| 10 April 2015
Dear Interested Readers,
Inside This Week’s Letter
This week’s letter is more like a magazine, which is fine with me and gives you the option to pick and choose what you read. It begins with a review of the team that produces strategyhealthcare.com. I am proud to be part of the team and want to showcase them because I hope that visiting the site is becoming something that you do regularly. I would love to see it become a resource for you in your attempts to communicate with those who look to you for leadership.
In the second section I discuss the very innovative practice enterprise, lora Health, in the context of the difference between greenfield and brownfield projects in healthcare. I hope that this section will kick off several weeks of discussion around some of the issues that the Iora model brings to mind. In the past I have touched lightly on subjects like the role of venture capital, public-private partnerships, and consumer driven healthcare. A closer look at Iora is a good way to begin to dig into these subjects that many of us would have little interest in without a focus for our attention.
After the final segment of Elizabeth McCarthy’s Story plus an epilogue with the brief discussion of the issues it raises and some of the personal meaning in the story for me, the letter concludes with my weekly attempt at some humor and recurrent advise that you get some exercise. I hope that you will find something in the letter that is of interest to you, even if every piece does not.
strategyhealthcare.com, A Resource For You
Next week Elizabeth McCarthy’s Story plus the epilogue will be available as a downloadable PDF on the strategyhealthcare.com website. I hope that you are regularly going to the site to find well-edited excerpts from recent weekly letters.
The first 297 letters were written while I had the resources of a great supportive team as the CEO of Atrius Health. Marci Sindell, an exceptional healthcare executive with a multiplicity of skills, edited those letters. Every Friday morning for almost six years Marci and I would huddle together as she quickly pulled the random thoughts and somewhat connected stories that I had sent her late on Thursday night into something that was readable. When Marci was away Donna Tolley would ably fill the editorial role. After the editing Cheryl Livoli, who kept me on track in all matters of my responsibilities, would publish it to the several thousand employees of Atrius Health and a growing list of outside interested readers. Since retirement I have realized that one of the greatest joys of writing is the collaboration with an editor and a team. When I was approached with the opportunity to once again be part of a team that could help produce a better product, I jumped at the chance.
The team leader for strategyhealthcare.com is Peter Kriff who is the President of PDI Creative in Burlington, Vermont. The idea of lifting content out of my weekly letters and shaping them into blog postings belongs to Peter. Peter and I are part of a larger team trying to improve communication about the transformation of healthcare in Vermont. Peter’s firm has been a very active participant in health care communication for more than twenty years and Peter is an advocate for disability rights. As Executive Director of Vermont’s Statewide Independent Living Council, he coordinates the efforts of the citizens’ council to disburse federal funds towards improving the quality of life for Vermonters with disabilities. Under his guidance, the council in 2013 launched Accessible Adventures, an original on-line peer-to-peer review system for accessible places to go in Vermont. Peter does more than manage. He likes to participate in the production. As a vital contribution to the feel of the letter, he takes a few photos that I send him each week and shapes one to be a thematically appropriate letterhead.
My editor is Robyn Warhol. After 26 years as a professor at the University of Vermont, Robyn recently joined the faculty at the Ohio State University, where she is currently Arts and Humanities Distinguished Professor of English and a core faculty member of Project Narrative. She completed her PhD at Stanford in 1982 and has taught writing and literature at Stanford, the University of Vermont, Harvard, Brandeis, Rice, and the Ohio State University. She has written and published numerous articles and university press books, and she is co-editor of several significant textbooks. Her areas of research expertise include narrative, serialized television, Victorian literature, life writing, and representations of addiction and recovery in contemporary popular culture. Robyn specializes in the conversation that a piece of writing creates between the “I” who writes and the “you” who reads. She is committed to brevity and clarity. Robyn is the perfect mentor for me.
The team came to me just as my efforts to independently get out the letter “hit the wall”. The technical aspects of managing a letter on the Internet are far beyond my skill set but with the guidance of Russ Morgan I am on a new learning curve. Russ is an Internet guru and entrepreneur based near me in Manchester who has started several businesses that provide coaching and technical services to businesses in New England. Russ is also committed to adding his efforts to the achievement of the Triple Aim. Russ worked with health insurance companies as President and Director of Nashua Industrial Machine Corporation from 1984 through 1998 to purchase and provide the most affordable health insurance choices for hundreds of employees. His company’s participation in the startup of Healthsource as a pilot corporate customer resulted in another health insurance alternative in New Hampshire to compete with Blue Cross/Blue Shield traditional insurance and H.M.O. and the Matthew Thornton H.M.O. Russ has guided me through a minefield of issues related to publishing the weekly letter.
