23 February 2018
Dear Interested Readers,
Ten Years On and Other ThoughtsThe first of these Friday letters was mailed to my colleagues at Harvard Vanguard Medical Associates on February 22, 2008. It seems like only yesterday. If 2008 seems like yesterday then 2028 must be tomorrow. There has been a new letter on every Friday since the first letter except for the first first three Fridays in November 2013. I see no end in site.
The letter has been a mechanism of discovery and growth for me. Through my preparation to write each week I have enjoyed an expanding appreciation of all of you who work everyday to make healthcare a better experience for patients. My understanding of history, evolving events, the political controversies, and the psychological, economical, and sociological issues of our day has been expanded by the study required to write. What began as an attempt to improve communications and participation within a group practice has become a process of personal education, growth, and evolution of ideas and understanding. I am positively addicted to the process, and am indebted to you, the readers, for the feedback that you give me and the encouragement to continue.
This week I reread that first letter. In many ways we have come a long way in our understanding of what works and what seemed like a good idea but doesn’t deliver. Through all that we have learned over the last decade, the recurrent core principle that keeps coming through is that it is most important to always put the patient at the center of everything we do and think. The primacy of the patient at the core of what we do is the constant upon which all other ideas and considerations rest and have their meaning. Some words near the end of that initial letter captures most of what was true then and remains true now for the larger community of healthcare. The central idea of the Triple Aim, the foundation upon which it rests has always been: “...to achieve something truly remarkable for our patients.”
We possess within our staff more than enough energy, passion and expertise to achieve something truly remarkable for our patients. Don’t limit your dreams and don’t stop demanding what our patients need. As the weeks go by I will try to use this weekly communication to help coordinate our efforts, improve the flow of information through our organization and share your questions about the details of our vision. As the conversation progresses, I hope that all of us will be able to contribute to the vision in such a fashion to have a rich image of our common goal. I hope to facilitate discussions that make you say, “I’m a part of something that is really great”. The truth is, we are pretty good now but I didn’t hear anyone say that they thought we were yet what we could be. I hope you will find great joy and enthusiasm for what you do over the next several months. I am anticipating that I will be having the time of my life. It is strange to read what I was thinking now ten years in the past. I have the feeling that what I am reading was written by someone I once knew. There have been interim events, experiences, much evolution of thought, and many formative experiences and yet the core purposes and the challenge to do the best that we can for the people who look to us for care has never changed over two or more millenia, much less ten brief years.
When I was a child I was amazed that my father could write a new sermon each week. When I looked at the Bible there seemed to be a limited number of stories and lessons. It seemed logical to me that preaching forty five or fifty times a year he would soon run out of material. It was true that he revisited many passages over the course of more than sixty years, but each message was unique and fresh. I realize that these letters have long gone past redundant, but I am now certain that I will never run out of fresh things to say about healthcare and the honor of caring for patients. The events of our times force us to reconsider the deep and abiding truths of old principles and the universal challenges of the human condition that are coupled with an ever expanding understanding of science and the nature of mankind. I am certain that the responsibility to aid our fellow travelers on life’s journey will never change, but the circumstances against which we must continuously strive to fulfill that mission are always changing.
Over the last ten years my role has changed dramatically. Ten years ago I was seeing patients in the office and in the hospital every day and investing sixty to eighty hours a week considering the circumstances and issues of one patient at a time. When I assumed a manager’s role I gave up most of my direct care responsibilities and had to learn how to achieve the professional satisfactions of patient care vicariously through supporting the work of others who directly provided care. It was my job then to seek to work with others in the careful creation of expanding opportunities for care improvement and the management of the materials, sites and personnel necessary for quality care. When both my direct care and management days were over I stepped back further to the role of observer, commentator, analyst, and occasional advisor. In this last role there is no direct control. My sense of mission and professional satisfaction is now totally dependent upon you. I am no longer at the bedside myself. I no longer can contribute “materially” to your success by participating in a managerial decision. My contribution can only be through words offered in these letters, in board meetings, and in opportunities to help others sort through the challenges of their day. Without your eyes, ears, hearts, and hands I am locked in to a pointless task of reassessing past moments with no opportunity to apply any learning from those lessons to today’s work or tomorrow’s challenges. I am vulnerable to you and your continued interest, and that is exactly where I want to be!
