| 17 April 2015
Dear Interested Readers,
Inside the Letter This Week
This week’s letter chronicles a trip to a college classroom and an enlightening moment in church. Inspiration and expanding experiences can occur anywhere if you are focused on a mission and are looking around for answers.
Perhaps you grow weary from reading what amount to memoirs. I hope that I have not gone to the well too many times but the letter contains a snippet of a story of a Marathon experience that I wrote long ago within the body of a longer story.
I hope that this next week you will find the complete text of “Elizabeth McCarthy’s Story” on strategyhealthcare.com . If I can pull it off, there will be both a written and an audio version. Your friends can also sign up to receive this letter on strategyhealthcare.com. Past newsletters can be read at https://app.getresponse.com/archive/strategy_healthcare. Finally, check us out on Facebook and Twitter.
Back to School
I had been looking forward to April 15 since last October. It was not because I was having dental work and not because it was time to file my taxes, but because I was scheduled for a return visit to meet with forty or so Harvard undergraduate students who were taking GHHP 50. I had had a great time a year earlier visiting with a similar class and was looking forward to the return engagement. GHHP 50 is Harvard College’s undergraduate course in Health Care Quality taught jointly by Drs. Ashish Jha and Bapu Jena. Professor Jha is a physician who is the K.T. Li Professor of International Health and Director, Harvard Global Health Institute in the Harvard T.H. Chan School of Public Health. Dr. Jena is an Assistant Professor of Health Care Policy and Medicine at Harvard Medical School and practices as a hospitalist at the Massachusetts General Hospital.
It is a small world. To my surprise, present within the class was a visiting fellow whose mother had seen me for management of her hypertrophic myopathy and associated issues from 1975 until I retired. Also present was the son of a colleague with whom I practiced for more than twenty years. My contact prior to the afternoon had been Ashley-Kay Fryer, a PhD. candidate at Harvard Business School and the Graduate School of Arts & Sciences who is the very able head teaching assistant. Last year Ellen Zane, the retiring CEO of Tufts, had joined me. This year I was joined by Carolyn Hayes, R.N., Ph.D., Associate Chief Nurse, Adult Inpatient and Integrative Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute and Peter Holbrook, M.D., former CMO, Children's National Medical Center in Washington. Our shared assignment was to sit with the students for ninety minutes and field one question after another about healthcare quality and leadership.
Wednesday was a beautiful day, even though by the time our session began the Red Sox were well on their way to losing to the Nationals. I prepared for the session by taking a three-mile walk around the Brookline Reservoir just for the joy of seeing crocuses and tiny buds that are still a few days away from bursting forth on the trees that stand between Route 9 and the almost perfectly oval one-mile path that frames the water. I was not alone and never have been at the Reservoir. There are always plenty of opportunities for people watching as you encounter other walkers and even a few urban fishermen. Over the years I ran there hundreds of times because of it proximity to the Brigham and the Kenmore offices where I saw patients. I have other connections to the grassy sloping shoulders and magnificent old oaks on the Dudley Street side of the reservoir; my wife and I would escape from the Brigham to sit there and play Scrabble and eat a picnic lunch on similar spring days, decades ago.
My two colleagues and I sat in front of the students and took dozens of questions. We were asked about managing quality when there was contention about the quality metrics. We were asked about compensation as it relates to quality. We were asked about how patients discern quality. We were asked about the tensions between unions and management in an era of quality management. We were asked about the tensions between doctors and nurses and between ambulatory and hospital based specialists. Lean leadership, relational contracts and the environment that must be present for Lean to be of benefit to the improvement of quality were discussed back and forth at length. All the questions kept coming back to what have we have learned, what works, and the choices that we have as we try to manage for quality and the Triple Aim in an era of transition.
As I was listening to the answers of my co panelists and formulating my own responses as the questions came in like waves breaking on a beach, I was amazed at the familiarity these undergraduates had with concepts that many medical professionals seem not to be actively considering. The students were familiar with the “classics” of the quality literature and they had read the current articles that described the controversies around our metrics and methods related to value based reimbursement. These students understood the achievements and failures of the last quarter century. I had a flashback to the moment when one of my sons asked me to help him with his eighth grade science assignment and I realized that his class was studying subcellular biology that I had first studied in medical school!
