Central to the problem of how best to live in a world that we cannot understand is how to regard:
“The Extended Disorder Family (or Cluster): (i) uncertainty, (ii) variability, (iii) imperfect, incomplete knowledge, (iv) chance, (v) chaos, (vi) volatility, (vii) disorder, (viii) entropy, (ix) time, (x) the unknown, (xi) randomness, (xii) turmoil, (xiii) stressor, (xiv) error, (xv) dispersion of outcomes, (xvi) unknowledge.” (Nassim Nicholas Taleb, Antifragile, London: Allen Lane, 2012)
To this impressive list, I would add seventeenth and eighteenth items: failure and death. All of these characteristics scare and frighten most of us, and so we do our best to avoid them.
Despite the popularity of self-help books emphasizing the pursuit of happiness, a vocal minority has advocated embracing all of the above negative items in order to live fully and successfully.
Eric G. Wilson perhaps provides the best overview of this minority report when he observes that
“To desire only happiness in a world undoubtedly tragic is to become inauthentic, to settle for unrealistic abstractions that ignore concrete situations.”
“Our passion for felicity hints at an ominous hatred for all that grows and thrives and then dies.” (Eric G. Wilson, Against Happiness, New York: Sarah Crichton Books, 2008)
To be alive and to realize that you are going to die means being insecure and vulnerable. According to Martha Nussbaum one should embrace this uncertainty.
Recent articles highlight challenges with holding providers accountable for the care they deliver. One of the major thrusts of efforts to transform the American healthcare delivery system has been to become more patient-centered and to allow patients to provide feedback that matters.
Emblematic of this is the emphasis on patient involvement in the final rules for the Shared Savings Program accountable care organizations (ACO).
Echoing former Centers for Medicare & Medicaid Services Director Don Berwick’s plea on the behalf of patients (“Nothing about us without us”), the ACO final rules emphasize patient engagement in governance, quality improvement and the individual doctor/patient interaction.
Michael Millenson’s white paper provides a summary of the patient empowerment movement.
The development of the patient activation measure (PAM) and the Center for Advancing Health’s 43 engagement behaviors has allowed us to study patient-centeredness with more specificity. Studies have shown that activated patients are less likely to choose surgical interventions, have better functional status and satisfaction, are more likely to perform self-management behaviors, and report higher medication adherence rates.
Healthcare policy experts and payers have embraced the argument outlined above, and patients’ reports of their satisfaction with both physicians and hospitals have increasingly been used to calculate financial rewards.
We physicians like to think that we are really different from other workers.
We physicians, perhaps thinking back to that medical school application essay we all wrote, really believe that we went into this career to simply help others. We physicians truly believe that we always put our patients first.Because we sincerely believe all of the above, we are shocked when someone like Uwe Reinhardt points out that collectively we act just like any other worker in the economy.
The classic 1986 letters between the Princeton professor Reinhardt and former New England Journal of Medicine editor Arnold Relman highlight the tension between how we think of ourselves and how we act.
Relman thinks physicians are special and he asks Reinhardt the following question:
“Do you really see no difference between physicians and hospitals on the one hand, and ‘purveyors of other goods and services,’ on the other?”
Reinhardt is ready with a long answer that should be read in its entirety. The short answer is that doctors act like any other human beings. A portion of his answer includes the following:
“Surely you will agree that it has been one of American medicine’s more hallowed tenets that piece-rate compensation is the sine qua non of high quality medical care. Think about this tenet, We have here a profession that openly professes that its members are unlikely to do their best unless they are rewarded in cold cash for every little ministration rendered their patients. If an economist made that assertion, one might write it off as one more of that profession’s kooky beliefs. But physicians are saying it.”
The 21st century challenge for the American health care delivery system is to deliver higher quality care for less money. Republican and Democratic experts agree that payment reform involving transitioning from fee-for-service to global, value-based systems is necessary for us to achieve that goal. Accountable care organizations (ACOs) are the new entities that will receive the new global payments and distribute them to the doctors, allied health professionals, hospitals, and post-acute care facilities that care for the patients; Medicare ACOs are being piloted under provisions in the Affordable Care Act (ACA) and Commercial ACOs are being developed by private insurance companies, hospitals, and physician groups.
