November 27, 2020

Dear Interested Readers,

 

Where Do We Begin The Work?

 

During this last week I have been listening to Barack Obama read his book, A Promise Land, on my afternoon walks. It has been an incredible experience. I am delighted that the book is over thirty hours long. That means that he will be with me for several weeks since my walks vary between an hour and an hour and a half and some of the parts of the book are so good that I hit the rewind button and listen a second or third time. 

 

It should not be a surprise to anyone that Obama is a master of self examination, and in the process he frequently finds that in retrospect he was lacking in understanding, or that a problem arose because he lost his focus on his purpose and drifted toward convenience or some other self serving motivation. At times as he talks about events that are easy to remember as significant public opinion problems I get the feeling that it took divine intervention or great luck for the problem to be resolved in his favor. Hearing his side of the story, I realize that most of the time he succeeded by doing the right thing rather than what was easy or expedient. 

 

One example is the  problem that arose around his membership in the congregation of the Reverend Jeremiah Wright. The Reverend Wright was a significant figure in his life, but the press discovered that portions of his sermons when lifted out of context could sound angry, anti American, and almost treasonous. You might remember that eventually the Clinton campaign tried to capitalize on video clips of Wright’s rants from the pulpit and by inference raise doubt about Obama’s fitness for office. Being young and inexperienced on the national stage, being biracial, being intellectual, and having a name that sounded like he was a foreigner who could be a jihadist were problematic enough without the suggestion that he was under the influence of a radical minister who hated white Americans. We all know how the story ended. Obama overcame the problem and was elected anyway, but what you may have forgotten is that to get past the innuendo he first gave a remarkable speech on the issue of race in America, and then when Reverend Wright continued his remarks during a speaking engagement in front of the National Press Club, Obama took the painful step of definitively separating himself from a man whom he liked and understood, but others could not understand, and who refused to manage himself. 

 

The issues associated with Reverend Wright were dramatic enough, but an even more potentially damaging problem that I well remember was a “gaffe” that Obama made when talking about white rural working class voters. He made the mistake that many of us have made, and continue to make everyday, of trying to explain the motivation of someone else in unfaltering language, and the accumulated result of our collective transgressions over the last few decades has been disastrous. Hillary Clinton made the same mistake, and it may have cost her the presidency in 2016. I am sure that you remember her “basket of deplorables” comment. 

 

Obama’s version of talking about the attitudes of white voters with limited educations who are suffering increasing despair and reacting with increasing hostility toward the intellectuals in coastal cities and in high tech was not quite as dismissive as Hillary’s statement, but it was a mistake that made him more sensitive to a problem that we have still failed to solve. America is divided in many ways, but one of the most significant ways it is divided is between what we have come to call the Trump base, and the progressive intellectual establishment. There is not a perfect match between the core of Trump’s base in the “red states” and those whom we have identified as potential victims of the “diseases of despair” but there is significant overlap of the populations. 

 

Here is a summary of what Obama said about what he called his “biggest mistake” of the campaign. (If you have the book, I am on page 144.) Between his speech on race and when he eventually denounced Wright, Obama spoke to an influential group at an exclusive fundraiser in San Francisco. He was tired and it was late after an evening of mingling with the rich and powerful. The gaffe occurred during a question and answer period after all of the socializing when someone in the audience asked him to explain why he “thought so many working-class voters in Pennsylvania continued to vote against their interests and elect Republicans.”

 

Obama tells us that he had answered the same question many times before by saying that he thought it was a mix of economic anxiety, frustration with a seemingly unresponsive government, and legitimate differences on social issues like abortion that pushed them to vote for Republicans. As in the past, had he left it there things would have been fine, but this time he went further. He says that for whatever reason, fatigue, impatience, whatever–for reasons he can’t explain–this time it came out differently. He said:

 

You go into some of these small towns in Pennsylvania, …and like a lot of small towns in the Midwest, the jobs have been gone now for twenty five years and nothing’s replaced them. And they fell through the Clinton administration and the Bush administration, and each successive administration has said that somehow these communities are going to regenerate and they have not…

 

So far so good, but here comes the error. It is one sentence that could have ended his chance for the presidency and the impact still lives with us:

 

So it’s not surprising then that they get bitter, they cling to their guns or religion or antipathy toward people who aren’t like them, or anti-immigrant sentiment, or anti-trade sentiment as a way to explain their frustrations.”

