Running Head: DOCTORAL FELLOW
Experiencing the Kaiser Permanente Organization as a Cancer Communication Research Center Doctoral Fellow Paula K. Baldwin August 14, 2011 George Mason University
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Experiencing the Kaiser Permanente Organization as a Cancer Communication Research Center Doctoral Fellow The middle of July 2011 marked a significant moment in time for 15 doctoral students from all across the U.S. A special conference designed to create a particularly salient interaction between theory and practice was held by the Cancer Communication Research Center with the support of the National Cancer Institute. By the time a doctoral student reaches his or her first year as a graduate student, he or she has attended classes for six or seven years. Many of us spend summers taking classes or workshops, with little time off from classwork. We live and breathe in the rarified air of theory and learn to turn out papers in the blink of an eye. We strive to learn as much as we can in the hopes of someday sharing what we have learned with others. We recognize in each other the quest for knowledge that few others possess, both in the drive and the knowledge itself. We put our lives on hold in order to reach a particular goal, the right to put Ph.D. at the end of our names. The introduction of the real world into our highly-theorized existences marked a turning point for all of us of that I am certain. Our time in Denver was marked by indepth looks at the Kaiser Permanente organization, with its strengths and challenges. We had the opportunity to interact with researchers clearly operating at a level we only dream about achieving at this point in our careers. We were challenged to bring something to the table: to look at our experience and this organization and give our benefactors an ‘out of the box’ point of view.
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To that end, I will be discussing my shadowing experience, the organizational challenges Kaiser Permanente faces, and future directions by way of a commentary on a theoretical perspective. Shadowing Dr. Daniel Johnson My first day shadowing was with Dr. Daniel Johnson. From his bio, I can tell you many things about his accomplishments. Dr. Johnson is the National Clinical Lead for Palliative Care at Kaiser Permanente’s Care Management Institute. He is also Director of Palliative Care innovations and Development at Kaiser Permanente-Colorado and is a practicing physician on the Palliative Care Consult Services at Exempla St. Joseph Hospital (Denver) and Exempla Good Samaritan Medical Center (Lafayette). Additionally, he serves as the Director of the Life Quality Institute – an organization that has provided over 120,000 hours of palliative care education for Colorado’s health professionals and communities. Dr. Johnson is clinical faculty at the University of Colorado and a Faculty Associate for the University of Colorado Center for Bioethics and Humanities. In short, Dr. Johnson is an extraordinary individual and I feel honored to have shadowed him. After an early morning meeting with just the two of us, Dr. Johnson and I went to Kaiser Permanente and sat in on their daily palliative care meeting. There are two palliative care teams and they meet daily. At this particular meeting there were two chaplains, three physicians, one nurse, one intern, one pharmacist and two social workers present. I have seen interdisciplinary team meetings on video, but I have never sat in on
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one. It was interesting to see how the team communicated, particularly in comparison to some of the team research I have done in the past. The team meeting began with a meaningful quote, given by one of the chaplains. The meeting is always opened with some sort of meaning quote or story in order to get the team in the correct mindset for the important work they are about to embark upon. Not all teams do this, but the quote definitely set the tone for the meeting. The majority of the patients discussed were geriatric with one outlier of someone in their 30s. One complication of treating patients is that they often present with multiple diseases which makes the palliative care treatment challenging. After the palliative care meeting, Dr. Johnson and I took a break and talked about the notes I had made, my observations and questions. Then we headed across the street where Dr. Johnson taught a palliative care class to group of first and second year residents. The residents presented him with a current case and he demonstrated where palliative care could be introduced and ways to overcome possible barriers. In one of our discussions, Dr. Johnson identified what he considered the two top areas of research needed. First, he thinks we need to investigate how we talk about death and dying, sort of an updated Kübler-Ross. Second, he feels that researchers need to examine how the intersection of meetings with the interdisciplinary team and the patient and family members impacts the patient-family decision-making process regarding care. For me as a researcher, both areas present important areas of potential research. Dr. Sorenna Kirkegaard My second day of shadowing brought me to Dr. Sorenna Kirkegaard, pediatrician. A bright, personable and highly competent physician, Dr. Kirkegaard, gave me an
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opportunity to watch a talented communicator in action. Her patient-provider interaction was amazing, particularly so because a pediatrician does not only need to interact with the patient, but with the parent as well. This can be challenging, but Dr. Kirkegaard did it with ease. I felt fortunate to be present during her appointments. Summation My shadowing with Dr. Johnson was the longer of the two and a very valuable experience. To sit in on the palliative care meeting and to watch a non-Communication scholar speak so eloquently about communication in a difficult situation was enlightening. Although my shadowing with Dr. Kirkegaard was very different, it gave the experience of being seeing the patient-provider interaction and seeing it done very well. Both experiences served me well, although I must admit to being partial to the day with Dr. Johnson because of my interest in end-of-life research, but I am appreciative of what each experience offered me. Organizational Challenges Organizations always face some sort of challenge. Sometimes the challenges are external such as the economy or national policy. Sometimes the challenge originates from the inside of the organization. During one of the fellowship meetings, we discussed how there are not enough people touching the data because there was no cohesion and no central organizing structure. One particular metaphor that resonated with me was the description of the patchwork quilt of research data. As a researcher, it is distressing to think of all that data just sitting there unmined and the description of the patchwork quilt stayed with me long after our conference ended. Because there is no unifying framework, it seems unlikely that much of data can be used in a conventional manner. I
