October 13, 2023
Dear Interested Readers,
A Break From My Story
It has been a disturbing week. The events in Israel and Gaza surprised and horrified us all. One thing that I have come to appreciate listening to commentaries and to Secretary of State Blinken is that Hamas is not the Palestinian people. Hamas is a terrorist organization more like ISIS than a legitimate government. The actions and policies of Hamas have resulted in misery on both sides of the struggle for peace. Hamas is a threat to the people of Israel, the people of Gaza, and the rest of the free world.
If like me your knowledge of the controversies leading up to this moment in the 75-year struggle for a solution to the problem is a blur of failed discussions, intermittent war, and brutal assassinations, David Brooks’ column yesterday in The New York Times might give you a little basis for understanding this ugly moment and the reality that Hamas has no plan that will lead to anything but continued death and destruction of innocent people who are trapped in one of the most frustrating standoffs in human history. Near the end of the piece, he writes:
As I went back and revisited all these events, I was struck by how negotiators [in December 2000] on both sides were immersed in resolving practical issues. Now politics is mostly theater and psychodrama. Hamas and its followers cultivate the fantasy that Israel, a permanent Middle Eastern nation, will magically cease to exist. Its terrorists seek to avenge the wounds of injustice and humiliation with mass murder, without anything remotely resembling a firm plan to improve the quality of Palestinian lives.
We are left with the inescapable conclusion that peace in the Middle East is unlikely ever to occur as long as Hamas is an active presence. One thing that emerges as a recurrent theme is that there are times when people who desire peace in the world must respond with force to the force of those who seek to use violence to gain control over others. Those of us, like me, who have little personal knowledge of the full picture must exercise trust in our leaders even while we seek to learn more.
It is hard to imagine the stress that our leaders face as they contend with developing the right response to the war in Ukraine, the continuing threat that is posed by China, the new war in Isreal and Gaza, the unresolved issues of migration and immigration, an economy stressed by inflation that is slowly recovering, and a House of Representatives that is held hostage by a very small group that disregards the norms that provide some stability.
The small number of far-right representatives that temporarily threaten the political stability of our country demonstrate a reactionary political philosophy that seems to desire a dystopian outcome. We have no idea when the House will be back in the business of taking care of the country. When I hear Matt Gaetz and the small band of right-wing flame throwers make their pronouncements it seems that they are calling for us to become a country that is as dysfunctional and oppressive as “The Republic of Gilead” which was what became of America when the far right took over in Margaret Atwood’s cautionary novel, A Handmaiden’s Tale.
Is it any wonder that issues like global warming, social justice, and policies that would improve the social determinants of health for every American have fallen to the bottom of our list of active concerns? One liability of living in New Hampshire is that our airways have been full of political ads and will be until after our “first in the nation” primary which will probably be sometime in January. The exact date of the election and the moment the ridiculous ads will end has not been set yet, but state law requires that we hold “the first in the nation primary” even if Democrats want to pass that claim on to South Carolina, and our airways will be cluttered with the misinformation of Republican wannabes until after that primary. The only thing positive about the ads is that they have displaced many of the drug company ads which are also a source of irritation for me. I have not heard the candidates say anything about our deficient healthcare system or our inadequate social services. If any of the candidates I hear win, China better get ready for trouble, and all the fentanyl-toting illegal immigrants would be best advised to turn around and head for home. Heaven help us,
As I was debating whether or not to give you a break from my old man’s recounting of all the events of my youth and evolution as a physician, my weekly copy of The New England Journal of Medicine arrived in my box at the post office. Like many physicians, I am a diligent reader of the cover of the Journal. Sometimes, I find an article that leads me to read its abstract. On even rarer occasions the abstract generates enough curiosity to motivate me to read the whole article. Most of the articles that I read in full come from the “Perspective” section. The third article in the Perspective section of the October 12 issue of the NEJM caught my eye. It had a provocative title, “A Reason to Retire?” Before I read an article I usually try to learn a little bit about the author. Not uncommonly, I have heard of the author and sometimes I even know the person. The author of the paper on retirement was familiar to me, Neil Berman, M.B., B.Ch. At the end of the article, I read: Author Affiliations, From Atrius Health, Newton, MA. I said, “Aha, the Neil Berman that I know.”
My memory can be unreliable, but it tells me that I met Neil in person sometime in the mid-nineties, but I had accepted cardiac patients from him on referral to our cardiac service at the Brigham when I was on call long before I met him in person. Neil practiced at the Granite Medical Group in Quincy and was one of its founders. He admitted patients to the Quincy Medical Center and South Shore Hospital in Weymouth.
