August 6, 2021

Dear Interested Readers,

 

Why I Have Been Writing About Race, Inequality, and Climate Change

 

As I look back over the last thirteen years that I have been writing these Friday letters to you I realize that there has been quite a progression of ideas. When I began writing I had more than one objective. First, I wanted to create a conversation and greater unity around our organizational mission, or if that term seems pollyanna, about our organizational goals and objectives. I realized that many of the able professionals within our organization did not have much knowledge about the state and federal policies that defined our organizational degrees of freedom. Some did not realize that we had self-imposed limits on how we pursued success that were rooted in a sense of what constituted the path toward more equitable care. Many did not know how we were paid. 

 

A good example of organizational values that were associated with expenses other groups might avoid was the time our board voted to continue to provide a full program of mental health care even though the reimbursement we received did not come close to covering our costs. We believed that mental health should be part of an integrated approach to patient care. Another example was when we declined the offer of an easy path to hospital ownership which would have allowed us to increase our charges on ambulatory testing by thirty-five percent. Positioning your practice to be paid more might sound like a good business move but it was not consistent with a major objective which was to be a leader in the effort to lower the cost of care. There are other intentions that I could also mention, but I want to stress that a major objective of my initial writing was to remind our practice of our values. 

 

Another objective was the celebration of the accomplishments of our many diligent contributors. So much was happening that it was never a struggle for me to write. The most difficult task was to try to write about what was most important in a manner that would entice the largest possible number of readers to look forward to the Friday afternoon email. 

 

After my practice days and management days were over, I did not write for three weeks. That was the only gap in the past thirteen years. I am very grateful to John Gallagher, my personal Lean guru who was a true friend and mentor. He challenged me to continue to try to write to a larger audience outside of Atrius/HVMA. Since I was no longer leading the organization I deleted the Atrius and HVMA addresses from the mailing list. They needed to get their organization information from those who followed me. John knew that over the years the Friday letter had acquired a readership outside of Atrius.  There were readers across the country as well as a few foreign readers. There were several hundred “interested readers” who were not affiliated with my old organization, and John pressed me to continue to write to them. Some of the interested readers were business partners. Some were previous competitors. Some were family and friends. The other big change at that time was the adoption of the title “Healthcare Musings.” I was no longer in practice and I was no longer an organizational leader, but I did have a half-century of experience in practice and over a quarter of a century in leadership, so I had a firm foundation for my “musings.” 

 

As I got further and further away from the time of my own professional activity, I did not lose interest in the challenges that faced the country and healthcare. I was not disheartened by the continuing difficulties that challenged the people who were still at the task of trying to improve healthcare in the pursuit of the Triple Aim. I have tried to write about issues and policies that touched patients, practitioners, and the community. I have never seen healthcare as a zero-sum activity. I have always believed that healthcare represented the most proximate example of the potential benefits of non-zero thinking. 

 

There is no question that the election of Donald Trump to the presidency in November 2016 unmasked my politics and modified the character of “Health Care Musings.” I would expect that even before that disastrous backlash to the Obama presidency most people knew that I considered myself a progressive Democrat. I had even endured bodily harm in my local efforts to help Hillary Clinton win in New Hampshire.

 

My wife and I were door-to-door campaigners in our town. On a chilly wet Sunday afternoon in late October not long before the election, I got no answer at the home of people I did not know when I rang their front doorbell. I could hear the Patriots game coming from deep inside the house. As I was going around to an outside door that was near the noise that I thought was coming from a basement den, I took a shortcut over a granite retaining wall between the front yard and their driveway that was down about four feet. The granite was wet and I slipped and fell. I landed from that four-foot drop on my back and shoulder in a way that tore my right rotator cuff. The pain was immense, and it took many months for me to recover. Was it worth it? A small consolation for my troubles was that Hillary carried my town by 500 votes and New Hampshire by 2500. In 2020 I considered myself retired from active door-to-door campaigning and chose to contribute dollars and advocate in these notes for the necessity of preserving the remnants of the healthcare quality and access gains of the last quarter-century by electing Joe Biden to be Donald Trump’s successor.

