December 16, 2022

Dear Interested Readers,

 

Why Are You In Healthcare?

 

The question in this title assumes that you are a healthcare provider or work in healthcare. I know for a fact that many of the readers of these notes do not work in any aspect of healthcare. For those readers who are not involved in healthcare, the question needs modification. How about, “Do you wonder why anyone, especially your providers, would go into healthcare?” Either question is complex and is a consideration of your or someone’s motivation or choices. 

 

I have had a home in the Sunapee/ Kearsarge region of New Hampshire since 1995 and have lived here full-time since 2014. My wife and I have slowly become integrated into the social and civic environment, but we are still meeting new people at almost every function we attend. In a way, it feels much like it did for me when I changed schools in the middle of the third grade and just before my junior year of high school. 

 

It is stressful for me to “break in” to a new group. That may explain why I worked in the same place for almost forty years. I forgave myself for clinging to one home base for so long by telling myself that I did not need to change jobs for my job to change or for my practice to change. Furthermore, I told myself that I enjoyed the richness of long-term relationships with patients and colleagues. All of my rationalizations were true, but they may have also been self-serving excuses for avoiding even greater changes that I would have found stressful. It was also true that it would have been hard to find a better place to work than for Harvard Community Health Plan, Harvard Vanguard Medical Associates, or Atrius Health which for me were always the same practice with an evolving name but stable values that resonated with my own. 

 

My ice-breaking trick when I meet someone new here in my new home in New Hampshire is to ask them how they got here. So far, no one has answered, “By car.” People like to talk about themselves, and I like to hear what they have to say. There is also some information revealed by whether they eventually reciprocate by asking, “And how did you get here?” What has been interesting to me is that the answers I get fall into just a few buckets, and only a few of them have anything to do with business. My neighbor across the road is here because New London is a very central location for his New England sales area, but it is also true that he skis more than a hundred days a year and in the summer he enjoys mountain biking and being on the lake for wakeboarding, water skiing, and wake surfing. There are a few others like him, but a more common answer I get to my ice-breaking question is,  “I, or my wife, started coming here every summer/winter with our families when we were children and it was a natural place to retire. Others say, “I came to love the area when I was at Dartmouth.” A variation is “ I discovered the beauty of New London when I was a student at Colby-Sawyer.” There are some who answer, “My family has been here since the seventeen hundreds. I have always been here.” A variation is, “I was born here, and after college, I tried living somewhere else, but I had to come back.” If my question ever elicits “Et toi?” I respond that I came to the area to visit a colleague who had a vacation home in the area, and after many visits over a few years, my wife and I decided to get our own place. It did not take us long to realize that the Sunapee area was not only a good place for a weekend retreat, but it was also the perfect place for us to retire.

 

One of the activities I enjoyed most as a CEO was the Monday morning meetings with our “new hires.” Sometimes I met only with the new physicians. At other times I met with all of our new employees. My job was to introduce them to our culture and mission, but what I enjoyed most was asking them why they had decided to take a job at Harvard Vanguard/ Atrius Health. I used the question much like I use the question now about how people came to live in New London. I rarely got an answer like, “You offered the best package of pay and benefits.” We did offer a very good compensation/benefits package that was strategically pegged to “lead the market.” What I wanted to hear and usually heard was, “I came here because I was drawn to your mission” or “I like Vanguard’s innovative approach to practice.” Sometimes I would hear, “My friend works here and told me it was a great organization.” The deeper question that sometimes got answered was, “Why did you choose to become a doctor?” I often did not wait for the “Et toi?” I probably bored many new hires with my own testimonial about why I became a doctor, and why I chose to practice at Harvard Vanguard. My own answer and the answer that I most often heard from the “new hires” was that they went into medicine because they cared about people, and wanted to help them. 

 

There has never been a more important time for us to ask “Why are you in healthcare?” The majority of us became healthcare professionals because we cared and wanted to help, but I fear that many of us who were so motivated have lost our way as things have become difficult, and may have forgotten what was once the source of so much enthusiasm for being helpful for others. I am very concerned about the high rate of burnout. I am increasingly concerned about staffing shortages, and the demands on the time and energy of those who are working more than full-time because of professional shortages.  What concerns me, even more, is that the solution to these twin issues will require transformational changes that I don’t see occurring. We need substantial innovations in how care is delivered before we can return with renewed energy to practice with the hope of finding once again the joy of providing care. 

