November 25, 202

Dear Interested Readers,

 

In Memoriam J.L.D.

 

Oh yet we trust that somehow good will be the final goal of ill!

 

Alfred Lord Tennyson worked for seventeen years to produce his very famous poem “In Memorium A.H.H.” which celebrated the life of his close friend Arthur Henry Hallam who had died in Vienna at age twenty-two of a cerebral hemorrhage. You may not know the poem, it is quite long with more than 130 cantos that took seventeen years for Tennyson to write, but you surely know its most famous lines:

 

I hold it true, whate’er befall;

I feel it when I sorrow most;

‘Tis better to have loved and lost

Than never to have loved at all.

 

I have known, and dreaded, for more than a year that my dear friend, colleague, and mentor, Dr. Joseph L. Dorsey would be dying sometime soon. His wife, Dr. Joanne Wilkerson, a long-time colleague, the PCP of several close friends, and my wife’s PCP had told my wife at her physical last summer that Joe had been hospitalized and was on hospice care. The reality that he would probably die sometime during the fall was startling news even though I knew that his health had been declining for several years.

 

I got the news of his passing on Wednesday evening from Barbara Ebert, the widow of Dr. Robert Ebert, Dean of Harvard Medical School when I attended and the founder of the Harvard Community Health Plan in 1969. Joanne did not have my email so she asked Barbara and another former colleague, another mentee of Joe, and my contemporary, Dr. Paul Mendis, to pass the word of Joe’s passing along to me. I got the news from both of them.

 

Paul and I are both retired and have not had much direct contact over the last seven or eight years, but we practiced together for many years and at times Paul had been my boss as the Chief of Medicine or as the Kenmore Center Director before he moved on to be the Medical Director of Neighborhood Health Plan in Boston. We are now both retired, and before the COVID lockdown, Paul and I had enjoyed getting together to see a Celtics game. Back in the Larry Bird days, we had shared tickets to the Celtics. Barbara and I have stayed in touch over the years. She is an “Interested reader” who sends me comments from time to time. In years past the Eberts had a vacation home on Dutchman’s Pand which is about three miles from where I now live.

 

Dr. Ebert was Joe’s mentor and had made him the Medical Director of Harvard Community Health Plan in 1969 when Joe was only 31. Joe was my mentor. It was Barbara who facilitated my review of Dr. Ebert’s papers in 2008 which were in the locked underground archives of the Countway Library at Harvard Medical School. On that visit, I discovered a letter written by Dr. Ebert in 1965 which contained an insight that I know Joe shared that I have repeated hundreds of times over the last fourteen years:

 

“The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.” 

 

Joe was one of the most significant people in my life. He was a role model. I could not write these notes if I was not writing from a foundation of medical philosophy that I learned from Joe. It wouldn’t be right to call him a father figure because Joe was only eight years my senior. I often thought of him as being like a wise and experienced older brother. He was definitely my mentor. 

 

I know exactly when I first met Joe. It was on the first day of my internship at the Peter Bent Brigham Hospital on June 20, 1971. I was one of two interns assigned to start the year on one of the most demanding rotations, F-Main, the men’s ward service. It was a challenging beginning to a difficult year. As I look back from the perspective of over fifty years, I realize that my assignment to F-Main set the direction for the rest of my life.

 

The men’s ward was at the far end of the old Brigham which had a very linear architecture. The Brigham had been built in 1913 prior to the antibiotic era. Originally there was a central building that was connected by open-air walkways to buildings A, B, C, D, E, and F. There were also tunnels that connected the buildings for when the weather was bad. The wealthier patients with private doctors were in A and B. Surgical patients were in C and D, and down the alphabet to E and F were the wards for “clinic patients.”

 

The idea behind the linear arrangement had been to isolate infections and force clinicians to be exposed to ultraviolet light as they moved between wards. It was a revolutionary concept for its day that won design awards in the era before antibiotics. At some time in the intervening years, the walkway had been enclosed and was called “The Pike.”

 

In 1971, F-Main, at the end of The Pike was where the sickest and often indigent men who had no private physician or insurance were hospitalized,  The floor above F-Main was F2 which was connected to E2 by a hallway a floor above “The Pike.” E2 and F2 were the women’s wards. The Chief Medical Resident’s Office was off the hallway that connected E2 and F2. Just to complete the picture of the geography, in 1971 E Main was called “The Clinical Center” or “TCC.” It was a research ward that George Thorn had created for elaborate metabolic studies. Whether it was true or not, it was generally believed that the “TCC” had been created with money from the eccentric billionaire Howard Hughes. Hughes as well as other members of the Hollywood elite like Spencer Tracy would come to Dr. Thorn as patients. There are many stories connected to the “old Brigham.”

