October 6, 2023
Dear Interested Readers,
Evolution of Ideas and the Environment
As I pick up my story this week, I am among the many who are shaking their head in dismay over what has happened to Speaker Kevin McCarthy amid the disharmony in the House of Representatives this week. I am also surprised by the strike at Kaiser Health. Ironically, the next chapter in my tale leads up to the emergence of internal political disharmony at a rapidly growing Harvard Community Health Plan. I don’t know what will happen next in Washington, but I do know what did happen in Kenmore Square in the late seventies and early eighties when a young dynamic leader was forced out by the circumstances that evolved in an atmosphere of rapid growth as our practice sought to evolve from being an innovative idea to a continuing reality.
Harvard Community Health Plan began as a multispecialty group practice with a focus on health maintenance and preventative medical practice managed in a primarily ambulatory environment. It might surprise you to know that before the HMO Act was passed in 1973, the plan was offered to the public through Blue Cross. When we became both a practice and an insurance company we were a competitor of Blue Cross and used the marketing line, “The Cure For the Blues.”
What also happened was that new business concerns began to develop that would over the next twenty years lead to the medical practice severing itself from the insurance company in an action that I had a role in leading as the chairman of the physicians group through the 90s. At the time I was fond of saying that with about 400,000 patients, we were the largest medical group east of the Mississippi that did not own a hospital. I was also arrogant enough to believe that we were the best place to get care in Massachusetts because we had the highest measured quality and were less expensive because we focused on eliminating overuse and misuse of resources. I never remember a moment when we were credibly accused of denying any patient necessary medical care because we were trying to cut costs to enhance our profitability.
In the seventies medical practice was hospital-centric which contributed to the rapidly rising cost of care. Comparative numbers are hard for me to find but I remember hearing that in 1969 as HCHP was just beginning practice was so hospital-centric that there were more than nine hundred “hospital discharges” per thousand patients per year.
No matter the exact number, people were frequently hospitalized for things like routine testing and procedures that are now done in the ambulatory environment. Not only were we using the hospital for procedures that are now done in the ambulatory space, but patients also stayed in the hospital much longer than they do now for a similar diagnosis. For example, as I have mentioned before, a diagnostic cardiac catheterization required a five-day hospitalization in 1975. A heart attack would result in a three-week hospital stay. When I retired ten years ago a diagnostic cath was an outpatient procedure, and most patients who had a myocardial infarction spent no more than a few days in the hospital. One of the most significant changes in our use of hospitals has been in obstetrical care where now an uncomplicated delivery is usually a two-day stay. That change was initially met with substantial resistance. One of the reasons that diagnostic testing was done in the hospital in the seventies was that the commercial insurance of the day would often not pay for outpatient care and testing.
Dr. Robert Ebert, Dean of Harvard Medical School and founder of Harvard Community Health Plan, described the situation and its flaws in a speech he gave for the Kate McMahon Lecture at Simmons College in October 1967. I will lift some of his description of the medical practice of the day from that lecture because he was describing problems that he hoped could be improved by a revolution in healthcare delivery that moved much of the care out of the hospital and into the ambulatory environment. Near the beginning of his presentation, we get a little bit of his assessment of the climate of public opinion about doctors at the time, and the uncertainty that many physicians experienced as care delivery was changing. Note that in 1967 Dr. Ebert was focused on the social responsibilities of the doctor. I doubt that many other doctors in the seventies thought much about their social responsibilities. In many ways, Dr. Ebert had a broader vision than most of his contemporaries. I was very fortunate to work in an environment that was built on his philosophical view of medicine. I have bolded a key idea. We read:
…The public has been indoctrinated to believe in the miracles of modern medical science, but the reality of delivery falls short of the expectation. The doctor is uneasy because his traditional role seems to be changing. He can no longer act solely as an individual, for he has become increasingly dependent upon others — other doctors, others in the health field, and above all upon the many people who work in the hospital. This changing role is related to his changing social responsibility and he is ill-prepared for the change.
