May 17, 2024
Dear Interested Readers,
Trouble In Massachusetts
I lived in Massachusetts from 1967 until late 2014. I loved the progressive attitude that was so easily discernable in the circles where I moved. The most dramatic expression of that unique Massachusetts mindset that is distinctly different from much of America was that I was surprised in 1972 when Nixon trounced George McGovern in the presidential election. Everyone I knew hated Nixon and was enthusiastic about McGovern. As you may remember, the only Electoral College votes McGovern won were from Massachusetts and the District of Columbia. I was an election denier of a different sort than Trump. I just couldn’t believe that the rest of the country could not see the virtues of McGovern over the obvious moral deficiencies of Nixon. If all my friends and neighbors agreed with me, how could Nixon have won?
These days I limit my trips to the Boston area. I avoid Logan Airport. It is way too busy and congested for my sensibilities. I would rather fly from our little regional airport in Manchester and pay more and need to make connections in other cities than pay the emotional price of dealing with the traffic and turmoil of Logan. I have given up my Red Sox tickets which I had prized since I joined a consortium of friends in 1977 that gave me two fabulous seats between home base and first base for a third of the home games. The hassle was just no longer worth it to see a team whose management sold off its best players.
The few trips that I do make to Boston are to visit with friends in the western suburbs or for rare medical appointments at Atrius Health. I can avoid going to Boston and the sites where I once worked because Atrius has a site in Chelmsford near the New Hampshire border where I see a great neurologist. I have shifted much of my care to Dartmouth Health because I am beginning to sense some negative changes in my old organization now that it is owned by Optum. I will brave the traffic to Logan to pick up my West Coast family when they visit, but invariably they land during either the early morning rush hour or the afternoon traffic snarl. It is no fun sitting for long stretches in four or five lanes of creeping commuters.
As I ponder why I avoid Boston it occurs to me that since I arrived in the sixties when building new roads into the city was abruptly halted coming from the northwest through Cambridge or the south through Roxbury, there have been no new roads built since then even as the population and the traffic congestion has increased. There is one new tunnel to Logan, The Ted Williams Tunnel, that was part of the infamous “Big Dig” of the 90s that cost much more than 10 billion dollars, the most expensive highway project in the history of the country.
Many of the delays I encounter on the overcrowded roads of Eastern Massachusetts are for construction as they repair or widen the inadequate roads that do exist. All of this is against the background of a public transportation system that is expensive, unreliable, and just about as frustrating as it was sixty years ago when Charlie’s fate was reported by the Kingston Trio:
Did he ever return?
No he never returned
And his fate is still unlearn’d
He may ride forever
‘neath the streets of Boston
He’s the man who never returned.
What endeared the area to me was its dominant political attitude. There was never any dearth of forward-looking people willing to talk and dream about a better day. When we were with friends and colleagues it was as likely that the conversion would turn to a discussion of progressive public policy as it was to review of Tom Brady’s most recent football heroics or a sensational controversy like “deflategate.”
What drew me to Boston was the sense I had, not entirely accurate, that it was the hub of the medical world. From where I was coming, its medical resources, its history of medical accomplishments, its amazing clinicians and medical researchers, and its focus on medical education made it seem to me to be a medical “wonder of the world.” I was flabbergasted when I was given the opportunity to be a part of it.
My four years at Harvard Medical School with my exposure to visionaries like Dr. Ebert convinced me that I wanted to continue to be part of this remarkable environment. Like all of my classmates, I did travel to other well known medical communities during the process of applying for my internship, but on Match Day I was overjoyed to learn that I would be one of the minority of my class that would be able to continue my training at a “Harvard teaching hospital.” At that time the Peter Bent Brigham Hospital took only fourteen medical interns for a year of mostly “every other night” call. I was delighted to accept the challenge and the opportunity to remain in Boston as the majority of my classmates spread out to other hospitals across the country.
During medical school, the house officer years, fellowships, and even into the early years of practice, I think most doctors are inwardly focused. It takes a lot of effort to keep up with what is happening to you and near you. Perhaps the exception to this for me was the “Harvard Strike” to which I referred last week. Other changes were also underway. All of us who were house officers in Boston in the seventies owe some thanks to the Boston City Hospital housestaff who fought for and won better pay in the late sixties. Their efforts made my life better, My pay as an intern was $9,000. As a Senior Resident, I earned $14,000. If you follow the link you will read:
In May, 1967, the Boston City Hospital House Officers Association (HOA) held a 3-day heal-in, forcing a pay increase from $3600 to $6600 for interns and $6600 to $10,000 for residents. The chief of the Harvard surgical service was sympathetic, saying: “It is time we faced the fact that these highly trained young doctors are carrying 80% of the work load in the hospital. They should be granted their maximum request, which really represents only a minimum demand for a professional per son.” Opponents of the action said patients were being used unfairly (Boston Interns Stage “Heal-in,” 1967).