 

As much as I am most concerned about the impact of our failing system of care on healthcare professionals, I am even more concerned about the increasing difficulty that all patients have getting the care they need, and I am especially concerned about the inequality in the system that makes it so hard for the poor and minorities to get the care they need. I understand that it makes sense that burnout and fatigue can induce “empathy or compassion fatigue” for the individual, but I fear that it now exists among groups of clinicians and is endemic in many organizations. Perhaps my fears about the future of healthcare and frustration with the current state of practice are why I found Eric Reinhart’s paper, “Medicine for the People: As more and more doctors awaken to the political determinants of health, the U.S. medical profession needs a deeper vision for the ethical meanings of care.” to be so profound. 

 

Last week, using Reinhardt’s wisdom, I tried to discuss what those of us who had been hoping that the health of the nation might be improved by improving the “political determinants of health” might do over the next few years during which Republican control of the House will make it unlikely for the passage of legislation that will enable innovative policies to improve the social determinants of health. I tried to suggest that progress was possible through state and local politics and that those “blue states” where progressive ideas were not a heresy could use the next few years to pilot ideas and policies that might later be employed nationally. I also suggested that within innovative practices and health systems internal improvement was always possible no matter what was happening externally. That idea lead me to realize that I knew that those concepts were possible because I had always worked within a practice that was innovative within a progressive state. Even in that environment change was hard, but it was possible.

 

My reminiscence led me to the realization that progress was possible because of the culture, and the culture was a function of the factors that motivated the professionals within the organization. In a subtle way, I tried to suggest that it was up to professionals to lead from their practices into their communities. As I have considered my own suggestion, I realized that my suggestion that we can make a difference in a time of deep political division depends on some undefined critical mass of professionals remembering why they chose to be part of healthcare as their life’s work.

 

More than just remembering why they are part of healthcare, they must once again become active in the effort to make a difference, and there has never been a more difficult time to rejuvenate the effort to deliver care than in the midst of what seems to have become an endemic infectious disease problem which along with a terrible war that could become nuclear at any moment, and frightening inflation has caused so many to focus on their own wellbeing. In retrospect my question to the “new hires”, “Why did you choose to join our practice?” when applied to the professionals of the nation as “Why are you in healthcare” is central to understanding the likelihood of progress over the next few years. Motivation, even in difficult times, makes a difference. 

 

As I thought about the importance of the question, “Why are you in healthcare?” in predicting progress toward health equity or the Triple Aim, I realized that we must begin to make care better for everyone by asking professionals to remember why they became healthcare professionals. In the nine years since my retirement, and the eleven years since my wife retired from her role as a nurse practitioner, we have occasionally had difficulty with access to care or received substandard care that caused us to wonder what might have happened to cause some specific provider whom we encountered to provide us with a less than satisfactory experience of care. That thought was often followed by the realization that if we are getting less than satisfactory care or are having problems with adequate access to care, what is happening to those who don’t have either “means” or “connections.”

 

Sometimes it has been hard to imagine why the offending provider ever wanted to be a caregiver since our problem did not seem to be what concerned them. We are not alone. As former providers of care, we hear more about inadequate care than care that exceeds expectations. If after I learn why a neighbor is living in the Upper Valley they ask about my history and learn that I am a retired physician, I am very likely to have to listen to the complaints about healthcare and poor access to care, and the lack of attention they get from their provider. 

 

If you went into healthcare to get rich, you are probably disappointed. You should have gotten an MBA and then gone into finance or started your own hedge fund. I have known many physicians, especially in the academic environment, who were drawn to the science of medicine and the joy of discovery. I appreciate them, and many are motivated as much by applying their science to clinical problems that improve the lives of their patients as they are by the desire to publish an article in The New England Journal. I have known surgeons whose first love was the technical challenge of their work. Care was a secondary but necessary concern to keep their schedules full. I valued them for their expertise, but if possible I referred my patients to surgeons for whom the desire for surgical expertise was motivated by the desire they had to serve the needs of patients. If you became a healthcare professional to provide care that makes a difference to individuals and the health of the nation, there has never been a time when you have been needed more. The question is how to revitalize within our healthcare professionals those motivating factors that have been so strained and will be delayed even more by our political divisions.