In a year or so most of these students will be in medical school or doing graduate work in public health or healthcare administration. They are the next generation of leadership. I am eager for them to take charge because they are smart, interested in improvement and are preparing to see if they can resolve the unsolved problems that my generation, and the generation between them and me, have not solved. As you might imagine I told them about Dr. Ebert as we talked about social responsibility, quality and economics. Dr. Ebert told us fifty years ago what we are looking for.
“The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”
Dr. Robert Ebert, 1965
Maybe this new generation of searchers will find the solution to the riddle of the interplay between the needs of individuals and the needs of everyone and come up with that elusive conceptual framework and operating system that will provide optimally for the health needs of the population.
Belief, Trust, Faith and Hope in the Focus on Quality
One significant advantage of writing as a “private citizen” and not as the CEO of an organization is that I can speak more freely about the intersection between my personal beliefs and interests and what I see in the ongoing saga that is the evolution of healthcare reform. I have mentioned before that one of my favorite writers is Richard Wright. His works, like The Moral Animal and Non Zero, look at history and humankind’s progress in history through the lens of evolutionary psychology. One of his more recent (2009) and controversial books is The Evolution of God. Wright’s thesis in the book is a contradiction to the commonly held assessment that the world is “going to hell in a handcart”. I read him as hopeful that in a very “two steps forward and one step back” sort of progression we are moving forward toward a better world and our progress is in some ways connected to the enlightenment that we have derived by pondering the issues related to our relationship to creation, our existence, and God. I certainly see the progress that has been made in healthcare in the fifteen plus years that have followed the publication of To Err Is Human and Crossing the Quality Chasm and the more than twenty years since the IHI got us all talking about quality and safety. That progress supports Wright’s thesis in The Evolution of God.
Wright, like Jimmy Carter, Bill Clinton, Al Gore, Harry Truman and E. O. Wilson, me, and some others, both famous and infamous I could name, grew up as Southern Baptists. I know that Carter retains his faith but has moved out of a close affiliation with the Southern Baptists, as has Gore. Hillary is a Methodist but Bill still calls himself a Baptist, though many Baptist have chosen to condemn him for his politics and his personal conduct. Carter and Gore had the same experience that I had; the church moved far to the right and decided to become political which left us estranged and on the outside. Wright and Wilson describe themselves as atheists or secular humanists. President Truman died as a Baptist. Oh, I left out the fact that the fourth Baptist president was Warren G. Harding. Enough said about Baptist presidents.
I now describe myself as a “progressive Christian” which may not mean much to you but the description by Marcus Borg, a theologian whose death I recently noted in a letter, has provided me with the best definition of who I am as I ponder the universal questions. “Where did we come from ?” “ Where are we going?” What does it all mean?”
http://en.wikipedia.org/wiki/Progressive_Christianity
Progressive Christians are drawn to social action out of the admonition to “love one another”. They are not looking for definitions that define one group as “in” or another group as “out”. They do not make long lists of things that should not be done but rather channel that energy to look for actions they can take that can improve the lives of others. At their best they remember that it is good game theory, if not righteous, to put self interest after the interest of the collective. They are not so much focused on rules and restraints as they are on compassion and removing barriers that protect a dysfunctional status quo. Progressives, regardless of their sense of spirituality, seek to find what unifies rather than divides. Progressives are inclusive or, in ecumenical terms, they are not only respectful of a diversity of religious opinions and traditions, they are respectful of everyone’s civil rights and equality in society. They believe that there is truth in scripture but truth is not always defined by researchable and defensible facts and that stories that seem contradictory to the laws of nature may have great meaning at an allegorical or metaphysical level when taken in the context of the time when the stories were first told.
Progressive Christians accept that there are many ways to try to understand God and that no one group has the franchise. Issues about heaven and hell are not as interesting and important as the issues of suffering and injustice that are closer to us and over which we have some possible influence and accountability here and now. Said simply, progressive Christians believe that there is much pain and suffering here in this world that is deserving of our attention and efforts for improvement. I do not want to bore you, but this is all an intro to the fact that I am interested in how we all experience religion or avoid it and I am open to and not apologetic about the fact that my healthcare thinking sometimes includes insights that I gained from appreciating the ideas that theologians have had. I believe that derivatives of those insights might inform our approach to the complex problems that we encounter on the journey toward the Triple Aim.
