November 24, 2023

Dear Interested Readers,

 

Some Thoughts Before Continuing My Story

 

I began the slow crawl through the memories from my professional life in the letter that I wrote to you on July 21. Eighteen weeks later I am only up to 1995, and I am beginning to wonder if there are any readers still following the story. I have learned much about myself as I have tried to tell the story, but I am beginning to be a little bored by my own story. I wonder whether my slow narrative is also boring you. Beyond my ambivalent feelings about continuing the tale, I have realized that the story is as much about my colleagues and our practice as it is my story. Perhaps, that is the best reason to continue. 

 

I began this long journey as an exploration of the origin of my personal medical moral and professional values. I had begun to think about how my own medical moral sensibilities had evolved after I read an article in the New York Times entitled The Moral Crisis of America’s Doctors that suggested much of the stress that some physicians and healthcare professionals are currently experiencing is not “burnout” but rather is “moral injury.” 

 

I had first written about moral injury in 2015, but at that time I was writing about how a former colleague and friend of over forty years had felt that his moral sensibilities had been violated by “the system.” I had not understood that he left our practice in 1984 and moved to Oregon because he was so injured that he felt he needed a new start. For years, I had blamed his “then-wife” for their move. In retrospect, I have never known a physician who has had a clearer concept of what constitutes ethical practice than this former colleague and continuing friend. In Oregon, his practice has been devoted to teaching in a DSH hospital. His practice has been populated by patients with AIDS, the homeless, and those whose position on the fringe of society has often compromised their access to healthcare until there was not much to offer them but sympathy and palliation. 

 

While I was debating whether to suspend my story, I discovered a brief article published this week in the online notes from The Atlantic.  The piece was authored by Arthur Brooks and is entitled “Why You Maybe Shouldn’t Write a Memoir.” Brooks is a regular contributor to The Atlantic. and he has a podcast entitled “How to Build a Happy Life.” 

 

Brooks gives us a warning in the second part of the title of his article: “Talking about ourselves too much hurts our happiness—and can signal deeper problems.” I was a little nervous as I began reading. Was the cosmos talking to me? Brooks begins:

 

Have you ever thought of writing an autobiography? Lots of noncelebrity people are doing that these days: Memoirs are more common, as we become more comfortable sharing intimate details of our personal lives with strangers. But before you start yours, consider this: What you think is riveting about your life might not seem so to others. As one publisher put it, too many submissions are “just the writer’s own story, which is ultimately boring.”

 

There is no question about Brooks’ wisdom in that statement. Now that Brooks had my attention he went for the jugular.

 

And now that you’re reconsidering your memoir project, you might even think about taking it a step further, and talk less about yourself in general. We like to talk about ourselves because, quite simply, for us it feels good…

 

I think that there is more to the issue than that observation. In fact, rather than making me feel good about myself, the longer I write the more uncertain I become about the merit of the project rather than feeling good about myself. I am becoming quite self-conscious, and I am hesitant about continuing. I am always faced with the question of how much of my life am I comfortable revealing. I can assure you that despite the length of my tale there has been more that has been left “on the cutting room floor.” 

 

The question for me has often been how to present the story and leave out the subjective aspects of the story that constituted much of my motivation at the time events were unfolding. Perfect examples of this are my feelings during the transition in cardiology leadership, the events around the closing of the HCHP Hospital on Parker Hill, and the events of the “physician revolt” in the early 90s. In these situations and others, there was much that I preferred to keep to myself. Had I told my story thirty years ago when my feelings were more intense, I probably would have tossed in a few more accusations. 

 

Brooks goes on to present data that suggests that talking about ourselves results in the release of dopamine which makes us feel good in the moment. That feels right to me. He suggests that positive feelings can be addictive even as they are annoying those who must hear our stories. As he continues, he gets close to me again since what I have been talking about is my work, or what happened at work.

 

 Sometimes the mechanism takes a roundabout form, such as talking compulsively about one’s work. Someone who suffers from this syndrome might be a workaholic whose self-worth is built on their job—in which case, talking about work is really a way of talking about themselves.

 

I would agree that there is some truth in that analysis. I am sure that one of the factors that led to the end of my first marriage was my intense focus on my work. He then suggests that talking about oneself can indicate depression. Talking about yourself all the time can make you depressed and can be boring for others who begin to avoid you. Brooks describes how this happens:

 

As is commonly the case with depression, this tendency is counterproductive, in the sense that talking about oneself and disregarding others are off-putting characteristics. Depressed people need love and support, and research shows that they react positively to experiencing a sense of belonging. But conversational narcissism—especially complaining—drives people away, which can make the mood disorder worse.

