September 10, 2021

Dear Interested Readers,

 

9/11 and 2001 Remembered and Reflections

 

I was deeply moved by a casual statement made by a news commentator about how young the thirteen soldiers were who were killed by the ISIS terrorist bomber who blew himself up near the airport in Kabul as we were evacuating our citizens and those Afghans who had supported our efforts to bring a democratic government to Afghanistan. NPR has given us their pictures and their brief biographies. The Washington Post emphasized the same point when it commented that all but one of the soldiers, Marine Corps Staff Sgt. Darin T. Hoover of Salt Lake City who was 31, were too young to have had a personal memory of 9/11. Five of the dead were only twenty years old and other than Sgt. Hoover the oldest was Marine Corps Sgt. Johanny Rosario Pichardo, 25, of Lawrence, Mass.

 

Like many of the elderly, I am a little “pseudobulbar” in my dotage, and just looking at the pictures that NPR gave us of these young people brought tears to my eyes and created a sense of fullness in my chest. I have experienced other tears over the last week as I listen to all of the remembrances that have been produced for this twentieth anniversary of 9/11. Our minds often protect us from the horrors of reality. Three days before the bombing as the evacuation was underway, the AP gave us a sense of what our twenty years of presence in Afghanistan actually cost us. They pointed out that the full cost of the twenty-year war was much higher than reported because with the interest on the debt associated with the money spent the final cost will be close to seven trillion dollars. 

 

Since we cut taxes while in a costly war rather than raise taxes to pay at least part of the cost in real-time, my two small grandsons will be in their mid to late thirties and my granddaughter might be a grandmother before all the debt associated with this effort is retired. I am one of those people who believes that when we count the dead we should count everybody and not just those who wore our uniforms. From the AP article, you can estimate the number of people who died from the war in Afghanistan to be into the hundreds of thousands even before our last thirteen casualties were added on the twentieth of August along with more than one hundred seventy others who died in the blast. 

 

Everyone over the age of thirty probably has distinct memories of 9/11/2001. The scenes of people jumping from the Twin Towers before they collapsed are eerily similar to the scenes of people falling from the sky after making an attempt to escape by clinging to the wings of military air transport planes carrying those who were luckier to a new life as an immigrant. For those of us who are a few years over fifty, the last two weeks of our presence in Kabul are also reminiscent of the chaos associated with the fall of Saigon. In my darkest moments of reflection, I am resentful of all our failed efforts to export democracy over the last seventy-five years. In those dark moments, I wish that we had used the money to establish broad-based equity here at home in housing, education, job creation, infrastructure improvements, and attention to the health of our citizens. Vietnam ended any possibility for success through Lyndon Johnson’s Great Society efforts. I fear that our adventures in the Middle East since 9/11 have negated most of our efforts to operationalize the recommendations of Crossing the Quality Chasm which came out virtually simultaneously with the attack on our homeland by Osama ben Laden’s Al Qaeda operatives. 

 

9/11 changed the world, but not in the way Osama bin Laden hoped it would, and in that fact, there is some solace and consolation for all that we have continued to lose. A recent article in Foreign Affairs asserts that ben Laden wanted to reestablish an all-encompassing control of the Muslim world free of all western influence. That has not happened although ISIS, the Taliban, and the remnants of Al Qaeda still have that dream. As others have said, we can be grateful that in return for the sacrifice of so many young American lives, the ongoing pain and suffering of the maimed, all the pain endured by the families of the dead and wounded, and all the money spent and the domestic opportunities lost, there has not been a second event of the magnitude of 9/11. Blocking many efforts to harm us over the last twenty years is a significant accomplishment for our military and intelligence efforts.

 

We should continue to grieve the loss of life on 9/11 and the even greater number of lives lost or forever changed over twenty years in the aftermath of 9/11. I am simultaneously advocating for the recognition of the loss of the beneficial things that might have happened but never did because of 9/11. I don’t bemoan the fact that since 9/11 we need to take our computers out of our briefcases, remove our belts, coats, and shoes, and walk through some minimal radiation before getting on an airplane. Given the complexity of the world, perhaps those precautions would make sense even if 9/11 never happened. My worry at this time is whether we have learned much over the last twenty years. My grief is for all that we have lost over the last twenty years, and for the loss of what might have been even if equity and the Triple Aim were always long shots. 

