Not Really But Just Imagine
You have been healthy your whole life and one day you're not. I'm not referring to an illness like the common cold or a headache but the type of illness that gets your attention. It is still a relatively minor illness but you realize you need some advice on how to treat it. Let's say it's heartburn that isn't responding to the usual over the counter treatments. Maybe it's some pesky little burning with urination that developed after that "wild weekend". What do you do? Well if your like most people you will plan on seeing a "Provider". If your uninsured, like 43 million Americans, then the cost will be out of pocket. If you're insured then you will most likely need to find a Doctor in your health insurance network. Either way you will need to find someone who will act as your gatekeeper to our Healthcare System.
Traditional Gatekeeper Approach
The following is how it works in most parts of the country right now. It starts with a phone call. If you are fortunate and were given a recommendation the first step has already been accomplished. You have the name of a Provider. If not then it is the luck of the draw, usually done out of a phonebook. You call their office to make an appointment. Sometimes they can get you in quickly but very often they can't. It may be days or even weeks before you are seen. You take off time from work, or for some, you must arrange childcare. You arrive on time but now must fill out what seems like a ream of paperwork before being seen. It doesn't matter because the Doctor is running late. (The Doctor's first appointment of the day which was scheduled for 15 minutes ended up taking an hour.) So now you wait in the waiting room with a bunch of sick people filling out forms and reading old magazines, all the while thinking, "this sucks." You finally meet with the Doctor and tell your story. There is a brief physical exam and you're handed a prescription. The whole encounter was less than 10 minutes. The Doctor was courteous and professional but obviously in a hurry. You are reminded to make a follow-up appointment on the way out and as you drive off to get your prescription filled you can't help but think, "there has got to be a better way".
Alternative Gatekeeper Approach
Fast forward to the Jetson's Age and start this process all over again. Forget the phone call. Don't worry about insurance. You won't need to take any time off for work. You now have 24/7/365 access to medical advice. You retreat, at your convenience, to your personal Virtual Reality Room. It used to be your home office but you have upgraded it. You engage the Interface and request to open an access to a health information counselor. Immediately you see a 3-D image of an "Old Country Doc" that you selected from a menu of counselors. He's "Old Doc Smith" and he knows your entire medical history. He has access to it through the National Health Information Network. He "knew" it was you because of the biometrics that were installed along with the other technology in your Virtual Reality Room. He begins to take your history and the medical decision making software program notes through the history you provide that this is a low complexity problem. There is a low probability that a physical exam will be necessary for "Old Doc Smith" to make a diagnosis and initiate treatment. He tells you there is no need to be seen by a traditional Provider at this time. Based on your detailed history the medical decision making software generates a treatment plan that meets the most up-to-date standard of care. He recommends that you should consider talking with a Nutritionist as some dietary changes may have a more lasting effect on your heartburn. You decline for now. He explains he will prescribe a medication and spends the time instructing you on its use, intended effects and any side effects. He tells you he has already forwarded your prescription to the pharmacy and you exit the program. No hassles. No inconveniences. No delays. No waiting room. The whole encounter is recorded in your health record and took less than 10 minutes from start to finish.
Why Wait For The Future To Think About The Future?
Sounds wild doesn't it? I think there will be a palette of options that comes with virtual reality interactivity. It won't just be a Health Information Counselor. There will be virtual therapists, nutritionists. trainers, psychologists, news reporters and just about any other virtual environment you desire. It will be the military and the "entertainment industry" that capitalizes on this technological leap in the beginning, but once it goes mainstream the whole frontier will be wide open. Healthcare will not be the last to get on board. I think these types of services will be delivered into our homes just like cable TV. We will sign up for certain packages. The more extravagant and complicated the virtual environment the more it will cost. The market will ultimately determine cost. Those that can not afford a personal virtual reality room will have a local virtual reality center they can go to get online. These systems will need to be efficacious and low cost to compete but I think they will have a market in Healthcare as well. We're not there yet but we can imagine. If you're thinking, "It'll never work", check out this link.
Tuesday, January 31, 2006
Monday, January 30, 2006
Transform, Not Just Reform, Healthcare
Designing a Different and Better System
It seems like everywhere you look today someone is calling for Healthcare reform. Let's think about this for a second. What is the difference between reform and transform? Here is a sampling of what you will find in the Merriam-Webster dictionary.
Reform: (vb) 1) to make better or improve by removal of faults 2) to correct or improve one's own character or habits (3) (n) improvement or correction of what is corrupt or defective.
Transform: (vb) 1) to change in structure, appearance or character (2) to change in potential or type.
The problem with describing the needed changes in Healthcare as "reforms" is that it limits those changes to perceived defects or faults. I would rather see what is happening in Healthcare as a much bolder vision unfolding before us. Over the last two weeks on this blog I have been toying with this idea. I've finally gotten around to drawing up an outline as I see it. I realize I will be making many changes to it in the future, but for now it is a first draft. It is somewhat lengthy for a blog so I apologize in advance. It is also very Doctor-centric but I figured, what the hell, I have to start somewhere. Constructive commentary is appreciated. I will leave you with one simple question. Is an open source or open design model for creating a new Healthcare System possible?
Hypothesis: The healthcare crisis in the United States is due to the conflict that arises when an emerging paradigm for delivering healthcare services challenges the established paradigm for delivering healthcare services. The crisis will resolve when the new emerging paradigm becomes established.
Assumptions:
1) The transformation will occur over three main phases, which can be best characterized as a paradigm shift that follows an S-curve pattern. Each S-curve represents the life cycle of a paradigm. A paradigm shift occurs when the upper part of the S-curve, representing the established paradigm, merges with the lower part of the new S-curve, representing the new, emerging paradigm.
a) Phase 1: This is the point of greatest overlap between the two paradigms and therefore the period of greatest conflict. It begins at the upper inflection point of the S-curve of the established paradigm and ends just before the lower inflection point of the S-curve of the new paradigm.
i) The established paradigm is reaching the point of diminishing returns. It requires greater amounts of resources to maintain and develop any further.
ii) The new paradigm is just beginning to emerge, however due to its relative immaturity it is characterized by a lack of organization, high costs and failed start-ups.
b) Phase 2: This is seen as the point of transition between the established paradigm and the new emerging paradigm. The established paradigm loses its standing as the pre-eminent source of healthcare services and the new paradigm begins to assume that position. It occurs during the lower inflection point of the S-curve.
i) The established paradigm becomes impractical as it is seen as inefficient and too costly.
ii) The new paradigm for healthcare delivery begins to become more easily accessible, efficacious, and cost efficient.
c) Phase 3: This is the period of accelerating returns of the new paradigm. It is seen as the upward slope of the S-curve between the lower inflection point and the upper inflection point.
i) The formerly established paradigm passes into history as the shoulders upon which the new paradigm stands.
ii) The new paradigm takes its turn at becoming the established paradigm until a new challenger arrives, and Phase 1 is started over again.
2) If this is a true paradigm shift then it must pass a simple Kuhn Test by answering in the affirmative to the following two questions.
a) Does the new paradigm appear different from the established paradigm?
b) Is the new paradigm better than the established paradigm?
3) The new emerging paradigm will conserve the fundamental reason for the existence of a Healthcare System which is to deliver and optimize the health of those within the System.
4) The cornerstone of the established paradigm for delivering healthcare is the patient-physician relationship. It is built on trust and assumes a value-for-value exchange.
a) Without the patient-physician relationship as defined by the current standards, the established paradigm would collapse.
5) The cornerstone of the emerging paradigm will be the patient-provider relationship.
a) The term "Provider" will become redefined as progress is made through the different phases.
b) This new relationship will prove to be more convenient, efficacious, and affordable.
6) Enabling technologies will be essential for the transformation to occur.
a) These will be technologies that currently exist but will be restructured in a unique way to facilitate the paradigm shift.
7) Enabling legislation will be essential for the transformation to occur.
a) Legislation that facilitates the transition from the established paradigm to the new paradigm will be necessary as each phase develops.
8) The variability of practice patterns will be minimized as each phase passes and the delivery of best practice patterns will become the status quo.
9) The delivery platform of healthcare services, where the physician acts as the gatekeeper, will become transformed into a platform that can consistently and continuously deliver the full capabilities of the system.
10) Health will be redefined from being not just an absence of disease to being fully alive and engaged in the living of life.
Transformation Projections
1) Phase 1:
a) Physician shortages will become more prevalent due to increased demand, particularly in "underserved" areas. Physician portability and commitment will be hampered by: Length of time it takes for credentialing and licensing, High cost of establishing a practice while paying off student loans, High cost of malpractice insurance, Limited practice options, Delayed payment of services provided, Excessive workload and duty hours.
b) Physician specialization will increase in an attempt to manage the increasing medical knowledge base.
c) Specialization increases specialty autonomy and power but decentralizes the power base of physicians as a group and effectively inhibits them from organizing as a whole.
d) The Patient-Physician relationship will become redefined as the Patient-Provider relationship.
e) The term "Provider" will become redefined to include Nurse Practitioners (NP) and Physician Assistants (PA).
f) Providers will begin to use enhanced technologies that utilize basic forms of Artificial Intelligence (AI).
g) The cost of the Patient-Physician relationship will be considered excessive for the services provided for two main reasons.
i) The cost of the physician is high (education, training, practice overhead, malpractice insurance, decreased reimbursement).
ii) The costs of the physician's recommendations are high (Brand names vs. generics, defensive medicine, consumer demand).
h) Costs will rise.
i) As the established paradigm reaches the point of diminishing returns it will cost more to maintain the system.
ii) As the new paradigm emerges it will cost more due to immaturity, lack of organization and failed start-ups.
i) Cost containment measures will come in the form of reimbursement caps, increasing difficulty in obtaining payment for treatment and prescriptions, rising co-pays, etc.
j) Conflict will develop over the "fitness" of Providers to maintain their gatekeeper role for the Healthcare System.
i) The Patient-Provider relationship will become increasingly adversarial.
ii) Providers will be increasingly called to task for their inability to safely and adequately deliver the full service capabilities of the current Healthcare System.
k) Enabling technologies: Computers, PDA's, Internet, Data Storage, evidence Based Medicine, Protocol Development, Basic Electronic Medical Record, Robotic Assistants.
2) Phase 2
a) The term "Provider" will be expanded to include any Interface that is directed by an approved AI medical decision making software package. This will be used independently by the patient for the evaluation and management of low complexity problems.
b) The AI will have current Standards of Care combined with cost effective controls embedded in the algorithms driving the decision making.
i) Physicians of the established paradigm will be instrumental in helping to build the AI directed Interface.
ii) Physicians will define the standards of care.
1) These standards will be embedded in the evaluation and management protocols utilized by the Interface.