 

Joe was my attending physician on F-Main on that first day of my internship, and I had no idea that the course of my life had been set by that assignment. Joe was the best attending I had during my training. He had an encyclopedic knowledge of medicine that I was never able to match, plus he was totally focused on the social issues that impact medical practice and often affected outcomes long before those concepts were the core of Crossing the Quality Chasm, To Err is Human, The Triple Aim, and language like “the social determinants of health.” By the time Joe was my attending he was not only the medical director of Dr. Ebert’s bold experiment in ambulatory preventative practice but he was well known as one of the people who had done much to make birth control legally available for women in Massachusetts. 

 

An article published in a  Boston College Magazine in 2011 tells the story of how Joe, then still a student at Harvard Medical School, convinced Cardinal Cushing not to oppose the legalization of birth control in Massachusetts. Another player in the story was Michael Dukakis who eventually became Governor and the 1988 Democratic candidate for president. 

 

For the story to make sense you must know that Joe had grown up as a devout Catholic in Scranton, Pennsylvania where he was a basketball star at a Jesuit high school before going to Holy Cross College, also a Jesuit institution, where he also played basketball, prior to going to Harvard Medical School. After graduating from HMS, Joe had been an intern and resident at the Brigham and then did an MPH at Yale. In 1964, while he was still a medical student, Joe contacted Cardinal Cushing while he was writing an article about birth control that would eventually be published in the New England Journal as a special article entitled “Changing Attitudes toward the Massachusetts Birth-Control Law.” If you click on the Boston College article you can see Joe’s young face next to the Cardinal and near a young Dukakis. Deep into the Boston College article, we read the story which I have augmented with a few bracketed comments for clarity.

 

In July 1964, Dorsey sent a draft of his text [of an article that was to be published in the NEJM] to Cushing, asking for his thoughts. (He also sent a copy to Rock.) [John Rock was an HMS professor, a Catholic, and one of the inventors of the birth control pill.] Cushing replied that if the issue faced another voter referendum, he would “state very emphatically, over and over again, the stand of the Catholic Church” in opposing birth control, but he would “make no effort to enter into a political phase.” [That was important because a large majority of the state legislature was Catholic and would follow the direction of the cardinal] Cushing told Dorsey outright that the repeal effort “should never be brought to a popular referendum again.” Together with the cardinal’s comments, Dorsey received a formal imprimatur from the archdiocese, signed by Cushing and O’Donohoe, recognizing that nothing in his article contradicted Church teaching.

Dorsey’s write-up appeared as a “special article” in the October 15, 1964, issue of the New England Journal of Medicine, under the title “Changing Attitudes Toward the Massachusetts Birth-Control Law.” Monsignor Lally wrote a short introduction, in which he noted that many felt “the time was ripe for reconsidering” the law.

In language that would be heard again and again as the debate played out, Dorsey acknowledged that the birth control law was perhaps “the cause of more hard feeling between Roman Catholics and their neighbors in the Commonwealth than any single issue in the past quarter century.” He went on to say there had been a recent “change in attitude on the part of Catholics,” who realized “the need in a pluralistic society for a consensus on a moral principle before it can be expressed as a civil law.”

 

Would it not be a blessing if men of vision like Cushing and Dorsey were leaders in sorting through the matrix of religious and civil issues associated with abortion? Joe maintained a close relationship with the cardinal over the remainder of Cushing’s life, and in the wider world over the next fifty years, Joe had the confidence of many of the political “shakers and movers,” the senators, congressmen, state legislators, mayors, business leaders, and academic leaders of Massachusetts. He was always close to Dukakis who supported the vision embodied by Harvard Community Health Plan.

 

I did not know of Joe’s importance when I met him as my attending on that first day as an intern at the Peter Bent Brigham Hospital. I just knew that every morning when Joe appeared to round with us, I learned something. Joe was not like any attending I had ever had as a medical student. Joe focused on the medical issues of every case, but he also looked at the whole person and how that person connected to the wider community. He did not see the disease first and the patient as its incidental carrier. He saw the patient first and demonstrated through his interactions with each patient how their social circumstances made them unique even if the man in the next bed had exactly the same diagnosis.

 

Some of my memorable experiences in medicine occurred during that first month of internship, but one of the things I remember most fondly was that Joe would take us outside where we would sit on the grass in the late June or early July heat and be lead by Joe in conversations that were unlike anything I had ever heard on the rounds of other attendings.

 

We would begin our rounds under the ‘big top.” The large ward on F-Main was a circular room and it had a large vaulted ceiling. We affectionately called it “The Big Top” because what happened there often had the drama of a medical circus. Under “The Big Top” there were beds for about twenty men arranged in a circle with curtains for privacy. F-Main had no air conditioning,

 

There was a smaller air-conditioned area across the hall from the nursing station and a few double rooms between “The Pike” and the nursing station. A central hall ran from “The Pike” down the length of F-Main and ended at “The Big Top.”  We called the smaller air-conditioned ward “Bird Land.” It had about eight beds and it was often true that every patient in that open ward was on a Bird ventilator.

