September 18, 2026
Dear Interested Readers,
Unraveling Quality
This week, as usual, I avoided watching the Emmy Awards extravaganza on television. I don’t exactly know why I don’t enjoy watching all the self-congratulatory entertainment awards ceremonies like the Oscars, the Emmys, the Tonys, the Country Music Awards, and all the other award presentations where we get to adore the artists that entertain us. I see bits and pieces of the programs because my wife either watches them live or records them for daytime viewing. She considers them to be her equivalent of sporting events.
Ironically, I am also not that interested in sports anymore, whether watching on TV or going to games. After the Red Sox traded Mookie Betts, I let go of my share of a couple of season tickets to Sox games that I had enjoyed for over forty years, and, more recently, I canceled my TV access to the Red Sox. I didn’t watch the Partriots v. Seahawks opening of the NFL season. My moral dilemma with the NFL has been compounded by the growing awareness of the risks of chronic traumatic encephalopathy (CTE), and the obviously right-wing orientation of many of the owners. My apathy is not a totality. I do search the newspapers for the winners of the awards ceremonies and follow the games at a distance on the sports pages and on “highlight replays.” I also enjoy pondering the complex political and social implications of the big business of sports.
I particularly enjoyed the interview that David Remnick, editor of The New Yorker, did this week with former NFL quarterback Colin Kaepernick, who was blackballed from the NFL following his 2016 pregame protests of hostilities toward Black Americans by “taking a knee” during the pregame playing of the National Anthem. Kaepernick’s mixed emotions about the benefits of football were very similar to my own. I was not a star, but I did suffer significant injuries in junior high school, high school, and college football. On the positive side, I developed a strong work ethic and enjoyed the team’s camaraderie. The fact that I received an award from the ACC (in 1966, the University of South Carolina was in the ACC; now it’s in the SEC) for having the highest GPR on my team may have been viewed favorably in the competition for admission to an elite medical school. Who knows?
My wife was delighted to see that the ER drama “The Pit” starring Noah Wylie won multiple awards, including best drama and best actor in a dramatic series for the second year in a row. My wife enjoys the show, and I have seen brief bits of a couple of its segments, but discovered that it “triggered” intense feelings in me. During training and in the early years of my career, I did a lot of ER work. Between 1972 and 1979, I frequently saw more than 75 patients during a 24-hour weekend shift and on rare occasions as many as 100 as the only doctor in the Lowell General ER. I would also usually work a 7 PM-to-7 AM weekday overnight shift about 3-4 times a month, then go to my daytime practice. In retrospect, this work had as much, if not more, impact on my career development as my years as a resident and fellow.
I first noticed being “triggered” by a medical drama, watching George Clooney, Noah Wyle, et al. in ER, which ran for 15 years (1994-2009) and was created by Michael Crichton, who graduated from Harvard Medical School in 1969 but never practiced. Our time at HMS overlapped, but I never knew him. I was profoundly influenced by his book Five Patients (1970), a nonfiction work that reflected on his experience during his medical rotation at the MGH.
When I first saw “ER” and again when I got a glimpse of “The Pit,” I focused on what I thought was a somewhat unrealistic premise: almost no one ever left the ER to go up to a bed in the hospital. Everything depicted could have happened, but back in my day, all those things didn’t happen at once in the ER. Later, I began to realize that I could relate to almost every vignette from personal experience; it was just too much to see them in such a concentrated presentation. I also believe that the presentations call to mind so many moments of “moral injury” that I had suppressed. In a way, the accumulated instances of moral injury that many physicians experience are metaphorically like the repeated small shocks to the brain that players in contact sports accumulate on their way to having CTE. I first wrote about moral injury from the perspective of a dear friend and colleague, Dr. Doug Beers, in late June 2015.
In my overview of the impact of medically oriented TV shows on me, I should say that part of what drew me to a career in medicine was the influence of those shows in the 50s and early 60s. The first one I remember was “Dr. Hudson’s Secret Journal.” Who can forget “Dr. Kildare” or Ben Casey? “Marcus Welby, MD” didn’t air until the late sixties, starring Robert Young and James Brolin. By then, I was in medical school, and it ran until 1976, when I was in the early years of my practice. The few shows I did see certainly had a positive impact on me. Who wouldn’t want to live such an exemplary life as Marcus Welby? There were generational conflicts in points of view between Welby and his young partner, Dr. Kiley, played by Brolin, but nothing in this mild and well-managed generational conflict could be the origin of any distress, much less be an example of moral injury. In retrospect, it was almost a fairy tale.
