February 11, 2022
Dear Concerned Readers,
“When You’re Accustomed To Privilege, Equality Feels Like Oppression.”
I was surprised by the response that I got last week from two loyal readers. As I have re-read the exchanges between them and me, it occurred to me that I should change the salutation on my weekly letter from “Dear Interested Readers” to “Dear Concerned Readers. As you read the exchanges I hope that you realize that the tone of my last few letters arises out of my concern for the future of healthcare and not out of personal despair, although I can understand that it may be that there is a strong connection between concern, fear of collective loss, and personal distress. My hope in writing as I did was that I would be at least one voice calling for us to rise out of our COVID-driven stupor and lethargy. It may be unrealistic, but I hoped that some healthcare professionals might be motivated to return to the challenging work of transforming healthcare where they work and live.
For us to refocus on the challenges that threaten the progress that we have made toward better equity in healthcare and improvement in the social determinants of health, we must be clear about how we got to where we are. I hope that over the next few weeks and months I can review that subject in these notes, and I fear that as I do that you may be concerned that my analysis is influenced by depression. I fear that a realistic analysis of a difficult and deteriorating situation will not come off as uplifting. I began the discussion last week with the area that I knew best, my own performance. There was an element of shoulda, coulda, woulda, in my description, but unless we own up to our own failures it does little good to comment on the shortcomings of others or the problems that we share or see in others.
The concerns expressed by readers about my emotional state initiated an exchange of emails that were more interesting and more directly addressed my concerns for the future of healthcare than did my original posting. As I was writing to reassure my concerned friends, I thought it would be beneficial to share the conversation with you. The first inquiry was dated around midnight last Friday, but it was written from France which is six hours ahead of the East Coast which means the reader responded in the first few hours after the post went up.
Feb 4, 2022, at 11:50 PM
Dear Gene
You can add this email to all of the others that your friends will be sending you after today’s blog.
Not surprisingly, my own “clinical sense” is identifying you as depressed. Knowing that telling someone how they should be feeling is no proper approach, I certainly won’t do that. To be truthful, I have entertained similar thoughts and wrestled with what I have been unable to accomplish in my own lifetime. I have come to recognize that what I think matters very little. Rather, the good that I have done in building relationships, siring a family that carries on, mentoring when I could – those are my major life accomplishments and are things to cherish and be proud of. I have never thought of myself as a “mover and shaker” but instead a genuinely good soul who treats every person as an equal and worthy of my attention and respect. I cannot say that I always get that right, but the nobility is in the effort.
BTW, I write this from Montpellier, France. [My wife] and I arrived Wednesday for a two and half week [stay] in the south – Provence, Languedoc, and Dordogne regions. It feels great to be back in our favorite country.
All the best,
xxxx
My response was:
Dear xxxx,
I really appreciate your concern. After you wrote to me another person also inquired about my mental health! I am actually quite happy and content with a busy life and many friends, but that does not preclude a reassessment of my failed good intentions in life. I guess I am in the acceptance phase of a Kubler-Ross process, or perhaps if you prefer Erikson’s integrity v. despair, stage 8.
I don’t see my life as a failure, but I do see many of the things that I care deeply about losing ground. In healthcare, I think that even before COVID we were in a losing battle with the downsides of fee-for-service practice. There was a small community of those who believed in the necessity of taking the message of the quality movement to heart, but medicine was/is mostly focused on income generation and not care delivery.
I don’t need to get on a soapbox about our civic move toward an authoritarian society. David Brooks has a great column this week about the change of direction in Christianity. All of the things I care about appear to be in decline.
Despite it all, I do find great pleasure in the natural world. My family is a source of joy. I am sustained by great friendships and activity in the non-profit groups where I can still exercise some of the same caring and helping that was so satisfying in medical practice…I am more distressed by what I see evolving going forward than by looking back at my personal failures…What distresses me is trying to imagine the world my grandchildren will inherit from us and our children.
I guess the issue is that it is hard to feel good and relax into the benefits you have when you imagine that more and more people have less and less. I am a little like the people in the movie “Don’t Look Up” which I wrote about recently. There came a moment when no effort could save them, so they gathered around a table, enjoyed a meal together, sang a song, and waited for the end which came soon.
