances it is almost always in line with the goal that I’m striving to achieve. They are simply helping me work toward that goal. Their feedback is an act of generosity. Or they’re just being an asshole. But they are being an identifiable asshole, and that’s ok.

The feedback I have difficulty is the anonymous kind, where there is an underlying essence that the person trying to give the feedback is striving to prove their expertise, rather than test mine. And  the reason I have great difficulty with it is that every time I’ve been in this circumstance the anonymous expert has delivered feedback that illuminates their blind spots as well as mine. Their area of unconscious incompetence. In trying to look clever, they have made one or two remarks discrediting something I have written that makes me doubt their credibility.

My immediate reaction is to let them have it and cut them down with academic angst. But this consumes a high level of emotional energy and at the end of the day does very little to help me achieve my goals. It also means I fail to face the elements of their feedback are valid. And there is always something that is valid, even if it’s just that I failed to be able to effectively communicate my message to a pain in the ass reviewer. That’s still valid.

I find this sort of thing really difficult to get past. But the reality is that I have to if I want to achieve my goal.

So yes, I did have a moment of fury on Friday, but it went down with the sunset. I was able to divorce what is needed to achieve my goals from the credibility of the process. It’s still not going to be easy, but that’s ok. I can save my emotional energy for systems that may be amenable to change.

Front Page News

As I said yesterday, I’m doing a story skills workshop so stories is what you’re going to get from me at the moment. Today I wanted to share a story about a moment that really shaped my professional life. It confronted me in multiple ways, and was a life defining moment that I hope I never have to repeat.

I made the front page of our city newspaper once. Not that they used my name. I was “The nervous novice” they referred to.

I wasn’t really a nervous novice. I had been working at that hospital for a few years and was in a senior role within the department. That was the reason I was called upon to provide cover when the long-term (like 25 years long term) oncology pharmacist took long service leave. Nobody else would do it.

She taught me the processes and how to make sure the kids got the right chemo at the right time. The diary, the clunky old computer program (basically a glorified calculator), the aseptic suite. Over weeks or months I was able to demonstrate my proficiency and was trusted to keep things tickling while she went on holidays.

I came to realise what I’m sure many people realise when they take over a job from someone who has been working in isolation- things that make sense to them don’t necessarily make sense to others. They keep a lot of important information in their head, resulting in ambiguity for the poor sucker trying to keep things ticking over as usual (aka me). There were processes, sure, but they were designed in a way to make her indispensable. This wasn’t exactly sustainable or safe.

I must have done a good enough job because a few months later I was once again called upon to provide cover when she retired. I was entrusted to provide support for her newly inducted replacement, who incidentally had even less experience in oncology than I did.

I did as requested and kept things ticking. Figuring things out as I went along. Until I found something that I couldn’t figure out. There was an irreconcilable difference between the computer generated batch sheet and the computer generated label for one of the chemotherapy agents. This meant we either prepared the correct amount of drug with the wrong label, or the correct label on an incorrect amount of drug. This is not good for any drug. It’s especially not good for a chemotherapy drug.

I didn’t know what to do with this problem. I first took it to my colleague who had been in her role for a matter of weeks. She wasn’t sure. I then went to my manager. I explained that either I had lost my ability to do basic maths or there was a systematic error occurring with this chemo drug. He confirmed that my understanding of ratios was still correct. Oh shit. What did this mean?

It meant a full enquiry of every time we had ever prepared that drug. It meant a full audit of all of our processes and documentation relating to chemotherapy. It meant long days and evenings working in an area that I was only supposed to be providing short term cover to. It meant a bunch of people pissed off that we had brought this error into the spotlight and created so much work. It meant a news story that cast aside the error as a serendipitous discovery made by a nervous novice.

It meant I never viewed the term ‘indispensable’ the same way in healthcare again, regardless of how much I enjoyed reading Linchpin by Seth Godin.

All That Glitters

Over the past few weeks I’ve been participating in a story skills online workshop, and I’ve got to say, it’s pretty amazing. I’m learning so much. One of the things that’s surprised me, was the power of storytelling in our day to day lives. So I thought I’d do the only appropriate thing to do about a topic like that. I wrote a story about it, obviously. I’m not saying I’m very good at it, but I’m enjoying the practice.

At the beginning of the year I was talking with my daughter about what she wanted for the year ahead. Her reply, “to be in a performance”. OK, that sounds pretty achievable, I thought. I looked up dance schools and was pleased to find a good one within walking distance. After initial disappointment of no availability, she was able to start dance lessons mid-way through March. In three weeks time she has her big end of year concert. The excitement is building. They have learned all the choreography. On Saturday she was provided with her costume in all its glittery glory.