 

Brooks finishes by making some self-help suggestions which I will let you explore if you wish, but I will try to vigorously employ one of his suggestions as I go forward a little longer with my story. Brooks advises a shift to a wider framing of the conversation that includes others.

 

When you want to address a particular topic, find a way to pivot from “I/me” to “we/us.” For example, if you are tempted to complain about your job to someone, instead ask them what they’d do in the particular situation you’re unhappy about. If you’re feeling disappointed with the weather today, depersonalize your complaint by saying, “It looks as if we’re going to get rain today.” These are subtle changes, but they will put you mentally into the company of others, shifting the focus toward them and their experience, instead of orienting it always on yourself. And after all, no one is bored when you talk about them.

 

There is more good advice in the article which you might want to explore. I began by writing to you about the origin of my own medical moral sensibilities. Perhaps, I should have been asking you about how you feel about moral injury in healthcare which may include a review of the origin of your own sense of what is right in current practice and what makes you concerned and depressed about the way our practice lives have changed. That is an invitation.

 

One thing that I have decided about the rest of my story is that it will be more and more about the remarkable people who shared my journey. My medical principles were significantly influenced by my colleagues. I was fortunate to have many colleagues who were as concerned about what was happening to our practice and to medical practice across the country as I was. Our collective concerns about the future of care “was the tie that bound us” together. It was often true that their point of view informed mine. That said, the installment of the story in this letter will be brief. 

 

After the dust had settled from the “revolt” within the Health Center Division of HCHP, a vigorous conversation developed about what was important and what we had that was unique to offer to the evolution of practice. Individually, many of us were stressed by the evolution of relative value units (RVUs) in the late 80s and early 90s. RVUs were based on work done by Hsaio and others in the Harvard Resource-Based Relative Value Scale (RBRVS) study group. On January 1, 1992, the RBRVS system of payment was implemented by Medicare. In the early 90s, our practice was centered primarily around employed individuals and their families.  We had very few patients coming to us through Medicare, but the methodology was attractive to our managers and to commercial insurers who began to apply the concept to commercial contracts. Our managers were eager to adopt RVUs as they were seeking to compete with the fee-for-service world. Their bias was that a salaried physician had little incentive to work harder. Our contention was that a physician who was driven to increase the total of RVUs was going to practice in a way that compromised the care of many individuals and was more like a squirrel running in a wire wheel than a thoughtful practitioner who was focusing on the concerns of the patient while avoiding unnecessary testing and procedures. 

 

As any doctor and most nurses now know, the “suits” ultimately won the argument, and medical “productivity” is now measured by RVUs, and RVUs are the foundation of most compensation plans and contracts. I have yet to meet a doctor who believes that RVUs accurately reflect his/her efforts. This is especially true for primary care and the “cognitively” oriented medical specialties.

 

As you may remember from my story, in the 80s our physicians were salaried. As RVUs began to be counted as a function of the “level of service” there were more and more efforts to make our compensation “productivity-based” as measured by RVUs. It is a subtle reality that as doctors were forced to individually account for what they did, collaborative efforts were undermined. Trust me, most people decide what they are going to do and how they approach their work on the basis of how they are paid. Many of us felt that our culture was being undermined by the desire of our managers to adopt the emerging payment methodology.

 

I can speak directly to the impact of RVUs in our cardiology department. Reading stress tests and echocardiograms generated many more RVUs per hour than working through complicated diagnostic problems or managing a complicated patient with an established diagnosis and associated emotional problems. As a group, we decided to pool our RVUs. As you might imagine, most groups within our practice did not make this choice and there was often internal warfare over the most lucrative work opportunities. Once again, the outside world induced internal stress and conflict. 

 

About the same time as our management was beginning to talk with Pilgrim Health Care about a new strategic partnership, the physicians began to have increasingly organized conversations about how to optimize our practices in response to the pressures we were feeling. The spirit of collegiality that existed within the Health Centers led us to realize that any conversation about the future of the practice should include our administrators, practice managers, nurse practitioners, and physician assistants.