 

There was a reporter from the Huffington Post present to document the event. She recorded the statement and reported it. You might remember the fall out. I do. Obama now says, 

 

Even today, I want to take that sentence back and make a few simple edits. “So it’s not surprising then that they get frustrated,” I would say in my revised version, “and they look to the the traditions and way of life that have been constants in their lives, whether it’s their faith, or hunting, or blue-collar work, or more traditional notions of family and community. And when Republicans tell them we Democrats despise these things–or when we give these folks reason to believe that we do–then the best policies in the world don’t matter to them. 

That’s what I believed. It’s why I’d gotten votes from rural white voters in downstate Illinois and Iowa–because they sensed, even when we didn’t agree on an issue like abortion or immigration, that I fundamentally respected and cared about them. In many ways they were more familiar to me than the people I spoke to that night in San Francisco. 

And so I still brood about this string of poorly chosen words…The phrases “bitter” and “cling to guns or religion” were easily remembered, like a hook in a pop song, and would be cited deep into my presidency as evidence that I failed to understand or reach out to working-class white people, even when the positions I took and policies I championed consistently indicated the contrary. 

 

The issue is the impression of a lack of respect,interest, and understanding that creates distance and estrangement. The pain is even greater because even though he said that his words were not a true representation of his attitude, it was how he was perceived. It is a national problem, and the problem has persisted through Mitt Romney’s comment about the “47 %” in 2012 and Hillary Clinton’s comment in 2016. The gulf has widened and will be the single greatest challenge to any success that Joe Biden might hope to achieve. In our society “to be understood” is the responsibility of the speaker. 

 

As these thoughts were rolling around in my head and I was heading down a long hill toward home I heard my phone ring. I had just paused at the top of the hill to take a picture of the evening sky and Mount Sunapee that you can see in the header of this letter. I had paused Obama’s words on the audiobook to take the picture. I usually do not answer my phone on my walks unless I recognize the caller. When I saw the number on my phone I recognized that it was another attempt by one of my medical school classmates to contact me. He had tried before while I was still on my RV trip and left a message which I had not gotten around to returning. He had even sent me a long email which contained the reason for my delay in answering:

 

What else is the point of me appearing out of the misty depths of 50 years besides genuinely wanting to connect and understand how life is going for you?  Full disclosure: I am also reaching out on behalf of our HMS ‘71 Reunion Committee to encourage you to consider making a gift to support HMS.  Over the years I’ve found that fellow HMS graduates usually are very supportive of various charities in their local communities.  So I’m shamelessly optimistic in writing to you to consider contributing to the Medical School for 2021.

 

I am not very good with long term relationships, and I hate being asked for money which I knew was a central reason for the call. My emotional response was that HMS has money in bags–my charitable dollars can find a needier home, but I really did want to talk to my friend because of all the people in my class there was no one that I felt more in tune with than this great doctor who had been a good friend so long ago. Our only contact over the last fifty years has been at a couple of class reunions, and when he appeared at a speech I gave at the Mass Medical Society way back in 2012. We have both been busy with practice, organizational responsibilities, community activities, and our families. Without much other thought I took the call, and heard a voice that had not changed in the 53 years since I first heard it. 

