The Joy of Healing
The Veritas Health Care Story
Michael F. Mascia, MD, MPH
What is it that makes a healer? For me, it was a childhood wish, to become a doctor. Why? Who knows the answer? However, the things I know, I share and I tell my story to encourage others to join Veritas Health Care and the healing professions. The needs are great and there is not enough money in this world to make it right. But, working together, Patients-Physicians and other Providers can fix it.
Call me, Dr. Mike, it seems more at ease and less formal. Born into a family of healers and raised in Port Chester, New York, recalling some of my earliest childhood memories … my childhood asthma, struggling to get a breath, house calls by Dr. Gundy, the local Pediatrician,, adrenalin injections, relief, house calls with Dad … yes, I always wanted “to be a doctor”. Sure, it is in the blood, Mom was a nurse, Dad is an MD, his father and grandfather were both chemists who ran pharmacies in Italy and in New York. But it was my early experience … the gestalt … the peace, joy, serenity and pleasure that accompanied special times of care and relief, and the house calls with Dad … if I had to put my finger on triggers, that’s where they would be found. These things were striking to me as a young child and I am certain they helped me conjure up and reach for my childhood wish. But, what does it take to turn a child’s wish into reality? I had no clue.
In addition to asthma, adrenalin, relief from shortness of breath and house calls with Dad in his 1950 Buick, flashbacks to childhood include, an occasional exceptionally high mark in elementary school (attributed to the “Virgin Mary”), attempting to play touch football and struggling with competitive swimming. Asthma interfered with the physical activities and distractions (was it ADD? :)) made academic achievement a challenge. Fast forward to the teenage years.
By the time I entered Archbishop Stepincac High School, the asthma had started to wane and the 5 foot 2 inch round boy started to participate in physical activity and grow into a young man. Mom orchestrated a devious plan to keep me off the football field and get me into lifeguarding. And, as a young life guard at a busy Rye Town Park beach, I came to know death. It was not on my watch, but during one of the busy days of Summer, a young boy was lost and … found dead after drowning. I remember praying that he would be found alive, or recovered soon enough to be resuscitated from his drowning, but it was too late. Despite CPR, he died. That critical event stuck me, reinforced my childhood dream and encouraged this high school boy life guard to push harder on accident and injury prevention as a life guard. During those life guarding years, I was able to prevent and abort several life threatening events before they became serious accidents and injuries.
Then came the challenges of high school and college. I was not a great student, but, for some reason, Biology got my attention, and that jump started my interest in academic work. Between one thing and another, Biology and science in general were of great interest to me. True life adventures got me reading in grade school, and that time turned to Philosophy and Religion, which, along with Chemistry became major areas of focus in college. And, yes, I got into college and I would do what it takes at Saint Anselm College to get into Medical School. That translated into a Biology major with minors in Chemistry, Philosophy and Religion. Grades were not the highest, but improved steadily as I worked my way through the classes. By the end of college I had clearly demonstrated the capacity to “get” the subject matter. And, What better way to help care for people than to be a Physician and Healer? But, how do I get into medical school?
As Fortune would have it, I learned to work hard on the academic front. Good grades in the Sciences, progressive improvement overall and “connections” enabled acceptance at Tulane University School of Medicine. It so happens that the man who delivered me was a graduate from and contributor to Tulane, and they had a new program that admitted a percentage of folks with “lower” college grades (my cumulative average was over 3.0) as an experiment to increase the number of folks who were more humane. Fortunately, Tulane interviewed me and I got in.
Medical School was another fruitful challenge, not because it was difficult material, but because there was so much of it. And memorizing … lots of memorizing … a dreaded task which I was not especially good at. But, I taught myself countless tricks to acquire the new languages and Nevertheless, Tulane University School of Medicine was great for me and I got through Medical School drudgery by spending spare time as a volunteer in the Charity Hospital Emergency Room (Medical Students were welcome help there) and by aligning myself with the Tulane School of Public Health and Tropical Medicine (the oldest in the country). The Department of Community Medicine was tuned in to the few students who were interested in the bigger picture and the human aspects of care and, because of our synergy (despite the lack of support from the Chief of Medicine), we were instrumental in starting the first combined MD, MPH program in the country. That gave me the opportunity to use much of my elective time in the School of Public Health, and to graduate with both MD, MPH in the Spring of 1972. Yay … basking in the glory of the graduation for a few minutes with my family … then onward and upward. Shape that dream.
