December 25, 2020

Dear Interested Readers,

 

Peace, Hope, Love, Joy?

 

Christmas has been on a Friday only twice since I began writing these notes back in February 2008. I decided to dust off “Volume I,” letters that were written between February 22, 2008, and October 25, 2013, and take a look at 2009, a year when Christmas fell on a Friday. I was surprised to find that I published my letter that year on Wednesday the 23rd which made sense, since back then I was heavily and beneficially edited by our very capable Chief of Public Relations and Governmental Affairs, Marci Sindell. Marci would have pointed out to me that most of our colleagues, the 5000 plus health professionals who staffed the offices and programs of Harvard Vanguard and the 3000 employees in the other practices that had joined Harvard Vanguard to create Atrius Health, would be unlikely to read the letter if we put it out on Christmas Day. 

 

The production process Marci and I developed was that I would write the letter each Thursday night and send the first draft to her usually around midnight. She would meet me in my office first thing on Friday morning, usually around 8 AM, to review and edit what I had written. I imagined that she had to rise at 4:30 or 5 to be able to get a little exercise, mark up my letter, get her kids off to school, and complete her half-hour commute to work on a very congested Route 128, the beltway that rings Boston. 

 

Everybody benefits from an editor. The advice on self-editing from my favorite professor in college was to begin by striking out the sentence or paragraph that you liked the best. Marci regularly performed that task for me. The lines that I liked best were obliterated by her red ink. After Marci and I were finished with eliminating unnecessary verbiage and tightening the message, my very capable administrative assistant, Cheryl Livoli, would proofread the result and occasionally offer a gentle suggestion about a further edit that might avoid offending a group who might not appreciate a comment that had somehow gotten through Marci’s filter. When the letter got Cheryl’s approval it went out to our staff–usually before noon. On the rare occasions when the letter was delayed, we would get calls from eager readers asking what was wrong. 

 

What I found when I read the Christmas letter for 2009 brought back many memories from a previous year when everyone felt vulnerable. In 2009 we were struggling to survive in the aftermath of the “Great Recession” of 2008. In the Christmas letter, I was filled with joy and gratitude. I knew we had survived a huge challenge. The letter begins:

 

Some thoughts at the end of a great year…sustaining a journey of improvement

 

Several times over the last month I have pinched myself and said that I can’t believe it as I think back on what has been accomplished. At this time last year, I was terrified because I knew that the economy would be a challenge. I knew that we were asking ourselves to be better at a time when most groups would prefer to sit and wait to see what would happen with healthcare reform. I knew we were going to expand our efforts when other groups and companies were deciding how much to save for a rainy day by reducing costs by laying off employees. I knew that we were planning to invest in our practice when others were planning to cut their capital budgets. 

I was quite apprehensive because I also knew our plans would require that we ask you to do more with less. I knew we had to challenge ourselves to begin a transformation just when it seemed we were out of energy because you had worked so hard to make 2008 such a great year. I knew that we would have to ask everyone to be more effective and to try harder to help our patients find it easier to be healthy at the same time that you may have been worried about your own financial health. This time last year, it did not seem fair that the challenges were so great. 

Now when we look back at this year, I discover instead that “our cup runneth over”. We have been described by people who know about organizations as a “high commitment, high-performance organization.”

Did you believe a year ago that we would improve quality and begin the process of lowering our per capita cost of care at the same time? Did you envision that in less than a year we would have a well-launched program of Lean process improvement that has already involved several hundred people? A great deal has been accomplished this year. 

This week you showed once again how engaged you are in the work of this community despite the challenges of 2009. We just received our annual Employee Opinion Survey results. We are processing all the numbers and will be sharing more in January to help us develop action plans to address many of the things you shared with us through the survey, but a few things stand out. 

The first is that our raw score on items related to workforce commitment remained exactly where it was a year ago at 4.09. That means that you remain very committed to our work despite the fact that you worked hard, experienced a change in benefits, and some raises were delayed. You said that you loved working here even in the midst of the stress of the H1N1 craziness this year. The results show that despite reporting that you are stressed by your volume of work and that you could be more pleased with your pay, more than 90% agree that they are proud to tell people they work at Harvard Vanguard. 

More than 90% of you say that you would recommend our practice as a place to work. But the fact that means the most to me is that despite knowing what problems we may yet have to conquer, more than 90% of you say that we provide safe, high-quality care and service that you would recommend our organization to your family and friends.

 

By 2015, the next time that Christmas fell on a Friday, I was retired and living here on Little Lake Sunapee in New London, New Hampshire. 2015 was our first Christmas in our newly remodeled home. Retirement has been a safe haven for me. In retirement, I enjoy feeling more like an observer in the grandstands than an actual player on the field. Despite the COVID-19 pandemic, the craziness of the economy, and the divisiveness of our nation’s politics, my world has been very stable. I feel protect and distant from the swirl and confusion in the wider world. I know that I am blessed. I am thankful for the benefits and satisfying life that my wife and I enjoy. 