 

My classmate and I spent a while catching up before we covered the business of the call. I agreed to give some thought to making a contribution and promised to fill out the questionnaire reporting what was going on in my life before the deadline in early December. Then the conversation drifted back to retirement issues, family reports, where we were living, how we were spending our time, and the recent election and its potential impact on medical practice. Somewhere along the line I repeated some of the ideas I had just published in the letter that had come out less than two hours earlier. And then I asked him if he realized that part of the explanation for who we had become was that we were graduates of a program that Dr. Robert Ebert had hoped would produce socially responsible physicians. I told him that several years ago I had learned of the speech that Dr. Ebert had given a few weeks after we had started at HMS in the fall of 1967. He did not know of Dr. Ebert’s speech which had described how important he believed it to be to prepare medical students for the challenges of providing care to rural and minority populations in the inner city as well as train hospital based academics. After a terrific conversation we agreed to get together after the pandemic and the call was over. When I got home I sent him the url to Dr. Ebert’s speech which is in the reference section of my website. Here it is for your reference. 

 

http://strategyhealthcare.com/the-kate-mcmahon-lecture-delivered-by-dean-robert-h-ebert-md/

 

I was surprised when he wrote back:

 

Thank you, Gene.  After helping…today with the pre-Thanksgiving food prep, I finally had the chance this afternoon to enjoy reading both your “Looking Ahead with Thanks and Hope” article as well as the stunningly prescient lecture by Dr. Ebert.  Looking back 42 years when I set up my solo practice, I can see how I was caught in the crossfire of the tectonic shifts that he described just 11 years before…I was immediately crazy busy and chronically overwhelmed by providing alone every detail of fairly high level inpatient care while simultaneously seeing the avalanche of people who showed up at my office door 7 days a week.  Before [my hospital]…became a regional tertiary care facility, I was doing things such as giving IV vincristine to a child with leukemia over the lunch hour in my waiting room at the direction of an oncologist based at Boston Children’s.  From today’s perspective that is unbelievable!  But I never had time to take a breath or, as Dr. Ebert said, even consider that there might be a better way of delivering excellent medical care on a community wide basis by involving many more stakeholders than just the solo physician who would vacuum the floors in the morning and take out the trash every evening!    

 

The shackles began to fall from my eyes when terrific partners came along and especially when I started 5 years of night classes to get an MPH and consider larger questions.  As bad as the setbacks by Trump have been in these past four years, it’s important to acknowledge that we have come a very long way in the past 50 years in delivering much better medical care, with greater dignity, to many more people.  We still have a very long way to go.  But the foundation is laid, the progressive concepts are part of the national dialogue, and, as you wrote, the arc of our history does bend very gradually toward justice.

 

I was deeply moved by his words. He has spent over forty years practicing in a relatively small New England town where he faced many of the challenges that Dr. Ebert had described. His work was hard. His hours were long. But he was not burned out, and the response I got when I asked if I could share his letter reinforced my impression that his life had been filled with the joy that can only come from giving care, from being an essential member of a community. 

 

It’s certainly fine to use what I have written either with or without attribution, Gene.  

To expand on Dr. Ebert’s observation that most doctors were happy to give free care in the pre-Medicaid days, it was at best a complicated issue.  As an example, when I started the practice I got a call from a large group home…that served children and teenagers with severe behavioral problems.  When I said that I’d be happy to see them, the administrator was thrilled.  I even received a lovely note from him about this 40 years later when I began to slip into partial retirement! … these kids …were difficult,…if they had any insurance at all it would all [be] screwed up and you usually did not get paid.  I didn’t care because I was having an exhilarating time every day, and I was making what I considered lots of money from the patients who did pay their bills….

 

Those days in the past century in medicine were really tough on families….The truth was that, even though it was overwhelming, I was addicted to the thrill and pace of my work.  I had trouble falling asleep some nights because I was so excited in anticipation and wonderment about what the next day would bring.  I really loved every minute regardless of how exhausting – or how terrible for the family.

 

The truth also is that the feminization of medicine in the past 50 years is a very good thing for women and men alike, and especially good for our children and families.  The buzz of constantly being on call and the thrill of figuring one problem after another is not a desirable or sustainable model for our modern world.

 

The exchange of letters has reassured me that we are still on the same page and have lived lives and had careers that underscore what has been enduringly good and rewarding in the practice of medicine even though we recognize and applaud the need for much more change. Change is slow and I am increasingly convinced that the continuing changes that my classmate recognies occur in a complicated dance with the basic issue that Obama addressed in his lament about his campaign gaffe, his deep regret that …the phrases “bitter” and “cling to guns or religion” were easily remembered.

