17 March 2017

Dear Interested Readers,

What’s Inside This Time


The dizzy pace of change and controversy continued in Washington this week. Do you remember how things felt in the runup to Watergate? As Yogi would say, “It’s deja vu all over again” with issues and Nixonesque questions plaguing the president related to his comments about being bugged by Obama, the Russian interference in the election, questions about his potential international business conflicts, and what is really behind his reluctance to release his income taxes. I can see the ghost of Ron Zeigler, Nixon’s Press Secretary from Disneyland, looking over the shoulder of Sean Spicer as he bravely tries to explain that “wiretap” in quotes does not mean what we think, while avoiding the reality that the quotation marks randomly float in and out of the nonsense coming from the president’s thumbs.

The Watergate ordeal of NIxon was a confirmation for me of what my saintly mother had always tried to teach me. She frequently said, “Be sure that your sins will find you out!” Another iteration on the same theme was, “You can’t do wrong and get by!” Nixon’s sins were eventually outed, largely through the efforts of Woodward and Bernstein, aided by “Deep Throat.” Years later we learned that “Deep Throat” was Mark Felt, an assistant director of the FBI under J. Edgar Hoover. Is there a “son/daughter of Deep Throat” somewhere in the vast Federal bureaucracy who has access to information that will be the source of this administration's unwinding in these strange times?

There are many questions that face our country, and everyone of them is impacted by concerns about what happened during the last election. My experience in life suggests that my mother’s concept is almost a law of nature. In the end the full story often comes out, if there is a story that is being hidden. In the political world there are a lot of people with something to gain from outing mischievous deeds and acts of political expediency. This administration should be sophisticated enough, but is not, to know that its reluctance to be examined will only result in a continuation and enhancement of the concern that things are being hidden. When the dirty laundry is finally found and examined in the light of day, my mother will be proven right once again. I know from experience.

The biggest event in a week of big events was the report of the scoring of the American Health Care Act by the CBO. What did we learn and where will the discussion go from here? In the first section I try to address the acceleration of the questions that surround the future of the AHCA. There are many subplots and a multitude of possible outcomes for this important conversation. After reading my attempt to look into the future of the AHCA, I hope that you will share your thoughts, worries and expectations with me.

In recent letters I have lightly touched on my concern that I need to maintain some balance in these notes. As much as I care about healthcare policy, perhaps the greatest threat to the future of healthcare is the increasing stress that clinicians and administrative healthcare professionals are feeling. “Burnout” is becoming a cliche, but the feelings and personal concerns that the word allows us to package without resolution are bigger long term threats to our ability to deliver the care that people want and need than is the AHCA. Professionalism is a concept that is not limited to healthcare, but I believe that there has never been a better time for us to renew our considerations of professionalism. The core concepts in medicine have persisted through more than two millennia but they can be lost in one generation of neglect.

I hope that you will look at the new posting on strategyhealthcare.com, “Understanding “Ryancare”, the AHCA.” The posting is an updated version of a part of last Friday’s letter. The fact that something written on Thursday night needs updating by Tuesday morning is an indication of how fast things are evolving. We are being blown in many different directions by the shifting winds of rapidly evolving change.

What Follows the CBO’s Report?

Monday’s big news was the CBO’s scoring of the AHAC. Almost immediately the Democrats in Congress were shouting praise and some version of “I told you so” while Republican’s were saying that 24 million people losing coverage was a manifestation of personal freedom and progress against the background of the impending financial disaster of Obamacare. A close reading reveals the prediction that by 2026 we will have more than 50 million Americans without health insurance. Ironically, Keith Hall, the director of the CBO, was hand picked by Tom Price and other House Republicans, so pushing back on the report should have been touchy. What is emerging for me is that the AHCA is not really an attempt to repeal and replace the ACA; it is part of a larger attack on all programs of social welfare that are an anathema for conservative Republicans. Paul Ryan confirms that notion when he points to the CBOs assertion that by throwing many Americans off of Medicaid it saves 337 billion dollars.


I get a lot of notices of healthcare events and requests for political donations in my inbox each week. Because of my past history of donating small amounts of money on line to Democratic campaigns and efforts there are daily requests for donations. This week one caught my eye. Rep. Joe Kennedy, III was writing for a group called Organizing for Action.

Mercy.

It is about how we care for the least among us -- not how we treat the powerful.

It calls on us to feed the hungry, clothe the naked, and comfort the sick.

It is kindness. It is grace.

There is no mercy in a system that makes health care a luxury. There is no mercy in a country that turns its back on those that are most in need of protection: the elderly, the poor, the sick, and the suffering.

There is no mercy in a cold shoulder to the mentally ill.

There is no mercy in a policy that takes for granted the sweat, the tears, and the sacrifice that working Americans shed every day so that they might care for their families' basic needs: food, shelter, health, and hope for tomorrow.