 

The recent question of whether to parole Sirhan Sirhan creates many of the same thoughts of loss for me. If Robert Kennedy had made it through that hotel kitchen pantry without injury would Vietnam have ended sooner, would Richard Nixon have ever been president, or would we have gone in a more positive direction? We will never know what might have happened, but unfortunately, we know all too well what has happened after all of our national tragedies and losses. 

 

I was very pleased that last Friday’s letter elicited some response from a reader that I did not know was still a reader. I had not heard from him in a long time. We exchanged a few notes catching up on events of the last few years, and near the end of his second email he wrote:

 

I’m still optimistic that the shift in payment models away from fee for service towards value-based, population-focused models like the ACO will be a major driver of improvement…Whether we’ll be able to make the further shift to a true population health perspective, as outlined by Gawande’s article, seems much more doubtful to me. 

 

In retrospect, I am surprised that I did not ask him to explain why he was doubtful that we could move from our extreme focus on the care of the individual toward a more balanced approach that considered what was best for the individual and the community. Thinking about our response to 9/11 and the last thirteen soldiers to die in Afghanistan I realize that it is possible for us to identify with both the individual losses and the threats posed to our community. What I don’t understand is why so many of us can’t see the connectedness between what we want for ourselves and what is best for the community. Our collective experience with COVID and the surge of infections in those who have refused the opportunity for vaccination raises many of the same concerns about how we balance the needs of all individuals and all communities. 

 

As I think about our failure over the last twenty years to move more effectively toward the suggestions for improvement made in Crossing the Quality Chasm, I realize that if we had adopted the suggestions offered we would have been moving toward a more robust public health program. My first reaction twenty years ago to the ideas and policy changes suggested in Crossing the Quality Chasm was to see the benefit to the individual, but in reality, to focus on the patient’s experience, safety, timeliness, efficiency, effectiveness, and equity of care for all individuals requires a union of good primary care with improved public health efforts. The pandemic has demonstrated to us that to provide excellent care for any patient requires that we care equally for everyone in the community. If this is true within the confines of our borders it is also true across borders. Viruses do not respect borders, care about wealth, have any awareness of your coverage, and don’t relate to a nation’s GDP. 

 

When we focus only on vaccinating Americans and don’t consider all the billions of unvaccinated people in the world we are not being realistic about how much risk we are continuing to accept. Recently the WHO has asked developed countries to delay COVID vaccine booster shots until more third world countries have vaccinated significant numbers of their citizens. That recommendation makes sense if you think about it from a public health perspective and if you take a long view. If the COVID virus persists and continues to mutate in the wild in underdeveloped countries, or if other viruses evolve because we do not make more robust efforts to survey the world for risks, our vaccines may become less effective against the new COVID mutants and will we always be as disorganized when future pandemics occur as we have been for this one. It occurs to me that if we have learned anything from our protracted 9/11 experience it should be that if we are wealthy enough to invest seven trillion dollars to try to eliminate terrorism we probably can invest more than we are currently investing to protect the world and ourselves from this and future pandemics. 

 

An interesting email circulated this last week among many of my friends here in New London. Most of the people on the distribution list have demonstrated interest in our community by their volunteer participation in Kearsarge Neighborhood Partners. I should say that KNP is a sectarian organization. By design, KNP has no religious affiliations. Here is a condensation of the letter which I have tried to cleanse of most of its religious trappings which I do not think are central to its universal truth:

 

“A few years ago, a…professor…decided to use the parable of the Good Samaritan to make a point about how fear influences the decisions we make. He turned to Luke chapter 10 and began to read… [Click here if you don’t know the story. It is an answer to the question, “Who is my neighbor?” The story begins with a traveler who is beaten and robbed as he traveled the dangerous road between Jericho and Jerusalem.]

 

After [the] professor finished reading, he looked up and said, “This is not a story about being nice. This is a story about the transformation of the world.” …he went on to explain that [the story suggests] that there are three types of people along the road [of life.]

The first type are the robbers, whose ethic suggests that “what is yours is mine at whatever cost”…These are the people who will leave us physically, mentally and emotionally beaten and bruised along life’s road with nothing left but our shallow breath.

