May 3, 2024
Dear Interested Readers,
Improving Healthcare Will Require Courage
Protestant ministers of my father’s era would frequently focus their sermons on the promise of John 3:16.
For God so loved the world, that he gave his only begotten Son, that whosoever believeth in him should not perish, but have everlasting life.
I am referring to the time when there was a generally accepted idea that there should be “a separation of church and state.” It was long before abortion and LGBTQ+ issues became divisive cultural and political issues. It was even before some ministers began to tell their congregations how to vote. Those more harmonious days were long before our deep political divisions paralyzed Congress and “Christian Nationalism” emerged as a movement that had the power to elect a bizarre president and move the Supreme Court to the far right.
Ministers of my father’s era would also advocate for “God’s Kingdom” on Earth as it is in Heaven as Christ taught his disciples and followers to pray for in his “Sermon on the Mount.” Matthew 6:10 reads:
Thy kingdom come. Thy will be done in earth, as it is in heaven.
In Matthew 22: 36-40 Jesus answers a question that seems foundational to any effort to bring forth the “Kingdom of Heaven on Earth.” When he is asked what is important he responds:
36 Master, which is the great commandment in the law?
37 Jesus said unto him, Thou shalt love the Lord thy God with all thy heart, and with all thy soul, and with all thy mind.
38 This is the first and great commandment.
39 And the second is like unto it, Thou shalt love thy neighbor as thyself.
40 On these two commandments hang all the law and the prophets.
As the son of a Baptist minister, I logged a lot of “pew time.” By the time I was in medical school, I was questioning the reality of these scriptures. My questions led me to marvel at how my dad could continue to talk about things that just didn’t seem like they could ever happen.
My dad died a few weeks before his 98th birthday in 2018. My mother died a few weeks before her 94th birthday. Both of them remained pretty intellectually active despite a host of medical problems until very close to their deaths. Dad preached his last sermon at age 94 which gives me hope that perhaps I will be observing and writing about what is happening in society, healthcare, and politics for many more years.
A few years before he died, Dad told me that he had kept a daily journal for many years. I asked if I could read it, but he said, “No, I am going to burn them before I die.” After he died, I discovered that he did not burn them. There are many boxes of notebooks that are filled with handwritten pages. Without fail, he usually wrote about a page every morning before 6 AM after beginning his day by reading his Bible and praying.
I try to read a bit from his journals every night before going to sleep. What I have learned from my reading is that he was frustrated by the lack of progress toward “The Kingdom of Heaven on Earth.” At times he had doubts about the effectiveness of his ministry and whether his prayers were answered. He admitted his frustration with his personal failures and lack of effectiveness in advancing the causes that he cared about deeply. I did discover that he had at least one prayer answered. In the aftermath of the presidential election of 2000 when there was controversy about “hanging chads,” he prayed that the Supreme Court would make George Bush president. His prayer was answered in that instance. Mine was not.
I don’t know when it occurred to me that my father and I had some significant similarities. I have certain quotes from some of the “saints of healthcare” that I repeat like verses of scripture. Most certainly Dr. Ebert’s 1965 quote is as true today as it was when he wrote it in a letter to the president of the Commonwealth Fund:
“The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”
It’s been 59 years since those words were written and we are still spending more money without providing “optimally for the health needs of the population.” It is my opinion that our failure is the result of an unwillingness to change our system of healthcare finance or the basic operating system of healthcare delivery.
Another healthcare scripture that I quote with the religious fervor of Billy Graham is the observation Dr. King made in 1966.
“Of all the forms of inequality, injustice in health is the most shocking and inhumane.”
I frequently recycle the insight for healthcare of Dr. Paul Batalden who helped Don Berwick found the Institute For Healthcare Improvement.
Every system is perfectly designed to get the results it gets.
If you click on the link above, you can read Dr. Batalden’s description of how he lifted this quote from a seminar he attended on systems improvement given by W. Edwards Deming, the famous manufacturing guru. The last time I visited the IHI offices (over ten years ago) this wisdom was painted on the wall in large letters.
Our current system of care was “designed” or has evolved to deliver care that is expensive, inequitable, wasteful, and unsafe for many patients. Although we talk about patient-centered care, our care is often system or provider-centric. Timeliness of care is a function of what works for the system and is often not what is optimal for the patient. It should not surprise us that such a system delivers a declining national life expectancy and outcomes that are often worse than those produced by other developed economies for a little more than half our costs.