The vision for stategyhealthcare.com is to grow and be a service to more and more healthcare leaders and consumers who want a dialog about better healthcare and are committed to contributing their efforts to the Triple Aim. Social media is another modality that has left me lagging as it has evolved over the last twenty years. I am just beginning to play with Facebook and Twitter is beyond my skill set but I am totally reassured that the final member of the team, Cecily Hill, can make it happen.
Cecily is a PhD candidate at Ohio State who has already won grants for her research, published work in national journals, managed improvements in website content and social media presence, and spearheaded a successful student wellness program at the Ohio State University. As the chair of an Ohio State University committee for graduate and professional student programming, Cecily has developed and launched an aggressive, university-wide wellness series that is currently in its third year. The series, which has attracted more than 2,000 students to its events, has become a model for interdepartmental collaboration and wellness innovation. Her recent overhaul of the committee’s social media presence resulted in a 40% increase in Facebook followers and a drastic rise in community engagement both on and off the Internet. At the same time, she has worked as a content developer and editor of OSU’s Graduate Studies in English website, transforming it into one of the most effective and informative such websites among peer institutions.
If you like what you read here, it is because a team always can do more than an individual. I am very fortunate to work with such a talented team. We are looking for other voices. Michael Pinnolis has been a contributor. Michael was recently named as Chief Medical Officer at Integrated Care Partners in Hartford, Connecticut. (ICP is a member of Hartford Healthcare, which is trying to build a integrated system of value-based care). You can also be a contributor to the conversation by leaving a comment on the blog or giving us a piece of your own writing that you would like to add to the conversation.
What Is Iora Health All About? Have I Seen This Movie Before?
Alan Gaynor, emeritus Professor at BU has become one of my most interactive readers. It is helpful to be in dialog with someone who is scanning the environment and asking questions that so many others should be considering. Alan recently sent me a brief email:
Gene, just wondering what you think of the Iora "experiment" (NYT article attached).
Best,
A.
Alan's question provoked me to think about concepts like “public-private” partnerships, employer focused products and “consumer driven healthcare” that are ambiguous to many but may be more important than the majority of us realize as the transformation of healthcare evolves. Also important to consider as we think about transformation in healthcare is the difference between greenfield and brownfield projects. If those terms are not in your vocabulary they should be because most of our efforts in healthcare today conform to the definition of a “brownfield project” where transformation becomes the difficult exercise of changing previously existing systems and enterprises.
Brownfield transformation is hampered by existing cultural norms and organizational structures, which must be cleared, changed or “repurposed”. A brownfield project is like my wife’s efforts to remodel our house. It would be easier to tear it down and replace it but because the current structure was built closer to the lake than regulations would now allow, we have chosen the more difficult road of remodeling. In the end the project may exceed the cost of new construction and we are continuously constrained by staying within the preexisting realities of the older structure.
Greenfield projects are new construction. They are like a “clean sheet of paper”. Often there is no choice between a greenfield versus brownfield project. It is often impossible to have a clean managerial decision. We often do not have the luxury of asking, “Do we blow it up and start from scratch to get what we want or can we build from where we are to get to where we want to be?” Most of the work of continuous improvement or Lean in healthcare is, in my opinion, brownfield work and for that reason “adaptive change” is a huge emotional component of our task as we try to agree on what stays and what goes in the transformation process.
Greenfield and brownfield projects are metaphors that are frequently used in telecommunications and manufacturing. Look them up on Wikipedia to learn more.
http://en.wikipedia.org/wiki/Greenfield_project
http://en.wikipedia.org/wiki/Brownfield_(software_development)
When I first heard the terms years ago I said to myself, “Dr. Ebert was trying to do a greenfield project when he conceptualized Harvard Community Health Plan”. In the early days at HCHP everything was new and innovative. There were no precedents, politics or existing bureaucratic structures to be overcome. The people that worked there thought of themselves as pioneers and they were vigorously imagining what might be rather than actively resisting change that was being forced on them by pressures from the outside world. Everything was aspirational. Everyone wanted to prove that the new ideas would make a difference.
Twenty-five years into the work as Harvard Vanguard and Atrius Health emerged from Harvard Pilgrim Health Care, the successor to HCHP, the transformation was a “brownfield” project. It was a remodeling of what had not quite worked as hoped or had been coopted and misdirected by experiments that did not meet the challenges coming from external threats. The Lean transformation efforts of the last five years have been further brownfield efforts to preserve cherished clinical and cultural values while responding to increasingly challenging externalities. This is the challenge for leaders and the story for almost all of our established healthcare organizations whether we are talking about Virginia Mason, Kaiser, ThedaCare, Denver Health or more rural or small-town systems like McLeod Health in South Carolina or Guthrie Health in Pennsylvania and New York. Even large and powerful institutions like Partners, Mayo Clinic and Geisinger Clinic must improve by working around what already exists. lora has the luxury of no past.
