December 22, 2023

Dear Interested Readers,

 

A Reader’s Response

 

Sometimes when I am writing these notes I wonder if I am writing to myself. It can feel as if I am talking into a closet, and then I get an email that lets me know that there is at least one person out there who is reading these notes. This week the “pick me up” email came from a long-time acquaintance and former patient. In over thirty years, we saw each other only once outside the confines of my office. The one out-of-office encounter occurred over twenty years ago when we noticed each other at a crowded restaurant on Lake Sunapee, and he offered my wife and me a seat at his table.

 

My interested reader and former patient is a retired healthcare attorney who saw me for at least a quarter of a century in my Kenmore Square primary care office. He is now in his mid-eighties. Before retiring, he had worked for a world-famous medical institution in Harvard’s Longwood Medical Area. Over the years, whenever I saw his name on my schedule I would smile to myself in anticipation of a stimulating conversation. He survived my care and retired to a hillside farm in Sutton, New Hampshire not far from where I live now. 

 

During our visits for check-ups, I would hear bits and pieces about his blissful life in retirement in Sutton, New Hampshire. From those conversations during office visits, I know that in retirement he was involved in many volunteer activities in and around Sutton. He built and repaired stone walls on his land, and even volunteered with the local EMTs.

 

I always thought that we would see each other after I too moved to the neighborhood in retirement, but it was not to be because I now know that he moved on to a warmer retirement in Florida in 2007, not long before I left the office to become the CEO of Harvard Vanguard and Atrius Health. In Florida, he has continued to enjoy being very active outdoors twelve months a year. After my retirement and his move to Florida, we remained in occasional contact as he would respond to these Friday notes, and give me updates on his good health. 

 

The picture in today’s header was taken last Sunday evening in front of the historic South Sutton Meeting House as people were leaving after a Christmas program. The Meeting House was built in 1839. It replaced an earlier structure built in the 1790s. If you follow the link and read the history you will learn that Minnesota Governor John Pillsbury who founded the Pillsbury flour company donated the lovely chandelier of oil lamps that hangs in the Meeting House. The town of Sutton’s offices are in Pillsbury Memorial Hall which was also donated by the wealthy governor who was born and raised in Sutton before heading west to make his fortune. Click here to view a previous Christmas pageant and learn even more about the Meeting House.  

 

We arrived early because we knew there would be a large crowd. As I was sitting in the cold and dark waiting for the program to begin, I began to think about my old friend, patient, and “Interested Reader” who once lived in Sutton. I wondered if he and his wife had ever attended the annual event.

 

When I say “dark and cold” it is not hyperbole. As you can see from the picture below, the Meeting House has no electricity. It also has no heat. If it weren’t so dark you could see that the audience is decked out in parkas and gloves as if they were headed off to ski. There were plenty of candles and a few battery-operated lights on the podium, but otherwise, the meeting environment was much like it would have been in 1840. I guess that there have been hundreds of angels and shepherds standing in the cold over many decades of Christmas celebrations. 

 

 

I love Christmas pageants for the carols and the children dressed up as angels, shepherds, or wise Kings who had followed a star from their homes in the East. In the far right corner of the picture, you can see one of the Kings from the east on a camel.

 

Out of view to the left older children took turns reading the Christmas story by dim candlelight while a choir accompanied by a guitar sang the appropriate carols. The nativity enactment was followed by a reading of Clement Moore’s “A Visit From St. Nicholas” which I always refer to by its first line, “‘Twas the night before Christmas.” After the ceremony of lighting everyone’s candle and more carols, we exited the hall and were greeted by a pretty authentic-looking Santa in front of the Meeting House. 

 

It was a strange coincidence when the next day, Monday, I received an email from my old patient whom I had been thinking about in the Meeting House. In my reply, I asked him if he had ever attended the pageant at the Meeting House. I also asked him if I could share with you a few paragraphs from the letter that he wrote to me. He responded:

 

I’d be honored if you used my language in the manner you proposed.

 

In a follow-up email, I sent him a couple of pictures from the Meeting House event and he responded:

 

Thanks for the pictures. We always went to that show. Seeing the various old traditions played out each year was one of the great joys of living in Sutton as were similar events in surrounding towns.

 

What he had written in his first email included some personal comparisons of his exercise program to the program I described that I follow, but then he expressed some thoughts that I think we should all consider: I have bolded the heart of his note. What he says convinces me that there is at least one person who shares many of the opinions that I express in these notes. As we roll toward the election for president, for congress, and for the offices that control state government this year, I plan to comment frequently on the importance of electing officials who care about the social determinants of health and who understand and are committed to effectively combating global warming and reducing the gun violence in this country. I think those are issues that responsible Democrats and Republicans could embrace in a bipartisan way. I seriously doubt that there could be progress on any of these issues if anyone who wears a MAGA hat, or fears a MAGA base is elected. My friend writes:  

 

I still enjoy your Musings writing both those about your career and health issues but especially your thoughts about social and political issues since I’m always of the same persuasion. 