 

Obama’s rapid rise to the presidency can be traced to his famous speech at the 2004 Democratic convention. At the time he was a state senator from Illinois but the very likely winner of the US Senate seat from Illinois in the November election. At that time he said:

 

It is that fundamental belief: I am my brother’s keeper, I am my sister’s keeper that makes  this country work. It’s what allows us to pursue our individual dreams and yet still come  together as one American family. E pluribus unum: “Out of many, one.”…

Now even as we speak, there are those who are preparing to divide us ­­ the spin masters,  the negative ad peddlers who embrace the politics of “anything goes.” Well, I say to them  tonight, there is not a liberal America and a conservative America: There is the United States  of America. There is not a Black America and a White America and Latino America and Asian America: There’s the United States of America.

…the pundits like to slice­ and­ dice our country into Red States and Blue States;  Red States for Republicans, Blue States for Democrats. But I’ve got news for them, too. We  worship an “awesome God” in the Blue States, and we don’t like federal agents poking around  in our libraries in the Red States. We coach Little League in the Blue States and yes, we’ve got some gay friends in the Red States. There are patriots who opposed the war in Iraq and there  are patriots who supported the war in Iraq. We are one people, all of us pledging allegiance to the stars and stripes, all of us defending the United States of America.

 

The “one America” is an ideal that people like my classmate believe in. It is a major part of the  motivation that drove Dr. Ebert to give his speech about evolving our healthcare delivery system so that it could provide equivalent care for every American. Obama was upset about his gaffe four years after his speech because he knew that we were still on the journey toward one America, and his comment had been understood as a demonstration that we were not there yet, and that maybe he was not the person to get us there or even convince everyone that it was a noble destination. 

 

I have come to realize that my efforts as a medical leader fell short of my hopes and expectations because I was focused on policy and performance as the path to the Triple Aim and did not pay as much attention as I should have to the divide in America and our responsibility as caregivers to address that reality. Ron Heifetz has pointed out that technical change is much easier than adaptive change that requires emotional growth or the development of cultural awareness. Societal change can’t just be the domain of politicians and philosophers. Healthcare professionals have the experience form practice to be leaders in moving us toward “one America.” Better policy and improved performance are necessary but insufficient. They must stand on a foundation of empathy, a desire to understand others, and mutual respect. Like my classmate I regret that at times my efforts robbed my family of the time and attention that they deserved. Obama makes this same lament again and again.

 

My classmate, as I have known him and as his words now and his career demonstrate, has lived a professional life that demonstrates what the Greeks called agape and what Adam Smith called “fellow feeling” in his book The Theory of Moral Sentiments. In medicine it motives us to follow Francis Peabody’s admonition that the care of the patient requires us to care for the patient. It feels to me like many many healthcare professionals have boundless empathy, agape, or fellow feeling as individuals, but we have a great deal of difficulty coming together with those sentiments to create durable change in our institutions. Eve Shapiro has recently pointed out to me that we say that Black Lives Matter, but it is hard to see how we demonstrate that by programs that will develop more Black physicians. Our good intentions perhaps are overwhelmed by the enormous divides that consume so much of our energy and thwart so many of our efforts. 

 

Sometimes we are sidetracked by our personal ambitions. There are plenty or legitimate excuses to provide us cover, but we all live with the realities of our collective failures. The same failures that exist in our local institutions and practices are present in our wider society. Even though we say that we need to create change that would improve the social determinants of health, accept that Black Lives Do Matter, reduce the inequities that hold back individuals as they harm us all, and even threaten us in our shared home, this planet earth, we have a hard time moving the focus from the individual to the community. We hardly know where to start the work.

 

It is distressing to realize that we have lost ground over the last four years. We are more divided than ever. In his column yesterday, which was unfortunately titled “The Rotting of The Republican Mind” David Brooks traced much of what divides us to the rejection of science and facts as the basis for discussion, compromise, and eventual progress. What has emerged he maintains is a conflict between facts and conspiracy theories. The result is the division and stalemate that is likely to continue to plague us and prevent progress where progress is sorely needed like in our delivery of healthcare. 