The article that Alan sent me presents Iora as a collection of new concepts that look like a greenfield operation. Like the old HCHP the ideas it is working with are both old and new; some are borrowed from the experience of others and some are freshly invented. What makes it innovative is the way in which medical home, value based financing, distributed leadership, concepts of excellent customer service, and a belief in the value of health promotion are reassembled in a fresh way to produce a “new” product that seeks to avoid the need for unnecessary hospital and diagnostic care by delivering more effective ambulatory care and by avoiding many of the barriers that make transformation of established healthcare organizations so hard.
In many ways Iora and its founder are very similar to Steve Jobs and Apple. The delightful Apple products that have come in rapid succession since the introduction of the iPod in late 2001 were made possible because the approach to product development of Steve Jobs' creation of Apple 2.0 did not represent absolutely new technologies but because they arose from Jobs’ evolving concepts of product integration. Build on the vision of integration, he developed new products by creatively assembling and integrating components that were available to many in the same industry and indeed were often developed by his competitors. Nokia engineers invented the touch screen that enables smartphones. Apple was a brownfield project when Jobs came back in the late 90s but in many ways Jobs chose the greenfield route to Apple’s iPod driven success.
The New York Times article that Alan sent me reads much like the presentation of an innovation like the iPod. The whole enterprise is built on tried and true components extracted from previous healthcare experience or pilots but assembled in a new environment where these ideas are not continuously challenged. I hope that you will read the Iora story and as you read it ask yourself whether the components of their system of care that are described are really new ideas. What is new is how the ideas are assembled and an over the top focus on customer service.
http://www.nytimes.com/2015/03/29/upshot/small-company-has-plan-to-provide-primary-care-for-the-masses.html?_r=0&abt=0002&abg=1
The article refers to Atul Gawande’s fabulous story in the New Yorker in 2011 called “The Hot Spotters”.
http://www.newyorker.com/magazine/2011/01/24/the-hot-spotters
You might remember that this famous article by Dr. Gawande was principally about the innovative work of Dr. Jeff Brenner in Camden, N.J. but it also touched on some work by Dr. Tim Ferris at the MGH, as well as Verisk, an innovative software firm, and toward the end he showcased a new and innovatively financed practice in Atlantic City that had reduced the cost of care while improving the quality of care for casino workers utilizing members of the community as contacts and coaches.
The leader of that Atlantic City practice is the same Dr. Fernandopulle who is the CEO of Iora. In the interim he has been opening new practices similar to the one in Atlantic City across the country. Finance is one of the unique things about the model. Much of the infrastructure has come from investments from the private sector. Many of the patients have their care purchased by their employer at a fixed cost like an old managed care product. The practice tries to reduce the wasteful utilization of services and avoid hospitalizations that are unlikely to improve outcomes by having a closer connection to the patient. Some of the patients are publically funded and come from Medicare and Medicaid as prepaid patients on a budget. At Iora the restraints of RVUs and concerns about volume are removed from the transaction.
Iora is also like a greenfield operation for many reasons other than finance not the least of which is the decision to carefully recruit fresh physicians who are focused on patient service, and want to work at the top of their license in partnership with other health professionals to whom they delegate many of their traditional activities. They trust that coaches who are trained but are not doctors or nurses can be effective where licensed practitioners have traditionally been used. These are professionals who are enabled to spend more time with patients because of changes in “standard work”. They embrace compensation programs where they share the risk of a budget but have many determinants of compensation other than volume.
Iora’s approach is a patient centered response to the misalignment of financial incentives that, in most systems, create a huge problem for patients and a barrier to real innovations that are not compensated. The design is an experiment not unlike early attempts at managed care. It is a 2.0 response to the reality that the United States has the costliest health care system in the world even as many patients suffer from preventable illnesses and die younger than their peers in other countries. The innovation at Iona is a creative response to the problems of a system that is so full of economic and work flow inefficiencies that it is unsustainable but feels almost impossible to redirect to avoid collapse.
Iora is small but rapidly growing. The article reports that there are only eleven offices across the country but will try to double in size this year using $28 million dollars that was recently raised from investors in a third round of venture capital financing. Investors have given an organization with less than 150 employees more than $40 million dollars in total. Iora wants to eventually be like Starbuck’s with small outlets everywhere. The article has a link to a paper from Stanford that outlines the principles that make a great practice. Iora’s design is the greenfield manifestation of many of the principles described in the paper which I have reproduced below. The list sounds familiar and is consistent with Medical Home concepts. It is the execution that is lacking in most brownfield practices.
http://petersonhealthcare.org/sites/default/files/images/media_library/Peterson Center on Healthcare_Stanford Executive Summary_1.pdf
10 Features of High Performing Primary Care Practices:
1. Practices are ‘always on.’ Patients have a sense that their care team is ‘always available,’ and that they will be able to reach someone who knows them and can help them quickly whether the practice is open or closed. Practices offer same-day appointments and accommodate walk-ins, extend evening and weekend hours, and more.
