Commencement Remarks to Indiana University School of Nursing - Bloomington, Indiana - May 4, 2013

I had the honor of presenting remarks to the Indiana University School of Nursing graduating class of 2013. I'm posting the text of the remarks below:

IU School of Nursing Commencement Remarks Bloomington, Indiana

May 4, 2013

Chad Priest, RN, MSN, JD

Dean Broome, Dr. Hendricks, Dr. Krothe, my fellow School of Nursing Faculty and Staff colleagues, parents and guests, and my brand new fellow alums, thank you for allowing me to share this important and joyous day with you.  There are rules about graduation speeches, namely that they be brief, hopeful and not radically challenge the status quo.  I promise to be brief and VERY hopeful.

Graduation day is an extraordinary day in the life of the university.  It is a day that marks the end of your undergraduate career and the beginning – the commencement – of your professional lives.  While you may not remember every detail about the ceremonies and the speeches -(excepting this one of course) - , you will surely remember the feelings you are having today for the rest of your lives: EXCITEMENT about what the future holds.  A bit FRIGHTENED about the world beyond the Sample Gates.  CONCERNED about what you will do with the forty Kilroy’s t-shirts you own, now that you realize you can’t wear them in public without deep shame in any town except Bloomington. 

CONFIDENCE gained from achieving your goals and making it to graduation.  The JOY of being surrounded by your family and friends.  And deep GRATITUDE for their love and support. 

Take a look around the tent at the people assembled here today to celebrate with you.  These are the people that matter.  You should say thank you.  Like, right now, you should say thank you.  My mom and daughter are here today too – my mom mostly because I don’t think she ever believed I would be speaking at a graduation ceremony.  Especially considering I just barely passed college math.  Emerson is just here because she wanted to see all the pretty college students. Sorry guys, she specifically was NOT talking about you.  Seriously, I love that she has 60 extraordinary role models to look up to – a wonderful opportunity for an 8 year old.  So thanks for everything mom and thanks Emerson for supporting your dad.  

For all these people around you – the ones you just thanked – remember that today is equally special for them and they will remember the feelings they have today for the rest of their lives as well.  They are feelings of PRIDE at your success. Perhaps some RELIEF at your graduation.  A bit of SADNESS as you formally embark out into the world and perhaps move away from family. --- But most importantly, they are feelings of HOPE.  All of us on this stage, and in this tent have a deep and relentless HOPE that your work - - that your lives - - will someday transform OURS… that maybe you will secure for all of humanity the future many of us envision but will likely never see ourselves.  

Our hopes for you are social and abstract, but they are also personal and concrete.  Every NURSE in this tent is entrusting the future of our profession to you.  We know that your first few years of practice will be spent doing your damnedest to make sure you don’t hurt anyone.  But we also know that soon – sooner than you think – you will be called upon to lead.  And we know that your leadership will either advance the science of human health – or not.   This is why over the course of your education, the extraordinary individuals behind me on this stage have sought to not merely train you to be competent practitioners, but to unveil new ways of thinking and inspire you to greatness.  It is a solemn obligation that we all take very seriously because our legacy is – ultimately – you.

Everyone in this tent, and everyone in your community, also has a great hope for you – that you will lead us to health – because we are all now your patients.  Of course we aren’t all sick but, as Jay Walker has pointed out, there is no word in the human language for someone who isn’t a patient, but is seeking health.  This should tell us something about our values.  Regardless, we have deep hope that you will keep us safe and competently minister to us when we are sick, that you will help us usher in new life, that you will tend to our emergencies and that you will help us to die with dignity and grace. 

We also hope, all of us, that you will keep us healthy.  And here your greatest challenge awaits because we are, by any measure, not a healthy bunch.  In fact, here in the US we are in deep, deep trouble. 

Consider that despite spending more money as a percent of GDP on healthcare than nearly every other industrialized nation, we have some of the worst health outcomes.  That’s hard to imagine when those of who are fortunate enough to have insurance have imaging on demand, can get a knee replacement with no wait and have access to hundreds of specialists.  But the reality is that while we are exceptionally good at providing specialized medical care in the US, we are in nearly last place on every measure of health among industrialized nations. Last place. 

