October 27, 2023
Dear Interested Readers,
A Very Bad Week
Late Wednesday night I turned off my computer after having written most of the first draft of this letter to you. Most evenings my wife and I watch the local 11 PM news for a summary of the day’s events, the weather forecast for the next day, and the latest sports scores before watching Stephen Colbert lampoon Donald Trump and other buffoons in public life. I was expecting to hear reports about the far-right congressman who had just been elected Speaker of The House earlier in the day and learn some more about Trump’s juvenile behavior during his fraud trial in New York.
We joined the program a few minutes late and it was immediately obvious that something big had happened. My first reaction was that Israel’s ground invasion of the Gaza Strip must have begun. We always record the news so we ran the tape back to the beginning and were horrified to discover that there was a mass shooting in a place we know well, Maine.
We have friends in Topsham, Maine which is less than 20 miles from Lewiston, the site of the tragedy, who have relatives who live there. A close friend is a Bates grad. My granddaughter is a junior at nearby Bowdoin College in Brunswick, and my youngest son and his wife moved to Gray, Maine from Brooklyn last year to begin their family while working close to college friends. Gray is less than 20 miles from Lewiston. Last weekend we were in Brunswick which is also about 20 miles from Lewiston. This is the first mass shooting that has come close to my family and friends. The problem of gun violence has come too close.
Mike Johnson, the new Speaker of the House, is a darling of the NRA. He denies that President Biden was elected, and actively worked to keep Trump in office. He wants to ban all abortions–period. He is against gay marriage and would make it illegal if he could. As further evidence of his position on the far right, he denies the fact that fossil fuels contribute to global warming. It has been a very bad week.
One of my favorite journalists is Nicholas Kristof of The New York Times. Kristof has written many articles on a variety of international issues. He is an advocate for universal healthcare and has written movingly about the social determinants of health and diseases of despair based on the outcomes of childhood friends in rural Oregon. He has also written some of the most common sense articles about our addiction to killing our neighbors with assault rifles. His political stance is the polar opposite of the new Speaker of the House if that makes any difference. Thursday morning, just hours after the shootings while the shooter was still on the run Mr. Kristof republished his excellent suggestions about how to improve our epidemic of gun violence. With this latest restatement of his common sense suggestions, he added an updated introduction, most of which I have copied below because it frames the question effectively and calls for an alternative approach of treating the vexing problem of our addiction to guns and the mayhem they produce as a public health problem. I have bolded some of Kristof’s thoughts that really resonate with me. Mr. Kristof is a member of the “educated coastal elites” who are politically progressive and the natural enemy of proponents of the expansion of our Second Amendment rights, but since he grew up in rural Oregon where guns are an accepted and sometimes necessary part of life and agriculture, I think he understands the problem from both sides. His suggestions have merit. He writes:
Once again the United States is seared by screams, shots, blood and sirens, followed by politicians’ calls for thoughts and prayers. Details are still emerging from a mass shooting in Maine, leaving Americans asking once again: What can be done to break the political stalemate on gun policy so that we can save lives?
This essay was originally published in January, 2023 after two mass shootings in California claimed 18 lives. But the issue remains tragically relevant, and it will continue to be until America adopts smarter policies for firearms. This toll from our guns — by our inaction, we make it our choice.
For decades, we’ve treated gun violence as a battle to be won rather than a problem to be solved — and this has gotten us worse than nowhere. In 2021 a record 48,000 Americans were killed by firearms, including suicides, homicides and accidents. So let’s try to bypass the culture wars and try a harm-reduction model familiar from public health efforts to reduce deaths from other dangerous products such as cars and cigarettes.
Harm reduction for guns would start by acknowledging the blunt reality that we’re not going to eliminate guns any more than we have eliminated vehicles or tobacco, not in a country that already has more guns than people. We are destined to live in a sea of guns. And just as some kids will always sneak cigarettes or people will inevitably drive drunk, some criminals will get firearms — but one lesson learned is that if we can’t eliminate a dangerous product, we can reduce the toll by regulating who gets access to it.
That can make a huge difference. Consider that American women age 50 or older commit fewer than 100 gun homicides in a typical year. In contrast, men 49 or younger typically kill more than 500 people each year just with their fists and feet; with guns, they kill more than 7,000 each year. In effect, firearms are safer with middle-aged women than fists are with young men.