Herb Stein, Nixon’s chief economist was famous for “Stein’s law.” it says that if something can’t go on forever, it won’t. I don’t see the current trajectory of healthcare costs being sustainable or the level of quality we achieved persisting. We have no solution to adequate access because of labor shortages. Insurance transfers more and more of the cost of care to consumers, especially for medications and procedures. When the Democrats lose control of the government which it seems they will, I see a more rapid shift toward consumer responsibility [and] away from employer or governmental responsibility. It will be slow, but my guess is that ten years from now we are much more likely to have a much more bimodal system of care than the utopia of the Triple Aim.
I think that you have just given me next week’s letter. Your self-description fits me to a T, and you say it so much better than I could.
I have come to recognize that what I think matters very little. Rather, the good that I have done in building relationships, siring a family that carries on, mentoring when I could – those are my major life accomplishments and are things to cherish and be proud of. I have never thought of myself as a “mover and shaker” but instead a genuinely good soul who treats every person as an equal and worthy of my attention and respect.
Enjoy your trip, and don’t worry about me. I am afraid of dying, love life, and I am not about to jump off a cliff.
All the best,
Gene
The other inquirer about my state of mind wrote on Saturday morning:
Feb 5, 2022, at 8:48 AM,
Gene, you are too hard on yourself. I can attest to your great skills and deep empathy as a physician as can many, many of your patients over your long years in practice. You were a visionary leader in your long years in governance and as CEO. In retrospect, most of us underestimated how deeply rooted FFS incentives were in the HC finance and delivery system. You should, as I do from time to time, listen to Mother May Belle Carter sing Keep on the Sunny Side!
I did listen to Mother Maybelle Carter sing “Keep on The Sunny Side of life. You can too if you click here. My response to him was:
xxxx,
Thanks for the comment and the attempt to lift my spirits. I am not really depressed. I just have had hope replaced with reality. I was not surprised to read in the Globe how the MGB [Mass General Brigham] lied to the HPC about how many hundreds of millions of dollars they expected to make as they expand more into the suburbs. It seems that things are worse with the cost of care in Massachusetts than they were ten years ago.
I do think the workforce shortages will force costs to be higher everywhere. I read that traveling nurses are getting up to $200/hr with their agencies taking another $100. My brother was just started on a new med that is $400 a month. I don’t see how we can ever imagine equity in healthcare when the cost of care out of pocket is high for even those on public assistance. So my emotions are not so much a sense of personal failure for things in the past; I am even more distraught about what is to come. I am reminded of Stein’s Law (Herb Stein, Nixon’s chief economist) “If something can’t go on forever, it won’t!” Perhaps, there is hope in that reality. Cost and access may become such a prohibitive barrier that the whole system will fail from the ability of its largest players to abuse their customers. That wasn’t the resolution that I hoped for, but it may well be the most likely destination at the end of the road we are on…
All the best! Stay warm,
Gene
This wise reader pushed back:
Be careful about wishing for failure, Gene. Too many on the right, and perhaps some on the left, are increasingly of the “burn it all down” frame of mind, with the ill-formed notion that somehow what will emerge will better suit them. What history teaches us is that systematic failure leads inevitably to great suffering, and what emerges is seldom what anybody wants (e.g., the Russian Revolution).
I didn’t feel like extending the discussion further. In my follow-up to his note, I shifted the conversation to our personal lives. Perhaps I could have said that there is a difference between wishing for a failure that brings a broken system down and realizing that a collapse was possible.
I have been surprised that no one has commented on my more frequent references to my growing religious and spiritual references. I have found no definitive answers that I would proselytize to others. What I do believe to be true whether your roots are in traditional religion, secular humanism, or like Ron Reagan, Jr. you are “an unabashed atheist not afraid of burning in hell” many of us do have a sense that there is something wrong when so many suffer from being born into poverty and then living their lives in a world where despite great personal effort the odds favor dying without much improvement in their situation or in the experience of their children.
I have always admired my colleagues who went far beyond what was required of them to try to mitigate the distress of the multitudes in their communities who suffered from unaddressed healthcare disparities. What I see around me and extending in the future, is more and more Americans who have enjoyed some privilege fearing a loss of privilege and becoming increasingly resistant to extending the benefits that we could all share for fear that such an extension of collective resources to the underserved will in some way prove to be a personal loss.
Journalists, political scientists, sociologists, historians, and psychologists have flooded the shelves of libraries and occupied much airtime over the thirteen-plus years since Barack Obama was elected as our first Black president with various explanations for why our society has become so divided. One curious observation that has needed an explanation is why so many people vote against their own economic best interest. I have reviewed many of those books and articles in these pages because I also believe that why people vote against their own economic best interest is coupled with the fact that they also vote and make personal choices that are against the best interest of their health and access to healthcare.