In summary, my father’s frustration with efforts to achieve the Kingdom of Heaven on Earth seems similar to my frustration with our inability to achieve or make meaningful progress toward the Triple Aim that calls for improving the health of the population while improving healthcare costs and access. Providing the health care we need seems to be as unlikely as waking up some morning and discovering that we live in a world defined by neighborly love and mutual support.
Like my father, a lack of seeing much progress in the transformation of beliefs and desires into reality does not diminish my enthusiasm for the work. I believe in the validity of the Jewish dictum that:
“You are not obligated to complete the work, but neither are you free to abandon it.”
I would go a little further and say that it is not enough to continue our efforts in a work that we will not see completed, but that we should recognize that there is benefit in this moment to small advances even if those advances don’t come near to achieving the total objective.
Efforts to overcome the status quo can occur through revolt and revolution but combining continuous improvement with “creative destruction” and its extension into “disruptive innovation” have always seemed to me to be strategies that are more likely to lead to lasting changes. Progress toward a distant vision requires the courage to be willing to “put the old aside.” It is my bias that the resistance to putting the old aside arises from at least two things. First, for most of us, there is the fear that what we know, even if defective, is safer than the unknown consequence of trying what we don’t know. The second bias that I have is that for those who control the defective status quo, there are profits and benefits from the imperfect system that those who hold power are reluctant to give up.
I read an article this week that gave me a new insight into how healthcare change can occur. After reading the article, I felt encouraged to believe that personal testimonies from very respected people about how they were failed by the healthcare system followed by suggestions for improvements or innovations might move us all a little closer to better health for everyone.
What you have read up to now was brought to mind this week by an article that was an exercise in courage published by a broadcast journalist for whom I have long had great respect, Martha Bebinger, who is the award-winning veteran healthcare correspondent at WBUR, the Boston Public Radio station affiliated with Boston University. Her pieces are often broadcast on National Public Radio across the country.
I heard Martha Bebinger on the radio many times before I met her because for more than thirty years, except for Red Sox games, the only radio stations I ever listened to were NPR-affiliated stations. Yes, I know that I live in an echo chamber, but facetiously, I like hearing what I already believe.
After I became CEO of Harvard Vanguard and Atrius Health, I had the pleasure of meeting Martha. (I feel comfortable using her first name because over time we developed a professionally based friendship.) We would often attend the same local healthcare events. I saw her on numerous occasions at the State House on Beacon Hill where we both would be attending a hearing on some proposed healthcare legislation. My last conversation with Martha was at my retirement party at a hotel in Newton near our corporate headquarters. Marci Sindel, who wore many hats on our executive team, invited Martha to “interview me” as the “entertainment” for the event.
Martha’s reporting on issues in mental health has earned recognition. This year she was the recipient of the Gracie Award for her reporting on the treatment of drug addiction. She has recently presented a radio report on an innovation in mental health treatment, “Peer Specialists.” The story suggests that trained community workers can help accomplish improvements that would never occur were they not an option in the treatment plan. Community health workers may be an innovation that can counter workforce shortages and produce better outcomes and patient satisfaction than our beleaguered traditional mental health practices can accomplish. Iora Health has demonstrated the benefits of Community Health workers in primary care.
What impressed and moved me was that Martha underlined her presentation of Peer Specialists in a piece that was published in the WBUR letter, The CommonHealth, in which she describes her own mental health problems in her twenties that might have been helped if a Peer Specialist had been available to her. She writes:
I lost a big chunk of my 20s to depression. I failed at college, drifted from one part-time job to another racked up debts and spent many hours in bed— staring at the walls.
Fortunately, she eventually got help and at age thirty got a job at a TV station doing a variety of entry-level tasks. After revealing her own struggles, she writes:
Certified peer specialists are people like me, today. They’ve struggled with anxiety, depression, schizophrenia, bipolar disorder or some other mental health illness, and are now stable enough to reflect on that experience and share it with others. That might mean commiserating about the despair, talking about the shame of not being able to complete simple tasks, the side effects of medications or anything else a traditional therapist hasn’t lived through or doesn’t feel comfortable discussing.
Most clinicians in any specialty make an effort to be sympathetic, but it is rare for them to be truly empathetic because they have never experienced what the patient is experiencing. As she explains, it’s different with a Peer Specialist.
