BHAGs, Bubbles and Dreams

Broken systems in healthcare abound. Exacerbated by Covid, emergency department overcrowding, ambulance ramping, and lack of access to care seem constantly in the spotlight. Quiet quitting, burnout and moral injury are no longer niche terms. They seem overwhelming, unsolvable issues.

I was recently invited to give a talk at the Don't Forget the Bubbles Conference (which brings together passionate providers of paediatric emergency care from across Australia and the UK) on the topic of: Patient Centred System Design. Yikes. I don't think I could design a system from scratch that would solve the myriad issues we face. I also don't think we could/should take a sledgehammer to the current system.

So here are my thoughts, as shared, on where may be a place to start.

Dream a Dream

Most clinicians started with some kind of dream of their role in bringing health and life to people. For some, it was a band-aid on a little brother when he scraped his knee. For some of the Gen Xers, it was the babysitters club stories. For some, it was a friend whose death left a scar tinged with purpose.

For me, my dream came slowly.?I never particularly liked kids, I never babysat.?My younger brothers at playtime were subjected to me turning the cubby house into a school room, sitting them down while I wrote on the chalkboard. I went into medicine because that’s what the smart kids did.?I cut up cadavers, I coloured in anatomy drawings. I decided to become a craniofacial surgeon, because it seemed that smart girls should do hard things to prove that they could.

But as an introvert with some social anxiety, I wasn’t a natural fit for the clinical side of medicine and surgery. I remember standing outside my first patient room on my first hospital placement, trembling and trying to drum up the courage to go and ask a complete stranger some very personal and intimate questions.??

It was when I got to paediatric emergency medicine that I found my tribe.?A wonderful mix of adrenaline and nursery rhymes - of cutting and casting, alongside cuddling and crying.?It felt like who I was meant to be. So I jumped into?the training pathway with both feet. And it honestly wasn’t until I was done with training, at the age of 30, that I really asked myself – apart from the fact that it’s fun and I like my colleagues, why am I doing this??

After 6 intense years of working 80-100 hours a week as a paeds resident and PEM fellow on the US training hamster wheel (and my husband being underwater with the US Navy on ballistic missile submarines for the better part of our marriage), we took some months away from work to travel, to get to know each other again, and to refocus who we wanted to be – as a couple, and as individuals.??

As we took the time to ponder, I had the margin for my heart and soul to feel deeply my incredible privilege.?Where I was born, the family I had, the education I had received. And my husband and I felt a fire stirring in our guts to care for people subjected to inequity and injustice.??That became our, and my, dream. That led to our family eventually moving to Kenya in 2011 to work as humanitarian/mission workers, and living there for 8 years. When we moved back to Australia in 2019, it led to my current role advocating for rural and remote health equity at the Royal Flying Doctor Service.

Changing equity of healthcare starts, in some small way, with a dream.

So what about you?

When you started your journey, did you have a dream? What was it? Is it still there? Is it something you are doing right now? Is it something you’ve given up on? Or is is something you are still trying to pursue – but your career and commitments have you sidetracked, and a little frustrated?

Maybe you have been able to pursue your dreams wholeheartedly.?

Maybe your dreams have been lost, or have changed - and somewhere, inside of you, maybe they are now dormant.?Maybe you have become burned out, maybe you have suffered - or are suffering - moral injury.

If that is you, can I encourage you first – take the time to heal.?Your wholeness matters more than any system.

But... if you are on the other side of that, or that is not you, maybe it is ok to give yourself permission to dream again.

As you dream, it can?be a fluffy feeling, a vague desire to push to the next frontier. But what if it was really concrete?

A Big. Hairy. Audacious. Goal.

A BHAG opens up possibilities you never considered.

It is so clear you can imagine it as a news headline.

It propels you from thinking small or settling for less.

And it has the power to inspire everyone around you.

Merck’s BHAG in the 1930s was to “Transform from a chemical manufacturer into one of the world’s preeminent pharmaceutical companies". Microsoft: “A computer on every desk and in every home.” Google: “Organize the world’s information.”

As I work at RFDS, I have a secret Big Hairy Audacious Goal of my own:

No Australian more than an hour from critical care.

It is, quite frankly,?ridiculous. I'll never make it happen by myself. But it is a guiding star that gets me out of bed in the morning.? Will this clinical KPI report get me one step closer? Yes – if I analyse this data, I can find out how long it currently takes my team?get to my patients.?Will this drugs and therapeutics committee meeting help me get there??Yes – because that peripheral adrenaline infusion guideline may help one of our RANs keep a child with sepsis alive.??Will the work I am doing for RFDS with the Stroke Alliance on brain imaging in the air help us get there? Absolutely! Will the paper I am working on about models of critical care in regional centres solve the problem??No – but what if it starts a conversation?