So when Speaker Ryan called his repeal bill "an act of mercy" last week, I knew I had to speak out.

It is an act of malice.

We, as Americans, are better than this. Every working family deserves better than this. And when millions of people have their access to health care put on the chopping block, we have to stand up to this....

Thank you.

Congressman Joe Kennedy III

That letter was written before Congressman Kennedy had seen President Trump’s “America First” budget which sent to Congress yesterday. The budget is the monetary manifestation of the meat cleaver that is being taken to our rudimentary attempts to address the social determinants of health and to lift people out of poverty into a fuller participation in the benefits of our society. Within just a few hours Boston’s Mayor Walsh was in front of TV cameras blasting the budget for the damage that it would do to people. There was precious little mercy in the budget except for laudable increases for programs to fight opioid abuse and increase health care resources for veterans.

It was tough to do, but I forced myself to watch the entirety of Tom Price’s “town hall” on CNN about the AHCA. I did not learn anything new except that Price discards the CBO analysis by saying that they only evaluated the bill (AHCA) but did not add into the analysis what he and Seema Verma, the new Administrator of CMS, could do by orders through their agencies, or other new legislation that would be introduced in the future. Fortunately for me I had recorded the event and watched it Thursday morning on an empty stomach. I only had dry heaves. Sean Spicer must take lessons from this man.

Behind the smoke screen of harmony with the administration Paul Ryan should be getting the message that the outcome of the bill is uncertain. I am not predicting that it will not pass. What I am predicting is that we will continue to experience pressure on both Medicare and Medicaid through their management by Price and Verma. We will also see Price use every administrative tactic under his control to further undermine the ACA as long as it is in place so that their assertions that it will fail will come to pass.

Those who are working hard for the broader coverage of more Americans at rates that ordinary people can afford are well advised to have strategies that go beyond fighting the AHCA. There is no doubt that to defeat it is important, but we should remind ourselves continually that the ACA is vulnerable because of its flaws. Despite the good that it has accomplished it is imperfect and needs revision. Unfortunately we will see several years pass before we have a chance to pass “ACA 2.0.” In the interim there is too much uncertainty to allow us to rest. We must articulate and pursue loftier goals than pushing back against Ryan, Price, Trump and company.

A Time to Renew and Expand Our Sense of Professionalism

Retirement is a time of reflection. Most of one’s agency lies in the past. Opportunities to contribute to the future require organizing indirect processes for the transfer of bits of experience, insight and wisdom to those who still spend their days laboring in the fields where you are now absent. I find that my ruminations yield a mixture of feelings. The dominant upside feeling is a great sense of gratitude for having had the privilege of working in a wonderful place with colleagues who were dedicated to optimizing the experience of the moment while planning a better future through the continuous exploration of what might be possible. The companion minority downside of my ruminations is the sense that I could have done a better job. An overarching and painful realization is that I have left the field of battle before the victory was won. My realization is that I must work to be a relevant advisor to those who still do the work if I am to have the joy of continuing to contribute to the dream of a future where we enjoy

...Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellness.

Much of my reflection is a review of the moments, places and people that molded my sense of professionalism and a growing awareness of how I came to understand my professional responsibilities. In retrospect I appreciate that the faculty at Harvard Medical School in the late sixties was interested in giving me much more than a foundational knowledge of anatomy and biochemistry, and even more than a sense of the traditional decorum between doctor and patient. Dean Robert Ebert addressed my class on the first day of medical school and gave us his preview of the challenges that would evolve for our generation of practitioners. I wish that I had a recording of those words to review now, but I do know what he said about the future of healthcare in a lecture at Simmons College five weeks later. In that lecture he focused on the training of physicians who understood the challenges of the populations of the rural and urban poor. His lecture was a fleshing out of much of the meaning that he had summarized in his pronouncement about where to look for the solutions to our problems in care.

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.

I believe that fifty years ago he intuitively knew that we were embarking on a journey of many generations as we struggled to find the elusive solutions to the complexity of healthcare that our president just recently realized in his own epiphany. I also believe that Doctor Ebert saw that the school needed to foster a new professionalism that was built on the realization that the care of the patient was done best when there was an appreciation of the population or community from which the patient came. These ideas would be for me and many others like the Arc of the Covenant that the Hebrews carried and followed as they wandered for forty years in the Sinai on their way to the Promised Land. He meant to train a generation of “socially conscious” physicians.

Before my classmates and I had a direct experience alone with a patient at the bedside or in a clinic exam room, we had witnessed our professors and instructors interacting with patients in the Saturday morning “clinics” in one of the amphitheaters in the “quadrangle” of teaching buildings on Longwood Avenue, which was our campus, or at one of the affiliated teaching hospitals.

