Category Archives: musings

Pincer funding: how to support appropriate coding of adverse events without rewarding bad behaviour

There’s a problem with correct coding of adverse events. In effect, we want a system that rewards correct coding, but punishes harmful behaviour.

If the institution is punished in any way for adverse events, they will be far less likely to code their occurrence.

If the institution is not punished (i.e. rewarded or unaffected) for adverse events, then adverse events will either continue or at best remain unchanged.

A thought bubble had today at the safety and quality commission workshop involves the idea of a pincer funding arrangement, specifically suited to Australia’s current funding arrangements.

At the local hospital district (or individual hospital) level, pay for coded adverse events, but then impose financial penalties at the state (or local hospital district) level.

I imagine they’d just all learn new ways to game this, but the intent is to reward correct coding, but punish harmful behaviour.

Navy Seal on changing the world…

According to Admiral William H. McRaven, if you want to change the world you must:

  1. start each day with a task completed
  2. find someone to help you through life
  3. respect everyone
  4. know that life is not fair
  5. know that you will fail often
  6. take some risks
  7. step up when the times are the toughest
  8. face down the bullies
  9. lift up the down trodden
  10. never, ever give up

Vinod smashes up doctors (again)

 

But Khosla devoted his hour-long keynote speech Friday to his long-held belief that technology will replace 80 to 90 percent of doctors’ role in the decision-making process.

“Sufficient data used properly and reduced to the right insights does in fact make up for errors,” Khosla said. “I would rather have 1,500 EKGs (electrocardiograms, a test that checks for problems with the electrical activity of the heart) done much more poorly than two EKGs done a year very well, because the sources of errors in the current system are just too large. When I have two EKGs a year, I may not be symptomatic. I’m not arguing that these systems don’t have errors. I’m saying the volume of the data, properly applied, makes up for it.”

http://blog.sfgate.com/techchron/2014/05/23/vinod-khosla-doctors-cannot-compete-with-machines/

Vinod Khosla: Doctors cannot compete with machines

Venture capitalist Vinod Khosla thinks the best way to improve health care is to get rid of most doctors.

Human judgment simply cannot compete against machine-learning systems that derive predictions from millions of data points, Khosla told an audience Friday, the third and final day of Stanford University School of Medicine’s Big Data in Biomedicine Conference.

“Biological research will be important, but it feels like data science will do more for medicine than all the biological sciences combined,” he said. “I may be wrong on the specifics, but I think I will be directionally right.”

The Silicon Valley billionaire has been in the news this month for restricting access to a beach south of Half Moon Bay, a move that is being hotly debated in court.

But Khosla devoted his hour-long keynote speech Friday to his long-held belief that technology will replace 80 to 90 percent of doctors’ role in the decision-making process. His is one interpretation of the implications of big data — the popular term for the massive volumes of digital information generated by electronic health records, genetic sequencing, clinical trials and other sources.

“Sufficient data used properly and reduced to the right insights does in fact make up for errors,” Khosla said. “I would rather have 1,500 EKGs (electrocardiograms, a test that checks for problems with the electrical activity of the heart) done much more poorly than two EKGs done a year very well, because the sources of errors in the current system are just too large. When I have two EKGs a year, I may not be symptomatic. I’m not arguing that these systems don’t have errors. I’m saying the volume of the data, properly applied, makes up for it.”

It’s only a matter of time before health care accepts that technology can do a better job of predicting patients’ risks for diseases, diagnosing illnesses and pinpointing the most effective therapies, Khosla said. He noted that Wall Street analysts and pilots also at first resisted, before they embraced, data-driven machines.

In particular, he said, wearable medical sensors, like Fitbit, will give patients power to make informed health and health-related decisions on their own.

Not surprisingly, this argument didn’t go over smoothly with some of the physicians in the crowd.

“I don’t agree with 80 percent of your remarks,” one clinician told him.

Khosla acknowledged his view is often not a popular one, but did not back down.

“Humans are not good when 500 variables affect a disease. We can handle three to five to seven, maybe,” he said. “We are guided too much by opinions, not by statistical science.”

A chat with Terry

An excerpt of a conversation with Terry Hannan on the business and bureaucracy of health and clinical care…

 

Terry, thank you for sharing those terrific papers by John Wennberg and Brent James… inspiring and affirming thinking.

