22 November 2013

Dear “interested readers”

Volume II

I was amazed and quite shocked when at the recent Harvard Vanguard awards dinner I was presented a bound copy of my letters to “Atrius Health and other interested readers”. The tome looks something like the old library sized dictionary that sat on its own reading table in my father’s study. It dwarfs the reliable Physicians Desk Reference that once had a place in
every practitioner’s office or made a good doorstop. All in all the 298 letters are printed on 1097 pages. Perusing them I sometimes wonder, “Who wrote this?”

Shortly after I had written my farewell letter, John Gallagher my friend, colleague and mentor in all things Lean asked me if I was done. His question surprised and challenged me since he might as well have asked me if I was dead. To my own surprise I heard myself answer, “No, I don’t think I am done!” (Thinking, “Not dead yet”). John had asked me the right question and as I reflected on his query over the next several days I realized that I was not done. I was in transition and I needed to pause for a few weeks to collect my thoughts and look around. I also
realized that the weekly exercise of writing added an important dimension to my life that I did not want to give up. When I write I am forced to be more observant and more reflective about what I hear and observe. Far from being a burden, my weekly exercise sustained and informed me.
Writing was as important to me as my daily walk. It had become part of my standard work.

I am no longer a practicing physician but I think about the challenges of practice everyday and even as a retired CEO I realized that I could not “retire” my interest in improving patient care by exploring new ideas in healthcare. John’s question underlined my challenge. I needed to find a way to be a continuing participant in the important conversations of our time. Caring about the future of patient care and how we can evolve a system of care that fits the objectives of the triple aim and is responsive to the personal needs of physicians and other healthcare professionals gives direction and purpose to my life and is an antidote to self-absorption. As long as I live I want to have a sense of purpose and be true to my “calling” and personal mission.

I will no longer be writing to the Atrius Health family because I owe it to my successors not to be an alternative or distracting voice. My father always thought that a retiring minister should move his own worship to another church and preferably just get out of town out of fairness to the successors and I think his advise applies to healthcare organizations as well. In the past I was speaking to Atrius Health colleagues and to you, the “other interested readers”. “The other or outside of Atrius Health readers are now the appropriate recipients of these missives and
I hope that your number will grow without the conversation losing a sense of conversational intimacy. “The other interested readers” began as a surprise to me when I discovered that there were people who were not a part of Atrius but had a connection and interest to the same critical issues that interested me and wanted to read the weekly letter. That discovery was a surprise and delight for me.

The end result of my reflections (Hansei) that John had prodded with his question was the recognition that I was now moving into a larger more complicated world that did not have the fine demarcations of a corporate boundary. The opportunity to participate and contribute arises from the reality that there are many of you in the larger world outside of Atrius Health who share my interest in the future of healthcare and my empathy and concern for patients and all of those who find satisfaction working in our industry. I believe that through conversation and actively relating to one another we can all participate in the search for the solutions for which we yearn at this critical moment of inflection in healthcare.

We are in a “Balsamic” moment, i.e., we are in transition. A Balsamic moon refers to the last moments of an old moon before a new moon appears. In times past those born under a Balsamic moon were thought to be agents of change. Ironically July 8, 1945 was in the last few degrees of a retiring moon and just before a new moon and if there is any one word that describes my experience on earth it is change. My work has always been about selling the need for change to patients, other physicians and to the organizations of which I have been a member. The “ancients” thought that a life of change was the “fate” of those born under a balsamic moon. Long ago I embraced my fate.

The old ways always pass but the adaptive changes that are necessary to make the future what we want it to be will require a common vision of what we want and that is the negotiation in which we are all either actively participating, actively ignoring or actively resisting. Our society changes slowly for long periods and then experiences sudden tectonic shifts. Dr. Ebert prescribed a need for change 46 years ago. We continue with the same great angst and uncertainty that he recognized that arises from our realization that the current climate of fragmentation and expense in healthcare is unsustainable without doing increasing harm to all of us but especially to the more vulnerable members of our community. There is still much to discuss!

Ebert predicted that the answer to the issues that plagued healthcare in 1967 and still trouble us in 2013 could not be resolved by more resources such as buildings and technology, more personnel, or more money but would require something much more fundamental, a new approach. He called for a new operating system that would be population based and would seek to improve the health of individuals, and the health of the nation without wasting the resource that we collectively need for the other common concerns of our society. Ebert knew that our wasteful approach to care was stealing resources from other import responsibilities like a healthy economy, better schools, more diverse programs of cultural enrichment and the maintenance of a strong infrastructure for a vibrant society where opportunity exists for all.