I should add that “progressive” is not a term that defines any one denomination and it is not limited to Christianity. There are progressive elements within all of the three “Abrahamic religions” and within most of the religions of the world. In the end, most religions teach respect for all people and at some point recognize and tolerate the religious feelings and cultures of others. Those attitudes are not new and we have been taught that in an earlier form of understanding they were present when we became a nation.
The roots of the progressive movement branch out in many ways but certainly one root includes the Second Vatican Council that was convened in 1961 and continued until 1965 as a conversation attempting to reconcile the Catholic church with modernity and move it into a closer harmony with other Christian groups, Jews and other religions.
http://en.wikipedia.org/wiki/Second_Vatican_Council
One distant outcome of that council is the fact that every Sunday across this country and around the world the majority of congregations are reading the same scripture, no matter whether they are Catholic or Protestant. The process is coordinated through a convention called the “lectionary”. More precisely it is the Revised Common Lectionary. “Lectionaries” in one form or another as a combination of the calendar and the coordinated reading of scripture go back to about the fourth century, but I have only about thirty years of experience with a lectionary.
http://en.wikipedia.org/wiki/Revised_Common_Lectionary
I must admit that it is thrilling to realize others around the world are reading the same words as you listen to a scripture being read or listen to the sermon that follows and is often drawn from that scripture. The search for some enlightenment and the desire for some inspiration was what passed through my head last Sunday as my wife and I continued a tour of churches in our general area. As we settled into a pew of a stately sanctuary that was built in the 1820s, I opened the order of service and noticed the scripture and the title of the minister’s sermon. The lectionary had decided that the whole world was reading about the events that forever branded Saint Thomas as “doubting Thomas”. Even the scriptures are searchable with Google.
https://www.biblegateway.com/passage/?search=John+20%3A19-31&version=NKJV
The sermon title was an interesting twist on the theme of believing what we have not seen, “Believing is Seeing”. Early in the sermon the minister surprised me with the statement that in our modern world we have equated belief with rational thought. We say that we believe what we have data to support. We say that we are searching constantly for information that supports as rational any new presentation or idea that comes our way. His idea correlated with some of my experience but it did not explain what was happening in healthcare. There is plenty of data that would lead us to believe we must act in a concerted and organized fashion if we are ever to solve our problems. The same is true for global climate issues; and the list goes on and on. Then I remembered that the whole thesis of behavioral economics is that we are not rational. My own experience as a leader was that presenting a “rational” argument for action that was loaded with data was rarely a way to move people.
The minister’s presentation seemed to corroborate my thought because he quickly began to focus on trust, hope and faith which are not so dependent upon rational arguments or the presentation of data. Trust can be destroyed by the data of a bad experience, but it often exists before supporting data is accumulated. Hope is usually a feeling that arises despite data that says the odds for the desired are unfavorable. Nothing creates joy and satisfaction like realized hopes in the face of data and circumstance that makes the odds long. Remember, “Havlicek stole the ball!” and Malcolm Butler’s interception in the last Super Bowl?
So, within my Sunday sermon revelry about healthcare, I realized something that came out later on Wednesday with the Harvard students. Data has carried us a little way in a desire for quality and our strategy of using quality as the point of the spear that pokes the industry toward a future of better healthcare. Quality data may be foundational for the new infrastructure of healthcare finance, but all the data we have generated has not overcome continuing resistance to the general concept that sustainable quality healthcare should be the expectation of every citizen.
When I was sitting in the Harvard class I realized that we had not spent a lot of time talking about data. We were talking about how leaders create trust. We were talking about the foundations of hope, and we were beginning to explore a shared faith in the fact that working together, in time, more people will enjoy a higher quality of care and that we will all be better off when that dream comes true. After trust is obtained, hope is realized, and as faith persists in the search for how to create equity in the quality of care we all enjoy, we will finally get to a place that we all will believe is better, not because the data says so but because our own experience confirms our belief and we will all see that we are living in a better world.
Marathon Memories
Within the partially written book that contained “Elizabeth McCarthy’s Story” are a few other drafts. One is the story of a patient that I was honored to know throughout the entirety of my practice. I first met her when in her twenties she presented to me with problems that were genetic in origin but had, among the many manifestations of that inheritance, significant structural cardiac ramifications. I am happy to say that she is now in her sixties. Her survival and full life after some serious medical interventions and complications of surgical and medical management is a testimony to her personal courage and her unwillingness to accept the limits that doctors (me included) tried to impose on her.