2) Confirming the use of the Standard of Care will become the equivalent of "required fields" encountered in most internet database forms.
iii) They will provide the initial feedback to the programmers as to the functionality of the Interface.
iv) Physicians will assume a new role as medical information managers for healthcare teams managing patients.
v) The owners of the proprietary rights to the development and maintenance of the medical decision making software will become liable for the recommendations.
c) Physicians, NP's and PA's will become increasingly dependent on "enhancing technologies" for most medical decision making. They will be primarily responsible for evaluating and managing moderate and complex medical problems.
d) Enabling technologies: Standardized Electronic Medical Record, National Health information Network, Virtual Reality Systems, Performance Enhancing Robotics.
3) Phase 3
a) Most Patient-Provider encounters will be completely managed by an Interface that utilizes approved AI medical decision making software.
i) The Interface will assume the role of the Primary Care Provider and Hospitalist.
ii) An Interface that utilizes advanced robotics will perform most of the low complexity operations.
iii) Human Providers will continue to provide both Interface assisted and non-Interface assisted services where the Interface is unavailable or impractical to use.
iv) When Providers work in a resource deficient or un-enhanced environment they will be held to a different Standard of Care.
v) Enabling Technologies: Advanced Genetics, Robotics, AI and Nanotechnology.
Essential Elements of a New Healthcare System
1) Accessible 24/7/365 from most environments.
2) Maintains the highest degree of up-to-date Standards of Care.
3) It will cost less per service than the current Healthcare System.
4) The Standards of Care and quality outcomes will be transparent and accessible on all healthcare entities.
5) Maintains a universal health care record on all participants.
6) Produces healthcare outcomes that far surpass current best standards.
7) Incorporates other type of Interfaces to facilitate the delivery of healthcare. (Nutritionist, Health Club Trainer, Physical Therapist, etc.)
If you don't think we have a healthcare system, just try to change it.
It seems like everywhere you look today someone is calling for Healthcare reform. Let's think about this for a second. What is the difference between reform and transform? Here is a sampling of what you will find in the Merriam-Webster dictionary.
Reform: (vb) 1) to make better or improve by removal of faults 2) to correct or improve one's own character or habits (3) (n) improvement or correction of what is corrupt or defective.
Transform: (vb) 1) to change in structure, appearance or character (2) to change in potential or type.
The problem with describing the needed changes in Healthcare as "reforms" is that it limits those changes to perceived defects or faults. I would rather see what is happening in Healthcare as a much bolder vision unfolding before us. Over the last two weeks on this blog I have been toying with this idea. I've finally gotten around to drawing up an outline as I see it. I realize I will be making many changes to it in the future, but for now it is a first draft. It is somewhat lengthy for a blog so I apologize in advance. It is also very Doctor-centric but I figured, what the hell, I have to start somewhere. Constructive commentary is appreciated. I will leave you with one simple question. Is an open source or open design model for creating a new Healthcare System possible?
Hypothesis: The healthcare crisis in the United States is due to the conflict that arises when an emerging paradigm for delivering healthcare services challenges the established paradigm for delivering healthcare services. The crisis will resolve when the new emerging paradigm becomes established.
Assumptions:
1) The transformation will occur over three main phases, which can be best characterized as a paradigm shift that follows an S-curve pattern. Each S-curve represents the life cycle of a paradigm. A paradigm shift occurs when the upper part of the S-curve, representing the established paradigm, merges with the lower part of the new S-curve, representing the new, emerging paradigm.
a) Phase 1: This is the point of greatest overlap between the two paradigms and therefore the period of greatest conflict. It begins at the upper inflection point of the S-curve of the established paradigm and ends just before the lower inflection point of the S-curve of the new paradigm.
i) The established paradigm is reaching the point of diminishing returns. It requires greater amounts of resources to maintain and develop any further.
ii) The new paradigm is just beginning to emerge, however due to its relative immaturity it is characterized by a lack of organization, high costs and failed start-ups.
b) Phase 2: This is seen as the point of transition between the established paradigm and the new emerging paradigm. The established paradigm loses its standing as the pre-eminent source of healthcare services and the new paradigm begins to assume that position. It occurs during the lower inflection point of the S-curve.
i) The established paradigm becomes impractical as it is seen as inefficient and too costly.
ii) The new paradigm for healthcare delivery begins to become more easily accessible, efficacious, and cost efficient.
c) Phase 3: This is the period of accelerating returns of the new paradigm. It is seen as the upward slope of the S-curve between the lower inflection point and the upper inflection point.
i) The formerly established paradigm passes into history as the shoulders upon which the new paradigm stands.
ii) The new paradigm takes its turn at becoming the established paradigm until a new challenger arrives, and Phase 1 is started over again.
2) If this is a true paradigm shift then it must pass a simple Kuhn Test by answering in the affirmative to the following two questions.
a) Does the new paradigm appear different from the established paradigm?
b) Is the new paradigm better than the established paradigm?
3) The new emerging paradigm will conserve the fundamental reason for the existence of a Healthcare System which is to deliver and optimize the health of those within the System.
4) The cornerstone of the established paradigm for delivering healthcare is the patient-physician relationship. It is built on trust and assumes a value-for-value exchange.
a) Without the patient-physician relationship as defined by the current standards, the established paradigm would collapse.
5) The cornerstone of the emerging paradigm will be the patient-provider relationship.
a) The term "Provider" will become redefined as progress is made through the different phases.
b) This new relationship will prove to be more convenient, efficacious, and affordable.
6) Enabling technologies will be essential for the transformation to occur.
a) These will be technologies that currently exist but will be restructured in a unique way to facilitate the paradigm shift.
7) Enabling legislation will be essential for the transformation to occur.
a) Legislation that facilitates the transition from the established paradigm to the new paradigm will be necessary as each phase develops.
8) The variability of practice patterns will be minimized as each phase passes and the delivery of best practice patterns will become the status quo.
9) The delivery platform of healthcare services, where the physician acts as the gatekeeper, will become transformed into a platform that can consistently and continuously deliver the full capabilities of the system.
10) Health will be redefined from being not just an absence of disease to being fully alive and engaged in the living of life.
Transformation Projections
1) Phase 1:
a) Physician shortages will become more prevalent due to increased demand, particularly in "underserved" areas. Physician portability and commitment will be hampered by: Length of time it takes for credentialing and licensing, High cost of establishing a practice while paying off student loans, High cost of malpractice insurance, Limited practice options, Delayed payment of services provided, Excessive workload and duty hours.
b) Physician specialization will increase in an attempt to manage the increasing medical knowledge base.
c) Specialization increases specialty autonomy and power but decentralizes the power base of physicians as a group and effectively inhibits them from organizing as a whole.
d) The Patient-Physician relationship will become redefined as the Patient-Provider relationship.
e) The term "Provider" will become redefined to include Nurse Practitioners (NP) and Physician Assistants (PA).
f) Providers will begin to use enhanced technologies that utilize basic forms of Artificial Intelligence (AI).
g) The cost of the Patient-Physician relationship will be considered excessive for the services provided for two main reasons.
i) The cost of the physician is high (education, training, practice overhead, malpractice insurance, decreased reimbursement).
ii) The costs of the physician's recommendations are high (Brand names vs. generics, defensive medicine, consumer demand).
h) Costs will rise.
i) As the established paradigm reaches the point of diminishing returns it will cost more to maintain the system.
ii) As the new paradigm emerges it will cost more due to immaturity, lack of organization and failed start-ups.
i) Cost containment measures will come in the form of reimbursement caps, increasing difficulty in obtaining payment for treatment and prescriptions, rising co-pays, etc.
j) Conflict will develop over the "fitness" of Providers to maintain their gatekeeper role for the Healthcare System.
i) The Patient-Provider relationship will become increasingly adversarial.
ii) Providers will be increasingly called to task for their inability to safely and adequately deliver the full service capabilities of the current Healthcare System.
k) Enabling technologies: Computers, PDA's, Internet, Data Storage, evidence Based Medicine, Protocol Development, Basic Electronic Medical Record, Robotic Assistants.
2) Phase 2
a) The term "Provider" will be expanded to include any Interface that is directed by an approved AI medical decision making software package. This will be used independently by the patient for the evaluation and management of low complexity problems.
b) The AI will have current Standards of Care combined with cost effective controls embedded in the algorithms driving the decision making.
i) Physicians of the established paradigm will be instrumental in helping to build the AI directed Interface.
ii) Physicians will define the standards of care.
1) These standards will be embedded in the evaluation and management protocols utilized by the Interface.
2) Confirming the use of the Standard of Care will become the equivalent of "required fields" encountered in most internet database forms.
iii) They will provide the initial feedback to the programmers as to the functionality of the Interface.
iv) Physicians will assume a new role as medical information managers for healthcare teams managing patients.
v) The owners of the proprietary rights to the development and maintenance of the medical decision making software will become liable for the recommendations.
c) Physicians, NP's and PA's will become increasingly dependent on "enhancing technologies" for most medical decision making. They will be primarily responsible for evaluating and managing moderate and complex medical problems.
d) Enabling technologies: Standardized Electronic Medical Record, National Health information Network, Virtual Reality Systems, Performance Enhancing Robotics.
3) Phase 3
a) Most Patient-Provider encounters will be completely managed by an Interface that utilizes approved AI medical decision making software.
i) The Interface will assume the role of the Primary Care Provider and Hospitalist.
ii) An Interface that utilizes advanced robotics will perform most of the low complexity operations.
iii) Human Providers will continue to provide both Interface assisted and non-Interface assisted services where the Interface is unavailable or impractical to use.
iv) When Providers work in a resource deficient or un-enhanced environment they will be held to a different Standard of Care.
v) Enabling Technologies: Advanced Genetics, Robotics, AI and Nanotechnology.
Essential Elements of a New Healthcare System
1) Accessible 24/7/365 from most environments.
2) Maintains the highest degree of up-to-date Standards of Care.
3) It will cost less per service than the current Healthcare System.
4) The Standards of Care and quality outcomes will be transparent and accessible on all healthcare entities.
5) Maintains a universal health care record on all participants.
6) Produces healthcare outcomes that far surpass current best standards.
7) Incorporates other type of Interfaces to facilitate the delivery of healthcare. (Nutritionist, Health Club Trainer, Physical Therapist, etc.)
If you don't think we have a healthcare system, just try to change it.
Friday, January 27, 2006
Fighter Pilots, Show the Way
We have met the enemy...and he is us.
Pogo
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.
Pogo
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.
Thursday, January 26, 2006
Breaking News: Doctors Go on Nationwide Strike
And the Word Gullible is not in the Dictionary
Every so often there is a rally cry coming from the physician's lounge or during a medical staff meeting for a doctor's strike. It usually begins with the usual diatribes about the current dismal state of affairs in our Healthcare System. "Decreasing reimbursement. Increasing expenses mostly due to the rising malpractice insurance costs. Greedy lawyers forcing patients to turn against us. Insurance and pharmaceutical company CEO's making millions ." This is soon followed with a call to organize and go on strike to "show them". If we somehow overlook the ethical dilemma of doctors forming picket lines and going on strike there is an even more pressing reason not to pursue this course of action. It won't work. Striking is an Industrial Age solution to an Information Age problem. The solution to these problems will be achieved by a better understanding of the age in which we live.