I think that I first met Neil in person during the discussions that led to the merger of Harvard Community Health Plan and Pilgrim Health Care which resulted in the creation of Harvard Pilgrim Health Care in 1995, but that may be wrong. Nevertheless, let’s just go forward with the story even if some of the inconsequential details may be inaccurate. At the time, I was on the board of HCHP as the Chairman of the Physicians Group and had a seat on the executive management committee representing the practice. In those capacities, I had been an active participant in the merger discussions. After the merger, and especially after the physicians in the staff model practice in the fourteen health centers of HCHP exited in 1998 as Harvard Vanguard and formed Atrius Health in 2003, I was in frequent meetings with Neil.
I had a great admiration for Neil’s practice, The Granite Medical Group of Quincy. Unlike most small groups of the day, they had invested in an automated medical record and were focused on improving their clinical quality. I sensed that Neil might be the very quiet source of innovation in his practice.
At the time that I began to work more with Neil, I was the Chairman of the Board of both Harvard Vanguard and Atrius. I held both of those responsibilities until 2008 when I became the CEO of both. For part of my tenure, Neil was on the board of Atrius. I also interacted with him as we attempted to put together an organizational-wide program of cardiac testing and care. Granite Medical was one of the suburban medical groups that joined Harvard Vanguard to create Atrius. Neil was always a voice of reason, and I had great respect for his clinical expertise and commitment to quality care. What Neil thought made a difference to me and many others.
I have been writing about the evolution of my moral sensibilities in medicine as part of a longer discussion of burnout and moral injury. Neil’s article is an impressive description of many aspects of those complicated issues. It is an example of the internal conversation with one’s self that must go in in the minds of many physicians. In his essay, he describes the objective posture he was taught and tried to maintain throughout most of his long years of practice. I must admit that I never even tried to have the relationship with patients that he describes that he was taught. I will let him speak for himself. The piece is only about a thousand words long and deserves to be read by you, but in case you pass on the opportunity, I will present it to you along with my comments. He begins with a reference to a conversation with a colleague that must have occurred about the time I first met him. He writes:
“Why are you retiring, Lennie? You’re only 64.”
I was in my 40s, part of a busy cardiology practice in a community hospital just outside Boston. Lennie was an old-time internist, an avuncular solo practitioner beloved by the community. His recordkeeping was meager, but his instincts were huge. When Lennie referred someone to see me and I couldn’t diagnose the problem, I looked again. Invariably, there was something going on that Lennie had sensed and I had missed.
Lennie’s decision to retire puzzled me. I knew he’d had some medical issues, but he was still running a busy solo practice. At the time, his answer puzzled me even more.
“My patients’ illnesses are starting to get to me,” he said.
I didn’t really appreciate what he meant, but his answer stayed with me. Having just retired myself at 71, I now understand exactly what he meant…
I didn’t think that I knew Lennie, but I met Neil at about the time Lennie would have retired and everything about Neil at the time was very positive. Neil was a terrific clinician and a good businessman, but I always sensed that we had some individual differences. For one, he was very quiet, but when he spoke what he said got everyone’s attention. Perhaps, I assumed that some of our subtle differences arose from the fact that he was trained in his native South Africa. One of my colleagues had also come from the same medical school in South Africa and in some hard-to-describe way, they shared some similarities. I counted on his support in most of the issues that occurred during the union of our practices. As Neil continues to write, he provides us with a clear picture of how his approach to patient care differed from Lennie’s. I get the sense that Lennie and I were more alike in our approach to practice. Neil continues:
Part of my professional effectiveness depends on maintaining a certain distance from my patients. I must be able to concentrate on the situation evolving before me: the symptoms, the signs, the lab tests, all the hard data that will inform the therapeutic decisions ahead. I can’t afford to be distracted by the “soft” data: the sadness of someone being struck suddenly by sickness, or sometimes the relentlessness of the condition. Some conditions are eminently predictable, but others are just sheer bad luck. Many are degenerative, and their frequency increases with age.
I am impressed by Neil’s ability to articulate his philosophy of practice. As you might imagine, mine was quite different, and I frequently had to fight to maintain objectivity as I would occasionally get so involved in the social and emotional aspects of my patient’s problems that I would have problems with transference and countertransference. Neil has a lot more to share with us and is very honest about the fact that his approach was not only an attempt to maintain objectivity, it was also an attempt at self-protection. I have bolded his honest confession.
