April 19, 2024
Dear interested Readers,
What Can We Do?
I should give you a warning that what follows is just personal opinion and speculation based on many years of observation and substantial frustration. As I think back over what I have observed in myself as I have tried to give you the story of my evolution in medicine, I realize that i was always “mostly hopeful.” I was easily inspired and influenced by my exposure to a host of thoughtful healthcare professionals. The peak of my positive expectations occurred with the passage of the ACA in 2010.
The ACA was not perfect, but it was evidence of great progress. I would have preferred the law to include a public option and a clear-cut path away from fee-for-service finance, but it was a huge step toward universal coverage and a great boon to the coverage of preventative measures that ensure health. Like others, I was disappointed by the chipping away of its structure by the Supreme Court and the constant attacks by Republican politicians and others who advocated for a status quo that was very beneficial to their interests. As much as those efforts worried me, I was increasingly reassured as the much-maligned legislation continued to survive all the attacks its enemies could throw at it.
I was proud of what we were trying to do at Atrius and was even more encouraged as I attended meetings of the Group Practice Improvement Network (GPIN), and continued to try to follow the advice coming from the Institute for Health Care Improvement (IHI). Atrius was part of a growing movement among progressive medical practices and healthcare institutions that shared a commitment to the ideas behind the Triple Aim.
To learn more and to transfer progress to Atrius made by other organizations I traveled to Geisinger Health in Pennsylvania, ThedaCare in Wisconsin, Virginia Mason, and Group Health in Seattle, and attended meetings with the leadership of the Permanente Medical Group. I developed many connections with other forward-looking groups and healthcare systems as I became active in the effort to use Lean and other process improvement philosophies to move toward systems of care consistent with the vision for a healthcare system for the twenty-first century as presented in Crossing The Quality Chasm in 2001.
The only moment of doubt I encountered in those heady years between 2008 and 2013 occurred at a small day-long conference that I attended at Dartmouth in Hanover as part of the Blue Cross-sponsored LEAD program. I spent the day sitting next to an idol of mine, Dr. Paul Betalden, who along with Don Berwick was one of the founders of IHI. As the day wore on, I had the sense that Dr. Batalden did not feel well. Late in the afternoon, I asked him if he was feeling well. He responded that he was fine. He was just worried. He told me that he had been promoting clinical improvement for most of his professional life, but now he was worried that all that had been accomplished could be lost in a few years if the enthusiasm was not transferred to the next generation of healthcare leadership and healthcare professionals. He was not certain that the work and the associated accomplishments would survive. At the time, I wondered whether of not he might be depressed. My enthusiasm for improvement was high, and everyone that I was meeting seemed to be equally enthusiastic about the process of transforming healthcare.
I retired six years later at the end of 2013. By then there was beginning to be a little suggestion that the status quo might be having some success in resisting a transformation of the sort I was advocating. Looking back now across the interval of a decade, I find that I now share Dr. Batalden’s concern. There have been many unanticipated challenges to progress. In 2014 we did not have such obvious workforce problems. COVID had not yet demonstrated the deficiencies of our system of public health, or the vast inequities that put huge segments of our population at greater risk.
In 2014 we were talking about the social determinants of health, but it was unclear whether or not healthcare providers could improve them or even had the capacity or responsibilities to address social problems and deficiencies. I would not have predicted then that in 2024 we would still be losing ground ten years later in housing, child care, public transportation, and education. Within our groups, we had plans and ideas about how to improve our operations and the safety and patient-centeredness of the care we provided, but we had no strategy for improving the social determinants of health. That seemed to be the job of someone else.
The election of 2016 was a shock and surprise. In retrospect, it feels like the only positive event of the next four years was the moment John McCain turned down his thumb to kill President Trump’s effort to “repeal and replace” the ACA. Then came COVID. Some hope for improvement in healthcare practice and in the social determinants of health returned when President Biden was elected and Democrats had a slim majority in the House and the slimmest possible control of the Senate.
