My DC hotel room last week was about the same size as a prison cell. But the towels were better, and they had an open wine bar at night, so maybe it was like a California prison.

One of the recent news shows has a healthcare-cum-fashion piece about women’s fall footwear; boots. Apparently, not all women can fit into the particular pair of boots they want to buy. My reaction was that the women in question should consider buying a different pair of boots. Apparently, my mind is too limited.

All was lost for these poor women until one group of healthcare professionals jumped in with a solution. If the shoe fits, wear it. If the shoe does not fit, it is because their calves are too large—I would never consider writing that their calves were too fat. Even someone as disdainful as I am about being politically correct does not need to go looking for trouble.

So the news reporter did her piece with the physician and the woman who wanted the boots, drew little red lines all over the woman’s calves, and yada, yada, yada, by the end of the piece the woman was able to fit into the new boots.

The question that immediately came to mind for me was, what if she finds a jacket that matches the boots, but whose sleeves are too short? Does she have her arms shortened?

For most problems, at some point we will encounter an easy answer that is so simplistic that our natural response is to disregard it.

For example, when people call your health system they call because they want a piece of information or they want to be able to accomplish something or they want to make a complaint. If your health system receives a million calls a year, ninety-seven point two percent of them will fall into one of those three buckets.

The easy answer would be to design your call center to be able to respond to those three types of calls. The more difficult solution would be to make your callers feel like you were telling them that the best solution you could offer them was to shorten their arms.

After your call center has shortened their arms, the callers may not be able to reach their phones, or if they can, they may just decide to call someone else.

I would write more about this topic, but I just saw an advertisement for a pretty dapper pair of boots—I hope they are not too snug.

“I do not believe we have a problem with access,” the CEO of a large IDN told me. “In fact, I challenge you to convince me otherwise.”

I’m guessing he thought that was the end of our discussion. Au contraire mon frère.

So, here is what I did. Please do not try this at home; remember, I am a professional.

I created a scenario that my son’s PCP wanted him to have his ankle examined by an orthopedist, and my goal was to schedule an appointment for him. The health system has a dozen hospitals, including a children’s hospital.

I tried to approach scheduling the appointment the way I assumed any parent would. I went to their website, found an 800-number on the site’s home page, and made my first call.

Unlike the websites of most health systems, this site had only one phone number on its home page. If you are bold enough to only have a single phone number, you probably want to give some consideration as to why people may be calling and what they hope to accomplish when they call.

The person who answered the phone told me that I had reached their referral center.

I then tried the site’s Find a Physician link, and I called the single children’s orthopedic doctor listed on the site. (It may be important to note that the health system has 217 orthopedists.) I was told that the doctor I called was a bone tumor specialist, a fact the web site did not specify.

Next I called pediatrics and asked whom I should call to get an appointment with a children’s orthopedic doctor. I was told, “This is pediatrics and I don’t have that number here.”

The next call had IVR to negotiate. The person I spoke with said, “For us to see him it would have to be a sports related injury.”

I then called the 800-number at the top of Children’s physician search page. The call was being recorded. I had to give the woman my name and insurance carrier before she would entertain the reason I called.  I began to get encouraged. After all, I thought she wouldn’t go through the trouble of taking my information if she wasn’t going to be able to help me. She could not give me the name of someone to call, but gave me the main number for the children’s hospital.

Finally I called Children’s, gave them my information, and was told “I don’t think we have orthopedics at Children’s.” I was transferred to a clinic and was told “We do not have orthopedics at Children’s, you have to call ABC Hospital.” ABC Hospital is not part of their health system; it is a competitor.

The series of calls took almost an hour. Had I really wanted to schedule an appointment, I would have given up much sooner.

Patient access, patient engagement, patient experience. The trinity of patient acquisition and patient retention.

Sometimes it all boils down to something so simple that getting it wrong is silly. If a health system cannot answer its phones and schedule an appointment, all of the other things that it does well will not matter to the person who made the call because that caller will buy their healthcare somewhere else.