The doctor is a frequent target for attack because he is said to lack a feeling of social responsibility. I believe this to be unfair, for in my opinion the average physician has a strong sense of social responsibility but it is a highly individualistic feeling which is largely invisible to the critical public…
Dr. Ebert’s analysis suggests that then, as now, there was some ambiguity in just what the proper role of the individual doctor was as healthcare evolved into an era of scientific breakthroughs, specialization, and a rapid succession of life-saving hospital-based innovations. Dr. Ebert was ahead of most physicians and medical leaders of the day by asking about the “social responsibilities” of individual physicians. I would say that without a sense of social responsibility, it is unlikely that physicians would individually have any interest in improving the social determinants of health. Dr. Ebert was making key observations about a change that was inevitable and its impact on those in healthcare. We had a new environment and confusion about how roles and responsibilities should change. His description of the moment continues:
How is the sense of social responsibility displayed by the physician? …In a simpler age, the physician knew not only his patient but the patient’s family; he was familiar with the patient’s social and economic background, and he was able to provide care with a kind of personal understanding often absent today. The physician was able to do far less medically than he can today but no one could do much more; the general practitioner could safely provide most of the care needed by a family.
When I began this autobiographical journey as an extension of the discussion of “moral injury” in medical practice my purpose was to explore the factors that were foundational in the development of my own healthcare moral sensibilities. In retrospect, the primary influences that formed my medical moral sensibilities were twofold. First, there were the teachers and more experienced colleagues who “showed me the way” and modeled the behaviors that I copied. The other influence was the environment. The environment in the organization that Dr. Ebert created was unique and quite different than the ambiance in the hospital. Later on in his speech, Dr. Ebert specifically described the importance of the practice environment. He continued:
The social values of the physician come from the environment of the medical school and the hospital in which he receives his internship and residency training…He is likely to assume the social values of those he respects and for the remainder of his professional life he imitates what he has seen and experienced as a medical student and as a house officer.
My own story confirms Dr. Ebert’s analysis. My medical values were very much a product of the doctors I was exposed to in the hospital and some of my professors in medical school. What Dr. Ebert could only hope for in 1967 was that by 1975 his new experiment in care delivery would be an equal if not greater influence on young physicians like me who would have the benefit of an ambulatory practice that was counter to the increasingly confusing environment in the hospital. In the end, it was Dr. Ebert’s HCHP that clarified the confusion about the positive principles that were being challenged as the hospital environment became more and more technical and oriented to business and less focused on traditional medical values. As Dr. Ebert continued his lecture he focused on the benefits and losses from the shift of most care from the office of the general practitioner to the new technological skills of the hospital specialist. He notes what has been lost in terms of an intimate relationship with the patient and the patient’s family, and the associated gains from the new hospital-based expertise, but he continues to focus on how to preserve a physician’s sense of social responsibility. One begins to see that he sees the outpatient environment as much or more than the hospital, as the place where a physician’s sense of social responsibility could be developed.
I think Dr; Ebert’s vision ultimately became the most significant part of my evolution as a physician who was concerned with social responsibility and ultimately the social determinants of health. I hope that my story will convince you that I acquired as much of my sense of social responsibility and medical ethics from my experiences in Dr. Ebert’s new organization as I did from my experiences in medical school and during my hospital training.
Later in his lecture, Dr. Ebert traces the history of hospitals. Hospitals began as eleemosynary institutions where the poor could get some of the care and attention that wealthier members of society could afford to get at home. It was not until technologies and procedures were available in the hospital that could not be delivered at home that the upper classes began to come to the hospital. He implies that the sense of responsibility to the patient that was such an important part of practice before the prominence of the hospital was lost as the hospital became the center of care.
I was not aware of any of Dr. Ebert’s innovative thinking during the first year or so I was learning how to work in his grand experiment. I was focused on my own survival and was not aware that some “sibling rivalries” were developing among the “early adopters” who had joined the process of change that had been launched in 1969 by Dr. Ebert. External developments were also an influence for change. Congress passed the HMO Act in 1973 which created new possibilities and new challenges for our practice that gained increasing momentum that would eventually result in the HCHP physicians evolving from members of an independent medical practice to employees of a non-profit corporation after a drawn-out discussion, interview process, and negotiations in 1977.
The structural change in 1977 had a huge impact on me because, from my point of view, the greatest downside of the process was the end of Dr. Joe Dorsey’s tenure as medical director. I was very upset when Joe went on a leave of absence to develop a road map for the next stage of HCHP’s evolution. I have always thought that the move was a poorly veiled process orchestrated by those interested in a new direction and jealous of his role. Joe handled the situation with grace because his commitment was to the principles of the practice and his patients. Joe will always be my hero. I was quite upset as I realized what was happening. I told myself that Joe had gotten so far ahead of the rest of us that we couldn’t see his tail lights. The series of medical directors that followed Joe until he was reinstated as the medical director of Harvard Pilgrim Health Care more than fifteen years later all were competent, but they were much more “corporate” and lacked Joe’s passion for practice, patients, and social justice.