You are asking about flashbacks to Tulane and New Orleans, right? OK, for now, just a couple notables that struck me at the time of our introductory meeting in the new auditorium. Soon after we stepped into the school, over 100 new and excited first year medical students were herded in there. The larger than life characters on the stage are still burned into my brain. Both physicians, the older gentleman … was encouraging … “Don’t let the bastards get you down” … that was his punch line. The middle aged woman, very professional, all decked out in her clean and neat white coat said, “Compassion without knowledge is dangerous.” Those two sets of exceedingly valuable words have rung in my brain countless times over the years. I will give proper recognition to these folks and share their names … once I dig them up.
Next … again, going against the grain, I decided to do a Family Medicine Residency at the University of Miami. Not my first choice, because it was a little soft on the “traditional” side, but U of M was the oldest Family Medicine program in the country, and Lynn Carmichael, the Chief, seemed to be fairly open minded. While I was there, I asked them to allow me to do a combined Pediatrics/Family Medicine Residency (which did not exist), but the Family Medicine Department would have none of that. However, I was able to beef up my clinical skills through clinical experience and electives. That gave me a chance to make sure I could “do what I was trained to do” after finding a place to work. And, after internship, two years as a resident, one year as chief resident … it was done. Hooray … celebrate again for a few minutes.
Now what? Find a real job! During the third year of my Family Medicine residency I was able to spend some elective time with folks who had completed the program before me. One was in Massachusetts (in the newly formed University of Massachusetts Family Medicine Program) program and one was an established practice in rural Maine. Having more interest in “doing what I was trained to do” and less in teaching it, rural Maine was a no brainer. In this setting I knew I could do virtually everything I was trained to do and I could walk to and from the nice little hospital where I would be able to deliver babies, help with surgery and take care of my sick patients. Wow, what a great opportunity … not much pay, but lots of fun work. For ten years it was mostly great, but not perfect. We were a group of three young and well trained docs, working in a small rural hospital, with dedicated nurses and a mostly grateful population. This was a very rewarding experience in itself, and I was able to teach at nearby residency programs in Portland and Augusta “on my own time”.
But, troublesome issues came up: money, disagreements with partners, partners leave, cash flow issues, “malpractice crisis”, bad outcomes (not malpractice) … mostly things which a young doc is not trained to handle, and which are disruptive to healing one’s self and patients. Most disturbing to me was the language used in accusations of malpractice … even if untrue, claims of egregious errors could be made with impunity. So, adverse outcomes that are disturbing to patients and families were trumped into FLAGRANT ERRORS in an attempt to get easy money from malpractice claims.
The “great storm” came in 1985 and showed me the “dark side” of the Medical Profession. It was a “perfect storm” against the medical profession and independent rural practitioners. Yes, in 1985, a year during which several several storms came together to crush us: they included a malpractice crisis (insurance was hard to get), Federal (Medicare) Reimbursement Changes known as DRG system (with flawed review processes), COBRA and Empowerment of Third Parties to scrutinize local care, Doctor Bashing in general and more. It was during this time, that I saw, advertising, competition, and the BUSINESS OF MEDICINE … emerging in such a way that it now became nearly impossible to “do what I was trained to do” for the sake of the patients. The worst of what I saw was this: The Doctor Run Malpractice Company made it impossible to get insurance. Why? We were competition with them. We, in our little rural hospital, had patients representing cash and they wanted our patients<>cash. So, Doctors were slicing each other up to get “business”, and not cooperating, not supporting each other … clearly a violation of the Hippocratic Oath. I was stunned by this, but not for long.