What’s worse, we’re messing up the easy stuff.  We have robots that can perform complex surgical procedures, but we can’t figure out how to get prenatal care for everyone who needs it – contributing to a disgraceful infant mortality rate that is worse than Lithuania and Slovokia and only barely better than Belarus. 

Over 48.6 million persons in the US are uninsured, nearly 910,000 right here in Indiana.  Unless you have faced a medical bill without insurance, it is nearly impossible to appreciate this terrible injustice.  Hard working Hoosier families are routinely forced to choose between medicines or rent -  healthcare appointments or a car payment.  Somehow, inexplicably, in 2013, a full-time working in the United States can still go bankrupt as a result of becoming sick.  

Despite what you may have heard on the television, these outcomes are not inevitable.  They are the result of choices we have made.  We have invested trillions upon trillions of dollars on a medical system that treats people’s illnesses without fixing what is that makes them sick in the first place.  In any other area of our lives we would find this cruelly absurd, but in healthcare we beam with pride at our ability to fix you once we’ve let you slip into illness.

You are a super smart group, but let me give you a concrete example.  If given the choice between professionally cleaning your gutters for $200 or mitigating a leak or flood that could cost $10,000, we would all choose to have our gutters cleaned.  We all understand that even though there never seems to be enough time, we need to change the oil in our car every 3 or 4 months or risk terrible, terrible outcomes.  I have a funny story about this. My brother, who is older and maybe wiser than me in most things, borrowed my car one summer. It wasn’t just any care. It was a 1978 Toyota Corolla hatchback, and it had an 8-track player. For those of you sitting in the middle here, that was a precursor to the audio tape.  Wait, you may not know what that is either.  Suffice it to say, the 8 track player was the coolest thing on the planet. I had the entire Woodstock concert on 8-track. At least two dozen 8-tracks in a sort of suitcase thing I bought at a thrift store for $5.00. The thing was, the car leaked oil. Which was understandable in 1998 because the care was almost 20 years old.  So you had to replace the oil and get it changed. Pretty regularly.  Except my brother didn’t, and once while driving on I-65 a piston in the engine actually flew out of the engine, through the engine block and onto the inside of the hood.  I sat stranded on I65 and Emerson Ave. counting the ways in which I would exact my revenge. The cost to repair the car would have bankrupted me – so the car had to go. And with it, my freedom to move on my own volition.  It was, as Vice President Biden would say, kind of a big deal.

It didn’t need to happen.  And while the example is sort of silly, this is really happening in America in 2013.  Fourteen states refused to expand Medicaid to provide primary care and hospital coverage to millions of uninsured this year (almost all of them working poor), ostensibly to save money.  Consider, however, that nearly 80% of all people who die are enrolled in Medicare, and that in 2009, Medicare paid $55 Billion dollars for care delivered in the last week of life.  Why is that we are comfortable with spending money on health only when it is too late for the money to do any good? This is the very definition of insanity and it is, cruelly, killing us.  For the first time ever, the current generation is likely to have a shorter life expectancy than the one before it.  This isn’t supposed to happen.  Our healthcare system and reimbursement scheme are also very, very broken.  And while the Affordable Care Act makes some changes on the margins, it doesn’t address the fundamental problem with American healthcare -  that we don’t have healthcare at all in the United States.  We have a sick-care system that, ironically – cruelly -  is making us sicker.  

Right now you are thinking – wow – glad we asked this guy to talk with us. He’s a real chipper guy.  

Despite the very real, and very concerning realities of American healthcare, I remain - as promised - profoundly hopeful.   I’m hopeful because spread out before me are 60 young women and men - 60 future nurses - 60 leaders who are poised to revolutionize healthcare.  Each of them, republican, democrat or undecided – Nick’s fans, Kilroy’s fans or the elusive Video Saloon connoisseurs, they all understand an epically important truth: That even though the biomedical sick-care system in our country is irreparably broken, we need not be held hostage by it any longer.   These graduates have a lot to learn.  What they don’t know about healthcare is epic.  You know that right? But they have an enormous advantage in that they have chosen as their calling – health.  And they know that in matters of health, none of us can afford to be neutral.  

