The Paradox of Success and the Healthcare Industry

The Cycle of Renewal

It may not look like it but many of the woes we see as a looming crisis in our Healthcare System are the result of our successes, not our failures. During my sabbatical I had the opportunity to reflect on my personal life as well as professional career. Recently I read John R. O'Neil's book, The Paradox of Success, and could not help but notice the parallels between what I experienced personally and what I observed to be happening in healthcare. O'Neil refers to it as the "Cycle of Renewal" and notes it is as important for individuals as it is for organizations. I think it applies to systems as well and what all the signs of the crisis are saying is it's time for renewal.

Surfing the S-Curve

The Paradox of Success utilizes an S-curve to describe the major stages one goes throughout the cycle. The bottom of the curve is the initial phase where the greatest amount of chaos exists. Learning is slow and frustrating. As one ascends the curve competence improves markedly and confidence builds. Performance continues to improve in a non-linear fashion until it reaches the top of the curve as one approaches the peak of success. Along the top of the curve the slope levels off and the pace of learning slows. We reach the point of diminishing returns and the slope begins to descend. We appear to be at the summit of our success but are beginning to stagnate. We've become so use to the non-linear growth phase we assume it will continue forever but as the cycle predicts it doesn't. It's a dangerous time. Doubt replaces confidence and slowly the crisis begins to build. Our first impulse is to fight this feeling. It can't be happening, we assure ourselves, but it is. We want to return to the glory days when we were on the rise up to the peak and each day brought new and exciting challenges. In our panic we can continue our futile struggle or choose to undergo renewal. Renewal is where hope lives. O'Neil draws the analogy of the surfer "who senses the dynamic wave beneath him, and... knows it is time to abandon the sinking or breaking wave and catch a new one that is building."

"You cannot solve the problems of the present with the solutions that produced them."
Albert Einstein (1879-1955)

In Geoffrey A. Moore's book, Dealing with Darwin, he also describes a similar cycle that he refers to as a "category-maturity cycle". A technology, service or industry will inevitably pass through this cycle and face the challenges each category provides. This cycle also has an early phase followed by a growth phase. The growth phase is a time when each day brings new and exciting challenges. Growth is non-linear and it is assumed it will continue forever. In time, a mature phase sets in when the disruptive innovation that initially precipitated the growth phase becomes entrenched. As it develops it soon becomes a legacy system which becomes large and less maneuverable. Much like the Titanic, the impending collision with the iceberg is inevitable but the great ship cannot turn in time to avoid a crisis. The crisis for mature phase industries is the approaching declining market. Depending on the solution they innovate they can either extend the shelf life of the current innovation or create a disruptive innovation and enter a new market. It is the new and typically disruptive innovation that helps solve the problems created by the old innovation.

"The Times They are a Changin."
Bob Dylan

Healthcare is made up of many people and industries each of whom will achieve some measure of success. The paradox is that as we achieve this success and rideout its natural cycle there is a tendency to view both ourselves and the industries we support as somehow failing after we reach the summit. The point of diminishing returns and the crisis it can invoke is not a sign of failure but a sign of past success receding and the need to prepare for a new cycle. I think our crisis in Healthcare is such a sign. It is going through a transformation from what it was to what it will become. Both of the above authors advocate for greater awareness and preparing for the next cycle or phase. Whether it is the "renewal imperative" or "repurposing resources for core" the encouraging news is that this crisis too shall pass.

Trauma Centers and the Need for Disruptive Innovation

Seeing What's Next

Recently I read Clayton M. Christensen's new book, "Seeing What's Next: Using the Theories of Innovation to Predict Industry Change", and found myself feeling more invigorated at the thought of participating in the transformation of our Healthcare System. The position I have taken in this blog is that what we are experiencing as a Healthcare crisis is really the transformation of an established paradigm for delivering healthcare into a new emerging paradigm for delivering healthcare. Chapter eight of "Seeing What's Next", titled "Healing the 800-Pound Gorilla: The Future of Healthcare", indirectly suggests this hypothesis and specifically outlines how it not only can happen but in all probability is happening. Christensen's "disruptive innovation theory" demonstrates how "new organizations can use relatively simple, convenient, low-cost innovations to create growth and triumph over powerful incumbents." The underlying assumption is that healthcare is an industry and like all industries is subject to the forces that influence the market in which it thrives. If so, then how could it influence the field within which I trained, Trauma and Surgical Critical Care?

Is the Field of Trauma Really in the Gunsights of Disruptive Innovation ?

