September 11, 2026
Dear Interested Readers,
Could It Be 25 Years? And Other Questions and Observations
If you were born before 1990, you can probably remember 9/11/2001 with more detail than you can remember the Fourth of July this year. My understanding of neurophysiology suggests that any event that creates a catecholamine surge is more likely to become deeply embedded in our long-term memories than what stays with us from the normal eb and flow of our ordinary days.
Looking back over my life at the moments beyond important family events and personal experiences to those moments that we all shared, 9/11 is probably the most deeply embedded, but other shared events that impacted me include the October 4, 1957 Russian launch of its Sputnick followed by the humiliating fizzle of our Vanguard rocket, the assasinations of John Kennedy, Dr. King, and Robert Kennedy, our 1969 landing on the moon, the explosion of the Challenger less than two minutes after it was launched, the tragic unexpected death of Princess Diana, the election of Barack Obama, both elections of Donald Trump, the reversal of Roe v. Wade, the Russian invasion of Ukraine on February 24, 2022, the October 7, 2023 Hamas atrocity, and waking on the morning of February 28 this year to discover the launch of “Operation Epic Fury.”
There are others, and you may disagree with some of those shared moments, but it is interesting to note that of that long list of well-remembered national events, the only day that comes close in significance to 9/11 for me was the day JFK was shot in Dallas. After both events, we were all joined in sorrow in front of our televisions, watching endless analysis and looping video presentations of tragedies that were hard to comprehend. My review also suggests to me that the moon landing and the election of President Obama were for me the rare celebratory moments unless we get into some amazing national athletic events like the Red Sox breaking the curse of the Bambino and winning the World Series in 2004, or the surprising victory of the USA Hockey team in the 1980 Olympics, and I don’t really understand all the rules of hockey! Getting almost all of us on the same page is a rare occurrence with a short half-life.
I think that it is very important for us as a nation to remember the horrors of 9/11 each year when it comes around. I fear that when those of us who can vividly remember the day are gone, the tradition may fade. Perhaps another reason the memory has stuck so firmly is that, in its wake, there was, for a long time and in some ways a continuing reality, great uncertainty about what might come next.
Each 9/11, I remember the horrors of what happened at the World Trade Center and the Pentagon, and we have collectively grieved and tried to avenge the loss of every life that day and the many who have died since as a result of the toxicity to which they were exposed in the aftermath, but I find myself differently moved by what happened to the flight that crashed in Shanksville. The story of United Flight 93 is the story of ordinary people choosing to take control of a horrible moment by collectively sacrificing themselves. It has always seemed to me somewhat like the defense of the Alamo, where the heroes knew there would be no tomorrow for them, but that their act might save countless others.
As I write these feelings, I realize it is ridiculous to elevate one loss over another. The losses that we should grieve go far beyond those who were on the planes that day and include hundreds or perhaps thousands more rushed to save as many in the World Trade Center as possible and the many, many we now know have suffered lingering disability or fatality from toxic exposures in the aftermath. And then there are all the families who lost a close family member: a mother, father, son, daughter, grandparent, uncle, aunt, nephew, or niece. The list of those who were touched in the aftermath of 9/11 extends beyond relatives to neighbors and, in truth, to all Americans.
Everyone who can remember the day has a personal story of its impact. For me, September 11, 2001, was a beautiful early fall day. I enjoyed my drive to the West Roxbury Health Center of Harvard Vanguard Medical Associates. It was an ordinary Tuesday. I was to see patients at West Roxbury in the morning and then travel to our Kenmore Center Offices in Boston, a few blocks from Fenway Park, to see patients in the afternoon. Some of my patients were at the Brigham, where they were being seen by a colleague who was on our hospital rotation, but I might have seen them in transition or at the end of the day if the day had played out as usual.
I was seeing my second or third patient of the day when I was interrupted by a knock on the exam room door. My medical assistant said that she was sorry to interrupt, but that I should come to the “breakroom.” In the breakroom, staff and a couple of patients huddled in shocked silence around the TV set used for instructional videos. Some were in tears. Others looked stunned. I soon realized that they were watching news accounts of an airplane that had flown into one of the towers, both of which at the time were still standing. The horror of their collapse was still unimaginable. I still struggle to understand the physics of how it happened, but reality does not depend on what I can understand.