Before you read further, I suggest that if you did not read my letter last week, you read the second section, which I titled “Another 25th Anniversary.” Just click on the link. I was using my wife’s small stroke early last Thursday morning as an introduction to a discussion about the fact that the “timelines of care,” one of the six domains of quality presented in Crossing the Quality Chasm over 25 years ago, was currently at risk.
I think it is important to remind you that I was not accusing the professionals who cared for my wife of any errors. I explicitly emphasized that quality defects and most medical errors are system issues. Furthermore, I suggested that external factors beyond the control of any system pose a challenge to healthcare systems and may be greater barriers to quality care than internal factors. Explicitly, despite the frustrations we experienced, the individual providers who cared for my wife all performed very professionally and, within the limits of the system’s available resources, endeavored to provide her with the best care possible.
At the time of her discharge late Friday afternoon, her optimal future management was still an unanswered question. We knew that in 2006, when she had somewhat similar neurological symptoms that resolved in less than an hour, an echo had revealed a patent foramen ovale (PFO) and a small aneurysm in her posterior cerebral circulation. The aneurysm has been stable on multiple scans over the last 20 years. In 2006, practical preventative management of a potential paradoxical embolism was limited to Coumadin or aspirin. After consultation with one of my colleagues at the Brigham, and since complex migraine could have explained the event, she was treated with daily aspirin.
Because of workforce issues, at the time of her discharge neither our community hospital nor the academic Dartmouth Medical Center, 30 miles away in Lebanon, had the capacity to perform a follow-up echo and “bubble study” to reevaluate whether her event could be the result of a paradoxical embolism. If the neurologist thought such an event was possible, a more potent anticoagulant like Xarelto, approved by the FDA in 2011, or Eliquis, approved in 2012, could protect her from future events. Neither was available in 2006. Alternatively, she could have an unnoticed episode of intermittent atrial fibrillation or a ruptured atherosclerotic plaque as the origin of her event. For the unlikely possibility of AF, she needed to have an ambulatory monitor. Suffice it to say, leaving the hospital without these tests being done and questions answered was an emotional challenge, but the tests needed for evaluation couldn’t be performed due to “systems” issues. The point I was trying to make is that workforce inadequacies that have evolved over many years of poor public policy undermine quality and put even those of us who think we have adequate access to quality healthcare at risk.
At discharge, the nurse capably reviewed the clinical plan and all the proposed referrals. My wife was to have an urgent echo early in the next week, an urgent consult with the “stroke” neurology service at the main Dartmouth medical center, a heart monitor, and occupational therapy. We were led to believe that we would be called on Monday with the appointment times for the echo, the consult, and the monitor. My wife was given an early appointment for OT on Monday. Monday passed with no calls about appointments.
On Tuesday, we called the hospital about the monitor, and after some delay, the scheduler found the referral in the record and made the appointment for September 22. We called about the echo and learned that the next available appointment at the local hospital was for November 17. In desperation, we asked if the referral could be transferred to Lebanon, and to our delight, it was, and my wife was given an appointment for Wednesday.
Encouraged by the success with the echo, we called neurology. The appointments manager searched the record and, after some delay, found the referral in the system. She said the referral would be evaluated “by the team” and that we would get a callback. We imagined that it would be later in the day. After waiting 48 hours without a callback, we called again. Apparently, there had been no review and no decision had been made, so my wife was given an appointment for March 3, 2027. I was incensed!
After expressing our displeasure without using profanity, we turned to other options. I contacted a friend I knew was on our local hospital board and laid out for him that the system had a quality problem. He said they were doing the best they could in difficult times that were rapidly worsening. It was true that the nurse who had cared for my wife was a “travel” nurse from St. Louis, and that the very personable echo tech in Lebanon was a travel tech from Tallahassee, Florida. It seems that echo techs are even more in short supply than nurses.
It then occurred to us to seek help from my wife’s new PCP, whom she had seen for the first time a few weeks ago. Miraculously, in less than five minutes after getting off the phone with her PCP, we got a call from stroke neurology saying that they would “squeeze” her onto the schedule on September 23. Even now, we don’t know what moved the Neurology department to “squeeze” her in. Was it fast work by her PCP, or did someone finally review the referral? I am convinced that nothing would have happened if we had just waited for a call.