I must admit that it took me many years to be able to look beyond my own concerns and have much interest in the failures of our system of care. As I have described in these notes over the last six months since I began to write about medical moral injury, that process also began as a form of self-interest and then grew as I accepted larger and larger responsibilities for the interests of my colleagues. It was not until I had some responsibility for the performance and reputation of our practice in the larger community that I began to see that the progressive concerns that energized my interest in state and national politics also should apply to my concerns about practice. It was a step even later and further to realize that ultimately there needed to be harmony between what was good for my professional life, good for the institution, and good for individual patients, the community, and the nation.
As the CEO of Atrius and Harvard Vanguard I soon became aware of the oppressive environment created by a huge competitor with monopolistic tendencies. I became convinced that Partners Health Care, now Mass General Brigham Healthcare was an overall liability for our community. I should hasten to say, that I never met an individual practicing clinician who worked for Partners who was not ethical and focused on the direct medical needs of the patient. Many were at Partners because of the unique research and teaching opportunities that the affiliation offered. When you are benefiting from a situation it is hard to see the downside impact that the institution that is so good to you might have on the whole community.
The biggest challenge of my tenure was how to compete with Partners. We chose to try to focus on the elements of quality as described in Crossing the Quality Chasm bolstered by Lean, a system of continuous improvement. We were convinced that at least 30% of medical expenses were from waste and that we could do more with what we did earn if we focused on improving the experience of care while practicing smarter.
We were not the only institution suffering from the growth of Partners which ensured that it got a disproportionate share of the healthcare dollar in Massachusets. Many local hospitals in the numerous Boston suburbs were having near-death experiences. Several like Newton Wellesley Hospital, the Faulkner Hospital, and the North Shore Medical Center survived by becoming part of the growing Partners network. Beth Isreal Deaconess Medical Center and Lahey Health suffered from the market-smothering effects of Partners like we did and eventually benefited when we moved care much of our hospital practice from Partners to the BIDMC and Lahey.
Caritas Christi, the network of hospitals owned by the Catholic Diocese suffered greatly from a movement of patients from its neighborhood and suburban hospitals to the Partners network. Its hospitals were in predominately lower socioeconomic neighborhoods like Brighton and Dorchester and the old mill towns like Fall River, Methuen, and Brockton. As a cardiology fellow, I had done some “moonlighting” at the Cardinal Cushing Hospital in Brockton and knew it to be a very good community asset. St. Elizabeth’s Hospital in Brighton was an excellent facility with many talented interns and residents some of whom eventually joined our practice. These hospitals fell on hard times and the system was eventually sold to Cerberus Capital Management, a private equity firm, in 2010.
I had apprehensions about the deal from the beginning since “Cerebus” refers to the mythical multiheaded dog that guards the gates of hell. More importantly, I sensed that no good could come from the invasion of the largely non-profit world of Massachusetts medicine by a privately held company seeking to turn a huge profit. We already had enough grief from a large non-profit organization that was seeking to turn a large annual surplus. Remember, non-profits have surpluses, not profits.
Perhaps the most interesting thing about the deal was that a very talented and personable young cardiac surgeon from the Beth Isreal, Dr. Ralph de la Torre, who had no real business experience, but lots of charisma was selected to be the CEO of the system which was renamed Steward Health Care, Ralph immediately got to work and was successful in hiring some capable executives and physicians, some also from the BIDMC. He was peripatetic. Everywhere I went I saw Ralph. Ralph and I had several private meetings, usually over a nice dinner at his expense, where he would make various offers to try to entice an affiliation of some sort that would be mutually beneficial. One offer included partial ownership of one of the hospitals if only we would direct care to it. I had three concerns. First, I had an aversion to the invasion of healthcare by private equity money, second, there were huge cultural barriers to overcome, and thirdly, I did not see a pursuit of profit as consistent with our efforts to lower the cost of quality care for our community. I did enjoy his personality and the widened perspective that I gained from our interactions.
