October 20, 2023
Dear Interested Readers,
Back To My Story
Last week I took a break from the story of my professional development to comment on the conflict between Hamas and Isreal and to review a New England Journal of Medicine article entitled “A Reason to Retire” by my former Atrius Health colleague, Dr. Neil Berman. I was horrified by the potential for further catastrophic events in Israel. I was dismayed and concerned about the long-term ramifications of our near-term political dysfunction in the House of Representatives.
Neither problem has been resolved and we all hold our breath as we try to factor in how these two issues will impact the support for Ukraine and push any political conversations about the social determinants of health and healthcare policy toward the bottom of a growing list of political concerns. In the midst of all the international turmoil, we were shocked to learn that the 1984 Olympic Gold Medal Winner, Mary Lou Retton, was severely ill in a Texas ICU and had no health insurance.
Her daughters did what many families do when they face large medical bills. They made an online request for donations. How does it happen that anyone from an Olympic Gold Medal winner to a less fortunate and totally unknown American living in poverty needs to ask for charity to cover a large medical bill? My guess is that someone living in any of the other G-20 countries would find both cases hard to understand. Another guess is that in our state of divided government, a substantive resolution of the medical expense issue will not be resolved during my remaining years. We seem further from the resolution of many issues ranging from adequate housing to adequate healthcare for all Americans than we were a decade ago when the ACA was launched amid great resistance. Having a non-functioning Congress doesn’t help make things better. It is ironic that many of our citizens who wear red hats suggesting that they want to make America great again seem to advocate for policies that put us behind some third-world countries in the ways we care for one another,
I thought Dr. Berman’s article was a terrific testimony to the impact of training on one doctor’s development of his approach to the doctor/patient relationship, burnout, and the moral sensibilities of practice. It touched on my story. Neil’s piece offered some contrast to the story I had been telling, and although our mentors had given us different philosophies we had ended up in places that if not identical were very compatible.
In a way, last week’s focus on Neil’s article was not a departure from my story, it was a preview of some of what I would describe in more detail in the coming weeks. In last week’s letter, I described how I had met Neil as his practice merged with mine in the mid-nineties. To introduce Neil I made a jump of 15 to 20 years in my own personal story because my introduction to Neil was facilitated by my positions as leader of the physician group at Harvard Community Health Plan and a board member of HCHP and Harvard Pilgrim Health Care after the merger of HCHP and Pilgrim Health Care in January of 1995.
The week before I left my story my account had progressed to the late seventies, I was an organizational maverick needing some help to assimilate into the culture of the practice. You might ask, “What happened between 1977 and 1995 to move you from the periphery of the practice to a leadership position?” How that transition began will be my story for this week.
Near the end of my letter on October 6, I wrote:
…Congress passed the HMO Act in 1973 which created new possibilities and new challenges for our practice that gained increasing momentum that would eventually result in the HCHP physicians evolving from members of an independent medical practice to employees of a non-profit corporation after a drawn-out discussion, interview process, and negotiations in 1977.
The structural change in 1977 had a huge impact on me because, from my point of view, the greatest downside of the process was the end of Dr. Joe Dorsey’s tenure as medical director. I was very upset when Joe went on a leave of absence to develop a road map for the next stage of HCHP’s evolution. I have always thought that the move was a poorly veiled process orchestrated by those interested in a new direction and jealous of his role. Joe handled the situation with grace because his commitment was to the principles of the practice and his patients. Joe will always be my hero. I was quite upset as I realized what was happening. I told myself that Joe had gotten so far ahead of the rest of us that we couldn’t see his tail lights…
I will begin this week’s installment by introducing another professional. Because of our phenomenal growth which was in my opinion largely driven by Joe’s evangelical presentation to multiple community groups, governmental agencies, and local employers of the benefits of our methodology and philosophy of care, HCHP grew remarkably and decided by 1978 that it needed to hire a second cardiologist. The new hire would be my colleague. I had no part in his selection. It was somewhat like an arranged marriage, but when I met my new colleague, Dr. Mark Stockman I was immediately impressed as much by his warm personality as well as by his obvious medical skills. Mark had done his internship and residency at the Beth Israel, had been a fellow of Dr. Bernard Lown, and had spent a year training in non-invasive cardiology at the Mass General. The plan we were given was that Mark would focus his activities at the BI, and I would focus on providing cardiac care at the Brigham. We were quite compatible and our assignments were similar but our paths rarely crossed in the form of any organizational programs.
