— Niccolo Machiavelli
It is easy to find numerous references on the Internet to this quote about the perils that innovators and agents of change face from the author of the The Prince (1513). Machiavelli was a businessman and politician and his famous book as well as his many other letters and papers about success in business and politics give evidence that he is a man who would have been a formidable presence in any age. Five hundred years after the peak of his influence, things have not changed much.
Dr. Ebert started thinking about a prepaid practice of medicine that would focus on prevention years before Harvard Community Health Plan opened for business with eighty eight patients and two doctors in the fall of 1969. Dr. Ebert came to the Massachusetts General Hospital as the Chief of Medicine and the Jackson Professor of Medicine from Case Western Reserve in 1964 with the big idea of an innovative practice with a focus on ambulatory care and prevention that would be financed by prepayment. He was convinced that teaching medical students in hospitals did not prepare them for practice that would improve the health of the entire population or control the rising cost of care. He was very concerned about underserved populations. He immediately ran into the reality of Machiavelli’s wisdom. He was not prepared for the resistance to his thinking that he would encounter from his colleagues at the MGH. There were many at the MGH who were profiting quite well “by the old order” and perhaps many who were “lukewarm” to his idea because they were of the number “who do not truly believe in anything new until they have had actual experience of it”.
In 1965 Dr. Ebert became the Dean of the Harvard Medical School and with that appointment he was able to win the support for his idea from Nathan Pusey, the President of Harvard University. He also found two new allies in George Thorne, the chief of medicine at the Peter Bent Brigham and Howard Hyatt who was the chief of medicine at the Beth Israel. Both men were welcoming of his ideas and willing to be advocates, even if all of their faculty members were not so sure. Even with the support of Pusey, Thorne and Hyatt and other notable Harvard faculty members like John Kenneth Galbraith, it took over three years to secure funding from HEW and the Commonwealth Fund to augment Blue Cross’ willingness to support a project to test prepayment and bring his idea from concept to reality.
My first awareness of the new practice occurred late in the fall of 1969 just a few months after the launch. I was a third year medical student and was learning the ropes in the emergency room at the Brigham. It was after midnight and I was trying to take a history from a very ill woman who was restless and moving around on her gurney with abdominal pain from her cancer. I was not making much progress and my patient’s pain was making us both quite uncomfortable. I was an overly earnest learner near the end of my few weeks in the emergency room and was sticking to the stepwise process of evaluation that my resident demanded. With private patients we would take a history, do a physical, discuss the case with the resident and then call the attending. I had never seen an attending physician in the emergency room at night. The highest level of professional training that I had seen show up at that hour in the emergency room was perhaps the chief resident or some fellow from a specialty service who might show up if the circumstances called for a higher level of expertise.
My exam was interrupted by a woman with a stethoscope in her hand. She was well dressed and was not wearing a white coat. She introduced herself to me as Dr. Sigrid Tishler. She said that she was my patient’s primary physician as well as her oncologist at the Harvard Community Health Plan. She had come to the emergency room from her home several miles away to see how she might expedite the care of her patient after she had made the decision to send her to us by ambulance. I was flabbergasted. What followed was immediate relief for the patient and a great learning experience for me.
A year and a half later I began my internship year on the men’s “ward service”, F Main, in the Old Brigham. F-Main or “ward service” looked more like a scene out of a movie about healthcare in the pre antibiotic era than a scene from a modern hospital. About twenty five beds separated by thin drapes and bedside tables were arranged in a circle “under the big top” in a large circular ward with a high ceiling that looked more like a circus tent than a place for the ill to be served. There was a smaller adjoining ward that we called “Bird Land” because most of the beds were occupied by patients who were on a Bird ventilator. The Brigham Internship year at that time was mostly an every other night rotation which translated into about forty hours with limited opportunity for sleep followed by six or eight hours of recovery that included falling asleep at stop lights on the way home and brief monosyllabic exchanges with my wife and little boys before becoming comatose for whatever time remained until it started all over again.
