Friday, January 27, 2006

Fighter Pilots, Show the Way

We have met the enemy...and he is us.

The cornerstone of the established paradigm for delivering healthcare is the patient-physician relationship and it is under attack. More specifically, it appears that it is the physician that is under attack. The relationship has degraded and is not uncommonly described as adversarial. Physicians approach each encounter with the thought that anything they do or say may result in a malpractice lawsuit. Attorneys and patients counter that if physicians simply provided the standard of care and adequately informed their patients there would be no need for a claim or a lawsuit. Day in, day out, this battle is fought and there does not appear to be a clear winner. If this is how we plan to deliver healthcare in the 21st century then there will be no winner, only losers. I believe it is not the physician but the physician's role as a gatekeeper to the Healthcare System that is being challenged. The battles we fight are really with ourselves.

Captain Kirk: "Scotty we need more power."
Chief Engineer Scott: "Captain, we're giving you everything she's got."

The patient-physician relationship is based on trust, however discord between the two involved parties suggests the trust has been broken. One or both parties believe they have been cheated as a result of actions or inactions on the part of the other. Physicians believe patients and their supporters have unrealistic expectations about what a Physician can deliver. Patients believe they are being short-changed by the physicians and not being delivered access to the full capabilities of our Healthcare System. Physicians believe they are doing everything they are humanly capable of doing to deliver the very best of our Healthcare System. Patients believe they are paying too much for what physicians provide and therefore feel entitled to pay less or ask for more. What if they are both right? Is it possible that we have designed a Healthcare System that has capabilities that exceed the capacity of any human to deliver? I believe this is what is at the heart of the patient-physician relationship issue.

Aim High

Years ago I had the opportunity to tour Hill Air Force Base in Utah which is home to the 388th Tactical Fighter Wing and the F-16 "Fighting Falcon" fighter aircraft. For decades this fighter has been one of the most advanced weapons delivery systems the Air Force has in its arsenal. The aircraft is capable of a performance standard that can potentially exceed the biological tolerance of the pilot manning the craft. The effects of G-forces have been known from the early days of manned flight. Advanced avionics, G-suits, and cockpit ergonomics were developed to facilitate and augment the pilot's ability to meet those performance standards. Despite all these advances, the need for an unmanned (not pilot-less) flight system became necessary. The remote piloted, multi-role, unmanned aircraft system known as the Predator is one of the recent additions to be used in battle. Boeing's Joint Unmanned Combat Air Systems X-45 A is now being tested for future use in our air arsenal. The idea that engineers can design aircraft technologies that exceed the capabilities of the humans that pilot them is not a new one for the United States Air Force. I suspect we have done a similar thing with our Healthcare System.

Approaching g-LOC

The patient-physician relationship is not only based on trust but also on expectations. If we have designed a Healthcare System that exceeds the capacity of humans to deliver on its capabilities then it is easy to see why both parties in this relationship have unrealistic expectations. Physicians are expected to be available 24/7/365, have access to all information about a patient (medical history and insurance parameters), and information to be available to a patient (evidence based medicine, standards of care, latest medications and research protocols). In addition Physicians are expected to deliver this to the patient in a way that takes into consideration such things as the patient's culture, ethnicity, IQ, EQ, education, personality and knowledge about healthcare systems. Adaptations to facilitate these expectations include things like: call schedules, emergency rooms, medical charts, electronic medical records (EMR), textbooks, journals, CME, internet based libraries and other medical information portals, and not to mention communication and documentation courses. Patients are expected to understand that physicians are humans and have limitations on their abilities. Physicians have adapted well but are now expected to function outside their design capabilities. The role of the gatekeeper for this system has become much more complicated not as a result of our failures but as a result of our successes. It is not the Physicians who are being challenged; it is the role they play.

Which Way Do We Go?

The short-term answer is to develop technologies that will continue to facilitate (EMR, PDA) and even augment(Robotics) the Physicians ability to deliver healthcare. The long-term answer is to develop an interface that will be able to coordinate the vast capabilities that are inherent in a highly advanced Healthcare System. Waiting until the 24th century for such an innovation is not going to work. I think we will see this capability much sooner. If the field of Aviation is any indicator it may be much sooner than we expect. The military application of manned aircraft to remotely piloted, unmanned aircraft is already upon us. Civilian application will most likely begin in cargo transport (Fed-Ex, UPS, USPS). As it develops a proven safety record I think people will gradually accept unmanned flight transportation. The day society accepts flying across the country in an airplane that does not have a pilot in the cockpit is the day they will accept asking a "Virtual Reality Doctor" (VRD) for medical advice. Who knows, they may accept it sooner if their insurance provider offers them a deep discount for doing so. If the patient has any questions about the quality of care they can call up their "Virtual Reality Lawyer" (VRL). So what will the real Doctors and Lawyers be doing? Probably hanging out on the beach drinking margaritas with the Fighter Pilots.

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