Glad to see that the press is finally openly noting that Trump is a fascist and hoping that the public finds that enough beyond the pale to reject him. It is too distressing to think of him in the White House again destroying democracy.

There are so many changes in science and technology these days that I can’t keep up with hearing about it all never mind understanding it. The James Webb telescope is changing long-held beliefs in cosmology, AI, robotics and quantum computing will change business and manufacturing, material science is producing new materials that will change many things, dramatic new battery technology will greatly advance the reality of electric vehicles, and quantum physics will keep us puzzled for a long time. Interesting times lie ahead.

 

Indeed, we live in interesting times, and even more interesting things lie ahead. I look forward to more conversations with my Florida friend as the 2024 election approaches. The stakes are always high when we go to the polls to vote for a president. This election could preserve democracy while advancing the possibility of policies that will improve the social determinants of health and reverse the trend of increasing costs and deteriorating access to needed care. The reverse could also be true 

 

More of My Story: The Serial Continues

 

When I was in elementary school I would walk down three blocks from our home at the corner of Washington Avenue and 28th Street where I would hang a left and continue walking three more blocks to Sanger Avenue Elementary School. If I turned right on 25th Street and walked one block over to Austin Avenue it was only a few blocks down to the public library at 18th and Austin. 

 

That was my world in my pre-teen and early adolescent years. I was a roamer. First, I traveled on foot. Later, I ranged more widely on my J.C. Higgins Sears bicycle, and later still, after age 14, I was all over town on, my Cushman Husky motor scooter that I bought with money earned from mowing lawns and bagging groceries at the A&P. I never had a license for the scooter, and in those more casual and carefree days, it didn’t seem to make a difference. 

 

By foot, bike, or scooter, the Twenty-Fifth Street Theater was a block closer to my home than my school on Sanger Ave. 25th Street was a commercial street with two pharmacies, a barber, a Texaco filling station, a couple of “greasy spoon” restaurants, and the theater.

 

Every Saturday afternoon the theater showed a double feature along with a newsreel, cartoons, and the next episode of a serial. Zorro was my favorite. The theater had air conditioning which was an attraction in itself during the summer in Texas in the fifties. The whole package—movies, cartoons, Zorro, and air conditioning— was quite a bargain for 25 cents.

 

As the next episode of the current serial began, there was often a brief flashback to the last episode. Following that format, the last paragraph of last week’s episode in the continuing story of the evolution of my medical moral sensibilities was:

 

Ken did a lot of work pulling Atrius together. I learned a lot from him in our weekly breakfast meetings at a local dive in Wellesley where we both lived and near our corporate offices in an office park nearby in Newton. You can imagine my surprise when in the summer of 2005, just as things were getting better, at one of those breakfast meetings Ken informed me that he was taking the position of COO with Allina Health Care in Minneapolis. It was time to call Carol Emmott again. We needed a new CEO. 

 

By the summer of 2005 when Ken dropped his bomb on me, Harvard Vanguard and Atrius were in an ascendancy. About sixty percent of the Atrius patients were in Vanguard, but the ability to have the other smaller Atrius groups participate in covering the overhead was a win for Vanguard and a boon to the other groups that had access to the benefits of Vanguard’s business infrastructure, quality management capabilities, and bargaining expertise. The additional patients from the other groups added bargaining clout. Collectively, we bargained for contracts with insurers, hospitals, and medical vendors with the advantage of a patient population of over 800,000.

 

Each Atrius member organization retained substantial internal control so that when all the benefits of collaboration were considered, there was virtually no downside for the groups that Ken had recruited in the formation of Atrius. The final reality was that the CEO of Vanguard was also the CEO of Atrius. Initially, the chairman of the Atrius board was a pediatrician from the Dedham Medical Group. By the time Ken announced his departure, I was the chair of both the Atrius and Vanguard boards. 

 

Ken had recruited an excellent management team, and two of its very talented members announced that they wanted to be candidates for his job. Neither one was a physician, and neither one had been a part of any Atrius group before Ken had recruited them. One, the CFO, became interim CEO, and the other continued in his role as Chief Operating Officer. 

 

The board felt that we needed to do a national search. By the time of Ken’s departure, the board of Vanguard was quite diverse and informed Carol Emmott as she began her search that it wanted her to develop a very diverse candidate pool. 

 

Carol exceeded our expectations. She brought us a very talented woman who was very successful in managing the ambulatory practices of Advocate Healthcare in Chicago. We were delighted, and I thought we had cleared another hurdle and were back on track.

 

Unfortunately, the Vanguard board was the primary “decider.” In retrospect, we did not give the other Atrius groups as much voice in the CEO selection process as perhaps we should have. Atrius had a very “loose” structure that was a confederation controlled by Vanguard because of its size and its structural assets which it “sold” cheaply to the other groups. Ken had the personality to make that loose affiliation work. Ken did not need to have a “reporting” relationship with the CEOs of the other groups to make Atrius a manageable entity. He was the “alpha dog” that all the other CEOs were delighted to follow. He also could manage a diverse and often internally competitive management team. No one worked harder than Ken and no one dared to focus on their own ambitions when Ken was present. 