Of all the books that I have read on the subject of our polarization, the best is Ezra Klein’s book, Why We’re Polarized. Klein is a journalist, and like a good journalist, he collects and analyzes the work of many other thinkers and writers and then explains what it all means. I wonder if many people have read the book even though it was a best seller because he has discussed the book on so many talk shows that reading the book is hardly necessary. Perhaps his best interview was the conversation at the Commonwealth Club of California. Another interesting conversation was between Malcolm Gladwell and Klein at the 92nd Street “Y” in New York.
“When you’re accustomed to privilege, equality feels like oppression.”
The title of this section is lifted from page 119 of Klein’s book. Klein attributes the quote to the women’s rights movement from the nineties, but in my mind, it explains much of the resentment that fueled the election of Donald Trump. The sentiment may explain why so many blue-collar white workers voted for Trump in 2016 and remain devoted to him against their own best interest. The reality behind the statement perpetuates the stagnation from the polarization that is the biggest threat to an improved and more equitable healthcare for us all. There has been a lot written about our emergence in the future as a “majority-minority” nation. It is a fact that white Americans are already in a minority in some states and by about 2040 will be a minority in America. In my mind, the defense of privilege is a poor trade-off for all of us experiencing more expensive, more difficult to access, and lower quality healthcare. Thomas Edsall published an excellent review of the anxiety about loss of status this week which I believe is a major factor in explaining why the future of healthcare is far from the center of the stage in the interval between Republican administrations. Edsall begins his piece by asking an important question:
What is the role of status discontent in the emergence of right-wing populism? If it does play a key role, does it matter more where someone stands at any given moment or whether someone is moving up the ladder or down?
Edsall has had a long career in political journalism and is on the faculty at Columbia. He used his contacts to survey many political scientists around the world to get their answers to his important question. I would recommend that you take the time to read his article for the insight it will give you about how the fear of the loss of white privilege “puts wind in Trump’s sails,” and I may add, threatens the future efforts to improve equity in healthcare and address healthcare disparities.
As much as I am inspired by the extra efforts of many of our healthcare providers from doctors and nurses down through housekeeping staff, I am disappointed by the quest for profit that characterizes so many of our world-class institutions and obviously amazing pharmaceutical and medical device providers. For-profit businesses may be able to defend their prices as secondary to the market and their obligation to stockholders. Non-profit academic medical centers can’t claim an obligation to shareholders. Some have huge reserves that can cover their concerns about rising overhead. What I often hear as a defense is that their prices support the research and resources that allow them to perform miracles for a few today that pave the way for better care in the future for everyone. I understand their perspective, but I do not buy their arguments. The advancement of science and the support of groundbreaking procedures should not be something that individuals pay for in the form of astronomical bills for ordinary care for the majority of Americans. We can and have collectively supported research and technological advances through government investment. As it is, it appears that our most famous institutions gain wealth and resources by both paths, they overcharge individuals and they also garner much of the government funding. I think they win in the moment, and we all lose in the long run.
There is a stark contrast between the “make as much as you can mentality” and the biased opinions we often invent to protect personal advantage and the African theological concept of Ubuntu. Ubuntu came to mind on Monday while I was reading the daily communication from Father Richard Rohr at the Center For Action And Contemplation in Albuquerque.
I was introduced to the wisdom of Father Rohr many years ago while I was having breakfast in Colorado Springs with Dr. Patty Gabow, the amazing long-term CEO of Denver Health. We are both retired now, but I enjoyed frequently seeing Patty at meetings and conferences where the subject was improving healthcare through better performance and a focus on the objectives articulated in Crossing the Quality Chasm. We both embraced the benefits of Lean management in healthcare. I know of no one who cared more about disadvantaged populations or did more to improve the care of the underserved than Dr. Gabow. The last time we spoke she was still contributing on important boards like the Robert Wood Johnson Foundation, our nation’s largest public health philanthropy.
Patty and I discovered in conversation that we were both moving back toward some of our spiritual heritage that had been dormant for years. She suggested that I check out Father Rohr. I did, and since then have been amazed by how often I have encountered people who regularly read his offerings, even if like me they are not Catholic.