 

Regarding your request for me to expand on how “true” priorities of the system are expressed:

My overarching thesis for eHealth and its myriad follies is that the systems built often correctly reflect the “true” priorities of the system. The only glitch is that these priorities are often so radically divorced from those stated by the system’s leaders and in turn expected by clinicians and/or the public.[I would like you to expand this # as I am not sure I entirely grasp your focus here.]

 

Different stakeholders expect different returns from their investments. Roughly speaking (and apologies in advance for some of the generalisations that follow):

– politicians want to maximise votes in return for policy announcements

– bureaucrats want to maximise budget, status and power, and minimise risk in return to turning up to work

– public sector doctors want to maximise the health of their patients and status in return for turning up to work and working hard

– private sector doctors want to maximise income and status and minimise legal exposures in return for doing as much work as possible

– private hospitals want to maximise revenue in return for getting as many patients through their doors as possible

– nurses unions want to maximise members in return for negotiating improved work conditions

– not-for-profit (mutual) private health insurers want to maximise their perks by keeping doctors and private hospitals happy

– for-profit private health insurers want to maximise their profit margins by minimising doctor and hospital payments and maximising membership

– health researchers want to maximise their research capacity in return for increased publications

 

(Patients don’t even make my list of stakeholders, because they are not truly involved at present. An interesting remedy for this is citizen juries, a discussion for another time – did you ever engage with Prof Gavin Mooney before his untimely death?)

 

This suggests that each of these tribes wants a different “currency” in exchange for the “value” they deliver to the health system. They all use “patient interest” as the public justification for their claims on the system, but most of them are not actually remunerated in a currency that relates to the patient’s interest.

 

Indeed, in true “rent seeking” fashion, most of these stakeholders would rather not have to justify their remuneration to anyone – see this recent HLM news article.

 

At present, the easiest way to see what the system actually values is by looking at what it invests in. One “tell” that belies the health system’s “true” priorities is what it goes to the effort to properly records in electronic form i.e. billing data. This therefore suggests that money is the priority, and so it is what is tracked carefully.

 

If “patient interest” was truly the priority of the system, then far more effort and expense would be put into tracking patient outcomes, and in time, paying for them. On this, I am encouraged by the early shoots starting to sprout in the US around the development of ACOs, though I’m sure there are a lot more warts on it when seen up close.

 

My favourite “tale” of how to get there relates to how I’m told traditional chinese medical practitioners used to be paid. Everyone in the village would pay the practitioner as long as they were well, but stopped paying them whenever they ever got sick. This tight pecuniary alignment between patient and practitioner interest excites me, and makes me think there is still hope for ACO-style reform here. Indeed, my current health policy horizon doesn’t even involve hospitals and doctors, but rather looks at prevention efforts as the focus, as separate system with separate funding and separate participants.

 

I suspect this is best discussed over a long lunch or dinner, which I look forward to when the opportunity next arises.

 

Best regards, Paul

 

 

 

 

 

 

 

From: Hannan, Terry J (DHHS) [mailto:Terry.Hannan@dhhs.tas.gov.au]
Sent: Tuesday, 17 June 2014 9:07 PM
To: Paul Nicolarakis
Subject: RE: contact

 

See my inserted notes.

 

From: Paul Nicolarakis [mailto:pnicolarakis@cmcrc.com]
Sent: Tuesday, 17 June 2014 5:45 PM
To: Hannan, Terry J (DHHS)
Subject: RE: contact

 

Thanks for your forbearance Terry.

 

I’m inspired by your resilience and enthusiasm for the area, and quite certain that this particular eHealth conversation is going to yield some interesting insights. I present these ideas (which tend towards the political more than technical or clinical) to you in confidence, with a view to sharpening up the thinking. In light of my political experience, I would not want to offend any past masters as they were operating within some diabolical constraints.

 

My overarching thesis for eHealth and its myriad follies is that the systems built often correctly reflect the “true” priorities of the system. The only glitch is that these priorities are often so radically divorced from those stated by the system’s leaders and in turn expected by clinicians and/or the public.

 

Applying this analysis, it makes sense that an EMR purpose built to support HIV treatment in Africa would work because the only people involved in its development are dedicated clinicians, developers and minimal funding from similarly aligned entities with the specific purpose of improving the quality of care.

 

It also makes sense that physician led, integrated health systems (e.g. Regenstrief, Intermountain) that understand the “triple aim” nexus between high quality care and reduced costs would employ these systems successfully.

