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Adrift in PolicyLand

May 29, 2009
by Anthony Guerra, Editor-in-Chief
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When the gulf between policy and reality grows too wide, we're in trouble

PolicyLand is a fun place. I like to visit, but if you stay too long, you lose touch with reality. In PolicyLand, everyone knows everyone else; luminaries continually present on panels with each other, reinforce each others' opinions, and are incredibly polite. In PolicyLand, you don't even need to redo your PowerPoint because you did this presentation last month - you can just tweak it. In PolicyLand, everyone co-authors papers together and endorses each others' work, writes intros to each other's books and congeals around the same tables at the customary conference lunch. PolicyLand is like an exclusive club - very hard to break into, but once in, it's almost impossible to get thrown out. That's because, in PolicyLand, nobody is responsible for making anything actually happen, by a certain date, within a certain budget. In PolicyLand, in short, there are no consequences.

To make it in PolicyLand, you need only to express a bold vision of where things need to go. You need to constantly instruct “stakeholders” to do things like “come/work together.” You need to say pithy things like, “No one group can do it alone.” You need to state incredibly obvious things like, “Electronic medical records, while critical, do not constitute a silver bullet.” In PolicyLand you want to make sure, “the bar isn't set too low,” because, as a policy person, that's your job, setting bars very high. (It's boring to talk about low bars among “visionaries.”)

Then, of course, there's RealityLand, where most of us live. In RealityLand, the bar more often refers to where you get a drink than to unattainable goals set by those not responsible for reaching them.

In a fascinating turn of events, I recently moved between these realms, and the contrast was startling.

A few months ago, I listened and “Tweeted” all day from the NCVHS hearing on Meaningful Use. While there were some useful presentations, and a few nuggets in those I wouldn't describe as such, the affair was largely a jaunt to PolicyLand. Little did I know RealityLand was about to demand equal time.

Around 3 p.m. of the conference's first day, I received a call from my wife, who was driving home from a nurse practitioner conference in Boston. At seven months pregnant, she's often in discomfort for this or that (she says I lack empathy), but during this drive, she had been in excruciating pain emanating from her back and radiating around to her “upper right quadrant,” as she described it. I could hear her crying on the phone as she raced down I-95 towards home. If the pain continued, her physician instructed, she should go to the ER and get an ultrasound to check for gall stones.

I quickly grabbed my coat and headed for home, where we would meet before heading to the hospital (a prominent and well-respected organization, mind you). Coming off the elevator at the hospital, we were greeted by a security guard who asked her a few questions such as name and symptoms, commenting, “Oh, that doesn't sound too bad,” as she jotted the information on the margins of some manifest.

From there, we were brought into an examination room and greeted by a nurse who asked for my wife's information (though we had been there many times) and began creating her paper chart. Within 10 minutes, an admissions representative was in the room, collecting information on a paper form and making a Xerox copy of her insurance card. That was fast. Admissions, to its credit, did have my cell phone from a previous visit as an emergency contact.

“Do we need to contact the insurance company? Since we were not admitted through the main ER, I want to make sure this isn't billed incorrectly,” I stated.

“It couldn't hurt,” she said. “They all bill differently. I really don't know.”

What wasn't fast was spending the next six hours at the hospital for my wife to receive some fluids and a 15-minute ultrasound exam. After we were told the order had been put in for the scan, we were informed there was no estimated time on how long it would take for the test to be done. “One hour?” I asked, “Three hours? You can give us NO idea?”

“No,” I was told. “Ultrasound will not give us a time.”

As we waited and the hours slipped away, I heard a nurse tell someone, “No. We're full here. We have no more room.” The bottleneck in ultrasound, it was clear, had started reverberating.

I also heard the following exchange between two nurses.

“Where is Mrs. X's chart?”

“The resident took it downstairs.”


I learned just how this could happen when Transport (a guy and a wheelchair) finally came to take my wife down for her ultrasound.

“I've got a job for you,” he said, handing Marie her chart. “You get to hold this.”

When we got down to ultrasound (which seemed oddly serene for a supposedly harried department), the tech asked Transport, “Where is her wristband?”

“I don't know,” he responded.

“Did they give you a wristband,” the tech asked my wife.


“OK, I'll go back up and get it,” offered Transport.

So Transport duly returned with the wristband, which was applied, and the ultrasound was completed. We were then brought back up to the exam room (my wife again performing her chart-transport duty) and sequestered there for the next two hours until discharge. As it turns out, nothing was found on the scan, so we left none the wiser, though her pain had fortunately subsided.

The next day, I was dutifully back in PolicyLand, hearing about vision and dreams and goals, how things could be and how things should be and how things ought to be. But few in PolicyLand seem to understand where things are and the skills, money, and time needed to move the needle even slightly from here to there.