The ideal payment system would support the ideal value-driven health care delivery system. Distinguished expert panels convened by the Commonwealth Fund and the Institute of Medicine have described the attributes of a system that would be far superior to our current delivery system:
· Care would be patient-centered
· Care would be safe
· Care would be timely and accessible
· Care would be efficient with little waste
· Care would be coordinated among providers and across facilities
· Continuity of care and care relationships would be facilitated
· Collaboration among providers would deliver high quality, low cost care
· Patients’ clinical information would be efficiently exchanged
· Caregivers would engage patients in ways that would maximize health
· Accountability for each aspect and for total care would be clear
· Continuous innovation, learning, and improvement would occur
One of the perks of giving keynotes all over the country is being able to hear what other health care leaders are saying without having to pay the conference fees. One of my major keynote themes is that everyone (patients, doctors, hospitals, employers, and health plans) will have to change in order to thrive during the current health care delivery system transformation.
Recently in Delray Beach, I stayed after my keynote to hear Florida Blue CEO Patrick Geraghty describe his first year of trying to change the Blue Cross/Blue Shield franchise to respond to health care reform. I have written elsewhere about the health plan response to the changing environment, but Geraghty’s speech highlighted how urgent and how difficult change can be when an industry business model is disrupted by federal legislation and market forces.
Geraghty has led the Blues effort in Florida to update their name, mission, vision, and values. Focus groups revealed that the new name Florida Blue was easier to say and communicated a less corporate, more friendly image than the old name Blue Cross Blue Shield which brought to mind adjectives such as corporate, distant, and expensive.
A four paragraph mission statement was replaced by a single sentence: “To help people and communities achieve better health.” The vision statement was rewritten to now describe the company as “a leading innovator enabling healthy communities.” The five corporate values now include the familiar “respect,” “integrity,” and “excellence,” and the more unusual “courage” and “imagination.”
What I found most intriguing and revealing was how these new efforts are being translated into concrete tactics such as opening retail centers and partnering with Disney on a new innovation institute.
1. You Will Have to Move a Lot
I went to medical school in Cleveland and did myj pathology residency in San Francisco at UCSF. I was on the medical school faculty at UCSF, Iowa, Allegheny University of the Health Sciences, and Michigan State.
Since leaving academic medicine, I have worked at a bio-tech start up in Cambridge, an educational and research institute in Grand Rapids, a $2 billion integrated delivery system in Iowa, and an evidence-based medicine consortium in Minneapolis.
In my experience physician executive positions do not always last a long time because the environment changes, my career aspirations changed, and getting the job done sometimes means alienating enough people to get in the way of long job tenure.
2. You Will Have to Reinvent Yourself Over and Over Again
My main professional roles have included: medical school pathology course master, surgical pathologist, division head, vice chair of academic department, chair of academic department, medical director of managed care, corporate operations officer of ambulatory care, special assistant to the president of a big ten university for managed care, search consultant, chief knowledge officer of a genomics bio-tech start up, president and ceo of an educational consortium, chief medical officer of a delivery system, president and ceo of an evidence based medicine institute, and health policy professor at a school of population health.
In September 2012, the Joint Commission recognized 620 hospitals (about 18% of the total number of accredited American hospitals) as “top performers,” but many were surprised when some of the biggest names in academic medical centers failed to make the cut. Johns Hopkins, Massachusetts General Hospital, and the Cleveland Clinic (perennial winners in the US News & World Report best hospital competition) did not qualify when the Joint Commission based their ranking not on reputation but on specific actions that “add up to millions of opportunities ‘to provide the right care to the patients at American hospitals.’”
The gap between the perceived reputation of America’s “best” hospitals and medical schools and their performance on an evidence-based medicine report card provides an interesting lens through which to understand the role and performance of America’s academic medical centers in the 21stcentury.
The most pressing challenge for American medicine has been summarized in the triple aim: how to cut the per-capita cost of healthcare, how to increase the quality and experience of the care for the patient, and how to improve the health and wellness of specific populations.