 

But finally, it also follows that systems built for governments in modern western democratic economies will never work because they are being built to get their political leaders re-elected, and make their vendors lots of money, but not really serve the community. The failure of these systems is ultimately guaranteed when the transparency they risk introducing into a system starts to threaten vested interests such as private medical providers and their associated institutions.

 

As per your slide from Blum, the red tail wags the yellow and blue dog because this is actually what matters in modern health care.

 

Microsoft learned this the hard way with their health solutions group efforts that I was involved in for a few years. The analytics software (Amalga) was quite impressive, initially developed by a group of keen, inquisitive (“data curious”) emergency physicians. They used the solution to monitor all sorts of clinical quality metrics across the business Washington Hospital Center service. Microsoft executives saw it, were impressed and acquired it. They then tried for 4 years to sell it to the world, only to discover that the “world” was not as interested in “clinical quality” as they were in bottom line revenues. What emerged from this experiment was the realisation that Microsoft had found itself ambushed by the gross conceit of modern healthcare i.e. stating that it was all about patient care, when in actual fact it was all about cash. Hence the highly administrative focus of most EMRs?

 

What has been terrific is to see US policy makers respond to this realisation by establishing “business models” around meaningful use and clinical outcomes. This is what seriously excites me now, though I suspect Australia is a decade away from adopting anything like what’s going on in the US at the moment.

 

One of the mantras we have here at the CRC (born in part out of our academic finance roots) is: “Healthcare is not a system, it’s a series of highly dysfunctional markets”. Applying this prism to healthcare really does start to clarify things, especially on the private side. On the public side, the currencies are sometimes different, but no less predictable.

 

I’ll pause here for fear of triggering some sort of global terrorist alert and/or offending you? Needless to say, I look forward to seeing where this conversation goes!

 

Best regards, Paul

 

 

 

From: Hannan, Terry J (DHHS) [mailto:Terry.Hannan@dhhs.tas.gov.au]
Sent: Tuesday, 17 June 2014 2:15 PM
To: Paul Nicolarakis
Subject: Re: contact

 

Take your time you just spark my enthusiasm. The fact that you are interested is such joy. Terry

Sent from my iPhone Terry Hannan
On 17 Jun 2014, at 1:40 pm, “Paul Nicolarakis” <pnicolarakis@cmcrc.com> wrote:

Please bear with me Terry… I’ve got lots on at work… will respond soon… Paul

 

From: Hannan, Terry J (DHHS) [mailto:Terry.Hannan@dhhs.tas.gov.au]
Sent: Monday, 16 June 2014 2:12 PM
To: Paul Nicolarakis
Subject: RE: contact

 

Paul, thank you for the taking the time to write to me and if you think about it this is the first time in our long association where we have done a bit of eHealth “together”.

Based on your enthusiasm in the text I will now send you some materials which should further extend our discussions.

 

Firstly I have attached nan short slide set that I had prepared for the Sydney meeting-just in case.

The next slide is explained in the text flowing it.

<image001.png>

 

This slide is taken from B. Blum’s Clinical Information Systems and you can see the small RED Administrativebox in the top left which is where most HIS funding and management comes from and they try to meet the needs of the most important cost generator Clinical Decision Making.

This is confirmed by the work in cost reduction in CDSS as shown in the slide set attached by Tierney in Regenstrief.

Also in the references below.

1.         Slack WV. Cybermedicine, How Computing Empowers Doctors and Patients for Better Health Care. 2nd ed. San Francisco: Jossey-Bass; 2001 2001.

2.         Tierney WM, Fitzgerald JF, Miller ME, James MK, McDonald CJ. Predicting inpatient costs with admitting clinical data. Med Care. 1995;33(1):1-14. Epub 1995/01/01.

3.         Tierney WM, Overhage JM, Takesue BY, Harris LE, Murray MD, Vargo DL, et al. Computerizing guidelines to improve care and patient outcomes: the example of heart failure. J Am Med Inform Assoc. 1995;2(5):316-22. Epub 1995/09/01.

 

In addition these results from institutions such as Regenstrief, Intermountain Health (HELP System), Brigham’ and Women’s Hospital and Beth Israel Deaconess Hospitals confirm these findings and show that the current funding models by governments are incorrect.

 

I am attaching two summary papers from the Kenyan project.