 

I have a lifelong preference for the cyclic repetitions of the seasons and the replaying of the same traditions each year. Today’s header shows our hearth and Christmas tree as it looks now. It has looked the same every year since 2015 and the scene was not much different over the last four decades. Each year we bring the cherished ornaments down from the attic and go through the same preparations which are the first step in the rituals that give us comfort and a sense of protection from the hostile world we see on television or read about in the newspapers. 

 

When I read my Friday letter from Christmas 2015 I was impressed by how slowly change occurs and how chronic today’s issues really are. Much of the letter was totally appropriate to this moment. I began by telling my readers what was to follow:

 

It’s a holiday letter that I hope will have meaning for everyone in the diverse world of the Interested Readers of these musings. Whether you are celebrating Christmas or just enjoying a few days of year-end respite with family and friends, I hope that you are happy and well at this very special time of the year.

 

It is a time of parties, homecomings, giving gifts, and making resolutions. It is a time when we review where we have been, sum up what we have learned, and look forward with the hope that we will do better with a new start. 

 

A few weeks earlier I had attended the IHI meetings in Orlando where the high point of meetings was Don Berwick’s introduction of his concept of “Era 3: The Moral Era.” In that speech, he had described nine changes that needed to occur in healthcare. Each change was a challenge to the status quo. I had been writing about the speech every week since I had first heard it and in the Christmas letter, it was time to focus on one of its most challenging aspects, the return of civility. Civility seemed like an appropriate concept for a Christmas letter. I began the section by listing the nine changes that were the challenge Don was offering:

 

• Stop excessive measurement

 

• Abandon complex incentives

 

• Decrease focus on finance

 

• Avoid professional prerogative at the expense of the whole

 

• Recommit to improvement science

 

• Embrace transparency

 

• Protect civility

 

• Listen. Really listen

 

• Reject greed

 

Looking back over the past five years, the validity of the list still holds great merit.  It is a set of objectives that would enable a very meaningful and beneficial transformation of health care. It is also quite applicable to all of our society. I am sad to observe that we don’t seem much closer to any of those objectives than we were five years ago. Let’s go down the list.

 

1. Regulations that are dependent on measurement have failed in education, business, and consumer protection. 
2.  Complex incentives don’t seem to lead to meaningful improvement in a world that rests on measurements that are not made. Incentives don’t seem to have much relationship to the goals they were meant to encourage.
3. Finance still drives everything and financial barriers still preclude innovation.
4. Individuals still focus on “what’s in it for them” versus what is best for the community.
5. Science, including improvement science, is often lacking as policies crafted to avoid pushback from the status quo fail to produce systems that solve problems.
6. A lack of transparency is a complaint that is registered against the government, corporations, and healthcare.
7. A lack of civility is manifested within stressed medical groups, between departments in hospitals, between tired healthcare professionals, and worried patients and their families. Most painfully, a lack of civility exists between races, political parties, and between sections of the country, and between our country and much of the world. “One nation under God, indivisible with liberty and justice for all” seems to be an aspiration, not a reality.
8. We all have the feeling that no one is listening to our complaints and concerns.
9. Greed still exists in any place where there is an opportunity to make a buck with “surprise bills,” items not covered in guarantees, and market opportunities to increase prices to whatever the market will bear.

 

I think that Don was directing each recommendation to three levels of participation. He holds individuals accountable. He recognizes that we work in systems that are resistant to change. He knows that the individual and organizational failures make changes at the national level impossible. Change is more effective from the bottom up although there are many fruitless attempts to drive change from the top down. My focus in that Christmas message of 2015 that was gleaned from Don’s list of nine things that we needed to change was #7, the need to protect civility. I wrote:

 

Perhaps because of the general lack of civility that we sense in human discourse today Don’s reference to civility should not have been a surprise for me. Harsh and hurtful expressions of opinion and deep disdain for others seem to hit us in the face every time we open a newspaper, turn on our computers, tune in to the radio or sit down to watch the evening news. Don called out this lack of civility as a huge barrier to progress in healthcare. From the moment he said it, I have been captivated by Don’s emphasis on this point. A great leader points out not only what we should begin to do but also what we must cease doing or give up. I really did not get it until Don made his point number 7. Since the moment he called for a return “civility” I have not been able to get that idea out of my head. I hear his suggestion as being more than giving up bad behavior toward one another. I hear him expanding and adding depth to our growing realization that respect is a cornerstone of collective problem solving and progress. Perhaps if there is any shortcoming in [reports on the speech which I have read it is that they] failed to generate the same sense of surprise for me about “civility” that I experienced when I heard Don say it.