What those who are too young to have their own memories of the day may not realize was that no one knew what might come next. Was the nation under an evolving widespread attack? We decided to call as many of those on the schedule as possible and tell them not to come for their appointments. For those who were already with us, or who came anyway before we could contact them, we filled prescriptions and then urged them to go home as quickly as possible. I soon learned that the patients scheduled for the afternoon were being canceled, and we were advised to go to the presumed safety of home. Part of the horror of the day was the apprehension about what to expect next.
My wife was in Worcester, where she was doing a clinical rotation as part of her training to become an NP. One son was a freshman at Reed College in Portland. Our younger son soon learned that the father of one of his classmates at Wellesley High School had been on one of the planes that hit the World Trade Center. My oldest son was working in Miami; his brother was nearby in Newton. My parents were living on Saint Simon Island in Georgia. Like many families, we were spread across the continent. I can only imagine that, as it was for my family, it was for most families across the nation, a day of checking in and locating distant family members out of fear and concern about what might come next.
After twenty-five years, it is easy to recognize how those few moments on that dreadful morning changed the future for all of us. Now we have TSA and Homeland Security. We have given up a list of freedoms we once enjoyed for the hope of greater security. We have suffered through two decades of wars that have cost many young lives and trillions of dollars on our side and even more lives lost and the destruction of societies from where we presumed the attacks originated. We should never diminish the losses experienced on 9/11, and we should continue to be vigilant to prevent something similar from ever happening again. Most importantly, we owe it to those who suffered most directly on the day that we will not forget them, and that we will continue to make the effort to extract lessons from the events of 9/11 and its aftermath that might be foundational for a better tomorrow.
Another 25th Anniversary
According to Wikipedia:
Crossing the Quality Chasm: A New Health System for the 21st Century is a report on health care quality in the United States published by the Institute of Medicine (IOM) on March 1, 2001. A follow-up to the frequently cited 1999 IOM patient safety report To Err Is Human: Building a Safer Health System, Crossing the Quality Chasm advocates for a fundamental redesign of the U.S. health care system.[1]
As frequent readers of this missive will recognize, of all the medical literature about optimizing our system of care that has been produced over the last half century or more, none has impressed me more than Crossing the Quality Chasm: A New Health System for the 21st Century. I find it interesting that I failed to focus on the 25th anniversary of this important book. It took the 25th anniversary of 9/11 to joggle my mind and cause me to recognize that I had overlooked an important milestone. This landmark book was a sequel to the groundbreaking commentary on medical culture and guilt, To Err Is Human, which was focused purely on patient safety and our tendency to blame individuals rather than systems and systems design when things go wrong.
All of the healthcare leaders across the country whom I was privileged to meet during my years as CEO of Atrius Health and Harvard Vanguard Medical Associates (2008- 2013), at meetings and on-site visits, were in agreement with the analysis and recommendations in Crossing the Quality Chasm. No one questioned the book’s premises of how quality is defined. Most of us can chant those six domains of quality as easily as we can say the Pledge of Allegiance to our flag. They are effectively summarized and defined by Wikipedia:
Crossing the Quality Chasm identifies and recommends improvements in six dimensions of health care in the U.S.: patient safety, care effectiveness, patient-centeredness, timeliness, care efficiency, and equity. Safety looks at reducing the likelihood that patients are harmed by medical errors. Effectiveness describes avoiding over and underuse of resources and services. Patient-centeredness relates both to customer service and to considering and accommodating individual patient needs when making care decisions. Timeliness emphasizes reducing wait times. Efficiency focuses on reducing waste and, as a result, total cost of care. Equity looks at closing racial and income gaps in health care.[1]
We have known the goals, but most of us are disappointed with our progress towards them over the past 25 years. The ACA was built on those goals as its foundation, but change in a firmly entrenched, far-flung, dysfunctional system with multiple vested interests is slow. An experience this week has made me acutely aware of how we have made localized improvements in some areas, but, in general, how much there is still to operationalize to realize the wisdom of To Err Is Human and Crossing the Quality Chasm. Across this land, I know that there have been great efforts by a dedicated minority of healthcare leaders and practitioners to bring the vision of Crossing the Quality Chasm to fruition. Their efforts have created pockets of excellence, and I think all of healthcare has benefited secondarily even though many of the issues discussed in Crossing the Quality Chasm have persisted and some, like increasing costs and compromised access to timely care, and healthcare equity may be worse than they were in 2001 in many places in our very heterogeneous system of care. I often wonder just how many members of the healthcare leadership who now control our system of care are dedicated to the mission as described in Crossing the Quality Chasm. I know that when Don Berwick was briefly the Administrator of the Centers for Medicare & Medicaid Services (CMS), these crucial ideas were front and center of all that he tried to do because he was a major part of the authorship of both books.