 

Reinhart suggests “accompaniment” as an exercise that rekindles care. If accompaniment needs a definition, consider “walk with” as a synonym, and if that seems too intimate consider “shadowing.”  Seeing and experiencing what happens to real people seeking care from the system of care where you work is not a new idea. Dr. Anthony DiGioria and Eve Shapiro described “shadowing” patients and families as they tried to contend with our complicated systems of care in their 2017 book, The Patient Centered Value System: Transforming Healthcare through Co-Design for which I wrote a preface and then reviewed in these notes.  Don Berwick wrote a forward for the book. I have bolded what I now see as a statement that is even more important now than in 2017. In his forward, Don wrote:

 

Excellence in healthcare depends on the quality of relationships with patients and families—really listening to what they want and need— and remembering the values that led healthcare professionals to their calling in the first place. Gone are the days when the simple view that “the doctor knows best” suffices. Now, if we listen carefully and with open minds to what patients and families tell us, we can find the best compass toward improving our delivery of care and their care experience. This is healthcare “co-design,” and it is the wave of the future.

 

Making progress toward a better system of care over the next two to three years will require finding many more providers like Tony DiGioria who will remember “…the values that led them to their calling in the first place..” We desperately need professionals who can look at what they do through the eyes of those who seek care from them and then have the courage to make the changes to our very rigid system of care that will move us closer to the ideals of the Triple Aim. We need a revival of enthusiasm for ideals that motivated so many of us when we made the decision to spend our careers in healthcare. To achieve the goal of a world where everyone has access to the care they need from providers who find real joy in their work will require many professionals to return to the active expression of the values that once motivated them.  

 

Finally, Some Snow

 

Today’s header is proof that we got about three inches of snow overnight from Sunday to Monday. Today it is snowing again. As I review these words we are in the midst of a possible twelve-inch “dump” of heavy wet snow. The scene in the header that I took last Monday after the sun had come out reveals the First Free Will Baptist Church of North Sutton, New Hampshire in the center. To its left is a little bit of the Folinsbee Inn and across the street is the Vernandale Store.

 

The Vernandale Store has been closed for over a year since its owner has been ill. Before it closed, going to the Vernandale Store was a trip back in time. There was a sign inside the store that claimed that was the oldest continuously operating general store in New Hampshire. It had penny candy, a lunch counter, and almost anything you might need to make it through a pleasant week at the lake, It was a favorite rest stop for cyclists. I guess that now the claim to be the longest-operating store is no longer true.

 

You can’t see Kezar Lake in the header, but it is just to the left of the picture. Mount Kearsarge looms over the scene and out of the picture to the right. You can see them both and the beach at the state park with the village in between in the picture below which I lifted from a drone video.

 

 

I frequently enjoy circumnavigating the lake as one of my walks. It is a beautiful three-mile jaunt that passes through towering majestic white pines, wetlands with red-winged blackbirds, old summer camps for kids, former inns, huge colonial-era homes with gorgeous gardens in the summer, a collection of small summer cottages, and a state park with a huge beach. As you might expect, there are loons on the lake. Click here for the beautiful three-minute drone video of the lake, the mountain, and the village from which I lifted the picture above. If you want to take a trip back in time to an earlier time in New Hampshire without having to cut through excessive commercialization, you can’t do better than a trip to North Sutton and nearby Musterfield Farm.

 

Last week I was yearning for the combo of snow and a frozen lake. The picture below was taken last Monday and shows that my wish was partially fulfilled by Monday morning.

 

 

As you can see, we bought our Christmas tree last weekend, but it is “resting” outside as it awaits a later dressing. During the week the lake continued its progression toward a complete covering of ice. I can hardly wait to see what it looks like when the current storm has passed. Then I expect it will be a complete blanket of white.

 

I have plenty of firewood and a Peliton to substitute for my daily walk, so I welcome the snow and the prospect of a White Christmas. I hope that you have great expectations of joyous holidays with family and friends. 

Be well,

Gene