2. Physicians adhere to quality guidelines and choose tests and treatments wisely. The care team has systems to ensure patients receive evidence-based care, proactively identifying needed tests and treatments and ensuring patients get them. At the same time, they conserve resources by tailoring care to align with the needs and values of their patients.
3. They treat patient complaints as gold. Complaints from patients are regarded as valuable as compliments, if not more so. High-value primary care sites take every opportunity to encourage patient feedback to improve the patient experience.
4. They in-source, rather than out-source, some needed tests and procedures. Primary care teams do as much as they can safely do rather than referring patients out. These primary care physicians practice within the full scope of their expertise, delivering care that other primary care physicians often refer out—such as skin biopsies, insulin initiation and stabilization, joint injections or suturing—because they take more time than the average patient visit. If they can arrange specialist supervision, they take on additional low complexity services, such as treadmill testing for cardiac patients.
5. They stay close to their patients after referring them to specialists. Physicians refer to carefully chosen specialists whom they trust to act in their accordance with their patients’ preferences and needs, and they stay in close communication as care decisions are made by specialists. Although these physicians can not always select the hospitalist or emergency department physician who cares for their patients, they stay connected to assure that treatment plans respect their patients’ preferences and needs.
6. They close the loop with patients. The care team actively follows-up to ensure that patients are seen rapidly after hospital discharges, are able to continue prescribed medications and see specialists when needed.
7. They maximize the abilities of staff members. Physicians are supported by a team of nurse practitioners, physician assistants, nurses, and/or medical assistants—all of whom are working at the ‘top of their licenses.’ This enables physicians to spend more time with the patients who need the most direct physician contact, and to take care of more patients.
8. They work in ‘hived workstations.’ Care teams work together side-by-side in an open ‘bullpen’ environment that facilitates continuous communication among both clinical and non-clinical staff. This approach goes hand in hand with maximizing the abilities of staff members. It facilitates staff learning through close collaboration with clinicians without regard to hierarchy.
9. They balance compensation. Physicians are not paid solely on the basis of their productivity. Rather than basing physician income solely on service volume—in other words ‘fee-for-service’—pay typically also reflects performance on at least one of the following components: 1) quality of care, 2) patient experience, 3) resource utilization, and 4) contribution to practice-wide improvement activities.
10. They invest in people, not space and equipment. By saving money on space, equipment and technology, these providers don’t need to see more patients or order expensive tests to generate a competitive income. They rent very modest offices. To save money and eliminate incentives to use expensive equipment, the practices only invest in lab, imaging, and other equipment if it allows them to provide care most cost-effectively in-house.
The article does not label Iora as a Lean practice but Iora uses a lot of “off the shelf” Lean tools and it is clear that Iora practices "collaborative autonomy" and "distributed leadership". Strategy is developed centrally and modified to meet local challenges. Some things are non negotiable like daily “huddles” in every practice everyday and a system wide emphasis on customer service.
It is a reality that if something is not sustainable it will not go on forever. Over the past five years, post the passage of the ACA, we have talked about the unsustainable nature of our current model of fragmented volume financed healthcare. Despite politics, partnerships for innovation between public and private sources of funding like Iora are evolving. The President and CMS continue to push for innovation and investors are betting that change will come.
One of my old football coaches was famous for his use of the slogan that some attribute to the revolutionary pamphleteer, Thomas Paine, “Lead, follow or get out of the way”. Whether Iora will ultimately succeed is yet to be seen but Iora is beginning to offer leadership by example. It is my prediction that an irreversible process is gaining momentum. Others may follow Iora’s lead and many others will be pushed aside by Iora or other new successful organizations that will look more like Iora and the old HCHP than the dominate organizations of the last few decades. It is fascinating to watch the evolution of the inevitable.
Introduction to the Last Installment of Elizabeth McCarthy’s Story
For those who have not read the three previous installments they are currently available by utilizing the archives that Russ Morgan has created for these letters. You can use the link below to access the letters for March 20, 27 and April 3 where Part 1, 2, and 3 appear.
http://app.getresponse.com/click.html?x=a62b&lc=9DFL5&mc=Iy&s=Gxi6Lx&u=VZl2&y=q&
In the near future the entire document will be available for download at stategyhealthcare.com. To summarize for you now:
Part 1 is a description of a night on call at the Brigham where I “pick up" Mrs. McCarthy as a patient after she presents to the EW in the middle of the night with an episode of “flash pulmonary edema” after several weeks of progressive symptoms.