Dr. Ebert described but did not name the Triple Aim 40 years before Tom Nolan coined the term at the IHI in 2007. Dr. Ebert began the search for that operating system when he launched the Harvard Community Health Plan in 1969. He believed that the operating system of the future would evolve if we changed the finance of healthcare to minimize the destructive potential of self-interest as perpetuated by fee for service funding and he also realized that we needed to change the way we educated the next generation of physicians. I see his launch of Harvard Community Health Plan as one big exercise in Lean thinking. I can imagine his thought process after his “box 4” analysis of the barriers to the creation of a better system of care. Perhaps he said to himself,

If we move most care out of the hospital to the ambulatory environment and teach new physicians and nurses how to work together in that environment while enlarging our focus to include preventative care that avoids many of the problems of chronic disease and finance the system by prospectively funding budgets with adequate resources to do the work in the most coordinated, effective and efficient fashion then we will be able to sustainably afford to improve the health of every member of the community.”

He saw HCHP as a pilot to develop and test those ideas. His ideas were valid and he never thought it would be an overnight transition.

So, here I am now standing outside the comfort of the structure and power of the strong organization that has evolved from Dr. Ebert’s ideas and that has added import to my words and opinions. Now my words must stand unsupported by a corporate infrastructure. My words will have merit in the future if someone finds them helpful. If in the future these words contribute to your vision and understanding of the complexity of healthcare and our mutual journey toward an operating system that might meet the needs of our state and nation then they have achieved their purpose. If they broaden your understanding of quality and the importance of managing our self-interest by become patient and community centered then they will have succeeded. If they in some small way contribute to your understanding of the inextricable way that waste in healthcare denies services to those who need them and makes us all vulnerable to economic distress then these weekly words will have succeeded. If my words motivate you and add energy to your own personal sense of mission and purpose or make you smile as I seek to share the things that contribute to my own holistic world-view, then these words and the effort to record them will have succeeded.

I hope that Volume II will be an extension of the same thoughts and feelings which have sustained me through more than 40 years of practice and as I tried to do my best to lead a large complex enterprise on an important mission at a critical time. Those activities are over but I can still speak and try to contribute. I hope that my words will invite you into a rich dialog that begins with the honest questions, “What part of the problem am I?” and “What can I do to make a difference?” You can always reach me at drgenelindsey @gmail.com and please share these notes with anyone else who might want to have his or her name added to the circulation.

50 and 150 years Later

I chose to resume my letters this week because 50 years ago I was transformed by my own personal experience at the time of John Kennedy’s death. Ironically he died almost exactly 100 years to the day from Abraham Lincoln’s enunciation of what are perhaps the ten most eloquent sentences ever put together to support and explain the necessity of personal sacrifice in the struggle to be a meaningful “national we” from a collection of states wanting always to be “I”. At the University of South Carolina in 1963 you could easily find the “stars and bars” of the Confederacy and the civil war was still described as the War of Northern Aggression which was fought not to end slavery but to preserve states’ rights. If you listen closely to the current discussions of the ACA, the theme of the autonomy of states in some if not all matters of rights remains a rock in our national shoe and in matters related to healthcare we are still not all “created equal” and although we were “conceived in Liberty” we are not yet able to equally pursue life and liberty. The work to honor those who have died for those ideas by making them a universal reality continues. We find the origin of the resistance to equality imbedded in self-interest that does not want to extend equal respect and opportunity to everyone perhaps for fear of the personal cost. Nowhere is there more need for continuing work than in healthcare where we have accomplished much for some individuals in the intervening 150 years and yet can’t find the collective will to insure basic benefits for all individuals. 20% of South Carolinians and North Carolinians and 25% of all of our citizens who live in Texas have no healthcare coverage.

Just as there is great animosity in some venues toward our President in 2013 so too was there poorly veiled animosity toward President Kennedy in many parts of the South in 1963. Today we face legislative hurdles because of a deeply divided Congress that looks on the surface to be a two party system but really represents three points of view. Now we have the Republican Party split between moderate conservatives and Tea Party libertarians. 50 years ago we had Southern Democrats functioning within the Democratic part as an alternative voice. It was because of Kennedy’s need to work with Southern Democrats, especially those in Texas, that he was in Dallas 50 years ago today. The year before Kennedy had used the National Guard to enforce the desegregation of Ole Miss as James Meredith, a veteran of eleven years in the Air Force and a highly qualified student was enrolled as the first African American student at that proud old institution. In June of 1963 he sent troops to the University of Alabama and the University of South Carolina had just two months before enrolled its first African American student. She was given an entire dormitory for herself and the National Guard also secured her safety.

