January 12, 2024
Dear Interested Readers,
Uncommon Greatness–Remembered
Monday, January 15, is the birthday of Dr. King. This is a rare year because the national holiday that honors his contributions to all of humankind falls on his birth date in 1929. If he had not been assassinated on April 4, 1968, he might still be with us at age 95.
Dr. King delivered many moving speeches in the last 15 years of his 39 short years with us. Perhaps, his most famous speech is the “I Have A Dream” speech which he delivered in 1963 from the steps of the Lincoln Memorial. (Click on the link to hear or read the speech.) My favorite speech, the one that moves me the most, is his last speech, the “I’ve Been to the Mountaintop” speech that he delivered in Memphis the night before James Earl Ray shot him while he stood on a balcony at the Lorraine Motel in Memphis where he was staying while supporting the Memphis sanitation workers who were striking for better pay. As Dr. King revealed in his speech, he was aware of multiple death threats. There had been attempts on his life before including a near-fatal stabbing by a deranged woman, but none of that mattered. The cause was bigger than any one person. Some say that the last paragraph is a prediction of his death which would occur the next day. What moves me is not that he was prescient, but that nothing, including the possibility of dying a horrible death, could prevent him from pursuing social justice. That willingness to put self behind the needs of others is rare. Is there any leader among us today who so obviously and willingly puts the needs of others ahead of a personal agenda? The speech gets into the nitty-gritty of life as experienced by Black Americans like the sanitation workers, but it ends with the assurance that things will be better. Maybe change won’t come tomorrow, but Dr. King knows that it will come in time. He says:
Well, I don’t know what will happen now. We’ve got some difficult days ahead. But it doesn’t matter with me now. Because I’ve been to the mountaintop. And I don’t mind. Like anybody, I would like to live a long life. Longevity has its place. But I’m not concerned about that now. I just want to do God’s will. And He’s allowed me to go up to the mountain. And I’ve looked over. And I’ve seen the promised land. I may not get there with you. But I want you to know tonight, that we, as a people, will get to the promised land. And I’m happy, tonight. I’m not worried about anything. I’m not fearing any man. Mine eyes have seen the glory of the coming of the Lord.
If you don’t know the story, Dr. King is referencing what happened to Moses who was not allowed to go to “The Promised Land” which was the destination of the Jewish people after forty years of wandering in the Sinai. At the end of the book of Deuteronomy in Chapter 34 (KJV) we read:
34 And Moses went up from the plains of Moab unto the mountain of Nebo, to the top of Pisgah, that is over against Jericho. And the Lord shewed him all the land of Gilead, unto Dan,
2 And all Naphtali, and the land of Ephraim, and Manasseh, and all the land of Judah, unto the utmost sea,
3 And the south, and the plain of the valley of Jericho, the city of palm trees, unto Zoar.
4 And the Lord said unto him, This is the land which I sware unto Abraham, unto Isaac, and unto Jacob, saying, I will give it unto thy seed: I have caused thee to see it with thine eyes, but thou shalt not go over thither.
5 So Moses the servant of the Lord died there in the land of Moab, according to the word of the Lord.
6 And he buried him in a valley in the land of Moab, over against Bethpeor: but no man knoweth of his sepulchre unto this day.
7 And Moses was an hundred and twenty years old when he died: his eye was not dim, nor his natural force abated.
I have always been fascinated by the phrase, “…his eye was not dim, nor his natural force abated.” I guess that means that he died in good health. His work was done. Dr. King’s work was not done when he died, but it was well-launched and he believed that “his dream” would come true someday.
After MLK Day in 2022, I gave myself the assignment of reading his last book which he wrote in 1967: Chaos or Community: Where Do We Go From Here? It is a book that stands the test of time because we have made almost no real progress in the struggle for equity, diversity, and inclusion since Dr. King used the pages of that book to advocate for the continued struggle toward those goals. In the book, he defends non-violence against more militant attempts to achieve change. He decried “Black Power” as incapable of creating the equitable pluralistic society that he dreamed of existing for his children. He scolded liberals who felt that the passages of The Civil Rights Act of 1964 and The Voting Rights Act of 1965 had solved our problems. He knew that getting to his dream would require the abolition of poverty for all Americans and the creation of a new power base that was founded on the issues that oppressed the poor of all races and ethnicities. He felt that America was rich enough to lift everyone out of poverty. He advocated for a floor of universal basic income and the individual freedom and opportunity that it fosters and is suppressed by most of our current welfare programs.