The story is entitled “Judith Adelman’s Story”. I am not sure about serializing this story but within it is a scene where I am in my old office at 690 Beacon Street, the original offices of the Harvard Community Health Plan. My office overlooked Beacon Street a few yards before Beacon and Commonwealth come together just a mile from the finish of the Marathon. This piece of the story is about my thoughts about the 1978 Boston Marathon which I had just competed not too many days before. It may be a revelation that sometimes we are not focused on the patient even when they are right in front of us. It is what it is, but I hope that it may contribute to your preparation to enjoy the marathon on Monday. For orientation, you need to know that Edwina was my MA.
A Little Marathon Memory From Judith Adelman’s Story
...my desk was crammed into a small office with the desk of this part time colleague who was a smoker and never threw anything away. She lacked my organization and the discipline of my piles. Her professional and personal clutter seemed to have erupted in a cascade from her shelves onto her desk and then trickled down to the floor in little puddles of torn journals, crumpled memos, empty Fritos bags, Hostess Cupcake wrappers, and an occasional shard from a Butterfingers candy bar. She was a junk food queen, but worst of all she chain-smoked Pall Mall cigarettes. She was a brilliant woman but was flawed by a lack of any sense of boundary or proprietary. Her area of the office was so unusable that when she practiced she used my desk. When she left at the end of her session, the refuse of the day remained as proof of her clinical activity. I began my work each day as her janitor. I spent the first five minutes in the office clearing a usable work area on the desk of all the little piles of papers, junk food wrappers and ashes she had left behind. I would just transfer the day’s production to the growing mountain on her desk. After my task the cone would be a little taller and then sometime during the night it would lose its face to the floor and resemble Mount Saint Helen’s again before my next deposit. This process of growing and overflowing had been going on for a few months. To crown my misery, I missed Edwina. She had been assigned to someone else. I was feeling abused.
I walked in to see Judith and it felt like the last visit had been the week before. She seemed genuinely happy to see me and announced that she had heard that I had run the Boston Marathon. I acknowledged that indeed I had finally done it. I gestured toward Beacon Street just outside the window. We were right at mile twenty-five. Down at the corner, just past our building where Beacon Street turned into Kenmore Square, big letters are painted on the asphalt saying, “One mile to go”.
As our visit began I was in two places. I was in the room with her but I was also back on the road. The crowd had been thunderous and louder the closer we came to Kenmore Square. There were people lined tightly down Beacon Street from Coolidge Corner toward Kenmore Square. I had been running well and was about to be redeemed by finishing, and finishing well. I was running close to a three-hour finish if I could just pick up the pace. As I came down the gentle slope from Coolidge Corner toward St. Paul Street, I picked up my speed. My legs were hurting but I was only two miles from the finish. I began to picture all my favorite runs and tried to transport myself in my mind to some point two miles from the finish on a usual route. It was so easy to run two miles in less than fourteen minutes. I had done it hundreds of times. I did it almost everyday.
I had something to prove. I first attempted the Marathon the year before, only one year after I was “inspired” to begin running by seeing the runners in the infamous “Run for the Hoses.” The 1976 Marathon had been run on a day when the temperature was over 90. I made all the novice mistakes on my first attempt in 1977. I was under trained. I went out too fast despite the fact that the temperature was near 80. I paid the price and died at mile 18 on the Newton hills. I had finished the New York Marathon six months later in November, just a couple of weeks after my first meeting with Judith. I finished, but it was not pretty. I went out slowly with caution and then ran even slower before walking off and on in Central Park during the last five miles. My time had been 3:44:24 and not much to talk about. My friends all said the same thing, “Well at least you finished this time.”
I had approached the 1978 Boston Marathon with determination. I was running with a “special” number given to doctors. My goal was to finish in three hours or less so that I could “qualify” by the current rules and be “legitimate” in the 1979 Marathon. A few months earlier, during the week after the famous “Blizzard of 78” while the roads were closed to cars, I had run over seventy miles while our offices were closed because of the storm.
