15 June 2018

Dear Interested Readers,


Joy in Practice, Part II

Over the years I have had some strange dreams. In one recurrent dream I am back in high school playing football. I am having a hard time with four problems. First, am I eligible to play since I graduated 55 years ago? My second issue is that I am wondering whether or not I will be identified as someone more likely to be a grandfather than a student. It’s a good thing that I have a helmet to cover my white hair. Somehow my white beard is not a concern for me. My third problem is that I am a little apprehensive about my ability to take the hits, but I am willing to try since I feel that with all my experience I should have some kind of advantage. Finally, despite the fact that I feel that that I am at least as good as the other guys, the coach is paying me no attention and I am wandering up and down the sidelines just hoping to get onto the field. It’s all very frustrating and potentially embarrassing if I am found out to be a fraud.

I also have dreams about going back to college. There are several variations. In one variation I am dressed only in my underwear and trying not to be noticed. Another variation has me discovering that instead of the all “A’s” that I racked up back in the ‘60s in the relatively non competitive environment of the state university, I am now struggling to make C’s and sensing that my chances of getting into medical school, even the state medical school, are “slip slidin’ away.” Perhaps this is because I know there is a final exam scheduled in each of my courses, but somehow I never went to any of the classes, and in fact do not even know where the classes are held or at what time the exams are scheduled. It very frustrating and a relief to wake up! I will leave the analysis of my “do over” nightmares to you and others, but this week I had a totally new “do over” dream that I have never had before.

Perhaps the dream was the result of a guilty conscious. As you may remember, and as I would like to remind you, last week’s missive was both my response to a request from an “Interested Reader,” Eve Shapiro, and an invitation for you. I wrote:

Last year I was delighted to write a preface for the book on patient and family centered practice written by Anthony DiGioia and Eve Shapiro, The Patient Centered Value System: Transforming Healthcare through Co-Design. This week Eve emailed me with the request that I help her find some healthcare professionals, “doctors, nurses, and others” from the front lines of patient care who would be willing to be interviewed for thirty or forty minutes on the telephone. Her note said that the interviews will “focus on what providers say they need in order to experience joy and meaning in work--specifically under what circumstances they have experienced it (or not), what promotes or inhibits it, and what people say they need in order to realize it.” She would also like to talk to some healthcare CEO’s and medical managers so that she can “understand the connection, or disconnection between the perspectives of front line providers, CEOs, and other medical managers.”

If you did not respond to Eve, here is another chance! I urge you to participate because this conversation is one of the most critical conversations in healthcare today. I have long said that I feel that the work life and staffing issues ahead of us will soon move ahead of access and finance as the most significant and rate limiting issues in determining our pace toward the Triple Aim. We are behind in understanding our frustrations and disappointments, and our lack of understanding and lack of clarity about potential solutions threatens the health and safety of patients and providers alike. The opioid crisis is a great example of how we can let critical issues sneak up on us.

What followed my suggestion to you that you contact Eve was my own attempt to answer some of her questions. I had scheduled my own call with her to occur after the letter was written. The letter was my prep. As I talked with her, I realized that I had not been as open with my concerns in the letter as I hope that you will be.

My letter had been somewhat evasive of the real sore points. I had seen her question list ahead of time and realized that she was very interested in knowing a lot about each individual’s past history. Eve is not a physician, but her question list clearly demonstrates that she understands the value of good social and family histories. In a metaphorical way she is also digging for a “past medical history” and is not quickly jumping to a “chief complaint. ” She cares about conducting the interview and considering the answers in the context of understanding the whole individual.

I was evasive. I gave a pretty positive description of my family of origin and my path toward a life in medicine. I emphasized the positives as I gave an overview of my training, and then pretty much avoided giving much detail about anything other than the “joy in practice” that I have experienced. I celebrated the serendipity of arriving at the right place at the right time through no effort of my own. In truth there is a lot of luck or “fate” in the explanation of what happened to me. All that is positive, but I am not sure I helped Eva very much in her desire to understand why so many clinicians complain of symptoms that can only be ascribed to “burnout.” In short, I was very light on the negative aspects. I was following the advice of Johnny Mercer in his 1945 hit, “Accentuate the Positive, Eliminate the Negative.” I did not give a very clear picture of what actually frustrated me. I did acknowledge the difficulties of others, but I implied that the safe havens of Harvard Community Health Plan, Harvard Vanguard Medical Associates, and Atrius Health had sheltered me from the trials that others endured. I was fortunate to work in an enlightened organization, but my review was “Pollyanna” and not realistically balanced. I knew more frustration than I admitted. Perhaps you remember reading:

Over the last forty years the practice of medicine has been bombarded by external challenges. Our growing knowledge and expertise from medical science and its applications for care through innovation has not been associated with a wisdom that has made the benefits available to everyone at a sustainable cost, and in an environment that supported professional growth, satisfaction, and joy. Running harder and faster has allowed many physicians to marginally maintain their income but they have become fatigued and disheartened as they labored in environments that were not supportive in the way I found HCHP and its legacy practices to be.