The two processes that should be extremely simple, that should provide a great user experience, and that should be completed correctly one hundred percent of the time are scheduling and payments. Making it easy for people to buy from your health system and making it easy for people to pay for what they bought will go a long way.

A weekend news article in USA Today included the following text; The whale was missing a giant hole in its side.

Really? It was missing a hole. Not only was it missing a hole, it was missing a giant hole. Does the fact that the whale was missing a hole mean there was no hole? The thing is, I would think one of the qualifications for being a writer is the ability to write. Maybe USA Today has different standards.

If you read an article stating Wells Fargo misplaced a thousand two hundred and fifty thousand dollar loans, you might think that was pretty stupid of them. Where are the controls, you might ask? They incurred an expense to make the loans, now that money, like the money they lent is up in smoke.

If the Mercedes dealer could not find the truck that delivered eight new cars to them yesterday, you might think that was pretty stupid of them. They incurred an expense to make acquire the cars, now that money, like the money they would have made selling them is up in smoke.

If the hospital’s marketing campaign got a hundred new people interested in scheduling their annual wellness exams, and when those people called to make an appointment half of them could not schedule one, from what I see day in and day out, the apparent thought process is stuff happens. They’ll call back. Or will they.

The health system incurred an expense to acquire the new patients, now that money, like the money they would have made taking care of them is up in smoke.

Assets disappear.

If the health system lost four laptops this week, there would be a big meeting next week, Sally would bring the coffee and Joe would bring the bagels, and an action plan would be created so that no other laptops would go missing.

People design processes to ensure assets are retained and tracked. People—patient people (consumers) go missing. Too bad we cannot staple an RFID device to their foreheads to track them the way we attach inventory numbers to laptops. That way we would know who went missing and when.

According to my small mind, the lifetime value of a patient is between $180,000-$250,000 over twenty-five years. And where did these missing patients go? Chances are they did not decide to give up buying healthcare; they just decided to give up buying healthcare from the system that delivered the poor experience.

Where are the controls? Who is guarding the chicken coop?

So, just how good do access and experience have to be? One of my clients was only able to schedule appointments for about fifty percent of the people calling to schedule an appointment. Even their schedulers no long tried scheduling appointments for themselves. Hint: it has to be better than that. Is a good success rate 80%; 90%?

How often do you have to get it right? I know it sounds silly but since a health system is in the business of providing care, and since people cannot just walk in to the orthopedics clinic and say, “I need to get my hip replaced today, which doctor is available?” it would stand to reason that the health system should target getting scheduling right a hundred percent of the time.

The thing is, getting ninety percent of anything right would seem pretty good. And it is until you quit looking at overall figures and take it down to the level of the individual. Down to the level of the individual whose appointment was not scheduled. That person does not give a hoot about how dandily all of the other calls went.

And since only about twenty percent of the calls have to do with scheduling, it would seem to make sense to figure out how to get the other eighty percent of the calls right a hundred percent of the time.

So what else should we know about the problem before we try to fix it? The first people to talk to the new patient, the people who get them to believe that the callers are talking to the right institution about where they should place their trust for their health, are probably the lowest paid people in your institution. Chances are that nobody on the executive floor has ever met one of these call agents. Chances are that he call center is not a stop on the management-by-walking-around executive tour bus.

These people also have no tools to do their jobs. Or, they surely do not have the right tools to dot their jobs. Neither do the other people in your institution, the people who receive the other 80% of the calls, and the calls that are transferred to them by the people in your call center. I italicized call center because I am 83% sure that your health system does not have a call center.

I have to go to the call center. What is it? It is a big room, crammed full of people and phones. And worksheets, and maybe some kind of software.

It just occurred to me. The people who are the first people to talk to your new patients are often also the last people to talk to the people who wanted to become your new patients.