I was just a little off pace as I passed through Coolidge Corner and went through the 24-mile marker, refusing the cups of water thrust in my face. I was gaining energy from the crowd that still lined the road three and four deep and roared encouragement to every runner who looked vulnerable. I was going to “pick it up”.
There were two miles to go. As you leave Coolidge Corner behind there is a gentle downslope then the road is virtually flat for more than a quarter of a mile approaching Carlton Street. It was time to make a move on the downslope toward St Paul’s Street. I started pushing as I tried to visualize the easiest two-mile runs I could remember. I only needed to run a few seconds faster than 6:50 a mile for two more miles and I would have my personal victory. Just after I passed St. Paul’s and headed on to the flat straightaway toward Carlton my legs just stopped. They froze or cramped. I didn’t own them anymore. They were thinking for themselves. They controlled me. I could not believe it as I found myself bending over with my hands on my knees. The clock was running and I was standing still. I had hit the infamous wall.
Some guy in the crowd was yelling in my ear. He was in my face. It was a personal affront to him that my legs were dead. He was yelling, “Get going, get going, you can do it. It’s only a mile”. He was lying. I knew it was almost two miles. It might as well have been two thousand miles. I wasn’t able to move. My cheerleader would just have to deal with it. I began to think about failing and the fact that there were people waiting for me at Kenmore Square. I was supposed to do my part. My job was to run by and be cheered. Hadn’t I set it up?
It was an “out of body experience”, but my legs began to move. They went very slowly at first. I ran for a hundred yards and then stopped again. A young woman leaned forward from the crowd and said, “You can do it, you know you can do it”. I liked her approach. Now I was moving again. Her words reverberated in my head, “You can do it, you know you can do it. You can do it, you know you can do it. You can do it, you know you can do it.” Over and over the words recycled. Her face shone with its obvious sincerity and remained in front of me in my mind’s eye. I was running for her. She was my “muse,” my inspiration and new reason for running.
Slowly her mantra was transformed into, “I can do it, I can do it, I can do it”, and then suddenly the rhythm reminded me of a favorite childhood book, The Little Engine that Could. The mantra became “I think I can, I think I can, I think I can”. Simultaneously I was both wondering if anyone I knew had seen me stop or walk and telling myself, “You’re almost to Kenmore Square. You can make it to Kenmore running and then crawl to the finish if you can’t run”. I was not going to walk past our office. The bridge over the Mass Pike loomed like Everest. It certainly was at this point more of a hill to me than all four of the Newton hills that were now fading in memory. The 25-mile mark is on the bridge but I didn’t notice it. I was just yards from my colleagues who were yelling, “Go Gene” from the balconies of our offices and the curb in front of the building. I really picked it up as I saw them.
In a moment I passed the building and rounded the corner onto Commonwealth Avenue. I crossed over the asphalt sign that said “one mile to go”, and then slowed to a walk in front of the T station in the middle of the square. I hoped no one I knew could see me. I walked a few steps on unsteady legs, certain that in a moment another self-appointed cheerleader would be in my face. I remembered my goal of finishing in under three hours. It was two fifty eight and I had almost a mile to go. I would not make my goal.
The last half-mile of the Marathon is triumphant no matter how or when you get there. I was carried along by the roar of thousands and thousands of voices who were still screaming almost an hour after the “winner” had finished. I “sprinted” the last quarter of a mile, calling myself a “hot dog” with each step but I did not care. I crossed the line and started to cramp at 3:07:16. I had wanted to do the last two miles in a little under 14 minutes and it had taken over 21. I had not reached my goal but then again there would be another marathon next year.
Spring Is Really Here
What a glorious week we have had! The Sox are off to a great start and by the process of some miracle the Celtics have become interesting. As the picture in the header (taken by my wife just below Pleasant Lake near Mount Kearsage) suggests, the snow persists only where the sun’s rays are blocked by trees and things. The creeks are running high and the mud on my drive is ankle deep. I am predicting “ice out” on the lake by next weekend and I bought some fresh “nymphs” and “wooly buggers” with the hope that sometime next week I might get them wet in the search for the first rainbow of 2015.
I hope that you celebrate the weekend and Marathon Monday with your own little mini marathon walk with a friend. I have a friend who is an “Interested Reader” booked for walk on Saturday morning.
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