February 19, 2021

Dear Interested Readers,

 

An Anniversary

 

It’s been exactly thirteen years since I wrote my first Friday letter to my colleagues, the staff of Harvard Vanguard Medical Associates. I had been the Interim CEO for a little over a week and had spent my time trying to get my bearings by walking around several of our many practice sites. I had hoped to visit every site in some sort of rotation many times a year. When I wrote the first letter I had no idea how long my term of service would be, but I was convinced that if we were to continue to be successful I needed to be available, and I wanted to make sure that everyone who was part of our family felt that they knew what was happening and trusted that I wanted to know what they were thinking.

 

I had been in the practice for thirty-three years and had heard a lot of complaints about top-down management. I knew that people had strong opinions and that some of our most effective programs and processes had begun as innovations suggested by our staff. I felt that to tap into those ideas and to promote a sense of participation and “ownership” I needed to be seen, and I needed to be listening. The letter was conceptualized as the “anti-memo.” I wanted it to be conversational and of interest to the people whom I felt made us the quality organization that we were. I thought it would be a way of developing a conversation, telling our story to ourselves, and building a sense of community.  

 

The letter went to everyone who was employed. I felt that our relationship with our patients and their families included everything from the cleanliness of the offices to the skill of our most sophisticated specialists. I hoped that some of the readers would see their role in a new light. I wanted them to know that without their individual contribution we could not offer the service that we wanted our patients to experience. For some readers, I hoped that the takeaway would be a new insight that without the efforts of many people that they frequently took for granted their ability to exercise their special skills would be compromised. 

 

Although I did not have the language at the time I was looking for what is called “ubuntu” in Africa, a sense of “I am because we are” or as Martin Buber called it an “I and Thou” relationship. Reciprocity and respect are the heart of positive human relationships in all aspects of life–including multispecialty group practice. All those feelings were there when I sat down to write the letter. I also wanted people to trust that a new letter with the latest information would be delivered every Friday afternoon. I thought that if the people I was trying to lead knew that I was reliable in this one simple act, they might trust me in more complex circumstances. Every letter ended with a request for the reader to pass on to me anything that they thought I should know. 

 

Looking back I have been the primary beneficiary of this process. Often I have benefitted from the fact that it was easy for a reader to write back to correct a misconception, inform me of something I needed to know but had not yet heard, or to inform me of something that needed to be celebrated. The exercise has forced me to expand my own fund of knowledge. I have learned a lot. It has fostered a process of personal growth or perhaps it flattened the slope of the decline of my aging faculties.

 

Over thirteen years there are almost seven hundred Friday letters, and another 200 plus Tuesday postings. Two things are derivative of so many letters and posts. First, I realize that there is some redundancy. I have said some things many times. I hope that when I do repeat myself I shine a new light on a previous subject. The second interesting thing that occurs more and more frequently is that when I am searching the Internet for some subject of interest, I find my own post. Sometimes when I read those posts it feels like I am reading the words of someone else. I know that the person who is beginning the fourteenth year of discovery is not the same person who began the journey. Sometimes that writer from another day has something interesting to say for today. At other times I cringe from the naivete of that distant writer. Either way, there is a sense that something was learned even if later some of what was said was forgotten or in time what was felt to be true was proven to be inaccurate. Recognizing past inaccuracies in the light of new information is real learning. 

 

Thank you for being an interested reader. I have benefited greatly from your interest and I hope that the experience has had some reciprocity. 

 

Commonwealth Fund Task Force Report, Imperative 4: Support Empowerment and Engagement of People, Families, and Communities

 

February has been a busy month. Tom Brady won his seventh Super Bowl and silenced all who doubted that he was the G.O.A.T. Donald Trump has escaped conviction once again in the Senate on the combination of a terrible legal defense and a “technicality” after his second impeachment by the House. The COIVD death count is still climbing toward 500,000. Ted Cruz tried to escape the ice, snow, and blackouts in Houston by sneaking off to Cancun. All this while millions struggle with faulty computer processes trying to get an appointment for their vaccination, or wait for their “group” to be eventually eligible for their  COVID vaccination with the hope that normality might soon follow. Considering all these distractions, it is certainly understandable if somehow you missed the last three posts and do not know that I am halfway through the process of reviewing “six policy imperatives” from a task force on Health Care Payment and Delivery System Reform chartered by the Commonwealth Fund. If you have not already gotten your copy, click on the link and download your own copy of the full report.

 

In the six domains of quality described in Crossing the Quality Chasm patient-centeredness is perhaps the most important, most controversial, and greatest item of clinician pushback and misunderstanding. All the doctors I have ever known would be offended by the inference that they ever fail to put the patient first. Most patients I know can tell stories of how they felt they were not heard, greatly inconvenienced, and sometimes abused by a system that seems to care more about the interests of the system than addressing their needs. Doctors were once treated like demigods, and hospitals were thought to be temples of healing. Now esteem for doctors has declined and hospitals feel like factories. The authors of the task force begin their discussion with a description of the “current state.”

