November 26, 2021
Dear Interested Readers,
Thanksgivings For The Opportunities For Service In Troubled Times
I hope that by now you have experienced a resolution of any Thanksgiving Day indigestion or mental distress that might have arisen from temporary gluttony or from failing to avoid a dinner table argument with an uncle who believes that Donald Trump would still be president if the election had not been stolen. At 6:15 AM yesterday my wife and I boarded the express bus from Lebanon, New Hampshire that delivers you to 42nd Street in midtown Manhattan in about five hours. From there we took an Uber to the Brooklyn apartment of our son and daughter-in-law who live on the far side of Prospect Park.
We are very thankful for our daughter-in-law who recently passed the New York bar and must work today in her new job as a public defender of women and families. Her job is a good fit for a woman who spent several years in the Middle East and stateside working to relocate the refugees of the continuing conflicts that seem never to end. For her previous work with the United Nations and the Episcopal Migration Ministries, her academic success in law school despite the challenges of COVID, and future opportunities she has to help families caught up in conflict, I am thankful. I am sure that she is thankful for the support of our son who has made sacrifices to support her desire to be of help to the underserved in a troubled world as she transitioned from her work with immigrants through law school to her new opportunity for service to women and families.
Another opportunity to witness the service of others that I am thankful for are the activities that I observe caring souls perform through the two non-profit organizations where I participate, Kearsarge Neighborhood Partners (KNP) and Kearsarge Regional Ecumencial Ministries (KREM). These two organizations work directly with individuals and families in need of all types of help including assistance with unpaid bills, help with car repairs, the need for firewood, and assistance with housing and transportation. For many, the work we do is to offer support and help in the navigation of the administrative barriers that make access to our tattered social services safety net a challenge for anyone no matter how many graduate degrees they possess.
The most recent activity of these two organizations that I am thankful for has been their ability to work together to give durable, reliable cars to those without transportation. KNP and KREM have come together to create Kars For Kearsarge. Through the commitment to service enabled by the innovative ideas of one very dedicated woman who is a retired manager from a federal agency, and with the support of the leadership and membership of both organizations an idea has gone from the recognition of a community problem to a shared dream, and finally to reality. Legal barriers were identified and solved, local garages were enlisted, a process to ensure fairness to all applicants was developed, and this past week the first three recipients of cars were identified. The two biggest challenges in a rural environment like ours are affordable housing and transportation. Housing and transportation are big issues in the social determinants of health and any successes in improving either move our community a little bit closer to our own local achievement of the Triple Aim. Improving housing remains a challenge, but I am grateful that now we will be helping many people have the transportation they need to get to work, go to medical appointments, and live with a little more dignity in a community where a car is a necessity for “the activities of daily living.”
A week ago I drove for the last time to a meeting of the board of the Guthrie Clinic which serves the “Twin Tiers” of southern New York and northern Pennsylvania. I have been on the Guthrie board for eleven years! How a doctor and healthcare executive from urban Massachusetts ever came to be associated with a healthcare system that serves a rural and small-town population is a story that also makes me grateful. The origin lies in a relationship for which I am also quite thankful.
While I was chairman of the Harvard Vanguard Board in the late nineties and early two thousands we needed to fill several executive positions including twice needing to hire a CEO. We were fortunate enough after sorting through all of the usual search firms to end up with Carol Emmott, a most remarkable woman with a deep understanding of healthcare going back to her days of working in Jimmy Carter’s White House on healthcare policy as a freshly minted Ph.D. from The University of Oklahoma. Carol had found CEOs for many healthcare systems and had extensive knowledge of the range of talents and attitudes that would contribute to the unique circumstances of each of her clients. Healthcare leaders are not fungible! A genius in one organization can be a cultural and operational dud in another organization. Carol had a knack for identifying the characteristics that were not on the CV that would ultimately determine success or failure. Over more than ten years our organization not only took advantage of her skills but I benefited from an interest she took in my professional development. She would frequently invite me to small conferences that she would organize where healthcare leaders could come together around a table in a small conference room in Washington or some other location to discuss the work of transforming healthcare. I joyfully participated in several of these events that she staged. I took a lot of useful ideas home with the confidence generated by the witness of others that we could also make them work for the benefit of our patients and staff.
One day I received an unexpected call from Carol. She told me that she hoped that I would be willing to join the board of the Guthrie Clinic. I knew of Guthrie’s existence because I had met some of their physicians at recent meetings of GPIN, the Group Practice Improvement Network. I had no idea of where Guthrie was located and was quite surprised to discover on the Internet that its flagship hospital, The Robert Packer Hospital, was located in Sayre, Pennsylvania less than two miles below Pennsylvania’s northern border with New York. I learned that Sayre has a population of a little less than 6,000 but is the center of a cluster of communities in Pennsylvania and New York with a population of about 35,000.