I hope I have not burdened you.

 

Terry

Dr Terry J. Hannan MBBS;FRACP;FACHI;FACMI
Consultant Physician
Clinical Associate Professor  School of Human Health Sciences, University of Tasmania Department of Medicine, Launceston General Hospital
Charles Street Launceston 7250

Moderator: http://www.ghdonline.org/

Ph. 61 3 6348 7578
Mob. 0417 144 881
Fax 61 3 6348 7577
Email terry.hannan@dhhs.tas.gov.au

Skype: thehannans

 

From: Paul Nicolarakis [mailto:pnicolarakis@cmcrc.com]
Sent: Monday, 16 June 2014 1:33 PM
To: Hannan, Terry J (DHHS)
Subject: RE: contact

Paper (PDF): Are docs the weakness in the ehealth building

Dear Terry,

Thank you for sharing the paper and referring me to ghdonline.org – I’ve just signed up.

The paper touches on many issues close to my heart, but two that I am particularly interested in is the exploration of “healthcare as business” vs “the business of clinical care”.

I won’t commit my dismal views to this email for fear of offending due to lack of context, but would welcome an opportunity to a vigorous discussion with you when we next have an opportunity? To the discourse I would like to add “healthcare as a bureaucracy” and “the bureaucracy of clinical care” as I believe this frame paired with “business” frame are particularly explanatory of most things that happen (or in the case of e-health, don’t happen) in the sector. Needless to say, the clinical and information systems you helped to establish in Africa represent something of an ideal in my mind for an end-goal of a “lite”, modern, effective health system following the “less is more” maxim.

Looking forward to continuing the conversation.

Best regards, Paul

I’ve now seen the Australian health system laid bare while working for the Minister, and many other health systems up close while working internationally at Microsoft. I’ve concluded that with rare exceptions, health care represents “just another unremarkable business” or “just another unremarkable

bureaucracy” depending on the type of funding system that is used.

On parenting

 

http://www.philosophersmail.com/relationships/why-when-it-comes-to-children-love-may-not-be-enough/

Why – when it comes to children – love may not be enough

Anyone of childbearing age will be surrounded by examples of catastrophic parenting in their own and previous generations. We hear no end of gruesome stories about breakdowns and resentments, shame and addiction, chronic failures of self-confidence and inabilities to form satisfying relationships. And at the root of all these varieties of suffering, one central cause sticks out: a lack of love. It was because the parents were remote and domineering, unreliable and frightening that life has never been quite complete.

From such failures, a major assumption has come to dominate modern ideals of parenting: that one must, above all else, love one’s child thoroughly, with immense sympathy, gentleness and kindness and that if one does so, the child will develop into a happy, loving and fulfilled human being.

This is the Romantic view of parenting and it is at its most vivid and self-assured in the early years, especially at moments when the child (finally) lies asleep in its cot, defenceless before the world.

Official Pictures of Princess Estelle Silvia Ewa Mary of Sweden, Duchess of Ostergotland
© Getty

Yet, despite immense investments and profound devotion, one is – gradually – liable to be inducted into a far more complex and challenging set of truths: that love is not a universal panacea and that giving unconditional affection is no guarantee of all the results one had hoped for.

The terrifying 3am truths about parenting run a little like this:

You are a punchbag

Nursery
© UIG/Getty

The blades of your child’s remote-controlled helicopter snapped after five minutes, just as you were starting to get the hang of flying it. The fault lies squarely with the manufacturers. But, sadly, they were not present in the kitchen – so, at once and not for the first time, you became the target for the raging disappointment of your child.

The repeated bad behaviour is surprising of course (it wasn’t meant to be that way), but it is a perverse sort of tribute to you nevertheless. One has to feel rather safe around someone in order to be this difficult. You certainly weren’t so tricky with your parents when you were young, but then again, you never felt so loved. All those assurances – ‘I will always be on your side’ – have paid off perfectly: they have encouraged your child to direct their every frustration and disappointment onto the loving adult who has signalled that they can, and will, take it.

You have to be the spoil sport

Human nature has a strong – and exceedingly inconvenient – bias towards indulging in whatever is most immediately pleasant and fun. And yet the central, unavoidable task of being a loving parent is to encourage the child to delay gratification in the interests of longer-term fulfilment. That’s why there will be fights. Constantly.

