By John Ballard
Here are three or four readings for anyone tracking the Overton Window of Healthcare Reform as it shifts a few more degrees. As I've said before, watching a paradigm shift in healthcare is like watching a tree grow. You know it's happening but it's not as exciting as a race or video game.
[If you don't already know who Atul Gawande it you have more homework to do, starting with another New Yorker article published as PPACA was making its painful journey through the sausage grinder called Congress. Here are a couple more links to catch up.]
?Last week he spoke to a graduating class of doctors at Harvard Medical School, shining a spotlight on how drastically the practice of medicine has changed in our lifetime.
The core structure of medicine�how health care is organized and practiced�emerged in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves. One needed only an ethic of hard work, a prescription pad, a secretary, and a hospital willing to serve as one�s workshop, loaning a bed and nurses for a patient�s convalescence, maybe an operating room with a few basic tools. We were craftsmen. We could set the fracture, spin the blood, plate the cultures, administer the antiserum. The nature of the knowledge lent itself to prizing autonomy, independence, and self-sufficiency among our highest values, and to designing medicine accordingly. But you can�t hold all the information in your head any longer, and you can�t master all the skills. No one person can work up a patient�s back pain, run the immunoassay, do the physical therapy, protocol the MRI, and direct the treatment of the unexpected cancer found growing in the spine. I don�t even know what it means to �protocol� the MRI.
Before Elias Zerhouni became director of the National Institutes of Health, he was a senior hospital leader at Johns Hopkins, and he calculated how many clinical staff were involved in the care of their typical hospital patient�how many doctors, nurses, and so on. In 1970, he found, it was 2.5 full-time equivalents. By the end of the nineteen-nineties, it was more than fifteen. The number must be even larger today. Everyone has just a piece of patient care. We�re all specialists now�even primary-care doctors. A structure that prioritizes the independence of all those specialists will have enormous difficulty achieving great care.
We don�t have to look far for evidence. Two million patients pick up infections in American hospitals, most because someone didn�t follow basic antiseptic precautions. Forty per cent of coronary-disease patients and sixty per cent of asthma patients receive incomplete or inappropriate care. And half of major surgical complications are avoidable with existing knowledge. It�s like no one�s in charge�because no one is. The public�s experience is that we have amazing clinicians and technologies but little consistent sense that they come together to provide an actual system of care, from start to finish, for people. We train, hire, and pay doctors to be cowboys. But it�s pit crews people need.
Read the whole piece (It's not all that long) to understand why it might rub a few professional feathers the wrong way.
?In this case a short post at Buckeye Surgeon illustrates the point.
His essential message is this: Healthcare is far too complex for any one doctor anymore. So gear up to be an interchangeable part, a faceless drone who performs menial tasks according to checklists and algorithms that Really Smart People will provide for you. Don't be a Cowboy (in the romanticized, individualistic sense of a bygone era) unless you want to be like a real live lower-case "c" cowboy in Wyoming who functions as part of a team and follows protocols (Dr Gawande talked to one himself, it's true!). All that debt you've taken on to be a physician? It's so you can be an anonymous member of an integrated Team. Like a Pit Crew. Who doesn't get jacked up to join a pit crew? I sure do!!!
Brief and to the point, and with a few supportive comments appended.
Not what anyone would call an enthusiastic endorsement of Gawande's message.
?Comes now Maggie Mahar with her customary economy of words.
In under three and a half thousand of them she underscores and endorses the importance of Gawande's message and fires back at Buckeye Surgeon at the same time.
Do Patients Really Need Fifteen Physicians?
Still, many hospital patients wonder: �Why are so many doctors involved in my case? Isn�t that part of the problem--too many cooks, not enough communication? Why can�t just one doctor take care of me? What happened to the idea of �my doctor?�
Yes, sometimes too many specialists are called in unnecessarily, and this can be a sign that a hospital is inefficient, �fishing� for a diagnosis, casting a wide net by running a dozen tests or more, rather than taking a careful patient history, actually listening to the patient, and narrowing down the possibilities before ordering the tests.
