September 22, 2023
Dear Interested Readers,
Getting Started At Harvard Community Health Plan
If you have taken a vacation from reading the Healthcare Musings letter for the past two months, you may not know that I have been on an autobiographical journey. It began with a discussion of moral injury in healthcare back on July 21. After writing that note, I was surprised to hear from several readers that they really liked the references to my personal history in that piece. If moral injury is a fuzzy concept for you, I would suggest that you review the article that I referenced in the July 21 letter from the Sunday Times magazine by Eyal Press entitled The Moral Crisis of America’s Doctors: The corporatization of health care has changed the practice of medicine, causing many physicians to feel alienated from their work. A key passage from that article which I quoted was:
…more and more doctors are coming to believe that the pandemic merely worsened the strain on a health care system that was already failing because it prioritizes profits over patient care. They are noticing how the emphasis on the bottom line routinely puts them in moral binds…when a person’s sense of what is right is betrayed by leaders in high-stakes situations. “Not only are clinicians feeling betrayed by their leadership,” she says, “but when they allow these barriers to get in the way, they are part of the betrayal. They’re the instruments of betrayal.”
Moral injury occurs when a person is forced by circumstances to be involved in activities that violate deeply held principles. As I thought about the origin of the principles that are a moral compass for so many in healthcare who may now be experiencing some sort of moral injury, I began to contemplate the origin of my own principles of practice and the many influences that have formed my own professional moral sensibilities. I was fortunate to be trained in an environment where there were many great examples to emulate. As I scan almost fifty years of practice, I feel very fortunate to have always worked in an environment where most of my colleagues shared a devotion to quality, safety, and patient-centric care. We felt it was our responsibility to try to be good stewards of resources and to seek ways to be more efficient, effective, and inclusive. I have had great sympathy for those who have persisted as professionals in the harsh practice environment that has existed over the ten years since I retired. I have a sense that the professional world I left at the end of 2013 is not the same world of healthcare that more and more medical professionals and patients are now dealing with every day.
It has been informative and enjoyable for me to look back on the individuals and the forces that formed my opinions and have made me at times intolerant of the forces that don’t seem to share those opinions or want better health for all Americans very soon as a very high personal and shared desire. It’s been more than twenty years since Crossing the Quality Chasm gave us a very well-considered potential path toward care objectives of “simultaneously improving population health, improving the patient experience of care, and reducing per capita cost” that was crystalized in the publication of the Triple Aim in 2008.
Looking back, I realize that I had been exposed to some amazing individuals in the academic environment. At the time, I did not fully appreciate the benefits of a broad view of community practice that I gained from my extracurricular activities as a moonlighter in a community setting. In retrospect, I had no way of knowing that the formation of my medical moral sensibilities was still a work in progress as I moved from my years of training at Harvard Medical School and the Brigham into my early professional years at Harvard Community Health Plan which is where we are now in the story of how my “moral instincts” in healthcare evolved.
I was not a part of the Harvard Community Health Plan when it was launched with less than one hundred patients in October 1969, but I was nearby and it did not take long for me to notice its presence. Not long after the launch of the new medical practice, I was on my medical school rotation in medicine at the Brigham and in the emergency room working up a new admission when I noticed something strange. It was late in the evening and a woman dressed as if she worked in a bank except for the stethoscope hanging from her neck was examining a patient on the gurney behind the curtain next to the patient I was seeing. It was a strange sight. “Attendings” always wore long white coats and were rarely seen in the emergency room which was the domain of medical students, interns, residents, and nurses. Who was this woman and what was she doing?
I learned that the woman who looked out of place was one of the doctors from the new medical practice that the dean of the medical school had recently launched. I did not know at the time that the woman was Dr. Sigrid Tischler, an oncologist, who would be my colleague for more than thirty years. Her presence in the emergency room was in itself good evidence that this new medical practice was different.
The first attending physician that I had as an intern in June of 1971 was Dr. Joseph Dorsey who was the very young and dynamic medical director of the new practice. Dr. Dorsey’s medical fund of knowledge was almost encyclopedic, but his major emphasis in our teaching sessions was on preventative healthcare and the social components of a patient’s history. Over the years as I watched him practice after I joined his organization, I realized that he treated every patient who came to him like a member of his family. That difference in his approach to patients from what I saw in hospital practice was dramatic. His relationship with the patient and the focus on health rather than disease seemed to be the core of this new approach to patient care that was being piloted at his practice, the Harvard Community Health Plan. I described how powerful an influence Joe was on me then and for the entirety of my practice life when I published a memorial piece in these notes last fall following his death.
Last week, I described my admiration for Dr. Marshall Wolfe. You can imagine my surprise when he came to me and suggested that I take his practice at HCHP on July 1, 1975. He had recently assumed responsibility for overseeing the teaching program at Brigham and saw patients at HCHP in the afternoons. He reasoned that I could manage the HCHP cardiac patients admitted to the Brigham and the Beth Isreal in the mornings and then travel the short distance to HCHP’s offices in nearby Kenmore Square as he had been doing in the afternoons. If I took his practice at HCHP, he would have more time for his new duties at the hospital. It would turn out to be a good move for both of us. Over the intervening years, Marshall has participated in the training of many of the current leaders in American healthcare.
