15 November 2019
Dear Interested Readers,
More Thoughts on Professionalism and Primary Care
I enjoyed writing last Tuesday about healthcare in Hawaii and the Hawaiian expression of our nationwide problems in primary care staffing. When I write my objective is to get a few people thinking. Sometimes the only thing I know for sure after posting a message is that I got myself thinking.
I am a primary care physician at heart. I grew up in a time and in a place where specialties as we now practice them were not very common. An internist was usually a consultant to general practitioners, and the concept of “family physician” was still in evolution when I was in medical school. My most gratifying experience in medical school was the parallel two year experience that I had over the third and fourth years in the Family Practice Unit at Children’s Hospital in Boston. My original plan was to take part in a residency program that was offered by Children’s and the Brigham that was designed to lead to board certification in both pediatrics and internal medicine. When I learned that the leadership of the program was uncertain because Dr. Joel Alpert was leaving Childrens to become chief of Pediatrics at Boston City I withdrew my application for the program since its future was uncertain. You should definitely click on the link to read more about Dr Alpert, a true believer in the value of primary care. After the matching process for internships in medicine was over, I still ended up at the Brigham. It was the middle of the War in Vietnam, so the next step in my career planning was to apply for a “Berry Plan” which would protect me from being drafted until I had completed my residency training.
I have been treated for hypertension since my senior year in high school. On a visit to my PCP in the fall of 1962 for a severe sore throat my BP was 170/110. Instead of giving me a prescription for penicillin, as I had expected, my GP admitted me to the Baptist Hospital in Columbia, South Carolina for a workup. It was a terrifying experience. It was the middle of football season in my senior year of high school. The experience terrified me on two levels. It threatened my plan of going to college on a football scholarship, and then it was just a horrible experience for a seventeen year old boy to go to the doctor with a little sore throat and then two hours later find himself between two old men in a three bed hospital room. I remember sitting in the admitting office at the hospital and wondering, does hypertension mean that I am “hyper-tense.” I was naive and so frightened that I thought that perhaps I had some sort of emotional problem.
It is strange to contemplate what you remember from a distant experience. I remember that the daily rate for the room that I was admitted to that first night was $13. It was in an ancient building with dark rooms and high ceilings. The man to my right by the windows must have had the DTs. The old man to my left near the door was demented or disoriented and hollered all night. It was impossible to sleep. There was nothing to read. I was alone in my own nightmare. Sometime after midnight while I was lying awake in the dark, I was startled by a young woman who said she was going to be a medical missionary. In retrospect, I realize that she must have been a doctor who was attending a local evangelical seminary, and was doing admission histories and physicals as a “moonlighter.” She apologized for the late hour, but said that she needed to do a complete medical exam on me, including a rectal exam. It was not a nightmare, it was a real confusing and frightening experience.
After that first horrendous night, my general practitioner called in an internist who was also a cardiologist, Dr. Edward Masters. Dr. Masters was perhaps the most knowledgeable physician in town. He was Vanderbilt trained, and was also a “cardiologist,” although I am sure it was not because of a fellowship in cardiology. It was because he had focused on cardiovascular problems in his practice of internal medicine.
My introduction to Dr. Masters was my first introduction to someone who exuded professionalism. He looked much like the friendly doctor in a creation of Norman Rockwell. He wore a suit with a bow tie, and there was a Phi Beta Kappa key hanging from the watch chain that decorated his vest pocket.
Dr. Masters sat down on my bed and grasped my hand. His voice was soft and relaxed and in a short time he gained my confidence by doing something no one else had done. He explained to me why I was in the hospital and what the plans were. He assured me that I would soon be back in school and no matter what the tests showed that I would be alright. Later that day my father had me moved to a more comfortable semi private room in a newer building that was $21 dollars a day. Two days later after missing an important football game during which a scrub wore my jersey, and sat on the bench, which I was sure would confuse the “scouts” that I hoped would be attending to watch me play, I was discharged on reserpine with a diagnosis of essential hypertension.
Over the next five years, during my last year of high school and four years of college, I was a frequent visitor to Dr. Master’s little office located in a converted house not far from the university and the hospital. It was because of Dr. Masters that I applied to Vanderbilt and won a scholarship for four years of tuition and living expenses, which is where I would have gone to medical school if he had not also written me such a good letter of recommendation that I am sure was influential in my admission to Harvard. Under Dr. Masters, my blood pressure improved to marginally acceptable levels on thiazides and various other poisons that were available, but it never really came under good control. What I did experience from him was a deep sense of caring. He became my original template for professionalism. I wanted nothing more than to be like him.
In the sixties and early seventies treatment beyond thiazides, which were not enough for me, was pretty distasteful. I was tried on a variety of drugs. The nastiest one was my original medication, reserpine. On reserpine I had “LSD” like nightmares. Later, I suffered on minoxidil. On minoxidil I became an edematous ape with hair growing everywhere and edema that required up to 320 mg of furosemide daily. Alpha methyldopa and hydralazine were not much fun either. Beta blockers, ACE inhibitors, and most of the usual repertoire of drugs we use now, were not yet available. The VA Cooperative study demonstrating the benefit of treating hypertension was not published until 1970.