The future of healthcare is in preventing illness.  The future of healthcare is in, ironically enough, HEALTH.  And these graduates have spent the last four years at one of the premier nursing schools in the nation learning how to maintain and restore health.  They understand that our patients desires are not necessarily the same as ours.  They know that community care can be delivered in the ICU as easily as it can be delivered in a community clinic.  They are ready for a future that will see shrinking hospitals, but larger and more accessible emergency departments.  They are prepared for a future when technology will disrupt our archaic models of care and open up doors to a future we can hardly imagine.  Consider that this group of graduates was practically raised on smart phones, which are already becoming powerful devices capable of diagnosing and even treating disease.  They also understand that the future of nursing is, in many ways, bound up in our past.  Florence Nightengale was not merely the founder of the first formal school of nursing – she was a statistician.  Something that the nurse researchers behind me surely can take pride in.  She understood then what we are now re-learning – that the power of evidence to inform decision making in healthcare will enrich and save lives. 

Maybe most importantly, they know that the cure for most of what ails us – most of what makes us sick – has nothing at all to do with healthcare.  It has to do with safe communities, clean water, clean air, strong social networks and healthy food. This is a group of nurses that can rescue you in an emergency – even in an underground subway, restore your heart to a normal rhythm, provide expert mental health care, look after young children as competently as old adults, and on top of all that – keep you healthy so you never need their services.   

While I may have lost a lot of my faith in our elected officials over the course of this year (on both sides of the aisle), I’ve had the privilege and opportunity to work with these leaders -- your sons and daughters, your spouses and friends -- nearly every week since August and I can assure you that our future – while far from certain – is in good hands.  

To the 2013 graduates of the Indiana University School of Nursing, here in beautiful Bloomington: we have placed our hopes and dreams with you.  It is a heavy burden to be sure, and it isn’t necessarily fair.  But it is the burden that every graduating class bears – and I know you will not let us down.  Leave this place prepared to make your mark.  Go out there and nurse us to health.  You don’t have to change the world all at once – start with what you know.  Start with that first patient of yours, the very first one you care for all on your own and recognize that that patient is all of us as well.  All of us in this tent.  Look into this patient’s eyes with respect and humility and hope, and ask simply “What shall we do together today?”  

Designing Resilience

This week has been one of difficult to reconcile dichotomies. Within the protective cocoon of TEDMED we've ben discussing medical innovation, the democratization of science, the power of community-based healthcare and the imperative to use data in new and meaningful ways. This week at TEDMED has been, predictably, transformative. It has also been, predictably, insulated.

 

TEDMED is the ultimate escape from the "real world". At TEDMED, years (sometimes decades) of science and innovation are condensed into 15 minute presentations that are designed to dazzle. The event corrals some of the most intelligent and innovative thinkers in the country together and creates situations in which they collide - releasing energy and ideas that almost always inspire. Of course our normal lives aren't really like this. We work in complex systems performing tasks that are often, well, mundane. There has never been a TEDMED talk to my knowledge that describes the time consuming and important work of documenting patient findings in a chart, or calibrating laboratory equipment in order to conduct experiments. This is because most of what we do is simply boring. TEDMED isn't real, and while that doesn't make it any less glorious, it does make it hard to reconcile with our ordinary lived experiences. Never has that been more true than this week, and especially today.

 

While my fellow TEDMED delegates are preparing to geek out on a steady diet of talks today, a terrorist is at large in Boston spreading fear among millions. Communities in West, Texas are still cleaning up and trying to understand how their lives could be so radically changed in such a short time. Cities and towns throughout the midwest are battling devastating floods. The world outside is so very different than the world inside the JFK Center. Some have decried the "business as usual" approach at TEDMED, but this is unfair. TEDMED is a global event, and while our week in the US has been challenging, communities all over the globe are engaging and interacting with the TEDMED community and the show must go on.