If you want to get this right, and you should, you should follow these simple steps:

• Define an enterprise-wide patient access and experience strategy, at least for your inbound calls.
• Ensure the strategy is uniform, especially with regard to scheduling. (But we do not do things that way! Doctors set their own rules about when they will see patients and what kinds of patients they will see. BIG HINT: NOT ANY MORE.)
• Inventory all the different types of calls you receive.
• Then define your processes and requirements for meeting those calls
• Then create an RFP for a CRM solution, one you will use to receive calls
• And allow the people answering the phones to chat online with people on your website, and allow them to use email—this is not anarchy, it really will help

Then sit back and relish in the fact that you now have a way to attract and retain patients.

It feels pretty good, doesn’t it?

To most, it probably seemed like a normal flight. It may have been if not for the other three passengers. My wife and I were seated behind, Dr. Phil, Hillary Clinton, and Carrot Top.

After eavesdropping for more than an hour, I whispered to my wife, “You know, I might even see circumstances that would aloud me to vote for her.”

She began screaming, “You are not going to waste your vote!” And, it took more than a minute for the air marshals to pry her fingers from my left and right carotid arteries—I used Google to make sure I had more than one carotid artery. I learned Tasers work pretty well, especially when used at close range. The charge was not only sufficient to reduce my wife to a quivering mass, but also turned my bottle of water into seltzer.

Then I woke. My national nightmare was over.

One of my favorite sporting events is the Boston Marathon. If you search for pictures of the marathon, most of them look like one of these two; the start and the finish.

When I was in high school my girlfriend was the editor of the yearbook. She took a lot of pictures of me like the first picture above, pictures of me leading the race. There were very few pictures of me coming in first. That is because what you do not see are many images that look like the one below, the things that happen between the start and the finish of the race.

That is where all of the action takes place. Like when someone calls your health system and when the call ends. Most of the notable access experience happens between the two dial tones.

For everything the people in charge of your health system think they know about how people want to interact with your institution on the phone, I bet nobody in your health system knows the following information.

Most health system executives could not state their system’s access strategy in a concise sentence. If they could, it would be something like this: “We want them to access us. We advertise on NPR, we put up billboards, and we call people.”

The following four facts should change your entire patient access and experience strategy.

• 80% of people access their cell phone within fifteen minutes of waking
• 79% of people have their cell phone with them at least 22 hours each day
• On average, people access their cell phones 150 times a day
• 98% of text messages are read versus 22% of emails

When you add tablets and laptops to those figures the asymptote—I hardly ever get to use this word, so I tossed it in here—for access approaches 100% for each of the above.

Let’s look for a minute to look at how behavior modification could impact patient and consumer access, patient and consumer experience. And which group of stakeholders needs to modify their behavior? (One of the benefits of blogging is the freedom it gives to redefine the rubrics of grammar. Also, people who believe that there is only one way to spell each word are limiting themselves.)

The patients and consumers, or the health system executives? The way I see the situation is as follows. The entire planet determines which way is up; 22 of every 24 hours based on what they learn from their cell phone. Aliens invade. Cubs win the pennant. People place much more credence on information they receive online. And on average they check for information online, using their phones, 150 times a day.

Here are some other facts health system executives should staple to their foreheads.

• The people passing a kidney stone are not the same people who happen to be driving past the health system’s billboard depicting a twenty-foot tall Instagram photo of the health system’s urology coven—double, double, toil and trouble; fire burn and caldron bubble.
• The people who are driving to work, who just passed the urology billboard, and who are now listening to an NPR blurb about the fact that your health system just hired a tarot card water-walker PhD from Our Lady of Clairvoyance, are not going to pull over and change their healthcare provider.
• People rely on information gleaned from NPR to learn about when ichthyopods (fish; I may have invented the word) first walked from the sea, and why republicans are the anti-Christ.) They do not rely on NPR as the determinant for where they should buy their healthcare.

I have always been the outlier. When I want to share an idea or make a point that I want to be very visible, I never erect a billboard; I do not advertise on NPR, and I never hire a telemarketing firm to get the word out. As my children would tell me, “That is so 80’s dad.”

The entirety of mankind, or at least the entirety of the U.S., uses online devices as a tool to gather information about how they will determine what they will do with their day. They separate the wheat from the chaff of what is important to them. Health systems use billboards and NPR to attract consumers and to retain patients. The people they are trying to reach do not use those channels.