Marshall, or someone, pointed out that as a member of the HCHP medical practice, my compensation would be more than double what I could expect as a second-year fellow. I would also get credit for a second year of fellowship which would make me eligible to take the board exam in cardiology. It was also true that the hospital was expecting that the government support for fellowships was likely to be reduced. I considered Marshall’s suggestion to be an order or an assignment and never questioned his reasoning. All that I needed to do to complete the deal was to meet with the chief of medicine at the Kenmore Center which I did in April 1975.
I remember experiencing some apprehension before my meeting with Lee Younger who was the chief. I had never visited the Kenmore practice which was then situated on the first three floors of an apartment building in the heart of Kenmore Square. Carl Yastremski could have hit the building on one hop with a baseball thrown from left field at Fenway Park. The back entrance to the building was from Commonwealth Avenue across from Boston University and the main entrance was on Beacon Street. All I remember from the conversation was Lee’s advice that I should “give it two years” before deciding to leave and go somewhere else. I was overwhelmed with the idea that instead of being a fellow I would be an admitting physician at both the Brigham and the BI. That idea did make me a little apprehensive. I had no other meetings or “onboarding” before I showed up for my first clinical session at HCHP on the afternoon of July 1, a Tuesday.
On that first day, I arrived a little early at the “Green Unit” of Internal Medicine where I was told that I would practice. My welcoming committee consisted of one very knowledgeable medical assistant who told me that she was glad that I was early because she had added an emergency patient to my schedule to be seen before the regularly scheduled patients arrived. His PCP had said that I needed to see him because he had come in earlier in the morning complaining of profound weakness when he moved about. The medical assistant handed me his EKG which was a textbook picture of complete heart block with a very slow junctional escape rate.
This start was not what I had expected because someone had told me that HCHP stood for “Horrible Care for Healthy People” and that I would be bored by seeing healthy young secretaries complaining of palpitations or chest pain of hysterical origin. As it turned out, I was seeing the first of many challenging patients that would come my way over the next third of a century. A man in his mid-fifties who needed a pacemaker would be just an introduction to the challenges that awaited me.
The comment about “Horrible Care for Healthy People” was also an introduction to the implicit bias in the medical community that the innovation of HCHP triggered. HCHP was a threat to the status quo of usual practice and comments like Horrible Care for Healthy People would not be the last attempt to undermine our vision with misinformation. Thirty years later we were still dealing with misinformation and resistance to the changes in medical practice that we tried to model. In retrospect, I think that I was energized by the fact that we were some kind of underdog or threat to a system that was becoming more self-serving than oriented to the concerns of patients.
Once things settled down after arrangements were made for my patient’s pacemaker, I discovered that Marshall had left me detailed notes on the ten patients in his practice that were of greatest concern to him. My new medical assistant told me that they had all been scheduled to see me in the near future.
As I was waiting for my first patient, my new practice partner, Barbara Taylor, NP came in to say hello. At the time I had no idea that I would have a “practice partner” or that she would be one of the “founding mothers” of HCHP. Barbara was more than a decade older than me and was one of the first NPs in Massachusetts. She had been an experienced VNA nurse in some of Boston’s toughest neighborhoods before joining HCHP when it opened in 1969. It did not take long for me to realize that my years of excellent training in hospital care with a “taste” of outpatient clinic experience had not adequately prepared me for the different world of ambulatory care and chronic disease management. Barbara would be more than my partner–she became my mentor and guide in this whole new world of practice.
Once again, I was very lucky, some might say blessed because Barbara turned out to be a better care provider than most doctors. She had seen everything and had done everything. She was a magnet for patients who had a combination of medical, social, substance abuse, and behavioral health issues. She was totally non-judgemental. Patients loved her because she cared about them. She gave them the time they needed, and she treated them with respect. I would often leave the office an hour or so after the last scheduled patient knowing that she was still in an exam room giving extra time to a patient who needed to talk and receive her counseling. People who were hurting because of the combination of their medical problems and their dependencies, their sexual orientation, the mistakes that they might have made in life, or anything that might have made them feel apprehensive about being open about their deepest concerns were immediately put at ease by Barbara. I was the greatest beneficiary of her expertise and her professionalism. It was not long before I was trying to copy her patient care habits. We worked together, or more accurately, I continued to learn from her almost every day for thirteen years before she died of ovarian cancer in the late eighties before her 60th birthday.