 

In late June and early July, “The Big Top” was hot and busy. We had no conference room, but there were double doors on one side of the “Big Top” that were often open for fresh air, and outside the doors, there was a shaded grassy area where Joe would take “the team” so that we could get some fresh air while we presented cases and he led us through the important medical and social points in the management of our patients.

 

The team that would join in those conversations was composed of Joe, me, and my fellow intern with whom I shared every other night call, our senior resident, our medical students, and the F-main head nurse. It was fifty-one years ago, but I still frequently wander back to those mornings with Joe in my mind. The memories always bring a smile.

 

My experience with Joe during that first month of internship was a big part of my decision to cast my lot with Harvard Community Health Plan in 1975 after my training at The Brigham. When I started at HCHP, Joe and I practiced in the same clinical unit. I remember looking at our posted schedules every day. They were posted in the nursing station. My schedule would show ten or twelve patients scheduled for an afternoon session after having spent the morning at the hospital, and Joe would have eighteen to twenty. Each of his patients seemed delighted with their encounter and he was always on time. To this day, I do not know how he did it.

 

Joe referred his cardiac patients to me. There was usually little that I could add to their management that he had not already initiated. I actually learned from observing and reviewing what he had done for them before referring them to me. It was backward compared to the usual referral flow. Some of  Joe’s patients were politically important or were well-known business or academic leaders; others were people contending with extreme poverty who had complex social issues. Joe was equally devoted to them all. He knew what concerned them, and he gave everyone all that he could. I don’t remember him ever using the phrase “healthcare equity,” but he lived it. He was the consummate practitioner of equity. 

 

What I did not appreciate in June 1971 was that Joe had been tirelessly marketing Harvard Community Health Plan to organizations and businesses all across Eastern Massachusetts for two years. There had been only a handful of patients when the doors opened in October of 1969. By the time I met Joe in June 1971, there were about thirty thousand patients. By the time I joined the practice in 1975, there were about seventy-five thousand patients. Joe was the heart and soul of the practice and the primary force that turned dr. Ebert’s idea into a reality.

 

By the late seventies, HCHP was on the threshold of explosive growth to about four hundred thousand patients and fourteen large delivery sites by the mid-eighties. In preparation for that next step of growth, it was decided that Joe would give up his duties for a few months to study the options that lay ahead for the practice. At the time the practice was transitioning from a “group” model to a “staff” model HMO.

 

Some of us imagined that with the structural changes, and a dominant CEO that sometimes stressed business success and growth over our mission, Joe might leave our group and join the Carter administration in Washington in some healthcare policy role. Fortunately, for all of us, that did not happen.

 

When Joe came back he did not return to the role of medical director. As he gave up the role of the medical director, he threw himself into practice and became a leader of our hospital efforts and a prime developer of our hospital teaching and practice. He became the chief of medicine at a small community hospital on Mission Hill near the Brigham that we bought where a colleague and I did noninvasive cardiac testing, rounded with residents from the Brigham and Beth Isreal that rotated through and supervised the ICU. Joe was there supporting us and became a major force behind our programs for chronic disease management and developed our first programs for older patients.

 

Over several years, Joe developed a collaborative partnership with Dr. Eugene Braunwald who was the chief of Medicine at the Brigham and the Beth Isreal Hospitals. The work that Joe did with Dr. Braunwald optimized our ability to deliver care in those institutions. Then after almost twenty years, he was named the Medical Director of the new Harvard Pilgrim Health Care after the merger of HCHP and Pilgrim Health Care in 1995. 

 

Throughout the years, Joe remained very close to Dr. Ebert. He was his doctor. It was largely through Joe that I came to have a deep understanding of Dr. Ebert’s vision of a system of care that was rooted in the pursuit of quality in an ambulatory environment that preserved health, reduced the frequency that hospitalization was needed, and did not waste healthcare dollars or resources. 

 

Over the years, Joe was active in many spheres. He was a social activist, a medical manager, a health insurance executive, a teacher, and an incredible physician. His influence was a function of his mentoring, his work ethic, his ability to negotiate with civic and political leaders, and his devotion to improving the delivery of care for everyone. He was driven by his commitment to service. Many outstanding practitioners and medical leaders were developed in the environment that Joe fostered. He wore many hats, but I will always believe that the role Joe enjoyed most was being somebody’s doctor. All the other things make sense if you imagine them in the context of improving the care of the individual and supporting the ability to deliver the care everybody deserves.

 

More than any other influence, Joe shaped my professional life and influenced my worldview. He passed on what he learned and experienced from Dr. Ebert to me and to others. Is that not the way it works best? Wisdom is passed down from generation to generation. New insights at one moment become an accepted reality a little further down the road after early adopters, like Joe, demonstrate a better way to practice and relate to the people who honor us by accepting our attempts to improve their health. 