The disconnect seems obvious, but then again there are people who think the earth is flat and who believe we never landed on the moon.

If the majority of people in your health system’s radius of service check their phones within fifteen minutes of waking, why aren’t they hearing about something meaningful from your health system? If the majority of people have their phones with them 22 of every 24 hours, why aren’t they hearing about something meaningful from your health system? If the majority of people check their phones a 150 times a day, why do they never get a message from your health system?

Mobile access seems like a much more effective way to communicate with the people the health system serves.

Mobile, online, and interactive healthcare opportunities continue to be missed by a huge percentage of the electorate. The opportunity to make population health and patient and consumer access more effective is being missed.

I may be wrong, but I doubt it.

While I was teaching my son to drive we encountered a stretch of highway that did not have any other cars on it. As he was talking to me I noticed that the dial on the speedometer had passed seventy.

I told him the next time he is traveling that fast in something with wheels on it that there had better be a stewardess in the same vehicle.

NPR was celebrating the life of a poet and it made me think, the last time I considered poetry was in high school, and that was because someone made me consider it. I suspect one’s knowledge of, and familiarity with poetry, decays exponentially—the further removed you are from it the less familiar it seems. There are times when for a Chi-Chi effect, when you happen to be at a Chi-Chi function, there are benefits to being able to quote a stanza from something like In Flanders Field:

We are the dead: short days ago,

We lived, felt dawn, saw sunset glow,

Loved and were loved: an now we lie

In Flanders field

I feel it gives me a certain je ne sais quoi. Sort of like looking at some of the art hanging in your corporate offices. Find a piece that looks like a child’s refrigerator art, and wait until someone senior is in the area. Then step back from it, hold one arm across your chest, and rest the elbow of your other arm on the first arm and place your fingers against your lip the way Bill Clinton would when he was feeling your pain. Then say hmmm, as though you understand the depth of what the artist was trying to convey. If you really have the technique down, you may even wish to use the opportunity to quote poetry.

Exponential decay of knowledge about something. The further removed you are from it the less familiar it seems.

Experience with Patient Experience has a similar exponential decay.

Willingness to make mistakes, trial and error, the idea comes first

To me, one of the great unknowns about Albert Einstein is the question of what he did when he was not publishing his theories.  Assuming you are not among those who read People Magazine, the average layman has probably heard of his Theory of Relativity.  Fewer still can state the theory, and only a small number of people have any idea of its implications.

So, he’s got a couple of theories to his credit.  I’ll ask again, what did he do with all of his non-theory time?

He failed; prolifically.  Einstein always began with an idea, something simple like explaining the entire universe with a single equation.  In between the idea and the equation were years of trial and error—lots of errors.

Einstein planned for failure.  If he did not fail nobody alive would know his name.

Who is in charge of failure at your firm?  Whose career hinges on making colossal failures?

Everyone in business fails.  Somebody didn’t plan correctly.  A large customer went elsewhere.  The new plant in China is two years late.  Joe was 1.3% over budget.  In the grand scheme of things, those failures are irrelevant, they are rounding errors, errors which over time have little impact on the bottom line.

There are two types of failures; operational—like above—and strategic.  Given the choice I’d opt for strategic failures every time.  To fail strategically means somebody is at least trying to do something.

Don’t place someone in charge of making sure everyone is on budget.  If you want to be innovative, make sure you have someone overseeing failure.

Terrence Holt, a geriatric specialist at the University of North Carolina at Chapel Hill, describes a situation in Internal Medicine, fictional fables based on his residency:

Any patient in a hospital, when we take their clothes away and lay them in a bed, starts to lose identity; after a few days, they all start to merge into a single passive body, distinguishable … only by the illnesses that brought them there.

Lost identities, distinguishable only by their illness. Unless, of course, the person calls the health system. When they call they are not even distinguished by their illness because the person speaking to them usually has no information about the caller.

Less than twenty percent of hospitals have a customer relationship management (CRM) system. Of those that do, ninety-five percent of those CRMs are only used by business development and marketing to try to acquire patients. Very few health systems use CRM in their call centers to help them retain patients.