The second type of person to walk along the dangerous road…is represented by [those] whose ethic suggests that “what is mine is mine and I must protect it even if it means you get hurt in the process”. They aren’t bad people. [They] are deeply respected in their communities. They very likely follow all the societal rules and norms. They sit on local boards. They pay their taxes on time and likely coach their son’s or daughter’s teams. They also show a great deal of love to those within their immediate communities, but because of what crossing the road to help might cost them, they put their head down and go about their business. So, without even recognizing it, they do more harm than good. Their focus is inward toward their needs and the needs of those who are most like them. It’s an ethic that…often results with them choosing their own individual rights over the health and well-being of their neighbors…And if we’re all being honest…it’s the category that most of us fall into more than we care to admit.

Then there is the Samaritan [Samaritans represent “the other” as well as an alternative way of being], whose ethic is love. And [he]…seems to live by a code that says “what is mine is yours…if you have need of it”...

My safety is yours…if you have need of it.

My security is yours…if you have need of it.

My resources are yours…if you have need of them..

My health is tied to your health.

My well-being is tied to your well-being.

Reverend Martin Luther King, Jr. … once said that the real difference between [those who left the victim unattended] and the Samaritan is the question that each must have asked. The first [passer] likely asked, “If I stop to help this man, what will happen to me?”. The Samaritan likely asked a very different question – “If I do not stop to help this man, what will happen to him?”

Fear has a way of making us all behave badly. When fear is the ethic of our lives, we tend to cling to our own safety and our own individual rights. When fear is the ethic of our lives, we retreat, mind our own business and rarely cross to the other side of the road to help. And when fear is the ethic of our lives, we end up placing our hope in mottos like “We Dare Defend Our Rights” or “Don’t Tread On Me” as opposed to “Love …Your Neighbor”. [The original text was in Greek so that agape, deep care, and concern for others, is probably the love or concern being described.]

…we are all on a [dangerous] road somewhere…It’s dangerous out there. The heart-break and exhaustion are real. It’s not just the virus. It’s everything. It’s layers and layers of being beaten and bruised along a dry, hard road these past 18 months.

So, we have some choices to make. We can choose to make our decisions with an ethic of fear. And for a time, choices based on fear have a way of making us feel safe, but that is fleeting at best.

The other choice is to cross the road to help our neighbor. When we cross to the other side, we’ll get a glimpse of …what transformation looks like. We’ll finally understand who we are…[ I would add and the better world that we could share.] 

 

My bias is that most people who chose to pursue the life of a healthcare professional demonstrated with their life’s choice an attitude similar to the Samaritan. Even now “Samaritan” appears in the name of several healthcare organizations. During the nineteenth century and into the mid-twentieth century and the end of the era of rheumatic fever The House of the Good Samaritan provided free care to the poor and afflicted women and children of Boston and New England. I think that COVID has demonstrated that we are still capable of the sort of concern for others that the Samaritan demonstrated. The pandemic has demonstrated that at the individual level we still have many, many healthcare professionals who set aside their personal fears, just like our soldiers who were willing to go to the Middle East between 2001 and 2021, and risk their well being to help people they had never met before. 

 

What seems a shame to me is that collectively as a nation we often seem to function more like those who through concerns for their own well being continued on our way with a focus on an incomplete and flawed understanding of our own self-interests. The incomplete nature of our analysis obscures the fact that caring for others is actually the best approach to the long-term assurance of our self-interests and national interests. As mentioned above, the WHO requested this week that we think more about those people in the wider world who have had no vaccinations. To do so would require that as a nation we set aside our fear of being infected for lack of a third shot or be willing to use our wealth to help everyone everywhere be adequately vaccinated which is really a better strategy for our long-term safety.  Ironically, in this country, anyone can have a vaccination, but a third of the country is so fearful that they don’t want one. I don’t know what to say to those who could have had a vaccination but declined and also refuse to wear a mask. Their fears must be enormous. 