We were unprotected and the business guys LOVED THIS … they liked nothing more than Doctors fighting amongst themselves, because Doctors had previously been very powerful and they had controlled the third parties. Now, in the midst of this infighting, the third parties bought off the willing and slipped in to take the cash and hijack the Doctor-Patient Relationship. One of our good guys got sanctioned by Medicare, in what was clearly a Vendetta … later confirmed in the court hearings. As this tragedy … these tragedies … rolled out before my/our eyes, I started to look at specialty and subspecialty training as a way to protect myself from this free for all feeding frenzy in which Doctors were eating their young with impunity and with glee.
By 1989, for many reasons, I had decided to go in the direction of Anesthesiology, Critical Care and Hyperbaric medicine, as an alternative to having a limited practice in rural Maine. As a trained and experienced Scientist, Healer and Physician I was not particularly interested in being restricted to doing what “my mother could do as an RN” and an office practice. Nothing wrong with that, but as a young doc who was interested in care of the sickest of the sick, limited practice was unacceptable. So, off to my second residency in anesthesiology and fellowship in critical care “we” went.
Yes, it was a good decision to get specialty and subspecialty training in Anesthesiology, Critical Care and Hyperbaric Medicine at the University of Maryland and Shock Trauma. And yes, for a while I was able to do what I was trained to do in academic medical centers, but “the business of medicine” had also invaded tertiary care centers and medical schools. In those places, “mission ambiguity” and “mission confusion” prevail, but in some, it is now clear that “mission abandonment” is in effect. In other words, not only are they confused about their mission, but they are so preoccupied with money and the “Business of Medicine” that they have completely lost sight of their Health and Health Care Mission. During training, we were quite well protected from most of the nonsense. But we caught a glimpse of it during residency and fellowship, and it shows up clearly once inside the “faculty role” of these institutions.
Good Times …
After finishing my residency and critical care fellowship, I had the opportunity to work the front lines in Saint Lucia for one month. That was the best month of my medical career. Simply mesmerized by the climate, the island, the people, the diving, the views, and struck by the care … the simple effectiveness inherent in providing health care with and among people who care about health care; this memorable experience lives in me and has lived in all my work since then. It is amazing what can be done in primitive conditions with little equipment, volunteer docs and a group of dedicated local nurses and assorted health care workers who were paid little for the good work they did. It was done “for the love of it.”
But Anesthesia in Paradise came to an end. After finishing my Anesthesiology and Critical Care training, upon returning from this heavenly assignment with Health Volunteers Overseas, I took a position at SUNY in Syracuse, NY as Director of Critical Care Anesthesiology. While there, we were able to set up and run a critical care division and fellowship, and quite a bit was accomplished. But, money started to creep into, then dominate the picture and there were some who wanted to “cut corners” on quality for the sake of money. In the end, I was asked (not directly) to compromise my values, quality and integrity at the cost of patient care, teaching and research. I refused to do so. At a certain point, it became apparent that I had to “fire my boss”, since the administration was not particularly sympathetic to my concerns and they had no intentions of fixing this/these problem(s). And, to find another job … not the first and not the last time I had to take such actions for the sake of my integrity and desire/need to provide the best patient care.
But, before I leave the SUNY story, it is important to point out that it was not all bad there. During that time we provided good care, excellent teaching and made substantial administrative progress. I was able to work with a group of dedicated and smart health care professionals: Doctors, Nurses, Pharmacists and Hospital Administrators. This group of front line care givers and one wise hospital administrator enabled a remarkably robust fix to optimize analgesia, sedation and neuromuscular blocker use in critically ill patients. The end result was a well used and valuable paper published in Critical Care Medicine: (Mascia MF, Koch M, Medicis JJ: Pharmacoeconomic impact of rational use guidelines on the provision of analgesia, sedation, and neuromuscular blockade in critical care. Crit Care Med; 2000 Jul;28(7):2300-6)
While working my way out of SUNY, I was exploring options back at Tulane. I thought it would be fun to go back to New Orleans and to give “something back to Tulane”. After all, Tulane did give me a great medical education and I did feel a certain fondness for the place for many reasons. And, why not go back to New Orleans? I had no excuses when the Chief of Anesthesiology asked me that question. So, I went back to Tulane to start up another Critical Care Division and Fellowship.