Over the last ten years since I retired, Steward has grown. It even has some operations in other countries. For reasons that I don’t understand its headquarters were moved to Dallas. Over the last year, the system has sunk deeper and deeper in debt. It has failed to pay its suppliers. It has staff that is uncertain of its future. It has sold many of its facilities to other private equity companies from which it theoretically rents them back, but fails to pay the rent. Ralph has been all over the Boston papers during the last couple of months as they point out that as the Steward hospitals in Massachusetts are failing Ralph has bought a 40 million dollar yacht and flies around in a private jet. Last week, Steward Health Care filed for bankruptcy in a Houston court and the governor of Massachusetts and the employees of Steward Hospitals in Massachusetts are all wondering what happens next and what is to be learned from the whole adventure.
Steward Healthcare is not the only item of discussion on the healthcare scene in Eastern Massachusetts this week. Salem Hospital on the North Shore of Boston has been a part of Partners, now MassGeneral Brigham, since the 1990s. It seems that even being buried in such a wealthy healthcare system does not guarantee an ideal practice environment. Last Sunday’s Boston Globe carried a front page article of interest entitled “Frustrated physicians look to unions to take a stand: Burned out and frustrated with bottom-line-oriented hospital management, doctors are starting to unionize, including at Salem Hospital.”
Early in the article, there is a testimony from Dr. Kore Anderson, a pediatrician who is frequently on alone in the emergency room. Early on in the article Katie Johnston, the Globe reporter who wrote the article quotes Dr. Andreson:
“As a physician, you’re raised to sacrifice,’’ said Anderson, 49, who grew up in Norwood. “But when you are asked to give and give and give, and you’re not given the support and resources you need to realize that vision of why you’re giving up the things in the rest of your life, it feels pointless sometimes. We keep coming to take care of the patients and each other. But I think so many of us are so, so close all the time to saying, I’m not going to come here anymore.’’
The resources of Mass General Brigham are measured in the billions. In a financial report they released earlier this month, we read:
The system reported an overall gain of $1.4 billion for the six months ended March 31, 2024, including a nonoperating gain of $1.3 billion. In the comparable 2023 six-month period the system reported an overall gain of $841 million, including a nonoperating gain of $849 million.
The reported financial realities seem out of sync with the experience of Dr. Anderson. Ms. Johnston expands on Dr. Anderson’s experience to make a general comment about healthcare in America at this moment:
That tension is playing out nationwide as staffing shortages and capacity overloads strain an already stressed health care system, and hospitals, including nonprofit ones, increasingly adopt for-profit practices to minimize costs and maximize revenue. Doctors are caught in the middle, helping people in greater need, but inhibited by a corporate mindset that they say is hurting patient care.
The article continues with the description of the union that the Salem doctors have created that is affiliated with AFSCME, the American Federation of State, County, and Municipal Employees. It is because of their protection from the union that the Salem physicians felt able to risk speaking out against their employer. According to recent data from the AMA about 50% of American physicians are employed and the number has continued to increase over the past few years. I was not surprised when later in the article “moral injury” was mentioned and defined as one of the motivating factors in the move to unionize at Salem Hospital and the possibility of doctors unionizing at the MGH and Brigham is seen to be increasing. Ms. Johnston continues:
Physician burnout rose 17 percentage points between 2011 and 2021, according to a 2023 report by the equity-focused think tank The Century Foundation, but doctors in Salem say what they’re really experiencing is “moral injury,’’ the psychological harm that comes from not being able to give patients the best possible care.
It’s not just doctors who are concerned. In a new survey by the Massachusetts Nurses Association, 80 percent of nurses said the quality of patient care had decreased in the past two years.
Nurses have long been unionized; doctors are just starting to do the same. The 112 Salem doctors are the first attending physicians at Mass General Brigham, the state’s largest health care system, to push for collective bargaining rights. But they likely won’t be the last. Fed-up physicians at the organization’s two flagship hospitals in Boston, which are merging clinical operations, are also talking about organizing.