The bills that were passed during the first two years of the Biden presidency before the 2022 midterms were remarkable, but the bill that would have had the most impact on the social determinants of health was the ill-fated Build Back Better Bill. It is disturbing to me that Build Back Better failed because of the resistance of Senator Joe Manchin of West Virginia. After Manchin’s opposition had stipped most of the social programs from the bill, the effort was passed as the Inflation Reduction Act of 2022. It was an opportunity lost, but there were still other disappointments to come, like the Supreme Court’s decision to overturn Roe v. Wade.
We are now moving toward another election which in my mind is an opportunity to get back on track toward the the principles of the Triple Aim. I no longer believe that we can “fix” healthcare through efforts at internal improvements in the operations of individual systems of care. I do believe that we can get back on the long road toward better healthcare through policies directed toward improving the social determinants of health and better programs to support workforce development. The positive application of AI does present the possibility of improving practice. How will it be applied in a broader way to public health and the effort to lift everyone toward a more equitable system of care? Success will require policies and legislation that directly address workforce issues, child care, poverty, mental health, gun control, the right of women to control their own reproductive decisions, global warming, and all of the other attitudes that are directly attacked by the political nihilism, isolationist attitudes, and attention to self-interest that characterize the MAGA movement.
I don’t expect much in the way of progressive benefit from the conviction of Donald Trump in any of his trials for corruption and violations of his oath to defend the Constitution. It amazes me that the polls show that he even has a chance to win the election in November, but after the disappointments of the last eight years, I accept that anything is possible.
Why should I care? I am nearing the end of my life’s journey, but I do care like Paul Betalden said he cared, about what the next generation would do with the enthusiasm to improve healthcare. I believe that what is detrimental to any of us is ultimately a risk for all of us. This election cycle is off to an early start. It will be characterized by misinformation and fear-mongering about the economy, crime, and the trouble at our borders. Many will vote for what they think will provide them with the best short-term protection. I am not a great historian, but I do believe that seeking relief through short-term self-serving strategies can lead to long-term problems and greater jeopardy even for those who are most advantaged by the status quo. If there is anything that global warming should teach us it is that we can’t expect any long-term protection if we try to cheat the moment. If we ever want to have a more equitable system of care we must give greater and more effective attention to rectifying the glaring inequities in the social determinants of health.
Marathon Memories, Sort Of Spring, and Trump’s Trial
In retrospect, it is surprising that I lived in Boston from 1967 until 1976 without ever paying any attention to the Boston Marathon. I knew about Paul Revere’s ride and the battle on Lexington Green on April 19, 1775, but during the years of medical school, internship, residency, and my fellowship, Patriots’ Day was just another day in the hospital. I did take note of Bill Rodger’s first marathon win in April 1975 because I read that he worked at Peter Bent Brigham as a nurse’s aide and in other capacities to fulfill his service duties as a conscientious objector. He was one of the faceless members of the support staff whose efforts were taken for granted.
It took a little effort to corroborate my memory, but I did find documentation of Rodger’s connection to healthcare in an article from 1977 in Sports Illustrated by Kenny Moore who was a champion runner and long-time writer for SI. Moore’s article was entitled “A GENTLE RADICAL WHO RUNS SCARED.” I became a consumer of most issues of Sports Illustrated for the next fifty years when in 1956 at age eleven I became fascinated with the 1956 Olympic Games in Australia. As an eleven-year-old, I was particularly fascinated by the story of Bobby Morrow, a young Texan who won three gold medals. If Moore’s article about Rodgers was not where I learned about Rodger’s connection to the Brigham, it does confirm my memory and expands my sense his commitment to social issues and the underserved. Moore writes:
…in 1970, Rodgers was granted conscientious-objector status, doing his alternative service at Peter Bent Brigham Hospital in Boston. “I was dirt in that hospital,” he says, his tone milder than his words. “I had one of those top-level jobs—washing dishes, emptying bedpans, taking bodies down to the morgue.” It was a disturbing time. “There were lots of nasty, horrible cases; don’t make me describe them. It bothered me most that here were people dying among strangers.”