 

Nevertheless, sitting in my Nurture by Steelcase armchair stage left at TEDMED has me feeling a bit guilty. I know other delegates must feel the same way. But here's the thing: the TEDMED culture of innovation, interconnectedness, design thinking and transdisciplinarity has the power to help detect, prevent and respond to emergency events - to build resilient systems and communities. The same high-tech, high-touch, mind-blowing innovation focused on cancer care and control, or the mapping of the human biome, can work to help us radically redesign how we build resilient communities. Eli Beer, founder of United Hatzalah, is living proof that effective design strategies can be applied to some of our most complex problems. Through thousands of volunteers and a fleet of ambu-cycles deployed throughout Israel, Beer has reduced pre-hospital care response times to 3 minutes and has a goal to get all response times down to 90 seconds. This was a design transformation, a radical re-think of the status quo. And like all great design interventions, it was developed by the end-users. Beer's community saw a need, figured out a solution and implemented it. Their solution, highly trained volunteers who receive a page to respond to nearby emergencies, can be implemented anywhere and I believe it soon will be.

 

So how do we turn our other-wordly TEDMED experience into something that can immediately help communities in need? We can use our unexpected connections to think like Eli Beer and recognize that good health requires resilient communities. We can disrupt the social determinants of illness and promote health by designing this resilience - together. During a tough week, this can and should be the TEDMED 2013 legacy.

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Can Paolo Friere Rescue Health in the United States?

TEDMED knows theater and impact. Really. Last year they kicked off the 3.5 day conference with a stirring talk from Bryan Stephenson, a lawyer (of all things!) and Director of the Equal Justice Initiative. Bryan's TEDMED talk is now required viewing for my community health nursing students each semester. This year, TEDMED introduced us to America Bracho, MD, MPH and Executive Director of Latino Health Access. Her talk will now also be required viewing for my students, and should really be required viewing for anyone who cares about health in a meaningful way.

I Tweeted yesterday that if you closed your eyes during America's talk, you would hear the voice of Paolo Friere as if he was in the room with you. Friere's work, especially his masterpiece text The Pedagogy of the Oppressed, serves as an invitation and guide for the most vulnerable among us to claim power and improve their lives. Although often associated with 'revolucion' and challenges to status quo power structures, Friere's work is really an opportunity for all of us to recalibrate our power positions in order to claim a quality of life which is rightfully ours.

What does this mean for health? At TEDMED on day 1 I met about 11 people who were desiging iPhone apps to empower patients. ELEVEN (11) (10+1). These apps do everything from recording biometric data (what is your posture? did you sleep well last night?) to connecting you with your doctor so you can ask questions. Arguably these applications position patients to receive and analyze data, a potentially important aspect of empowerment. But these apps, even if they become powerful adjuncts, can never substitute for human empowerment based on dignity and respect. This was America's core message: our patients are the experts in their care and we must partner with them to co-create the health we seek. All of that sounds great, of course, until you get to the next part: to be effective we must unveil power structures and acknowledge our own role as oppressors of patients. The term "oppressor" is likely to lead to jeers from some readers, but we aren't talking (necessarily) about despotic physicians and nurses who adopt paternalistic attitudes. We are really talking about systems of care that are built around models of intentional disempowerment. For example, we maintain primary care models that rely on appointments - a convenience for the practitioner which can be very difficult for low-income patient due to transportation and work concerns. When our low-income patients "no-show" for their appointments, or seek care in the emergency department (where no appointment is necessary) we get frustrated, lament the impact on health outcomes and decry the financial impact on our healthcare system. In response, we invest millions of dollars in 'patient engagement' strategies that will prompt patients to arrive on-time, discourage them from using EDs, etc... What we often fail to do is recognize that our system of care itself is fundamentally flawed. It isn't built around our communities and patients - it is built around healthcare providers. This is the very definition of insanity. There isn't another industry in the world that could make money by creating customer experiences that don't serve the basic needs of the customer.

It turns out that Freier's "revolutionary" concepts, articulated and implemented by visionaries such as America Bracho, are having an impact on a few in healthcare who seem to get it. And these folks aren't your likely community health heroes. I had the opportunity to run this morning with a healthcare executive at a major retail corporation in North America. Listening to him talk about serving patients and creating health, he could be mistaken for a Community Health Center leader in a major metropolitan area. He spoke eloquently about creating environments of health for customers and explained how retail intuitively understands how to make customers the center of the experience. Guess what? When patients are placed at the center of the enterprise, they are engaged and empowered.