Wow … talk about bait and switch … making promises that can’t be kept … and that sort of thing. I do recall waking up one morning and looking at myself in the mirror … and saying, “What have you done?” It does not matter now … that was then, and this is now, but, despite the challenges, I learned, gave good care and made things better. This is the abbreviated version of what happened at Tulane. We (a dedicated core of anesthesiologists) slowly recruited a solid group of new Anesthesiologists and constructed/reconstructed a very fine Anesthesiology Department and Critical Care division. Our goals, objectives and targets included quality patient care, teaching, research, administration. Part of that included construction of a robust Scientific, Comprehensive, Continuous QIPI System. This Process and Outcome based Quality and Performance Improvement System was designed to protect patients and doctors and to train people up to meet the needs. We did what we set out to do. By the Spring of 2005 we had produced some QIPI (Quality and Performance Improvement) research, which was presented at a national meeting. By Summer, we (the Anesthesiology Department and Critical Care Division at Tulane) were on a steady upward course. Then came KATRINA. So much for the power of humans … Katrina literally blew it all away in just a few hours.
Yes, I was there, before, during and after Katrina. And, I returned to help put things back together at Tulane starting within about 6 weeks of Her exit. But She and her aftermath; the winds, rains, flood and damage of Katrina … the death and destruction … created some twisted minds as well. The damage was severe enough that I thought physical repairs alone would take at least ten years. Add to that the psychological damage, hand wringing, woe is me, theft, lack of support, lies, swindling, crime, drug dealing, thugs, lack of population, bad leadership and other political-social nonsensical excuses for bad behavior in New Orleans and of course Post Traumatic Stress. What I called “Post Katrina Madness” was rampant. We all felt it and we were all struck by it. This made things in New Orleans nearly impossible in the Wake of Katrina.
Nevertheless, I was again fortunate and, because my circumstances allowed it, was able to return to help put things back together at Tulane. Yes, we put the Anesthesiology department back together; first at Lakeside Hospital (for clinical purposes). At the start, we worked “blocks” and stayed at the hospital, because most of us had no usable housing. It was an adventure, if your life was otherwise intact. Once reconstruction of the downtown hospital (Tulane University Hospital) was accomplished, we moved back there and were soon able to resume the academic, research, administrative and critical care mission in addition to the clinical enterprise. It was, however, soon evident that the leadership void at the medical school enabled a few twisted minds to carry out suboptimal plans and things started to crumble. I left in the Spring of 2007, soon after bizarre contracts started to appear. I could not in good conscience sign mine for many reasons.
But despite all the madness, it was in New Orleans that the seeds for Veritas Health Care started to germinate. Why? Because this is where I first saw people in the hospital treated like hamburgers on an assembly line … “keep it moving” without regard to personalized needs and personalized care. But, I was wrong, it was not the McDonald’s business model that was being used, it was the Kentucky Fried Chicken model. Tulane was an HCA hospital and I later found out that HCA’s co-founder was the business guy from Kentucky Fried Chicken. Then, it became obvious that the Corporate For Profit Model for the “Business of Medicine” was incompatible with Quality Health Care, because profits go to Executives, Managers, Shareholders and other third parties who don’t have the capacity to care about health care, patients or outcome. Despite this obscenity, our QIPI program was able to protect Patients and Physicians, and to move things in the direction that allowed us to provide the best possible care to patients and protect the Docs when they stood up for patients. Yes, that’s right, we needed to protect the Physicians in our department from attack by .. let us say … others in the institution.
My first efforts to plant the seeds for better health care outside the “Business of Medicine” involved a single business guy … the husband of one of our PACU nurses. Seemed like a good idea at the time to work with a private business guy. We set up Nova Health Works in New Orleans about 10 years ago, but this private, for profit business did not work, because I frustrated the hell out of my partner with my time constraints and business ignorance. Soon thereafter, I started talking and meeting with a group of Good Docs I worked with at Tulane. We all saw the problems and we planned to start another for profit medical group, which we thought could help us set things right. This was Nova Healthcare Associates and it too was blown away by Katrina … but not completely. Chuck Fox and Trey Wyche were members of this group and they were not forgotten.
