I don’t really remember when I first met Don Berwick. He joined Harvard Community Health Plan in the late seventies as a pediatrician. I began my career there a few years earlier in 1975 right out of my training at the Peter Bent Brigham Hospital before it became the Brigham and Women’s Hospital in 1980 with the merger of the Pent Bent Brigham Hospital, The Robert Breck Brigham Hospital, and the Boston Hospital for Women which itself was a the result of a previous joining of forces of the Boston Lying-In Hospital and the Free Hospital For Women.
I probably first met Don at one of our many staff meetings. By the early 80s he had become our Vice president for Quality and Safety. Other than the fact that he once made a house call in 1985 in the middle of the night when one of my son’s had the croup, it was in his administrative role that I knew him best. I have told the story before, but one of our most dramatic encounters occurred a few years later when I was hurrying to a meeting in our administrative offices and we both arrived at an elevator at the same time. Don was out of breath but he was eager to tell me that he had data that in his opinion showed it was not really safe to get care in our flagship offices at our Kenmore Center!
I don’t think that information was well received by those people to whom he reported because not long after that encounter he left HCHP, and not long after his leaving the IHI was formed. Since that time we have maintained a relationship, and I felt quite honored that on several occasions Don made a referral to me. I reciprocated by bringing him back as often as possible to speak to our medical staff at our annual meetings. Years later when Don was the Administrator of CMS I traveled to Washington twice to confer with him as our organization became one of the original and most successful Pioneer ACOs. In 2013 I was a vigorous supporter of his attempt to win the nomination as the candidate for governor of the Democratic Party in Massachusetts.
During the second week of December, going back over thirty years, the IHI has called together clinicians and medical managers from around the country and the world to exchange ideas at a very well organized event in Orlando, Florida. I attended for many years. Don Berwick’s annual keynote speech was always the highlight of the meetings for me. I have reported on several of those meetings in these notes over the past dozen years. I was delighted to hear that the conference would be delivered “virtually” this year. I was hoping to attend, but the fee was beyond my reach without a sponsor, and as a retired doc I no longer need CMEs. I was happy to read that even in its virtual format over 8000 medical professionals did attend. What made me even happier was to discover that the recording of Don’s keynote was being offered online for free. I highly recommend that you invest the 43 minutes necessary to hear it even though what follows will be my attempt to give you what I got from his presentation.
Dr. Berwick’s annual IHI Keynote has become an annual event for those of us who live and work in expectation of the coming of the Triple Aim. The Triple Aim in its current form first appeared in 2008 in a paper in the May/June edition of HealthAffairs entitled “The Triple Aim: Care, Health, And Cost” and written by Donald M. Berwick, Thomas W. Nolan, and John Whittington. The abstract of this landmark article reads:
Improving the U.S. health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care. Preconditions for this include the enrollment of an identified population, a commitment to universality for its members, and the existence of an organization (an “integrator”) that accepts responsibility for all three aims for that population. The integrator’s role includes at least five components: partnership with individuals and families, redesign of primary care, population health management, financial management, and macro system integration.
The ideas behind the Triple had evolved over several decades of progressive thought which I can personally trace back to the mid sixties, but had existed much longer. It is my assessment that clarifying the common objectives of the progressive thinkers in healthcare policy was a huge leap forward. I became the CEO of Atrius Health in February 2008 at almost the exact same time the paper came out and found that being able to model our strategic objectives on the framework of the Triple Aim was a huge benefit in the work of aligning multiple delivery sites into a more effective organization. In essence Atrius was an “integrator” that functioned as Berwick, Nolan, and Whittington described in the paper.