 

My challenge to you is for you to think about what civility means to you. For me, it means much more than avoiding poor humor that degrades others as some of our current politicians use for short term gain. I think that calling out a lack of civility is to open a window that reveals the contempt that we sometimes hold for some of our colleagues and neighbors who honestly have a different point of view that arises from an experience in life that we have not tried to understand. Practicing civility would require us to earnestly ask one another, “What matters to you?”. Practicing civility would also include diminishing discord by each of us asking ourselves, “What part of the problem am I?”. A journey toward civility would be a journey toward understanding why progress toward the Triple Aim seems to be so difficult. Don has launched a conversation that should attract us all.

 

I did not mention Donald Trump in the piece but he was present between the lines when I wrote it means much more than avoiding poor humor that degrades others as some of our current politicians use for short-term gain. By December 2015, Trump was already six months into his campaign and had made some of his most offensive remarks about other candidates, Mexican rapists, women, the disabled, and a plethora of other targets. He had demonstrated no respect for the usual norms of civility. 

 

My hope this holiday season is that what we have experienced over the last four years is not an expression of our nation’s true character but rather is an “infection” from which our nation is finally recovering. I also hope that now that we seem to be getting better from our affliction we will have immune resistance that will protect us from similar plagues in the future. 

 

December has always given us our darkest days. Lighting candles, gathering around a hearth, coming together to sing and feast, and sharing expectations for better things to come usually helps get us through the darkness. There is nothing sadder than the unfilled expectations of a child or the absence of a beloved family member at this time of the year. This year more of us will be challenged to remember better holiday seasons from the past and focus on the possibility of better times that may be on the horizon.

 

One of the most poignant country songs I know is Merle Haggard’s song “If We Make It Through December.” I guess it is a Christmas song. I know it speaks to the reality that many Americans may experience this year during this dark season. You might want to read the lyrics while you listen to the song.

 

If we make it through December

Everythings gonna be all right I know

It’s the coldest time of winter

And I shiver when I see the fallin snow

 

If we make it through December

I got plans of bein in a warmer town come summer time

Maybe even California

If we make it through December we’ll be fine

 

I got laid off down at the factory

And their timings not the greatest in the world

Heaven knows I been workin’ hard

I wanted Christmas to be right for daddy’s girl

Now I don’t mean to hate December

It’s meant to be the happy time of year

And why my little girl don’t understand

Why daddy can’t afford no Christmas here

 

If we make it through December

Everythings gonna be alright I know

It’s the coldest time of winter

And I shivver when I see the fallin’ snow

 

If we make it through December

I got plans of bein’ in a warmer town come summer time

Maybe even California

If we make it through December we’ll be fine

 

Millions of Americans are dependent on Congress getting its work done to provide some relief or the promise of relief in the near future. It is hard to understand what the president’s objective is as he suggests that he won’t sign the relief bill that Congress has passed because it is not generous enough while he knows a redo at the moment is impossible, and there may not be time to override his veto. The most turbulent month of the last four years may lie before us as his leadership becomes erratic with unconstitutional attempts to retain power while tens of thousands die and millions are newly infected even as we wait our turn for vaccination. 

 

Our food banks are seeing more people than ever before. People who have never needed help see no way they will make it through December without help from somewhere. For many Americans, their savings are gone. Their rent is due. Their electric bill is in arrears. Their phone and Internet services have been disconnected. Homelessness looms as a likely possibility for many. If we were to update Don’s list of nine things that need to change, we might make #10 be “End indifference.” 

 

I do embrace the season. Thinking back to past holiday seasons does give me hope that we will make it through December. It is not time to give up peace, hope, love, and joy as the expectations of this season, but peace, hope, love, and joy are achieved through focused effort and cooperation that are driven by empathy and the desire to see a better world for everyone. Peace, love, hope, and joy are not the outcome of complacency and self-interest. Peace, hope, love, and joy are not the fruits of inequality. Peace, hope, love, and joy are not an unearned gift. Peace, hope, love, and joy are the result of compassionate and inclusive efforts. Peace, hope, love, and joy can not be bought. Perhaps the right sequence for the quartet is that love enables hope and when hope is turned into action the result is peace and joy. 

 

Most of us will make it through December. Next week’s letter on New Year’s Day will express expectations for the new beginnings that might follow in January. We will “Build Back Better.” It is time to do what Don Berwick challenged us to do five years ago and move beyond mere civility toward a genuine love for all of our neighbors. In the interim this week, I hope that you will enjoy this most unique holiday season we have had in a long time. 

 

Be well, and live and work in expectation of love, hope, peace, and joy. Endure the distances and absences that are required to keep everyone safe by knowing that this pandemic will pass. Let me hear from you in this season of hopeful salutations,

Gene