This week’s letter comes at a very strange time. Our leaders in Washington have never seemed more “dazed and confused.” The surviving children of the most recent school shooting seem to be more focused and mature than most of the elected leaders who have a Constitutional responsibility to look past personal concerns and to attend to the business of the nation. With each passing day some of us are amazed beyond flabbergasted misbelief by the revelations of past behaviors that would make most of us blush and by daily utterances, many of which are lies that even a small child could detect, that come from the holder of what is assumed to be the highest leadership position in our government. There are increasing concerns about the validity of past elections and fears for fairness in coming elections that go past mundane concerns about gerrymandering and the legislative attempts in some states to deny the vote to minorities, yet our president is focused on denying the vague concept of “collusion.” It is an understatement that Constitutional principles seem vulnerable, and it is not a big step from where things stand to what could be a quick step into the abyss of authoritarian behavior from the executive branch as we watch many of the societal gains of the past four or five decades become vulnerable to self serving policies that favor an already wealthy elite.
It is fine with me if you disagree with the dark picture of possibilities that I paint. When I was a practicing physician I always tried to imagine the biggest threat to the health of my patient. If there was a plan to manage the worst outcome then everything else fell into place. The greatest clinical problems arose from a lack of awareness of what was perhaps unlikely, but still within the realm of possibility. Less than 18 months ago knowledgeable people (at
538) put the likelihood of a Trump victory at less than 12%, yet it happened. Against that background we need to consider issues like the future of Medicare and Medicaid as threatened. The piece below begins with a facetious tone but then tries to look through the larger lens of what creates poverty and inequality at what might threaten the future of healthcare. I fear I have bitten off too much. Perhaps to say there may be more uncertainty to our future than is comfortable to admit is more than enough.
What concerns me most is that rather than doing things to protect the future of what we have accomplished, we may be acting in self serving ways that will add to the possibility of an outcome that would be bad for us all, and especially our most vulnerable patients. I offer no solutions. Just a warning and a reminder that it is only you working with others who are concerned, that can make a difference.
The Many Gifts The President Gives UsThe foundational fairy tale that Michael Wolff tells us in his bestseller,
Fire and Fury: Inside The Trump White House, is that the president and none of his campaign staff, except Steve Bannon, ever thought he would win. He paints a picture of depression, terror, tears and fears as the results became clear on the night of the election back in November 2016. Those adjectives were a description of the winner, not the loser. Apparently Trump’s plan had been to use the campaign as a brand enhancing promotion and as a springboard to greater fame and financial success as he harassed Hillary Clinton during her term in office, much as he had carried on in the early Obama years with “birtherism.”
It seems far fetched but plausible considering he had never held public office and was surrounded by inexperienced people who were a rag tag coalition of those “who had never been,” family members with less than impressive business experience, and his own up and down business career notable for bankruptcies and lawsuits. His reality show and his cultivation of fringe media events and appearances had made him one of those in our culture who qualifies as famous for being famous.
Said simply, when the dust settled we have an administration that depended on retired generals, second tier financial types, a few billionaires, family members, and one bizarre conspiracy theorist supporting someone who was ill prepared and yet had a personality that made him constantly promote his every act of daily living with a sixth grade list of superlative adjectives. He had a big learning curve ahead of him, and it was not possible for him to say, “I was just fooling!”
Considering where he started and where everyone else started with him, we have all been on a steep learning curve beginning with disbelief. I would argue that he has partially learned some lessons and his handlers have learned even more, although they are still forced to greet each day with a list of issues to deny, positions and tweeted policy decisions that must be reshaped or denied, and endless explanations. They have exhausted Roget’s Thesaurus of all of the alternative ways to describe a lie other than to call a lie a lie. Almost every member of the staff that has any public recognition has endured personal humiliation.
That said, I want to credit the president for what he has done. He has made us all much more aware of what is and is not in the Constitution. Did you know about the 25th Amendment before January 2017? How many of us even knew the steps to passing a bill in Congress? How informed were you before last spring about passing laws through the “Reconciliation” process to avoid the 60% supermajority hurdle necessary to avoid the downside of the “cloture rule, Rule 22, in the Senate? The list goes on and on of things most of us should have learned in a high school civics class, but did not, or did, and forgot.
I spent years trying to explain the ACA to friends and relatives with no success. Donald Trump pulled it off in a flash with a little help from Paul Ryan and Mitch McConnell. What was the deal with CHIP? Did you ever really care much about the ins and outs of the Paris Climate Accords before Donald Trump? Immigration has always been so complicated that unless you yourself were an immigrant why would you care? Before Trump I had no idea that the Vermont Cheddar and the occasional pint of Cherry Garcia that I buy from Ben and Jerry’s would be impossible to produce without the one thousand or so illegal Mexican farm workers in Vermont!