We can learn a lot from executives like the one I ran with this morning and from public health heroes like America Bracho. In their programs and ideas (some for-profit, some not-for-profit), we can hear the not-so-faint echoes of Paolo Friere reminding us that empowerment is at the core of all that we hope for. Now THAT is a way to start TEDMED 2013.

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Healthcare Resilience in the Face of Terror

The bombing at the Boston Marathon yesterday left me with a range of emotions and a flood of thoughts. As with every other decent human being on the planet, I watched the news reports with deep sadness. Along with thousands of others, I also experienced those brief moments of concern wondering about the safety of my friends who were running and my extended family living in Boston. As a marathoner, although one not quite fast enough to qualify for Boston, I also worried about the sport I love, and what it would mean for our iconic Boston Marathon to be forever associated with such vicious cruelty. I was also plenty upset at the unknown individual who perpetrated this cowardly and violent act.

 

Unlike most people, however, I observed events in Boston with a professional interest. I am in the business of healthcare emergency and crisis management, meaning that thinking about mass casualty events is part of my job. In fact, almost all of what I do involves building resilience among healthcare providers and organizations so that they may take better care of folks like you and me when something awful happens. So when I watched those videos and photos of the explosion, I kept a close eye out for the markers of resilience that may not keep us safe, but allow us to bounce back as a community and go about our business. Of course my vantage point is limited. I'm not on the ground in Boston, am not overly familiar with their plans/protocols and I don't have any inside knowledge about events there. But I sifted through dozens of grizzly photographs pulled by our Intelligence team off of social media platforms and readily observed the resilience I was looking for. I saw pictures of pre-hospital providers performing what appeared to be sophisticated and street-hardened triage (in one photo you may have seen a medic is checking the carotid pulse of a lifeless-looking woman while simultaneously scanning the victims around her). I saw marathon volunteers and runners helping out victims. I saw the ubiquitous use of tourniquets, suggesting an army of trained healthcare providers or an impressive group of lay volunteers. I saw rapid transport of critical victims by any number of means, including wheelchairs and two-person carry maneuvers. I saw law enforcement and other public safety officials rescue individuals while simultaneously drawing their weapons and looking for the source of the explosion.

 

Throughout the evening I monitored reports, mostly public, from the hospitals in the area that absorbed hundreds of patients in very short order. Their ability to flex and adapt to accommodate this "medical surge" appears to have been textbook-perfect as well. I'm sure it didn't feel that way to them, and there will be lots of findings and areas for improvement identified in the coming months. But there seems to be little question at this point that the hospitals in Boston, many of which are world renowned for their extraordinary patient care innovations, demonstrated real resilience in the face of terror yesterday. We underestimate the importance of this resilience at our own peril. Consider that the end point of any rescue operation is usually a victim who is delivered safely to a hospital. We frequently assume these hospitals have infinite resources and can adapt and take on any challenge. This is of course not the case. Hospitals are, in many ways, some of the most fragile institutions in our society - they are highly dependent on external support (power, water, communications) and that they already contain some of the most vulnerable people among us (the sick).

 

I was reminded of a lot of things last night watching the news reports, including just how important our collective work in this area really is. Over the next four days at TEDMED I will be networking and co-learning with over 1500 thought leaders from around the country, all of us seeking to find ways to improve healthcare and the quality of our collective lives. It seems a trite thing to attend a TED conference while so many suffer and an entire community begins the arduous work of recovering from an intentional act of terrorism. But I am convinced that the spirit of innovation and entrepreneurship that defines TEDMED provides the ideal platform to promote healthcare resilience and radically re-think how we approach this important work. As we have seen, the health of our community depends on it.

 

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The (Guitarist) Healthcare Provider Will See You Now

A below the fold front-page article by Pam Belluck in this morning's New York Times highlights recent research published in Pediatrics that suggests live music may reduce physical manfiestations of stress among premature infants. The study found that infants exposed to live music had lower heart and respiratory rates, had more and better sleep and had improved sucking reflexes.