 

Glenn Hackbarth and Jennifer Leaning were active partners in the conversation within the Physician Council. We decided to expand the conversation to include a representative group of doctors, mid-level clinicians, nurses, and site administrators from across the organization. We called the expanded conversation “The Assembly.” Meetings were held offsite and were facilitated by Dr. Marc Bard who had once been one of our internists, first at our Cambridge site and then at our Wellesley offices. Marc had developed a national consulting practice, and Kaiser and the Permanente Medical Group were also his clients.  

 

The work was slow. There were questions about how to amicably exit first HCHP and then Harvard Pilgrim after the merger. It was obvious that initially, Harvard Pilgrim would be our only source of patients. That was like the arrangement between Kaiser and the Permanente Medical Group, but we needed access to more patients. How would that work? Would we rent our offices from Harvard Pilgrim or would we own them? Who would employ the nurses and other staff? Would we accept risk contracts? Should we develop the ability to do some fee-for-service practice?

 

There were many difficult-to-answer questions and good reasons to stay put in our employed relationship with Harvard Pilgrim. Fortunately, there were C-level corporate officers and board members of Harvard Pilgrim who shared our view that both the practice and the insurance function would be better if separated. Very slowly the idea that we should separate the practice from the insurance company gained acceptance by the medical group and by Harvard Pilgrim. All of the doctors who had been a part of Pilgrim were independent practitioners. 

 

By 1997, the discussion had advanced to the place where both sides decided that separation with the physicians becoming a self-governing non-profit medical practice was best for all parties, including patients. Initially, we would have seats on their board, and they would have seats on our board. One last question remained. What should we call ourselves?

 

With groups like the Lahey Clinic and the Mayo Clinic in mind, I suggested that we adopt a name like The Ebert Clinic. Glenn eventually suggested Harvard Vanguard Medical Associates. He argued that Vanguard suggested up-to-date leadership. I was the only person for whom Vanguard suggested failure. I could easily remember when in 1957 I was sitting in my elementary school classroom in front of a black and white TV eagerly waiting for the blast off of  America’s first rocket with a satellite. The Russians had made us feel “behind” with their “Sputnick” success.  Our rocket was named Vanguard. 

 

The excitement built as the countdown began—10, 9, 8. and so on. Finally, we heard, “Blastoff!” On the TV there was a lot of smoke as the rocket rose a few feet and then flopped over on its side. I was terrified, stunned, and like many Americans felt vulnerable when I realized that we were less successful than our arch-enemy. The feelings were made even worse when we were told that our satellite hadn’t been much larger than a grapefruit, and the Sputnick that had launched successfully was bigger than a basketball. In my 12-year-old mind, I thought our rocket failure made us even more vulnerable to the Russians than I had ever felt as we did drills to prepare us for nuclear attacks. Click here to see archival footage of the Vanguard “flop.”

 

I tried to explain to Glenn that others might also remember that the name—Vanguard—had been linked to failure. Did we want to take a chance? I think that he was focused on the successful Vanguard Financial Services. We hired lawyers to secure the name. Little did we know that our lawyers failed to uncover that a Nashville-based nursing home chain had claimed the name Vanguard a few weeks before we filed for it. That was not discovered for months and ended in a lawsuit that was eventually settled with a cash payment from us to them. We did not fall off the launching pad, but the launch was not as smooth as I had hoped it would be.

 

Once we had a name and an agreement, I was chosen to be the chair of the Vanguard board and continued as a member of the Harvard Pilgrim board. On January 1, 1997, we began a “trial separation.” It was a dress rehearsal. By plan, if the year went well, the separation would be formalized on January 1, 1998. It felt like we were making it up as we went along. It did not take me long to realize that the problems that we, the physicians, once blamed on management, were now our problems to solve. It is nice to have someone else to blame. Now we had to address the problems and solve them without blaming managers who “just don’t understand our problems.” 

 

There is much more to come. Less than two years into independence, the source of more than 90% of our patient contracts was to be belly up and in receivership. We were about to lose our revenue from more than 100,000 patients as employers bailed from Harvard Pilgrim as Y2K rolled in. I’ll tell you my version of that story next week. 

 

A Remarkable Opinion Piece That You Should Read

 

These days my wife is usually up before I can develop the courage to meet the day. I can have coffee as soon as I can get to the kitchen because I gave up the responsibility of making the coffee to her after hearing complaints for many years that my brew was too strong. After I pull on my pants and shirt, I drag myself to the kitchen. On my way, I usually pause to look out the window to see if there has been snow overnight. Even though I have transferred the responsibility for brewing the coffee, it is still acceptably dark and strong. We brew Starbucks French Roast.