I have always had a great admiration for Mark’s clinical skills, the clarity of his thinking, and his organizational skills. I am also amazed by his commitment to practice. He is still the heart of the Atrius Cardiology practice forty-six years later!
Mark and I did share tasks and on-call responsibilities. We both read EKGs and collaborated on specific cases from time to time as he settled in and began to learn the ropes of our practice. It was “parallel play” because our practices were focused in different hospitals. In retrospect, we did not spend much time together until 1979. In 1979, things changed dramatically for both of us after Joe Dorsey came back from his leave “to think about the future of the practice.” While Joe was thinking on the mountaintop, he was replaced as medical director. On his return, he began to focus his immense energy on our hospital care while continuing his own very active practice.
Joe came to Mark and me with an interesting proposition. He told us that HCHP had been offered ownership of the Parker Hill Medical Center (PHMC) for $1.00, the assumption of its debts, and the promise to provide support to the elderly general practitioners from the surrounding community as they continued to use the hospital until their retirements.
Parker Hill Medical Center was located on the backside of Mission Hill on Parker Hill Avenue, a few blocks away from the Brigham. Parker Hill Avenue rises precipitously from Huntington Avenue just past Brigham Circle. The “Green Line” trolley stops at the base of the hill and then continues on down Huntington Ave toward the Jamaica Plain VA Hospital, Jamaica Pond, and the Arnold Arboretum. In a short walk of a few blocks, one could walk from the world-leading teaching hospitals of the Longwood Medical Area and Harvard Medical School to a failing community hospital in the midst of an economically distressed community.
A few steps further up the hill from the Parker Hill Medical Center was the New England Baptist Hospital where many of the patients of the Lahey Clinic received their hospital care, and next to the Baptist was the Robert Breck Brigham Hospital which was known for its orthopedic surgery and the expert treatment of joint diseases. The view from the top of the hill is spectacular. Boston and Boston Harbor lie at your feet, and on a clear day looking South you can convince yourself that you can see the entire South Shore and most of the way to Cape Cod. In 1980, The Robert Breck Brigham and the Boston Hospital for Women, both its Lying-In Division and its Parkway Division, would be merged with the Peter Bent Brigham to form the Brigham and Women’s Hospital and move together to a new building on Francis Street. The old Robert Breck Brigham building is now occupied as an extension of the New England Baptist Hospital and the expanded New England Baptist is a leading hospital for joint disease and orthopedic surgery.
Joe told us that we had been given the opportunity to turn the little fifty-bed community hospital into a facility where we could confidently admit patients for secondary hospital care including routine general surgery. We would continue to admit patients who had more complex problems to the Brigham and the Beth Israel. The hospital had a small four-bed ICU which HCHP would fit out with the latest monitoring equipment. Joe felt that with our cardiology presence in the hospital, our surgeons would have more confidence in using the hospital for more complicated surgeries.
Joe added that the move would also offer us the opportunity to create our own non-invasive cardiac testing lab outfitted with the latest echo and stress testing equipment. We would also read all of the hospital’s EKGs. We were already reading the EKGs from the central practice. I was also reading EKGs at the Brigham when I was on service there in rotation with the other members of the Brigham staff. One of us would need to be available to the little hospital at all times. We would also continue to see patients at HCHP ambulatory sites. Another interesting angle was that we would have both Brigham and Beth Israel residents rotating through the hospital and that Joe and Dr. Andy Epstein would round out the hospital coverage and teaching staff.
The most interesting aspect of the offer was that since we would be offering services to some patients whom HCHP did not insure, we should be independent contractors. Joe said that we would have a contract for the work we did at the hospital which would be generous enough to give us the flexibility of hiring some staff and the money to pay other cardiologists to help us with weekend coverage. When we worked in one of the HCHP offices we would be salaried. When we were at the hospital we would be working for ourselves. The idea was interesting and required us to form a company which we named Cardiac Care Associates. The downside for me was that I would no longer have the time to do diagnostic cardiac catheterizations at the Brigham. The first cardiac angioplasties in America were still a few years in the future. To accept Joe’s offer, I was giving up the likelihood of a career in invasive cardiology. Despite that loss, I was excited about the opportunity that Joe was offering to us.
