Decision Making in a Crisis

I have railed against what I call the stakeholder model for some time now.  I really didn't understand it months ago when this pandemic started, but I have come to despise it.  The stakeholder approach to decisioning making is based on speaking to multiple stakeholders in order to try to develop some type of quasi consensus.  I use the term quasi consensus to differentiate the stakeholder model from other consensus models that utilize experts and essentially keep out politics and other motivations.  

During a crisis, and a pandemic qualifies as a crisis, the decisions one makes need to be based as much as possible on facts.  The priorities must be on the greater good, in this case, saving lives.  For example, if a fire was about to engulf a town, would you spend weeks speaking to various stakeholders in order to determine the impact of the fire that is about to burn the town down. Would you speak to the bank owners in order to ascertain what the impact of the fire would be on the bank?  Is there enough federal deposit insurance to not have to worry about whether the bank actually burns down? How fireproof are the safe deposit boxes? Is anyone actually working at the bank right now and might they be in danger if you don't act before the flames engulf the bank?  What's more important, the money and physical assets in the bank or the people who work there? 

How about the restaurant owners?  Do they have insurance that will cover their losses? What about the owners of the restaurant real estate? What type of insurance do they have. The people who eat at the restaurant?  Are there people there now? Are they in danger? Are there restaurant staff preparing the ingredients for later in the day service? Are they in danger? What will be the impact of the fire on the jobs of these people, if they manage to survive the fire? Will they be able to find new jobs? Will they be eligible for unemployment insurance? Are they only part-time workers, who work in a few restaurants, so they won't be eligible for any benefits or support?

What about the nursing home, where low wage workers perform menial tasks while delivering compassionate care for vulnerable older adults? What about the older adults themselves? What type of help will they need to be saved before the nursing home is engulfed in flames? Are there buses available? Do they have the necessary handicapped setup to allow for wheelchairs and gurneys? Are there enough people to move all of the residents out in a timely fashion? What about the real estate? Do the owners have enough insurance to cover their losses? What will happen to the staff if the nursing home burns down? Will they be able to find another job? Will they qualify for unemployment insurance?

Who should be making the decision to evacuate the town? Who should be deciding whether to close the bank and send everyone home? The restaurant? Who should be making the decision as to whether to evacuate the nursing home? Has someone ordered buses? Has someone found "homes" for the residents? Are hospital beds available for those who need specialized care? Who is making these decisions? Is the local government convening an advisory committee composed of bank, restaurant and nursing home real estate owners? Are they asking for recommendations from the unions who represent bank, restaurant and nursing home workers? Are they including the community in the discussions to determine the impact of the bank, restaurant and nursing home being shut down or burned down?

Who is talking to the vulnerable older adults who live in the nursing home? Who is asking their families for to share their thoughts and concerns? Are the clinicians who care for the residents being asked to help the decision makers understand the impact of transfer trauma? On how to effectively move people who have dementia? Are the subject matter experts in the care of vulnerable older adults even being considered as the flames approach the nursing home? For that matter, are the residents and families at the table? Or, are they about to become the meal? 

Decision making during a crisis is poorly informed by a stakeholder model.  Crisis management requires an incident commander to make decisions at the level of the bank, the restaurant and the nursing home. Crisis management dictates that the local fire department and health department look out for the safety and lives of the people who work in the bank and restaurant, and particular for the workers and the vulnerable residents they so compassionately serve.  

As we've observed the response to COVID-19 over the past 9 months at the federal, state and local levels, what type of crisis management have we seen? What has been the decision making process? When we look back, will we discover that a focus on stakeholders has kept us from making the right decisions?

Pacing Myself

I dreamt last night that I was helping a bunch of physicians with their billing codes.  Not sure where that came from or why, but I was really engaged in the details of it. It's been a long time since I've even thought about such things.  While I've been trying to "power down" on the weekends, there's once again too much going on right now. There are too many opportunities to let a day go by without working, though someone did comment that I am the busiest "semi-retired" person that they know.  Touche. Not sure I am really good at pacing myself when it comes to life.