We’re not going to restrict guns to women 50 or older, but we can try to keep firearms from people who are under 21 or who have a record of violent misdemeanors, alcohol abuse, domestic violence or some red flag that they may be a threat to themselves or others.
Early reports from Maine have included the fact that the alleged perpetrator was recently discharged from a mental health facility where he was sent for two weeks after demonstrating paranoid behavior and making threats of gun violence. Does it make sense that a person with that recent history is allowed to have a gun? I am sure that we will learn more in time. I am also afraid that there will be moss on my tombstone before a common sense gun policy like the one Kristof advocates is universally adopted in this country where the ability to kill whomever you want whenever you feel like it is considered to be enshrined in the Bill of Rights by pandering politicians.
My Story Continues: My Early Experience In Governance With A New Hero and Mentor
The chapter of my story last week described the wonderful experience I had between 1979 and 1985 developing a community hospital cardiology program with my colleague, Dr. Mark Stockman. The experience ended unexpectedly when Harvard Community Health Plan accepted an offer to move all of its hospital care including care appropriate to a community hospital to the Brigham and Women’s Hospital. Our contract to provide coverage for cardiac services in HCHP’s little hospital on Parker Hill ended rather abruptly and we moved from being part-time contractors to being full-time employees. As I mentioned, Mark was chosen by management to be the new “Chief of Cardiology.” Moving from a horizontal to a vertical relationship with my friend was hard for me, but what I did not know at the time was that the transition would open new and more interesting doors for me. Near the end of last week’s letter, I wrote:
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.
That advice sounded good when the corporate shrink said it, but when I was alone with myself, I wondered, “So what do I do?” Fortunately, there was one opportunity open to me that did not require getting the approval of the management of HCHP, an elite group that must have had some concerns about me.
As I wrote earlier, before 1977 the physicians of HCHP were a group practice. We were much like the Permanente Medical Group that provides Kaiser with its medical staff. The laws of California do not allow the corporate practice of medicine so it is impossible for what happened to the physicians who provided care to HCHP in Massachusetts to happen to the doctors who work in the Kaiser facilities in California. As the website of the California Board of Medicine states:
BPC, section 2400, states, in part: “Corporations and other artificial entities shall have no professional rights, privileges, or powers.” This section of the law is intended to prevent unlicensed persons from interfering with, or influencing, the physician’s professional judgment.
That accurately states the basis of what was my ongoing conflict with the “suits” that took over the management of HCHP after we were converted to a “staff model” HMO. If there was ever any real “moral injury” for me in practice it was my continuing concern that what I could do for patients would be curtailed by some business decision. Once HCHP became as much or more a provider of health insurance as a direct provider of patient care I felt that there would always be a looming risk of something that I now have the language to describe as “moral injury.” It should not surprise you that after the physicians exited Harvard Pilgrim Health Care in 1998 to become Harvard Vanguard of which I was the original board chair and later the CEO, I developed ties with the leadership of the Permanente Medical Group and was invited to attend many of their retreats where their long experience was a welcome support.
But, I am getting ahead of my story. Originally, HCHP was offered through a relationship with Blue Cross of Massachusetts. After the HMO Act was passed in 1973 we began the process of creating our own insurance offering. Unlike Kaiser, the management and board favored becoming a staff-model HMO. The idea needed to be negotiated and sold to the physicians because it required a change in our status. I objected as vociferously as possible, but I was not very effective. I was a relatively new member of the group. My clinical skills were appreciated, but I think I was considered to be not aligned with the mainstream thinking because of some of my random comments at organizational meetings when I began to be concerned that a decade into Dr. Ebert’s experiment we were losing touch with some of the ideas that had drawn me to the practice and which were so aligned with my own moral sensibilities.
Ultimately, the proposal passed after some money was indirectly added to physician retirement accounts, and a new committee of the HCHP board was created which was entitled “The Physician Council.” The Physician Council was given two seats on the HCHP board, one for the chair of the council and one for another member elected by the council from its membership. Even more strategically important was that the council was given a list of fourteen rights and responsibilities. Those bylaw rights were treated perfunctorily until I became the chair of the council, but I am getting ahead of my story again.
There was some real power in those responsibilities which included participation in the selection, review, and renewal of contracts for the CEO and the CMO. Both of those positions had five-year terms, which theoretically gave the doctors the ability to remove the CEO or CMO. The chair of the council was also a member of the management committee of HCHP with the responsibility of representing physician interests. The council had the responsibility of approving and credentialing any medical facilities and hospitals that the plan might use as it expanded. It had to approve the creation of new practice sites. There were some other duties, but perhaps the one that was most critical in the minds of many of the physicians was the fact that the Physician Council negotiated and approved the compensation program for physicians.