The term “social determinants of health had not been coined” in 1968. It evolved in the nineties. Again, it is easy to make a case that Dr. King understood the concept better than many of our conservative politicians today and tried to emphasize that health was much more complex than just having access to medical care. That is not just my opinion. It is shared by others. I invite you to read “MLK’s Legacy: Health Equity & the Social Determinants of Health” published by Mental Health Partners of Colorado. Their article begins:
Each year on the third Monday in January, the nation celebrates Martin Luther King, Jr. Day – an opportunity to reflect on the individual, ideas, and impact of this civil rights icon. Throughout his life, Dr. King championed important social causes such as poverty, discrimination, education, and housing – factors that many experts today refer to as the Social Determinants of Health.
Dr. King was well ahead of his time in understanding that the conditions and environments where people are born, live, learn, work, play, worship, and age greatly impact their quality of life and a wide range of public health outcomes.
At a Convention of the Medical Committee for Human Rights held in Chicago in March 1966, Dr. King declared:
Of all the forms of inequality, injustice in health is the most shocking and the most inhuman.”
Maybe fifty-six years is not long enough to reverse all the biases and self-serving attitudes that have been the foundation of the inequities that have evolved since 1619. We make a little progress then we lose ground. Progress in spreading understanding of our history of racial inequality, Critical Race Theory, has been thwarted in recent days by the same biases that plagued Dr. King and from which I hope that we will eventually escape. Racial biases, inequality, and persistent unnecessary poverty are difficult to overcome, but each year on his holiday, I renew my hope that in time we will come together around Dr. King’s beautiful vision and we will achieve the dream that motivated him. He was certain that one day the dream would come true because he had been to the mountaintop and had looked into the future where he saw that his vision was not just a dream; it was a picture from the future.
I Had A Lot To Learn
From time to time I need to remind myself that this long biographical journey has been an attempt to explore the origins of my medical moral sensibilities. What I have learned is that if I feel that my moral sensibilities feel threatened it is because the situation is at variance with values established through my relationships with my family, teachers, colleagues, and patients. I have reminded myself of this as I have contemplated how to describe the early days of being the CEO of Harvard Vanguard and Atrius Health. That opportunity was a gift and expression of confidence from some of the members of our boards. I don’t think the willingness to offer me the opportunity was applauded by all of the members of both boards. I felt that we needed to quickly make some changes in our management team and articulate and begin to implement a strategic plan, Those are not usually the tasks of a caretaker interim CEO. I also asked them to delay the search for a new permanent CEO for several months. I was asked to leave the room while these ideas were explored.
After I had been offered the opportunity, one very supportive board member asked me straight on, “How will this change our relationship?” I told him that I hoped that there would be little change in our relationship and that I would be listening more closely than ever before for his opinion on every one of his concerns. It was a heads-up that I needed to be in contact with each board member as much as time allowed. I have always believed that the work of a board is done between meetings, and the meetings are best when they produce a formal expression of what has evolved as a consensus from personal conversations and committee explorations between meetings.
As I look back on those early scary days, I realize that there were a few people who carried me. Each one knew things I did not know. Each one gave me a window or open door into a subject where before I had been metaphorically seeing only what I could see looking through a keyhole into the daily management of a very large enterprise.
First, and foremost, and until my last day at the end of 2013, I leaned on Cheryl Livoli, my administrative assistant. Cheryl had worked with Ken Paulus and my predecessor. Before coming to us, she had supported corporate executives. I quickly learned to seek her opinion on many things. She knew what our internal temperature was and could predict the weather. She could see a corporate “storm” on the horizon. She always reminded me that there were informal conversations on any subject, and I should try to hear them. Through Cheryl, I quickly realized that our success as a provider of care and as innovators of better care was as much or more dependent on that broad category of contributors that we lump together as “support staff” as it was on the doctors, nurses, and others with direct patient care responsibilities. I would always ask Cheryl for an opinion about how a point of view would be perceived, and she always gave me a truthful response that frequently prevented me from doing something foolish.