The search for an optimal treatment program continued when I went to medical school. Over the years I would get fed up with treatment and assume that I was just a “cuff reactor,” after I learned that term, and go for many months without having my blood pressure checked. I reasoned that a good exercise program and a low salt diet was all that I needed. My doctor at the student health service who would calmly debate these issues with me was the eminent cardiologist, “father of nuclear medicine,” and retired Chief of Medicine at the Beth Israel from 1928 to 1962, Hermann Blumgart. Dr. Blumgart had retired from his research and professorship. He seemed to enjoy being the PCP for Harvard Medical School students like me before his death in 1977. My blood pressure and problems with the meds he tried me on were a source of frustration for both of us. But his kindness and patience, and the sense that he was genuinely interested in me as a person, was my second encounter with exceptional professionalism.
I did not really know for a long time what a famous doctor I was privileged to see. Initially, I assumed that he was just an old guy who needed to continue to practice to have something to do. As time passed, and I had an opportunity to learn more about who he was, I realized that I was exceptionally lucky to get care from someone who had been a colleague of Francis Weld Peabody, the author of “The Care of The Patient,” and Soma Weiss, the 43 year old Chief of Medicine at the Brigham who died on rounds after announcing to the interns and residents with him that he had just experienced a ruptured aneurysm. It was startling to realize that I was in the presence of a clinical giant who was treating me with with care and respect despite all of my non compliance, resistance, and magical thinking. He was demonstrating patient centeredness to me before the term was in popular use. Patient centeredness is the core of medical professionalism. He, like Dr. Masters, intuitively knew that the key to the care of the patient, as his colleague Dr. Peabody famously taught us, is caring for the patient. Ironically, Dr. Blumgart did not live long enough to see the introduction of the drug I needed which was captopril. I have been on hydrochlorothiazide plus an ACE inhibitor since captopril was first released in 1980 with excellent blood pressure control. I moved to enalapril, and finally lisinopril for once daily convenience, as the longer acting ACEs were developed.
I tell my story of my blood pressure because it did two positive things for me. First, it introduced me to two incredible role models of patient centered care and professionalism. Second, my blood pressure saved me from Vietnam. After securing my Berry Plan, I had to report for an Army physical as part of the processing of my “deferment.” The Brigham internship was mostly an every other night experience. I had been up all night admitting patients the night before the morning that I boarded a bus in downtown Boston with the other “recruits” who were headed to a huge building on a pier in the South Boston Naval Annex for our induction physicals.
Those who were destined to be officers were treated with a little more dignity than the other recruits. We were in shorter lines and allowed to cover ourselves a little bit more as we moved from station to station. I was pulled out of the line when after three tries my BP remained in the 240/120 range. I was asked to lie down and wait for more readings. An hour or so later I was told to go home and come back the next day. The numbers went up and down a bit but stayed in the same range, and in the end I was rejected. My draft status became 4F, and my Berry Plan was revoked. Perhaps my life was saved. I assume that the Army figured that they did not want to waste a deferment on a physician who might have a stroke or develop renal failure and then be a long term liability when there were plenty of other young doctors to draw from.
My reaction was that the Army had just given me back two years of my life. I could complete my residency as planned. After my residency, I could do a cardiology fellowship in those same two years that I would have spent in an army hospital somewhere, perhaps in Vietnam. I reasoned that if I wanted to be a primary care physician like Dr. Masters, I would be even better if I also had specialty training. Serendipity, is a wonderful thing. During my house officer years and fellowship, one of my mentors was Dr. Marshall Wolf, who was also an exemplary role model of professionalism, and who knew of my combined interest in primary care and cardiology. I was surprised when Dr. Wolf asked me if I would be interested in taking over his practice at Harvard Community Health Plan, where all the “specialists” also had a primary care practice. He was leaving to take over the full-time responsibility for the housestaff training program at the Brigham. I walked into the HCHP office on Beacon Street on July 1,1975, having never applied for the job. I soon realized that I still had a lot to learn about being a professional, but I also soon realized that I was surrounded by a group of colleagues who had come together to realize the vision of more effective primary care through the genius and persistence of a visionary.
At the time, I did not realize how extremely lucky I was to have the opportunity to work in an environment where the mission was to improve the experience of care. In retrospect HCHP was an attempt to structure a delivery system that would carry traditional medical values into a world that was rapidly becoming more and more focused on technology and finance. Dr. Ebert was a clinician and academic with an intense interest in optimizing the experience of both the patient and the physician. He realized that change was inevitable. He was concerned that we were becoming so focused on the issues of hospital care and the technical aspects of specialty practice that we were losing contact with the patient and the professional and social responsibilities of care delivery. He knew that good health could be the product of a long term positive relationships between a doctor and a patient. A core research question that we were exploring was whether or not those caring relationships could be extended to a team, and the efforts of the team so effectively organized, that everyone in the community could have access to the sort of patient centered care that I had enjoyed. There is no doubt in my mind that without the persistence of Dr. Masters and Dr. Blumgart, I could have ended up in renal failure, or have had a stroke and died in my early 50s, sharing the same fate as my great grandfather, a country doctor in North Carolina.