By 1985, HCHP had expanded from its original site in Kenmore Square to many neighborhoods in greater Boston including Cambridge, Wellesley, Medford, downtown Boston (on Milk Street in the heart of the financial district), and Braintree. By the early nineties, there were fourteen practice sites. Each site had primary care, behavioral health, medical and surgical specialties, a lab, visual services, radiology, and a pharmacy. Each site was represented on the council.
I had run for a seat from Kenmore in the early 80s which was the location of my primary care practice. That election was even before we lost our contract and the effort was motivated by my disagreement with the process that had made us a staff model HMO and my fear that eventually, the doctors would lose their clinical autonomy. It was a three-way race that unseated the incumbent who was one of the original doctors when the plan opened in 1969 and had advocated for the transition from the group practice to the staff model. He lost, but so did I. Not too long after the corporate shrink suggested that I focus on policy and governance, I had a second chance to run for the council. The previous winner from Kenmore decided not to run again, and I was the only person who elected to run. Perhaps by the mid-eighties, the council did not seem critical to the practice since it had “rubber-stamped” most of what management did and HCHP was riding a wave of growth and clinical success. By that time Don Berwick was establishing us as a national leader in quality and safety. We had over 200,000 patients and were opening sites all over the greater Boston area.
When I joined the Physicians Council a very experienced pediatrician, Dr. Paul Solomon, from our Cambridge site was the council chair. Honestly, before I got to know Paul I thought that he was a corporate “pupit.” Paul was older and had enjoyed a very successful practice in Belmont, Massachusetts before joining HCHP. He was very community-oriented and had all of the sensibilities of a doctor who was loved by patients and very respected by other physicians. As the leader of the council, he had become a respected member of the HCHP board and the management committee. From a distance, it looked to me like he was “sucking up” to management, some of whom I thought had made life complicated for my hero, Joe Dorsey.
At first, to say it most objectively, I did not appreciate Paul’s talents or his wisdom. In fact, I sort of saw him as one of the problems with the practice that I wanted to change, but my eyes were on the second board seat that was available to one of the council members. That seat was also open, and I decided to throw my hat in the ring. When the votes were counted I had eight votes and a woman who was a psychologist had eight votes. Paul asked us each to give a speech about our objectives and why we thought we should be given the opportunity to represent the physician group on the HCHP board. I don’t remember exactly what I said, but I think that I must have sounded a little like Matt Gaetz sounds in Congress these days. I certainly presented a laundry list of my concerns about the current management and board. When the votes were counted either something that I had said or the presentation of my opponent had convinced two council members to change their vote. My flame-throwing was not very strategic. I lost ten to six. My consolation prize was that when no one else volunteered I became the secretary of the council.
My clumsy efforts at producing council minutes brought me into very frequent and close contact with Paul, and through that contact, my opinion of him changed. I saw that he did value the same things that I did, he was committed to clinical autonomy and improvement just as I was. He just realized that he could best defend the practice by picking and choosing his battles. I was ready to fight with the least hint of a change that seemed antithetical to our mission. Paul began to soften some of my attitudes, and I began to appreciate his commitment to our practice and to care that was patient-centered with principles of equality, safety, and quality at the core of everything we did.
Paul is now in his late 90s. After he retired in 1998, he went on to serve as a selectman in his hometown of Belmont, Massachusetts for many years. While doing a little Internet research I discovered that he and his wife Phyl had done an oral history in 2019 as part of a “Belmont Story” project at the Belmont Library. It is pure Paul. I recommend it to you. He has not changed in the many years since I last saw him and the picture shows him looking quite good in his 90s. In the conversation, he relates that he always thought he was more effective as a listener than as a speaker. I would agree, but would add that somehow he had the ability to have others say what he thought needed to be said.
I was surprised one day when Paul said that he wanted me to have more direct contact with the management team. He thought that I could represent the practice quite well as the chairman of the compensation committee. He reasoned that The Tax Reform Act of 1986 would have a significant impact on the salary and benefits structure that had been enjoyed by physicians that had not been extended to other employees. Big changes would be required as we lost our status as “special employees,” especially in terms of our benefits if we were to be in compliance with the new law.