I have already spoken about Marci Sindel who wore many hats on the management team. She managed our PR and government relations but did much more than that. She was an engineer by training who also had an MBA from Stanford and throughout an interesting career had even built factories. Like Cheryl, she assigned herself the responsibility of making sure that I didn’t impulsively say or do something foolish. She led me around the statehouse and we made many trips to Washington together. Perhaps the most helpful thing that Marci did was to introduce me to “The Long View.” Marci helped me put ideas we had gleaned from an extensive survey of the ideas, feelings, and concerns we learned from our visits and conversations with staff from all over our dispersed organization into a comprehensive strategic plan that we had developed and written by June of 2008. That strategic plan never got stale. I followed it until I retired at the end of 2013.
I have mentioned my friendship with Tom Congoran before. I first met him in 2007 when he was our interim CIO. We took a trip with a few others to visit the corporate offices of Allscripts and Epic in Illinois and Wisconsin. Our medical record was failing because we had not kept up with the Epic updates while we were having financial problems. Our IT professionals had “customized” it until there were times when it was almost impossible to use. On the worst days, you had plenty of time to read the newspaper between “screens.” It had become a huge barrier to patient care. Our immediate response was to blame Epic. During the trip, we rode around in a van together with four other colleagues visiting medical groups in the Chicago and Milwaukee suburbs that used the Allscripts medical record or the latest iterations of Epic.
What we discovered was that we had made the mess, and could not blame Epic. Either way, we had an expensive repair. Our choice was to buy and install Allscripts or reinstall Epic. When my predecessor hired a new CIO, I thought Tom was gone because I did not see him. Fortunately, he was busy with some other assignments that were not obvious to me.
What I learned by interrogating Tom while we were driving around the Midwest was that he had been the COO of New Hampshire Blue Cross, the CFO of Healthsource, a large HMO in New Hampshire that was sold to Cigna in 1997, and a serial entrepreneur. He had most recently worked for Pegasus Systems in Cambridge after he had sold them one of his companies and the software he had developed. Through all of this, he had lived in Hopkinton, New Hampshire where he was the moderator of the town council and where he and his wife had started and funded a non-profit that helped people who were having financial problems. He commuted over seventy miles each way every day. All of this info emerged slowly and in dribs and drabs of deep probing by me because Tom was not the kind of guy who would quickly announce all that he had done.
Probably, the smartest thing I did in the first couple of weeks was to call Tom in New Hampshire to see if he would meet me in Warner at a local breakfast place on my way home from my weekend home which at that time was in a recreation community in Grantham, New Hampshire that was about thirty-five miles north of Tom on I 89. I was concerned about finance, contracts, operations, and IT. I knew that Tom had experience in all these areas. On the back of a napkin, he made some notes for me that essentially opened my eyes to the fact that we needed to have a strategic CFO. Tom showed me that finance has two parts. There is the day-to-day work managing budgets and following accounts, and there is strategic finance that leverages the resources of the corporation to obtain the resources that are required to achieve the objectives of the mission.
I thanked Tom for his advice and drove on to our offices in Newton. I knew that we had the bill paying and accounting aspects of finance covered, but I also knew that we faced huge problems that stood between us and our mission and tens of millions of dollars of debt that needed to be refinanced, buildings that needed to be facelifted, and new clinical programs that needed to be developed. What I did not know was that in September 2008 the economy would enter the greatest recession since the Great Depression.
After giving the issues and challenges we faced some thought and checking with a few close advisors on the board, I called Tom and asked him if he would take the job as CFO. I would give the current CFO who had hoped to become CEO when Ken left some new assignment and title because I was hooked on the idea that we needed a “strategic” CFO, and I knew we did not have one. It is tough to tell someone that they are being replaced. It was the hardest part of my job. It was not long until I was also looking with Tom for a new CIO because I had no confidence in the ability of the CIO my predecessor had hired to effectively address the challenge of getting Epic back in shape.
I was blessed with a very talented management team besides Tom and Marci. Our attorney, Kim Nelson, was always a terrific source of guidance for me. I believe that no organization in Massachusetts had a better VP of Contracting than Beth Honan.