So, is Massachusetts leading the way again? This time in bankruptcies of medical systems owned by profit-oriented private equity firms and by physicians who are responding to burnout and moral injury by joining a union in one of our nation’s most respected providers of “non-profit” medical care? Frankly, it took longer than I had expected for the disconnect between traditional medical values and private equity to lead to a healthcare disaster. I am not totally surprised by the possibility of physicians organizing when they finally come to grips with what they believe is care that is compromised by a profit motive. It is possible that a cynical skeptic might say that the union is about improving the work and pay of doctors, but I would prefer until there is evidence to refute the idea to believe that it is a movement driven by concerns about the jeopardy of patients in systems whether for profit or non-profit that are more concerned about profit than quality and safety. Don’t quote Sister Irene Kraus, the CEO of one of our largest Catholic hospital systems, to me. I think she was much more mission, patient, and efficiency-oriented than most of our financially oriented systems when she famously said, “No margin, no mission.”
Healthcare, along with the social determinants of health, equity, and diversity, and our climate catastrophe, seem to be second tier issue in the politics of 2024. It is my opinion, that the moment you or a family member shows up at an inadequately staffed emergency room to see a morally injured or burned-out doctor your concern about the Southern border, the cost of eggs, or how Trump was cheated at the last election will quickly become much less important. Oh, let’s not forget that medical bills are the leading cause of bankruptcies once again. You are paying more, getting less, and standing in harm’s way while Ralph is enjoying cruising on his yacht.
I hope Massachusetts can lead us out of the danger that events there suggest threaten us all. It is good to know that some bright people, the governor included, seemed to be asking the right questions. I will leave it to you to read “How Mass. could prevent another hospital crisis” by Larry Edelman, another Boston Globe columnist.
What I Missed
Last weekend the Northern Lights were revved to a twenty-year high by eruptions on the surface of the Sun. There was no shortage of press extolling the joy that awaited us as the incredible show evolved and would be visible as far south as Georgia and Florida. When the publicity began, I was still a little upset from having missed the “totality” of the recent solar eclipse because I was reluctant to get into the traffic jams going to and from northern Vermont and New Hampshire. I really wanted to see the Northern Lights, again.
I say “again” because I have seen the lights twice before. The first time was during a late-night flight from Boston to Portland, Oregon in the mid-eighties. Flying west, I was lucky enough to have been sitting on the right side (north) of the plane when the captain announced that if we looked out a window on the right side of the plane, we would see the Northern Lights. The sky was clear and the show was spectacular. The second time was shortly after we bought our current home in New Hampshire in 2008. It was a clear summer evening and I was enjoying listening to the loons while sitting on a comfortable chair on the end of my dock. To my surprise when I looked north over my left shoulder, the sky was an iridescent green.
In 2015, my wife and I took a trip to South Africa and Zimbabwe. The main objectives were to see the animals, visit Victoria Falls, and spend some time in Cape Town. Those were the primary objectives, but I was also hoping to view the Southern Cross. I could not believe it, but every night for two weeks, the stars were hidden by dense clouds. In 2019, we traveled to Alaska, but there is not much night in Alaska in June, so I had no chance to see the Northern Lights.
Last Friday was the best night to see the Northern Lights. We had driven to Maine to visit our new grandson. After a wonderful afternoon and an early dinner at a local restaurant, we headed to a local B and B where we planned to spend the night. At about eleven, after we were in bed, we began to get texts with photos of the Northern Lights from our son. I redressed and headed out to see what I could see. Gray, Maine is a quiet little town with many more streetlights than it really needs. Across the street and blocking my view to the north was a lovely church. I walked down the street to get a better view, but houses still blocked my view to the north, and the street lights made the sky so bright that all I could see was a steely gray. It was cold so I gave up and went to bed.
I was encouraged that I might get a second chance to see the lights again when I read in the paper that it might be possible to see them on Saturday and perhaps even on Sunday, cloud cover permitting. Unfortunately, on both Saturday and Sunday nights the clouds over New London were dense. If the lights were present, they were blocked out by the cloud cover.
I can’t claim to be the photographer who took the picture of the Northern Lights that is the header for today’s letter. The picture in today’s header was taken by my my daughter-in-law. I think I have learned a lesson. To see remarkable things, you must put yourself in the right place. I missed out on the experience of “totality,” and I also missed the Northern Lights this time around. I don’t know if I will live long enough to have another chance to view a total eclipse of the sun, but the chances are that if I pay attention, I might see the Northern Lights again. I also still hope to see the Southern Cross. A trip to New Zealand or Australia might make that possible.
I hope that you had better luck or made a better effort than I did with both the eclipse and the Northern Lights. If you failed to see the show like I did, I hope that both of us will eventually get another chance. Until then,
Be well,
Gene