Doctors are pretty independent thinkers on any subject. The reference is made frequently to the fact leading doctors is like “herding cats.” I quickly came to realize that employed physicians in the late 80s agreed on one thing, they didn’t think that they were fairly compensated. As chairman of the compensation committee, I could call for a groupwide conference to discuss compensation and expect four hundred doctors to attend when only half that number would attend our annual awards dinner. Behind the scenes, Paul was guiding me during the negotiations while giving me enough freedom to learn from my mistakes and occasional successes. What I did not appreciate until we had been through the process twice was that he was grooming me to take his place. He was constantly coaching me. One of his favorite maneuvers was to form a “T” with his hands and give me a wink and a smile when it was time for me to shut up and listen to what management had to say. He really did believe that the ear was more effective than the tongue.
By 1990, Paul was ready to give more time to his practice and to accept a part-time job as the leader of our physician recruitment efforts. In the turbulent early 90s at HCHP, he was always available to me. When he eventually retired, we established an award in his honor, The Paul Solomon Leadership Award, that was presented every year at our awards banquet.
Next week, the story will continue as I assume the position as the chair of the Physician Council and a member of the Harvard Community Health Plan management team and its board of directors.
The Bird Mystery
As I have recorded in these weekly letters, it has been a very strange summer. We never needed to water our lawn or garden this summer because it was rare for three days to pass without rain. The fall colors are slowly improving as you can see from the picture in today’s header. The best color year in and year has been sported by the lovely Japanese maple in my front yard which you can see in the picture below. This lovely tree has finally turned to flaming red at least two weeks later than usual after a tough summer during which a heavy storm cost it one very large limb.
The strangest occurrence of the summer was the fact that during much of late August, September, and late into October there have been no birds at my bird feeders. The normal state of my birdfeeders is to be covered from dawn to dusk with chickadees, titmice, nuthatches, yellow finches, purple finches, woodpeckers, cardinals, blue jays, various non-descript “brown birds,” and even an occasional rose-breasted grossbeak. I was even forsaken by the hummingbirds and there were no doves wandering around on the lawn doing whatever they usually do. I thought that perhaps my birdseed had gone bad. I bought new seeds and cleaned the feeders, but there were still no birds. I was somewhat relieved when my neighbor told me that there were no birds in her yard either.
Normally, I see three to five hummingbirds dive-bombing each other at their feeder almost continually during the summer, but not recently. I did see one ruby-throated fellow getting a snack from some purple flox near my bathroom window one morning while I was brushing my teeth. I had a moment of hope that perhaps things were changing, but then nothing changed.
My usual summer concern has been the bears which will occasionally make a visit at night, but at times they even come during the day to trash my feeders for a snack. I really knew something was wrong when I realized that all the squirrels and chipmunks were gone. I wondered what was wrong. I was greatly relieved when my wife discovered a post on Facebook with the explanation for this strange summer. Since I have confirmed the Facebook post with a couple of articles on the Internet. An article on “Maine Birdfeeding Notes” was entitled “Why There Are So Few Birds at Your Feeder (Sept-0ct. 2023 Edition).” the article began with reassurance that I wasn’t crazy. I was just obsessed.
…While I don’t want to talk you out of being concerned about the general welfare of all birds, I want to assure you that what your feeders are experiencing right now is nothing to be worried about. It’s impacting our enjoyment, yes, but it’s not a bad thing for the birds!
The most important thing to remember is that birds always prefer natural food sources (our feeders are only a helpful supplement) so if they can find what they need in their natural habitats, they do not need to visit our feeders nearly as often…
That reassurance was a relief, but even more helpful was the explanation for what I had observed. The answer has two parts. First, this just happens. It has happened before. Second, is the weather. There has been so much rain that there is a superabundance of the natural foods birds enjoy in the woods. They don’t need to come to my feeder. They are doing just fine in the woods. I was further reassured when I found a second article that gave the same explanations.
Information on the Internet can be wrong even when it is reassuring, but what I read gave me hope. This week a few birds are back. The titmice were the first to return. Then I saw a couple of chickadees and a downy woodpecker. I also saw a little chipmunk. So there is hope. I never thought I would look forward to seeing a squirrel hanging from one of my feeders, but it’s been so strange that even a hanging squirrel would be a relief!
There is a lot to learn in the natural world. I hope that you will be out and about to see what you can see this weekend. I’ll be looking for more birds.
Be well,
Gene