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see two possible courses of action, one of which may be novel and the other, quite predictable. Dataset Lending Library First, if indeed these various sets of data comprise the different patches of the patchwork quilt, then most likely the patches vary in size. If there are a few patches of fairly good size, it might be possible to set up these sets of data for use by newer scholars, or perhaps even graduate students, perhaps by setting up a library of datasets. While a student in different classes during my schooling, particularly in methods classes, both quantitative and qualitative, there have been several instances where we would have appreciated real world data. Oftentimes, during a semester we did not have time to collect the data ourselves, not enough time to get approval from IRB, or did not have access through which to collect it. Even collecting the data, if it were possible, would mean subordinating the time needed for a thorough analysis of the data or the time needed to learn the statistical software in order to analyze the data. As long as all identifiers were removed from the datasets, some kind of research library cooperative could be set up with local, state, or national universities. The parameters set for the use and grooming of these data sets would be determined by Kaiser Permanente. These datasets could be for classroom use only or they could be used for papers with the possibility of being submitted for conferences or publications. Of course, any datasets would have a pre-determined set of use restrictions before being loaned out and the Cancer Communication Research Center and Kaiser Permanente would always be acknowledged and could only be submitted for publication if the paper went through the review process of the Cancer Communication Research
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Center. If Kaiser needed help grooming the data, perhaps that could be part of the conditions of usage. I mention these limitations, but I am certain that someone more familiar with Kaiser Permanente’s research structures could certainly outline a program like this and the conditions and restrictions of use more clearly. However, if a program like this could be initiated, it would reflect well on Kaiser’s organization as well as making a substantial contribution to future researchers. The most important thing is that a program like this would substantially multiply the number of ‘hands’ touching the data. Standardized Research Protocol Second, and this was mentioned in our discussion, there needs to be a standardized research protocol set in place so that future research has a standard data organization procedure to enable all data collected to be usable. To that end, unless the past data can be utilized in a manner such as suggested above, the new goal would be to make sure that future research does have standard procedures. Future Directions A biologist, von Bertalanffy, proposed the general systems theory in 1928. Although originating in biology, systems theory has been applied in many contexts, but in this instance, I am applying systems theory to the Kaiser organization. An organization is comprised of multiple elements that function as an interactive web of relationships. The elements and relationships of the organization share common patterns, behaviors and properties. The relationships are between the different parts of the system and the resulting barriers have differing degrees of permeability. Oftentimes,
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there is overlap in the different parts of the system and sometimes they work independently and sometimes they work interdependently. One observation I made during one of our meetings was the cowboy culture that seemed to exist within the Kaiser organization. If I may extend that analogy further, cowboys often spend a great deal of time alone, but when it comes to the bigger jobs: taking the cattle to market, branding, or dealing with the herd during unusual weather events, it takes every cowboy working together to get the deed accomplished. It is the same thing with interdisciplinary teamwork. If you look at a typical interdisciplinary team, you see professionals from many different disciplines, specialties, and sub-specialties. An interdisciplinary team can be comprised of social workers, nurses, physicians, pharmacists, chaplains, volunteers, and interns. Each of them has specific tasks to accomplish according to their discipline, but overall, the main concern in the well-being of the patient. Using this metaphor, we can say that the different departments may have different goals, but overall their main concern should be the wellbeing of Kaiser. That may sound simplistic, but in the end, the best things are really simple. You have departments that are brilliant, but perhaps have never experienced or are apprehensive about working in a team environment. In fact, if you want to hear a loud, collective groan from a class, just announce that they will be doing group projects this semester. Anyone who has ever worked on a group project knows very well that your group might get stuck with a student who will virtually contribute nothing, but still get full credit.
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In the corporate world, I am certain that could happen as well. However, in implementing this new culture of interdepartmental collaborations, the departments can pick their team partners and therefore, can feel like they maintain some control over the workload and the quality. It is trepidatious to venture into an unfamiliar team research environment, but the benefits can be exciting. Perhaps the Cancer Communication Research Center could hold a series of brown bag lunches with the different departments to get the dialogue going about possible collaborative research projects and the how to’s of implementing a intradepartmental team project. In the end, the goal is all about creating a new norm for the research culture within Kaiser Permanente. Conclusion My experience during the Cancer Communication Research Center/Kaiser Permanente fellowship was educational and enlightening. The real world exposure and insights gained cannot be overstated. My shadowing experiences and interactions with Dr. Johnson and Dr. Kirkegaard provided me with a rich background for potential research areas. The in-depth description and analysis of Kaiser Permanente’s inner workings gave significant meaning to the challenges any healthcare organization faces today in this uncertain economic and political climate. Kaiser Permanente is an extraordinary organization with a high level commitment to providing their members with the best healthcare possible in an economically feasible manner. Kaiser’s emphasis on research and progressive outlook convinces me that not only is healthcare research alive and well outside of academia, but if Kaiser’s standards are any indication, it is in good hands.