Getting the care my wife needed scheduled required great effort. During the process, I wondered what would have happened if we could not proactively advocate for ourselves. Was our experience a manifestation of an externally stressed system of care? The local newspaper reported this week that there would be significant staff reductions at the Dartmouth Medical Center, where substantial financial losses were occurring. You don’t need to be an economist to imagine that things are likely to get worse as the damage from the One Big Beautiful Bill intensifies after January 1.
I was further disturbed while sitting in the cardiology patient waiting area during my wife’s echo. As each new patient checked in on arrival, the check-in person reviewed their insurance status and any outstanding bills. At first I thought that the loud, inappropriate review of personal finances was coming from another room. Then I realized that it was coming loud and clear from across the waiting room. I heard the clerk tell an elderly woman that she was out-of-network and would need to speak with someone in finance before she could be seen. A young man was told he needed to have his Medicaid status reviewed and was also referred to the finance department. The clerk tried to be positive, telling him he might be able to set up a payment plan. The lady loudly reviewed the coverage deficits for what seemed like the majority of patients trying to check in. I shudder as I try to imagine how these conversations will go once the major changes in Medicaid take effect after January 1, 2027. She was trying to be positive and helpful, but she was not discreet.
As I reflect on the past eight days, I am very grateful for the caring professionals who have helped my wife. It is not their fault that the system is financially strained by years and decades of poor public healthcare policy. Timeliness of care is compromised by inadequate staffing. The workforce issues that delayed my wife’s care have led to inadequate staffing and delays in care delivery. The failure to provide timely care results from a defective financial system and decades of political controversy, both of which are manifested as compromised system operations. Inadequate staffing leads to burnout and, in extreme cases, makes medical professionals vulnerable to moral injury. Discharge confusion resulting from workforce deficiencies undermines patient satisfaction, safety, and efficiency. It contributes to poor outcomes and increased costs. If you need a medical degree to navigate the system, then equity is out the window. The domains of quality fall like dominoes, and people suffer despite well-equipped yet understaffed and precariously financed facilities, where everything is connected within a system under stress.
What feels like salt in a wound are the inflammatory negative political ads I see on TV. John Sununu is the Republican candidate for the open Senate seat in New Hampshire created by the retirement of Senator Shaheen. He was one of our senators from 2003 until 2009, when he was defeated. In his political ads, he blames rising healthcare costs and the system’s dysfunction on his Democratic opponent, Chris Pappas, who has been one of our two members of Congress for the last eight years. Sununu gives a sly smile when he indirectly attributes our healthcare deficiencies to the ACA; he reminds the viewer of the promise that “You can keep your care if you like it” and blames much of our current pain on his opponent’s desire to raise taxes. Healthcare and the problems my wife has experienced are not going to disappear overnight if, as he suggests, he is elected to bring New Hampshire’s disdain for taxes to Washington once again. We are into a season of political misinformation and outright lies about a system that is so complex and so damaged that the average patient and voter is mired in confusion.
The problems of access and timeliness of care demonstrated by my wife’s recent experience won’t be solved anytime soon, even if Democrats take back the House and Senate at the midterm election on November 3rd, which is now only 46 days away. Inevitably, there will be quality defects that harm people and create waste and unnecessary expense for many years to come. Repair of the damage done over the last two years may take decades of hard work, innovation, and societal change, but we could begin to limit the slide into further dysfunction with a November Blue wave. If you think that you are protected from a dysfunctional system of care by your “Platinum” insurance policy or your years of medical expertise, give my wife’s recent experience some consideration, and good luck to you.
The Autumnal Equinox
It’s amazing. You can count on the cosmic clockwork. Just on schedule, the nights are colder. Sundown is sooner. Leaves are beginning to turn. Fall officially arrives on Tuesday, September 22nd at 8:05 PM, Eastern Daylight Saving Time.
As I look back on the summer, I realize it was great, but once again I made more plans than I could complete. Maybe that is good. I will use the experience to make plans for next summer. Now I am beginning to get ready for winter. Fall has its unique pleasures and some challenges, like this year’s election, but its work is to prepare for the challenges that will surely present themselves between late November and early December and remain a concern until sometime in late April. I love living in expectation.
Be well,
Gene