Dr. Ebert did believe that highly organized team based ambulatory care could be scaled up to a system that was capable of giving everyone in the community the sort of primary care that my privileges gave me. The fifty year experience of his experiment is one of continuing tension between professionalism and the business of medicine. As is true with so much of our medical knowledge, the benefits could be theoretically available to everyone, if there was a universal will to make access to patient centered primary care available to all of us.
Professionalism is about the experience in the moment, as was true when Dr. Masters sensed that I was frightened and apprehensive. He sensed what I needed, and sat down on my hospital bed and relieved my immediate discomfort by explaining what was happening while offering reassurance that ultimately things would be ok. Professionalism is about long term relationships. Dr. Masters was there with me for over four years, and then Dr. Blumgart was a steady presence for four years. Both men offered me more than just their knowledge of hypertension. They were interested in me as an individual, and they integrated their advice with real interest in who I was and what I hoped to be. They did the best they could for me in the context of what was available and my capacity to comply with their advice. At no point did they accuse me of non compliance or tell me to stop wasting their time. I also believe that professionalism requires us all to work diligently to find a way to make patient centered primary care available to everyone. The sad truth about Hawaii, Arizona, and so many places in our country is that we are losing ground in our effort to achieve the essential goals of the Triple Aim. I think professionalism calls us to work diligently to reverse this trend.
When I think about what I have enjoyed about my own experience as a professional in healthcare, I realize that it was the long term relationships that I valued most. There were many patients that I knew for over thirty years, and I am sure that the most significant contribution that I made to their care was not the prescriptions that I wrote, or hospitalizations that I managed. It was the steady presence that the system of care within which I worked allowed me to offer to them. The patient and I were on a journey together. My rationalization when I left practice for management responsibilities was the hope that I would have the opportunity to use what I had learned from caring for my patients in a changing medical environment to stabilize the practice and continue the quest for universal patient centered primary care through a better deployment of our resources and further clarification of care as an essential American human right.
A year or so ago Johann Hari authored a book entitled Lost Connections: Why You’re Depressed and How to Find Hope. The message of the book is that many people live in a world devoid of sustaining relationships. A lack of sustaining relationships is not only a tragedy in the life of an individual, but a society that is devoid of the sort of long term relationships that professionalism fosters is one that often experiences wasted resources and efforts, as well as poor outcomes. Perhaps one of the reasons that your ZIP code is more of a determinant of your longevity than your genetic code is not that the poor have less access to high tech medical care in the midst of a sudden medical catastrophe, but rather that the long term sustaining relationship with a medical professional for their primary care is not easily available, just as good nutrition is less available where they live. As professionals we need to realize that our responsibilities do not end at the door to our office. They extend into the community.
The View From The Mountain Top
On our first trip to Maui we enjoyed driving to the summit of Haleakalā, the 10,000 foot “shield volcano” that is almost always in view wherever you might be on the island. On this trip I was looking forward to a return to the mountain top. You never know whether or not you will abe see much more than the clouds, but once again we were lucky. There were a few clouds that were hovering far below at about six thousand feet, but they were more effective as a frame for the picture rather than an obstruction of the view. The mountain rises ten thousand feet above the beaches, but there is another 15,000 feet of mountain between the ocean floor and the shore line which makes it taller than Denali, and just a little shorter than Everest.
Since it was pretty clear day, we could see the “big island” to the southeast and all of Maui and the nearby islands to the west, but the most remarkable view was the view into the crater. It has been many hundred years, sometime in the 17th century, that Haleakalā last erupted, but you get the sense when you look into the crater that something is iminent. The crater is massive. It is more than seven miles in diameter, and 2,000 feet deep, but as you can see from the picture looking into the crater that is today’s header, the most remarkable thing to see is the swirl of otherworldly colors.
When you look into a crater you are filled with a sense of wonder as you realize how quickly the world can change. In 2007 we walked across the caldera of Kilauea on the southern shore of Hawaii, the big island. I am not sure that that is possible now, since Kilauea is the most active and southernmost volcano on the “big island” and has erupted several times since, especially during 2018. The Kilauea caldera is small compared to the crater on Haleakala. It is 400 feet deep and two miles in diameter. Since 2007, Kilauea’s eruptions have extended the island by more than a mile into Kapoho Bay. The lava flow destroyed almost 800 homes. I guess that is nature’s demonstration of “creative destruction.” There is nothing like a big mountain to put your own cosmic insignificance into perspective.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