After all, it is so much nicer to play Minecraft than to learn how to spell ‘scythe’ or ‘embarrassment’; so much more amusing to see what happens if you put a hosepipe in the car’s exhaust than to do maths homework; so much better to read a magazine than brush one’s teeth, so much more gratifying to stay in bed than have a shower.

Out of love, a parent must – all the time, in small ways and large – say no. And for this, they will be severely punished. They will be treated as if they had arbitrarily made up the mechanics of tooth decay or had designed an economic system where the playing of computer games was disconnected from a capacity to pay bills. They will be punished for always bringing up unwelcome facts. And they will be very unfavourably compared with people who give the child whatever they want – because they just don’t care about them. It’s the thoughtless hedonistic characters, the ones who suggest all-night cartoon sessions and come around with iPads, who will be viewed as the heroes while the caring, denying parent has to contend with being called a ‘meanie’ and, later perhaps, a fascist.

Two children playing while a man reads a newspaper, c 1949.
© SSPL/Getty

You have to exert authority rather than teach

The dream is to coax the child into doing certain difficult things without ever having to demand they do so by force. The dream is not to have to ‘exert authority’, by which one means, bypass reason in order to impose a conclusion. The dream is to teach, and never to rely on the more basic weapons, like the assertion that one is the older, richer, bigger party.

One thinks with distaste of the Victorian parent demanding obedience simply by saying ‘I am your mother, I am your father’. To the child, the meaning of these words, mother and father, have changed entirely; they now mean merely ‘someone who will make it nice for me’ and ‘someone I will agree with if I see the point of what they’re saying.’

But attempts to teach and appeal to a child’s reason can only go so far. Whatever one says in a gentle voice, the children won’t eat vegetables; they won’t want to get out of bed in the morning; they will want to mock their younger brother or sister; they won’t stop playing the computer game.

When the child is very small, it is easy enough to deal with these protests: one can just lift them up or distract them in some kindly way for a moment. But later, by six, one has to use authority: one must simply assert that one knows best without explaining one’s reasons.

The child wouldn’t have the relevant bits of experience that would render one’s lessons comprehensible. A nine-year-old girl cannot understand how humiliating her six-year-old brother physically is a bad idea because this might make it hard for him to relate easily to women when he is older. It isn’t her fault she can’t understand. It would indeed be wholly unreasonable to expect a nine-year-old to be reasonable – and correctly comprehend the force and direction of adult concern.

The dream is that one will be able to pass on insights to the child that were painfully accumulated through experience, and thereby save them time. But in the absence of experience, insight doesn’t work. One cannot rush children to conclusions; one cannot spare them time. They will need, with difficulty, to make many of the same mistakes (and a few new ones too) and waste a good part of their lives finding out what you already know full well.

You can’t make things too nice for them

Volume 2, Page 74, Picture, 1. A picture of a mother telling off her son. 1958
© Popperfoto/Getty

Modern culture is deeply vexed – and appalled – by the thought that development might require suffering. We have been traumatised by the barbaric old-fashioned enthusiasm for punishment, the view – expressed by generations of sadistic Victorian school masters – that success demands pain, that there is a necessary relationship between early discomfort and humiliation and later strength and ‘character’.

But we have not merely rejected the Victorian mechanisms for inflicting suffering (the cold showers, the beatings), we have for the most part sought to abolish suffering altogether. Kindness has been triumphant.

And yet this attempt to abolish suffering involves waging a counter-productive and ultimately cruel war with the facts of human nature. We know from our own experience that we have at key moments grown through things that had a painful side to them: that there were terrors, rejections and disappointments that – in the end – made us more mature and better able to pursue our goals. We know that the drive to accomplish certain things, to master some difficult material, to win out over others, gained some of its power from fear and desperate insecurity. Because someone (perhaps a parent) didn’t believe in us, we redoubled one’s efforts. Because we were afraid of the consequences of failure, because succeeding was the only way to impress someone we loved but who wasn’t easily impressed, we put on an extra spurt.

We desperately want our child to grow mature but without going through awful things. We hate being an agent of fear. We want always to cheer and to hug. We want everything to be nice. Yet we also know, in our hearts, that this can only be a path to ruin.

You can’t guarantee their goodness

The Romantic view of existence sees all humans as fundamentally good from birth: it is only upbringing and a lack of love that corrupts and damages us and in the process, makes us cruel. Romanticism states that if only a child can grow up anxiety free, secure and encased in love, it will never break another child’s toy, rip up their paintings or try to scare them. The child will be reliably kind if she or he has reliably been shown kindness.