 

Joe gave a lot, and he demanded a lot of those around him, but always with a smile on his face and the intent of doing as much or more than what he was asking you to do. I can’t remember ever seeing a frown on Joe’s face. The face you see in the picture below, is the face that I see in my mind’s eye when I think of Joe.

 

 

Joe lived in the world of “what might be possible” so his life was always about moving forward. I don’t know if Joe ever read the writing of the Franciscan priest, Father Richard Rohr. I think Joe’s wisdom predated Rohr’s writing. Father Rohr published a book in 2011 entitled Falling Upward: A Spirituality for The Two Halves of Life which I have been reading with a few friends. We read a chapter and then have a Zoom meeting to discuss what we have read. The book reminds me of David Brooks’ recent book THE SECOND MOUNTAIN: The Quest for a Moral Life. Both books suggest that it is often true that in the first part of life we are busy “becoming.” Then something happens. It often is a defeat or some sort of setback that opens us up to a greater appreciation of what is valuable in life, and then we are launched into an even more satisfying and meaningful second half of life that is free of the need to become and is focused on being all that is possible for us to be. 

 

I have often wondered whether or not Joe went through a transitional moment in 1977 when he took some time off to organize an approach to our future. I don’t know if his shift in focus from day-to-day operations to examining the possible future options of our practice that occurred when he took that assignment was the equivalent of falling upwards or climbing the second mountain. What I do know is that after Joe came back he was just as laser-focused as always on improving the experience of both patients and practitioners. 

 

Joe loved seeing patients and trying to improve the practice of medicine and the experience of care. He loved passing on what he learned and believed to others. Over the years, I was a beneficiary of his presence and concern. I have already missed him as we have been apart since I retired, but I will never forget him, and will always feel blessed to have had the double experience of learning from him and being his colleague. Thank you, Joe! Rest in peace. You lived a life that made a difference for the thousands of patients who loved you as their doctor, and even more who may have never even known your name.

 

Stopping By the Lake on a Chilly Evening

 

This time of year the sun goes down early. If my day is full of tasks in the non-profit work I do, or if my day is filled with doing the little jobs my wife assigns me, I don’t start my daily walk until after three and finish using a headlamp after it is very dark. One of the benefits of a twilight walk along the shore of a lake is that you are frequently treated to beautiful colors in the evening sky and their reflections on the surface of the lake as you can see in today’s header.

 

Our lake is a glacial lake. It is full of huge rocks that a glacier deposited over ten thousand years ago. Natural lakes rise and fall as a function of rainfall and snowfall. I have discovered that most of the lakes in New Hampshire are “natural lakes.” By natural lakes, I mean that they were not created by a dam as was Lake Mead in Nevada or most of the lakes in my native South.

 

Years ago I was surprised to learn that all of these “natural lakes” have had small dams and spillways placed across their outlets. The purpose is to regulate water levels. It does help in the summer. The lake level stays rather constant no matter how dry or wet the season may be. In the middle of the spillway, there is a little house where the water level is managed by dropping wooden boards that are about a foot wide into an opening that is like a door. The opening is only about three feet wide, but by adding or subtracting boards the water level of the lake can be controlled. In late October two or three boards are removed which allows the lake level to rise or drop to the desired level for three purposes: people can more easily repair permanent docks, the shoreline can be cleaned of branches, fallen trees, and any other detritus that might have washed ashore, and finally, the lake is lowered to a point where it is ready to accept the winter snowfall and the spring thaw. 

 

For some reason, it always makes me sad to see the lake level fall. I imagine that as the lake level is dropped by as much as two feet, many of the fish that I want to catch next year are escaping downstream to “big” Lake Sunapee. The drop in water level is a transitional moment for me almost like the falling of leaves. I much prefer the lake to be either full or frozen! Our first snowfall last week was beautiful and much of it persists because it has been very cold with night time temps down to fourteen degrees. The early snow was nice, but it did not meet my expectations. I like to see the snowfall on a frozen lake. I love the huge white blanket that is the result. Snow may be dirty looking along the roadsides and in scattered patches in the woods as it melts, but the snow will remain pristine on a frozen lake with gorgeous frozen ripples created by the wind and present until we have substantial rain or a springtime thaw. 

 

One of the first things I do every morning this time of year is to look out at the lake with the hope that I will see ice. I know it is coming. When it arrives the dreary part of the seasonal transition will be over. I know it will happen soon. I hope it will happen before Christmas. “Ice out” in the spring is a big deal that coincides with the emergence of spring, but “ice in” is what I am looking for now.  

 

I hope that you have had a very satisfying Thanksgiving experience. If you are traveling home this weekend, be careful and travel safely. 

Be well,

Gene