Specialization and Power
Once again we have become victims of our own success. It started with the Flexner Report in 1910 which criticized the wide variation in Medical School education that occurred at the time. By standardizing medical education the heterogeneity of practice patterns was reduced and the quality of medicine improved. Over the latter half of the 20th century medicine experienced some of the world's greatest advancements ever seen on this planet. With these advancements came the need for greater specialization. To understand, develop, and apply these great achievements required individuals to focus their practice of medicine into a more and more defined niche. Specialists became more highly valued for their services which pressured them, along with the assistance of newer advancements, to sub-specialize. Procedurally oriented specialists and sub-specialists became the most highly valued of them all. Many developed competing interests with each other and there in lies one of the obstacles to any meaningful effort to organize. If your competition wants to go stand in a picket line while you treat the sick people in your community that only improves your standing in that community. There is another reason why specialization discourages widespread organization and that is because as we become more specialized we tend to lack common interests. Rheumatologists rarely cross paths with a Trauma Surgeon and neither can see how they can help each other's cause. Specialization increases specialty autonomy and power but decentralizes the power base of physicians as a whole group.
Parts is Parts
There is another factor at work here which is also a derivative of the Flexner Report and that is the positive benefit of medical education and training standardization. The high tide raises all boats and that is what the Flexner Report did for medicine. This spirit spread to the residency and fellowhip training programs and lives on in the mission of the American Board of Medical Specialties (ABMS). This has the effect of allowing for personnel who are "interchangeable". That is not a word Physicians like to use but I believe it is a concept that patients use. Patients don't care where you trained or even where you ranked in your Medical School class. Some might ask if you are board certified but really most are only concerned with whether you accept there particular health insurance. That is not a failure of a Healthcare System; it is a success. The differences that physicians detect in the quality of healthcare are not as big a concern to the consumer as we would like to imagine. As we all know differences exist but to the average patient so do costs and that drives their decisions as much as it pains us to hear that point. Striking, for more pay or whatever, will only serve to alienate patients even more.
This is not the Age of Aquarius, Is It?
The key to solving the problems of today is to understand the age in which we live. I believe we are undergoing a transformation from an established paradigm for delivering healthcare to an emerging paradigm for delivering healthcare. If you have read any of my other posts you are probably sick of hearing this by now but it is worth repeating as it may hold the key to solving our healthcare crisis. This emerging paradigm predicts that our Healthcare System will appear different but will be better as a result of the change. As the patient-physician relationship is the cornerstone of the established paradigm this is were the greatest change will be generated. The physician/provider of the future will play a much different role. In doing so, physicians will change to meet the needs of the future. That change is occurring now.
You Don't Have a Real Job, Do You?
The supreme irony of this change is that physicians will ultimately become more organized and achieve more power as a result of it. I know what you're thinking, "Terry did you actually read any of what you just wrote? And by the way have you gotten a job yet?" Ok, ok quit giving me a hard time, the answers are yes and no. (But not necessarily in that order.) What I mean by that is organization and power will be held within the context of the emerging paradigm not the older established paradigm. Let me explain.
Are You Team Worthy?
Physicians of the future will function in a very different capacity than they currently do. Standardization of medical training allowed for development and specialization within healthcare. With specialization comes decentralization of a central power base for all physicians but increases it for specialties. I think this trend will continue. We gave up power as a group to achieve it as specialists. I think the next step is to transfer some of the power as specialists in order to achieve it personally. Professional autonomy will give way to personal autonomy. Physicians of the future will need to be more flexible and adaptable. This will provide greater freedom of choice. They will also relinquish control of their individualistic practice styles to make way for a team approach for delivering healthcare. The patient-information axis will become the cornerstone of the Healthcare System and it will be the Multidisciplinary Healthcare Teams that will be charged with administrating that care when call upon to do so. Since standardized Physician training will decrease heterogeneity for knowledge and skills, the ability to adapt and fit in with the team will become a priority for team fitness. The niche a team fills will be the basis for organizational growth and development for both the team and the team members. This may seem like a wild idea but I believe this system is changing for the better.
Every so often there is a rally cry coming from the physician's lounge or during a medical staff meeting for a doctor's strike. It usually begins with the usual diatribes about the current dismal state of affairs in our Healthcare System. "Decreasing reimbursement. Increasing expenses mostly due to the rising malpractice insurance costs. Greedy lawyers forcing patients to turn against us. Insurance and pharmaceutical company CEO's making millions ." This is soon followed with a call to organize and go on strike to "show them". If we somehow overlook the ethical dilemma of doctors forming picket lines and going on strike there is an even more pressing reason not to pursue this course of action. It won't work. Striking is an Industrial Age solution to an Information Age problem. The solution to these problems will be achieved by a better understanding of the age in which we live.
Specialization and Power
Once again we have become victims of our own success. It started with the Flexner Report in 1910 which criticized the wide variation in Medical School education that occurred at the time. By standardizing medical education the heterogeneity of practice patterns was reduced and the quality of medicine improved. Over the latter half of the 20th century medicine experienced some of the world's greatest advancements ever seen on this planet. With these advancements came the need for greater specialization. To understand, develop, and apply these great achievements required individuals to focus their practice of medicine into a more and more defined niche. Specialists became more highly valued for their services which pressured them, along with the assistance of newer advancements, to sub-specialize. Procedurally oriented specialists and sub-specialists became the most highly valued of them all. Many developed competing interests with each other and there in lies one of the obstacles to any meaningful effort to organize. If your competition wants to go stand in a picket line while you treat the sick people in your community that only improves your standing in that community. There is another reason why specialization discourages widespread organization and that is because as we become more specialized we tend to lack common interests. Rheumatologists rarely cross paths with a Trauma Surgeon and neither can see how they can help each other's cause. Specialization increases specialty autonomy and power but decentralizes the power base of physicians as a whole group.
Parts is Parts
There is another factor at work here which is also a derivative of the Flexner Report and that is the positive benefit of medical education and training standardization. The high tide raises all boats and that is what the Flexner Report did for medicine. This spirit spread to the residency and fellowhip training programs and lives on in the mission of the American Board of Medical Specialties (ABMS). This has the effect of allowing for personnel who are "interchangeable". That is not a word Physicians like to use but I believe it is a concept that patients use. Patients don't care where you trained or even where you ranked in your Medical School class. Some might ask if you are board certified but really most are only concerned with whether you accept there particular health insurance. That is not a failure of a Healthcare System; it is a success. The differences that physicians detect in the quality of healthcare are not as big a concern to the consumer as we would like to imagine. As we all know differences exist but to the average patient so do costs and that drives their decisions as much as it pains us to hear that point. Striking, for more pay or whatever, will only serve to alienate patients even more.
This is not the Age of Aquarius, Is It?
The key to solving the problems of today is to understand the age in which we live. I believe we are undergoing a transformation from an established paradigm for delivering healthcare to an emerging paradigm for delivering healthcare. If you have read any of my other posts you are probably sick of hearing this by now but it is worth repeating as it may hold the key to solving our healthcare crisis. This emerging paradigm predicts that our Healthcare System will appear different but will be better as a result of the change. As the patient-physician relationship is the cornerstone of the established paradigm this is were the greatest change will be generated. The physician/provider of the future will play a much different role. In doing so, physicians will change to meet the needs of the future. That change is occurring now.
You Don't Have a Real Job, Do You?
The supreme irony of this change is that physicians will ultimately become more organized and achieve more power as a result of it. I know what you're thinking, "Terry did you actually read any of what you just wrote? And by the way have you gotten a job yet?" Ok, ok quit giving me a hard time, the answers are yes and no. (But not necessarily in that order.) What I mean by that is organization and power will be held within the context of the emerging paradigm not the older established paradigm. Let me explain.
Are You Team Worthy?
Physicians of the future will function in a very different capacity than they currently do. Standardization of medical training allowed for development and specialization within healthcare. With specialization comes decentralization of a central power base for all physicians but increases it for specialties. I think this trend will continue. We gave up power as a group to achieve it as specialists. I think the next step is to transfer some of the power as specialists in order to achieve it personally. Professional autonomy will give way to personal autonomy. Physicians of the future will need to be more flexible and adaptable. This will provide greater freedom of choice. They will also relinquish control of their individualistic practice styles to make way for a team approach for delivering healthcare. The patient-information axis will become the cornerstone of the Healthcare System and it will be the Multidisciplinary Healthcare Teams that will be charged with administrating that care when call upon to do so. Since standardized Physician training will decrease heterogeneity for knowledge and skills, the ability to adapt and fit in with the team will become a priority for team fitness. The niche a team fills will be the basis for organizational growth and development for both the team and the team members. This may seem like a wild idea but I believe this system is changing for the better.
Wednesday, January 25, 2006
Trauma Surgery: A Victim of Its Own Success
Trauma Team to the Emergency Room!
Attempting to predict the future of medicine using current trend lines is a lot like evaluating a trauma patient. When evaluating a severely injured patient with multiple gun-shot wounds(GSW) in the Trauma Room you are faced with a large, continuous flow of data, of which, only a fraction will be of any use for determining how things will turn out. If you choose correctly the patient lives and you're a hero and if you choose incorrectly, well it doesn't go that way. The process is all about training, experience and pattern recognition. We were drawn into the discipline of Surgery because we enjoy "thinking on our feet" and using our hands to solve problems. When it goes well it is a tremendous rush and when it doesn't life sucks. The thrill of extracting the necessary details from a huge data stream, recognizing a pattern, making a decision and acting on that decision is what keeps us coming back to trauma. For better or worse it is also this skill set which got me to begin looking at patterns I see happening in medicine. As of yet I have avoiding looking at the field of Trauma Surgery and making any bold predictions. It is tempting to take a pass and say I don't have enough information to make any predictions yet, but then again if I did that I wouldn't be a Trauma Surgeon.
I Promise Only One Anecdote
Several years ago I was on call as an attending at a teaching hospital when I was asked to consult on a "sick" patient by one of the ED attendings. As I entered the ED we were alerted to the arrival of a trauma patient. I decided to check out the trauma patient first and walked up to the ambulance entrance with an intern and medical student. We were about thirty feet away from the back of the ambulance as we watched the EMT's unload the patient. I turned to the intern and said, "I want you to check this patient out, I'm going to go look at the 'sick' patient we were called about originally." As I walked away he said, "Are you sure?" I turned back and said, "Don't worry he's ok.", and kept walking. As it turned out he was ok and the "sick" patient was "sick" and needed an operation. Later that evening I was eating dinner with the Trauma Team and the Medical Student turned to me and asked me, "How did you do that? How could you look at someone from thirty feet away for a few seconds and know he was not seriously hurt?" It was a good question because up until then I just did it. I didn't bother to analyze that kind of thing. "Paralysis by analysis" as they say. The student was persistent and when I did reflect on it the answered surprised me as well as the student. What I noticed from that far away was that, despite full spinal precautions, the patient had his legs crossed at the ankles, knees slightly bent and hands clasped and resting on his abdomen. Commonly referred to as "positions of comfort". I also noticed how slowly the EMT's were moving and that all of them, patient included, were smiling and joking. Trauma by mechanism. He still needs to be assessed but does not fall into the category of a "sick" patient. All those years of Medical School, Surgical Residency, Trauma/Critical Care Fellowhip and sitting for the boards and here I am teaching common sense, that and the basics of pattern recognition.