…During my deep depression, I went to therapy so someone could tell me what was wrong and fix it. The clinician was the expert. My job was to follow their plan, if I could. Peer specialists recognize patients as experts themselves who can figure out what they need and how to get it.
I wrote a note to Martha thanking her for her openness and commitment to care improvement. I think she took a risk because she cares deeply for those who need help that they are not getting because of the limitations of our current system of care. I don’t know if the Kingdom of Heaven will ever come on earth, but I do believe that in time because of the commitment of many people like Martha Bebinger, we will continue to make incremental progress toward the Triple Aim,
Conformation That Summer Is On The Way
Except for Monday and most of Thursday, weather-wise, it’s been a bleak week. Today it is overcast, cool, and a little windy. We are expecting clouds and some more rain over the weekend. I was surprised on Monday when I returned from an errand to find that the man who installs our dock each year was busy doing his work. I had spoken to him a few days before, and he had suggested that he was overworked and could not hire a crew to help him do all the work that comes to him this time of year. He led me to believe that we would be lucky if he got the dock in by Memorial Day. I said that I understood his stress, and I hoped things improved.
He was in the water in a wet suit along with a crew of three helpers, so I waved and expected that we would speak when the job was done. I went inside to wait for him to finish his work. The next time I looked out the window to check on his progress, the job was done and he and his crew had hustled off to their next job. What a surprise! Monday evening my neighbor did me the favor of carrying down the chairs that usually sit on the dock while I took the picture which is the header for this letter.
You may not have personal experience with docks on lakes that freeze. If the dock is a fixed item the ice will lift it and damage it. The solution for the problem of damage from the ice is to constantly run a circulating pump that keeps the water moving which prevents ice from forming under the dock. The alternative is to have either a floating dock that can be floated away in the fall for storage or one that is fixed and can be removed in the late fall and then returned to its usual place in the spring after the ice is gone. We live in a region with dozens of lakes and ponds. There are hundreds of docks in the Sunapee/Kearsarge area that must be removed every fall and reinstalled every spring. It is a big business that temporarily employs many people who also work the ski resorts or do snow plowing in the winter and do landscaping and construction in the summer and early fall.
We have never had the dock put in this early. Perhaps, my dock man took pity on me when I told him that I had recently had surgery and was looking forward to sitting on the dock and fishing in the evenings, and possibly realized that his promise of “by Memorial Day” was a month of fishing and enjoying evenings on the dock that I would miss. Whatever the explanation, he did his part, and I am very grateful. Now I must wait for the rain to stop and for the temperature to rise enough so that I can sit on the dock without wearing a parka.
Winter is definitely over. Spring is making an effort to establish itself but keeps getting interrupted by storms. I hope that the pattern will not continue into the summer. Whatever the weather for the summer turns out to be, the dock will be the center of my outdoor activity for the next five months, maybe longer. I hope to build strength will daily swims which I hope to begin by mid-May.
The other big event on the lake since the last of the ice melted was the return of the loons. They showed up about two weeks ago. I have great expectations for our loons this year. We have not had baby loons for the past two summers.
Even loons have difficult relationships. Two years ago the male loon was challenged by a younger male. The older fellow lost his position with the female. It seems that new loon relationships take a while to become established, so no baby loon. Last summer, we had hopes, but violent weather disrupted the artificial “island” that protects nesting loons. The “island” is a moored platform placed in the sheltered cove created by a small peninsula. The island was placed several years ago by the Loon Preservation Committee of New Hampshire. We had some violent storms last spring which broke one of the mooring cables. Again, there were no baby loons.
I once thought loons were monogamous. They aren’t monogamous to another loon. They are monogamous to “place.” I feel sorry for the older male who was rejected. This summer I will be waiting on the dock to see what happens. I can monitor the loon island from my dock with my binoculars. You can be sure that if a loon chick arrives plenty of pictures will be taken and the chick will be featured in the header of this letter. There are a lot of things to see sitting on a dock. I am all set for sitting on the dock and eager for warmer weather to return, if only for a day or two each week.
I hope that you are beginning to make plans for your summer. I have said it before. Having something to anticipate is one of the three key elements of happiness. The other two elements are something meaningful to do and others to love. I am all set with the trio. I hope that you also have all three.
Be well,
Gene