It’s been a crash course for President Trump and all of us. It’s a little bit like childhood when we enjoyed taking things apart to see what made them work. What is childhood at its best other than a continuous cycle of challenges, frustrations, failures and ultimate mastery? Learning to walk may be one of our first successful applications of the PDSA cycle. Everything in childhood is a cycle of goal setting, attempting the task, failing, learning and finally achieving. In the process of growing up we gain great skills, and we also learn how to accept the reality that there are some skills that we will never acquire and can only enjoy watching others perform. I am reminded of this every time I turn on the Winter Olympics and see some snowboarder doing twists and turns high in the air before coming down to earth in a perfect landing. What the president is learning is a bit like a child learning how to walk, albeit his job description requires something more like freestyle skiing than walking. We all have an investment in his learning process, but more importantly we have been forced to have our own learning process as he has presented us with one challenge after another to try to master in our attempt to preserve many of the accomplishments we have made at home and abroad over the last couple of centuries or the last seven or eight decades.
It is reassuring to observe the president in his struggle to learn how to overcome his addiction to Tweeting, or to see him attempt to “stick” the landing and sound sincere in an address to Congress, or pull off an expression of condolence and hope in the aftermath of a national tragedy. In my frailties and failures I feel like I have a fellow traveler in Mr. Trump. President Obama’s sincerity and clarity were inspiring. When I heard him speak I was impressed, but I knew that I was observing someone with a special skill. I felt like I feel when I see those snowboarders and ice skaters stick their jumps. Obama’s performance of his public duties, like the performance of a great Olympian, was just a reminder of how inadequate my own skills were which allows me to be empathetic to the struggles that President Trump has trying to communicate like an understanding and empathetic leader. In his inability to enlighten or inspire us he reminds us that we just sat back and let Obama do the work that we all should have taken more seriously.
Like many Americans who have been awakened by the aches and pains that are inevitable later in life, I am on a renewed course of self improvement. I exercise hard to delay the day when I need a walker. I am trying to stave off dementia by attempting a second language, reading lots of books, and trying to practice piano and guitar. Despite the many efforts I feel the inevitable slip and sliding away of some diminishing number of remaining cycles around the four seasons of a year. I feel so much better about my lackluster efforts and rare successes when I see an infamous negator of the necessity for self improvement giving me a daily reminder of why I should not give up the struggle.
We are continuously looking around to compare ourselves to others, trying to see where we are in the standings. It is easy to see that we are rarely on top. What is sometimes harder to judge is how far from the bottom we might be. Back when I was running marathons and ten k’s I never expected to win. I was running against myself and the people behind me. I had the dual hope of doing my best time, a “PR”, and not being last. In a big event like the Boston Marathon I could see miles of densely packed runners ahead of me, but I never knew for sure how close to the “back of the pack” I was. It was the footsteps behind me that kept me going. The individual that “defines” the bottom actually provides us all with a very useful service. Such was the utility of the loveable town drunk. That is also why it is so reassuring to hear that the local fire and brimstone minister has been caught in an affair of the heart. It is the great gift that our president gives us every day.
When I look in the mirror every morning I know that I have not always been truthful. I know that I have failed in my roles as a father, son and husband. I have sometimes chosen the expedient over the enduring path. I have forced others to my will and ignored their concerns. I have been impressed by my feeble transient accomplishments, and blind to my enduring failures and the irreversible impact that my mistakes have in the lives of others. There is much for me to want to hide and forget. Trump’s greatest gift to us all as we flagelate ourselves for our failures is that he seems not to be aware of his shortcoming and continuously denies them to us. That is a fabulous gift to us all because so many can reassure themselves that although they can’t fly through the air, do flips on a snowboard, glide across the ice in perfect harmony with beautiful music, or speak with the eloquence and wisdom of an Obama, they are running well ahead of the forty fifth president in personal awareness, personal honesty, fundamental integrity, respect for the rights and feeling of others, and personal humility and generosity of spirit for those whose challenges are different and are not blessed with their own experience and gifts. Ironically he has shown us an easy formula to employ in our desire to make America a continuing benefit to all humankind and the planet, and that is to watch what he is doing and decide to do exactly the opposite thing. Rarely in history has the best way forward been so clearly demonstrated by a leader who knows without knowing how to lead from behind in such a transformative way.
My words may sound like a factitious analysis that is mostly a complaint, but I do believe that the president has given us all a gift when his words, personal behavior, and political actions leave us no other option than to set aside petty differences, focus on the bigger issues that threaten us all, and work with renewed zeal to become a more perfect union.