 

Long before the election, I was beginning to realize that my assumption that healthcare could evolve on its own toward greater equity and quality was not probable. I am sad to say that at this moment healthcare does not seem to me to have the motivation to live up to the challenges articulated 20 years ago in Crossing the Quality Chasm. I see a huge resistance to healthcare equity despite all of the talk about it and the needless suffering of all of our poor. Our healthcare disparities are like our climate challenge. Both are problems we recognize but lack the collective will to rectify despite continuing evidence of great human injury and loss. Despite the best efforts of noble individuals, some amazingly effective practices, and thoughtful developers of policies that should have made a difference, there has been little real progress toward affordable, equitable, quality healthcare available at a sustainable cost. There has been a steady and effective resistance to change coming from those with a financial self-interest in the status quo and from political groups that feel that expanding benefits to others will be a personal loss for them.

 

 The AMA and its associated governing bodies of specialties have tried to look like they support progress, but my sense is that their intent has not changed much from their history of almost one hundred years of resistance to meaningful change.  The resistance from the AMA and similar professional bodies has buoyed and supported the businesses that make billions off healthcare in its present configuration. I won’t repeat the numbers that show that our outcomes are similar to or worse than some third-world countries, but you know it’s true. The great paradox in our situation is that while many suffer from getting much less than they need, other more privileged Americans benefit from what our technologies, clinical expertise, and resources can deliver. These amazing results for the privileged occur at a staggering cost but are expanded by skillful presentations to give many uninformed Americans a sense that we all are blessed to have access to the best the world has to offer. To that misconception, I would add, maybe if you’re covered and even if you are covered you also need to be lucky.

 

Over the past few years, I have enjoyed collaborating and writing about professional work-life issues with people like Paul DeChant and Eve Schapiro. Those explorations have led me to the conclusion that if the work-life issues are problematic for all professionals they are even more challenging for physicians who are not a part of the dominant White population. If healthcare presents a challenge for professionals who do not identify as Caucasian there are reams of verified data in prestigious academic journals that show that the situation is much worse for patients who do not self-identify as Caucasian or White. COVID has exposed the inequalities in our system of care in dramatic and undeniable ways. 

 

As I have read much of the literature about critical race theory that many politicians don’t want to be taught in public schools or public colleges and universities, I have become convinced that although the pursuit of the Triple Aim is a laudable objective and that quality needs to be the North Star of practice all of our efforts toward these objectives have been and will continue to produce suboptimal outcomes until we address the question of race more effectively in healthcare. I believe that every healthcare professional needs to be a student of “critical race theory.” We teach medical students that a key principle in the management of a difficult problem is to understand its root causes. The root cause of much of what is not right in healthcare becomes much clearer as you acquire a greater understanding of the racist policies that besmirch our national history and persist in our acceptance of the persistent outcomes of those policies.

 

It is my opinion that if you are a healthcare professional in the twenty-first century there is a lot of science that you need to know, but that is not enough. You need to continuously educate yourself about at least three other critical subject areas: poverty/inequality, race/antiracism, and climate change. It is not an exaggeration to imagine that these large areas of concern will have as much impact on the future health of the nation as cancer, cardiovascular disease, and recurrent viral pandemics. Healthcare professionals need to understand how these three factors alter their work from what they think it is and must be factored into the resolution of the problems their patients bring to them. These are social/public health issues that play out in the lives of individuals. One of the greatest misconceptions that many more fortunate Americans have is that they are somehow immune from the impact of these problems. 

 

Ibram X. Kendi is one of our most thoughtful proponents of antiracism and an acknowledged expert in the history and origins of racism. He has explained in great detail the misconceptions and coverups in our history around slavery, segregation, efforts at abolition, and the fruitless efforts to solve the problems that flow through racism by attempts to advance racial assimilation. He defines our collective problem, not as racism but racist policies that are created to benefit a select few. In Colonial America, the select few were the wealthy planters whose profits required the free labor of slavery. Today racist policies still have their origin in economics as wealthy individuals and corporations seek advantages that have the result of creating greater economic inequity. A racist policy is any policy that yields advantages that create unequal outcomes. In chapter ten entitled “White” in his 2019 book How To Be An Antiracist Kendi makes the same point about how most White Americans suffer greatly from the racist policies that we generally conceptualize as being harmful to Black Americans that Heather McGhee makes in her recently published book, The Sum of Us.

 

On page 129 he writes:

 

We must discern the difference between racist power (racist policymakers) and White people. For decades, racist power contributed to stagnating wages, destroying unions, deregulating banks and corporations, and steering funding for schools into prison and military budgets, policies that have often drawn a backlash from some White people. White economic inequality, for instance, soared to the point that the so-called “99 percenters” occupied Wall Street in 2011, and Vermont senator Bernie Sanders ran a popular presidential campaign against the “billionaire class” in 2016.