My attending for that first “rotation” on F Main was the dynamic young Chief Medical Officer of Harvard Community Health Plan, Joseph Dorsey. He was the “doer” whose energy and commitment were the principal reasons that Dr. Ebert’s dream moved from concept to reality. Having Joe Dorsey as my attending was a life changing experience. He was well known for a 1964 paper in the New England Journal of Medicine that had paved the way for the repeal of a Massachusett law against contraception. Dr. Dorsey, a Holy Cross College grad worked with leaders of the Catholic Church to gain acceptance of the birth control pill and repeal the oppressive law that had been passed by the predominantly Catholic legislature of Massachusetts. Making rounds with Joe Dorsey was more than an introduction to the hospital practice of medicine. It was an introduction to the social issues that are inseparable from the care of the patient.
Fast forward to 1975 when I was about to begin the last year of my cardiology fellowship. I was approached by Dr. Marshall Wolf who was one of my mentors at the Brigham and who was also the cardiologist at HCHP. He suggested that during the last year of my cardiology fellowship that I assume his practice at HCHP in lieu of the usual research that fellows in cardiology did. He knew that I was interested in practice and not research and that I was also interested in primary care. At that time it was HCHP’s policy that all “medical specialists” also had primary care practices. It seemed to Marshall that it would be a perfect fit for me. He was leaving his part time practice at HCHP to assume full time responsibility for the medical residency program at the Brigham. So on July 1, 1975 after two brief interviews and a week shy of my thirtieth birthday, I walked into the HCHP offices in Kenmore Square to begin my new career. There was no “onboarding” other than I was presented with a large cardboard box that contained all the memos and documents that had been generated by Dr. Dorsey and his colleagues between 1969 and 1975.
I cannot say that I read everything in the box but I did see by its contents that over the previous five and a half years the doctors had collaboratively researched, debated and negotiated what they considered to be the best way to do everything that pertained to the care of the patient. They had trusted each other enough to “trade in” their individual “clinical autonomy” for a systematic approach to practice that was shared by everyone. It was clear, for example, what would be done on an “Initial Visit”. The were documents that clarified what tests should be done to screen for disease and the frequency with which they were to be done. Since there were no RVUs and we were salaried in a “prepaid” environment there was clarity about the work commitment that was expected for an acceptable performance.
Some people joked that it was a “socialist’ environment that appealed to those of us who had been turned a little pink by the issues of the sixties. We were piloting new methods of practice, for example, “telephone encounters”. Our medical record was a computer based hybrid of short written notes and dictations that were entered by a small army of “inputers” for future reference and then were delivered to us as a “printout” that included all pertinent notes and labs for each visit. Every PCP was coupled with a newly minted nurse practitioner. Many of the NPs were experienced nurses who had worked in ERs and ICUs or had been out in the community as visiting nurses. HCHP had established joint training programs with local colleges to produce the NPs that it needed. There was a sense of teamwork that was reflected in the fact that we called each other “providers”. Some joked that in our socialist model of care we might as well call each other “comrade”.
It did not take me long to realize how right Dr. Ebert had been. My training at the Brigham, which had mostly occurred before the educational objectives of his dream could be realized, had poorly prepared me for taking care of patients in the ambulatory environment. Some of the early physician hires had worked at Columbia Point, which was the first federally qualified health center created by legislation written by Ted Kennedy. Some had experience in the Indian Health Service. I learned the finer points of practice from these dedicated nurses and physicians who were already veterans of the effort to meet the needs of the underserved and who were now transferring those lessons learned to a population that was employed and insured. I eagerly anticipated each of the monthly evening meetings in the home of one of the older physicians who had experience either serving the underserved or had an academic interest in care improvement or experience in private practice. The meetings were exciting because we were all participating in the continuing evolution of our system of care, and I was at a banquet of learning that was just too good to be true.
What made it all the more exciting was that my day was divided between seeing patients in the office and then following all of my patients plus the patients of my colleagues who had cardiac issues and were in the Brigham. It as the best of two parallel worlds that visionaries like Dr. Ebert, Dr. Dorsey and even Dr. Eugene Braunwald, who succeeded Dr. Thorne, were committed to bringing together. Those first five years for me from 1975 until 1980 were an amazing opportunity that I never could have planned, and it just seemed to happen by being in the right place at the right time. Being part of a “greenfield” experiment where you are free to create and are not being challenged by onerous externalities is a blessing that only a few have the joy of experiencing. I only wish that I could have been a part of it from day one rather than an observer for the first five years.