Seeing her with her blue tutu prompted me to get online to get our tickets. I had left it too late to get prime view seats I was sure. What I hadn’t expected was for them to be completely sold out. My heart sank. Her first big concert and we couldn’t even get one lousy ticket. I only wanted two! Why had I left it so late? Why do I always leave things to the last minute? My mum would never be in this position. My sister would never be in this position. Why did I put us in this position? I couldn’t hide my disappointment. I couldn’t hold back my tears. When my daughter asked what was wrong I told her I’d stuffed up. “That’s OK, I’ll have other concerts” she said. That helped me refocus, and turn my attention from woe is me to what now.

Previously my instinct would be to get mad. Surely they’d allocate tickets for each kid! Surely they’d communicate this more proactively! Surely they’d make a point of telling first timers! These thoughts did go on in my head, but they didn’t take hold of me like they would have in the past. And sure, I did go back and search through emails to gather evidence, but I kind of knew it would be evidence that I had ignored their communication, not evidence of their transgression. And sure enough, there in the email I received at the end of October announcing tickets were on sale it stated very clearly “tickets will sell out”. In red type and all. I just didn’t interpret this as act now or miss out. In my mind, buying with three weeks to go is planning ahead!

So I didn’t get angry, but I was still upset. An emotionally together person would have got on the phone straight away. But I hate talking on the phone at the best of times, let alone when I know it will end in tears. Disappointment or anger, I wasn’t sure which. I emailed. As I was writing my email I thought, what’s the point? I’m sure I’m not the only one that’s missed out. They’re probably used to getting blasted by angry parents about this, that’s why they have the disclaimer in the email. They’ve probably prepared a standard response they use for everyone. Then my mind shifted. Maybe I could communicate in a way so they actually want to help me? Maybe I could tell them a story.

I mustered up all the story telling skills I’ve acquired so far and started on my story. I tried to engage them by making it clear that I wasn’t like the other angry parents – I was the one at fault and wasn’t blaming them. I tried to make them care about my situation – I was feeling terrible that I had misinterpreted the information and just wanted some way of being there to support my daughter at her first performance, volunteering back stage, whatever. I acknowledged that I had learned my lesson – I would never ignore their spammy emails again (obviously I didn’t say it quite like that).

I didn’t get a reply, but the process did help me to get my head around the situation enough to call them, which I did just now. As I predicted, the conversation started with a fairly standard and guarded response, but she gradually softened throughout the interaction. My name is on the waiting list for the “ticket master”, and I’m on the list for backstage volunteers. The storytelling might not have made any difference to the outcome, but it made a difference to the process. I still feel a bit sad and annoyed with myself, but I don’t feel angry and distracted. So I’ll take that as a win.

 

Girl Interrupted

I’m having one of those weeks where I feel very disrupted. I know I need to take my own advice and be disciplined rather than motivated, but I am resisting it. It’s a combination of things. Workers at the house building our carport makes me distracted. Hot weather making me lazy. Crazy windy weather giving me allergies. I feel discombobulated. But that’s ok. We all have these moments and I’m sure it’ll pass. Quickly though, I hope.

Posy or Perish

It’s a stifling hot day today in Adelaide. 42 degrees in November. The kind of day where you can feel your skin tightening as soon as you walk out the door. To make things worse, it’s windy as hell. My allergies have gone crazy. I’m procrastinating like you wouldn’t believe. This is not a great day.

Needless to say, I didn’t feel like going for a run this morning. And I could tell my daughter wasn’t exactly energetic either. So I made the decision early to drive which gave us some extra time. Time I could spend watering the garden so it at least has a chance of surviving the day.

My daughter came out to help. I noticed the sweet peas and picked one for her. They looked especially beautiful this morning and I knew they wouldn’t stay that way for long. You should pick some for your teacher, I suggested. She agreed. We collected a posy of flowers, wrapped the stems in some alfoil as my mum and grandma would do, and took them with us to school.

I could see the look of pride on my daughter’s face as she approached the teacher’s desk who was already surrounded by a group of children. But she waited patiently. I stood back by the door as I hadn’t said goodbye yet, and have been told off before about escaping too hastily in the past. So I waited. I too was patient.

I got distracted while I was waiting and tuned out for a while but my ears tuned back in when I heard an exclamation “Are they for me? Oh thank you so much”. I looked up and saw the teacher blissfully inhale the heady scent of the sweet peas. “My dad used to grow these in our garden. I used to love smelling these”. It was like she had been momentarily transported back to her childhood and had a sparkle in her eye. My daughter was thrilled. My heart was warmed. Much better than letting them perish in the garden on this hot spring day. That’s the thing about kindness I think. It doesn’t take much effort at all.

Discovery Doesn’t Always Lead to Happiness

I know I’m probably setting up my kids for a lifetime of emotional eating, but sometimes the short term benefits of using food as an incentive are just too good to pass up. Yesterday was one of those days. It was hot in Adelaide. Not as hot as today (a stifling 42 degrees) but still hot.