Early yesterday morning, my wife and I had an unanticipated opportunity to evaluate adherence to quality as described in these two monumental books, published more than 25 years ago by Berwick et al. and by the Institute of Medicine. Our observations occurred when my wife needed care in our small-town/rural healthcare system.
One of the attractive things that we noted when we purchased our home on Little Lake Sunapee in New London, New Hampshire back in 2008 was that it was less than 2 miles from our local hospital, not to mention many of other amenities we imagined we would need in retirement like the Post Office, a supermarket within 15 miles, a hardware store, a gas station, and fasicitously one of many of New Hampshire’s State Liquor Stores which are an easy to access source of reasonably priced wine in the state where you can choose to “live free or die.” I actually imagined that if one of us ever had a stroke or a heart attack, there would be help close enough to make a difference.
Early yesterday morning, about 2 AM, my wife woke me to say that she could not move her left arm or use her left hand. The appendage hung from her shoulder like a wet towel and was useless for any task. We made that urgent trip to a nearby hospital that I had imagined some 18 years ago when we bought the house, and arrived at 2:30 AM.
In my early years in practice, I spent a lot of time moonlighting as an ER doc on nights and weekends. During my years of practice, I was in the ER often as an on-call cardiologist or to meet one of my patients who had a sudden change in the circumstances of their chronic cardiac disease. I am lucky that, with the exception of a strange neurological event my wife had in 2006 while she was administering a stress test to a patient, which eventually was deemed to be a complex migraine, I have been blessed with the ability to avoid being in an ER as a spouse. That 2006 ER visit also uncovered the facts that my wife had a very small posterior aneurysm and a patent foramen ovale (PFO) that were news to us. The small aneurysm has been stable over the intervening 20 years on multiple imaging follow-ups. That history of an aneurysm is interesting, but what happened early yesterday morning was not related to that interesting past history. When she finally had an MRI after 10 hours in the ER, the study showed a small fresh infarct in the frontal lobe, where motor control of the left arm and hand is located. It is conceivable that a small “paradoxical embolism” through her PFO was the cause, or that, for reasons we don’t yet understand, she had an embolism from the left, or that plain old vascular disease was the cause of her sudden disability. One moment she was up to the bathroom to get a pill with no problem other than insomnia from her Parkinsonism, and minutes later she couldn’t move her arm.
The most positive aspect of my wife’s experience has been the patient-centered care that her providers at New London Hospital have lavished on her. All the nurses have been focused on her needs. The ER doctors she saw over the 15 hours she was there went out of their way to keep us updated on the status of their plans. I was impressed with the technology. The doctors used voice recorders for their notes. All Dartmouth-affiliated hospitals are on Epic. Her records from Atrius Health were quickly available. So far so good.
There aren’t usually board-certified neurologists floating around small town hospitals at 3 in the morning, but my wife was seen by two board-certified neurologists via impressive video capabilities. The first neurologist was in Miami at 4 AM. He thought the event was a peripheral nerve injury, although he could not rule out a small CVA and recommended the MRI. Somehow the second neurologist was not told the MRI results, and after his exam, he announced that he thought she had suffered a small CVA and needed an MRI for confirmation. He was quite surprised when I told him that his diagnosis was already confirmed. As a former consultant, I could sympathize because over the years I had been asked to see many a patient where the referral questions were quite vague and important data was missing. I would then ask myself: What question would I ask if I were the first doctor to see this patient, who is not quite sure why she/he is seeing me?
Part of the explanation for our many hours in the purgatory of the ER was that all of the hospital’s beds were occupied. Even after the diagnosis was known, we remained under the care of a very caring nurse because a controversy developed between the hospitalist, who wanted to transfer my wife to the Dartmouth Medical Center stroke service in Lebanon because there would be no availability in New London for a specialized cardiac echo to rule out a cardiac origin until next week. I am thinking, “Well, this is not timely care, and it’s thirty miles up the road to Dartmouth. I was surprised to learn that an argument then developed. Dartmouth had “stroke beds” but wanted to save the access in case they had several admissions that needed acute intervention.