I could fool myself in the light of day, but I think my dream this week was an attestation to the fact there were many feelings that I was trying to forget. My subconscious mind “outed me.” In the frightening new dream that I had this week I am back on the wards of the “old Peter Bent” Brigham Hospital although the scene did switch to my old office at 690 Beacon Street, the building that was the first home of Harvard Community Health Plan. In both variations I am overwhelmed and panicked. Early in the dream, the problem is that I am the “admitting” intern for the ward service at the Peter Bent Brigham. I am called once again by the senior resident in the emergency room to tell me that I am getting another “hit.” I can’t tell him that I still have not finished working up or writing orders for the last two patients that came up. Everything is falling apart around me. I can’t even find a pen or progress note paper for the chart. Nurses keep interrupting me to ask me questions. When I try to dial the operator to answer the pages that keep coming to my beeper, I can’t get my fingers to dial the phone without making a mistake that forces me to start all over, again and again. The operator has long since moved from beeping me to calling my name over the PA system. I am sinking under waves of fatigue. It is way past 3 AM and long ago I gave up on the idea that I would ever get to bed. To top it off I am sure that somewhere on the floor one of the established patients is bleeding out from an active upper GI bleed and I haven’t sent a clot to the blood bank for her or called a surgeon. I felt that nothing was working and that I had no time to think or get things under control.

In truth the dream was an enhanced “remembrance.” I was in the last group of Brigham interns to endure 10 months of every other night call. We had two “recovery rotations” that were “light call” and every third night in the hospital. I well remember the morning of June 21, 1971. I saw the sun rise over the parking lot where the Brigham built a new bed tower nine years later, as I wrote orders for the fourth or fifth admission that I had received on my first night as an intern. There were only 364 more days to go. I am delighted that things have changed for young doctors now, but I fear that much of what I endured has morphed into something different that has its own new horrors and excellent reasons for sweat producing anxiety, a pounding heart, and the ability to fall asleep at intersections while waiting for the light to turn from red to green.

At my age your dreams get several installments since there are multiple obligatory trips to negotiate during any given night. One must be careful not to hop out of bed too quickly. Pre bedtime planning is a good idea to make sure that there will be no obstacles to trip over in the dark. The ibuprofen is strategically placed near the bathroom sink since things get sore when you wrestle with demons in your dreams. It is honestly true that I often dream in installments. It is a relief to wake up and say, “Well that was just a dream!” But often, as soon as I have returned to bed, a new episode in the same story begins. It’s just like binge watching on Netflix.

Once back in bed, the time of my dream had shifted forward a few years and a few miles from 1971 toward the late seventies and the scene had moved from near Brigham Circle to Kenmore Square, about a mile away. Now I in the new installment, or second episode, I am experiencing much of the same sense of being in an environment that is out of control. My schedule is full, over full, yet I feel inadequate because I see Joe Dorsey’s schedule and he has about thirty patients booked for the afternoon session compared to the 17 that I have. I ask myself, “How does he do it?” When I arrived from a morning in the hospital there was a stack of “call slips” waiting for attention. People want to come in or they want to talk about a lab result and hope that I will call soon. Perhaps someone really needs to be seen right now.

Sitting next to the call slips is a ream of that old time computer paper that made great banners. It’s not a banner. There are dozens of printed lab results for me to review, scribble a little note reassuring the recipient that there is no need to worry about a slightly abnormal MCHC . It’s a calculated index of almost no potential clinical significance based on all the other things that I know about them.

Then a colleague calls and asks whether or not he should send down a patient he is seeing. Alternatively, I could come up to his office and take a quick look at his EKG and listen to his heart so that we can avoid sending another patient to the ER. I tell him that I will pop up in a couple of minutes. Oh, and there are a hundred or so EKGs that must be read before I go home. They are sitting next to the lab results that need reporting and the call back requests.

My medical assistant pops in to tell me that both of my exam rooms are occupied by patients who are getting a little “antsy” waiting for me. I sure was hoping to get to see the last few innings of my son’s little league game. I had promised him that I would do my best to get there. Was it all a dream or just a more honest memory?

As Eve interviewed me I remembered much more than I had originally admitted to myself. What I also remembered was that I was part of a group that felt responsible for not just accepting things as they were. We did feel that there must be a better way to “manage the practice,” which in retrospect was a less terrifying way of admitting to ourselves the we were facing some huge problems that few people fully understood, and that no one could “fix” for us. We felt there were both personal and collective necessities to be involved in the search for solutions.