Sometime during those first few weeks, I was scheduled to have an introductory visit with Dr. Dorsey. I had not had any significant contact with him since the first month of my internship although I was pretty sure that he had been involved in the decision for me to take over Marshall Wolfe’s practice. I don’t remember much about our visit. I think he asked how I was settling in. When the conversation was over he presented me with a large pasteboard carton that had once been filled with bottles of wine. The wine had been replaced by copies of all of the memos he had written to the practice over the six years since that opening day in October 1969! My guess was that he expected me to read them as my orientation. In a way, I wish that I had read them, or that I had at least kept them. In time I think that I did become familiar with all the ideas they covered. What had happened was that over time in conference with one another and Joe, the members of the group had written expectations for the standards of their practice that covered everything from what should be covered in a “well visit” to when an EKG should be done for the first time. It was an early effort to wisely eliminate overuse and misuse of services and resources while making sure that all of the things that should be done were done.
One other “adjustment” was necessary for me to make as I moved from working in the hospital to working as a member of a group. I was very independent, and not that conscious of the time concerns of other people. My independent attitude led to a memorable encounter when I was “called on the carpet” by my medical assistant. I had a bad habit of showing up for my office sessions late. It wasn’t because I was taking long lunches. It was because I was terrible at time management. It was also true that in the hospital the physician set the pace. Patients and families would wait hoping to “catch a moment” with the doctor. Invariably, as I was leaving the hospital to go to the office something always seemed to come up that I felt needed immediate attention, or I had not completed seeing all the patients that I thought I needed to see. Sometimes I just wanted to make sure that an intern or resident was clear about how I thought we should manage a problem. When I would eventually arrive in the office whether I was fifteen minutes late or a half hour late I would find irritated staff and annoyed patients. I felt justified because I was somewhat self-righteous and felt that I had my priorities correctly aligned. After about a month of arriving when the spirit moved me, my medical assistant asked to meet with me. She minced no words as she reminded me that when I arrived late I was creating problems for her and disrespecting the patients who had every right to expect that I would be there when they arrived. She could not believe that I had an “emergency” at the hospital every day. She was right, and she put her finger on a problem that would remain a challenge for me as long as I practiced medicine. I was often behind, but rarely after that conversation with my MA was it because I started late. More often than not it was because I spent more time with a patient than the schedule allowed, or I was behind because there was a “walk-in” or someone was added to an already full schedule.
There is much more that I want to tell you about my experience at HCHP. I will return to the story again next week. I hope that what you are beginning to realize is that my “moral sensibilities” about the practice of medicine were largely shaped by my experience with exceptional colleagues at every level of the medical hierarchy. Some of my most effective mentors were support staff, nurses, and other advanced practice clinicians. I had the privilege of working in a very special place that was created to address the questions of how to deliver better care that predated the Triple Aim by forty years and intuitively implemented many of the suggestions that would be published in Crossing the Quality Chasm more than a quarter century before the book was published. It should not be a surprise that the principal author of The Triple Aim, Don Berwick, joined our practice as a pediatrician in 1977.
Cramming Summer Into Its Dying Days
Fall starts tonight at 2:50 AM Eastern Daylight Time. I am not sure when summer started in New Hampshire this year. It may have delayed its start until last week which meant that this last week had a few days when I was challenged to make the most of not much. Over the so-called summer, we did have some scattered days of sunshine with low humidity, but like the Red Sox, we rarely put together a run of three wins. If summer ever did occur, today is the last day. Tomorrow, fall will arrive with its own wet weather as the next storm moves up the East Coast.
This week after Hurricane Lee whacked the Northeast, we have intermittently enjoyed some lovely weather as today’s header proves. The picture was taken on Sunday at Musterfield Farm at an outdoor concert of Nick’s Other Band. Most of the money raised at the concert went to support local charities. I am on the boards of Kearsarge Neighborhood Partners and Kearsarge Regional Ecumenical Ministries and both will get a good payout from this end-of-summer event.
To get to the concert, my wife and I got out of Nova Scotia just in time before Hurricane Lee hit last weekend, but the people with whom we were traveling hunkered down and endured the loss of electricity and water at the Airbnb they were renting. Nova Scotia, especially Cape Breton Island, is lovely, and we did have a couple of days there that could pass as summer, but we also had rain. We were thoroughly soaked on a whale-watching excursion. It seems that the Canadian Maritimes have had the same mini-summer that we have had in New Hampshire.
There is ample evidence that fall is here. Swamp maples are beginning to turn red and ferns along the road are turning brown. The sun is now down before seven, and if I wanted to see the sunrise, I could still stay in bed past six. I am taking the weather one day at a time, but I haven’t given up my daily swim, although I am wearing a wet suit. I keep asking myself where the summer went. It was mostly a washout.
The challenge now is to try to cram in all the fishing and sailing I meant to do this summer if it had not rained so much or if we had traveled less. Perhaps we will have some “Indian Summer.” Looking forward, we are expecting the next tropical storm/hurricane to come up the coast and wash out much of this weekend as well as the early part of next week. The one thing that I have learned this summer is not to waste any day the sun does shine. I hope the sun does shine on you this first weekend of fall wherever you might be.
Be well,
Gene