The article also gives a very robust view of Rodger’s work with autistic children at the Fernald State School as well as his evolution as a marathon champion. Sometime in the late seventies Rodgers and his older brother opened a running store in Cleveland Circle at about mile 22 where the marathon course takes a slight left from Chestnut Hill Avenue onto Beacon Street. For many years I would see Rodgers on his training runs since both of us frequently ran around the Chestnut Hill Reservoir, Jamaica Pond, and on the track of Boston College which is located on the other side of the reservoir not far from his store.
After winning the 1975 Boston Marathon, Rodgers did not run in the famous 1976 race known as “the Run for the Hoses” because he had qualified earlier for the Olympic Marathon in Montreal. Patriots’ Day in 1976 was one of the hottest days of the year in Massachusetts. The official temp was in the nineties, but I am sure that on the road the temp exceeded one hundred degrees.
As fate would have it, I scheduled myself to have some extensive restorative dental work done on Patriots’ Day 1976. By then I was working at Harvard Community Health Plan and Patriots’ Day was a legal holiday which HCHP observed. Perhaps also as a function of fate, my dentist’s office was located in Cleveland Circle. When I went into his office for a two-hour appointment sometime before noon, Cleveland Circle looked fairly deserted like one expects of a business district on a legal holiday. When I emerged from the dentist’s office several hours later I was confronted with a scene like I had never seen before. There was a river of hundreds of runners barreling down the hill on Chestnut Hill Avenue and making the turn onto Beacon Street. Even more amazing to me was that these athletes appeared to be ordinary people and not gazelle-like long-distance runners like Rodgers and Frank Shorter.
The marathon through Newton is run mostly on Commonwealth Avenue. The race takes a sharp right turn from Washington Street onto Commonwealth Avenue at a fire station not far past the Charles River and Newton Wellesley Hospital From there the course runs over the series of famous Newton hills as it approaches Boston College. The last and longest climb is the famous “Heartbreak Hill.” After reaching the top of “Heartbreak,” Boston College and the Chestnut Hill reservoir are on the runner’s right as they enjoy a downslope run toward Cleveland Circle. The race departs Commonwealth Avenue which turns to the left to head into Brighton toward Kenmore Square where it will be crossed again by Beacon Street. The runners continue straight down an incline on Chestnut Hill Avenue and into Cleveland Circle where they turn left onto Beacon Street. My dentist’s office was in the first building on the inbound side of Beacon at the turn.
My first shock as I exited the building where my dentist’s office was located was the heat. In Boston, the temperature is above 90 only a few days each summer and on this day in mid-April, it felt like I was standing in front of a blast furnace. An even greater surprise was all the runners coming down Chestnut Hill Avenue and making the turn onto Beacon Street right in front of me. I had never seen the marathon before and had no idea that it was an event that “ordinary people” could join. The determined faces of the runners covered with the sweat and exhaustion of running 22 miles in the heat were an immediate inspiration. In an instant, I reasoned that If these ordinary-looking folks could do it, so could I. My running career began at 6 AM the following day when I put on a pair of old tennis shoes that were too small and jogged about a mile round trip down to a neighborhood playground and back.
Everyone benefits from a guide. Not long after I had bought myself a pair of “real” running shoes and had extended my runs to about four miles, a young woman was referred to me for evaluation of her palpitations. In conversation with her, I learned that she and her husband who was a dentist and had run track in college both had recently run a marathon in Baltimore. Her arrhythmia consisted of benign APCs. After resolving her problem, she invited me to join her and her husband on some of their longer Sunday runs, She encouraged me by saying that I could get in shape for the marathon within the year. It’s great to have a coach!