Time to Reflect
Recently I've taken a sabbatical from my career as a Trauma Surgeon and have had some time to reflect on the field of Trauma Surgery. My first impression is similar to that when I see a "sick" patient. Somethings wrong only this time it is with the field of Trauma Surgery as it is currently practiced in much of the United States. It clearly has signs of life but is struggling. As I've mentioned in previous posts I believe this is happening across all of the disciplines in medicine. Some disciplines seem to have it worse than others. While I believe it is the same issue affecting all of us some disciplines also appear to be more vulnerable. For today I will limit my comments to Trauma, not only because it is the field I love the most, but also because I am concerned its status is approaching critical. Trauma Surgeons are becoming fewer and fewer. I used to consider that a sign of job security but not anymore. Trauma Surgeons are quitting trauma, retiring or dying. Many of the few braves souls left in the field tend to be bitter, disillusioned, older men, much like myself. Change the word "older" to "middle-age" and that pretty much describes me. So how does that happen? How do honest, well-trained, compassionate, hard-working professionals reach this point in their careers? I believe it is because we are victims; victims of our own success.
Time to Rock the Boat
We love to operate and we love to take care of sick and seriously injured patients. That is why we became Trauma Surgeons. Over the years we focused our efforts in Trauma Centers and that was good for the patients. The economics of assessing and treating victims of trauma were a disincentive for the non-trauma center hospitals which encouraged them to divert all victims of trauma , regardless of injury severity, to the Trauma Centers. Our Intensive Care Units and wards were overflowing and our Trauma Services were filling up fast. In that time operative rates plummeted, especially for those in an exclusive trauma practice. Prior to my sabbatical my most recent operative rate was 5.5%. When I excluded soft tissue cases it dropped to 3.8%. That means I was not performing major operations on 25/26 trauma patients I assessed. That may sound great for the patient but for an individual who loves to operate that is awful and not the best use of years of training to be a Surgeon. Now I would hope these kinds of numbers are not representative of the nation as a whole but I don't think they are that much different. Our patient distribution matched up closely to the numbers from the most recent National Trauma Data Bank (NTDB). Like the distribution in the NTDB most of our "Level 1" trauma patients had minor injury severity scores. Efforts to convince my colleagues that we need to address "overtriage" fell on deaf ears. As someone reminded me, "Terry, we're making a lot of money and you're making a lot of money, why do you want to rock this boat?" Oh, I don't know, maybe because this is wrong and not the best way to "run a railroad". Well, like I said I was getting bitter and decided to take some time off, to write and to reflect.
"It is difficult to get a man to understand something when his job depends on not understanding it."
Upton Sinclair (1878-1968)
We call trauma a "surgical disease" but I think that has done the field of Trauma Surgery a disservice. We have convinced everyone that we are the only ones who can take care of these patients. It is simply not true. Even in my fellowship we had many non-surgeons providing excellent care for trauma patients. We have created a system that has served the needs of our patients well. I am not convinced that we have done as good a job for ourselves. In our efforts to be everything to everyone we discourage those who would follow in our footsteps. Attrition has hurt the ranks of those in Trauma Surgery and has decimated the ranks of those who could be joining Trauma Surgery. They are voting with their feet long before we had a chance to hear their footsteps. The reasons are numerous and go beyond a low operative rate and managing (babysitting) a service of patients treated by other surgical specialties (Primarily Orthopedic Surgery, Neurosurgery and Plastic Surgery).
The Signs of Things to Come
So what patterns exist that may shed some light on all of this. As I have mentioned in previous posts I believe that the many changes in medicine we are experiencing are the effects produced by an emerging paradigm for healthcare delivery. The established paradigm for delivering healthcare services, including how we deliver trauma services, is undergoing a transformation. It is being driven by the Digital Revolution and the Information Age. The goal is to create a radically different but markedly better Healthcare System. In the process it is transforming the providers of the established paradigm into providers who will be better adapted to the emerging paradigm. I know what you're thinking, "Terry, you have had way to much time off. Get a job!" Well that much is true but I can't help recognizing and commenting on the patterns that I'm seeing.
Such As?
There are trends that I am sure we have all noticed in the recruitment of physicians. They tend to make the same set of promises. The Locum Tenens offers are some of the most revealing. They typically use the term "flexible" which is code for "life style". The phrase older physicians tend to loathe. They offer part-time and even shift work for surgeons. They offer "travel and adventure". In order to do this they facilitate portability. That is another way of saying that they take care of credentialing and licensing. They take care of liability insurance, travel and lodging expenses. Payment for services is usually within weeks of the service provided. They offer greater choice in practice options and the list goes on. I don't think Locum Tenens is necessarily the future for all providers but I believe they are offering the conditions that will be necessary for future providers practicing in the emerging paradigm. Think of the buzz words and phrases being floated around in these ads and withhold judgment because I think they are really trying to tell us what the future of medicine is going to look like. Flexible. Portable. Freedom of choice. Predictable scheduling. Team work. Shift work. Adjustable practice style. Variable assignments. No overhead or administrative concerns. Medical liability covered. Remain independent. Entrepreneurial. Adventurous. Likes to travel. Comfortable meeting new people. Detail oriented. Adaptable. Competent. Skillfull. Full and timely payment for services rendered. Focus on patient care. Time with family. Healthy lifestyle. Too good to be true? I think the ads are but you have to admit they are definitely shaping the minds of those who will be a part of the future of medicine.
Attempting to predict the future of medicine using current trend lines is a lot like evaluating a trauma patient. When evaluating a severely injured patient with multiple gun-shot wounds(GSW) in the Trauma Room you are faced with a large, continuous flow of data, of which, only a fraction will be of any use for determining how things will turn out. If you choose correctly the patient lives and you're a hero and if you choose incorrectly, well it doesn't go that way. The process is all about training, experience and pattern recognition. We were drawn into the discipline of Surgery because we enjoy "thinking on our feet" and using our hands to solve problems. When it goes well it is a tremendous rush and when it doesn't life sucks. The thrill of extracting the necessary details from a huge data stream, recognizing a pattern, making a decision and acting on that decision is what keeps us coming back to trauma. For better or worse it is also this skill set which got me to begin looking at patterns I see happening in medicine. As of yet I have avoiding looking at the field of Trauma Surgery and making any bold predictions. It is tempting to take a pass and say I don't have enough information to make any predictions yet, but then again if I did that I wouldn't be a Trauma Surgeon.
I Promise Only One Anecdote
Several years ago I was on call as an attending at a teaching hospital when I was asked to consult on a "sick" patient by one of the ED attendings. As I entered the ED we were alerted to the arrival of a trauma patient. I decided to check out the trauma patient first and walked up to the ambulance entrance with an intern and medical student. We were about thirty feet away from the back of the ambulance as we watched the EMT's unload the patient. I turned to the intern and said, "I want you to check this patient out, I'm going to go look at the 'sick' patient we were called about originally." As I walked away he said, "Are you sure?" I turned back and said, "Don't worry he's ok.", and kept walking. As it turned out he was ok and the "sick" patient was "sick" and needed an operation. Later that evening I was eating dinner with the Trauma Team and the Medical Student turned to me and asked me, "How did you do that? How could you look at someone from thirty feet away for a few seconds and know he was not seriously hurt?" It was a good question because up until then I just did it. I didn't bother to analyze that kind of thing. "Paralysis by analysis" as they say. The student was persistent and when I did reflect on it the answered surprised me as well as the student. What I noticed from that far away was that, despite full spinal precautions, the patient had his legs crossed at the ankles, knees slightly bent and hands clasped and resting on his abdomen. Commonly referred to as "positions of comfort". I also noticed how slowly the EMT's were moving and that all of them, patient included, were smiling and joking. Trauma by mechanism. He still needs to be assessed but does not fall into the category of a "sick" patient. All those years of Medical School, Surgical Residency, Trauma/Critical Care Fellowhip and sitting for the boards and here I am teaching common sense, that and the basics of pattern recognition.
Time to Reflect
Recently I've taken a sabbatical from my career as a Trauma Surgeon and have had some time to reflect on the field of Trauma Surgery. My first impression is similar to that when I see a "sick" patient. Somethings wrong only this time it is with the field of Trauma Surgery as it is currently practiced in much of the United States. It clearly has signs of life but is struggling. As I've mentioned in previous posts I believe this is happening across all of the disciplines in medicine. Some disciplines seem to have it worse than others. While I believe it is the same issue affecting all of us some disciplines also appear to be more vulnerable. For today I will limit my comments to Trauma, not only because it is the field I love the most, but also because I am concerned its status is approaching critical. Trauma Surgeons are becoming fewer and fewer. I used to consider that a sign of job security but not anymore. Trauma Surgeons are quitting trauma, retiring or dying. Many of the few braves souls left in the field tend to be bitter, disillusioned, older men, much like myself. Change the word "older" to "middle-age" and that pretty much describes me. So how does that happen? How do honest, well-trained, compassionate, hard-working professionals reach this point in their careers? I believe it is because we are victims; victims of our own success.
Time to Rock the Boat
We love to operate and we love to take care of sick and seriously injured patients. That is why we became Trauma Surgeons. Over the years we focused our efforts in Trauma Centers and that was good for the patients. The economics of assessing and treating victims of trauma were a disincentive for the non-trauma center hospitals which encouraged them to divert all victims of trauma , regardless of injury severity, to the Trauma Centers. Our Intensive Care Units and wards were overflowing and our Trauma Services were filling up fast. In that time operative rates plummeted, especially for those in an exclusive trauma practice. Prior to my sabbatical my most recent operative rate was 5.5%. When I excluded soft tissue cases it dropped to 3.8%. That means I was not performing major operations on 25/26 trauma patients I assessed. That may sound great for the patient but for an individual who loves to operate that is awful and not the best use of years of training to be a Surgeon. Now I would hope these kinds of numbers are not representative of the nation as a whole but I don't think they are that much different. Our patient distribution matched up closely to the numbers from the most recent National Trauma Data Bank (NTDB). Like the distribution in the NTDB most of our "Level 1" trauma patients had minor injury severity scores. Efforts to convince my colleagues that we need to address "overtriage" fell on deaf ears. As someone reminded me, "Terry, we're making a lot of money and you're making a lot of money, why do you want to rock this boat?" Oh, I don't know, maybe because this is wrong and not the best way to "run a railroad". Well, like I said I was getting bitter and decided to take some time off, to write and to reflect.
"It is difficult to get a man to understand something when his job depends on not understanding it."