Of course, ordinary White people benefit from racist policies, though not nearly as much as racist power and not nearly as much as they could from an equitable society, one where the average voter would have as much power as superrich White men to decide elections and shape policy. Where their kids’ business class schools could resemble the first-class prep schools of today’s superrich. Where-high quality healthcare could save millions of White lives. Where they could no longer face the cronies of racism that attack them: sexism, ethnocentrism, homophobia, and exploitation.

Racist power, hoarding wealth and resources, has the most to lose in the building of an equitable society…

 

Kendi believes that everyone is a racist. He describes with great pain his own racism against both Black and White Americans. Our hope lies not in calling out racists but to collectively move toward being anti-racist and working across all races to eliminate racist policies. Racist policies don’t really benefit most White Americans and White Supremacy is ultimately a death wish. The majority of White people don’t benefit from the racist policies that create inequities, and virtually no Black American has anything to gain. Eventually, racist policies don’t even benefit the people for whom they were originally designed to advantage. Racist policies are a curse wrapped in a thin cloak of immediate benefit for their advocates.

 

Kendi is specifically disdainful of organizational efforts to promote “diversity” training since the study of these well-intended activities rarely shows a persistent beneficial outcome. These activities may be programs that an organization can point to with pride but unless they are designed to achieve specific objectives and they do indeed achieve those objectives then they are distractions or the equivalent of social placebos. (My term not his.) Even if we claim to be antiracists but can’t identify improved outcomes from our antiracism then we need to reassess whether we are really not being hypocrites. Held to these standards and examining the experience of the poor and racial minorities in the pandemic, healthcare has a very long way to go. 

 

I hope that you will stay with me as I continue to build my focus on poverty/inequality, race/antiracism, and climate change. I am learning a lot, and I m eager to continue to share with you what I am learning. Most of the links in these notes about these subjects are to the reviews of books and to original articles that I think will expand your understanding of these critical issues that healthcare needs to embrace with the same focus and strategic thinking that we focused on vascular disease, cancer, and all of the other areas where we have shown that focus yields improvement. In our lifetimes we may not end poverty, establish greater equity, become blind to race, or lower the global temperature, but we can mitigate some of the growing losses and give our children a better start. Technology can help us, probably more with climate change, but technology can not unravel the mess we have made with race and so far technology has increased inequity. The alternative is that at some time in the not-to-distant future we all will lose, some more than others, but eventually, no one will be unharmed, and our children will be right to curse us for the mess we are leaving for them.

 

It’s Always Refreshing To Get A West Coast Perspective

 

I like to try to make a connection between the picture in the header for each week’s letter and my own life. I hope it is not a manifestation of narcissism. I would rather think that the practice is an attempt to share and connect. 

 

I had some difficulty picking the picture that I wanted to share with you this week. There were so many great shots that I took this last week during a brief six-day trip to California to see our son and his family. We had not been to California to see them since our RV trip across the country last fall. 

 

At seven and nearly four years old little boys change fast. We have an acute and chronic case of an elderly version of “FOMO,” fear of missing out. We know that because we live so far apart we are missing out on the big things like holidays and birthdays. Most of all, what I fear is missing out on a deep appreciation of how their lives are evolving as they grow and develop. We want to be more constant figures in their lives than an occasional image on Zoom. I know that our plight is shared by many other grandparents, and we have all had things get worse as travel has become more difficult in the age of COVID.

 

If we have any chance for “immortality” it will be through the memory and experience of these little boys and my much older granddaughter who will be coming to see us soon on her way to Bowdoin where she will be a freshman this fall. I look forward to seeing a lot of her over the next four years. When my granddaughter was a baby I vowed to fly down to Florida to see her at least every six weeks. I kept up that routine until her middle school years when flying to Florida became more difficult because of my administrative responsibilities. I rationalized my pass on the promise of frequency by saying that she was busy with her teenaged social life. 

 

It pains me that our grandchildren are also missing out on some of the richness we enjoyed from relationships with our extended families when we were their age. I am convinced that my relationship with my maternal grandmother and paternal grandfather and grandmother were lifelong influences on me. I have wonderful memories of my maternal grandfather, but he died about six weeks after a debilitating myocardial infarction when he was 64 and was buried on my eighth birthday in July 1953. 

 

“Missing out” on family relationships seems inevitable and reciprocal when you are separated by over three thousand miles and all the COVID-related fears of travel.  During this trip, we have made reservations to return for the Christmas Holidays, When the times together are limited to a few days a few times a year there is a great sense of urgency to make every moment count and to participate in as many holidays and birthdays as possible. One of my most difficult moments in life was when I had to choose between staying in California for my youngest grandson’s first birthday which he would not remember or flying back to North Carolina to be with my sister at the bedside of my unresponsive father as he died peacefully.   