Since the articulation of the Triple Aim I have conceptualized Don’s annual appearance and Keynote at the IHI conference as the latest presentation of greater depth and understanding of the core concepts of the Triple Aim. He usually explores a subject that is of timely interest to those seeking to follow the path toward the objective of the Triple Aim. Perhaps the most memorable expansion of the core idea presented at one of these December updates was his presentation a few years ago of “Era 3: the moral era of healthcare.” I have passed along the idea of a “moral era” as a whole, and in bits and pieces, in many of these letters since he first presented the idea. Perhaps the best review can be found in the posting from February 18, 2018 where I report on a podcast discussion between Zeev Neuwirth and Don that is focused on the Moral Era. It may be obvious that I have thought of Don as “the high priest”of healthcare. He has gone far beyond healthcare policy as he describes healthcare’s role in a better world. His addresses have taken on the shape of well constructed sermons, and like many sermons end with a challenge to elevate our behavior to higher ground. This year’s speech entitled “‘Hands Across the Hills’–and Other Ways to Healing” was no exception to that trend.
Kadar Mate, the president of IHI, introduced Don by saying:
In times when we have collectively despaired about the state of health in his country and beyond, when we have sought moral clarity in the fog of uncertainty, and when we have needed a voice of reason and principle in the midst of relativism and confusion, we have so often turned to one voice to help us collectively navigate and get our bearings that voice…belongs to Dr. Donald Berwick.
As is usually the case, there was a story that ran through Don’s speech. The story began on the morning after the 2016 election when Paula Green, a college professor who had studied conflict resolution and communication between opposing groups in many locations around the world, woke up in her home in Leverett, Massachusetts to discover to her disbelief and horror that despite the fact that almost 80% of her neighbors had voted for Hillary Clinton, Donald Trump was going to be the 45th president of the United States of America. 836 miles away in Letcher County, Kentucky, Gwen Johnson, a woman who owned a bakery and whose father was a coal miner, awoke quite happy to discover Trump’s victory. Almost 80’s of the residents of Letcher County, which is heavily dependent upon coal mining to support its economy, had voted for Trump. His introduction of these two women concluded that they lived in a polarized country and that they represented the distance between the two poles. What follows was the story of how Paula decided to try to close the distance between the two poles by creating a project of affiliation with her polar opposite Gwen. The program was entitled Hands Across the Hills and its success at creating understanding between two very different communities was publicized recently on NPR, in the Boston Globe, and a variety of other media outlets. If you click on the two previous links you can see a YouTube video about the success of the program and can read or listen to the NPR description of it.
After introducing and giving the background to “Hands Across the Hills,” Don digresses into a scholarly discussion of the history of polarization in America from George Washington’s warning until the present moment and its many implications for healthcare. We are more politically polarized now than we have been since the Civil War. We have the highest level of income inequality of any developed country to go along with our status of having the most expensive healthcare in that group. Our quality is also lower so that polarization is associated with expensive, inequitable, poor quality healthcare that has made us vulnerable to a public health disaster. He points out that the annual income of the average medical assistance is below the poverty level for a family of four and that many “essential workers” in healthcare do not have health insurance. How bizarre is that? What does it say about us? Is it a surprise that this same population has been so vulnerable to COVID-19?
Don spends some time discussing his deceased friend and mentor, Tom Nolan, one of the authors of the Triple Aim paper, and whose book The Improvement Guide, 2nd Edition, is Don’s Bible for continuous improvement. He quotes the lengthy appendix as saying that improvement is not possible without effective communication and that effective dialog must occur in an environment of common objectives, trust, and respect. He is really concerned that the mergers in healthcare are not nearly as effective as collaboration between organizations with the same objectives because mergers require the work of blending cultures or more likely one culture absorbing another. It is clear from the multiple examples Don gives that polarization is antithetical to improvement.
After a thorough description of polarization in this moment in time, and the warning that improvement stalls when polarization prevents effective dialog, we need look no further than Congress to see that reality, and the associated reality that everyone loses in a state of polarization, Don brings Pamela from Leverett, Massachusetts, and Gwen from Letcher County, Kentucky, together to describe the work that they had to do to reduce the polarization between them and their communities and move on to a more effective dialog. At one point Don emphasizes that you need not give up your own values to move into this space, but it does require that you acknowledge the other party’s equal right to a different point of view. The work is hard and both women describe how they felt vulnerable at times.