Upton Sinclair (1878-1968)
We call trauma a "surgical disease" but I think that has done the field of Trauma Surgery a disservice. We have convinced everyone that we are the only ones who can take care of these patients. It is simply not true. Even in my fellowship we had many non-surgeons providing excellent care for trauma patients. We have created a system that has served the needs of our patients well. I am not convinced that we have done as good a job for ourselves. In our efforts to be everything to everyone we discourage those who would follow in our footsteps. Attrition has hurt the ranks of those in Trauma Surgery and has decimated the ranks of those who could be joining Trauma Surgery. They are voting with their feet long before we had a chance to hear their footsteps. The reasons are numerous and go beyond a low operative rate and managing (babysitting) a service of patients treated by other surgical specialties (Primarily Orthopedic Surgery, Neurosurgery and Plastic Surgery).
The Signs of Things to Come
So what patterns exist that may shed some light on all of this. As I have mentioned in previous posts I believe that the many changes in medicine we are experiencing are the effects produced by an emerging paradigm for healthcare delivery. The established paradigm for delivering healthcare services, including how we deliver trauma services, is undergoing a transformation. It is being driven by the Digital Revolution and the Information Age. The goal is to create a radically different but markedly better Healthcare System. In the process it is transforming the providers of the established paradigm into providers who will be better adapted to the emerging paradigm. I know what you're thinking, "Terry, you have had way to much time off. Get a job!" Well that much is true but I can't help recognizing and commenting on the patterns that I'm seeing.
Such As?
There are trends that I am sure we have all noticed in the recruitment of physicians. They tend to make the same set of promises. The Locum Tenens offers are some of the most revealing. They typically use the term "flexible" which is code for "life style". The phrase older physicians tend to loathe. They offer part-time and even shift work for surgeons. They offer "travel and adventure". In order to do this they facilitate portability. That is another way of saying that they take care of credentialing and licensing. They take care of liability insurance, travel and lodging expenses. Payment for services is usually within weeks of the service provided. They offer greater choice in practice options and the list goes on. I don't think Locum Tenens is necessarily the future for all providers but I believe they are offering the conditions that will be necessary for future providers practicing in the emerging paradigm. Think of the buzz words and phrases being floated around in these ads and withhold judgment because I think they are really trying to tell us what the future of medicine is going to look like. Flexible. Portable. Freedom of choice. Predictable scheduling. Team work. Shift work. Adjustable practice style. Variable assignments. No overhead or administrative concerns. Medical liability covered. Remain independent. Entrepreneurial. Adventurous. Likes to travel. Comfortable meeting new people. Detail oriented. Adaptable. Competent. Skillfull. Full and timely payment for services rendered. Focus on patient care. Time with family. Healthy lifestyle. Too good to be true? I think the ads are but you have to admit they are definitely shaping the minds of those who will be a part of the future of medicine.
Tuesday, January 24, 2006
Enabling the Paradigm Shift in Healthcare
Birthing a New Healthcare System
In order for an emerging paradigm in healthcare to overtake the currently established healthcare system, enabling technologies are required. What we see as our healthcare crisis is , at times, the painful birth of a radically different way of delivering healthcare. Throughout the internet discussion groups, websites and blogs and on out to the hallways, lounges and lecture halls of hospitals and clinics I hear the cry for a paradigm shift. Well, here's a newsflash; it's already here. We are experiencing it right now. What we are witnessing is the initial rollout of the long awaited paradigm shift everyone, ok maybe just some of us, have been demanding. The Digital Revolution enabled the Information Age , and now both are in the process of creating a Healthcare System the likes of which will alter our entire approach to medicine. When it is up and fully operational we will know it when we see it. As Thomas Kuhn, who coined the all too often quoted phrase "paradigm shift" said, it is "always better, not just different."
Artificial Intelligence and the Virtual Provider
The patient-physician relationship is the cornerstone of the current Healthcare System model and I believe will be a focal point of change for the emerging Healthcare System. Physicians have acted as gatekeepers to the Healthcare System for patients and as a cornerstone of that system have performed their role admirably over the years. Times are changing and with those changes we must ask ourselves, can this role be, in part or even completely fulfilled by an alternative source? I think we know the answer to that question already. The alternative source comes in the form of Nurse Practitioners (NP) and Physician Assistants (PA) that are already at work in places like Minute-Clinic. In time Artificial Intelligence (AI) with highly developed algorithms embedded in their software will assume these roles as well. I think people will be initially attracted by the convenience, low-cost and accessibility to the services provided by AI. Over time as these technologies prove themselves with patient satisfaction as well as improved outcomes society will demand that they be incorporated into the more complex levels of the emerging Healthcare System. I don't' think people will be interacting with a laptop or even a Hal 9000 but are more likely to engage a provider in a virtual reality setting. Patients will choose the type of provider they prefer based on their unique style. This will include things like age, sex, ethnicity, and personality. A virtual provider could even be some futuristic being from Star Wars like "Dr. Yoda" or if your mood prefers, try paging "Dr. Moe, Dr. Larry or Dr. Curly". Then again, I wouldn't recommend their ear exam. Nyuck, Nyuck, Nyuck.
Standardized Medical Record
Access, connectivity and storage of healthcare information will play a key role in the emerging paradigm of our Healthcare system. The current "Medical Records Department" approach to storing and communicating patient health information needs to go. Health records are slowly, and I might add painfully, transitioning to an electronic format. A standardized way to electronically exchange data will be an essential step. Hospitals and Clinics will no longer need to ask the same old questions for each visit. Standardizing the format of the electronic medical record and storing it at an off-site facility will make life easier for patients and providers. It will no longer be locked-up in the basement of St. Elsewhere's Medical Record Department; it is the patient's permanent record and is accessible from anywhere in the world. Think of the advantages of portability. The recent hurricane season taught us important lessons regarding the emergent need to move hundreds of thousands of people whose medical records are now permanently lost. Off-site storage and back-up of electronic medical records is becoming the answer to national disasters and patient portability.
National Health Information Network
Recent efforts to accomplish this in the form of Regional Health Information Organizations (RHIO's) have been slow to develop. There has been local resistance to this approach as hospitals and independent health networks are more interested in developing their own version of an Electronic Health Record (EHR) and do not have any outside incentive to share data. This will be changing in the near future as the Department of Health and Human Services recently awarded four contracts for the development of a prototype National Health Information Network (NHIN). Dr. David Brailer the National Coordinator for Health Information Technology said, "Eventually physicians and hospitals will buy electronic medical records software with the network connectivity tools embedded." Patients will provide access to their medical record at the point of care.
Will The Thought Police Patrol This Highway?
A single, unified and standardized system is where it is headed. It is reminiscent of what was done for the National Highway System. This started out as a grassroots effort which was developed by the state and local authorities. It eventually grew and prompted the Interstate Highway Act in 1956. By assuming the responsibility of the interstate highway system this allowed local governments to focus on other priorities. I know what your thinking, "Terry are you out of your mind? This is the beginning of Big Brother and Socialized Medicine." I don't think so. While I am hesitant to turn over that amount of data about the personal aspects of our health histories to the federal government some degree of involvement on the part of the feds is going to be needed to encourage the local health care entities to make our records electronically portable and secure. The National Highway System became critical for our economic, defense and transportation sectors and I think a National Health Information Network will play just as important a role in the healthcare sector. It will have its own share of problems but I believe it will move us forward. If this is truly a paradigm shift it will not only look different but more importantly it will be better. That is how we will know if is the real thing or not.
In order for an emerging paradigm in healthcare to overtake the currently established healthcare system, enabling technologies are required. What we see as our healthcare crisis is , at times, the painful birth of a radically different way of delivering healthcare. Throughout the internet discussion groups, websites and blogs and on out to the hallways, lounges and lecture halls of hospitals and clinics I hear the cry for a paradigm shift. Well, here's a newsflash; it's already here. We are experiencing it right now. What we are witnessing is the initial rollout of the long awaited paradigm shift everyone, ok maybe just some of us, have been demanding. The Digital Revolution enabled the Information Age , and now both are in the process of creating a Healthcare System the likes of which will alter our entire approach to medicine. When it is up and fully operational we will know it when we see it. As Thomas Kuhn, who coined the all too often quoted phrase "paradigm shift" said, it is "always better, not just different."
Artificial Intelligence and the Virtual Provider
The patient-physician relationship is the cornerstone of the current Healthcare System model and I believe will be a focal point of change for the emerging Healthcare System. Physicians have acted as gatekeepers to the Healthcare System for patients and as a cornerstone of that system have performed their role admirably over the years. Times are changing and with those changes we must ask ourselves, can this role be, in part or even completely fulfilled by an alternative source? I think we know the answer to that question already. The alternative source comes in the form of Nurse Practitioners (NP) and Physician Assistants (PA) that are already at work in places like Minute-Clinic. In time Artificial Intelligence (AI) with highly developed algorithms embedded in their software will assume these roles as well. I think people will be initially attracted by the convenience, low-cost and accessibility to the services provided by AI. Over time as these technologies prove themselves with patient satisfaction as well as improved outcomes society will demand that they be incorporated into the more complex levels of the emerging Healthcare System. I don't' think people will be interacting with a laptop or even a Hal 9000 but are more likely to engage a provider in a virtual reality setting. Patients will choose the type of provider they prefer based on their unique style. This will include things like age, sex, ethnicity, and personality. A virtual provider could even be some futuristic being from Star Wars like "Dr. Yoda" or if your mood prefers, try paging "Dr. Moe, Dr. Larry or Dr. Curly". Then again, I wouldn't recommend their ear exam. Nyuck, Nyuck, Nyuck.
Standardized Medical Record
Access, connectivity and storage of healthcare information will play a key role in the emerging paradigm of our Healthcare system. The current "Medical Records Department" approach to storing and communicating patient health information needs to go. Health records are slowly, and I might add painfully, transitioning to an electronic format. A standardized way to electronically exchange data will be an essential step. Hospitals and Clinics will no longer need to ask the same old questions for each visit. Standardizing the format of the electronic medical record and storing it at an off-site facility will make life easier for patients and providers. It will no longer be locked-up in the basement of St. Elsewhere's Medical Record Department; it is the patient's permanent record and is accessible from anywhere in the world. Think of the advantages of portability. The recent hurricane season taught us important lessons regarding the emergent need to move hundreds of thousands of people whose medical records are now permanently lost. Off-site storage and back-up of electronic medical records is becoming the answer to national disasters and patient portability.
National Health Information Network
Recent efforts to accomplish this in the form of Regional Health Information Organizations (RHIO's) have been slow to develop. There has been local resistance to this approach as hospitals and independent health networks are more interested in developing their own version of an Electronic Health Record (EHR) and do not have any outside incentive to share data. This will be changing in the near future as the Department of Health and Human Services recently awarded four contracts for the development of a prototype National Health Information Network (NHIN). Dr. David Brailer the National Coordinator for Health Information Technology said, "Eventually physicians and hospitals will buy electronic medical records software with the network connectivity tools embedded." Patients will provide access to their medical record at the point of care.