My first reaction to this article was "of course!" What parent doesn't understand, intuitively, the value of singing to a young child to calm them down? In our house, we an extensive song catalogue to fit various moods and circumstances. My wife went so far as to quasi-formally designate a special lullaby for each child that we sang to them almost nightly for the first three years of their lives. The kids will sometimes ask for their songs even now, although as they get older they do so with some embarrassment. And just as the Music Therapists in the Pediatrics study did, we took ordinary songs we liked and sang those. Twinkle-Twinkle has nothing on James Taylor or The Beatles. Not all of our songs were lullabys and, unlike in the study, not all of them were designed to soothe. We had a particularly jaunty song for waking up and getting your clothes on. Sadly, as the kids have aged and the demands of school have replaced unfettered at-home playing, that song has turned into a chorus of yelling - "GET DOWNSTAIRS AND EAT, NOW!"

I don't think we needed this research to know that live music has a powerful impact on all of us (it calms me down, I know that much). However, what I love about these studies is that they serve an important role in helping healthcare providers realize that lots of different kinds of folks are responsible for improving health. As licensed providers we have a hard time appreciating the value of "lay-people" in promoting health. Of course the reality is that healthcare providers have only the most limited role in promoting health as it is a construct that permeates our entire society. In order to help our patients, we have to see beyond our stethescopes and begin to appreciate the enormous impact that others can have as equal members of the healthcare team. We have to not only respect, but seek-out transdisciplinary opportunities to improve health.

Imagine the rounding of the future in a pediatric hospital: nurses, physicians, students, parents, public health professionals, social workers, allied health professionals and mental health workers meeting and engaging with patients and families to promote health. And maybe, just maybe, a young woman with a guitar in the center of it all singing a Carol King cover.

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Welcome to Forward to Health

 

Welcome to Forward to Health, a progressive blogging experiment focused on improving lives through better healthcare with a focus on: community health, public health law, design methods for health, crisis management, global health, justice, ethics, nursing and teaching/learning in the health professions. So pretty much anything that this new blogger is interested in that relates to creating and maintaining health for all. I'm not sure where this blog will go, what sort of discoveries may be made in the course of writing it or whether it will be maintained for any definite period of time. If you are reading, I invite and encourage you to comment and engage and we can co-create this space together.

Importantly, Forward to Health is my own personal blog. It isn't reviewed, edited or approved by my employer(s) or anyone else. Unless otherwise stated, the content on this blog (and the views expressed herein) are my own. As it may soon become obvious, I have no editor. I expect that mistakes will be made, blogging norms violated and learning opportunities will ensue. I'm looking forward to all of those things. I ask that if you see something interesting here and wish to repeat it, that you give credit where it is due. I will be carefully citing quoted material and academic references with hyperlinks whenever possible.


Who are you and why are you writing a blog about healthcare?
Simply stated: I care about health and am interested in how we can make a meaningful difference in improving the lives of all people. I am convinced of the value of transdisciplinarity based on my own personal experiences and the opportunity to witness mind-bending feats of ingenuity and creativity that result from bringing folks with different backgrounds together to work on big challenges.
I am a Registered Nurse, a Clinical Nurse Specialist in Community Health and an attorney who focuses on healthcare related legal matters. You can learn a little about me at www.chadpriest.org. My full time job and passion is leading MESH, a non-profit public-private partnership that enables healthcare providers to respond effectively to emergency events and remain viable through recovery. I also serve as Adjunct Assistant Professor at the Indiana University School of Nursing where I teach courses in bioethics and community health in Bloomington, Indiana. Finally, I serve as a core faculty member of the Disaster Medicine Fellowship at the Indiana University School of Medicine, Department of Emergency Medicine.
What will you be blogging about?
I will begin this blog with a daily recap from the upcoming TEDMED conference in Washington, DC where I will be attending as a Front Line Scholar. My blogging strategy at TEDMED will be to comment on things that catch my gaze, partly in an effort to identify the types of things worth writing on in the future. I will also be using the blog as a place to trial my own concepts and ideas in the hope of generating some crowd-feedback.
Thank you for reading/commenting. I look forward to moving forward to health with you.

Chad Priest, RN, MSN, JD

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