And that is a silly mistake since the people who are calling are usually grappling with one of two questions; will I buy healthcare from this system, or will I buy healthcare again from this system.

Maybe after they make the decision to change health systems their old system will call them back on a marketing call using the CRM they should have used when the person was still their patient.

We only need about a hundred more reads for this little missive to hit 100,000 reads. Nobody is more amazed by that statistic than I, but I am also very appreciative of the fact that you continue to play along, and I have learned a lot from your thoughtful feedback.

And I have decided that the hundred-thousandth person to read a post will win my neighbor’s new BMW—he is not among the readership, so that will serve him right.

Over the last few years several of you have been kind enough to read and comment on the draft of my second novel. As an undergraduate I majored in math, in part because I wanted to get through university without writing a term paper. My strategy worked, save one. Political science.

A philosophy professor mentioned that if you ever did not know how to reply to an essay question on an exam, the best approach was to rewrite the question in a manner that turns the question into one you could answer. I took his advice. Apparently my Poly Sci professor had also taken philosophy. He wrote on the top of my Blue Book, “Great answer. But we both know that was not the question I asked.”

Fifteen years ago I was taking a flight to Rio to meet with my client. The book I had purchased at the airport wasn’t worth the money; it wasn’t even worth it in Canadian dollars. I started thinking about what it might take to write a novel, wondering what authors had done that I had not done. They wrote. I tossed the paperback aside and I began to write about a former boss of mine. A gentleman for whom I had very few fond memories.

Twenty pages later he was dead. I read what I had written, and concluded I was even less fond of him than what I had written, so I did away with him in a more egregious manner. It was a very cathartic experience. Six weeks later I had written almost four hundred pages.

The second most entertaining part of writing is that some character that I would invent during the day would wake me in the middle of the night and tell me what he was going to do next. The best part about writing is that I had finally found an outlet for the voices.

A month after that I had an agent. The agent said I wrote like a mathematician, and she suggested I might want to use a few adjectives. She would see me again in a month.

Upon reading the revised draft, chocked-full of adjectives, she asked, “Paul, have you ever spoken to a woman?”

Her question left me confused and concerned. She saw my look and knew I had no idea as to why she had asked. She explained saying, “Women do not talk the way you have them speaking in your book.”

“Have you even spoken to a woman?”

I thought of that question today and I thought we could tie that question into the topic of customer/patient experience.

“Have you ever spoken to a customer?” To a customer outside of the hospital. It is easy to speak to a customer or patient inside the hospital. Part of the reason it is easy to speak to someone in the hospital is that the ratio of employees to customers is probably something like one to five.

What I am asking is have you ever spoken to someone outside of the hospital, someone who was trying to schedule an appointment? To someone who wanted to understand their bill? Get a refill, and so forth and so on. Outside of the hospital the ratio of employees who speak to customers is astronomical; probably something like one to several thousand.

It is not a fair fight. And the employees do not get much better at it over time even though they answer the same questions day in a day out. Their failure to speak well with your customers is not a reflection of their skills or their motivation.

The people who answer your phones speak with more of your customers each day than most people speak to in a month. They are usually the ones with the lowest compensation. They have little or no authority to meet the customers’ needs, and they have no tools to help them present the health system properly.

If asked, hospital executives would tell you that people (customers) call the health system to get answers to questions about billing, refills, and scheduling. They would tell you that, and they would be wrong. They would be wrong because they have never spoken to their customers outside of the hospital.

In the last month I have spoken with two non-provider healthcare executives. We were discussing patient access, patient engagement, and patient experience. I did not ask them what they thought of their health system. But they availed themselves of the fact that they had a captive audience; me. Paul’s 12-Step program for disgruntled patients.

One of the executives mentioned that the experience was worse than what he imagined Beirut was in the 1980’s. The other, who is friends with the CEO of a large health system in our nation’s capitol told me that trying to do business with his friend’s health system was the worst business experience of his life. He continued by saying, “These people have no idea how bad it is because they never have to interact with the system as a customer.”