Several years ago I bought a book,
Why Nations Fail: The Origins of Power, Prosperity, and Poverty by Daron Acemoglu, an MIT economist, and James Robinson a Harvard political scientist, because of interesting reviews. I started it with enthusiasm and was enthralled by their concepts of the economics of “extraction” and “inclusiveness.” Despite my enthusiasm for their ideas something happened and after reading just a few pages something displaced it from the center of my attention and it sat unread in my Kindle for five years until recently when I decided that it might fit nicely with other books that I was reading on inequality and the relative fragility of democracies.
I can’t remember whether it was an interview that I heard on NPR or a review that I read shortly after it came out that interested me enough to cause me to buy the book.
Tom Friedman’s column in the New York Times may have brought the book to my attention. A Friedman column from early 2012, when the book came out, reads like it was written today and underlines the current value of the book. In a quote from Friedman that quotes the book we read:
“Inclusive economic institutions that enforce property rights, create a level playing field, and encourage investments in new technologies and skills are more conducive to economic growth than extractive economic institutions that are structured to extract resources from the many by the few,” they write.
“Inclusive economic institutions, are in turn supported by, and support, inclusive political institutions,” which “distribute political power widely in a pluralistic manner and are able to achieve some amount of political centralization so as to establish law and order, the foundations of secure property rights, and an inclusive market economy.” Conversely, extractive political institutions that concentrate power in the hands of a few reinforce extractive economic institutions to hold power.
The book is an impressive tour of world history, economics, psychology, and political science with a little bit of earth sciences and archaeology thrown in to validate how recurrent the patterns of oscillation are in the history of man between inclusive and extractive economic and political institutions. We are always flirting with the short term benefits and conveniences of absolutism and authoritarian political structures that favor a few and allow them to extract benefit from the efforts of others.
There are really a limited number of options that can occur in the dynamics of our societal relationships. Societies have two basic components, economic institutions and political institutions. Both have the option of being extractive or inclusive. “Critical Junctures” in history or in the experience of a nation have a profound effect on future wealth and poverty. At times the social context or contingencies send a nation toward economic decline and widespread poverty. Empires want to maintain the status quo and their leaders deny the future because of the threats progress brings to their control.
Sometimes disease like the plague have lead to radical changes that may favor inclusion as workers gain a better bargaining position because of labor shortages. Big events like the discovery of the New World are critical junctures that can establish either inclusive economies like the United States and Canada or the extractive economies that historically plagued South America. An extractive path is favored by the sudden discovery of gold and silver. An alternative path of inclusive institutions is favored by the delayed wealth of working the land, as was the case for North America.
The fall of the Roman Empire, the bubonic plague, or the failed Spanish Armada can push either the economic or political system to move to be either more inclusive and expansive or more extractive and in favor of a rigid status quo and eventual failure. Sometimes, as in the case of the Soviet Union, extractive political and economic systems can be initially very successful but “run out of gas” because they do not allow “creative destruction” or innovation and suppress individual initiative.
Inclusive governments establish property rights, the rule of law, and broad opportunity. They shun monopolies and special relationships that allow elites to extract wealth from the labor of others. Opportunity depends on the acceptance of the role of “creative destruction” of the status quo in favor of the progress offered by invention and innovation. Extractive environments allow the elite to protect their investments in the current environment by resisting “creative destruction” and innovation. To quote Friedman quoting the authors again:
“Sustained economic growth requires innovation,” the authors write, “and innovation cannot be decoupled from creative destruction, which replaces the old with the new in the economic realm and also destabilizes established power relations in politics.” The book came out in 2012 so it was written long before the current administration was even a well formed bad idea in the mind of anyone other than Trump and his friend, the disgraced political operative and Nixon defender, Roger Stone, along with a few other even less known and less respected operatives. Despite the fact that five years is like a millenium in the political world, the book’s message is applicable now because history shows that the basic formulas for human behavior and interaction tend to be stable. It’s just “the contingencies” and “critical junctures that change, and those changes can be relatively unnoticed or even appear beneficial or logical in the moment.
Societies frequently “decay” from inclusive to extractive both politically and economically. They can also move from extractive to inclusive, but that often involves revolution or natural disaster. There is always some natural decay in either state and both have a need for commitment and require continuous infusions of energy. Things move either as an expression of oppressive force to create or reinforce an advantage for an elite few, or as widespread participation in efforts for inclusion.
Inclusion favors technical and scientific breakthroughs. There are “virtual cycles” of inclusion that support the emergence of inclusive systems that more widely distribute opportunity and benefit. There are also “vicious cycles” of deterioration that undermine inclusive systems and move the institutions of government and economics in favor of smaller and smaller groups of elites. Centralized systems are important for both. Inequality and poverty are the products of extractive systems. A broader distribution of opportunity and more generalized prosperity with less variation in wealth is the usual outcome of more inclusive systems.