These Saturday morning exercises were the highlight of my week. Not all that I saw should be emulated. I remember one famous professor from another era who enraged our class by referring to his patient, a distinguished appearing African American man in midlife who had sickle cell disease, as “Bobby”, and once by the derogatory “boy”. The language of the distinguished professor was like nails on a blackboard even though doctor and patient clearly had a long and mutually beneficial relationship that included the realities of midcentury racism.

The other activity that was a glimpse of what would eventually come to us in the third year was the chance to “go on rounds” with one of the professors. I was delighted to tag along behind the famous cariologist, Dr. Lewis Dexter as he moved from patient to patient on the wards of the Brigham. These rounds were a preview of all that would follow in our own lives over the years to come when we would move from the classroom to the teaching hospitals and clinics. On rounds we would follow our guide like ducklings behind their mother as he or she went from bedside to bedside interacting with patients about their specific issues and concerns. Up close and in real time while real work was being done, we were interlopers on the dramatic interpersonal relationship that involves the trusting reciprocal interaction that forms the basis of a therapeutic alliance.

The medical school had distilled the essence of the technicalities of how to take a history and more effectively communicate with the patient in a little pamphlet that was called the “Little Red Book.” The mindset of how to “be with the patient” in an effective therapeutic relationship was the essence of the little “Grey Book” which was a pocket sized copy of Dr. Francis Peabody’s famous lecture/essay delivered in 1926 and published in 1927, “The Care of the Patient.” The last three sentences of the monograph sum up his philosophy and are the cornerstone or entryway to all discussions of medical professionalism as I believe it must be experienced in these times.

The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.

Updating that statement which was published in the same town and the same year as Sacco and Vanzetti were executed primarily for their “otherness” as symbols of a threatening immigrant population, there are many things to consider. On the technical end we struggle with the challenge of managing medical information both in terms of electronic records, oceans of information in multiplying databases, and an explosion of medical science and technology. “Knowing the patient through and through” has new meaning as does “bought dearly.” These days both doctors and patients bemoan the loss of time spent together that is a reality of expanding care to larger numbers while trying to use antiquated concepts of finance and old systems of care. Dr. Ebert told us that we would need to work at organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.

What is as true now as it was back in the mid twenties of the last century is that “the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”

As medical students we easily absorbed the lessons of the Little Red Book. The lessons Dr. Peabody was trying to pass on as described in the Grey Book take much longer to understand, as Joseph Ladapo explained in an essay written when he was a third year resident at the Beth Israel Deaconess Medical Center in 2010.

Harvard Medical School did a fantastic job emphasizing the intangible aspects of medicine in our patient–doctor courses, but the focus of our education fell resoundingly on anatomy, physiology and pathology. Further, the fact that we were students and not yet doctors made Dr. Francis Peabody’s storied 1927 essay, “The Care of the Patient,” seem more like words on a page than a living reality...Only during the second year of residency did we finally have enough free mental space to reflect deeply on our experiences.

For me, this reflection led to a new understanding of what Dr. Peabody meant. Our profession as physicians affords tremendous room for creativity, because after the “medical” part of patient care is complete, the rest of our experience is up to us. This includes everything from how we welcome patients into our offices to how comfortable we make them feel during the course of their treatment to how we explain a new diagnosis to how we organize our appointments… We are all aware that doctors are limited in their ability to diagnose and treat illness, but to live within that reality is another thing entirely.

I am continually amazed by the way in which ideas can come together in a series of interactions over just a few days. My recent ruminations on professionalism have been part of my internal reaction to the complexity and acceleration of the “repeal and replace” debate as I try to see what practice and the experience of receiving care will be like in the new world of Trump influenced care. I hope that our residual professionalism will be a sustaining source of strength and insight as we grapple with the reality of how to deliver care to the people in those populations that will realize a loss of resources and access. I never expected to find solace and insight in the words of a “rock star.”

As fate would have it I have been enjoying Bruce Springsteen’s autobiography, Born to Run. I had heard him interviewed about his book on Stephen Colbert’s show last September. When a friend wanted to know what book I wanted to read after the one she gave me for Christmas turned out to be a duplicate of one I had gotten from my wife, I remembered the interview and said, Born to Run. The book is terrific. I then learned that Springsteen not only wrote the book without a ghost writer but he did the recording of the full audiobook. Last weekend as I was walking and thinking about professionalism, Bruce chimed in with his insight on professionalism.

...We are a philosophy, a collective, with a professional code of honor. It is based on the principle that we bring our best, everything we have, on this night, to remind you of everything you have, your best. That it’s a privilege to exchange smiles, soul and heart directly with the people in front of you. That it’s an honor and great fun to join in concert with those whom you’ve invested so much of yourself in and they in you, your fans, the stars above, this moment, and apply your trade humbly (or not so!) as a piece of a long, spirited chain you’re thankful to be a small link in.