When you get up in the morning, is there a Big Hairy Audacious Goal you are working towards??What would things look like, if your dream for health came true? Each of us is just a drop in the ocean - but the ocean wouldn't exist without those drops. If system change doesn't start with me dreaming big about it being different, it doesn't start at all.

Create a ludicrous BHAG. Dream a ridiculous dream.

So – what next?

Stretch Your Bubble

Let's reflect on a literary masterpiece that has impacted many of our lives.?An incredible series of books that took the world by storm, with each newly released tome eagerly anticipated.?And then, exquisitely brought to life on the big screen.?

You of course know which series I am talking about.

Twilight.

If you have not experienced the wonder of Twilight, our protagonist, Bella Swan, is a woman who falls in love with a vampire, and is then voluntarily envenomated so she herself can become a vampire.??

And as you know from the Meyer Cinematic universe, vampires each have their very own unique super power.??Our hero Bella’s super power, is that she has a mental protective bubble that shields her from all vampire mind tricks and powers. Over time, Bella realizes that her shield, if she trains her mind, can actually expand – and protect not just herself, but those around her who she loves. So she works really hard to expand and stretch her initially tiny protective bubble to cover those around her.

Each of us has a bubble.?

A sphere of influence, an environment?in which we are comfortable. Where we have agency,?a tribe, and maybe the confidence to experiment a little.

Some of us have taken a long time to find our bubble.?To find that place of belonging, and a sense of meaning.?A place where the words we say matter, where our influence ends up with tangible results. Some of us are comfortable in our bubbles, and strengthening the little bubbles around us. Some of us are amazing in our bubbles.

Some of us are in a shrinking bubble.?A bubble that is sucking the life out of our dream, or drifting further and further away from our dream and we feel powerless to stop it. Some of us can’t see outside of our bubbles.

The problem with?even the best bubbles is that there are sometimes not enough of them - or our bubbles are just too far apart. That was where I found myself when we moved to Kijabe, Kenya. Our 350-bed regional hospital had an 80-bed paeds ward, with a nursing ratio of 1:16, vital signs done only three times a day. Most nights on call I had a baby die.

My bubble was a small team of paediatric doctors, physician extenders and nurses in our hospital paediatric wing. So we started small. With targeted nursing education about early recognition of abnormal vital signs and the importance of assisting breathing for a struggling baby with oxygen and bag valve mask technique. We also recognised that babies at higher risk of deterioration needed closer monitoring than three times a day – so we started advocating to manage some higher risk babies and kids with a reasonable prognosis in our hospital's 5-bed adult ICU.

After a year, we had a visit from some paediatric critical care doctors from Nairobi and Seattle. ?It turned out that the main referral hospital in Nairobi, 1.5 hours from us, had opened the country’s first public Paeds ICU – 6 beds for 55 million people.?And they had heard we had a Paeds ICU too.??They were thinking of starting a Paeds ICU training program: were we interested in hearing about it and possibly participating?

And that’s how our 2 bubbles, in Kijabe and Nairobi, came together and grew to become PECC Kenya.

After 5 continuous years of working working together on a curriculum, engagement with the Kenya Paediatrics Association,?the Kenya Medical Practitioners and Dentists Board, and navigation of the University of Nairobi Senate, in 2018 we finally got East Africa’s first fellowship training program in Paediatric Emergency and Critical Care?launched in Kenya.

As?result, we now have have 5 PECC graduates running 5 paediatric ICUs across East Africa. Two of them are?now starting their own programs in Rwanda and Tanzania. There are 5 more fellows in the pipeline, with more to come. The Kenyan PECC program joins 2 other Paediatic Emergency/Critical Care medical training programs in Northern and Southern Africa, training doctors, physician extenders and nurses?for 1.2 billion people across the continent. Our bubble has has now become PECC Africa,?a community of clinicians providing emergency medicine and ICU care for kids across the continent, learning from and with each other despite the scarcity of formal training.

What about your bubble?

When you think of your BHAG, who else outside of your bubble might share the same dream?

Maybe there’s someone in the same location in a different discipline.??Maybe there's someone in a similar role in a different location.

Are there bubbles of people who are dreamers like you that you haven’t thought of? - school nurses and counselors who are struggling to find tools and resources to truly connect their students with help? Remote area nurses for whom support in management of common childhood illnesses may be valuable, with teaching at the next CRANA Plus conference? Rural generalists who provide fantastic inpatient care of children but would like additional support in high acuity care? Regional volunteer paramedics who’d value training and support for recognition of the unwell child?

Is now the time for your bubble to stretch? To grow your tribe and improve the system? Maybe your bubble is more stretchy than you think....