All of us who were alive and aware 50 years ago can remember the moment of first hearing of the assassination. Like 9/11 the memories are sharp and the events now divide time into neat categories of things that happened and the way life was before the moment and after the moment. We all will live forever with the question of what would life be like if these events had not happened. I am sure that like me, today you will travel back those 50 years and have emotions that have been packaged away out of site, comeback and fill you with a great sense of loss.

I had lunch at the Russell House Student Union cafeteria on November 22, 1963 and as I walked toward Davis Hall where my advanced placement course in Freshman English was meeting I began to hear the twitter about the rumor that someone had shot the President in Dallas. By the time I got to the classroom there were jokes flying about the appropriateness of the action. The room had all of the atmosphere of a fraternity party well into a second keg of beer by the time our professor arrived.

The professor was Jack Russell. He was the perennial recipient of the award for the best professor in the University. It had taken a lot of strategic focus on my part to get into his very popular class where enrollment was “first come first served” in those days before automated class scheduling. Dr. Russell looked like a basketball player. He was tall, agile and moved about the classroom with the ease of a point guard who could see the whole court. In fact he had played basketball at Cornell but even more interestingly his father, “Honey Russell”, had been
a barnstorming basketball player in the 30s before the NBA and had been the first coach of the Boston Celtics before going on to coach Seton Hall and before Red Auerbach arrived and made everyone forget that there had been a Celtics coach before him. “Honey Russell” is in the Hall of Fame in Springfield. Check it out.

Dr. Russell had been standing at the door for some indeterminate period of time before the class noticed that he had arrived. When I saw him I felt immediately ashamed not because of my participation but because I was just sitting and watching and listening in my own personal state of confusion. I was in the midst of this disrespectful and juvenile cacophony and complicitly saying nothing. Saying nothing in the face of bad behavior was a way of life in the South and if nothing else it was a major factor in the perpetuation of the racism and social injustice of the time.

Suddenly everyone saw Dr. Russell and there was an immediate replacement of a party atmosphere with a church like stillness. Dr. Russell just lowered his head and said, “The President is dead. There is no way that I can teach this class. Go away.” The room cleared in an instant and without another word. As I left the room in the wake of my classmates I was filled with a remorse and sadness that was transformative. Until then I had been vaguely interested in Kennedy’s ideas of a New Frontier but in an oppressive environment that aggressively resists change you keep your ideas to yourself. Even Kennedy had been slow to deliver on his campaign promises to champion civil rights because of his own fears and reluctance to create disharmony with the Southern Democrats but he had separated from them with his famous speech on June 11,1963 after he had sent troops to Alabama when he addressed the nation from the Oval office and said,

“We are confronted primarily with a moral issue…It is as old as the Scriptures and is as clear as the American Constitution…One hundred years of delay have passed since President Lincoln freed the slaves, yet their heirs are not truly free. They are not yet freed from the bonds of injustice…this Nation…will not be truly free until all its citizens are free… now is the time for this Nation to fulfill its promise.”

Dr. Russell was a liberal, Northern, Irish, Roman Catholic intellectual capable of using literature to heighten the awareness of our feelings and give me insight into the sensibilities of others in the world around me. He was the opposite of almost everything and every person who had been part of my world before him and November 22, 1963. Over the next four years I took every class
that Dr. Russell taught. He made a difference in my life not only because of his appreciation for words and the power of literature but also because through him I began to understand more about responsibility and the need for critical thinking about where you stand and why some things are so important that they are larger than your own self interest.

We both left the University in 1967. He wrote a letter of recommendation for me that I will always believe was the reason that I was accepted to be a student at Harvard Medical School where Robert Ebert continued my transformation. He left at the time of my graduation as a Fulbright Scholar headed to Argentina and then spent the rest of his life teaching at the University of Maryland.