Part 2 is a description of the teaching process and ward life that was quite common in healthcare in the sixties and seventies. Positive and negative elements of that culture live on to this day.
Part 3 is a description of the care provided to patients in the ambulatory clinics of teaching institutions. Again much has changed yet much persists unchanged.
I hesitate to say it but for me it feels like the progress in the teaching of medical students and physicians in training is much like the training of young recruits in military service. The basic principles have not changed much over centuries even though the technology and complexity of the challenges continue to grow. Watch, try, fail, try again and eventually succeed is a part of most learning curves. I believe that there has been real progress in safety and quality over the last 44 years since the events occurred that comprise Mrs. McCarthy’s story. I also believe that there is still much to improve and that there are still patients and young clinicians that are injured.
Elizabeth McCarthy’s Story, Part 4
When clinic day before Christmas arrived, I suddenly remembered she would be back. I felt a little guilty knowing that I had not given her a thought for weeks. As I topped the stairs to the clinic, I saw her sitting forward on a metal folding chair in anticipation of my arrival. She had a radiance that was immediately observable. She looked very healthy and happy. A very obvious Christmas gift was only partially concealed in a brown bag, which she held carefully on her lap. She spoke first. “Oh, Dr. Lindsey, I’m so glad to see you”, she said. “It’s so nice to see you too,” I replied. “You certainly look like you have the Christmas spirit.”
I opened the door to the office and held it for her as she picked up her things. She collected her black wool coat that sported a Santa Claus pin on the lapel, her “special” package and a large tote bag filled with her purse and sundry other items and then preceded me into the room. We were into the room for only a second before she dropped everything but the “special” package and sat down with a sigh. She reached up to me, held out the gift and exclaimed the obvious; “I’ve brought you a Christmas present!” I raised my voice a half tone and squealed, “What a nice thing for you to do for me, thank you so much!” We did the usual verbal dance. “Oh, I hope so much that you will like them. I made them myself.” “What do you mean, them?” I said. “Oh, you’ll see,” she said. “Open it, open it, please open it now”.
I carefully removed the ribbon and the paper. Inside the box were three bow ties. She immediately said again, “I made them myself, I so hope you like them. I love your ties and wanted to make you some that you would really like.” They were beautiful and I said so immediately. I was impressed. One tie was a dark burgundy Batik print. There was a flower child lavender tie that was wider than the Batik tie. It was a real butterfly. It had yellow daisies with wispy green stems. It was the kind of tie I loved to wear. I would stand at the mirror and tie a bright tie in the early morning light and say to myself, “Do I really want to wear this”. A little debate usually ensues and then chances are I’ll take the new tie off and go with an old reliable friend. It usually takes two or three aborted attempts to get out of the house with a really distinctive tie. When I finally overcome my better judgment in favor of flare and controversy and make it out of the house where change is no longer possible and I’m committed to the new tie for the day, I am always exhilarated.
The third tie was a Christmas tie. It was red with green wreaths and bells. She looked at me with a slightly cocked head and a smile and said, “Merry Christmas.” I was flabbergasted. Each tie was a work of art. I found most of my ties on the sale rack at the Coop in Cambridge. Occasionally I would impulsively buy a distinctive tie in someplace like Filene’s Basement as I followed my wife around town on a Saturday afternoon with the kids in tow. She was a recreational shopper. The ties that I now held could not be purchased. I was quite moved and very pleased. I did not know what to say so I just turned them over in my hands admiring them. They were individually wrapped in tissue paper. I unwrapped and rewrapped each one as I admired its individual qualities and speculated out loud about where I would wear it and the sort of reaction I would get. The ceremony ended with a final pronouncement, “This is the best gift anyone has ever given me, Mrs. McCarthy”, I meant it. There was something exhilarating about receiving a gift from a patient. It was a brand new experience for me.
The remainder of the visit was downhill. She was doing very well. I reduced her dose of Lasix. We reviewed the lab tests and the official x-ray report which corroborated what we had observed when she had the x-ray on the last visit. No doubt about it she was much better.
I had a dilemma. She was better and really did not need to be seen again in the three or four-week cycle of the last few visits but intuitively I knew that she would be unhappy if I announced that she did not need to return for two months. My clinic schedule was getting heavy. With only one afternoon a week to see return patients, I needed to manage my appointment availability carefully to prevent overloading the schedule. Were the ties a bribe? I did not think so. Would she be unhappy and look downcast if I suggested she should come back in two months? It was a definite possibility. I was loosing my objectivity.