Will The Thought Police Patrol This Highway?
A single, unified and standardized system is where it is headed. It is reminiscent of what was done for the National Highway System. This started out as a grassroots effort which was developed by the state and local authorities. It eventually grew and prompted the Interstate Highway Act in 1956. By assuming the responsibility of the interstate highway system this allowed local governments to focus on other priorities. I know what your thinking, "Terry are you out of your mind? This is the beginning of Big Brother and Socialized Medicine." I don't think so. While I am hesitant to turn over that amount of data about the personal aspects of our health histories to the federal government some degree of involvement on the part of the feds is going to be needed to encourage the local health care entities to make our records electronically portable and secure. The National Highway System became critical for our economic, defense and transportation sectors and I think a National Health Information Network will play just as important a role in the healthcare sector. It will have its own share of problems but I believe it will move us forward. If this is truly a paradigm shift it will not only look different but more importantly it will be better. That is how we will know if is the real thing or not.
Monday, January 23, 2006
Patient v. Doctor: Two Men Enter, One Man Leave
"Adversarial"
This the word I hear most often from physicians to describe the patient-physician relationship. Simply put, it means involving antagonistic parties or interests. The fundamental element of the modern day healthcare system was and continues to be established on this relationship and yet this word has crept into our lexicon as a way to best describe it. Clinics, exam rooms, emergency departments, operating rooms, intensive care units and the wards are our initial fields of engagement. In so doing we approach each encounter as a mini "Thunderdome". The patient and their doctor enter into an encounter and one is expected to win and the other to lose. The crowd roars in unison, "Two men enter, one man leave". Despite major advances across all disciplines in medicine physicians are no longer trusted to assure safe and effective care.
Patient advocacy, it is perceived, is secured, not from the compassion of the physician, but from the sword of the attorney.
If physicians continue to see patients as potential adversaries the essence of the relationship is destroyed. It's too easy to say, "but they started it". All relationships are a two way street. Both sides played a role in this massive arms build-up and both sides must be involved in its eventual resolution. So is it time to part ways? Or as Stephen R. Covey suggests, if we can't reach a win-win deal then it may be time for no deal. Our instincts for potential adversaries is so highly tuned it is almost impossible to meet a person, think of them as an adversary, and not communicate that to them in some way through our style of interaction. Is this the message patients and physicians are silently communicating to one another?
Something changed.
Throughout much of modern history the patient-physician relationship has been a central feature of the current healthcare system paradigm. It was based on trust. There was a value for value exchange. Using a combination of their intellect, training, skills and experience physicians provided the means, as best they could, for patients to overcome or at least manage their illness or injury. In return patients provided, as best they could, payment in the form of money, esteem, status or a sense of achievement and contribution on the part of the physician. For centuries this model worked well, both parties benefited. It was a win-win deal. Over the latter half of the 20th century it slowly became a win-lose deal characterized by an adversarial environment. The trust is broken on both sides. Physicians are expected to act like Marcus Welby, MD but more frequently find themselves preparing for a potential complaint or lawsuit before the encounter occurs.
Pistols at Twenty Paces
If an encounter results in a complaint, claim or lawsuit we manage to turn it into a modern day duel. In the old days after an insult to one's honor a duel was considered a "respectable and acceptable manner to resolve disputes". After an offence occurred, "whether real or imagined, the offended party would demand 'satisfaction' from the offender". The physician, I mean offender, then had three choices.
1) Public apology
2) Restitution
3) Choosing weapons for the duel
Choices number one or two were non-violent means of resolving disputes. Choice number three was an entirely different matter. The winner of a duel was considered a hero and was accorded increased social status. Failure to show up to fight in a duel was considered an act of cowardice. Honor meant something then and I think it still does today. Dueling was outlawed years ago and the primary method of resolving disputes is though our legal system. We still expect a winner and hero to emerge from these disputes. The problem is when we allow ourselves to relate to people as potential adversaries we set ourselves up for the inevitable showdown. We are seeing the gauntlet thrown down before doctor and patient meet. Many in the medical profession feel the problem is physicians are not communicating well enough with patients when it may be that they are reading us loud and clear. We consider them future adversaries. Patients are also accused of not being very good at communication. I suspect that is equally misunderstood as well. Physicians are reading them loud and clear. They don't trust us and unfortunately the patient-physician relationship depends on trust. What is more concerning is that the current paradigm of healthcare depends on the patient-physician relationship.
Circle the Wagons
The patient-physician relationship is what I believe is under attack. It is the cornerstone of the established paradigm for our healthcare system. It is exactly where a truly challenging and emerging paradigm must strike in order to become established. If that is the case then the patient-physician relationship is undergoing a fundamental transformation. Whatever form it takes must conserve the essential elements of the relationship. It depends on the patient's trust in the intellect, training, skills and experience of the source providing the healthcare service. A new paradigm for healthcare will continue to provide these services but its form will be different, radically different. The source of the services provided may be at the heart of what will appear radically different.
Essential Elements for a New Healthcare System
1) Be easily accessible
2) Always maintain the highest standards of care
3) Cost a fraction of the current healthcare system
4) Support transparent and accessible quality of care standards on all healthcare entities
5) Maintain a universal health care record
6) Produce outcomes that far surpass current best standards
7) Resolve disputes in a win-win manner
8) Transformed source of healthcare services
Oh Yea, One Last Thing
There is one other thing that I predict about the form of a truly new paradigm for delivering healthcare. It will most likely involve a markedly diminished role for both physicians and attorneys. Sorry but that is just how I feel about it. The essential element, and therefore the most conserved part of the current healthcare system, is that it was created primarily for patients, not for physicians and attorneys. It may be in order for our Healthcare System to survive it will need to jettison unessential baggage and personnel. If physicians and attorneys continue to consume time, energy and resources in these ugly battles in Bartertown it will ultimately be the patient who walks out of Thunderdome the survivor.
This the word I hear most often from physicians to describe the patient-physician relationship. Simply put, it means involving antagonistic parties or interests. The fundamental element of the modern day healthcare system was and continues to be established on this relationship and yet this word has crept into our lexicon as a way to best describe it. Clinics, exam rooms, emergency departments, operating rooms, intensive care units and the wards are our initial fields of engagement. In so doing we approach each encounter as a mini "Thunderdome". The patient and their doctor enter into an encounter and one is expected to win and the other to lose. The crowd roars in unison, "Two men enter, one man leave". Despite major advances across all disciplines in medicine physicians are no longer trusted to assure safe and effective care.
Patient advocacy, it is perceived, is secured, not from the compassion of the physician, but from the sword of the attorney.
If physicians continue to see patients as potential adversaries the essence of the relationship is destroyed. It's too easy to say, "but they started it". All relationships are a two way street. Both sides played a role in this massive arms build-up and both sides must be involved in its eventual resolution. So is it time to part ways? Or as Stephen R. Covey suggests, if we can't reach a win-win deal then it may be time for no deal. Our instincts for potential adversaries is so highly tuned it is almost impossible to meet a person, think of them as an adversary, and not communicate that to them in some way through our style of interaction. Is this the message patients and physicians are silently communicating to one another?
Something changed.
Throughout much of modern history the patient-physician relationship has been a central feature of the current healthcare system paradigm. It was based on trust. There was a value for value exchange. Using a combination of their intellect, training, skills and experience physicians provided the means, as best they could, for patients to overcome or at least manage their illness or injury. In return patients provided, as best they could, payment in the form of money, esteem, status or a sense of achievement and contribution on the part of the physician. For centuries this model worked well, both parties benefited. It was a win-win deal. Over the latter half of the 20th century it slowly became a win-lose deal characterized by an adversarial environment. The trust is broken on both sides. Physicians are expected to act like Marcus Welby, MD but more frequently find themselves preparing for a potential complaint or lawsuit before the encounter occurs.
Pistols at Twenty Paces
If an encounter results in a complaint, claim or lawsuit we manage to turn it into a modern day duel. In the old days after an insult to one's honor a duel was considered a "respectable and acceptable manner to resolve disputes". After an offence occurred, "whether real or imagined, the offended party would demand 'satisfaction' from the offender". The physician, I mean offender, then had three choices.
1) Public apology
2) Restitution
3) Choosing weapons for the duel
Choices number one or two were non-violent means of resolving disputes. Choice number three was an entirely different matter. The winner of a duel was considered a hero and was accorded increased social status. Failure to show up to fight in a duel was considered an act of cowardice. Honor meant something then and I think it still does today. Dueling was outlawed years ago and the primary method of resolving disputes is though our legal system. We still expect a winner and hero to emerge from these disputes. The problem is when we allow ourselves to relate to people as potential adversaries we set ourselves up for the inevitable showdown. We are seeing the gauntlet thrown down before doctor and patient meet. Many in the medical profession feel the problem is physicians are not communicating well enough with patients when it may be that they are reading us loud and clear. We consider them future adversaries. Patients are also accused of not being very good at communication. I suspect that is equally misunderstood as well. Physicians are reading them loud and clear. They don't trust us and unfortunately the patient-physician relationship depends on trust. What is more concerning is that the current paradigm of healthcare depends on the patient-physician relationship.
Circle the Wagons
The patient-physician relationship is what I believe is under attack. It is the cornerstone of the established paradigm for our healthcare system. It is exactly where a truly challenging and emerging paradigm must strike in order to become established. If that is the case then the patient-physician relationship is undergoing a fundamental transformation. Whatever form it takes must conserve the essential elements of the relationship. It depends on the patient's trust in the intellect, training, skills and experience of the source providing the healthcare service. A new paradigm for healthcare will continue to provide these services but its form will be different, radically different. The source of the services provided may be at the heart of what will appear radically different.
Essential Elements for a New Healthcare System
1) Be easily accessible
2) Always maintain the highest standards of care
3) Cost a fraction of the current healthcare system
4) Support transparent and accessible quality of care standards on all healthcare entities
5) Maintain a universal health care record
6) Produce outcomes that far surpass current best standards
7) Resolve disputes in a win-win manner
8) Transformed source of healthcare services
Oh Yea, One Last Thing
There is one other thing that I predict about the form of a truly new paradigm for delivering healthcare. It will most likely involve a markedly diminished role for both physicians and attorneys. Sorry but that is just how I feel about it. The essential element, and therefore the most conserved part of the current healthcare system, is that it was created primarily for patients, not for physicians and attorneys. It may be in order for our Healthcare System to survive it will need to jettison unessential baggage and personnel. If physicians and attorneys continue to consume time, energy and resources in these ugly battles in Bartertown it will ultimately be the patient who walks out of Thunderdome the survivor.