 

As I think about what is happening around us now, I am beginning to understand why my friend and interested reader who is definitely wiser than I am is not convinced that we will ever move toward a better balance between our individual concerns and the benefits of a better program of public health. This letter may seem to ramble but there are deep connections between what has happened, what was lost, what we should learn from our experiences and losses, and the choices we face for the future. I have got to believe that the best strategy for individual protection and health is to extend our care and concern to everyone. It would be a wonderful way to honor those who lost their life on 9/11 and those who have died since 9/11 because of 9/11.

 

Good Bye To A Great Friend

 

Yesterday morning as I was rushing to make an appointment in Boston, my wife opened her email, gasped, and then began to cry softly. She looked up and said, “Tom died yesterday.” Tom Congoran has been one of my closest friends and my most supportive colleague since 2007 when we first met. With great determination, he had remained remarkably active until late last year. Over the last six months, he had quietly and bravely dealt with his disease without ever losing his quiet humor and his deep care for other people. 

 

I first bonded with Tom when he came to Atrius as an interim CIO. He had recently sold a software company that he founded to Pegasus Sytems and was looking for an interim challenge on the way to retirement. Along with several other board members and senior managers, Tom and I flew to Chicago and then took a road trip through the upper Midwest to observe how several high-functioning practices were optimizing Epic or using other EMRs. As a result of the trip, we realized that we needed to “reinstall” EPIC, an expensive and time-consuming process, to recover from five years of failing to keep up with the maintenance of the software while we were in financial peril. By the end of the trip, much of it in a van with Tom driving and me asking him all sorts of questions, we were good friends committed to a common cause.

 

Tom finished the gig as Interim CIO, and then I did not see him for a few months before I woke up one day to realize that I was CEO. One of the first things I did in my new role was to call Tom. His home in New Hampshire was not far from my weekend home. He suggested that we meet for breakfast in Warner, NH. At the time I was at exit 13 on I 89. Tom lived near exit 5. We met at exit 9. I had a ton of questions, but I was mostly concerned about finance and contracting. Earlier in his career, Tom had been COO at New Hampshire Blue Cross, and later the CFO of Healthsource which was eventually sold to CIGNA.  I knew that he was a “serial entrepreneur” who created and sold a couple of IT companies. Over the years he has been on the boards of several “healthcare startups” that valued his wealth of experience. I wanted to tap into his experience.

 

The straightforward advice that I got from Tom was that Atrius needed a “strategic approach to finance.” He helped me to understand that the complicated part of finance was not getting out the bills for our professional services or building a budget, it was “financial strategy” that was the part of the job that many healthcare CFOs did not understand and that we did not have. 

 

After a couple of days of ruminating, I made the most important decision of my life as a manager. I called Tom up and asked him if he would be the CFO of Atrius. For seven years he drove seventy-five miles to work at our offices in Newton and seventy-five miles back home to Hopkinton, New Hampshire. Several days a week we would have meetings that lasted long after 9 PM. Many evenings when he returned home he chaired the meetings of the selectmen in his hometown. 

 

Tom’s greatest skill was his ability to lift others. Tom was a master listener and a superb teacher. He never promoted himself. He cared deeply about our practice. His financial skills brought us excellent contracts and he steered us through the financial collapse of 2008. Under Tom’s leadership, all of our practice sites were refurbished. We acquired new properties and other assets. We upgraded our IT systems to become the best in our market. Our data warehouse produced more informative data about our practice and our expenses than we got from the insurers, the state, or Medicare. We developed a very profitable reference lab to cut our costs and provide our clinicians with the information they needed in a matter of a few hours. Tom and I regularly visited all the hospitals, insurers, and state regulators that impacted our practice. Our business partners respected and trusted Tom.

 

Tom was very interested in the nuts and bolts of office and hospital practice. Early in our relationship, not long after we came back from our trip to Chicago and the Midwest while Tom was our interim CIO and before I was CEO, I asked Tom to make rounds with me at the Brigham. I wanted him to see how our clinicians were hampered by our dysfunctional IT connections to the hospital. Things got better whenever Tom was given a problem to solve. Tom was not a doctor, but he cared about the care experience we offered patients and how what we did could make a difference in their lives. I never met a doctor who was more patient-centered, concerned about safety, had a greater appreciation of the importance of the timeliness of care, focused more on efficiency and effectiveness, or pursued equity with more vigor than Tom did. 