Can we expect academic medical centers to lead the country in meeting the challenge? If history is any guide, the answer may be no. In a 2001 article titled “Improving the Quality of Health Care: Who Will Lead?” the authors write:
“We see few signs that academic medical leaders are prepared to expend much effect on health care issues outside the realms of biomedical research and medical education. They exerted little leadership in what may arguably be characterized as the most important health policy debates of the past thirty years: tobacco control, health care cost containment, and universal access.”
Having been a professor at several medical schools (UCSF, University of Iowa, Allegheny University of the Health Sciences, and Michigan State), I learned early on that the key to academic advancement was NIH funded basic science research. While lip service was paid to the ideal triple threat professor (great clinician, superb teacher, and peer reviewed published investigator), the results of the tenure process clearly resulted in a culture where funded research counted far more than teaching and clinical care delivery.
I was surprised when the Opening Ceremonies of the Olympics in London honored two of my favorite institutions: the National Health Service and the World Wide Web. I was not surprised when LA Times sports writer Diane Pucin posted the following tweet: “For the life of me, though, am still baffled by NHS tribute at opening ceremonies. Like a tribute to United Health Care or something in US.” @swaldman responded to the sports writer with “Well, maybe, if United Health Care were government-run and a source of national pride.”
I was not surprised when Meredith Vieira and Matt Lauer of NBC admitted they had no idea why Tim Berners-Lee was being honored by sending out a tweet. Ever since I read his book Weaving the Web: The Original Design and Ultimate Destiny of the World Wide Web by Its Inventor (HarperSanFrancisco, 1999), Berners-Lee has been one of my heroes. Finally locating my hard copy of the book in the guest bedroom where my son Colin used to sleep, I quickly located the marked passage I was looking for:
“People have sometimes asked me whether I am upset that I have not made a lot of money from the Web. In fact, I made some quite conscious decisions about which way to take my life. These I would not change…. What does distress me, though, is how important a question it seems to be to some.
“If you cannot measure it, you cannot improve it.” Lord Kelvin
“Asking science to explain life and vital matters is equivalent to asking a grammarian to explain poetry.” Nassim Nicholas Taleb
Of course the quantified self movement with its self-tracking, body hacking, and data-driven life started in San Francisco when Gary Wolf started the “Quantified Self” blog in 2007. By 2012, there were regular meetings in 50 cities and a European and American conference. Most of us do not keep track of our moods, our blood pressure, how many drinks we have, or our sleep patterns every day. Most of us probably prefer the Taleb to the Lord Kelvin quotation when it comes to living our daily lives. And yet there are an increasing number of early adopters who are dedicated members of the quantified self movement.
“They are an eclectic mix of early adopters, fitness freaks, technology evangelists, personal-development junkies, hackers, and patients suffering from a wide variety of health problems. What they share is a belief that gathering and analysing data about their everyday activities can help them improve their lives.”
According to Wolf four technologic advances made the quantified self movement possible:
“First, electronic sensors got smaller and better. Second, people started carrying powerful computing devices, typically disguised as mobile phones. Third, social media made it seem normal to share everything. And fourth, we began to get an inkling of the rise of a global superintelligence known as the cloud.”
The essence of professionalism is to be constantly striving to take better care of our patients. “The aspiration to do better, coupled with commitment and a sense of personal responsibility will drive knowledge seeking” and empathy and compassion for those who are our patients.
And yet we know that during medical school students become less compassionate and less altruistic; the largest drops in empathy have been documented between the beginning and the end of the first year and between the beginning and end of the third year of education.
And we also know that there have been recent revelations of numerous occasions where practicing physicians have failed to live up to the ideal. The Wall Street Journal documented spine surgeons who did large numbers of spine surgery and received large payments from a medical device manufacturer. Pro Publica has shown that faculty at prestigious medical schools have failed to comply with university conflict of interest policies. A Maryland cardiologist has had his medical license revoked and his hospital had to pay back Medicare millions of dollars because of allegedly inserting stents in patients who did not need them.
How can we support our fellow physicians and medical students so that we all strive to become the best caregivers we can possibly be? Is the problem with living up to the ideal a specific problem within medicine or is it a more general problem of human nature and the current cultural environment?