Sunday, January 22, 2006
Wake-up Doctor, Your Paradigm Shift is Almost Over
The central theme of this blog is that what we perceive as a healthcare crisis is really the turmoil produced by a major paradigm shift on how healthcare will be achieved in the near future. It implies that there is an established paradigm that is undergoing a radical change as a result of forces generated from an emerging paradigm. Those forces are largely being felt at the level of the patient-physician relationship. Physicians have played a key role in this relationship for thousands of years however lately they appear to be under attack and are fighting back. In yesterday's blog I proposed that in order to drive costs down for specific services a gradual shift is being introduced from relatively high cost providers (MD/DO) to relatively low cost providers (NP/PA). This shift would culminate in the transfer of these services to a form of artificial intelligence (AI). I know this sounds strange and maybe a little paranoid but it wouldn't be the first time a highly valued member of the community was displaced as the result of a major paradigm shift.
Is it really possible for a society to phase out someone so esteemed and valued as a physician? I think American society already has done this in the past. It happened during the Industrial Revolution and that esteemed and valued member was the blacksmith. The history of the blacksmith is illustrative of what physicians can expect. A blacksmith is a person who, by definition, works with iron. They were the toolmakers and every town needed them. A communities survival depended on their presence. In the colonial days 90% of the population were farmers. In order to work the land you needed tools. The blacksmith forged these tools and just as importantly repaired them when they broke. They enabled the very existence of an agrarian society. Henry Wadsworth Longfellow eulogized these tradesman in his famous poem,
The Village Blacksmith.
Toiling,---rejoicing,---sorrowing,
Onward through life he goes;
Each morning sees some task begin,
Each evening sees it close;
Something attempted, something done,
Has earned a night's repose.
Thanks, thanks to thee, my worthy friend,
For the lesson though hast taught!
Thus at the flaming gorge of life,
Our fortunes must be wrought;
Thus on its sounding anvil shaped,
Each burning deed and thought!
As the Industrial Revolution gained momentum the blacksmith was favored heavily as the advancements in the iron industry progressed. His earnings and productivity gained early on as his skills developed. These same skills were then used to build the machines that made the tools and other products he formerly produced with his hammer, anvil and fire. This was also his undoing. I have heard it said it was the mass production of automobiles introduced by Henry Ford that put the majority of blacksmiths out of business for good. Going from the horse and buggy to the horseless carriage was another paradigm shift to contend with but I think the writing was on the wall long before Mr. Ford opened shop in Detroit. I think it began when the blacksmiths helped build the very machines that would one day deliver goods and services for which they were once highly valued. It can happen again.
If we are undergoing a paradigm shift in healthcare I suspect it will be the physician whose time has peaked. So what will come of us? If we ultimately turn over the intellectual services we provide to patients to artificial intelligence then what is left for us to do? I don't have the long-term answer but I think there will still be plenty to do in the short-term to keep us busy. Such as:
1) We will continue to build, refine and work with the AI that will serve the needs of patients.
2) We will continue to provide those services where AI cannot function as safely or efficaciously.
3) We will continue to provide the human contact that cannot be embedded in the algorithms of AI.
4) We will continue to adapt our skills and talents to new enterprises as the emerging paradigm reveals itself.
5) We will continue to teach, inspire, innovate, laugh and enjoy life more than ever.
Is it really possible for a society to phase out someone so esteemed and valued as a physician? I think American society already has done this in the past. It happened during the Industrial Revolution and that esteemed and valued member was the blacksmith. The history of the blacksmith is illustrative of what physicians can expect. A blacksmith is a person who, by definition, works with iron. They were the toolmakers and every town needed them. A communities survival depended on their presence. In the colonial days 90% of the population were farmers. In order to work the land you needed tools. The blacksmith forged these tools and just as importantly repaired them when they broke. They enabled the very existence of an agrarian society. Henry Wadsworth Longfellow eulogized these tradesman in his famous poem,
The Village Blacksmith.
Toiling,---rejoicing,---sorrowing,
Onward through life he goes;
Each morning sees some task begin,
Each evening sees it close;
Something attempted, something done,
Has earned a night's repose.
Thanks, thanks to thee, my worthy friend,
For the lesson though hast taught!
Thus at the flaming gorge of life,
Our fortunes must be wrought;
Thus on its sounding anvil shaped,
Each burning deed and thought!
As the Industrial Revolution gained momentum the blacksmith was favored heavily as the advancements in the iron industry progressed. His earnings and productivity gained early on as his skills developed. These same skills were then used to build the machines that made the tools and other products he formerly produced with his hammer, anvil and fire. This was also his undoing. I have heard it said it was the mass production of automobiles introduced by Henry Ford that put the majority of blacksmiths out of business for good. Going from the horse and buggy to the horseless carriage was another paradigm shift to contend with but I think the writing was on the wall long before Mr. Ford opened shop in Detroit. I think it began when the blacksmiths helped build the very machines that would one day deliver goods and services for which they were once highly valued. It can happen again.
If we are undergoing a paradigm shift in healthcare I suspect it will be the physician whose time has peaked. So what will come of us? If we ultimately turn over the intellectual services we provide to patients to artificial intelligence then what is left for us to do? I don't have the long-term answer but I think there will still be plenty to do in the short-term to keep us busy. Such as:
1) We will continue to build, refine and work with the AI that will serve the needs of patients.
2) We will continue to provide those services where AI cannot function as safely or efficaciously.
3) We will continue to provide the human contact that cannot be embedded in the algorithms of AI.
4) We will continue to adapt our skills and talents to new enterprises as the emerging paradigm reveals itself.
5) We will continue to teach, inspire, innovate, laugh and enjoy life more than ever.
Saturday, January 21, 2006
Where's the Beef?
It's my impression that the health care crisis we are experiencing is really a paradigm shift. The current older, traditional and fully established model for delivering health care is grudgingly giving way to an emerging model. I have to admit when this first occurred to me I was using nothing more than gut instinct to guide this impression. It may not seem like much but it was just enough to allow me to drop my pre-existing ideas about the causes of much of the problems in medicine. More importantly it gave me the freedom to explore different reasons for the current state of affairs rather than succumb to the usual rhetoric heard within the medical culture. It is not uncommon to hear of just about anyone involved in the health industry today as greedy, selfish, uncaring, incompetent, parasitic, incapable, needy, whining and inhuman. The list goes on and each of these words is used to describe doctors, lawyers, nurses, hospital administrators, insurance companies, pharmaceutical companies, CEO's, politicians, and even patients. Are we all really that terrible? I don't think so. Have you ever walked into a very warm environment? Let's say a committee meeting room and the air conditioning wasn't working. No sooner does the meeting start and everyone is at each other's throat. If you're fortunate and the air conditioner turns on and the room cools off, what happens. The meeting calms down and everyone starts treating each other more cordially. I think an emerging paradigm for health care delivery is the source of our discord. It is the factor we can not see but can certainly feel. I haven't convinced you have I? Let me try it from a different approach. You decide if I'm on to something here or not?
In medical school I was taught that the fundamental basis of our health care system was built upon the patient-physician relationship. That bond was the focal point. Without it and the entire system would collapse. A patient would develop a symptom of a disease process and seek the advice and treatment from a physician. The physician would diagnose the disease process and prescribe a treatment. It was a very simple formula and it works most of the time. It has served the interests of both patient and doctor very well for hundreds if not thousands of years. This fundamental relationship is under attack. There are two main reasons for it and both have to do with the rising costs in medicine.
The first cost to be dealt with is the cost of the encounter with a physician. Managed care and Medicare have whittled away at this for years but there is only so much they can do in the long run. The costs of medical school, residency, medical liability, and practice overhead continue to rise. Physicians are beginning to cost too much for certain services. The solution is to change the nature of the encounter from patient-physician to patient-provider. A provider can be a physician (MD/DO) or they can be a nurse practitioner (NP) or physician's assistant (PA). It doesn't take as much to train an NP or PA so each patient-provider encounter will not cost as much. An interesting model for this is beginning to develop in several major cities in the United States in the form of Minute Clinic. These are clinics that are based in either the bigboxes (Target, Cub Foods Store) or major pharmacies (CVS, Bartell Drugs). They are walk-in clinics that target common, relatively easy to treat illnesses (e.g. sore throat, ear infection, bladder infection). They promise quick, affordable and convenient care. While the clinics are overseen by an off-site physician, they are run by NP's and PA's. You can walk in, go shopping, be evaluated for your bladder infection and walk out with your groceries and prescription in hand. The entire encounter is guided by proprietary software (Artificial Intelligence) embedded in their electronic medical record (EMR) which is based on national clinical practice guidelines. These guidelines are thanks to the hard work of The American Academy of Family Practice, The American Academy of Pediatrics and The Institute for Clinical Systems Improvements. Interestingly they promise "autonomy of practice" on their web site for the NP's and PA's they are recruiting as future employees. I'm not sure how they can say this when the artificial intelligence is guiding the patient-provider encounter. It kind of reminds me of the old Texas politician who once said, "If these boys get any smarter we're going to have to water them twice a week." OUCH! Oh who am I to judge? They will be getting great benefits and of course flexible scheduling. (Sorry, there I go again, waaa, waaa, waaa.)
The second cost that will be addressed with this type of approach is probably the more important of the two and I alluded to it in the above paragraph. A few years ago an older, wiser doctor once pointed out to me that most of the direct costs of medicine flow from the physician's pen. What he meant by that was the treatments and prescriptions we write for our patients are what drive the costs in medicine. In the old days hospital admission orders, drug prescriptions, physical therapy, consultants, operations, length of stay and outpatient clinics and rehab referrals all came as a result of what the physician recommended. Control the pen and you control the costs in medicine. Again, managed care and Medicare whittled away at this but they are beginning to reach the point of diminishing returns. What if, instead of physicians driving this process we displaced them with someone who could be guided? Maybe someone who is willing to work for much less? Maybe in time patients will come to trust the artificial intelligence guiding the encounter and would be willing to be assessed by someone of even less training and cost? It could happen and I believe is happening. I think this is a trend line and there are sure to be others if this is the direction the emerging paradigm is going. The trend goes something like this. A service is initially provided by high cost biological intelligence (MD/DO), followed by lower cost biological intelligence (NP/PA) guided by artificial intelligence (AI) and finally completely provided by even lower cost artificial intelligence (AI). If so then the fundamental basis of our health care system will become a patient-AI relationship. I know that may seem pretty far out there and I may be stretching things a bit but what if? We don't talk about these things but I believe we need to start. I'm not saying I'm for it or against it but I think this begins to explain some things we are experiencing. Society has been hammering away at the patient-physician relationship for years. This may be the reason why. If so then I think the emerging paradigm will definitely be stronger. I would just like some assurance it will be better.
In medical school I was taught that the fundamental basis of our health care system was built upon the patient-physician relationship. That bond was the focal point. Without it and the entire system would collapse. A patient would develop a symptom of a disease process and seek the advice and treatment from a physician. The physician would diagnose the disease process and prescribe a treatment. It was a very simple formula and it works most of the time. It has served the interests of both patient and doctor very well for hundreds if not thousands of years. This fundamental relationship is under attack. There are two main reasons for it and both have to do with the rising costs in medicine.