The years between late 1979 and 1985 when HCHP accepted a very favorable contract from the Brigham that was contingent upon closing our hospital were some of my most satisfying years in practice. Mark and I had compatible skills. Mark was a great day-to-day operational manager. I was free to practice, teach, and enjoy expanding the scope of our practice. I particularly enjoyed the annual renegotiation of our contract. We would present the volume of work we had done the previous year along with budget projections for the next year. I would usually get quite animated in the negotiations and at some point, Mark would play the “cooler head” and close the deal.
By 1984 our work had expanded to the point where we decided to hire a third cardiologist, Dr. Geoffrey Hirsowitz, who had also been a Lown Fellow, like Mark. Geof was a joint hire. He worked half-time for Cardiac Care Associates and half-time at the new HCHP site in Medford. I was very proud of the fact of what we had accomplished. Mark and I were given the highest award at the annual awards dinner for the work we had done creating a cardiology program that had made the hospital a great place for care. Even more satisfying for me was when the hospital was recognized by one of the local newspapers for its high levels of quality and patient satisfaction,
As we became successful, HCHP began to plan the expansion of the facility and presented us with blueprints for the work. Construction would be a little complicated because we were literally hanging off one side of a steep hill. You can imagine my emotional response when I learned that without any discussion with us, the managers of HCHP had changed their minds and had negotiated an extremely advantageous contract with the Brigham that would give HCHP long-term discounts if it would move all of its business from our hospital and from the Beth Isreal to the Brigham.
We were told that HCHP would have office space at the Brigham. We would have our own emergency service and our own teaching rotations within the Brigham. We would still have our testing lab which would be moved to some other location. We would be critical to the success of HCHP’s inpatient service at the Brigham, but we would be full-time HCHP employees and Cardiac Care Associates would cease to exist.
I did not like the deal. It may be hard to believe now given the wealth of the Mass General Brigham system, but at that time, the Brigham had financial difficulties. It had a low occupancy rate and a very large mortgage on its new building. Our volume was the solution to their financial problems. I did not trust that the deal would last long after we had lost the leverage that having our own hospital gave us, and in a few years many of the advantages of the deal, including the low rates and our own emergency room, were lost.
Mostly, I grieved the loss of the creative autonomy we had enjoyed on Parker Hill. What made the Brigham deal work as well as it did for as long as it did was the presence of Joe Dorsey. Joe developed a very trusting and collaborative relationship with Dr. Eugene Braunwald, the Brigham’s Chief of Medicine. Dr. Braunwald was the dominant force within the hospital and the entire Longwood Medical Area, especially after he was allowed to be the Chief of Medicine at both the Brigham and the Beth Israel. Without a doubt, he was one of the most influential men in American Medicine. I learned a great deal from him as a resident after he came to the Brigham in 1972, and I always had a good “occasional” relationship with him.
There was no way to “sugarcoat” my sense of loss. One of the associated pleasures that I enjoyed during our years on Parker Hill was that Mark, Geoffrey, and I would enjoy a great five-mile run around Jamaica Pond and other parts of Olmstead’s Emerald Necklace during the lunch hour most days. On those runs, Mark and I, and later when we were joined by Geoffrey, would have long discussions about our goals and plans. We felt like a team. When the change came the organizational leadership rightly deemed that Mark’s skills made him a better choice as the leader of our small cardiology department that needed to find a new “home” for the testing and consultative services that would be an organization-wide cardiac service.
Having Mark named as chief was another loss for me. I had egotistically considered myself to be at least a partner, if not the leader. A year or so earlier the organization had sent us both to an off-site training program for leadership development where I enjoyed being exposed to some management theory and corporate leadership skills, but when I had presented my desire to have a more direct management responsibility I was informed that my skills were really more clinical than managerial. I guess that I had earned a reputation as a maverick or “lone wolf.” In truth, some of our organizational leaders probably considered me to be a “loose cannon.”