As a young physician, I was able to compartmentalize illness: it was something that happened to my patients, not to me. I could understand their illnesses, but I never saw myself in their place. I would try to alleviate their suffering, but my primary task was to diagnose and treat their condition. Patients were almost a different species from me: they developed different conditions, and we had different problems.
There was a certain egalitarianism to this approach: all patients were treated equally, no matter how sad their plight. I’d been taught to avoid identifying too much with my patients, for both our sakes. My patients wanted a cool head to be responsible for their treatment, not someone who was as scared and overwhelmed as they were; and I needed the distance from their suffering to be able to face the same situation with the next patient. Empathizing was not considered “professional,” but I think the real reason for avoiding it was that it undermined our defenses against the disappointment of failing in our mission to cure disease.
Wow! Neil is a powerful writer. I think that he has articulated the traditional vertical relationship between patients and their doctors which is often misunderstood by patients as a cold aloofness or a lack of patient-centeredness. The truth was that he cared a lot, and was assuming a lot of personal stress in an attempt to maintain his objectivity. To be less distant does create difficulties, but Neil’s approach also has its costs. I suppose that it is often true that being more emotionally involved can lead to a loss of objectivity, but Dr. Francis Peabody advised that the secret to the care of the patient is caring for the patient.
I always assumed that Dr. Peabody’s advice was a directive to expose oneself to the concerns that Neil was taught to avoid. Managing the personal aspects of the tension between empathy and objectivity was what made you a professional. I know that Neil cared for his patients, so I imagine that holding his “objective” position was often a very painful task. He continues by giving us more insight into his method and the dynamics of his interaction with patients:
Objectivity helped me cope with the stress of dealing with my patients’ life-threatening and life-changing situations. It enabled me to see my work in a more intellectual and less emotional light. Did I make the right diagnosis? Did I choose the best treatment? Did I explain the condition to the patient and the family well enough? Rather than: How does he cope with not being independent anymore? How does her family survive without a breadwinner anymore? How does he feel knowing he has just a few months to live?
Some things that make sense don’t work. Neil reveals that in time he lost the ability to avoid emotional engagement. Neil confesses that in time the chatter in his head turned into one that I would say begins to sound a lot like the “trap” of transference/countertransference. Caring about the patient has a personal cost, and I might add makes one a setup for burnout or moral injury.
But as I grew older, this distinction became harder to maintain. The typical description in my chart of a “70-year-old elderly gentleman” could suddenly be me. My patients and their problems became more difficult to compartmentalize as separate from me. I started to feel the “extra-medical” aspects of their illnesses much more acutely than I had when I was younger — the unfairness of disease, the inevitability of age and the breakdown of the body. Now there was an extra dimension to treating my patients: each of them was a reminder of where I could be going. I identified with them on a new level, feeling each progression of their illness in a personal way that I hadn’t before.
Neil gives us his insight into why COVID made everything so much worse for healthcare professionals.
During the Covid pandemic, rates of physician burnout increased dramatically. Many factors contributed to the stresses causing burnout, including long working hours, increasing administrative burden, and rising caseloads, all of which worsened during Covid. But Covid also carried the additional personal risk of infection, potentially leading to serious illness or even death. The patient lying in front of me was not only someone who could have been me, but now also someone who presented a distinct danger of infecting me and causing me to develop the very illness I was treating. The shelter of objectivity was never less evident than during the pandemic, producing a situation not unlike what I was experiencing.
In the next section, I was surprised to learn the great effort that was required for Neil to maintain a protective distance from the emotional concerns of his patients. I would agree with his concept that sharing details from one own life with patients can be problematic, but we do it. How often have you been to a doctor’s office that did not have personal pictures on the desk and academic certificates hanging on the wall? It is one thing to be unknown as a person if you see only patients who are intubated in an ICU or anesthetized for surgery, but it does not take patients very long to begin to try to figure out a little bit about the person who has assumed such an important role in their lives. More information can be beneficial and reinforce their confidence in the fact that you recognize that both of you are human and vulnerable to the same threats.
Effective relationships are bidirectional and information eventually flows both ways. The art of practice is to be able to make that flow of information part of the therapeutic process. I think that Neil’s patients must have learned more about him than he realized, and what they suspected was beneficial to them. The next section is somewhat contradictory to his stated objective to have a vertical relationship with patients where he knew about them, but they knew little about him.