 

After I have my coffee in hand, I move to the fireplace where I spend a few minutes moving the ashes from yesterday’s fire around before getting a new blaze going. From the hearth, I proceed with my cup of coffee to my easy chair where my laptop is waiting to present the day’s news to me. Monday, when I logged on to my copy of the New York Times, I got a first-class hit of dopamine when  I opened the “Opinion” pages where I saw an essay by Cass Sunstein.

 

Cass Sunstein is a professor at Harvard Law School, but I know him most for his interest in the interaction between behavioral economics and public policy. Sunstein co-authored a book in 2008 with the Nobel prize winner, Richard Thaler. The book, Nudge, opened my eyes to the potential power of behavioral economics to improve health care. Sunstein has written or co-authored several books since 2008 about how we reason and make decisions. 

 

Sunstein’s essay on Monday deserves your attention. He is writing like the law professor he is, trying to teach us how names and labels confuse us and can position us to be vulnerable to autocrats on both the far left and the far right. He begins the piece which is entitled “Why I Am A Liberal” by writing:

 

More than at any time since World War II, liberalism is under siege. On the left, some people insist that liberalism is exhausted and dying, and unable to handle the problems posed by entrenched inequalities, corporate power and environmental degradation. On the right, some people think that liberalism is responsible for the collapse of traditional values, rampant criminality, disrespect for authority and widespread immorality.

Fascists reject liberalism. So do populists who think that freedom is overrated.

In ways large and small, antiliberalism is on the march. So is tyranny.

 

As we read on he teaches us that many “conservative” politicians are liberals because they believe in the rule of law and personal freedom. His words brought John McCain, Mitt Romney, Adam Kinzinger, Liz Cheney, and even Mitch McConnell to mind. Sunstein then writes:

 

Perhaps more than ever, there is an urgent need for a clear understanding of liberalism — of its core commitments, of its breadth, of its internal debates, of its evolving character, of its promise, of what it is and what it can be.

Here is one attempt at an account, in the form of 34 sets of claims about liberalism.

 

That’s right, the rest of the essay is a list of 34 characteristics of liberalism, each fully explained. I found the list fascinating and informative. From his list, I can distill substantial support for a system of healthcare delivery that seeks equity in serving all Americans as it pursues the Triple Aim. I leave reading the list to you. For me, Sunstein’s list was like a “master class” of history and political philosophy.

 

I Hope That You Had A Great Thanksgiving

 

My Thanksgiving was terrific. Our son and daughter-in-law who now live in Maine a little north and west of Portland are close enough to join us for a family Thanksgiving. We had a great time sharing the excitement of the anticipation of a new grandson who is arriving in late February or early March. 

 

The whole week has been interesting. Monday was cold, bright, and clear. As I drove past Herrick Cove on Lake Sunapee after delivering a turkey and “the fixings” that had been donated by a KNP member to a family in need, I was struck by the beauty of the scene, so I pulled over and took the picture that you see as today’s header. If you look closely under the “s” in Musings, you can see the small lighthouse that marks the entrance to the cove. As is usually true, the moment was better than my picture. 

 

The scene shows the pier where more than a hundred years ago small steam ships would unload tourists who had escaped to the lake from the summer heat of places like New York and Washinton. Trains would bring the tourists to Newbury at the south end of the lake. From Newbury, the boats would distribute the travelers to the hotels and estates that were around the lake.

 

Perhaps, Theodore Roosevelt used this pier. He is known to have enjoyed visiting the area to enjoy the nearby estate of his friend John Hay, who had been Lincoln’s secretary and the Secretary of State in McKinley’s administration when Roosevelt was Vice President. Hay then continued as Roosevelt’s Secretary of State until he died in office while at his estate in 1905. Hay’s accomplishments include negotiating the treaty that allowed the building of the Panama Canal. John Hay’s home and estate, “The Fells,” is a cultural center and tourist attraction now in our area. 

 

By Tuesday the clear skies were replaced by clouds, and then overnight there was a dump of almost six inches of snow that was followed by rain and drizzle. There was a nice cover of snow that survived the rain, Thanksgiving was bright and clear.  We had a “White Thanksgiving.” It was a near-perfect day that I hope was terrific for you.

 

Now it’s “Black Friday.” The name is scary and reminds me that the last thing in the world that I would want to do this weekend is to go shopping. However you plan to spend the weekend, I hope that you will have the chance to continue to enjoy time with family and friends.

Be well,

Gene