The first cost to be dealt with is the cost of the encounter with a physician. Managed care and Medicare have whittled away at this for years but there is only so much they can do in the long run. The costs of medical school, residency, medical liability, and practice overhead continue to rise. Physicians are beginning to cost too much for certain services. The solution is to change the nature of the encounter from patient-physician to patient-provider. A provider can be a physician (MD/DO) or they can be a nurse practitioner (NP) or physician's assistant (PA). It doesn't take as much to train an NP or PA so each patient-provider encounter will not cost as much. An interesting model for this is beginning to develop in several major cities in the United States in the form of Minute Clinic. These are clinics that are based in either the bigboxes (Target, Cub Foods Store) or major pharmacies (CVS, Bartell Drugs). They are walk-in clinics that target common, relatively easy to treat illnesses (e.g. sore throat, ear infection, bladder infection). They promise quick, affordable and convenient care. While the clinics are overseen by an off-site physician, they are run by NP's and PA's. You can walk in, go shopping, be evaluated for your bladder infection and walk out with your groceries and prescription in hand. The entire encounter is guided by proprietary software (Artificial Intelligence) embedded in their electronic medical record (EMR) which is based on national clinical practice guidelines. These guidelines are thanks to the hard work of The American Academy of Family Practice, The American Academy of Pediatrics and The Institute for Clinical Systems Improvements. Interestingly they promise "autonomy of practice" on their web site for the NP's and PA's they are recruiting as future employees. I'm not sure how they can say this when the artificial intelligence is guiding the patient-provider encounter. It kind of reminds me of the old Texas politician who once said, "If these boys get any smarter we're going to have to water them twice a week." OUCH! Oh who am I to judge? They will be getting great benefits and of course flexible scheduling. (Sorry, there I go again, waaa, waaa, waaa.)
The second cost that will be addressed with this type of approach is probably the more important of the two and I alluded to it in the above paragraph. A few years ago an older, wiser doctor once pointed out to me that most of the direct costs of medicine flow from the physician's pen. What he meant by that was the treatments and prescriptions we write for our patients are what drive the costs in medicine. In the old days hospital admission orders, drug prescriptions, physical therapy, consultants, operations, length of stay and outpatient clinics and rehab referrals all came as a result of what the physician recommended. Control the pen and you control the costs in medicine. Again, managed care and Medicare whittled away at this but they are beginning to reach the point of diminishing returns. What if, instead of physicians driving this process we displaced them with someone who could be guided? Maybe someone who is willing to work for much less? Maybe in time patients will come to trust the artificial intelligence guiding the encounter and would be willing to be assessed by someone of even less training and cost? It could happen and I believe is happening. I think this is a trend line and there are sure to be others if this is the direction the emerging paradigm is going. The trend goes something like this. A service is initially provided by high cost biological intelligence (MD/DO), followed by lower cost biological intelligence (NP/PA) guided by artificial intelligence (AI) and finally completely provided by even lower cost artificial intelligence (AI). If so then the fundamental basis of our health care system will become a patient-AI relationship. I know that may seem pretty far out there and I may be stretching things a bit but what if? We don't talk about these things but I believe we need to start. I'm not saying I'm for it or against it but I think this begins to explain some things we are experiencing. Society has been hammering away at the patient-physician relationship for years. This may be the reason why. If so then I think the emerging paradigm will definitely be stronger. I would just like some assurance it will be better.
Friday, January 20, 2006
An Emerging Paradigm?
Transforming crisis is a process and a way of looking at the world in which we live. As I refer to it in this blog it is not only a personal journey for me but one I believe we are witnessing in the medical community as well as the world around us. There is not a day that goes by that we are not bombarded with more news of the worsening health care crisis. It remains on the front page and there are few who have not been touched by the crisis in some manner. Just think, half of the bankruptcies in the United States are due to medically related bills and 75% of those individuals filing for bankruptcy had health insurance. Primum non nocere as we say in medicine or first do no harm. While our health care system has done some great things I believe we are reaching a point of diminishing returns and may be falling short of this maxim. I left medicine and decided to go wander in the desert for awhile. I didn't want to listen to any more bad news from the world of medicine. My initial plans were to write a book but there is something very fiendish about the process of writing. It appears to take on a life of its own. What really happens is that you end up learning more about yourself and the world you live in as result of the process of writing. In the course of writing I kept returning to my own bitter complaints about the world of medicine. Every day I wrote, my journal became more filled with angry entries. Every day I wrote, I swore this would be the last day I complained. And then of course I would wake up the next day and start the process all over again. The effect was cathartic but incomplete. For all my complaining about the state of our health care system I deeply felt something was missing. That all changed one evening while watching Book TV on CSPAN2. I happened to catch a program with Ray Kurzweil discussing his new book The Singularity is Near. Kurzweil, as you may know, is a writer, inventor and futurist. The concept of the singularity grabbed my attention. I had heard bits and pieces of it before but not in a way Kurzweil was explaining it. It wasn't just a concept for mathematicians and physicists there was potential for broad application in other disciplines.
I read the book and it was during this time that I began to see that what he was describing for the genetics, robotics, artificial intelligence and nanotech industries was probably having similar effects in other industries, especially medicine. It is one thing to make some fairly outrageous predictions about the future but it is another to back them up with an explanation of how you do it. (For more information see www.singularity.com.) Kurzweil uses the law of accelerating returns and the S-curve to assist him in predicting the future. The S-curve when viewed on a graph begins as a relatively flat line moving from left to right followed by an upward inflection point. This upward inflection point continues in an exponential manner in a line that moves almost straight up. It then begins to flatten out once again at the top of the curve as an asymptote. When applied to the growth cycle of a technology the entire cycle can be see as representing a paradigm or model for that technology. The classic example is in the semiconductor industry but it can also be applied to other technologies. Moving from one S-curve to another is considered a paradigm shift. I won't attempt to further explain something he does a much better job of doing in his book but will say it is a fascinating read if you have the time and according to Kurzweil if you can make it to the year 2045 you will have plenty of time. What struck me though was his description of how people act during the different phases of the S-curve. As I read it I became intrigued with the idea that our current health care system is an established paradigm. What if all this madness we are seeing in this system is really the birth of an emerging paradigm for a new health care system, not one based on the traditional US model or the European/Canadian socialistic model but something completely unique.
Is that what all this complaining is about(my own included)? If it is then it changes everything. These cries that the system is failing and crumbling before our eyes may be true. The old established system may be failing and crumbling before our eyes but there may also be a new emerging system that is developing before our eyes as well. We may be so focused on preserving the failing system when we really should be focused on nurturing the emerging system. The issues we interpret as crises may be the emerging paradigm's way of saying what needs to go in order for it to mature. Our attempts to fix our current health care system crises with a toolbox from the older established paradigm may be futile. Not only are our attempts to repair it futile but may be directing away precious resources. We spend so much of our time running around blaming one another for the smoke and ash none of us has realized there is a volcano erupting. When the dust settles and the magma cools the landscape is going to look much more different.
I read the book and it was during this time that I began to see that what he was describing for the genetics, robotics, artificial intelligence and nanotech industries was probably having similar effects in other industries, especially medicine. It is one thing to make some fairly outrageous predictions about the future but it is another to back them up with an explanation of how you do it. (For more information see www.singularity.com.) Kurzweil uses the law of accelerating returns and the S-curve to assist him in predicting the future. The S-curve when viewed on a graph begins as a relatively flat line moving from left to right followed by an upward inflection point. This upward inflection point continues in an exponential manner in a line that moves almost straight up. It then begins to flatten out once again at the top of the curve as an asymptote. When applied to the growth cycle of a technology the entire cycle can be see as representing a paradigm or model for that technology. The classic example is in the semiconductor industry but it can also be applied to other technologies. Moving from one S-curve to another is considered a paradigm shift. I won't attempt to further explain something he does a much better job of doing in his book but will say it is a fascinating read if you have the time and according to Kurzweil if you can make it to the year 2045 you will have plenty of time. What struck me though was his description of how people act during the different phases of the S-curve. As I read it I became intrigued with the idea that our current health care system is an established paradigm. What if all this madness we are seeing in this system is really the birth of an emerging paradigm for a new health care system, not one based on the traditional US model or the European/Canadian socialistic model but something completely unique.
Is that what all this complaining is about(my own included)? If it is then it changes everything. These cries that the system is failing and crumbling before our eyes may be true. The old established system may be failing and crumbling before our eyes but there may also be a new emerging system that is developing before our eyes as well. We may be so focused on preserving the failing system when we really should be focused on nurturing the emerging system. The issues we interpret as crises may be the emerging paradigm's way of saying what needs to go in order for it to mature. Our attempts to fix our current health care system crises with a toolbox from the older established paradigm may be futile. Not only are our attempts to repair it futile but may be directing away precious resources. We spend so much of our time running around blaming one another for the smoke and ash none of us has realized there is a volcano erupting. When the dust settles and the magma cools the landscape is going to look much more different.
Thursday, January 19, 2006
The Beginning
My bags were packed and I purchased my exit ticket when it occurred to me that I still did not have a good reason for leaving. It has been almost fifteen years since I graduated from medical school. I was feeling like many of my colleagues in medicine and said that I had enough and wasn't going to take it anymore. I closed my office, said goodbye to my friends at the hospital where I practiced and paid the tail on my medical liability (malpractice) insurance. (The total exit fee was around eighty thousand dollars which is about what it cost me to get into medicine.) My reasons for leaving were numerous and sounded like those I listened to for years in the doctor's lounge. I began writing which was amazingly therapeutic. Much of what I wrote about were justifications for why I was leaving. Decreasing reimbursements. Rising costs, especially medical liability insurance. Litigious patients. Greedy lawyers. Manipulative insurance companies. Hospital administrators that really didn't understand patient care and were only concerned with the bottom line. Corrupt politicians who for years turned their backs on the growing problems. Incompetent physicians and medical societies that lack the good sense to know when to function like a team and circle the wagons when they are under attack and in the fight of their life. You name it, I found a reason to point the finger and blame and there was plenty to go around. I came to the initial conclusion that the whole United States health care system was quickly going down the toilet. I thought, "Good. Flush twice because these endotoxic swine need to be pushed far out to sea." Ok, I was a little bitter and slightly burnt around the edges. I wrote like this for months and then one day the writing changed and I realized that so had I. After mentally purging myself I began to see something different happening in our health care system. I don't have a crystal ball but I noticed an emerging pattern which I believe explains what this process is. Our health care system is not dying. Far from it. It is being reborn. There is an emerging paradigm happening before our eyes that will eventually replace the currently established paradigm. I began writing feverishly in my journal and thought I would share this publicly. It is what this blog is about. There is a crisis in our health care system but it is a transforming crisis. Things are going to get ugly for awhile but when it's over it will be better and stronger as a result. There will still be problems and there will still be challenges but I truly believe it will better and stronger. I also believe it will fundamentally appear radically different then what it looks like today. So I have unpacked my bags and put the ticket on hold. I'm going to stick around a little longer to see how it shakes out in the coming years.
Subscribe to:
Posts (Atom)