 

I always wanted to know what Tom was thinking. I would present my crazy ideas to Tom with the confidence that he would give me his honest opinion. Tom related to everyone in the same straightforward way he related to me. He could hold people accountable in a way that led to their improvement without them feeling belittled or disrespected. Our parking lot attendants and cleaning staff got the same respect and attention from Tom that he offered to site administrators and senior managers. He seemed to know everybody’s name. 

 

After we were both retired and I was living a few towns over from Tom in New Hampshire, I got a close look at the charitable work that Tom and his wife Mary did in their community. Their foundation was a source of fuel assistance and financial support for many of the less fortunate people in their community. During the first year of COVID Tom used his relationships with the businesses in his community from many years of service as a selectman to raise even more money to assist those who did not have enough. Tom had been the moderator of the town meeting for many years and was interested in keeping the Hopkington schools at the top of the rankings in New Hampshire long after his children had finished school. Just like at work, what Tom and Mary did with their foundation and in their community was done without fanfare. Tom did not want to be noticed or commended for what he did for others or for his community. He never offered condemnation or judgment to someone who was down as a result of poor judgment or bad luck in life. He just offered help. 

 

Over these retirement years, Tom and I got together several times a month. Often we would meet for breakfast at the same dive in Warner where we had that first meeting after I became CEO. We hiked to the summit of several of New Hampshire’s mountains, but we never did realize our shared objective of doing all of New Hampshire’s 48 mountains that are over 4000 feet tall. We did catch a lot of fish, but we never did the trip to the island his family owned on a lake in the wilds of Canada. He invited me every summer before COVID and it just never happened. Getting to the island required “hiking in” and the portage of canoes. Perhaps I declined because I could not get comfortable with the idea of seven or eight days with no electricity or Internet. Not going was my loss, and now I wish that I could turn back the clock and take that trip. 

 

We saw Tom for the last time last week. He was comfortable in a motorized wheelchair. He could not say much, but it was just good to sit and visit with Mary while he listened. Even in his silence, we knew he was following the conversation. I am sure that we will miss Tom in ways that we have not yet imagined. My wife answered the email from Tom’s daughter that announced his death by saying, “We will miss his quiet wisdom and good humor.” I have dreaded his passing for several years now. Tom was one of a kind. He was a rare friend who was always willing to give the enthusiastic support and advice that was needed. You just knew that he really cared.

 

Summer Ends With “Crazy,” “Sweet Dreams,” and “Walking After Midnight” 

 

This summer was the 89th season of New London’s Barn Playhouse. For 88 summers the “Barn” has presented its productions in a bright red antique barn on Main Street. Last summer COVID canceled the show. This summer “The Barn” made its comeback “under the stars.” (Click on the link to get a look at The Barn Playhouse.) All of the shows were in a tent raised in an open field at the back of the Colby-Sawyer College campus. The backdrop to the scene was Mount Kearsarge.

 

Every summer we promise ourselves that we will see more shows at the Barn but then things get busy. This summer we almost did not make it to a Barn performance. We saw the last show of the summer on a chilly rainy night that felt more like late fall than late summer. 

 

Patsy Cline has always been one of my favorites. I get goosebumps when I hear her sing Willy Nelson’s “Crazy,” or Don Gibson’s “Sweet Dreams.”  The show, we saw, “Always…Patsy Cline,” had an off-Broadway run in the late ’90s. I was surprised to discover that it was much more than twenty-seven of her best-known songs. It was scripted with humor and a plot. 

 

I had a great bike ride on Monday afternoon. The storm that made an evening in the show tent a little damp and cold had passed through, and we had a bright blue sky with a few puffy white clouds. The temperature was in the low seventies. Everything about the day was perfect. I was still flying high from my dose of Patsy Cline. Her songs were still ringing in my head. I usually ride to the campus and back over a scenic ten-mile route. The campus is my turn-around point. The header for this post shows workmen taking down the Barn’s tent. As I paused my ride to take in the scene, I thought it was a good metaphor for the end of an unusual summer. Now I am hoping that global warming gives us an unusually pleasant fall to make up for some pretty unsettling summer downpours.

 

Wherever you are, I hope that it’s a great weekend for you.

Be well,

Gene