By the late seventies things were beginning to change. Last week I wrote:
...in the innovator’s world, integrating what is new with what exists inevitably produces conflicts as “creative destruction” becomes a reality. Years ago I imagined HCHP as an “island economy”. As long as we were an isolated pioneer outpost and there was a spirit of adventure, life was less stressful. We were not concerned with our work load or our compensation. We were happy exploring a better way.
One day we faced the reality that we had to be integrated with the wider world. If we were going to survive, we needed to grow. To grow we needed to attract professionals who wanted “a market compensation for market responsibilities”. It was as if we had built a causeway from our happy little island to the realities of the “mainland”. I sense that Iora is fast approaching some of the same realities that faced HCHP. The number of similarities are astounding, from the fascination with prepayment, to the redesign of the concepts of an optimal practice, and the attempt to create a more clinically useful medical record.
It was writing that passage that made me realize that reviewing my experience at HCHP in more depth might add to a better understanding of the challenges that face Iora. The initial years of Iora seem very similar to me to those initial years at HCHP. Both were “greenfield” projects that could prosper for a while in an environment that was largely separate from the rest of healthcare. Iora’s progress has been a function of a leader’s ability to engage others in a vision and to successfully develop and defend the fledgling endeavor with the capital it can raise from others who can see the possibility it offers and are willing to take a chance. There is a moment when it must fly on its own wings into a world where they will meet:
...those who profit by the old order, and only lukewarm defenders in all those who would profit by the new order, this lukewarmness arising partly from fear of their adversaries … and partly from the incredulity of mankind, who do not truly believe in anything new until they have had actual experience of it.
In the next letter I will recount what I experienced during those years of transition and integration of HCHP into the wider world.
Looking at Loons is a Relief from the Tension of Politics, the Olympics, and Baseball.
You may remember that the “header” for the letter on innovation back on July 8 showed the new baby loon that had just been hatched on our lake. My wife has continued to photograph the “baby” and its parents every time she is aware that they are near. The loon parents do a lot of “calling” to each other and if the voice seems near it is often a good time to see what her Nikon can capture. We have seen a lot of the loons this week. They seem to like our end of the lake which is fine with us. I thought that this shot taken in a bright midday sun might show you just how much the baby has grown in five weeks.
I am enjoying the Olympics but somehow I am always remembering the unplanned tragic events of the 1972 games in Munich. My favorite games were the 1956 Melbourne games. I had just started reading Sports Illustrated and read everything I could about the triple gold medal performance of my new hero Bobby Morrow, a religious farm boy from the Rio Grande Valley of Texas who could fly like the wind. It is fun to thumb through the years in my mind and remember Abebe Bikila winning the marathon barefooted in Rome. I recall John Thomas, the first man to high jump seven feet in 1960, setting an Olympic record in Tokyo in 1964. What about Bob Beamon’s incredible long jump of over 29 feet in 1968 at the high altitude in Mexico City? I fondly remember Bruce Jenner’s decathlon victory in 1976 in Montreal and my disappointment with the second place marathon finish of Frank Shorter or the even further back finish of Bill Rogers, another hero of mine. I have not even given thought to all the gymnastics, swimming, soccer and other events that flow forth every four years in this fabulous but conflict laden attempt at the ideal of a better world achieved through friendly competition. Let’s pray that the only memories this year will be from the amazing performances we witness.
And then there is baseball. Will the Sox find a way to the playoffs? It is still possible but miracles will be required to get them to the World Series. I am amazed by their consistent inconsistency which mesmerizes me and leaves me bobbing up and down like a dinghy in rough water. The most interesting event in baseball this week only reminds us of human frailty and how hard it must be to be the keeper of extraordinary athletic gifts. The New York Times editorial from Tuesday this week contrasting A-Rod and Ichiro is a must read. It underlines for me that no matter what gifts you have been given everything is a choice.
I hope that your weekend is a banquet of great options from which you may chose a winner!