Father Rohr began the letter for last Monday by writing:
CAC friend Rev. Dr. Jacqui Lewis finds inspiration in the African concept of “ubuntu,” which means “I am who I am because we are who we are.” The ubuntu vision of relatedness can provide healing in the midst our many current crises and divisions:
Even before COVID-19 showed up in our global family, we were living in what I call “hot-mess times.” In our current context, race and ethnicity, caste and color, gender and sexuality, socioeconomic status and education, religion and political party have all become reasons to divide and be conquered by fear and rancor. . . . Put simply, we are in a perilous time, and the answer to the question “Who are we to be?” will have implications for generations to come.
We have a choice to make. We can answer this question with diminished imagination, by closing ranks with our tribe and hiding from our human responsibility to heal the world. Or we can answer the question of who we are to be another way: We can answer it in the spirit of ubuntu.
You might remember that ubuntu was the spirit that enabled Nelson Mandela and Desmond Tutu. In an amazing union of sport and philosophy, it was the concept that Doc Rivers used to propel the Boston Celtics to an unlikely NBA championship in 2008. If you read deep into the article that is linked to Mandela and Tutu you would have read:
But the idea of ubuntu holds a more radical possibility: the possibility of finding a way of living in society that augments the interests of everyone. This is an idea that goes beyond an ethics of consensus or accommodation, to an idea of mutual flourishing and uplift. And in this way, it offers a challenge to find new and creative forms of political organisation that might serve this mutual flourishing.
The bolding above is my work, but I think the phrase offers us a plausible road to our collective success in achieving an equitable system of healthcare that serves us all. We must realize that we are interdependent. If we act on that knowledge we have a chance. If we don’t my apprehensions about the future of healthcare are an under call of what we all may experience together.
As I said to both of the individuals who wrote to encourage me, Herb Stein nailed it when he said, “If something can’t go on forever it won’t.” We should apply that concept to healthcare and the future of our democracy. Realizing and adopting the wisdom of ubuntu has already won a basketball championship and freed millions from the grasps of apartheid philosophy, maybe it could also heal a riven nation and give us a more hopeful collective future.
It’s Been Icy Cold, And It’s Still Two Months To “Ice Out”
The weatherman got us very excited last weekend about another big storm to be followed by a deep chill, but he was only half right. We were on the rainier side of the front so instead of a foot of snow we were the lucky recipient of only about two inches of new snow that followed quite a bit of freezing rain. North of us it was all snow. The half of the forecast that was correct was that it would be very cold, sub-zero cold, after the snow had passed through on its way to Maine, Canada, and out to sea.
It seems that it never fails that the day after a storm passes through there is not a cloud in the sky. The sun seems to rule after the storm passes even if the temperature is below zero, as it was when I took this picture last Sunday morning. It feels like it should not be so cold when there is so much sun. As I braved the cold to walk less than twenty yards to get wood from my woodshed, I was struck by the beauty of the scene before me. I was standing in front of the shed which is attached to my garage and less than about fifteen feet from the lake. The only thing that would have made the picture better would have been if there was still snow on the trees, but it was breezy. All of the shoreline down that you can see in the picture is conservation land which is nice.
Punxsutawney Phil did not see his shadow which means we have six more weeks of winter. I never have quite understood the Groundhog Day thing since in my experience there are always at least six weeks of winter after February 2nd. I consider the end of winter to be some combination of “ice out” and Opening Day at Fenway Park, both of which occur sometime in early April. So, only six more weeks of winter would mean winter ends a month sooner than usual in mid-March.
One big winter event around here occurs in early February, and I am kicking myself for having missed it again. Every year for many many years there has been an “ice harvest” on Kezar Lake which is about seven miles south of me. I keep trying to remember the event and make sure that I see it. It occurred in the cold a few hours after I took the picture that you see in today’s header. It was so cold I could not imagine doing anything but staying inside. It would have made a great picture because the blocks of ice that are harvested are about the size of a hay bale.
In the past, the ice would be packed in straw and used through the summer at Muster Field Farm which is about a half-mile up a hill from the lake, and at the Follansbee Inn which is just a few yards from where the ice is harvested. I know exactly what I missed because in the age of YouTube I can show you exactly what is done. If you watch the video you will see a motorized saw. I think the motor might be from an old T model Ford because they start it with a crank. You can also see some huge hand saws that look like they could be used to cut down trees. The other observation is that the ice harvest is definitely a community effort. The spirit of ubuntu is present, and is a motivating factor!
Wherever you are, I hope that you are warm and enjoying some favorite winter activities.
Be well, and be warm,
Gene