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Don pushes both women for their feelings and descriptions of moments of stress in their work together. We come away from his conversion with Gwen and Pamela who both say that we must start listening to one another with a new sense of possibility. Gwen says that in coal country they really do know about climate change and believe in science, but at the end of the day if they can’t feed and cloth their families, “What is it that we are working for?” Her question goes unanswered but there is the sense that she has presented an opportunity. In essence she has demonstrated a possibility for breakthrough as she seems to be asking for an alternative choice that might offer opportunity while giving up what provides benefit now at an unacceptable cost to the planet.
After thanking the women for their help, Don segues back to healthcare by referencing Bryan Stevenson, the founder of the Equal Justice Initiative, and the author of Just Mercy, who had spoken at the IHI meetings in 2017 and said:
If you are willing to get closer to people who are suffering, you will find the power to change the world.
He also quoted Father Greg Boyle, the founder of “Homeboys Industries,” who spoke to the IHI in 2018. Father Boyle said:
Human beings cannot demonize people they know. Put enemies together, say baking bread, and humans can’t sustain animosity. Impossible.
“Hands over Hills” and the work of these two men who are current well known reformers and “social saints” allows Don to mention “intergroup contact theory.” He is drawn to the examples all of these people offer and then questions whether it:
(Please forgive any error of transcription here. I did it myself from the YouTube video because I did not want to chance missing the points he was making at the end of his speech as he was giving his challenge to us.)
“…is [it] too sappy, is it too naive, is it out of touch with the state of nature?” After asking his [Father Boyle’s] question he says that he “is constantly searching for a change concept, a simple change idea that can birth new symptoms of good new systems for good people trapped in old systems, and here’s one idea. It’s proximity. It’s breaking bread. It’s taking that long drive from Letcher county to Leverett and from Leverett to Lecher. So I’m going to recommend that we take this very seriously.
I propose a year of tests of change based on the search for proximity. Based on the baking of bread. I’d like to propose that every one of us here as individuals, every organization represented in this meeting, take a leaf from the book you just heard, the book of “hands across the hills.” Create an opportunity for social contact between people in your town, your state, and your nation. Take the risk of spending time together. What’s the worst that can happen? I guess sparring, insults traded, raised voices, slammed doors. We’d retreat to our tribes, and I want to be very clear about one thing, when it comes to ethics, morality, compassion, I will fiercely defend the values I hold dear. I say no to racism. I say no to cruelty. No to turning our backs on suffering, but I also sense that maybe most of us, most of us, share and honor the same values, the same values you just heard…that we want the same things for ourselves and for our neighbors and that we need to have ways to uncover that fact with each other.
Polarization may not reflect us. It may blind us, and the best that could happen would be really wonderful. It would be water for very thirsty souls now. Possibly now where we are trapped in the fragments and can only see each other as cartoon figures. We can build some bridges. Maybe we could break some good bread together…maybe we could fight the same fight.
Don has often launched us on an adventure with a great challenge. This challenge seems to be in line with the work that Joe Biden says that he is going to try to accomplish, and that many people say is unlikely to work. The idea of finding a way to pull us back toward one another is a huge task and Don’s challenge will once again get a negative response from the many cynics among us, but change begins with individuals responding to uncomfortable realities. It seems the right place to go now. Without some attempt to address polarization the future seems destined to be a continuous downward spiral away from the hopes of the Triple Aim, and away from democracy.
Don always says to think globally and act locally. I am going to accept the challenge and look for the opportunities that I know could reduce polarization in my community. I hope that doing the same in your community will be one of the things that you put on your list of resolutions for the New Year. Let’s hope that 2020 was the nadir of many things including polarization, and that in 2021 we can come just a little closer together.