She was right. I was ready for my first attempt at Boston on Patriots Day 1977, which was probably the second-hottest Boston Marathon in history. I was running with a number from the American Medical Joggers Association. My goal was to run a three-hour marathon so that I would be an “official” entry in 1978. My coaches advised me that if I started too fast I would “die in the heat.” They advised me that my objective should just be “to finish,” but I was unable to restrain myself. Despite the heat, I ran at a sub-three-hour pace until mile 18. After running up “Firehouse Hill,” I was dead. My wife and little boys were standing at the corner of Commonwealth and Chestnut Street not far from my home at the time in a nearby Newton neighborhood. They were expecting to cheer me on as I ran past them. It was a great disappointment to them when I stopped and said I was “cooked.” I felt better later in the day when I learned that Bill Rodgers had also been “cooked.” He had also dropped out because of the heat. I soon learned that the best weather for me and Rodgers was an overcast day in the forties. Rodgers has said that he ran best when he needed to run with gloves and a stocking hat. Ditto for me.
I learned from my error. I was able to get a number for the New York Marathon for the fall of ‘77. I took my time and enjoyed my tour of New York’s boroughs. I finished at 3:40. The following February at the Lowell Marathon which was the last “qualifying” opportunity for me for the 1978 Boston Marathon, I ran a 2:57:57 on a day which was perfect for me. Six weeks later, not completely recovered from Lowell, I finished my first Boston at 3:07:16 after walking a little around mile 24 in Brookline. Between 1978 and 2005, I finished over 20 times. There were a few years when I was injured or again failed to correlate my pace with the temperature and was a DNF (Did Not Finish). 13 of those races were with my oldest son who holds the family record for the marathon at 2:57:07. I remind him that he was in his twenties when he did his best time. I was in my thirties. We are very competitive.
I made several attempts to get back to Boston after 2005, but my joints began to fail me. One of my daughters-in-law wanted to run a marathon. We trained vigorously in 2007, and she did finish the marathon at Disney World in January 2008. The race began with my son, my DIL, and myself running together. In the second mile, something tore in my right thigh. I started walking and jogging. My family thought I had dropped out and gone back to the hotel. They finished their race and after they discovered I was not around my family began to look for me. After getting them worried about what had happened to me, I crawled across the finish line in a little over six hours. I did not know then that I was crossing the finish line for the last time. Each year after that something happened to deny me.
In 2010, I was making yet another comeback attempt when my left knee which had been injured playing football forty-five years earlier “blew out” as I was doing a track workout. I was lame in one stride. It would be two years before I could even jog a slow mile again. The orthopedic surgeon said that I needed a “total knee.” I was busy with work as the CEO of Atrius, and I felt that I could not take the time off for the surgery. I chose conservative treatment, and over the next two years I got back to being able to jog for five or six miles at a pace of about ten minutes a mile, but now that too is gone to further injuries which have forced me to become a walker.
I don’t know what lies ahead, but if all my efforts are plotted against time it is easy to see where I am headed. What I have learned is that it is not the time or the distance that is the reward. The reward is just the joy of moving with the desire to do your best. The header for today is a picture taken of me by my wife not long after the marathon this week. I did a 35-minute mile with my rolling walker. Just making that mile gave me almost as much satisfaction as running Boston.
One thing that was obvious from the TV presentation of this year’s marathon is that spring has come to Boston. My wife was thrilled to see the scene as the race ran through our old neighborhood. Our home in Wellesley was just a few yards up a hill from the marathon course down Washington Street between miles 14 and 15. Over all those many years she drove me and my running buddies to the start in Hopkinton and then spotted us along the way before meeting us at the end of the run. In memory, it was great fun for her.
We are only a hundred miles north of Boston, but spring is still an off-and-on event for us. We do have one brave daffodil in our yard. Spring is a day-by-day thing.
I assume that this coming week will be dominated by former President Trump’s trial in New York. Other possibilities for entertainment and the pondering of “What’s to become of us” will perhaps be the continuing drama the Republicans are offering in the House. Although I share almost no political positions with Speaker Johnson, I am hoping that he will survive whatever damage Marjorie Taylor Greene and Matt Gaetz try to do to him. I strongly believe that we must support Ukraine and continue to support and advise Israel to work to achieve its objectives without unnecessary harm to innocent civilians. A lasting peace for Israel and the Palestinians is best facilitated by overcoming Hamas. I am resting up this weekend in anticipation that next week will be a very interesting week.
Be well,
Gene