A dysfunctional riff developed between Mark and myself. Our continued collaboration was key to the future of the cardiac service at HCHP so Joe or someone arranged for us to have “marriage counseling.” One of the best-known corporate psychologists in Boston was engaged to work with us. We met with him together and alone. It was a good process that redirected me. The process helped me to accept that Mark’s operational skills exceeded mine and that he should have the responsibility as our “chief.” The consultant surprised me when he told me that in his opinion I should set my sights on higher goals. He thought that my skills though not a natural fit for day-to-day management of a small unit were more in line with policy development and organizational governance.
Once again, I was given direction toward the next step in my development. I was denied what I wanted at the moment, but I was directed toward a role where I could have a voice in attempting to preserve Dr. Ebert’s vision even as outside market forces were compelling internal changes that threatened physician autonomy and the quality, safety, and patient-centeredness that were our guiding objectives. Joe was my role model. If he could maintain his long-term commitment to the vision even after internal politics had moved him toward the periphery, I could certainly manage my temporary disappointment and realize that with Mark guiding the continued success of our cardiology practice, I was free to explore where my principles and skills might be best directed. The late eighties would be a period of great change for me as I searched to find a way to follow the advice of the “corporate shrink.” My “old man musings” on my personal story will continue next week.
Fall Is Not A Total Loss
For the past several weeks or perhaps months, I have ended my letters with my complaints about the rain, cloudy days when it’s not raining, cooler than normal temps, and the lack of our usual fall color. I have learned one thing. Everything looks better with more light! This week we have had a couple of days when the clouds parted and things did look much better.
So, I am reassessing my dour remarks about the fall colors. There is indeed a dullness that I am beginning to believe may be enhanced by our endless days with more clouds than sunshine. I have noticed that for those few hours on some days when the cloud cover breaks a little, the colors look better. I also think that the colors are appearing later this year than in the past when they seemed to peak around the early October Monday holiday (Columbus Day or Indigenous People’s Day–your call).
I have a few favorite vistas around town where I go for inspiration. Most of my favorite places have mountain views. I love looking at Mount Kearsarge and Pleasant Lake any time of the year, but no time is better than the fall. I heard on the radio that we were going to have a partial clearing on Wednesday afternoon so I decided to alter my recent bicycle route to include the view from Morgan Hill Road. I hoped that I might get a picture to share with you.
As the name suggests, the road climbs up Morgan Hill. It begins at the intersection of County Road and Little Sunapee Road which was once the site of the Messer farm. The farmhouse came down a few years ago, but the land is still farmed and it will remain permanently undeveloped because it has been placed in the Ausborn Sargent Land Trust. A few hundred yards down Morgan Hill Road on some of the Messer farmland is where Kearsarge Neighborhood Partners has about twenty cords of well-seasoned wood waiting for delivery to families in need this winter.
Down another hundred yards or so is the old Bucklin Farm with its multiple barns and stately antique brick farmhouse. It’s now got a new owner who has got it looking good. Just past the Bucklin Farm, the hard top turns to clay and gravel, and the road gets steep. For the next mile or so there are only three or four houses that probably would sell for millions because they are on large tracks and I assume that their view is one that I could endlessly enjoy.
My viewing point sits in front of an old red colonial that commands an even better view from higher land. My view is across fields that must have been farmed years ago. The land in the foreground of the header for today is no longer farmed or grazed, but the forest has been kept at bay probably to preserve the view for me and whoever owns the big red house.
Just past my viewpoint the road takes a hard left and climbs past several other newer homes that all have great views, but their driveways are probably a real challenge when the snow comes. About a quarter of a mile up from my viewing point, the road ends at one of the trail heads of the Sunapee, Ragged, Kearsarge (SRK) Greenway, which is an eighty-mile circular trek around our region.
Who knows when winter will begin? In years past, we have had a significant dump of snow before Halloween. Winter is the season that comes when it wants to come and lasts as long as it wants to last. Our best strategy is to do our best with what we have. The color is not the best ever, but it is still great. I hope that your weekend will be a fall jewel!
All the best,
Gene