But the days of �my doctor,� the hero who I can count on to know everything are gone. The truth is that, given the complexity of 21st century medicine, a very sick patient may well need those fifteen pairs of hands, not to mention fifteen minds. As Gawande points out, no one health care worker can do everything; no one doctor knows enough to provide the best care. Physicians need to listen to each other, nurses and other health care specialists, respecting each others� knowledge.
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Humility, a belief in teamwork, understanding that following evidence-based guidelines is essential. . . �These values are the opposite of autonomy, independency, self-sufficiency,� Gawande acknowledges. �Many doctors fear the future will end daring, creativity, and the joys of thinking that medicine has had. But nothing says teams cannot be daring or creative or that your work with others will not require hard thinking and wise judgment. Success under conditions of complexity still demands these qualities.�
He ends by congratulating his audience: �You are the generation on the precipice of a transformation medicine has no choice but to undergo, the riders in the front car of the roller coaster clack-clack-clacking its way up to the drop. The revolution that remade how other fields handle complexity is coming to health care, and I think you sense it . . . Two years ago, the Institute for Healthcare Improvement started its Open School, offering free online courses in systems skills such as outcome measurement, quality improvement, implementation, and leadership. They hoped a few hundred medical students would enroll. Forty-five thousand did. You�ve recognized faster than any of us that the way we train, practice, and innovate has to change. . .�
She goes on to describe a possible disconnect between medical specialists and journalists with a view of informing the former that the latter are simply doing their jobs and doing it well, I might add. Check out her Who's Who lists of medical writers, journalists and opinion shapers.
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?Not linked to either of these sources I came across this article in the NY Times illustrating the core points.
With Republicans in complete control of Maine�s state government for the first time since 1962, State Senator Lois A. Snowe-Mello offered a bill in February to limit doctors� liability that she was sure the powerful doctors� lobby would cheer. Instead, it asked her to shelve the measure.
�It was like a slap in the face,� said Ms. Snowe-Mello, who describes herself as a conservative Republican. �The doctors in this state are increasingly going left.�
Doctors were once overwhelmingly male and usually owned their own practices. They generally favored lower taxes and regularly fought lawyers to restrict patient lawsuits. Ronald Reagan came to national political prominence in part by railing against �socialized medicine� on doctors� behalf.
But doctors are changing. They are abandoning their own practices and taking salaried jobs in hospitals, particularly in the North, but increasingly in the South as well. Half of all younger doctors are women, and that share is likely to grow.
There are no national surveys that track doctors� political leanings, but as more doctors move from business owner to shift worker, their historic alliance with the Republican Party is weakening from Maine as well as South Dakota, Arizona and Oregon, according to doctors� advocates in those and other states.
That change could have a profound effect on the nation�s health care debate. Indeed, after opposing almost every major health overhaul proposal for nearly a century, the American Medical Association supported President Obama�s legislation last year because the new law would provide health insurance to the vast majority of the nation�s uninsured, improve competition and choice in insurance, and promote prevention and wellness, the group said.
Because so many doctors are no longer in business for themselves, many of the issues that were once priorities for doctors� groups, like insurance reimbursement, have been displaced by public health and safety concerns, including mandatory seat belt use and chemicals in baby products.
Even the issue of liability, while still important to the A.M.A. and many of its state affiliates, is losing some of its unifying power because malpractice insurance is generally provided when doctors join hospital staffs.
�It was a comfortable fit 30 years ago representing physicians and being an active Republican,� said Gordon H. Smith, executive vice president of the Maine Medical Association. �The fit is considerably less comfortable today.�
Mr. Smith, 59, should know. The child of a prominent Republican family, he canvassed for Barry Goldwater in 1964, led the state�s Youth for Nixon and College Republicans chapters, served on the Republican National Committee and proudly called himself a Reagan Republican � one reason he got the job in 1979 representing the state�s doctors� group.
But doctors in Maine have abandoned the ownership of practices en masse, and their politics and points of view have shifted dramatically. The Maine doctors� group once opposed health insurance mandates because they increase costs to employers, but it now supports them, despite Republican opposition, because they help patients.
More at the link.
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