22 May 2015
Dear Interested Reader,
Inside This Week's Letter
I have mentioned before that I notice obituaries. This week there were two obituaries that I thought deserved some comment. My friend and colleague, Gordon Vineyard passed away earlier this month and his obituary appeared in the Sunday Boston Globe this last week. Gordon’s life was lived with a passion that could instruct us all. The other death that caught my eye and ear was the passing of B.B. King, the great bluesman. In my mind there is a connection to be made between these two well-lived lives and a couple of books that I have been reading lately written by David Brooks and Charles Handy. Finally in an attempt at the equivalent of a complex set of moves by a diver from a high platform, I will try to bring all the pieces together into an essay that says a little bit about the future of healthcare. You be the judge. I doubt that I will get a ten from you but it is my hope that you will consider the letter worthy of your time.
As always, thank you for your attention and your valuable time. I hope you will also check out strategyhealthcare.com this week and some of you will take the time to send me your responses to the letter or the blog.
Notable Passings
I was shocked when Kathy Gardner, Chief Administrative Officer at Atrius Health, leaned over at the recent annual meeting of VNA Care Network and Hospice and asked me if I had heard that my long time colleague, Gordon Vineyard, had died the previous week. At home that night I combed through the Globe from the previous week desperately looking for his obituary. I could not find it. I was surprised because I had not seen it and these days I read the obits as closely as I read the sports pages or the op-ed page and generally find that the time spent on the obits is the better investment.
Gordon’s obituary finally did appear on May 17th and was well written but did not give the complete picture of the man I had worked with. Last week a very experienced nurse who is an “Interested Reader” who probably knew Gordon as well as I did wrote me:
Dear Gene,
I was surprised there was no mention of Gordon Vineyard in your newsletter. I was sad to learn of his passing and remember him as a skilled surgeon, teacher and mentor. Our initial work together was rough as he blasted me for even suggesting his patients could go home. Undaunted, we worked it out…
My response to her was:
Dear X,
It is great to hear from you. I did not hear of Gordon's passing until late Tuesday. I did not really have any information to work with. I could not find his obit in the Globe. These are just excuses. I think that I was just not ready to write…
It is a dilemma. On one hand it is hard to sit alone and put your feelings into words for others to read about someone that you worked with and respected. I think that is why we have wakes. At all the wakes I have attended there is great relief in sitting and talking with other people who also knew the departed. Memories are shared. Funny stories are interspersed with solemn moments of reflection about a shared loss. Kathy Gardner started the process of remembering Gordon for me because between items on the agenda we were able to share a few memories. The note above from the nurse also helped.
Last Monday I got an email from Andy Epstein, long time colleague and fellow “virtual” retiree who had just read Gordon’s obituary in the Sunday Globe. His brief note began to open up my thoughts. Our email exchange ended with a decision to get together for lunch yesterday as we do from time to time.
Shortly after we sat down and had completed the usual inquiries about recent personal events, pleasantries and updates, I asked Andy if he would spend a little time with me remembering Gordon. He agreed and then I asked him how he would describe Gordon to someone who had never met him. His immediate response was, “Gordon was really an internist who could do surgery!” We laughed because I knew exactly what he meant. He then went on to talk about Gordon’s passion for the patient and our practice. We reveled for a while enjoying our mutual memories of Gordon and the associations and events that were sparked by thoughts of him. It was a conversation that gave me the energy to begin to select a few of my own impressions and stories of Gordon to share with you because there is nothing that is more fundamental to medical education than stories and Gordon’s story is worth telling for the lessons it underlines.
Gordon is intertwined in my mind with Joe Dorsey and a few other “big brothers and sisters” who guided me in my early years of practice and organizational life. I met both Gordon and Joe for the first time at the Brigham in 1971. Joe was my first attending, even as he was the CMO of the bold faculty practice that was HCHP. Gordon was the Chief Resident in Surgery and he came around at my request with some of his underlings to see a “ward” patient who was very ill. As they approached I was steeling myself for the sort of harassment and condescension that I was conditioned by my residents to expect from surgeons. I guess they had not expected that Gordon would be seeing the patient. We visited the patient together and I was impressed with the concern and respect that he expressed for this elderly woman and with the fact that his interest in her extended beyond the operation that was being considered. After a long conversation with the patient and a thorough exam he talked with her about the risk and benefits of the proposed operation and told her that he was going to be studying the issues and would be back to see her later.
We stepped into the hall and the discussion continued. He addressed me as a professional equal when I was not and then carefully lead me through a discussion of his concerns while his team listened intently to our exchange. That exchange would be remarkable if it had happened once but it happened time and again over the next three decades as we were colleagues and shared the care of many patients. Andy and I agreed that we had shared the same Gordon and smiled together as we both confessed that we had shown Gordon the greatest respect a physician can show to a surgeon; we had each trusted him with the care of one of our own family members.