 

As our new CEO began to learn the inside story of Atrius, I sensed that the extroverted personality that had attracted us to her began to fade. Early, she was very interactive with me and the other board members. As time went on things changed. What I did not know initially was that a similar wall of non-communication had developed between her and the other Atrius CEOs and with some on the management team. Ken was a hard act to follow, everyone missed Ken’s easygoing collegial style which was both gentle and firm. Ken made things work.

 

Remember that there were at least two members of the management team that the new CEO inherited who had wanted her job. 2007 was an increasingly difficult year. It became increasingly obvious that our loose confederation was a problem for our new CEO. It was becoming apparent to the CEOs of the member groups that she wanted a single Atrius board with all of the Atrius “partners” reporting to her. She had come from an organization that had a traditional corporate structure with well-defined roles and responsibilities reporting up one line with one board at the top. 

 

In such an environment rumors develop and animosities become obvious. What had begun with great expectations deteriorated further as a couple of key executives resigned, and announced that the environment was the reason for their departure. The Vanguard board became increasingly concerned as 2008 began and rumors of distrust increased. As the board tried to understand the extent of the dysfunction it became clear that the problems had escalated past a point of no return. In early February 2008 I was appointed as the interim CEO. 

 

At the time of my appointment, the board knew that I was much like the previous interim CEO, Dr. Gordon Vineyard.  Like Gordon, I was a longtime member of the group. I had been in the organization for 33 years. Also like Gordon, I had been talking about retiring. I was 63. My youngest son had graduated from college the previous year. I think that I was suffering from increasing fatigue and burnout.

 

The previous twenty-five years of organizational leadership had taught me a lot, but leading the physician group and then the boards in difficult times while practicing full time seeing about a hundred patients a week, and rounding in the hospital had taken their toll on me. I also suspected that I had asked too much of my family. I needed a change. A few months as an interim followed by retirement was a plausible way forward. 

 

’Tis The Season

 

I grew up in a church that no longer exists. The name is the same, but almost everything else has changed. It is hard to believe now, but in the early and mid-70s, the Southern Baptist Convention and 70% of Baptists in Texas supported abortion as described in Roe v. Wade. That was before religious fundamentalists took over the denomination. The church of my youth valued the separation of church and state. People would have been dumbfounded by the concept of “Christain Nationalism.” Baptists of the era of my childhood and adolescence were against a lot of things other than abortion. Alcohol. smoking (except in tobacco-growing states), gambling, dancing, marital infidelity, and premarital sex were theoretically what the church warned against. Abortion didn’t get much concern since it was generally considered that life began at birth.

 

The Baptist church of my childhood did not try to be a political force until a Catholic ran for president. Baptist ministers were concerned that the pope could control a Catholic president. John Kennedy set those concerns aside with a speech to Baptist ministers in Houston in September 1960, but the election of a Catholic president did not irradicate the concerns that Baptists had about Catholic orthodoxy. Sometime in my adolescence, my saintly mother asked me to promise her that I would not date or marry a Catholic girl, but of course, I did. My wife remembers how she was taught by the nuns that protestants like me were going to hell. She was very sorry for the fate of her little protestant friends, and she has told me that she was a little frightened and nervous when the baccalaureate service of her nursing school graduation was held at the First Baptist Church in America in Providence, Rhode Island. 

 

Perhaps it was a concern about Catholic orthodoxy that prevented the Baptist Church in the era of my youth from making much of Advent and Lent. That is no longer true, and it is probably a good thing although both of those seasons on the liturgical calendar still feel foreign to me even as both are faithfully celebrated in the American Baptist Church that I now attend. The Baptist Church in America split into a Northern, now American Baptist Convention, and the Southern Baptist Convention in the mid-1840s over the issue of slavery. 

 

Advent has been a learning curve for me, but I love its themes of “hope, peace, joy, and love.” As I listen to the presentation of the Advent themes many thoughts run through my head. Could these themes not apply to the promotion of the social determinants of health? Why are these themes claimed by Christians when in fact I know that many secular humanists, Jews, Muslims, Buddhists, and thoughtful people everywhere embrace these themes?  Any glance at a newspaper is likely to reveal a Christian somewhere who is behaving in a way that seems counter to the objective of “Peace on Earth, Good Will to All.” You may note that the phrase as I have stated it varies from the King James Version of the Bible translated in 1611 as “Glory to God in the highest, and on earth peace, goodwill toward men.” In these days when every word is searched for hidden meaning we need to emphasize that peace and goodwill are deserved by everyone on the planet. 

 

I believe that we do not need to be dualistic and focus on who deserves hope, peace, joy, and love plus health and freedom from fear. Those are universal desires and should be the entitlement of every one of the earth’s almost eight billion inhabitants. I also believe that those who think that those goals belong only to those who think in ways they approve of are likely to be doomed to disappointment while living a life without much hope, peace, joy, and peace. I need to listen to that wisdom myself.

 

I wish you hope, peace, joy, love, and health in this season and the will and strength to do what you can to pursue those benefits for every other person in the New Year.

Be Well,

Gene