But experience suggests the existence of some ineluctably dark sides hard-wired in us and beyond the reach of the gentlest behaviour: certain kinds of aggression, cruelty and violence appear to be a given. A child may just want to hit its sibling out of excess vitality, boredom or native sadism. It might just be fun to smack someone in the face to see what happens.

That’s why there used to be such an emphasis on manners. Those who upheld them didn’t believe that a child ever could be spontaneously good simply because they’d been shown love. Indeed, a firm denial of love was what was necessary to help the child to create a wall between what they might feel inside and what they knew they could express with others. Being strict wasn’t a route to making anyone evil, it was a way to teach a person to keep their evil firmly locked up inside themselves.

You can’t guarantee their success

Book At Bedtime
© Getty

The modern parent believes that it might be possible to mould a happy, fulfilled, successful human. From this flows the minute attention to detail, from the purchase of the cot to the time-tabling of after-school activities. It is this that explains the Mandarin lessons, the French horn, the educational trips to the countryside and the ruinous tutor fees – because with all this in place, fate and failure can surely be kept at bay.

Yet the relationship between effort and return is more bizarre and more random. We cannot spare those we love the cup of human sorrow – whatever the intensity of our after-school programmes. We are always statistically most likely to give birth to mediocrities.

You will be forgotten

You take great care not to be frightening. You make silly jokes, put on funny voices, pretend to be a bear or a camel – all so as not to intimidate, so as to be approachable, the way one’s own parents were not. It should be a recipe for reciprocated love.

But weirdly, we rather like difficult people in a way, people we can’t quite read, who aren’t around so often, who are a bit scary. They hook us in – in a way the kind, stable ones never quite do. One loses authority by being natural, approachable, friendly, a bit daft, the clown who doesn’t want to scare.

An even more dispiriting thought comes to mind. Love them reliably and without fear and you will be forgotten. Be distant, intermittent, often absent and deeply volatile, and they will be obsessed with you for life.

And with these thoughts fully aired, it will be time for the kindly parent to attempt to return to sleep. It will be a long day – with the kids – tomorrow.

When is one ready to get married?

This is all very excellent and pertinent…

http://www.philosophersmail.com/relationships/when-is-one-ready-to-get-married/

When is one ready to get married?

Fletcher Jones III And Dalene Kurtis Wedding
© WireImage

It used to be when you’d hit certain financial and social milestones: when you had a home to your name, a set of qualifications on the mantelpiece and a few cows and a parcel of land in your possession.

But when, under the influence of Romantic ideology, this grew to seem altogether too mercenary and calculating, the focus shifted to emotions. It came to be thought important to feel the right way. That was the true sign of a good union. And the right feelings included the sense that the other was ‘the one’, that you understood one another perfectly and that you’d both never want to sleep with anyone else again.

These ideas, though touching, have proved to be an almost sure recipe for the eventual dissolution of marriages – and have caused havoc in the emotional lives of millions of otherwise sane and well-meaning couples.

As a corrective to them, what follows is a proposal for a very different set of principles, more Classical in temper, which indicate when two people should properly consider themselves ready for marriage.

Baron Axel de Sambucy de Sorgue and Charlotte Paul-Reynaud wedding, Marrakech, Morocco - 08 Jun 2014
© REX/DNphotograhy/SIPA

We are ready for marriage…

1. When we give up on perfection 

We should not only admit in a general way that the person we are marrying is very far from perfect. We should also grasp the specifics of their imperfections: how they will be irritating, difficult, sometimes irrational, and often unable to sympathise or understand us. Vows should be rewritten to include the terse line: ‘I agree to marry this person even though they will, on a regular basis, drive me to distraction.’

However, these flaws should never be interpreted as merely capturing a local problem. No one else would be better. We are as bad. We are a flawed species. Whomever one got together with would be radically imperfect in a host of deeply serious ways. One must conclusively kill the idea that things would be ideal with any other creature in this galaxy. There can only ever be a ‘good enough’ marriage.

For this realisation to sink in, it helps to have had a number of relationships before marrying, not in order to have the chance to locate ‘the right person’, but so that one can have ample opportunity to discover at first hand, in many different contexts, the truth that everyone (even the most initially exciting prospect) really is a bit wrong close up.