Some of my colleagues speculated that Joe would go to Washington and join the Carter administration in some medical leadership capacity. What he did do reinspired me. He remained in the practice and continued to be our best doctor, mentor, and moral beacon. I did not know it at the time, but what I did not like and hoped would not happen in 1977 would ultimately create a path of opportunity for me which I will describe as the story continues next week.
This series of letters was initiated by an examination of moral injury. That subject came up in an opinion piece in the New York Times which was published yesterday, October 5. The article was written by a New York EW doctor and was entitled “The Kaiser Strike Isn’t Your Typical Labor Action.” Within the article, we read:
As health care has become more corporate in recent decades, physicians have also increasingly felt caught in the liminal space between their Hippocratic oath and the demands of health insurance companies. Providers routinely speak about “moral injury”: the feeling of guilt about being unable to care properly for patients in the face of hurdles like preauthorizations, diminishing reimbursements or unmanageable patient loads.
It’s a good article worthy of your time and attention. It contains suggestions that are worthy of consideration. In the last paragraph the author suggests that unless significant changes occur, the Kaiser strike will only be the beginning.
In most places, the Kaiser strike is expected to last only three days. But the issues that pushed health care workers to the picket line will remain. And although the strike at Kaiser may be the largest of a U.S. health care institution in history, without overhauling the conditions under which health care workers do our jobs, it undoubtedly won’t be the last.
My story will continue next week.
Martha’s Vineyard, Mostly In The Rain
You may recognize that today’s header is a picture of Gay Head and its lighthouse on Martha’s Vineyard. If you recognize the scene, you may also remember that a few years ago the lighthouse was in danger of falling off the eroding cliffs, but the 400-ton structure was moved back from the edge of disaster. If you find that hard to believe, click here for a short YouTube clip about the feat. You may also remember that on this same weekend last year, I was on Block Island where there was also a lighthouse that was moved back from the brink. I do like lighthouses, but there is no other connection. A year ago, my wife and I were just enjoying a short vacation. Our explanation for being on Martha’s Vineyard last weekend was the wedding of the son of very close friends and to simultaneously have a reunion with two of our sons and their families. The highlight for me was seeing my California grandsons for the first time since April.
Last year at this exact time, we enjoyed spectacular weather on Block Island. This year there was a lot of rain. The same storms that flooded the subways and streets in New York also visited the Cape and Islands. Friday and Saturday were washouts. Unfortunately, the wedding had to be moved indoors. It was still a great event, but not the one that had been planned at great expense. The picture of Gay Head was taken late Sunday when things were beginning to clear and most of the guests at the wedding were boarding ferries and taking flights off the island. We stayed until mid-day on Monday and left under very clear skies and warm sunshine that would have been perfect for a wedding day.
Before last weekend, I had not been to Martha’s Vineyard since 1975. As I tried to answer the question of why such a long absence, I realized that getting there required clearing several hurdles. First, just getting to Woods Hole to catch the ferry was a challenge. Traffic to the Cape is usually heavy. The accesses to the bridges are often backed up for miles on summer weekends. Accommodations are expensive. If you want to take a car you must book your place on a ferry long in advance. In 1975 we took a day trip on our bicycles. Crowds on the island are often large. When I wanted to go to an island Nantucket seemed a little more attractive for all the effort required. There are other places on the Cape and in nearby coastal New England that are just easier to access. Despite the weather, construction on the Bourne Bridge, large crowds, and substantial expense even late in the season, I am happy that I finally returned. A chance to be with close friends and family always trumps bad weather. I shudder to think that as global warming accelerates, we may have more and more washed-out weddings and weekends.
We have had great weather all week. I took a last sail for the year yesterday before taking my sailboat out of the water for the season. This week the temp was in the high 70s. Next week the forecast is for overcast days, some rain, and a twenty-degree drop in the temperature.
This weekend we are in Brunswick, Maine where we will celebrate my granddaughter’s 21st birthday and watch her play volleyball for Bowdoin against Hamilton and Middlebury. I hope that you have great fall plans. The colors of the leaves seem a little dull this year, but they are still pretty and Maine should be pretty nice. I hope that you have plans to be in a pleasant place without rain. We have had more than enough rain this year.
Be well,
Gene