Carol described Guthrie to me as an innovative rural healthcare system that had unique assets and a very good management team that wanted her to find three “outside” healthcare professionals with a national perspective. She recruited me, Doug Hastings, the managing partner of Becker Epstein, a very prominent healthcare law firm in Washington, and on my advice, Ethan Arnold, a healthcare consultant with a national practice whom I had engaged to help us with some of our projects. All of us joined the board together. Doug retired from the board a few years ago and now is the Chairman of the Board of the Bassett Health System centered near his retirement home in Cooperstown, New York. Ethan is continuing to provide great insights on the Guthrie Board. I am thankful for the entire experience that Carol, who died of cancer several years ago, gave me.
My trips to Guthrie were adventures. From Boston, there are two choices by air. You can fly to Rochester and then drive one hundred and twenty miles, or you can fly to Detroit or Philadelphia and then fly to Elmira, New York and drive the thirty miles to Sayre. Over the years I tried all of the options and discovered that I had a bating average below my weight in making the trip without some forgettable travel adventure. After I retired, I decided that flying from Manchester was not worth the effort because it would require difficult connections and it made little sense to add the one hundred-mile drive from my house to Boston before getting on a plane. after which I might need to make another long drive in a rental car. I could much more efficiently drive the three hundred miles across Vermont through Troy, New York, and on to Binghamton, New York on my way to Sayre. It was a predictable six-hour trip through mostly gorgeous scenery while listening to an audiobook. What could be better?
I have no idea how many times I made the trip by air or car, but the experience when I arrived in Sayre or another site where we were meeting like Corning or Ithaca always made the trip worthwhile. Over the course of eleven years, the system prospered. It adopted Lean. It added hospitals in Towanda, Pennsylvania, and Cortland, New York. It won awards for its excellent performance with Epic. It built, replaced, or refurbished many facilities with impressive Lean-designed efficiencies. The CEO through all of this development was a wonderful leader, Dr. Joseph Scopelleti, a gastroenterologist who had come to Guthrie as a house officer in the late seventies and never left until he retired. I am thankful to have known and worked with such a talented leader as Joe, and the very capable group of medical leaders that he attracted to aid him in the effort to continuously improve the care Guthrie provided. Last Thursday the board honored Joe’s leadership accomplishments and my eleven years of service.
On my first trip to Guthrie Joe had proudly shown me a painting. One of the most famous paintings in the history of medicine is “The Doctor” painted by Sir Luke Fildes on commission from Henry Tate in the 1890s. That famous painting now hangs in the Tate Gallery in London. I actually own a little ceramic version of the famous painting. What I did not know was that Fildes had made many sketches and painted several versions of the famous picture before his final famous version. In the 1940s a wealthy grateful patient had presented Donald Guthrie, the Mayo Clinic trained surgeon who founded the Guthrie Clinic, with one of those variations on the famous painting. In the final version, the doctor is observing the patient from the left. As you can see in the preliminary version below, the doctor is on the right. In every other way, the pictures are virtually identical. To my delight, both Joe and I were presented with framed copies of the painting that hangs in the Robert Packer Hospital to honor our years of service to Guthrie.
As I look back on my many trips to Guthrie, I am very thankful for the way the experience gave me a sense of the problems that challenge those who provide medical care to rural and small-town populations. I enjoyed participating in the growth and evolution of Guthrie. Along the way, we had some challenges which were met and resolved. Service to the community and improving the care of the patient were always the motivating drivers for all we did. The care of the patient can not be managed effectively without a very deep understanding of the community where the patient lives. What is plausible in Boston, New York, Philadelphia, Chicago, Houston, or San Fransico will not necessarily work in Sayre, Corning, Elmira, or Cortland. The ACA seeks to lower the cost of care by fostering Improvements as a strategic response to competition, but it requires competition. There is often only one available provider in small-town America. In a rural and small-town environment, improvement requires more self-motivation than the challenge of aggressive local competitors.
Guthrie provides care over a very wide geographical area. East to west from Binghamton, New York to Corning, New York is about seventy-five miles. North to south from Cortland, New York to Towanda, Pennsylvania is also about seventy-five miles. Guthrie’s service area is huge. It covers over six thousand square miles. Staffing and scheduling for offices and hospitals over such a large area and for dozens of primary care, specialty care, and diagnostic activities in small towns is a challenge. Large geographical areas with dispersed populations have problems and challenges that are different from the problems of crowded urban environments. I am thankful for having had the opportunity to observe those realities and learn from what I saw.
Over eleven years you can see many things and meet many people. Will Rogers was famous for saying that he never met a man that he did not like. I met a lot of men and women during my tenure on the Guthrie board. Some were clinicians, some were medical professionals in management positions, some were not clinicians but were just as dedicated to service as they provided their management expertise to the collective effort, and most importantly many were community leaders who were committed to the success of Guthrie and the health of their community. I can honestly say that I never met anyone there whom I did not appreciate and respect. The work they do is important and every last person is committed to bringing the best possible care to the communities of the Twin Tiers. Teamwork is essential to their success. I will miss them all and will miss the scenic drive across Vermont and New York that I enjoyed each time I made my way to Guthrie. All good things end, but I am so grateful that the great experience I had lasted long enough for me to see Guthrie make substantial movement toward the objectives of the Triple Aim.