2. When we despair of being understood

Alain Delon And Romy Schneider
© Mondadori/Getty

Love starts with the experience of being understood in a deeply supportive and uncommon way. They understand the lonely parts of you; you don’t have to explain why you find a particular joke so funny; you hate the same people; they too want to try out a particular sexual scenario.

This will not continue. Another vow should read: ‘However much the other seems to understand me, there will always be large tracts of my psyche that will remain incomprehensible to them, anyone else and even me.’

We shouldn’t, therefore, blame our lovers for a dereliction of duty in failing to interpret and grasp our internal workings. They were not tragically inept. They simply couldn’t understand who we were and what we needed – which is wholly normal. No one properly understands, and can therefore fully sympathise with, anyone else.

3. When we realise we are crazy

This is deeply counter-intuitive. We seem so normal and mostly so good. It’s the others…

But maturity is founded on an active sense of one’s folly. One is out of control for long periods, one has failed to master one’s past, one projects unhelpfully, one is permanently anxious. One is, to put it mildly, an idiot.

If we are not regularly and very deeply embarrassed about who we are, it can only be because we have a dangerous capacity for selective memory.

4. When we are ready to love rather than be loved 

Confusingly, we speak of ‘love’ as one thing, rather than discerning the two very different varieties that lie beneath the single word: being loved and loving. We should marry when we are ready to do the latter and are aware of our unnatural, immature fixation on the former.

We start out knowing only about ‘being loved.’ It comes to seem – very wrongly – like the norm. To the child, it feels as if the parent is simply spontaneously on hand to comfort, guide, entertain, feed, clear up and remain almost always warm and cheerful. Parents don’t reveal how often they have bitten their tongue, fought back the tears and been too tired to take off their clothes after a day of childcare. The relationship is almost entirely non-reciprocal. The parent loves; but they do not expect the favour to be returned in any significant way. The parent does not get upset when the child has not noticed the new hair cut, asked carefully-calibrated questions about how the meeting at work went or suggested that they go upstairs to take a nap. Parent and child may both ‘love’, but each party is on a very different end of the axis, unbeknownst to the child.

Bormes-les-Mimosas (Cote d'Azur, French Riviera)
© U. Baumgarten/Getty

This is why in adulthood, when we first say we long for love, what we predominantly mean is that we want to be loved as we were once loved by a parent. We want a recreation in adulthood of what it felt like to be ministered to and indulged. In a secret part of our minds, we picture someone who will understand our needs, bring us what we want, be immensely patient and sympathetic to us, act selflessly and make it all better.

This is – naturally – a disaster. For a marriage to work, we need to move firmly out of the child – and into the parental position. We need to become someone who will be willing to subordinate their own demands and concerns to the needs of another.

There’s a further lesson to be learnt. When a child says to its parent ‘I hate you’, the parent does not automatically go numb with shock or threaten to leave the house and never come back, because the parent knows that the child is not giving the executive summary of a deeply thought-out and patient investigation into the state of the relationship. The cause of these words might be hunger, a lost but crucial piece of Lego, the fact that they went to a cocktail party last night, that they won’t let them play a computer game, or that they have an earache…

Parents become very good at not hearing the explicit words and listening instead to what the child means but doesn’t yet know how to say: ‘I’m lonely, in pain, or frightened’ – distress which then unfairly comes out as an attack on the safest, kindest, most reliable thing in the child’s world: the parent.

We find it exceptionally hard to make this move with our partners: to hear what they truly mean, rather than responding (furiously) to what they are saying.

A third vow should state: ‘Whenever I have the strength in me to do so, I will imitate those who once loved me and take care of my partner as these figures cared for me. The task isn’t an unfair chore or a departure from the true nature of love. It is the only kind of love really worthy of that exalted word.’

5. When we are ready for administration

The Romantic person instinctively sees marriage in terms of emotions. But what a couple actually get up to together over a lifetime has much more in common with the workings of a small business. They must draw up work rosters, clean, chauffeur, cook, fix, throw away, mind, hire, fire, reconcile and budget.

None of these activities have any glamour whatsoever within the current arrangement of society. Those obliged to do them are therefore highly likely to resent them and feel that something has gone wrong with their lives for having to involve themselves so closely with them. And yet these tasks are what is truly ‘romantic’ in the sense of ‘conducive and sustaining of love’ and should be interpreted as the bedrock of a successful marriage, and accorded all the honour currently given to other activities in society, like mountain climbing or motor sport.