 

When we are visiting we try to resist the response of being overscheduled and prefer to just drop in on life as they live it, but I have a suspicion that our presence creates a “Heisenberg phenomenon” that makes any moment when we’re present a distortion from the usual. Realizing that it is impossible to be part of their “normal” we do the best we can which is to fall into line with the midweek routines helping out with house cleaning, shopping, and joining in on the rides to summer camp, daycare, and after school pickup during the school year.

 

The weekends are special. This past weekend we took two of our favorite jaunts. On Saturday, we went over the coastal range through where the “Big Basin and CZU fires” burned tens of thousands of acres this time last year. That smolder fire lasted for over six months after it was contained. After less than a year, it still feels like traveling through the path of random destruction. You see burned-out homes across the street from houses that look absolutely normal. Once we reached the coastal highway on the other side of what was once Big Basin State Park, we headed north toward the Pigeon Point Lighthouse where I took a walk with my grandsons before we began the trip home. 

 

On Sunday, we enjoyed our favorite drive down the coast through Big Sur to Nepenthe where we had lunch. We were interested in seeing how fast the coastal highway had been repaired from the washouts that occurred following the double whammy of fire and torrential rain. You must click on this last link to read The Washington Post’s description of the disaster and see the pictures.

 

My wife likes says to say that you can pay a fortune for food that is pretty ordinary at Nepenthe, but the view from the dining terrace is one of the most beautiful natural scenes on the planet. The view plus its bohemian past history makes Nepenthe one of her favorite places in California. 

 

After we had enjoyed the view and our lunch, we drove a few miles further south to Julia Pfeiffer Burns State Park where a short hike brings you to the spectacular scene in today’s header. If you look closely you can see a small waterfall that drops from the cliff above to the beach below. The boys always take a long nap on these rides. The naps make them quite lively in the evening when we return home. 

 

Between the views along the coastal highway and the magnificence of the remaining coastal redwoods which are not the biggest but are the tallest trees on the planet, my need for a nature fix is always satisfied in a place that has begun to have the familiar feel of a second home. There are several huge old-growth coastal redwoods in my son’s yard that are approaching a hundred yards tall, and his home is just a quarter of a mile from the entrance to Henry Cowell State Park which has one of the best-preserved groves of the largest coastal redwoods. 

 

I am a people watcher as well as a lover of tall trees and breath-taking shoreline vistas. In California, I see an amazing diversity of humanity. I see “Black Lives Matter” signs with a greater frequency than I saw “Trump 2020” signs last fall when I was driving across “red states.” Whether I am sitting in the San Jose Airport waiting for my flight or parked on a bench in front of a good bookstore in downtown Santa Cruz sipping a rich cup of coffee I feel like I am looking into the diverse future of America. The variety of people and the way they present themselves to the world around them convince me that we are going through a difficult time but if the planet survives we are headed toward a new and more equitable world. In a way, my generation is wandering about in its own Siani. Those of my generation are like Moses. We will not live in the promised land, but we can enjoy the journey and from time to time we can go to some of our more diverse places like California and be like Moses who was allowed to go up on Mount Pisgah and take in the magnificent view of what is to come.  The only cloud on this hopeful future is also quite visible in California. The environment is reeling. Just as they led the way in the fight to reduce air pollution, the people of California are trying to lead the way in learning how to live with frequent climate-related emergencies. 

 

My final salute to California is for its healthcare. In the Santa Cruz area, there are three excellent providers, Kaiser, Palo Alto Medical Foundation/Sutter, and Dignity Medical Group/Dominican Hospital. I saw no resistance to COVID precautions. Almost everyone was masked. Most people were practicing social distancing.  Most people seemed to use hand sanitizers as they entered businesses. I offer Texas and Florida for comparison.

 

Don’t imagine that I think California is a perfect place. It has numerous problems from many homeless people living under bridges and in the woods to terrible drought-induced fires and water shortages. There is a reluctance to pay property taxes to optimally support schools and social programs, but one has the sense that California is on the move. There are many people who embrace and try to implement a progressive agenda. The Monterey Bay area of California feels like it is trying to move toward a social order that is consistent with its natural beauty. I am delighted to be an occasional visitor because I always leave with a sense of hope. Maybe there are problems that I don’t see because they are lost in the trees, but I Iike that too!

Be well,

Gene