 

Engaging and empowering patients in health care has long been a goal of delivery system leaders and policymakers. Progress, however, has been slow and insufficient: reports of mistrust in the health care system are increasing; we continue to take a top-down approach to designing and delivering care; and there is ongoing racism, sexism, and other bias in the health care system. 

 

That is so well written that it almost sounds positive. It feels like a lack of patient empowerment is a vague “systems” issue. We all know that no one individual is culpable for a systems issue. That is like trying to blame the weather on someone. If someone is to blame for the weather it would have to be anyone who puts carbon dioxide into the atmosphere and we all have good reasons to support a justification of our own carbon footprint. Mine is definitely smaller than Bill Gate’s carbon footprint. He admits that he flies around burning lots of carbon based fuel in his own jet. The debate about whether you or whether I am more patient-centered is a waste of time. We all work in a system that is flawed. Like global warming, the solution to our shared problem will require global (within healthcare) change. Most of the solutions I have heard bring to mind the concept of “after pigs fly” or more appropriately after Mitch McConnell becomes bipartisan. The task force is hopeful:

 

By involving patients and communities more in the design of care delivery approaches and policies, we not only can improve patients’ experiences, but we can also improve health outcomes, reduce the burden on clinicians, improve patient-clinician interactions and trust, and increase health system efficiency. Their perspectives can be powerful tools for identifying and combatting inequities, particularly structural racism, in our health system. 

 

For the first time in my reading, the authors attempt to connect their recommendations into a solid policy platform rather than present them as separate issues. The other planks in the platform are “necessary but insufficient” to provide us with the system of care that produces the healthcare we want and need for everyone at a cost we can pay without compromising other import objectives. I own the bolding.

 

If the other recommendations in this report are realized, we will come closer to making health care more accessible, more patient-centered, and more appealing for people to interact with. For example, increasing the supply of primary care clinicians and reforming the way they are paid (see Imperative 3, “Strengthen the Nation’s Primary Health Care System”) could improve access to care and enable clinicians to spend more time with their patients — helping to build trust and continuous relationships. 

 

However, even success in the other areas is not sufficient for achieving the level of health system performance the Task Force envisions. A separate and explicit focus on designing care delivery that is more authentically responsive to patients’ needs is necessary to reverse longstanding trends in mistrust, disengagement, and disparities, as well as to improve health outcomes, equity, and affordability. 

 

The task force says that success will depend on doing four things:

 

• Engage Patients, Care Givers, and Local Communities in the Care Delivery and Policymaking Process

• Confront and Combat Racism in Health Care

• Promote Digital Platforms for Patient Engagement

• Implement Patient Protections from Fraud, Abuse, and Invasions of Privacy

 

Under each title, there are concrete suggestions. Some require Congress to act. Others can be implemented by HHS through administrative action. I am accepting of the fact that giving healthcare organizations financial incentives to do the right thing or penalties for ignoring responsibilities is the way that public policies usually work but there are other alternatives if we as healthcare professionals and members of healthcare organizations want to deliver safe, high-quality care that respects patients and families and encourages and educates individual patients and families and communities to move toward sustainable healthcare practices. 

 

The pioneer thinkers who wrote To Err is Human and Crossing the Quality Chasm were emphasizing the opportunity for healthcare professionals to do the right thing, what works for better care, not for greater profits, but because it is a professional responsibility and should be a natural desire of a caregiver or an institution that provides care. When Don Berwick and other clinicians and healthcare improvement advocates started IHI their motivation was not to comply with a directive from HHS or take advantage of an income opportunity for healthcare generated by Congress. They were motivated by the simple belief that we could do a better job for patients if we applied continuous improvement science to our practices. 

 

One of the most positive people that I ever met in healthcare was Dr. Anthony DiGioia, an orthopedic surgeon at the University of Pittsburgh Medical Center, and creator of the Patient Centered Value System which is beautifully described in a 2017 book that he co-authored with Eve Shapiro, The Patient Centered Value System: Transforming Healthcare Through Co-Design. What is remarkable is that Tony and Eve demonstrate that systematically involving patients and families in the design of care not only improves their satisfaction with their care but also improves safety, increases efficacy, and lowers the cost of care. Doing the right thing, engaging and empowering patients, families, and communities yields care that moves us toward the Triple Aim without bonuses or penalties from the government. Perhaps it is time for all of us to reread books like The Patient Centered Value System. In the forward to the Book Don Berwick wrote:

 

Excellence in healthcare depends on the quality of relationships with patients and families– really listening to what they wanted need–and remembering the values that led healthcare professionals to their calling in the first place. Gone are the days when the simple view that the “doctor knows best” suffices. Now, if we listen carefully with open open minds to what patients and families tell us, we can find the best compass toward improving our delivery of care and their care experience. This is healthcare codesign, and it is the wave of the future.

 

I feel that the most important of the set of four recommendations is “Confront and Combat Racism in Health Care.” Just this week we have learned that during the first six months of the COVID pandemic life expectancy for white Americans has fallen a year, but life expectancy for “Black and Brown” citizens has fallen up to three years. The pandemic has shown a light on the impact of racism and tribalism in healthcare. Perhaps the biggest quality gap in healthcare quality is its racial inequality. 