As I thought about it, I could see the wisdom of preserving rare resources, even if it meant my wife didn’t get the optimal, timely testing. She was being treated; there was little likelihood that the echo would significantly alter her management, but I was surprised to learn that the controversy became moot when it was discovered that the academic medical center also lacked the resources to perform the test until next week. It seems that echo techs are an endangered species in the Upper Valley of the Connecticut River, whether you are at the academic center or at the local “emergency access hospital.” Our dilemma redefined what access means for us. It is not necessarily about whether you have a ticket to ride, but about whether there is any ride to be had. Obviously, delays in testing add hospital days, and wasted hospital days add cost that we all end up paying. The alternative is to go home and return later for the test as an outpatient, but if the test shows a need for more aggressive anticoagulation, there is an increased risk that could have been avoided with a timely test.
Let me be clear: in our situation, the timeliness defect that impacted my wife’s care can’t be efficiently repaired at the local level. Our workforce issues are a national problem that impacts timeliness and can only be addressed with improved healthcare policies and public support for the education of an adequate workforce. Our local hospital is doing the best it can in a compromised environment.
When the system is shown to be deficient in any quality domain, the whole enterprise comes into question. We thought that we had the best possible coverage through Federal Retirees Blue Cross because my wife worked as a cardiac nurse practitioner at the West Roxbury VA Hospital. Plus, since we are over 65, we have Medicare Part A. Out-of-pocket costs are no fun, but not really a problem; we have the best possible access to dedicated professionals who are skilled and patient-centered, but it becomes an expense to all and a frustration for us when there is the unlikely but possible exposure to risk because of systems issues.
You may think that your coverage is great and the issues that are involved in the journey toward quality don’t impact you in any way, but if you do think that way and imagine that we can make healthcare better just by focusing on market competition and cutting costs by denying care to welfare cheats, then you or someone you care about may be at risk. The lives we can improve or save with attention and implementation of the insights of twenty-five years ago may include yours or someone close to you.
Goodbye Gloria
I won’t say that I was a reader of Ms. or went out of my way to read Gloria Steinem’s latest book, but I was moved when I heard that she died this week. It is sad that we have lost, in less than two weeks, Gloria Steinem and Dolly Parton. They are two of the most iconic women of our times who had totally different skill sets and personal presentations but were both remarkable pioneers, leaders, and teachers in the work of diversity, equality, and inclusion. I doubt that either one ever imagined total victory for the causes to which they committed so much of their time and passion. I expect that they believed, like those of us who care about the future of healthcare and realize that there is little likelihood of “victory” in our lifetimes, that their efforts would surely add up to some measure of progress toward those distant visions.
I was further inspired this week when I learned that in a 2015 interview Ms. Steinem described herself as a hope-aholic. In the interview, she was asked,
“Are you still optimistic about the push for equality?”
Her answer was:
“Yes. We have to imagine something before it becomes reality. So yes, I am a hope-aholic.”
Was she drafting on Obama? I think not. In her own right, she was always a person willing to work through a mess today even when an immediate measurable improvement was unlikely. It takes authenticity and hope to survive with your goals intact when, day in and day out, you meet resistance and, at times, ridicule from opponents. I hope that, in the currently traumatized crop of Gen Zers and Millennials, there are some descendants of Gloria and Dolly who have taken note and are getting ready to pick up their torches and continue advancing their causes, fueled by their hope. That has always been the plot in the story of progress.
An Observation
On a trip home from the hospital yesterday to pick up some things my wife needed, I was impressed yet again by the beauty free for observation on our little dead-end road. I stopped my car and got out to take the picture that is today’s header. The images aren’t super clear, but on the roadside bank there are ferns, a few golden rod, and a neat little patch of Doellingeria umbellata, or Flat Top White Aster.
We are quickly moving toward the official start of fall. I continue to enjoy all the late summer offerings that nature provides in my neck of the woods. I didn’t get to walk or swim yesterday because I was at the hospital all day, but I can tell I need to be out and about this weekend. There is a lot to process. I hope that you will also have an opportunity to gain some immunity from stress by getting into nature. The opportunities may be closer than you think.
Be well,
Gene