The list of the things that I am thankful for would not be complete without adding thanks to the person who has the hardest job in America, President Joe Biden. Joe has not been getting the most favorable press lately. He deserves better. He is committed to policies that will improve the social determinants of health for everyone, but especially for our most vulnerable citizens. If work is defined as activity against resistance, Joe is doing some very hard work against ferocious resistance from those who benefit greatly from the continuing inequities in our society. The Build Back Better bill that passed in the House this week was full of compromises that should have led to very wide bipartisan support, but it did not. As the bill moves to the Senate it will face even more aggressive attempts to block its passage or diminish its benefits.
There are few politicians who care about what is right more than Joe. His many years in government have been a very long learning curve toward the belief that government, good government, with policies designed to lift people is possible and worth the struggle to achieve it. I am thankful that we have him as our leader in these very troubled times which have been made worse than they needed to be by a leader who possessed no interest in eliminating inequity and failed miserably to set an example worth following. I am thankful that he is gone although his destructive and divisive attitudes persist in a dangerously large number of his followers. I hope that in time we will learn how to heal our divisions. For the moment I am thankful for at least a brief reprieve from the uncertainties we tolerated for four years.
Phenomenal In Many Bright Colors
I visited Amsterdam in 1969, 1974, and 2013. Some things changed through the years, but a constant reality was that Anne Frank and Vincent Van Gogh remained as two of the biggest draws the city had to offer. In 2013, we were lucky to visit the newly reopened Van Gogh Museum. We stood in line for several hours to revisit the hidden rooms where Anne Frank and her family lived after The Netherlands was invaded by the Nazis.
At some moment on my last visit to Amsterdam, I had a strange thought. The two biggest tourist draws in Amsterdam which probably accounted for billions of dollars of commerce each year for Amsterdam never made a nickel during their lives. They died with no idea that the world would ever care if they lived or had suffered in life. Anne Frank never knew that her diary would be published in over seventy languages and that over seventy-five years after her death hundreds of people would line up every day to see where she lived and wrote as a teenager. Van Gogh’s genius was appreciated by very few people during his 37 years. He may have sold one painting. He went from failure to failure as he descended into psychosis while simultaneously demonstrating that he was a genius that no one appreciated.
A few months ago my daughter-in-law sent us some pictures from the visit that she made with our seven-year-old grandson to the Van Gogh Immersive Experience in San Fransico. The pictures were amazing, and I was immediately disappointed that I had not been able to share the experience. A week or so later my wife learned that the same Van Gogh presentation was being offered in Boston. Today’s header reveals a glimpse of the show. Click here to get a feel for the size and beauty of the experience.
The header shows the immersive experience for “Sunflowers.” Equally impressive was “Starry Night.”
I enjoyed “seeing” Van Gogh in Amsterdam, but I was amazed and thrilled by the “immersive” Van Gogh experience being offered at many sites around the world, and to us in Boston. As I have learned more and more about Van Gogh’s challenges, I have wondered how he would have faired in our world. Would he have fared better or would he be just as lost in our world as he was in his? It’s hard to know. I am sure that he would have been medicated if he presented himself for help now which would be likely since he did ask for help at a mental hospital in his own time. Perhaps before asking for help he would have reached beyond alcohol to other attempts at self-medication that are more available on our streets. Once he asked for help would we have found a way to support his genius or would we have piled even more burdens onto his troubled mind? Are there Van Gogh’s among us now living under bridges, wandering our streets, or waiting for help in our mental health clinics, emergency rooms, or prisons?
My speculations and rhetorical questions are just musings. I am thankful that in his time he was able to produce an amazing amount of art which we now can enjoy despite the fact that in his own time he was mostly ignored. What is also wonderful is that we know a great deal more about him than we do about many others from his time because before he took his own life he wrote more than eight hundred letters to his brother who preserved and published them.
One interesting speculation among the many about such a creative and unusual soul is the idea that he had a defect in his ability to see color! Looking at the amazing display of colors in his art and factoring in his psychosis to the body of his work creates an interesting thought. How much “genius” which we usually consider a “gift” is an expression of what we think of as “disease?”
If The Van Gogh Immersive Experience is available near you, don’t miss the opportunity. Seeing something that is so remarkable ameliorates some of the disappointments of our days. I am thankful that my daughter-in-law brought it to our attention. It’s neat to know that we don’t have to go to Amsterdam to receive the benefits of his gift to us.
I would be delighted to hear what you are thankful for during this season of reflection. I hope that the weather where you are is conducive to some outside activity. So far we have enjoyed two lovely walks in Olmstead’s gift to Brooklyn, Prospect Park.
I hope that your Thanksgiving weekend is off to a great start!
Be well,
Gene