 

Many of us have read Isabel Wilkerson’s book, Caste: The Origins of Our Discontents. In the book, Wilkerson describes the history of the cultural infrastructure of a skin color-based societal hierarchy that determines the inequality that many of us think will diminish the arc of America’s future. Most recently Heather McGhee has carried the analysis of how damaged all of us are by the legacy of racism in her new book, “The Sum of Us: What Racism Costs Everyone and How We Can Prosper Together.” If you have not begun to read the book I urge you to read the transcript or listen to the conversation between McGhee and New York Times columnist Ezra Klein where she dramatically and convincingly reveals how much we have all lost to racism. When I finish reading the book you can rest assured that I will be writing more about what Ms. McGhee’s research reveals. 

 

The other two suggestions of the task force are:

 

• Promote Digital Platforms for Patient Engagement

• Implement Patient Protections from Fraud, Abuse, and Invasions of Privacy

 

These are “no brainers.” I totally agree with the recommendations and will leave you to study them. They are more amenable to policy actions. The most significant recommendation that falls under “promote digital platforms” is an obvious recommendation that would improve healthcare and the economy. 

 

Through the Federal Communications Commission, Congress should fund the establishment of broadband internet services in all communities currently lacking them. 

 

 Protections from fraud, abuse, and invasions of privacy are the domain of the government and the government should act to correct the injustices, but again a healthcare industry that is designed to be most compassionate and populated by professionals who care deeply about their professional responsibility should be able to minimize the number of offenses that the government must manage. Fixing for ourselves what exists now should be motivated by a collective sense of professional embarrassment. 

 

I am encouraged that with a return to traditional norms in the behavior of our president there is hope. The window of opportunity to prove that integrity makes a difference is small. The strategy of Republicans campaigning for control of Congress in the midterm elections will be to block President Biden’s efforts to make progress on our chronic problems. That is what they did to President Obama. Their best strategy for regaining power is to create disappointment with Biden’s ability to improve lives through improvements to healthcare, education, and housing while addressing the issues of the environment and racial equity. The political realities that make progress difficult through necessary legislation underline the importance of socially responsible healthcare professionals to lead change through their own efforts to empower and engage people, families, and communities in the vision of better healthcare for everyone.  

 

The No Name Stream

 

As I write, the snowstorm that was dropping snow on Houston and San Antonio earlier in the week is adding to our accumulated wealth of snow. Later today I will put on my metal spikes and head out on my walk. I love walking in the snow. The snow subtracts a few minutes a mile from my pace and walking in it is often like walking on a beach with deep sand. About three-quarters of a mile into my walk I will pause and take in the scene in today’s header. I took that picture yesterday. 

 

When I stop and ponder the stream that rushes under the road and tumbles over 200 feet in less than a quarter of a mile into Goose Hole Pond I often think about Robert Frost’s poem. The last four lines lead me to contemplate the unknowns of my own future. As I look down the run of the stream I see nothing but woods and snow:

 

The woods are lovely, dark and deep.

But I have promises to keep,

And miles to go before I sleep,

And miles to go before I sleep.

 

I have looked everywhere for the name of this stream. Since it is less than a half-mile long, I guess it does not deserve a name. The major inflow to our lake is Kidder Brook. When the snow melts in the spring it is a roaring flow that makes it almost a river. Kidder is the name of one of the pioneer families of the area. The Kidders have been farmers, merchants, bankers, and local politicians. Currently, our town clerk is a Kidder. It puzzles me that the outflow of the lake doesn’t have an easy-to-discover name. The stream flows downhill through the conservation land that is called the Little Sunapee Forest and the “yellow” trail follows the stream for more than half of the distance to Goose Hole. By the way, I have recently learned that “Sunapee” means “geese” in the Algonquin language. 

 

Things change slowly on “No Name Creek.” The log that lies across the stream must have fallen many years ago. I have been walking or running by this spot since the fall of 2008 and the log has been there at least that long. 

 

The stream leads me to think about beauty, eternity, and my own limitations. Perhaps that and the snow is what brings Frost’s poem to mind. It is not really depressing to consider, but something about this spot makes me think it is a “thin place.” I think that Frost was talking about a “thin place” in his poem. 

 

A few cars go by every hour so it is not a desolate place, and it is not unusual for a car or truck to pass as I pause to take in the view. The public landing for the lake is a few yards up the road and there are some houses on the lake hidden in the woods on the other side of the road. I don’t stay long, but it is a joy to pause for just a moment and look as far down the brook as possible with the expectation that if I return often enough, someday something remarkable might be revealed. 

 

Be well, I hope that you will visit some meaningful thin place that you cherish this weekend. Thin places are good places to think about healthcare’s most important responsibilities and how we can improve our abilities to partner with those that we serve. If you have the time, please let me hear your thoughts about what might be accomplished if we act in concert at this transient moment of opportunity.

Gene

 

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