And I went on my merry way … back to Maine … to recover from this New Orleans and Katrina. And, while searching for another Academic Anesthesiology Critical Care job, I worked with Weatherby Locum. I met their young recruiter at a meeting and we had a bit of kinship. He helped me get locum critical care work in two upstate New York hospitals. This was fun and different, because they were both private. One of them was actually quite appealing and, at the start, I thought it might be a long term destination. But, for many reasons, that did not happen. Then along came West Virginia University Department of Anesthesiology … another place looking to reconstruct their department and create a critical care division … my kind of challenge. And, they needed me. So, again, since I had no excuse, after several months of credentialing (It is amazing how long it takes to get credentialed if you have experience. Most places would rather take new grads, because they are less expensive and they have no records. It is simply easier and cheaper. But, you get what you pay for.) I took the job: Director of Critical Care Anesthesiology and co director of the Surgical Intensive Care Service. Sure, when I first went there, it was all good, because they needed me desperately to cover the unit and to fix their residency … which I was glad to do. But, the winds change fast … and the guy who recruited me was taken out of the Chair position, and replaced by someone who … let me be kind … had no appreciation for the work I was doing. So, again … searching … for a place where I could put my knowledge and skill to work for the benefit of the patients and the institution, I stumbled upon Geisinger. The newly appointed Director of Critical Care, whom I had known from the University of Florida, put out an APB asking for help. And, so it was, in July, 2012, I started working at Geisinger in the eICU, while still on the faculty at WVU in Morgantown and working with Medical Students from afar.
But, in the back of my mind … while searching for places that are true to the mission of providing quality health care … the unmet needs and the madness of these tertiary care centers was constantly disturbing and prodding me to set up an alternative to “the business of medicine”. I took a chance with Geisinger, because they have a reputation for being a good place for patients and during interviews, they seem to be true to their word and on Mission for the patients. I am still testing those waters, but the prodding in the back of my mind would not stop. Everyone, professional and patient alike with whom I spoke was disgusted with the “business of medicine” and we needed to create an alternative.
I talked with David, who had been working with me on my private consulting/products/services business (Infinity Health Solutions) for a few years as my webmaster. He, started his own tech business, while still in school and both of us thought it would be right to start a non-profit health care business. I was enchanted with the idea of starting a Non Profit Health Care Cooperative and we decided it would be done before the end of 2012.
A few things happened in the Spring of 2012 to encourage me. One, I met a “Guardian Angel”, who set me up with a conference … where, two, I met Irv Rubin, PhD. We were able to “talk” during our teleconference and he has been a great inspiration. I shared this information with my Dad who wanted to help get this thing going. One thing led to another and Nova Health Care Cooperative was born in our minds. Legal help, honed things down, and I soon learned after meeting with Tom VanMeer and Betts Gorski, that Non Profit and Cooperative are mutually exclusive. So, we went in the direction of Nova Health Care … a Non Profit. Betts also pointed me to Don McCormick and his work, so I contacted him at that time. He generously offered to help us. In the middle of the legal talks, I recruited Chuck Fox, Trey Wyche, Terry Hobbs and Henry Banks, to create a solid Board of Directors and we were set to go. But … oops … Nova is already taken. And that is how Veritas Health Care was born … in Maine … in February of 2013. So, folks, we are one month behind schedule.
And … I told Don what we were up to and he offered to join us as a “Founding Member” and he told us about his son Tony and his two daughters potential offerings. Don and Tony are now “Founding Members”, along with Irv Rubin, and I am waiting to hear from Don’s Daughters.
There is not enough money in the world to make health care right. It is all about Love. And, that’s my story and I am stickin’ to it.
Michael F. Mascia, MD, MPH
To be continued …