Gordon’s passion was legendary and he demanded that those who worked with him have what he called the “fire in the belly” that he felt. He was a leader who would share his time, his knowledge, and his passion with anyone who was trying to contribute. He could tolerate someone with a different point of view than he had, but showed very little patience for someone who did not seem to care. For many years he was our Chief of Surgery and he demanded the very best from our surgeons. If he saw evidence of effort and care, he would tolerate almost anything that could be improved by more effort or by accepting help; but I also know that he invited some who did not seem to care about improving to not care somewhere else.
There are two specific things that Gordon did near the end of his career that further enhanced my respect for him. The first was his decision to leave the OR. Gordon died after a fifteen-year struggle with Parkinson’s Disease but long before he had that diagnosis he sensed that his skills were not up to his own standards. He told me this when I asked why he was “hanging it up” so early. The decline of exceptional skills is a problem we see in many endeavors where dexterity and coordination are major determinants of the outcome. It is always sad to see a great athlete struggle at the end of a long and successful career. Few people do what Gordon did and make the hard choice made by a Sandy Koufax, Mariano Rivera, or Derek Jeter to retire when they are still better than the majority of players. Most make the mistake of a Mickey Mantle or Willie Mays and play until they can’t get to fly balls in center field or get there and then drop them. Gordon was determined not to drop any fly balls in surgery.
When Gordon decided to retire the timing was perfect as the resolution of a huge problem. Our group had just lost Charlie Baker as CEO and we were facing a near death experience financially without a seasoned leader to immediately take charge. We were losing thousands of patients who were fleeing Harvard Pilgrim for fear of its financial insolvency and we were grossly over staffed and dying under the weight of an overhead we could not manage. Something needed to be done. The board had a very long discussion. There were frank comments from colleagues who may have been intimidated by his passion but in the end we asked Gordon to take the job as our interim CEO as he was retiring.
He agreed and with a surgeon’s passion took on the job of right sizing our overhead. There may be different opinions now as there were then, but it has always been my opinion, and I think the weight of the evidence reveals the truth, that our practice exists today as much because of Gordon’s managerial courage and decisiveness as for any other reason. When our new CEO arrived most of the politically tough decisions had been made. Our new CEO did not have to spend his political capital making difficult decisions about what needed to go. Gordon did the heavy lifting and then he retired.
People like Gordon are rare. He could be tough as nails and as soft as down. He always smiled and he always cared. Thousands of patients benefited from his touch and thousands more have no idea that their excellent outcome was in part due to the tough lessons that Gordon taught their surgeon or the great advice he once gave their primary care physician. His was a life well lived. His judgment was always good whether he was in the operating room or the management offices. He made a difference and then he left quietly knowing, I hope, that he had done a job no one else could have done.
I also hope that no one will misunderstand my attempt to connect Gordon’s passing to the death of B. B. King, but I see similarities that are more significant than the fact that they died within a few days of each other. I learned of B.B. King’s death while I was out on a walk while listening to Terry Gross’s program “Fresh Air”. Terry’s was away and her stand-in announced that B.B. King had died the night before and that they would be replaying an interview that Terry had done with him in 1996.
At this juncture I should say that I do not own a big B.B. King collection. Honestly I have only one of his CDs and it was recorded with Eric Clapton who, like many of the music stars of the sixties and seventies, had a tremendous respect for him and his music. Sure, I know the song “The Thrill is Gone” and I could probably remember a couple more of his other songs if you prompted me. I knew that he called his guitar “Lucille” but that was probably it. At the end of the forty-minute conversation with Terry Gross I had a new and significant appreciation for the man and his remarkable story. Obituaries are useful but I learned nothing from the obituary that I had not heard from King himself in the interview as his wisdom was patiently drawn out and exposed by a great interviewer.
I was impressed with King’s commitment to his art. He was a critic of himself who knew what he could do well and was honest about what he could not do. To my surprise I learned that he could never strum chords so that it was impossible for him to ever play rhythm guitar, and therefore he focused on playing sequential notes and developed his own unique sound within the confines of his ability. He accepted his manager’s wisdom that he not try to be a crooner like Nat King Cole because that was not his gift. When he acquired a white audience it was because they came to him and not because he sought their attention. He toured continuously until his late eighties because that is what he did, that was his purpose and passion in life. He was open and unapologetic about his relationships with women and his 15 children, all of whom he supported and for whom he tried to be a good father. In the end I was impressed by his honesty and his openness. He knew who he was and what he could do and could not do and that is what reminded me of Gordon. Here were two men from worlds apart but both had a remarkably strong sense of self and what you saw was never an act or a façade. Neither seemed capable of or interested in being anything but the best they could be. There should be more people like them.
Two Good Books
I am a compulsive purchaser of books and I am frequently reading two or three, sometimes four at a time. I also tend to be on the outlook for new work by my favorite writers. Currently, my wife and I are reading David Brooks’s new book The Road to Character and I was simultaneously delighted to discover that one of my all-time favorite writers, Charles Handy the British business guru, has recently produced a new book of essays at age 83! Both of these writers are really philosophers who are concerned with the way things are evolving and with how one constructs a life of meaning and purpose in the midst of change. It occurs to me that certainly Gordon intuitively knew what these two writers spend time trying to explain to most of us who need help. There is a very balanced review of Brooks’s book from the New York Times that you might enjoy that will quickly introduce you to the book if you have not heard about it, or you can click here to hear an excellent interview with him and hear him talk about his book. The interview was recently aired on New Hampshire Public Radio. Charles Handy’s The Second Curve is positively reviewed in Management Today.