I also got in a run yesterday.  I've backed off running over the last few weeks due to some discomfort in my lower left leg.  I absolutely don't want to end up with a stress fracture, and that's what it was beginning to feel like it might be.  I'm still not sure, so I'll be careful.  I've been focused since June on running volume and not speed, but yesterday, I allowed myself the luxury of running fast.  In fact, after warming up for a couple of miles, I ran the first mile of what is normally my 8 mile route in a personal best time of 7:30. Turns out that was nearly 30 seconds faster than any time I've run that mile in.  I needed to be a little careful, as the first quarter mile is downhill, and then the rest is all uphill.  Pacing. For a couple of reasons.  First, running the first part too fast might have put too much stress on my leg, downhill running can do that.  Second, if I went out too fast, I wouldn't have what was necessary for the end of the mile.

Running 3/4 of a mile uphill hard felt good, it also was hard.  Running a mile hard was something that I felt like doing, although I didn't want to put too much stress on myself. My allergies have been acting up this week, which is usually a sign of fatigue.  This time my fatigue hasn't been from training, it's been from work and lack of sleep.  Pacing.

This past week I've gotten in the habit of starting my day with my blog and then spending some ritualistic time getting myself focused on myself.  I'm trying not to get either too caught up or wound up before the day begins.  I want to begin the the balanced, only that way will I be able to truly pace myself.

COVID-19 Dreaming

There was a time that I used to dream about Ironman. There was definitely a time that I used to dream a out work. In the early days of COVID-19, that was all I dreamed about, but then, for awhile I stopped dreaming. It was for a short while, though, because now my COVID dreams are back.  Sometimes they will guide me through my day, sometimes they'll guide me through my blog.  Other times they will just be a reminder of the world we live in right now.  Last night was probably one of those. Nothing major to do this morning or to think about, except perhaps that I woke up without an alarm clock, because I know that in a few minutes I have an opportunity to be on a call with the office of a United States Senator.  Right now, all any of us can do to make a difference is to try, and I don't know anything else.  

Dreams have meaning.  For me, they've always been about processing my day and sometimes literally thinking about and preparing for the next one.  Not bad, I guess.  It certainly fits into my obsessive personality!  And so, I keep dreaming.  I'd like to have some of those Ironman dreams back, though.

Looking Out for Oneself

It's human nature to look out for oneself.  It's about survival.  It's instinctual, and evolutionary. It's truly hard to get away from. As children, the world revolves around us. We need to be in charge. We need to have what we want to have. For some of us, that evolves in various ways.  Some people grow up to be followers, but in their minds, they're still looking out for themselves. They just fit neatly in the role of a follower.  Others are natural leaders and gravitate to the role of being a leader.  I never really considered myself to be a leader growing up. On the other hand, I was never going to be a follower.  Whether it was nature or nurture, I have always rebelled to any type of authoritarianism.  That includes parental authority. I've always gone my own way.  In that way, I guess I also naturally was always looking out for myself.  

Ironically, caring about others has also been who I am.  It's an interesting dichotomy, that caring about others reflects my need to look out for myself.  If I'm not caring about others, then I'm not happy.  As I grew up and got married and raised a family they became part of that orbit.  Getting a job, earning a living, taking care of them.  For me, however, there has still always been the drive beyond my family to make a difference and to impact the lives of others.  In that regard, becoming a doctor was a natural profession.  At an early stage in my career, however, impacting the life of one patient paled in comparison to impacting the lives of many.  The balance between looking out for my family and trying to change the world has always been a precarious one for me. Which brings me back to the concept of looking out for oneself.

In 2015, I was offered a job.  It was literally the lowest paying job that I could have found, but it offered an opportunity to make a difference.  That difference was in improving quality in nursing homes.  Thus, I reengaged on a journey that I'd started years before. To improve the quality of care of vulnerable older adults.  In its own way, taking the job was looking out for myself. It was just a new part of my journey. I learned to build a team around me by putting all of the successes on them.  The more that I did that, the more the success of our team built, and ironically, the more the perception of my success increased.  What I loved about that job was the fact that I was literally my own boss, not really answering to anyone else. Of course, that had limits, and when I pushed beyond those limits, it was time to leave.  There wasn't much reason to stay in a low paying job when I could not longer enjoy the freedom of doing what I wanted to do.

