An Open Letter to Providers. OR: What I Learned From Crows
Or: Project: Real Collaboration
By David E McCarty MD, FAASM (But you can call me Dave!)
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Crows are cool.
If you’ve strolled around our website, picked through our Beautiful Blue Book, or listened to our awesome PODCAST, you’d have noticed a few crows hanging around.
I’m fascinated by them.
First, crows are smart— really smart. If you enrage a crow, he will spend time teaching his friends to recognize you, so they’ll be enraged by you, too. Crows take whatever they want, wherever they find it, and they use it for their own needs. They’re the Engineers of the bird world.
But it’s the behavior of crows in a group that fascinates me the most. Crows in a group are a marvel, because as you watch, you realize one beautiful, predictable, and powerful fact: Crows are always Pro-Crow.
Crows always vote for crows. They help each other. They hang out in groups that are so cohesive and thick it’s scary. We humans (being on the outside of this group) are so threatened by their thickness-as-thieves state that we labelled the group as something monstrous—we call it a murder.
If we imagine what it feels like to be part of that group, a big loud bustling economy of voices and personalities, curious and clever, but always cohesive, and always helping each other, I’m picking up on a signal that is decidedly different from intentional violence. It’s a signal that feels more like love.
I have fun thinking about the weird names there are for groups of things, or even coming up with some of my own:
A congress of apes.
An ennui of goats.
A juggernaut of scorpions.
If I could rename what a group of crows should be called, I think I’d call it a Collaboration, because that’s what they make me think of. When a crow gets hurt, another crow helps.
Crows always vote for crows.
As I think about our current healthcare landscape, I see much separation, not just of ideas, but of hearts. The two concepts go together.
Silos.
I’ve been thinking recently about the real meaning of the word collaboration, about what it feels like to truly be in a collaborative state. I know that it’s something more than just 500 people all getting into the same building to broadcast their message, to show the slides of truth, as seen from their silo.
Real Collaboration means that something must change in ourselves, as well. Real Collaboration means that we are willing to receive, as well as broadcast. Real Collaboration means taking the humble step of removing our armor and admitting that we don’t have the whole story.
We must admit in our hearts that we need each other, that all the silos have something to offer.
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I recently wrote a lengthy piece about the harms that siloed thinking can cause—it was so long that I think only a few people read it! —but the response I received from people of all silos was powerful. Everybody is feeling this problem. In the essay, I sketched out a Dramatis Personae of some of the players (silos) in this elaborate play, and how these players (silos) relate to one another, how they can naturally come to despise one another, and start throwing verbal rocks at one another. I explored how exercising the muscle known as empathy can help break down those barriers.
I confess, I spent most of my career in the fighting trenches, defending my silo, throwing rocks. I cared for thousands of souls who had been run over and left behind by a Profiteering practice only offering a One Size Fits All solution. I’ve cared for patients left behind by surgeons, CPAP-slingers, mandibular-advancement device factories, and pioneering Airway Centered Dentists. I’ve seen patients suffer needless harm, because an algorithmic label-based approach was used, rather than a patient-centered one. I had a special rock collection for the Profiteers and the blind algorithm-followers (they start to fade into each other, after a while), and I developed quite a throwing arm.
I realized recently that my rock-throwing was part of the problem. The Profiteering instinct is not necessarily evil. Any enterprise must be financially solvent and efficient to survive. Such is the nature of the world. If I spend all my time throwing rocks at the Darwinian successes currently on our business landscape, I will cancel out any opportunity to put a Healers’ spin on the delivery.
Throwing rocks induces pathologic deafness, remember?
This does not mean standing by, silent, while watching maltreatment occur. Far from it.
It means finding another way.
Real collaboration is finding a language that unites all of us, and one of the biggest rifts to close is that between the Profiteers and the Healers.
The problem as I see it: Profiteer-Engineers out there have closed their ears. They can’t hear the harm that’s being caused by the focus on efficiency and profitability. They don’t understand the demoralization patients feel, when they feel reduced to a label, when they have no agency or understanding. They’ve been unable to learn from the experience of Healers, because we’ve been throwing rocks.
When patients feel demoralized and abandoned, when they feel duped by a One Size Fits All promise, they leave your silo, eliminating the opportunity for you find out about their pain.
When patients like this end up with actual harm from a treatment, they lawyer up, and the rock-throwing starts in earnest.
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There is a curriculum you can teach people, to help with all of this. There is a curriculum that can impart a personal sense of agency and empowerment to the journey of Sleep Apnea, which frees both the provider and the patient from this scenario and allows Real Collaboration. I worked it out, and field tested it on thousands of patients.
This is not braggadocio, it’s fact: In my personal clinic, from 2016-2021 the long-term intention-to-treat success rate with PAP therapy was >90%. The reason? My patients were empowered and engaged. Simple as that. No one started therapy until they were comfortable in the driver’s seat, grinning with a thumbs-up.
There are many overlapping bidirectional relationships in Sleep Medicine, making Sleep Apnea a complex terrain to master. It’s human nature to latch on to reductionist explanations, and then hold on for dear life. Most providers have no idea how to present this complexity to their patients.