The people who call the health system, your health system, are actually calling to answer for themselves one of two questions; will I buy healthcare from this health system, or will I buy healthcare again from this health system?

My first novel has yet to be published, but I remain hopeful. My agent died. And no, I did not do it.

I am thinking about creating a fantasy-consulting league modeled on the fantasy football league. My sense is that the players will be somewhat more nebbish, and the tattoo factor may be less than that in the football league.

Health systems are approaching the eleventh hour with regard to reinventing how they do business. The bad news about the eleventh hour is that nobody will ever warn you when the time is quarter to—you only know the time when it is five after.

If a health system tried to trace the results of its failure to recast patient access to a seminal point the failure would point to their failure to engage, to interact the way people choose to interact with all of their institutions.

Patients leave their health system. They leave it before they are admitted, and they leave it after they are discharged. And people leave it because after trying to accomplish something on the phone with the health system they feel that their time would have been spent better teaching a hamster to tango. And the health system is left with a permanent look of surprise and irony.

One of the curious things about how healthcare is managed is its ability to count and account for things. Supply chain management. The number of bedpans. The number of patients. The number of wilted hibiscus plants by the elevators.

There is also a category of uncountable things, things like leaked patients. Nobody knows when he or she leaked or why they leaked or how many leaked.

For the most part, health systems do not engage people, even though engagement is a priority. They do not have plans to interact. That is because health systems react. Answering the phone is not interacting. It is Pavlovian—stimulus, response. Phone rings, phone is answered; at least some of the time.

This lack of an engagement strategy makes revenue growth for many, many health systems a zero-sum game. One of the teams, Team 1, playing the game is comprised of people from the health system’s marketing and business development departments. They have a budget and tools. In simple terms, their job is to fill the revenue funnel. Get patients. Get new patients; ‘Like us”, ‘Follow us’, ‘Call us’. Millions of dollars are spent trying to get people to buy their healthcare from a given health system.

The membership of the other team, Team 2, playing the zero-sum game is ill defined. Its members include people at the health system’s call center—a euphemism for what is really just a scheduling center. Its members also include people in billing, authorizations, referrals, registration, admissions, and so forth and so on.

The game works like this. Team 1, Marketing, gets a point each time it convinces a potential patient to consider buying healthcare from their health system. Team 2 causes a point to be subtracted every time they fail to engage the potential patient. Team 2 earns bonus points for patient leakage—leaked patients are those who leave the hospital and disappear into a black hole.

In many health systems, patient acquisition, patient retention, patient referrals, and revenue growth are not zero-sum games. They are negative-sum games, games in which both sides lose. Patient revenues are falling, costs are rising, and reimbursements are falling.

The October 2014 issue of Health Leaders Media included an article, “What’s Your Growth Prescription?” The article included a chart showing survey answers to the question, “How will your organization fuel financial growth over the next five years?” The responses, listed in declining order are:

• Expand outpatient services
• Strategic marketing campaign for the existing market—59% plan to do this
• Strategic marketing campaign for new market—41% plan to do this
• Develop or join an ACO
• Acquire or merge with hospitals
• Develop or partner with a convenient care facility
• Acquire or develop a health plan
• Increase inpatient bed capacity

While those may be interesting ideas, none of them does away with the fact that the health system will continue to play the same zero-sum game. Increasing bed capacity without retaining patients will lead to empty beds. Having a strategic marketing campaign will be no more effective than having a non-strategic marketing campaign if the health system cannot engage with the people who respond to the campaign. Acquiring a hospital or a convenient care facility or an ACO or a health plan, without recasting access and engagement will likely pair one zero-sum organization with another zero-sum organization, thereby reinforcing a negative-sum outcome.

Sometimes I am a bit of a pedant when I feel the need to make a substantive argument, and I am afraid that this was one of those times. All of the growth options listed above will require a significant capital investment, and they will take years to become operational.

However, initiatives to improve patient engagement and patient access are measurable, and they can deliver significant short-term results, without a gross outlay of capital. If anyone asked, my plan to grow revenues would focus on recasting access and engagement. And its three tenants would focus on increasing retention and referrals, and a significant reduction in leakage.