It is understandable and right for patients to expect better access and the focused attention of the doctor, PA, or NP when they do finally get to the office. It occurred to me one day that the last patient that I saw long after 5:30 PM had every right to expect the same level of attention from me as the one that I had seen at 8:30 AM. It is perfectly acceptable and understandable for patients to complain about the rising cost of their care, especially if they do not see a commensurate rise in value. It is also a reality that each of us has emotional, intellectual, and physical limits that can be overwhelmed. I can’t run my car for hours and hours at 5000 RPM and expect that it will last long.

I do believe that part of responsible professional behavior is to recognize one’s limitations and ask for help when the limits of responsible performance are approaching. It is not productive to complain about the incessant demands coupled with the non compliance of our patients. It is also not healthy to sense that everything “depends” on me as I sensed in my dream and often sensed in the light of day.

I will still contend that there are solutions that we can find with the help of a focus on what quality means, what constitutes safety, what electronic devices can provide, what innovation can generate, and what new tools like AI effectively applied to well considered problems can replace. I believe that the way forward toward anything better requires flexibility and a willingness to discard what has been “usual practice” but is no longer productive. What we discard must be replaced by changes in care delivery that can provide a better experience for the patient and less frustration and physical and emotional destruction for providers. I feel we suffer needlessly from being too slow to discard what can never work and from resisting a thoughtful embrace of new possibilities and formations in care delivery that are worth trying.

The biggest disappointment for me over the time since November 8, 2016 is the loss of momentum to the process of improvement. We have gone from experimentation with ideas of how to improve care, to defending some fraction of the gains we have made toward universal access. Our goal should be to discover how we can create the opportunity for the development of therapeutic relationships between providers and receivers of care that allow time for the development of personal knowledge of the patient and the application of critical thinking to the issues that uniquely challenge each individual patient and provider. Instead of making progress we are forced into a retreat that has as its objective the preservation of a fraction of what we had already accomplished.

Well, I may have just imagined my next nightmare. Unlike waking up from bad dreams or refusing to watch gruesome tales on Netflix, we can’t heave a sigh of relief from our dystopian experience and instantly return to a happy and progressive reality. It will take focus and commitment to a common set of ideals and many new innovative ideas to ever improve the deteriorating lot experienced by many clinicians, and restore the full measure of joy that was always the payoff for the realistic and survivable levels of stress that have always been associated with practice.

Never has there been a better time to think about the “reason for action.” It is imperative that we honestly describe the “current state,” and invision together a fuller vision of what the Triple Aim or “Quadruple Aim” would be like. After we have addressed the reality of where we are versus where we want to be, we can enumerate and analyze the barriers to progress, and articulate a hypothesis that might lead us toward our objectives. There will be discovery along the way, just as there has been in the past. There will be a sense of possibility once we start again toward making healthcare universally available.

I have no doubt that we will continue to get better and move closer to our objective if we just keep applying what we learn from our failures as course corrections moving forward. That’s how I survived my fears, frustrations, and disappointments, and now at the end of road can find some joy in the fact that even though I never got to where I wanted to go, I do look back with some satisfaction that is greater than the regrets. “Do overs” are not possible, but there can be great joy in less than perfect efforts.


Illiberalism and Populism: The Greatest Threats to the Triple Aim?

I am not going to completely discuss this idea now. What follows is a brief introduction. I will deliver a spoonful at a time. To effectively ask, understand, and answer the question there is much explaining to do. It will also be necessary to establish some generally accepted definitions and facts. There is nothing that seems to be more difficult in the the dystopian post November 8, 2016 world than establishing facts that we can all accept as a basis for discussion and a launching pad for the negotiation of a way forward.

Opinions are important but they are not facts. I certainly am capable of confusing my opinions with facts, and I have come to recognize that it is dangerous to do so. Misconceptions and falsehoods are destructive and counterproductive when attempting to solve complex problems even if they are called “alternative facts.”

It is a fact, not opinion, based on human experience in history that continuing disregard for truth and the denial of facts prevents the evolution of workable policies, and is the harbinger of the loss of the evolving Liberal Democracy we have enjoyed for almost 250 years. That is not a quote but it is close to the core of the idea put forth by the Harvard University Professor of Political Science, Yascha Mounk, in his new book, The People VS. Democracy: Why Our Freedom Is In Danger & How To Save It.

