Saturday, February 10, 2007

Trauma System 2.0

Health Care System 2.0

There is an evolving change happening in trauma systems that is occurring within the context of our "Health Care Crisis". Before I discuss this any further I need to remind you of the original concept of this blog which describes, what I believe is, this greater context. I've discussed this previously but let me summarize this idea. What we are experiencing as a "Health Care Crisis" is really the emergence of a new paradigm for delivering health care. The established model of delivering health care was built on the idea of the Patient-Physician relationship. Physicians acted as gatekeepers to the services, accumulated knowledge and experience of the health care system. The nature of this relationship is changing. It is evolving into a Patient-Provider relationship where the "Provider" will be an information technology based platform that uses artificial intelligence for delivering health care. What we are experiencing now as a "crisis" is the deconstruction of the established paradigm, the conserving of the essential elements of that paradigm and the building of a new model on the foundation of the older model. If you are wondering where the deconstruction is occurring look no further than where everyone is pointing to as the cause of the crisis.

The Prime Directive

Not a day goes by when someone in the popular media is not commenting on the health care crisis. We hear it all the time. "The system is collapsing." "Medical costs are spiraling out of control." "There are over 45 million Americans without health insurance." "Greedy trial lawyers are suffocating the health care system." "Insurance and pharmaceutical company executives are profiting off of the sick and dying." The list goes on and yet amazingly despite these complaints medicine on the whole continues to improve. How does that occur? The reason is because the system was designed to improve the health of our society over time. That is the prime directive. It says nothing about how we will deliver that directive. It is only concerned with improvement over time. If that means disrupting a time honored delivery platform to replace it with one that is fundamentally better than so be it. This will and is affecting all sub-systems of Health Care version 1.0.

Trauma System 1.0

The latter half of the 20th century saw the dramatic development of trauma systems and the improved delivery of health care to the acutely injured patients. It took the bold actions of Trauma Surgeons such as R Adams Cowley, MD to advocate for those systems. He and others of his generation identified the need for Trauma Centers and impressed upon the leaders of the time to implement such systems. While slow to develop these systems have proven their worth to our society. These systems were primarily established through the hard work of those who worked in the trenches, so to speak. They are the surgeons, emergency medicine physicians, nurses, paramedics, emergency medicine technicians and all other clinical personnel who evaluated and treated the people injured by traumatic mechanism. In time these professionals created societies and networks for the physicians, nurses and allied health personnel. This allowed for greater improvements in the delivery of trauma health care. There are limits to this process and I believe we are approaching them.

The Trauma Club

The people who work in trauma tend to be a tight-nit group. It is a very small club and there is a belief that if you have never done time in the trauma trenches then your opinion doesn't matter. We're the insiders and all others are the outsiders. While this sense of camaraderie and control was essential for the establishment of trauma systems I believe it may be the very factor that is holding back their further development. Trauma Surgeons are the main gatekeepers to the definitive treatment centers for trauma care. As we continue to improve we have become victims of our own success. It is an ironic twist of fate that as a Trauma Surgeon gets better at what they do, they tend to do less of what they were originally trained to do, which is surgery. The majority of the trauma patients in the National Trauma Data Bank (NTDB) have minor injuries as measured by the Injury Severity Score (ISS). It is becoming increasingly obvious that not all of those patients need to be evaluated by a Trauma Surgeon. The ones who benefit the most from the services of a Trauma Surgeon are those with more severe injuries. In order to direct those patients to where a Trauma Surgeon is requires a highly developed Trauma System. Taking the current systems to the next level to meet those needs is going to require Trauma Surgeons to give up something they worked so hard to get. That is, control of those systems.

"A man must not deny his manifest abilities, for that is to evade his obligations."
Robert Louis Stevenson

We have gotten so good at what we do we have forgotten what it is that we don't do so well. Trauma Surgeons are leaders in the trauma room and operating room. We make difficult decisions often based on little information which can directly affect the life of our patients. We perform regularly and successfully under stressful conditions. It's a small world we live in. We're distrustful of outsiders and certainly don't wish to allow others to control our destiny as society so often grants us the privilege to do for it on a daily basis. What we don't do so well is run large scale operations of the system type. There are others, particularly in the world of business, who are much better at doing that. They understand and work on a daily basis with the concepts of "complex systems architecture", "disruptive and sustaining innovation", "economy of scale" and "value chain". Ideas such as these are essential for understanding the way organizations progress and succeed. Trauma systems are at the threshold of a new type of delivery system. They need strong leadership of a different kind. The kind of leadership needed is one which has experience at running large complex systems. Trauma Surgeons will need to make some decisions. They can go back to doing what they were trained to do. They can recruit others from outside the club to run these systems. Or they can venture outside the club walls and seek the education and training it takes to manage these systems. One way or another Trauma System 2.0 is coming. It will be built on the conserved essential elements of Trauma System 1.0. While version 2.0 may diminish the role of the traditional Trauma Surgeon, let us not forget that the leaders of it will be standing on the shoulders of those giants who built version 1.0.

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