“Mrs. McCarthy you have done a great job with your medications and diet. You really must be watching your salt. I bet you are feeling a lot better. Are you beginning to get out and do things?” She replied, “Dr. Lindsey, I really don’t have anywhere to go. I try to help around the house but mostly I stay in my room where I won’t be in the way.”
As on a previous visit, I began to try to think of suggestions that might help her break out of her isolation. I knew it was a futile exercise but I tried. I said, “We know that you are able to get to your appointment and home again riding the T. It would be the same ride if you were to try to visit some of your old friends on Mission Hill”. I gestured in the general direction of the hill. “I bet you have lots of friends you could visit in your old neighborhood,” I said.
She looked at me with a skeptical expression that I had never seen on her face, “Calumet Street is very steep Dr. Lindsey and even if I could climb the hill all my friends are dead or have gone to a nursing home. I told you this before. I really am all alone. My friends are all gone.” I decided to hold my counsel. I dropped the fantasy of advising her out of her circumstances. She would have to find her own way to make herself happy.
I changed direction and abruptly ended the visit. I had done all that I could do this day, “ I hope you have wonderful holidays Mrs. McCarthy. I decided that I would split the difference. She had waited four weeks from the last visit. Two months was more appropriate. Six weeks would be a compromise that moved the interval toward the more appropriate level of frequency. Maybe next time it would be two months. I announced, “I’ll see you back at the end of January in about six weeks. I know that you will do just fine as long as you take your meds and watch your salt. Knowing you, I bet you will have found a lot of things to do with your new energy. I can hardly wait to hear about all your adventures when I see you next time. You can call me anytime if you think your condition is changing.”
The appointment was over. Its mood had started high and then swung low. I could not figure out why such a medical success left me feeling like such a failure and why I was so worried about someone who was clearly better in every way that I could measure.
Christmas was a great relief. Half of the interns had three days off at Christmas and the other half had three days off for New Years. It pretty much split along religious lines. My little boys were thrilled with my continuous presence for such a long time. It was not enough time to fly home to the South. So for the first time we had our “own” Christmas. I wore my Christmas tie to church and it was noticed. People asked me where I got it and I was more than proud to say that it was a handmade gift from a patient. My favorite tie was the Batik. Its dark burgundy and black tones looked mysterious and unusual.
During early January she popped into my head frequently and especially when I wore one of her ties. I thought about calling to see how she was but somehow did not get around to the task. January was very, very cold. For more than three weeks the temperature failed to break the freezing point. It snowed several times. I like snow. It always excites me like a gift. I love the veil it puts over all the ugliness of the tired city when it first falls. Snow creates urban adventures. I feel like a pioneer when it snows. Every task of daily living becomes a little challenge. We had a thaw a few days before her appointment. The temperature was over forty for three days. I thought it was a good sign.
Once again I was excited when the day of her appointment came. It would be good to see her. I decided to wear the lavender tie. I had finally made it out the door with the lavender tie still around my neck. I rushed down the pike and ran up the stairs to the second floor where the clinic was located. Then I stopped short. She was not there. Other patients had arrived but she was not in her usual metal folding chair near the top of the stairs. I asked the secretary if she had come and perhaps had gone to the restroom but was told that she had not checked in yet. I waited for fifteen minutes but she did not come.
The second patient was waiting and so I saw him. I kept glancing out the door all afternoon. I would walk to the window and try to spot her on the street coming off the T. Maybe there was one of the frequent interruptions of service further out the line in JP where she lived. Maybe she thought her appointment was next week.
By the end of the afternoon I had considered at least a dozen possible explanations for her failure to show. I had looked up and down the hall between each visit. I thought that perhaps she had fallen on the ice and had broken her arm. She might be in the EW. The EW would never think to call the clinic. They probably would not call me even if she asked them to do it. I knew those secretaries in the EW. They put people off all the time. The secretary would probably have said, “Sure honey, don’t worry. I’ll give the clinic a call in just a minute”. Then she would forget to do it.
She might even be there languishing in pain waiting for her turn to be seen. She might still be in the EW waiting room. She could be in x-ray. I worried and waited but she never came. By the end of the afternoon I was anxious and unable to concentrate on what my patients were saying. I was worried sick about her. Something must be wrong. I did not know her well but I knew her well enough to know that she wouldn’t forget to come nor would she just decide to skip an appointment.
Earlier in the fall I had a patient who did not show up for an appointment and I called his home. His son answered and said that he was sleeping. I asked the son to wake him up so that I could speak to him. The son came back to the phone and said his father was “breathing funny” and would not wake up. We sent an ambulance and the man had a respiratory arrest on the way to the hospital. I could not let myself believe this sort of thing could happen twice in the same year. There was some logical explanation for her missing the appointment. Whatever the reason was I had not thought of it. It was time to find out the answer.