There were some new people on the senior management team that I did not know well. One was Mary Dawley. Mary was an experienced nurse manager with a long history of site management in the local system of practices affiliated with the Catholic health services in Massachusetts. She had been hired by my predecessor to manage the day-to-day operations in a portion of our sprawling network of health centers. Because of her abilities, I soon gave her operational responsibility for all of our practice sites. There are forty-four miles between our Chelmsford offices in the north and our most southern site in Braintree. Harvard Vanguard covered all of Eastern Massachusetts. Fortunately, our corporate office lay in the center of our geographical footprint. Despite the distances between our sites, Mary was the connection that made our site managers a close-knit team that met regularly to share ideas and best practices. Each site had its unique character which was a function of the population it served. It would have been impossible for me to have coordinated such a sprawling network. Mary did it with ease and was always a source of support for me. My job was to make sure that she had the resources she needed.
Two other key members of my team helped me enormously in those first days with specific problems or opportunities. Diane Gilworth was our Chief of Nursing. Diane is an extraordinary clinician and clinical leader. Our relationship with our nurses had been complicated since the beginning of Vanguard. I felt that Diane needed to have more resources and should be treated as an equal member of the management team if we were ever to improve our relationship with our nurses so I elevated her title to Vice President of Nursing and made her an independent member of the management team and envisioned her as a partner with equal status to our Chief Medical Officer.
No other person had more impact on my thinking about our mission and responsibility to the community than Dr. Zeev Neuwirth who was our Chief of Clinical Innovation. Zeev was young and relatively new to Harvard Vanguard. Zeev graduated from medical school at the University of Pennsylvania and was an intern and resident in New York. After getting involved in quality improvement efforts in his first post-training position, he decided to get an MPH at the Harvard School of Public Health. We hired him in 2005 after he had gotten his MPH to be the Chief of Medicine at Kenmore, our largest and oldest health center. Kenmore was the sight of my primary care practice, the home of our cardiology department, and the primary site of our teaching relationship with Harvard Medical School. All roads led to Kenmore, and Kenmore had suffered injuries following the collapse of Harvard Pilgrim that had left deep scars. It was also one of our two sites where our employees were represented by a union, the SEIU.
When Zeev learned that the Chairman of the Board worked for him he brought me a stack of papers about Lean management. He was excited about the possibility of Lean solving many of the operational concerns that plagued our large department. His enthusiasm was infectious. I told him that he should “go for it.” Zeev gave the support staff and nurses more attention than they had experienced in a decade. In a very short time, there was a new enthusiasm in our unit that was easily palpable. Perhaps you have also been captivated by Zeev’s enthusiasm for innovation and improvement in healthcare. He is the author of two books and has an award-winning podcast.
When Ken’s successor arrived several of us told her of Zeev’s remarkable accomplishments. She responded by moving him to our management offices, creating a new position for him, and giving him a new title, Chief of Clinical Innovation. When I became CEO, Zeev greeted me with enthusiasm. There was only one office door between my “corner office” and his little office where the walls and whiteboards were covered with diagrams of ambitious projects. I am sure that I spent as much time in his office as I did in mine asking him questions as we bounced ideas about our quest for the Triple Aim and the social determinants of health back and forth as if we were playing ping-pong. I was so rarely in my office that I eventually asked Cheryl to have my desk replaced by a conference table and convert the room into a library and conference room for anyone to use.
Our CEO had put Zeev in charge of a remarkable opportunity that was given to us by Blue Cross. The CEO of Blue Cross was Clive Killingsworth. He shared the vision that healthcare delivery needed transformation. Under his direction, a program named LEAD was created and managed by Truepoint, a consultancy that was closely tied to the Harvard Business School. Eventually, the work morphed into Blue Cross’ innovative Alternative Quality Contract (AQC). I was proud that we were the first organization to sign on for this contract that was designed to improve quality while lowering the cost of care.
In the lead program, Atrius, Beth Isreal Hospital, Mount Auburn Hospital, New England Baptist Hospital, and Cooley-Dickenson Hospital in Northampton were collectively granted more than ten million dollars to launch experiments to improve care delivery. Zeev was in charge of our participation. He immediately began the introduction of Lean at two of our suburban sites, Chelmsford and Medford.