And so came my next job, which turned out to be a stepping stone to the polar opposite of the job I had just left.  This was the highest paying job that I could have ever found. I was in charge, yet in many ways I wasn't. There were ultimately others calling the shots, leading me into a dark hole where I used every means at my disposal to actually be in charge, and convinced myself that I was.  But, I was never truly convinced. Because, at the end of the day, we're always looking out for oneself.  As I reflect on my life and my work experiences, it strikes me that most people are always going to defer to what they perceive as best for them and their family. Perhaps that's where religion comes in, and the concept of doing unto others? Otherwise, wouldn't society just unravel into the anarchy of every man for themselves?

In looking out for oneself comes the concept of rationalization. We rationalize that what we're doing is for ourselves, or family, or even for a greater good. We do that despite the reality of the circumstances around us. We ignore signs and signals.  We develop excuses and reasons for our actions or the actions of others.  We want to believe.  Ironically, when it comes to religion, we want to believe. Otherwise, how else could we be looking out for ourselves?

Can We Fix Stupid?

I find myself going on to Facebook once a day.  I specifically look for the Ventura County Coronavirus page with it's updates on the status of COVID-19 in our county.  We're actually doing pretty well.  While there has been an uptick in cases, the number of hospitalizations and deaths has been low.  Inevitably, there's someone who comments that this is all a media hoax, and they highlight the low numbers and say that 99% of people recover from the virus.  Every time I see these types of comments, I feel an obligation to respond.  I don't call them stupid.  I don't call them ignorant.  I don't lower myself to the name calling that some of these comments include in their rants.  I actually try to point out where they're correct.  We have been doing well in our county.  That isn't cause to celebrate. Other counties that have taken their eye off the ball, so to speak, are doing much worse.  Now is the time to continue to stay focused.  I also repeatedly let people know that not everyone recovers from this virus, and the risks go up with age.  

Why do I bother? Does it make a difference?  I think I bother for the same reason that I've been obsessed with battling this virus and every entity that doesn't know what it's doing.  If you don't say something, you have no one to blame but yourself.  I have no idea if the people who rant ever read my comment, and if they do, whether it makes a difference.  However, if just one of them stops to think for a second, it would have been worth it.

Maybe not.  As I wrote this, it struck me that if one of the people who go on a rant pauses for a second to reconsider their position...is that one second worth the several minutes that I took to write a response?  One thing is certain, there are only 24 hours in a day, and I have been pushing the limits of that day for 8 1/2 months.  I do need to pace myself.  Life is, after all, just like an Ironman.  The only analogy I can come up with related to doing an Ironman is my propensity to tell other athletes to walk during the run portion, especially when I see them struggling on an uphill portion.  I feel a need to let them know that if they "save their energy" early on, they'll have more at the end.  I've learned that the hard way and have always felt a need to share what I know with others (pretty standard fare for me).  Does it change their behavior?  I don't know.  Maybe. Sometimes.  I still do it.  I guess that's who I am. It doesn't matter if we can fix stupid. I always have to tri.

Being at Peace

I was terribly unsettled yesterday.  I couldn't put my finger on it.  I was definitely not "at peace."  When I was in Kona I felt a "peace" that I have rarely felt.  There was no goal, other than to truly be in the moment.  There's an irony to the need for purpose as it relates to "being in the moment." In its own way, that is also a purpose.  There are so many positive things in the world to be in the moment for.  Children get this. Adults forget. Ironically, in many ways, I was never a child. I was always striving for something. Always striving to "do something." In many ways, Kona was a high point for me.  Yes, it was an accomplishment, but that wasn't the feeling that I had.  I felt like I was able to "rest" on the things that mattered. 

We are not defined by "things." We are not defined by accomplishments. We are defined by who we are and what's inside of us.  I've always been a very goal oriented person, but those goals are not who I am.  We know that there is value in purpose, but purpose doesn't have to be existential.  It doesn't have to be concrete.  It doesn't have to be an act or a "thing." Being "in the moment" is actually a very purposeful act.  The fourteen and a half hours that I spent on the course at the Ironman World Championship over a year ago had meaning beyond numbers.  It was about the experience.  When the numbers and the accomplishments become the priority, there can be no peace.  

Over the course of the last 8 1/2 months, my life has not been my own in many ways.  Every day has been shaped by forces beyond my control, but in fact, that has been my choice.  Everything that we do in life is a choice, whether we choose to accept it or not.  Being at peace is a choice.  Why haven't I been willing to make that choice? 

The choice begins with the rising of the sun. It begins with the purposefulness of the day.  It is not about a single act.  It isn't about a particular accomplishment.  It is the day. That is peace.