I sat at my desk for a few minutes looking at my clinical notes. Everything was perfect. All her labs were normal. Her x-ray was improved. Finally I turned to the front of the record where the telephone number was recorded. I was filled with apprehension. I dialed her number.
A man answered. My voice was unreliable and sounded strange to me as if someone else was saying, “This is Dr. Lindsey, is Mrs. Elizabeth McCarthy at home? I missed her in clinic today”. There was silence at the other end of the line. After a long time the silence was broken by a matter on fact, flat toned announcement, “She’s not here. She has been dead for three weeks.” I felt like I had been hit in the stomach with a two by four. I stammered, “Would you please tell me about what happened?”
There was another long pause and then the voice spoke with a little more inflection and a hint of feeling and fatigue as if it was about to tell a story it had told before and was tired of delivering, “She liked you a lot Dr. Lindsey. She talked about you almost every day. We should have tried to call you but we didn’t. I guess we’ve been too upset to try. She just left her room one afternoon without speaking to anyone. She rode the T downtown. Sometime later she must have jumped off the platform in front of the train.” I could not speak. After a moment he continued, “We really did not know where she was for several hours but then the police called us. I’m sorry we did not call you. We tried to help her but she was never happy here. She always said she was a burden and that there was nothing in her future. We thought she was just upset about having to leave her apartment and would get over it.”
I gave him my condolences and asked him to call me if there was anything that I could do. I sat at the desk for a long time. I could not finish my clinic notes. I could not comprehend what he said. I did not believe it. I could not imagine her taking her own life no matter how unhappy she was. Even if she did choose to end her life, I could not imagine her choosing such a violent form of suicide.
There was some other explanation. It must have been an accident. Maybe she finally decided to try my idea and go downtown. Those platforms can be crowded and tight. Late in the afternoon when people are headed home from work and shopping they shove and push their way to where they think the doors will open so that they will be sure to get on the train and maybe even get a seat. Perhaps she was shoved and accidentally fell off the platform. It was a tragedy but I knew she did not jump. It’s possible that she had an arrhythmia and collapsed while standing just at the line on the edge of the platform. As she dropped, she could have fallen off the platform into the path of the oncoming train. There was always a crowd in those underground T stations downtown and anything could happen in a crowd.
Who could know what really happened? I was angry that her son-in-law implied that she had jumped to her death. I had never seen him during the entire time she was in the hospital. Why hadn’t he and her daughter made her feel welcome in their home? There was probably a lot of family tension and perhaps some long held anger over something that should have been resolved decades ago.
I found myself halfway down the Pike and did not remember leaving the clinic. I could not cry but could hardly breathe. I felt weak. I felt lost. I felt so terrible. I had never felt this way before. Halfway down the Pike off to the right, behind the blood bank, there was a dirty room with vending machines and scarred Formica topped tables surrounded by folding chairs in various states of disrepair. The tables and chairs had graffiti scratched into their surfaces. Many of the messages made impolite comments about the hospital management. The escort messengers and dietary workers hung out there during the day. It was one of the few places where they could go to smoke and relax.
No one was in the room. Sometimes I would go there and buy a candy bar or a drink from the machines. It was dark outside and the room was gloomy because it had no windows. The air was stale from old cigarette smoke. I collapsed into one of the chairs and dropped my head into my hands. I sat there for a long time. I sat there until my trance was broken by the sound of my beeper.
There was no phone in the room. I did not care. I did not move until the beeper called again. I realized I would never know what really happened. Did it make any difference? I had not really helped her in any lasting way. She was dead. In some way I felt I must be responsible.
I took off the tie and just looked at it for a long time. I can’t remember if I put it back on then or not. I needed to answer my page. I had responsibilities. It would probably be a long night. As I walked out of the room and turned onto the Pike I saw my resident. He was well on the way to being a famous clinician and scientist. I told him about Mrs. McCarthy. As my beeper went off for he third time he shrugged and said, “Strange, get over it”.
I don’t have the ties anymore. I don’t remember what happened to them. I could not look at them again. Several years later my marriage ended and maybe that’s when I lost them. I know that I never wore them again. Mrs. McCarthy’s face still pops up before me in my mind's eye from time to time. I have also seen her looking at me from behind the faces of other patients over the thirty years that have passed.
I guess that I could write a book about what she has meant to me and how knowing her has impacted my practice of medicine. I always have a very full office schedule because I’ve never learned to manage my schedule well. Perhaps in part because of her, I always try to be available when patients say that they need to see me. She taught me that I should be looking for more than just a disease to treat.