Over the course of my career in clinical cardiology, the part of the job that brought me the most satisfaction was my interactions with my patients. Sure, I loved the challenge of constructing a coherent narrative from a series of disparate clues and then working out how to test the validity of that narrative. I loved the feeling of being “knowledgeable,” albeit about a very small section of the human condition, and being asked to weigh in when a problem arose in that section. But what really sustained me throughout my career were the relationships I built with my patients. We had a contract whereby I would listen to them, examine them, direct the appropriate testing, explain their condition, and suggest the best options for their treatment. It was a professional relationship. I was taught that as little as possible of my personal story should be shared with my patients. The purpose of our interactions was to address patients’ problems, not my own, so I knew much more about their lives than they knew about mine.
I was surprised by the conclusion of Neil’s testimony:
About 6 months before I retired, I wrote a letter to my patients explaining that I was going to retire and telling them somewhat personally what being their doctor meant to me. My subsequent visits were more personal, took longer, and were more emotionally laden than previous visits, but they were also more satisfying and helped me see my career from a slightly different perspective.
Our relationships with our patients are complicated. On the one hand, the lack of time, the number of patients, and the administrative burden associated with caring for patients all interfere with our relationships with them and contribute to job dissatisfaction and burnout. On the other hand, when those relationships become more personal and more intense, our work may also become more stressful because holes have been poked in our armor of objectivity.
As I grew older and more susceptible to the conditions I had spent my professional life combating, that armor became increasingly porous, ironically permitting more fulfilling relationships with my patients but also causing increased stress and perhaps leading to earlier retirement.
I know from personal experience that at the end of a career, we are full of questions examining what we did, what we failed to do, and what we wish that we had done. Those questions are inevitable. It is wonderful when we can ask the questions and then accept the answers with a sense that perhaps we could have played it differently but we did the best we could under the difficult circumstances that occur in every life. Neil reports that he has learned that we share a lot of vulnerability with our patients. Neil says that he doesn’t know the answers to his questions. From what I observed in Neil, every patient he ever saw was quite fortunate to have such a caring doctor. I think that was the feedback that he heard as he was saying goodbye to his patients.
Should I have developed more personal relationships with my patients all along, or would that have made me less effective professionally and more stressed personally? I really don’t know the answer to that question.
I often think of Lennie’s answer to my question about his retirement some 25 years ago. As usual, Lennie was spot-on — it just took me a while to understand why.
I hope that Neil’s piece got you thinking about your own professional life. Even if you are not directly involved in patient care, and even if you are one of the “lay” readers of these notes, I think that Neil’s reflections offer us all an opportunity for personal insight and growth. We are connected, but we also need to have some boundaries. There is work in properly managing relationships. The key to success is caring. Caring makes you vulnerable to burnout and moral injury, but it also leads to enormous rewards and satisfaction. Caring and sharing something of yourself when it promotes an effective therapeutic relationship doesn’t have to destroy objectivity. Not caring and remaining distant can lead to bad outcomes for both sides of the relationship.
The Weather Matches My Mood, It’s A Dull Fall
As you might have guessed from the intro about war and politics, it has been difficult to maintain a cheery outlook this week. Neil’s essay in The New England Journal was a breath of fresh air. On the upside, we enjoyed a visit from my youngest sister and her husband who had come north from Atlanta to see the fall foliage. The scene was disappointing for them, but we enjoyed each other’s company, and we had several side trips together including a trip to Bowdoin last weekend to watch my granddaughter play volleyball and to help her celebrate her 21st birthday.
You don’t get a lot of lobster in the Southeast so our visitors substituted the satisfaction of good Miane lobster rolls for the lack of colorful mountain vistas. As my sister can attest, our leaves do lack their usual color. Many that should have turned by now remain green, and others went directly from green to brown.
I had hoped to decorate this letter with a header that sported a scene with gorgeous foliage. The best I could do was to lift a drone shot from a video posted by my neighbor Peter Bloch who regularly presents gorgeous photos and videos from our area on the Internet. If you look closely you can see a little red in the leaves of the swamp maples that line the shores of the Danbury Bog that is a few miles north of us. Ragged Mountain with its ski runs is seen in the distance. The mountain shows absolutely no evidence of color. Usually, by this time of the year, the mountains and hills around us present a blaze of color.
I hope that your weekend goes well and that you can find some color to enjoy near you.
Be Well,
Gene