A central vow should read: ‘I accept the dignity of the ironing board.’

Mid adult man looking at iron over colored background
© REX/Mood Board

6. When we understand that sex and love do and don’t belong together

The Romantic view expects that love and sex will be aligned. But in truth, they won’t stay so beyond a few months or, at best, one or two years. This is not anyone’s fault. Because marriage has other key concerns (companionship, administration, another generation), sex will suffer. We are ready to get married when we accept a large degree of sexual resignation and the task of sublimation.

Both parties must therefore scrupulously avoid making the marriage ‘about sex’. They must also, from the outset, plan for the most challenging issue that will, statistically-speaking, arise for them: that one or the other will have affairs. Someone is properly ready for marriage when they are ready to behave maturely around betraying and being betrayed.

The inexperienced, immature view of betrayal goes like this: sex doesn’t have to be part of love. It can be quick and meaningless, just like playing tennis. Two people shouldn’t try to own each other’s bodies. It’s just a bit of fun. So one’s partner shouldn’t mind so much.

Jealous Wife
© Getty

But this is wilfully to ignore impregnable basics of human nature. No one can be the victim of adultery and not feel that they have been found fundamentally wanting and cut to the core of their being. They will never get over it. It makes no sense, of course, but that isn’t the point. Many things about us make little sense – and yet have to be respected. The adulterer has to be ready to honour and forgive the partner’s extreme capacity for jealousy, and so must as far as is possible resist the urge to have sex with other people, must take every possible measure to prevent it being known if they do and must respond with extraordinary kindness and patience if the truth does ever emerge. They should above all never try to persuade their partner that it isn’t right to be jealous or that jealousy is unnatural, ‘bad’ or a bourgeois construct.

On the other side of the equation, one should ready oneself for betrayal. That is, one should make strenuous efforts to try to understand what might go through the partner’s mind when they have sex with someone else. One is likely to think that there is no other option but that they are deliberately trying to humiliate one and that all their love has evaporated. The more likely truth – that one’s partner just wants to have more, or different, sex – is as hard to master as Mandarin or the oboe and requires as much practice.

One is ready to get married when two very difficult things are in place: one is ready to believe in one’s partner’s genuine capacity to separate love and sex. And at the same time, one is ready to believe in one’s partner’s stubborn inability to keep love and sex apart.

Two people have to be able to master both feats, because they may – over a lifetime – be called upon to demonstrate both capacities. This – rather than a vow never to have sex with another human again – should be the relevant test for getting married.

7. When we are happy to be taught and calm about teaching

We are ready for marriage when we accept that in certain very significant areas, our partners will be wiser, more reasonable and more mature than we are. We should want to learn from them. We should bear having things pointed out to us. We should, at key points, see them as the teacher and ourselves as pupils. At the same time, we should be ready to take on the task of teaching them certain things and like good teachers, not shout, lose our tempers or expect them simply to know. Marriage should be recognised as a process of mutual education.

8. When we realise we’re not that compatible

The Romantic view of marriage stresses that the ‘right’ person means someone who shares our tastes, interests and general attitudes to life. This might be true in the short term. But, over an extended period of time, the relevance of this fades dramatically; because differences inevitably emerge. The person who is truly best suited to us is not the person who shares our tastes, but the person who can negotiate differences in taste intelligently and wisely.

Rather than some notional idea of perfect complementarity, it is the capacity to tolerate difference that is the true marker of the ‘right’ person. Compatibility is an achievement of love; it shouldn’t be its precondition.

Conclusion 

Healthy Marriage Initiative Classes Held In Pennsylvania
© Getty

We have accepted that it is a truly good idea to attend some classes before having children. This is now the norm for all educated people in all developed nations.

Yet there is as yet no widespread acceptability for the idea of having classes before getting married. The results are around for all to see.

The time has come to bury the Romantic intuition-based view of marriage and learn to practice and rehearse marriage as one would ice-skating or violin playing, activities no more complex and no more deserving of systematic periods of instruction.

For now, while the infrastructure of new vows and classes is put in place, we all deserve untold sympathy for our struggles. We are trying to do something enormously difficult without the bare minimum of support necessary. It is not surprising if – very often – we have troubles.