The contract with LEAD/Blue Cross covered several years and required a day-long meeting once a month for the CEOs of the participating organizations. The meetings were facilitated by Nathaniel Foote, Thomas Rice, and Kathy McDonald of Truepoint. Each day-long meeting included a nationally known expert, usually a CEO or some other notable person in healthcare. The “experts” came from all around the country. At each meeting, there was an update on the project from one of the participant institutions. It was an unexpected opportunity for me to spend even more time with Zeev and to develop close and supportive relationships with like-minded CEOs. LEAD began a coaching relationship for me with Nathanial Foote that lasted throughout my tenure at Harvard Vanguard/Atrius.
At the beginning of my experience as a CEO, I was graced with wonderful relationships with people who shared the goal of improving healthcare. These people filled my days with gratifying experiences and gave me an increased opportunity to develop an even greater sense of moral responsibility that extended beyond the walls of our offices. Zeev helped me see that what happened anywhere in healthcare also had a ripple effect on us. We were not an island economy. We were connected with and had an interest in Healthcare and Health writ large. Next week, I will continue the story of Lean at Harvard Vanguard and Atrius.
Bad News
The bad news is out. 2023 was the hottest year “ever.” It is at least the hottest year since we started keeping records in the 1800s. I recommend reading the article published in The New York Times this week by Raymond Zhong and Keith Collins. In the article, they write:
When scientists combine their satellite readings with geological evidence on the climate’s more distant past, 2023 also appears to be among the warmest years in at least 100,000, said Carlo Buontempo, director of the European Union’s Copernicus Climate Change Service, at a news briefing. “There were simply no cities, no books, agriculture or domesticated animals on this planet the last time the temperature was so high,” he said.
Those are just words, the graph published in the article is consistent with the cliché that a picture is worth a thousand words.
The jump from 2022 to 2023 raises questions. Was it a one-off year or has there been a dramatic change that is consistent with the fact that we have entered a new era of rapid, irreversible change? It should be hard for the climate deniers to convince anyone who is of sound mind that the weather we experienced this last year was not the worst in their lifetime.
In human physiology, we depend on reservoirs like fat and bone to buffer abrupt changes in the internal milieu. The result is that we can absorb a lot of change until that capacity is saturated. In the environment, wetlands and lakes perform much of the same buffering. New Hampshire has a lot of lakes, ponds, and wetlands. A big dump of rain is not the challenge to us that it is to Vermont on the other side of the Connecticut River where there aren’t wetlands or as many lakes and ponds.
One of the big buffers for climate is the temperature of the oceans. The authors write:
About 90 percent of the energy trapped by greenhouse gases accumulates in the oceans, and scientists have found that the oceans’ uptake of heat has accelerated significantly since the 1990s. “If you look at that curve, it’s clearly not linear,” said Sarah Purkey, an oceanographer with the Scripps Institution of Oceanography at the University of California, San Diego.
The result of hotter oceans is more moisture in the air and more rain. Ironically, the temp where I live was lower than normal last summer but has been substantially higher this winter. The dramatic change has been the violent storms. I have had my home on Little Lake Sunapee for over fifteen years. The creek that runs from our lake down to Goose Hole as part of the Connecticut River watershed did run under Little Sunapee Road through two small culverts. Twice this summer huge storms dumped volumes of water on us that overwhelmed the capacity of the old culverts and washed out the road. There are now three huge culverts to manage the continuing larger flow of water. Is that our future? Is the best strategy to accept change and adjust to it as we continue to watch the temperature rise?
I am hoping that 2023 was a one-off explained by something that doesn’t have long-term consequences. Today’s header showed the frozen snow-covered lake last Monday after we finally got the snow that my grandsons had hoped to see when they came from California for a White Christmas that did not happen. Since Monday another big storm has roared through. It began with about eight inches of wet snow before turning to rain as the temperature rose into the forties and then dropped back into the twenties with everything freezing.
Wherever you are I am sure that you have also had a taste of unusually violent weather. It is becoming the new normal for all of us. It is puzzling to me that those who want to “Make America Great Again” don’t seem all that concerned about the weather, nor do they realize or admit how their devotion to maximizing the profits of carbon-producing corporations is undermining their supposed MAGA objectives.
I am trying to stay flexible. Is it a day for my down jacket, gloves, stocking cap, and boots, or is it a day for my umbrella and slicker?
Whatever the weather is bringing you this weekend, I hope that you enjoy the three-day weekend and remember to take a moment to think about the lessons that Martin Luther King, Jr. was willing to give his life to try to teach us.
Be well,
Gene