Bruce Springsteen, Born to Run, Page 217

I was stopped in my tracks as I kept playing the words over and over again. It is a privilege...exchange soul and heart with people in front of you...apply your trade humbly...a long spirited chain you’re thankful to be a small link in…

Bruce Springsteen’s words haunted my thoughts. I went home and pulled a book off my shelf that has been there for more than a dozen years. It was Robert Coles’ book from 2003, Bruce Springsteen’s America: The People Listening, A Poet Singing. In the book Coles talks about his personal experiences with physician author Walter Percy and poet William Carlos Williams and places Springsteen in a lineage that includes Walt Whitman and William Carlos Williams as a poet of American place, people and time. His is a voice that arises to express in a more positive way all the confusion and pain that describe the blue collar experience and sense of loss that we read now in JD Vance’s Hillbilly Elegy. His songs offer insights that exceed the academic explanations for why the legion of white blue collar Americans with lost hopes in an America that failed them have looked to Donald Trump to shake things up.

After my epiphany on the road with Springsteen, I had another encounter that reinforced my idea that our professionalism needs to be at the core of how we see ourselves in service to our patients in these times of challenge for us all. I have enjoyed volunteering on Monday afternoon’s in an after school program for fourth, fifth and sixth graders in Newport, New Hampshire. Newport is about ten miles from my home. In those ten miles you travel from lakeside homes with seven digit prices to a post industrial community with all the woes of a town with empty factories, decaying storefronts and shabby homes along neglected streets. It is another world. Hillary won in my town. Donald won in Newport.

Between activities I was in conversation with one of my co volunteers. I discovered that we had one degree of separation. He and his wife had lived in Brookline for many years and they had gotten their care from Dr. Phil Wade at the Cambridge offices of Harvard Vanguard/Atrius. My new friend bubbled on and on about the great care they had received from Dr. Wade and then mentioned his colleague Dr. Andy Modest. I heard the word professionalism several times as he sought to find ways to expand his gratitude for Dr. Wade. We both knew that Dr. Wade had died much too soon in 2013, but we were certain that the echo of his commitment will linger in the lives of those he touched way into the future.

I hope that we will explore as professionals all that we can do as individuals and together seek to move our system of care toward the ideal that delivers

...Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellness.

I hope that more and more professionals will try to collectively advocate for a better future and not just sit and wait to see how this moment works out. We do know the issues. Dr Price and Dr. Verma are not the only physicians who have ideas to present that should be heard and considered. We must decide as individuals or in groups if we need to be involved in the petition of Congress not to repeal the benefits and stability of the ACA before there is certainty that we will have ACA 2.0 and not ACA 0.5.

Away from Washington, where we live and work, we can direct more attention to the one thing we do control more than we wish to admit, which is the cost of care. We must be the ones who say that there is waste that can be removed that adds to the growing cost of care. We can recognize and educate others that there are social determinants of health that must be addressed in the communities where we live and practice. We need to accept the challenge to understand the 2017 realities of the truth of 1927:

...One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.

Winter’s Encore and a New England Tradition

It’s been a big week in my hometown. We had sub zero temps over the weekend followed by a blizzard with two feet of snow on Tuesday. Tuesday was also town election day and about 450 voters found a way to the poll in the center of town. It was a tropical 15 degrees Wednesday night for the annual town meeting, but the gymnasium at the “Outing Club” was full of people ready to speak their minds.


After a contentious debate we spent $210,000 for a new street sweeper, and turned down by one vote an extension of a $500 tax rebate for any veteran who served 90 days and had an honorable discharge. Currently, only veterans who served during a time of conflict get a rebate, and by one vote it is going to stay that way to save $75,000. I voted for the extension. After the veterans extension lost by one vote on a secret ballot, we then voted by a two thirds majority to request that the government stop spending money on modernizing nuclear weapons systems, and use the same money to support human services and infrastructure investments. We are the mouse that roared.


It was a grand evening of 25 articles to be considered and voted. Some were no brainers, but there was usually someone who wanted to give their point of view on any subject. One frequent speaker seemed to suggest that the selectmen were incompetent because two pipes had frozen and burst at the library and yet they still wanted to spend another $10,000 on a external drainage problem. I could not connect the dots on the reasoning of that citizen. What do frozen pipes last year have to do with an external drainage problem this year? We all listened respectfully before passing the item over his objection.


This week’s header was taken during my Tuesday walk in the blizzard. As you can see the visibility was limited. If you look closely you can faintly see the tree line across a small inlet less than two hundred yards away. The going was slow but the experience was exhilarating. The weatherman is predicting more snow for this weekend! I am looking forward to a little more winter time adventure. I hope that whatever the weekend weather is where you are that you and a friend will pry yourselves away from March Madness and appropriately celebrate the St. Patrick’s Day weekend by some renewing outdoor adventure of your choice.