I read recently that Vision without execution is hallucination.

The feed from the satellites tethered above the northern hemisphere beamed down. I could hear the synthesized voice of my GPS chuckle as I tried to find the field for my daughter’s softball game. The location for today’s game was posted to my calendar by my wife—you will understand shorty the italicizing. The location placed us in the middle of a harvested field of corn.

I asked my daughter to Google the high school in the hope of getting us to the game before it ended. She responded telling me she found a picture of the school online.

I asked, “How does having a picture of the school help me find it?”

“Because I’ll know it when I see it.”

“Do you see it now?” I asked as I pointed to the rows of denuded corn.

“No.”

“Well which way should I turn to get you to where you can see it?”

“I don’t know.”

“Do you think maybe you should have Googled the address instead of a picture?” I could see she had no understanding of why I asked the question.

I called my wife, having failed to engage my daughter, hoping to engage my wife’s help. “By any chance do you have any additional information to help me find where the game is being played?”

She checked her email, and replied, “Oh, it looks like the game was cancelled.”

“And you know this how?” I was still trying to engage her in a meaningful conversation, hoping she would give me access to the information I needed.

“I got an email at nine this morning—four hours ago.”

“Do you think this information would have been helpful to me? We have been driving over corn kernels for an hour.”

“Oh, quit whining. You are having special time with your girl.”

My desire to engage my wife in a meaningful conversation about why I did not have the information had hit a virtual Chinese wall. The empathy fairy wasn’t going to make an appearance.

When the need to engage someone fails repeatedly, people become frustrated. And when people become frustrated they become stupid. And when they become stupid they get a time-out. And when they get a time-out America’s prisons become overcrowded.

My desire for empathy, my effort to engage my wife, to have her help me solve my problem had failed. Were I less amiable, less even-tempered, had I less jocundity, I would have become frustrated and done stupid things. And I would have received a time-out, and I would have added to the problem of prison overcrowding.

Had I received a time-out and added to the problem of overcrowding our prisons, I would have been among friends. After a few months of being locked in the big-house, I would meet other husbands who had failed to engage; simple men who had become frustrated and who had received a time-out.

We would shuffle around in our prison slippers and K-Mart pajamas, and we would play pinochle in the prison’s cafeteria. Then, after a few months of planning, my group of men would have devised an escape to get back to our former lives.

Then one of us, the one who had been serving his time-out the longest, would make the point, “Look, if we break out, and return home, sooner or later something will happen that will get us sent right back here. It may be from one of us trying to engage by asking something stupid like, ‘Why do you need so many pairs of black shoes?’ It may come from a misunderstanding of how to use pronouns, like if you asked, ‘Why do you ask me can we take out the trash when what you really mean is can I take out the trash?’”

Then the other guys on the escape committee would look forlornly at each other. Then the guy who had been inside the longest, the one who had carved a hacksaw blade from a bar of Dial soap would get up, walk to the closest guard, and hand over the blade.

The guard would simply nod. For he had been a guard for many years, and he had learned to spot the groups of husbands planning their escape. And he knew that as the planned date for their escape approached, sooner or later the men would see the folly of their plan.

Then the guard would return to the guard’s locker room, as he always did, and he would drill a hole through the end of the soap hacksaw blade, and thread a string through the hole, and tie the ends. He would place the soap-on-a-rope blade in the jar that held all the other roped blades that had been made by all the disillusioned groups that had preceded this group.

Patient engagement is good. Patient disengagement causes people to get frustrated and it makes them want to carve a bar of soap. And when patients get frustrated they get stupid. And when they get stupid they take a time-out. And they take a time-out from trying to engage their health system.

After a while they may think about trying to reengage their health system. But many of them will remember how frustrating their last engagement experience was. And instead of taking another time out they will try to engage a different health system.

An important rule of patient engagement is that people do not want to work hard to engage a health system. People want to engage the system when it is convenient for them, not when it is convenient for the health system.