Congestive heart failure is fascinating to treat and over the intervening decades my academic colleagues have added greatly to our understanding and management of the diseases of the heart. Never the less, sometimes the circumstances of life create heart ache in the lives of patients that is often harder to help or treat than angina, edema and shortness of breath.
Epilogue to Elizabeth McCarthy’s Story
A month ago after a conversation with Melissa Cronin and Russ Morgan about posttraumatic stress disorder I realized that I had experienced something like PTSD as a derivative of the medical training process. I also realized that over the forty plus years since Mrs. McCarthy’s death I was not sure of the facts of my experience with her or of her death. In 2001 I had attempted to “exorcise” some of the suppressed grief and distress by writing the story but the effort frightened me and reawakened so much pain that I quickly put it away after showing it to a few close friends. It has ridden as a Word document on the desktop of every computer that I have had since it was written. I just could not force myself to open it and read it. I sent it to Melissa and Russ even before I read it and then after sending it to them I decided that it was time to look at it again.
It is a true story even though some of the descriptions are composites. Dr. Dexter was a wonderful scientist and clinical teacher. I did my best to accurately describe him. I was fortunate to train at the Brigham when there were many clinical giants from an old school where every specialist was a master of medicine. Examples in cardiology included giants like Dr. Bernie Lown, Dr. Richard Gorlin, and Dr. Eugene Braunwald. I know that everyday they were trying just as hard to improve medical safety and training as they were to advance science. In complex systems with centuries of cultural precedent, change is a slow process.
In retrospect the piece is an under call of the impact Mrs. McCarty’s death had on me. She did make me ties. I did treat her CHF. I did sense her depression but my concern was not associated with understanding and I took no action.
I was totally blindsided by her suicide. I guess my process of countertransference relating her to the stalwart older women in my family and my limited experience as a novice in the care of the elderly precluded my considering the possibility that an older woman like Mrs. McCarthy would do such a thing. My training had not introduced me to what is known now, that suicide is not a function of age. A review of current literature suggests that suicide within the cohort of the elderly is quite common and often unrecognized as either a potential problem or that it happened even after the fact of its occurrence.
Do I know for sure that she died on the platform under the old Filene’s Basement where I suggested that she go for a pleasant activity? I do not but that is the image that is burned in my imagination and memory. What I remembered for sure was soon an issue of internal speculation for me. It was not long before I was not sure just exactly what her son said when I called. Recently I have made a half-hearted effort to use the Internet to go through old records of the MBTA to try to document such a death in early 1972. Even more recent records are not very complete. Perhaps if I really wanted to know, a trip to the Boston Public Library to look at old copies of the Globe or the Herald might yield a certain answer, but to what end?
My fantasy that there was some explanation other than suicide for her death would not be corroborated or refuted by more information. What is more significant is how paradoxically memory is both in its power and its inadequacy. I have waffled back and forth over the last month about whether to give you the story as I wrote it years ago or modify the ending. In the end I chose to limit my edits to the correction of typos.
The greatest truth in the story is that her death was the defining moment of my years of training. She was the only patient in four decades of practice of whom I am aware whose death, while under my care, was from suicide. After Elizabeth McCarthy I always treated heartache with the same focus and concern as I treated angina from coronary disease. I looked for evidence of depression with the same vigor and concern that I looked for an elevated blood sugar or evidence of CHF.
Baseball Is Back And Better Weather Is On The Way
I had a camera with me on all my walks this week so that I might take a picture that proved spring was here. Philadelphia looked very warm on Monday when Pedroia whacked two homers but then by the game Wednesday night the players looked frozen. I tried to photograph yellow finches at my bird feeder. They have discarded their winter coats that turned overnight form drab olive green to their bright yellow plumage of spring and summer just in time for opening day. The finches just would not stay put long enough for me to get a picture of this single indicator of spring in my world.
The scene outside my window on Thursday morning looked like late January with everything sporting a new clean coat of white and evidence that a snowplow had just come rumbling down my little road. As the day wore on I gave up on a credible spring shot from New England and opted to offer you a scene from the West Waddell Creek Wilderness just across scenic California Route 1 from the Waddell Creek Beach where surfers and hang gliding enthusiasts are probably enjoying weather this weekend that we will not see in New England until June.
I hope that the predictions for warmer weather beginning this weekend are accurate. It would be great to enjoy a warm weekend with great walking weather for a trip around my little lake or for you to enjoy wherever you might walk. Don’t waste the taste of this little bit of predicted good weather watching the Masters. Winter can keep taking encore bows until Memorial Day no matter how many yellow finches you might see.
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