 

He begins his essay with a statement followed by a question:

 

In a recent Monmouth University survey, 77 percent of Trump backers said Joe Biden had won the presidential election because of fraud. Many of these same people think climate change is not real. Many of these same people believe they don’t need to listen to scientific experts on how to prevent the spread of the coronavirus.

We live in a country in epistemological crisis, in which much of the Republican Party has become detached from reality. Moreover, this is not just an American problem. All around the world, rising right-wing populist parties are floating on oceans of misinformation and falsehood. What is going on?

 

The remainder of the essay is essentially his answer to his question. In the answer he goes back over the same issues to which Obama was referring in 2004 and again in a less positive way in 2008 with his gaffe. These are the issues that have plagued my classmate, me, and other healthcare providers for so long, and they are the issues that limit our success and continue to undermine the experience of providing care and receiving care. Talking about patient centered, safe, effective, efficient and timely care goes nowhere unless the conversation begins with a commitment to respect, understanding, and fellow feeling that can bridge the widening chasm of the inequity, misunderstanding, and disrespect in our society that was reflected in this election and its disturbing aftermath. 

 

In his analysis Brooks gets to some of the same divides that Dr. Ebert, Obama, Don Berwick, and Angus Deaton have described in their work:

 

While these cities have been prospering, places where fewer people have college degrees have been spiraling down: flatter incomes, decimated families, dissolved communities. In 1972, people without college degrees were nearly as happy as those with college degrees. Now those without a degree are far more unhappy about their lives.

People need a secure order to feel safe. Deprived of that, people legitimately feel cynicism and distrust, alienation and anomie. This precarity has created, in nation after nation, intense populist backlashes against the highly educated folks who have migrated to the cities and accrued significant economic, cultural and political power. Will Wilkinson of the Niskanen Center calls this the “Density Divide.” It is a bitter cultural and political cold war.

 

All of this leads me to say that we can not begin to improve healthcare, build America back better, or even efficiently end this pandemic and avoid the ones that will surely follow without going back at least to the place Obama thought we had established in 2004 when he said that there was only one America. We will always have differing opinions, and there will always be those who have more than others, but we must at least get back to the place where we begin with the shared respect and consensus on the facts that allow for productive conversation. Or as Brooks says at the end of his essay:

 

The only solution is to reduce the distrust and anxiety that is the seedbed of this thinking. That can only be done first by contact, reducing the social chasm between the members of the epistemic regime and those who feel so alienated from it. And second, it can be done by policy, by making life more secure for those without a college degree.

Rebuilding trust is, obviously, the work of a generation.

 

Dr. Ebert gave his speech 53 years ago. My classmate began his solo practice that became a robust group practice on principles  consistent with that speech over forty years ago. We have had the concept of the Triple Aim for almost as long, and in its current form since 2007. Crossing the Quality Chasm was published almost twenty years ago. The ACA was passed a decade ago. Obama’s presidency is now a memory and source for reflection and education. Fellow feeling has been under direct attack for a long time, and the great threat of mutual contempt has controlled our government for much longer than the last four years. The road ahead requires that we go back and repair much of what has been lost over at least the last quarter century and especially the last four years, but even those remedial steps will not produce success unless we recommit ourselves to the journey toward respect and opportunity for everyone no matter where they live, who they love, their gender, their ethnicity, or their core beliefs. I agree with Brooks that there will be no quick recovery. I also agree with Obama that the possibility of “a promised land” still lies ahead. It is time to resume the journey.

 

Be well! I hope that you enjoyed  a very special, and very safe Thanksgiving! Anticipate your vaccination next spring in a way that will allow you to tolerate wearing your mask and continue to practice social distancing as best you can until the vaccine is a reality. Look for opportunities to be a good neighbor. Let me hear from you. I would love to know how you are managing the uncertainties of our times.

Gene