Kennedy, like all of us, was defined by his failed good intensions and subject to the judgment of others. We have heard a lot about him as the media has dissected his death, its meaning to us all, and the accomplishment of his 1000 days in office. I have heard little or nothing this week about his accomplishments in healthcare but they were significant and foundational to Lyndon Johnson’s successful passage of Medicare and Medicaid and their implementation in 1965. I would refer you to the excellent book The Heart of Power: Health and Politics in the Oval Office by Blumenthal and Marone. Their 31 page chapter “John F Kennedy: The Charismatic with a Stricken Father” is enlightening and shows just how Kennedy’s own medical problems and the stroke that his father suffered were foundational to his own health care agenda that set the stage for Lyndon Johnson’s successful passage of Medicare and Medicaid just as his initial work in Civil Rights prepared the way for the Voter’s Rights Act and as the New Frontier morphed into the Great Society.

The most public manifestation of JFK’s healthcare policy was his famous speech at Madison Square Garden that was nationally televised on May 20, 1962 the day after Marilyn Monroe had made some sort of history singing “Happy Birthday” to him at a gala event and after he had spent much of the day at the hospital with his father who was recovering from his CVA. You can easily hear the speech on “You Tube”. In it he makes a case for what will become Medicare Part A. He is aware of the opposition of the AMA and indeed the next day the president of the AMA gave a rebuttal speech while standing in the middle of Madison Square Garden before the clean up from the crowd at Kennedy’s rally the night before.

His speech is full of empathy for the elders of the country who unlike his father can’t pay for their own care or unlike him can’t afford to pay for the care their parents need. It is ironic that a few hours before his assassination, Wilbur Cohen who was the Secretary of HEW (Health and Human Services of today was called Health, Education and Welfare in 1963) met with Wilbur Mills of Arkansas, the powerful Chairman of the House Ways and Means Committee, and secured his support for the legislation that would become Medicare. Mills was wily and Johnson had to work on him some more before Medicare became the law in 1965 but like Civil Rights, Johnson completed the legislation that Lee Harvey Oswald prevented Kennedy from finishing.

The 150 years since Gettysburg and the 50 years since Dealey Plaza teach us that the journey from idea to awareness, dream to reality is a long one. Plato saw the connection between ideas and realities but failed to make much of a comment about the time, effort and commitment that was required to connect the two. Professor Debra Ancona of MIT writes about the role of leadership as involving visioning, sensemaking, relating and inventing. In healthcare Kennedy was well into the task of visioning and sensemaking , and his May 20, 1962 was an excellent act of relating. Because of the events of November 22, 1963 most of the inventing was left to others like Johnson, Dr. Ebert and now us. The process goes on and on. Kennedy was aware of the slow and evolutionary path that healthcare would by necessity follow. He anticipated the critics in his speech as he closed by saying:

In closing, let me say that on this issue and many others we depend upon your help. This is the only way we can secure action to keep this country moving ahead, to have places to educate our children, to have decent housing, to do something about the millions of young children who leave our schools before they graduate.

 

Every day I am reminded of how many things were left undone. Thirty years ago they provided that no drugs be put on the market which were unsafe for hogs and for cattle. We want to take the radical step of doing the same for human beings. Anyone who says that Woodrow Wilson, as great a President as he was, and Franklin Roosevelt and Harry Truman, that they did it all and we have nothing left to do now, is wrong.

 

We ask you, the citizens of this country, the responsible and thoughtful doctors, the hospital administrators, all those who face this challenge of educating our children, finding work for our older people, finding security for those who have retired, all who are committed to this great effort of moving this country forward: come and give us your help.

So there is still much for us to do because as Kennedy implyed and as we know from Lean and as our own personal experience teaches us it is a never ending journey and the joy and reward is in the process, the anticipation, and the satisfaction as we see the benefit of our continued effort and are encouraged yet again to continue.

I will be back again next Friday with an open invitation to you to continue the conversation and continue the dream as we celebrate the small steps we take each day.

Brady versus Manning

My recovery from the excitement of the World Series is still incomplete. I had a small exacerbation of athletic excitement when Green’s 3-pointer beat the Heat and LeBron James at the buzzer but now the Celtics have lost 5 in a row. The refs seem to have it in for Tom, Bill and company but any chance to beat a Manning taps into the same emotions as the joy of watching A-Rod shuffle back to the dugout after striking out with the bases loaded. It should be a great game and I have no early meetings on Tuesday so that I may sleep in to recover. Life is good. I think that I will take a few walks this weekend and I hope that you will too.

Be well,

Gene

Dr. Gene Lindsey, MD.

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