I want to lift just one quote from each book to stimulate your interest. The most quoted line from Brooks’s book is in his introduction. Being a great journalist, Brooks delivers a book’s worth of wisdom in the introduction. The quote is:
“I was born with a natural disposition toward shallowness. I now work as a pundit and columnist. I am paid to be a narcissistic blowhard, to volley my opinions, to appear more confident about them than I really am, to appear smarter than I really am, to appear better and more authoritative than I really am…I wrote this book not sure I could follow the road to character, but I wanted at least to know what the road looks like and how other people have trodden it.”
Brooks spends some time developing the concept that each of us have two personas in conflict. One that he calls Adam I is focused on creating, building and exploring in the external world. This persona is driven by logic and economics. The other persona, which he labels Adam II, encompasses a moral logic that suggests, “…success leads to the greatest failure which is pride”. He uses historical figures as examples on his journey to help himself and us understand through the examination of their lives how to manage this inner persona that succeeds by diminishing the focus on self.
Handy has always been about community and the future. In his introduction he says:
The message of the Second Curve is that to move forward in many areas of life it is sometimes necessary to change radically, to start a new course that will be different from the existing one, often requiring a whole new way of looking at familiar problems…The real problem is that the change must be initiated while the first curve is still going. That means that those who have been in charge of that first curve have to begin to think very differently about the future, or, more often, let others lead the way to the new curve. That is something that does not come easily. Why change when all is well, we ask ourselves. Change is easier to envisage when crisis looms but harder to implement with resources and time running out.
The Second Curve is not a new concept. Drucker said as much more than fifty years ago and the futurist Ian Morrison predicted Curve Two in healthcare almost twenty years ago; but the shift remains the greatest challenge facing healthcare today. The pain of the shift is the feeling or confusion that healthcare organizations have when they find that fee for service revenues are declining and they are not sure about how to proceed in a world of value-based reimbursement. Handy argues for simpler organizations that are closer to the community and where authority is distributed to where the work is done or where the value is created. Transformation turns the enterprise upside down. His recommendations align almost perfectly with a Lean culture.
In 2010 the Supreme Court in Citizens United v. The F.E.C. ruled that companies and organizations, just like individuals, have “free speech” and since “money talks” or is the energy source behind "louder" speech like negative ads in the media about candidates, organizations can use their resources to promote positions that they prefer in elections. If it is really true that enterprises are like people in their right to speak, then do they also have the same issues of character that Brooks raises about individuals? Are there Adam I and Adam II components to the “character” of organizations?
One book on my shelf, Higher Ambition: How Great Leaders Create Economic and Social Value by Michael Beers and co-authors, is a good argument that enterprises are capable of Adam I and Adam II like components of character. That concept and the concept that the cultures of organizations are influenced by the personal values and characters of their leaders and employees brings the reasoning full circle. All of the healthcare organizations that I have known have a culture or character and that character is often an expression of the character of those that lead and populate them.We have also come full circle back to Gordon Vineyard. I can give witness to the fact that the remarkable accomplishments of Harvard Community Health Plan and its legacy organizations are reflections of the character of leaders like Dr. Robert Ebert, Dr. Joseph Dorsey, and Dr. Gordon Vineyard plus many of their close colleagues. They were leaders who were anticipating and preparing for a better second curve in healthcare. Second Curve thinking persists at Atrius Health because of their legacy and is evidence of their wisdom. Their enduring wisdom and leadership are the platform from which further transformation will occur.
Walking in the Big Apple
Late last Sunday my wife and I fought the traffic into New York so that we could attend the various graduation ceremonies of our youngest son who had just completed his master’s degree in the program of Media, Culture and Communication at the Steinhardt School of New York University. It was three plus days of subway rides and urban walking. I do believe there is less obesity in New York where everyone seems young and on the move.
The first event was at Madison Square Garden’s theatre on Monday followed by a subway ride back to Washington Square and a departmental party with recognition of honors where my son won awards both for academic achievement and his remarkable thesis on the study of sound in the subway system of New York. There is a lot of politics and evidence of New York’s diverse culture in the ecosystems of sound down in the subway that is not seen in other cities like Washington,D.C. Tuesday we spent time at the 9/11 memorial and then on Wednesday we were among the tens of thousands in purple at Yankee Stadium for the graduation ceremonies followed by the crush in the subways on the long ride back to Brooklyn.
New York is exciting but it can easily exhaust an old man. It is a piece of cake to rack up 10,000 steps a day in the city that never sleeps. I am looking forward to walking this weekend in the solitude of New London where I have the road or trail to myself. I have books to read and fish to catch. Make sure that your plans for the long weekend include some exercise. Plan sometime during the weekend to pause for a moment and remember the whole point of this holiday. That pause and a moment of reflection on the millions of our citizens who over the years offered their lives for our freedom may be one stop on the road to character and a reminder of our enduring collective values.
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