Let Go of the Lolly

There is a tendency for those of us who dream to dream in straight lines.?To hold so firmly to our dream, that it can’t be pried out of our hands to be shared and shaped. Sometimes in our passion, we jump quickly to identifying a single solution to the problem in the system that we see. To step from our known, and to try and replicate it in a place where it is missing – and where it might not fit. We see a need, and we think we have the answer.

In identifying the gaps we see, we try to plug them - our way. We hold so tightly to the lolly, that to pry it from our hands would break the jar.

Sometimes, we need to let go of the lolly.

In Kenya, our hospital did not have the paediatric volumes or facilities for me to focus as a specialist on purely PEM care. I had to let go of my subspecialist lens, and be a paediatric hospitalist-plus. A generalist who could also bring some additional PEM and Paeds ICU concepts and training to general paeds, paed surg, newborn nursery, emergency and ICU teams, helping our hospital grow in areas of specialty expertise, while the bulk of my work was still general paeds.

When I think of regional and remote Australia, it would be easy for me to focus purely on what is missing and what I think is needed: a lack of GPs in small communities. A lack of neonatologists when prem labour threatens. A lack of regional ICUs outside of Adelaide.

A?"needs-based" approach.

But what if I look through the other end of the binoculars and ask – what is already there?

A. B. C. D.

This approach is known as "Asset Based Community Development".

In every system where there is a need, there is probably already something, some asset, already in place. How can we be a part of identifying, building on and amplifying assets that are already in place? Maybe there are passionate regional school kids who don’t want to relocate to the city to learn. Or culturally embedded and respected community elders. Incredible volunteer CFS/SES workers. Dedicated rural generalists or highly skilled RANs. Paramedics looking to grow a Community paramedicine model of care.

Find those people - and maybe rather than trying to moosh them into your lolly jar, take an assets-based approach. Try the following:

1. Ask questions – what do you already have and and what do you need - and how can I best help?
2. Be curious – consider if there is a model of care that is new that could build on existing strengths, and use and develop existing assets in new ways.?This is how GP anaesthesia was developed. It is how nurse practitioners came to be. It is how the emergency critical care clinical officer program was developed in Kenya, physician extenders who run the ICU 24/7. Maybe you are a specialist in critical care - and you work in a capital city because that's where the jobs are. What if you changed your lens, and instead of focussing on "specialty-minus" ICU-only care, the focus of ICU training was "physicians-plus" providing care as regional hospitalists, with additional expertise in critical care - that equips the broader team, hospital and region?
3. Co-create – start something small together with the people in need and those connected with them. Together define what success looks like, and give it a red hot go.
4. Depend – on your local assets to guide what success, and your next steps, look like.

And as you start to see incremental progress; as the system starts to strengthen, and adapt, and grow...

Remember Who You Are

It can be tempting to dream a dream and have a goal, and then have it run away from you.??

Things either go nowhere because it is impossible – or your ideas take off and become a runaway freight train.?And you either come to a standstill - or are swept up in the chaos and commitment and are at risk of derailing. I have to confess, I struggle with this.

When this happens – and it will happen - remember who you are.

Have you heard of the The Hedgehog Concept? Hedgehogs are simple creatures that?understand what they do best and just focus?on doing that one thing. And they remain hedgehogs, for their whole lives.?While the concept was initially conceived to apply to businesses - to focussing on just one thing to achieve organisational success - I believe that as leaders, it applies equally to us as humans in a volatile, uncertain, complex and ambiguous world.

The months my husband and I took off in 2005 resulted not just in articulating a dream - but in helping me hone my own hedgehog.??For me, this looks like 3 core values of which I need to regularly come back and remind myself – they have for over 15 years been the yardstick by which I measure my priorities and my decisions:

Love. Serve. Mentor.

When I get busy, when I become self important, when my goals take on a life of their own, the question I keep coming back to is this: Today, will my priorities help me -

• Love my family, my friends, my community?
• Serve those less fortunate than me, those who my faith tells me are my neighbour, and who deserve equity and justice?
• Mentor – life is beautiful and fleeting, what happens to my community and my dreams when I am not here? How am I working with others to pass on what I have learned from my mistakes, from my succesess, from my overeducation, from my own mentors?

Love, Serve, Mentor.

As you dream your dream, and as you stretch your bubble – remember this: there is only so much of you to go around. Every so often, take a step back and ask yourself: aside from what I am doing, who am I being? And is that consistent with the me that I am, the me who I want be?

What are your own core values?? When the wind blows, and pandemics come; when pain befalls you, or when serendipity strikes – who are are you at the core??

Because this is the foundation and meaning of the legacy and systems?you leave behind you.

Changing Systems Starts With You.

The only way that systems change, is with the germination of a dream, and someone taking a step towards it.

Dream a dream – our kids need them.

Be brave and stretch your bubble.?

Don’t be afraid to let go of the lolly.

And always, always remember who you are.??