The first stumbling block is the word liberal. Margaret Thatcher and Ronald Reagan were advocates of Liberal Democracy even though they they were “conservative.” Liberalism in reference to the larger picture of government does not necessarily mean a proponent of progressive left leaning social policies. It also does not mean advocating for limited government and an isolationist foreign policy as advocated by many who call themselves “libertarians” and believe that less government in their lives is always better. “Liberal” means a belief in inalienable human rights, the rule of law, and the protection of the rights of minorities. Our founding fathers believed in the these things in regard to those who were franchised by the fact that they were male, white, and had property. Their idea was right. They just did not extend the franchise to slaves, women and many minorities. The last 200 years or more has been about the extension of their idea to everyone and the expansion of “rights” to issues like clean air, drinkable water, adequate education, and healthcare. To achieve the full concept there has been a necessity to fight a civil war, debate the enfranchisement of women for over a hundred years, and continue the fight for the elimination of injustices and the full defense of the rights for all minorities. Along the way we have recognized that a huge barrier to the full realization of the right to “life, liberty and the pursuit of happiness” has been inequality for minorities, women, and the all poor people that has often been buttressed by legislation and regulatory policy.

Populism enables the rule of the majority to curtail the goals of “liberal” thought. Mounk describes the delicate balance of powers within government, between the branches of government, and the freedom of the press to inform us with acceptable facts that are necessary to keep the balance. He challenges the idea that once “liberal Democracy” had gone through a few cycles where one government is peacefully replaced with its opposition, it becomes secure and can never be disrupted by a regression to “illiberalism” and authoritarian government.

So what is illiberalism? Merriam and Webster’s Dictionary offers the simple definition: opposition to or lack of liberalism. Some political scientists offer examples of proponents of illiberalism, like Vladimir Putin, and the leaders of Turkey, India, Hungary, Poland, China, North Korea, and the Philippines who find guaranteeing the universal concepts of liberal thought to be disruptive to their desire to force the solutions they favor. Some of the “Jeremiahs” among us see our president trying to put us on a road to illiberalism by assigning blame for social ills to immigrants and minorities, by undermining the courts and press, and by violating many of the delicate norms that are required in a culture of “liberal Democracy.”

The most concerned individuals point out data that suggest that a majority of Americans do not understand the theoretical foundations of our government and that a majority of those under thirty see no problem with illiberalism and authoritarian government as long as it works for them. Liberal Democracy has not really been working for them since their standard of living has deteriorated over their lifetime and the prospects seem to be for further decline unless someone “fixes” things.

I leave it there for now. What concerns me is that the growing “fix” seems to include the withdrawal of any protections that the underserved and the chronically ill have gained over the last decade. We now know that this administration’s Department of Justice does not see insurability of everyone, regardless of preexisting conditions, as a right that they will defend. They consider it unconstitutional. What will go next?

To be continued. The threat of illiberalism and populism to good healthcare for everyone will be with us for a while. I once said that my patients did not get sick overnight. Most of the time their illness was “the acute presentation of a chronic problem” that had been gaining momentum for a long time. It is rare that we resolve a problem in less time than it took it to evolve. Problems have their fans who will defend them.


Evenings on The Water

This time of year after reading the paper, after Words with Friends, after writing, after chores assigned by my wife, after my walk, after trips to the hardware store for gadgets that might actualize a little project I have been considered for weeks, and before the supper my wife has been conceptualizing, I go out on the water. I time it all to coincide with the first pitch of the Red Sox game which is coming through my earbuds as I push off in my kayak or crank up the little three horse Johnson that pushes my fishing boat around my lake. The choice of which to take is never decided until the last moment. If I go left to the beach, it is the kayak. A turn to the right takes my to the dock where my forty year old aluminum boat waits for me. Sometimes the decision is made by the wind. More breeze favors the boat. A glassy surface on the water favors the kayak.

Most evening I have almost five hundred acres of water to myself. Well, I usually see the loons. Often mallards or mergansers scoot along the shoreline. An old bald eagle surveys it all from a tall white pine on Stanley Point. I almost always catch fish as we approach sunset.

I am not an early riser. While drinking my coffee and looking out at the lake in the morning, I see boats out on the water testing my favorite places. I assume they have been at it since dawn. They are usually gone by ten. The middle of the day is rarely a good time to fish. I also believe there is more to see late in the day, but I am biased. It is rare that I see the sun come up, but it is the rare evening during the summer that I do not see it go down.

The time on the water is a form of meditation. Fishing is almost an automatic function. I do the same thing every night, but the results vary. The Red Sox announcers say the same things night after night, but the outcome of their description also varies. How can a pitcher be unhittable one night and unable to get the ball over the plate a week later? These are issues worthy of deep consideration, and I am more likely to come to a definitive decision about what explains pitchers and fish than I am to ever understand why our country feels so divided or why it is vulnerable to the purveyors of simplistic and self serving solutions to complex problems. On the water, as the sun goes down, most of life’s big questions can be considered without anxiety as their sting is buffered by the beauty that surrounds me, and is much more worthy of my attention. You can catch a glimpse of that feeling in the header for this letter.

I hope that you have a place where you can let your mind tread water, and that it will be available to you this weekend. I am headed back to North Carolina where four generations will gather to talk about the past and pledge to hang together despite different points of view about the world we share.