My son is 5 days short of his second birthday. He still likes to have a long nap, and on school days it always seems to be that they are perfectly timed so he has to be woken for school pickup. This is annoying for everyone involved. He’s understandably grumpy about being woken and put in the car. My daughter is understandable grumpy because he’s grumpy which means she can’t stay and play with her friends. I’m grumpy because they’re both grumpy,and the walk to the car, although not far, is a physical struggle when you’re carrying a squirming two year old and it’s a hot day.

Enter the food bribe incentive. Hot day, perfect for an ice block. This provides my daughter with the momentum she needs to move to the car and be a good example for her brother. It does nothing to help my son, but at least there’s only one grumpy one to deal with now.

Once home, both children head straight to the freezer. We have one of those fridge/freezers where the freezer is at the bottom so there’s no going back now, the door is open and the selection is being made. I get them into a position on the kitchen table to limit sticky spills and let them have at it. No one is grumpy any more.

I watch my son navigate the ice block. A zooper dooper. This treat turns into a lesson in physics for him.

He furrows his brow and experiments with how the ice moves as he squeezes it in the middle. He breaks it in half and moves each of the sections. He realises he doesn’t need the wrapper and displaces the ice chunks into the bowl that I gave him to catch the inevitable drips. He feels the cold of the ice on his hands, and touches other items to compare. Then he spots his cup of water.

In goes the first chunk of ice. The water turns green (this is not some sort of organic fruit juice, no added colours type iceblock). The ice disappears quickly. He looks perplexed. He tentatively drinks this mysterious liquid. He doesn’t enjoy it. He looks at the other chunk of ice in his bowl, as though he’s weighing up his options. Into the water it goes. He has regret and puts his hand in to retrieve it, but it’s too late. The ice chunk has disappeared and he’s left with the green liquid. He is not pleased.

He escapes the chair and makes a bee line for the freezer. He knows where there is more supply. He makes his selection and looks proud. Pink this time. But he’s unable to break through the packaging. He needs scissors. I have the scissors. His grumpiness returns.

Where’s the Neutrino?

Sometime around the 1930s there were all sorts of scientists working on deciphering equations to explain beta decay in radiation. I am not even going to pretend I understand this, it’s not important for the story. What is important is that one of these scientists came up with a theory about why noone was able to come up with an equation that held up. He suggested that some kind of particle that was neutrally charged must exost and be influencing things. And he got laughed at. Dismissed. It wasn’t until years later (sometime in the mid 1950s I think) that someone else discovered this particle and called it the Neutrino.

Oftentimes when we’re in the midst of out problems we don’t recognise the invisible forces that are holding us back from making progress. To do so requires us to have an overarching view of the big picture, remain somewhat detached from what is known and open to possibility, and make ourselves vulnerable as we risk looking foolish to others.

Over the 16ish years I’ve been practicing as a pharmacist, issues relating to transitions of care, preventable hospitalisations and poor adherence have persisted throughout. In spite of the significant level of investment that has been made into hospital pharmacy services and community based services such as the HMR and DMMR programs, the stats have remained persistently high. If this were a drug trial it wouldn’t be looking all that promising. In their recent report, AIHW estimate that around 7% of hospital admissions were potentially preventable, accounting for around 10% of hospital bed days.

It’s clearly not acceptable that there were 748,000 potentially preventable hospitalisations in 2017-18. I think this should be seen as an indictment of healthcare policy, not necessarily of the individual providers. Of course we need to improve and we need to strengthen the quality and safety of the community based care sector. But we need to achieve systemic improvements supported by effective policy. Short term policy and chopping and changing the structure of the primary care sector has failed us for too long.

One likely reaction to this sort of data is that we obviously need more resources and services in order to meet these needs. In the case of pharmacists, we need post discharge HMRs, pharmacists in GP practices, pharmacists in RACFs, more hospital pharmacists providing outreach, pharmacists anywhere anyone will pay for them. But I want to be somewhat controversial, zoom out, and take a different viewpoint. I don’t believe the best way to fix a fragmented healthcare system is to throw even more people, services and referral pathways into the mix. We need to rethink the overall strategy. Maybe there’s something else that’s holding us back – the neutrino that we can’t see.

I believe the neutrino relates to undervaluing generalist care providers. My firm belief is that we need to start investing in strategies that strengthen the community based workforce. Not through increased numbers, but by valuing and respecting the workforce that we already have and optimising their capability. For too long community based care providers have been considered the poor cousin of their hospital counterparts. The after thought for funding models. If we want to make improvements in things like preventable hospitalisations it needs to start with recognising that our health system will only ever be as strong as our community based sector. They deserve our respect. They deserve to be prioritised. They deserve financial investment.

For my entire career thus far we have been talking about the same issues and making limited improvements. Maybe there’s something else going on here that’s holding us back, and maybe that thing is a culture that doesn’t value community based care and generalist providers. Maybe we need to stop putting culture change in the ‘too hard basket’ and start taking action to change it. Because it needs to change. I believe that improving the connection between acute and primary care providers is a good place to start.