My Healer’s heart helped me learn what patients needed to know, to participate in Real Collaboration with my patients. My Star Wars childhood helped me learn how to teach it to people, in language everybody could understand.
My Engineer’s unrest forced me to make tools that other people can use.
(Crows teaching crows.)
That curriculum is all contained in our Beautiful Blue Book and is also available free by listening to our five-episode PODCAST. The main thrust is this: patients who are empowered will be more successful on the journey because they will help their providers find the answers.
It’s like having a full-time medical assistant who will relentlessly work on your behalf, for every patient, never asking for breaks or overtime pay.
The main tools of the Empowered Sleep Apnea method are two five-point mnemonics, constructs that are shared between provider and patient. They are conceptually easy to learn, and easy to teach, but they both require a deep dive into terminology and jargon that makes most providers nervous.
That’s why most people don’t do it. That’s why the approachability and friendly tone of Empowered Sleep Apnea is so crucial.
The Five Reasons to Treat discussion is a structured disassembly of the rationale to treat Sleep Apnea. This discussion is nuanced, because it requires a careful deconstruction of the label “Sleep Apnea” into something more grounded that the patient can understand, and it is deliberately designed to strategically inject the patient’s narrative into the label. It’s designed to strategically give the patient a voice in the process. It’s designed to instill empowerment.
By doing so, the Five Reasons discussion strategically places a brake in the system, making the provider and the patient both consider the possibility that treatment may not be necessary at all. In this way, the Five Reasons to Treat discussion can be likened to a pre-surgical Time Out, a ritual that is now commonplace in operating rooms everywhere, to avoid cutting off the wrong leg.
The ritual of the Time Out happens because the wrong leg has been cut off, a few too many times. That’s why surgeons do it.
The first of the Five Reasons—RISK—is the most misunderstood, and the hardest to teach, so most providers shortcut to the simplest possible version of this discussion, which is to announce that “Sleep Apnea raises the risk of early cardiovascular death, stroke and cancer” and leave it at that. This is the kind of information that’s typically made available in well-intentioned reductionist “trifold handout” educational materials, making an amusing target for some of my rock-throwing ire.
Patients subjected to this strategy of “education” often feel shamed, coerced, even browbeaten, and commonly respond to these feelings by leaving, and never coming back. The provider, meanwhile, sighs about how ignorant and noncompliant the patients seem to be these days and moves on to the next 15-minute appointment, never understanding the true reason for the patient’s disappearance.
The Five Reasons to Treat discussion also requires a careful dissection of the many moving parts that are under the hood of every case of Sleep Apnea. It requires the provider and the patient to both examine those moving parts, so that a sensible treatment plan can be envisioned. This is a built-in strategy that helps protect our patients from Profiteers out there with poorly developed Healers’ instincts, advertising a One-Size-Fits-All solution. The many moving parts part of the discussion instills agency in our patients, giving them knowledge to self-advocate.
The Five Finger Approach is a rational deconstruction of a larger question: how does one investigate non-airway contributions to a given patient’s sleep-wake complaints? One of the problems with our label-obsessed system is that once you get plopped into the box of Sleep Apnea, it’s very difficult for providers to return to the problem-solving table, when the patient remains dissatisfied with their sleep. Patients with Sleep Apnea can suffer for years with also-ran diagnoses that nobody thought to look for, because everybody, including the patient, thought the problem-solving was done, once the CPAP was prescribed.
Both the Five Reasons to Treat and the Five Finger Approach were designed as tools of provider-patient collaboration—in other words, they’re meant to be taught to our patients. When properly deployed, these tools create an intellectual and emotional bond between provider and patient that’s very difficult to break. When properly taught, patients achieve a state of agency and empowerment which accelerates their progress towards success, because they become invested and curious agents for their own recovery.
When properly taught, patients can teach these techniques to their friends, like crows teaching crows.
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In the final wash, collaboration must come to something more than just a bunch of siloed thinkers coming together to put their thoughts onto projection screens and drink. In the final wash, I’m starting to think it’s a challenge to gaze inward as well as outward. Our task is not just to gather with a mission of broadcasting.
Our task is to open our hearts and listen, especially to those who are operating outside our silo, which is a hard concept to wrap one’s head around. Our task is also to remove the mask of infallibility we show our patients, and truly collaborate in that relationship as well, providing the patient with the knowledge that helps them participate in the process as a respected partner, not as a disempowered pawn.
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We can learn something from our corvid friends. Crows are always Pro-Crow. Crows teach each other and take care of one another. Crows, having the gift of flight, are the ultimate symbol of empowerment and agency, because they have the capability of seeing the world from an elevated perspective.
As we providers work on ways to improve the lives of our patients as they navigate the vast landscape known as Sleep Apnea, we would be wise to remember these attributes. We would be wise to emulate this type of collaboration.
Real Collaboration.
When we get there…dare I say it?
That’ll be something to really crow about.
(tee hee!)
Recommended Reading:
McCarty DE. Beyond Ockham's razor: redefining problem-solving in clinical sleep medicine using a "five-finger" approach. J Clin Sleep Med. 2010 Jun 15;6(3):292-6. PMID: 20572425; PMCID: PMC2883043.