Our nation has always been relatively inclusive for white, male landowners. Others, all the minorities, have experienced an extractive environment. The president’s policies feel extractive even as he promises that they will improve things for everyone. History argues that if that were to happen it would be short lived at best. What seems possible is that globalization, automation, and increasing economic inequality may be part of a developing vicious cycle moving us toward more and more extractive economic institutions supported by extractive political forces.
How does the future of healthcare and the Triple Aim fit into this larger drama? I feel that healthcare has become extractive in the way that it has been able to demand what it wants and generally get it. There is a status quo within healthcare that resists change for fear of losing what it has. We all talk about innovation, but we do not easily accept the “creative destruction” of what is not inclusive in favor of ideas and new processes that could form a new foundation for broader access and improved health for all which is the healthcare equivalent of “prosperity.” “Extractive” political systems would not advocate for supporting programs that expand access to care through programs like the financially supported exchanges of the ACA, Medicaid, Medicare, CHIP and federal support for Federally Qualified Health Centers.
The picture of American medicine that Elisabeth Rosenthal painted in
An American Sickness: How Healthcare Became Big Business and How You Can Take It Back is a description of a system that has developed its extractive capabilities. Don Berwick’s Era 3 is a vision of an inclusive system of care. What Ziblatt and Levitsky warn us of in
How Democracies Die is complacency in the face of authoritarian tendencies. The checks and balances of our democracy are fundamental to our as yet imperfect inclusive political system and the preservation of the essentially inclusive economic institutions that support our prosperity, but even as they are essential they are also inadequate by themselves to preserve an open process.
Democracy depends upon participation and a higher degree of loyalty to its preservation than to short term individual and party objectives that are extractive. The future of better healthcare and the vision of the Triple Aim are dependent upon an inclusive political environment and inclusive economic institutions. Just as the president’s attempts to undermine the ACA led more Americans to a deeper understanding of what is at risk, will it be true that extractive laws like the recently passed tax “reform bill” will wake up a critical number of voters who will vote to defend an inclusive society and reject the politicians who support extractive policies and seem not to object to the chaotic economic, trade, and foreign policy pronouncements from the president’s twitter feed that startle us on an almost daily basis?
For the Triple Aim to have a chance we need a president who embraces principles of inclusion and clearly rejects extractive practices. How will we ever obtain control over healthcare costs if we allow extractive and monopolistic business practices in healthcare and do not embrace the “creative destruction” that will replace the current finance system and operating processes that make up our failing system of care? The key is to accept the lessons and insights that the president’s policies and behavior are screaming for us to learn before their momentum creates a vicious cycle of deterioration as we revert to an extractive society focused on only self interest with increasing inequality that brings our brief experiment in democracy to an end. By historical standards our “greatness” is still a very short story.
Weird Winter WeatherI like winter. I do not like intermittent winter. Last weekend was sort of winter lite with about five inches of snow but then it was interrupted by rain followed by temps in the 70s! I find it hard to accept that during the President’s Day school week holiday temps have been adequate for Opening Day which is still over six weeks away?
The warmth created a fog over my frozen lake that was ethereal in the early morning sunlight. I did not get a good picture of the fog that would show its beauty, but I love winter scenes like the one in this week’s header. The picture was taken by one of my sons and I love how it shows bare branches against a cold late afternoon sky.
On Wednesday I drove west across Vermont through more eerie fog and over the mountains passing by the Bromley Ski resort. It was 72 at 10 in the morning and I saw people in shorts! I was traveling to attend a board retreat and meeting in Corning, New York. As I turned off the thruway west of Albany and began the beautiful drive down I 88 toward Cooperstown and Binghamton, the temp on my dash hit 75.
I was hoping that I would be driving into winter, and I guess I was. When I arrived in Corning around four on Wednesday afternoon the temp was down to 50, and I was rewarded on Thursday with the return of snow. I like predictability and order in everything, including my weather. February is still winter. It does not need to snow to meet my expectations, but I want consistency and predictability. If it’s going to be seventy five in February, what’s to prevent it from being 30 in April? Perhaps there is some sort of metaphor in our weather experience. We are vulnerable to what is, and not what we wish. I always wish for certainty, yet I live in chaotic times when even the winter refuses to conform to norms.
In times like these we long for control. There are few things that I can consistently control. I try to control my access to exercise in any weather. I offer that idea to you. I hope that this weekend you will be out and about with your exercise.