Trauma is a field that is ripe for innovation based on one simple observation. A large proportion of the patient population served is what Christensen would describe as "overshot customers". This is a patient population (particular customer segment) for which existing services are "more than good enough". You may ask, How can I make this claim? I base it off the observation that the majority of patients treated at Trauma Centers and registered in the National Trauma Database (NTDB) have minor injuries. Over two-thirds (68.4%) of the patients in the NTDB were found to have an injury severity score consistent with a minor injury and yet all of them were evaluated by a Trauma Center. Nearly half (49.1%) of all patients with minor injury severity scores were treated at Level I Trauma Centers which are the most resource intensive hospitals in the country. So why do almost half of the least injured patients in the United States end up at centers which are the most expensive providers of healthcare services? Like many things in life, it's complicated.

Is it Possible to be Too Good?

Trauma Centers, especially Level 1 Trauma Centers are victims of their own success. To maintain a "Level 1" status a trauma center must commit to a very high level of resources, not the least of which is human resources. Patients who meet specific anatomic (gun-shot wound to the chest), physiologic (low blood pressure from blood loss) or mechanistic (rollover motor-vehicle accident) will be triaged to a trauma center. Trauma centers have the resources and expertise needed to treat the most severely injured patients on a 24/7 basis. As they became proficient at what they did they attracted more patients. Trauma patients usually don't choose where they go so this is done by the EMT's or Paramedics transporting the patient. Since they prefer not to undertriage (send a patient with a serious injury to a non-trauma center) they tend to overtriage (send a patient with minor injury to a Level 1 Trauma Center). The Trauma Centers are loathe to discourage business so the cycle continues to progress and the total trauma patient population is "overshot". In most Trauma Centers Trauma Surgeons are the leaders of the teams activated to evaluate these patients. What this means is that a Surgeon who spends most of their professional career mastering the art of Surgery ends up taking care of patients who don't need a Surgeon to care for them. How does this happen? I've commented on this in a previous post but it is worth repeating.

"It is difficult to get a man to understand something when his job depends on not understanding it."
Upton Sinclair (1878-1968)

There is actually another reason and in the parlance of the business world, the Trauma Centers have become the "incumbents" of the trauma market. There once was a day not so long ago when the high end care provided by modern day Trauma Centers was not available. It took the vision, dedication, hard work and commitment of individuals such as Dr. R Adams Cowley to introduce the "disruptive innovation" of Trauma Centers and move it into the mainstream. Trauma Centers have gone from being rare and the exception to the common and the exceptional. As with all growth industries Trauma Centers have matured and in doing so have "overshot" their customers. While this may introduce an element of waste it also exposes the industry to opportunity for innovation. Overshot customers create potential opportunities for "Low-end disruptive innovation". This is an "innovation that offers overshot customers good-enough performance along traditional metrics at lower prices".

Innovation Lessons from Healthcare

In "Seeing What's Next", Christensen et al, point out there are three general lessons to be learned regarding innovation in healthcare which are:
"1) Scientific progress leads to better categorization and the development of rules guiding prevention and treatment.
2) Those rules open the door for less-skilled people to do what previously required deep expertise.
3) Nonmarket forces affect the market for innovation by influencing industry players motivation and ability."
So how does this apply to the overshot customers within a trauma patient population?

"Bad laws are the worst form of tyranny."
Edmund Burke (1729-1797)

Trauma Centers are very good at categorizing patients and providing timely treatment. Most of the rules, that is protocols, for guiding treatment have focused on the more severely injured patients as their injuries are the most life-threatening. Minor injuries were relatively easy to treat and did not warrant the time and energy to develop specific rules for treatment. This is particularly true at the major Trauma Centers. Protocols were reserved for the common injury and disease patterns seen in the more severely injured patients. That is, after all, the specific patient population for which Trauma Centers were designed. Based on disruptive innovation theory I predict that the development of protocols that specifically address the needs of those patients who have minor injuries and are being treated at Trauma Centers will be one of the first steps in the direction of a low-end disruptive innovation in the field of trauma. The key to these protocols will be to incorporate them into a quality improvement program that is designed to continually improve the care of the patients for whom they were developed, because without this they are no better than "bad laws".

Now the Difficult Part to Accept

With a set of rules to guide medical decison making in the treatment of patients with minor injuries this allows the next step to occur. This is a "provider-level disruption" where less-skilled providers such as Nurse Practitioners (NP's) or Physician Assistants (PA's) provide care which does not require the judgment and skill of higher-skilled providers such as Trauma Surgeons or Emergency Medicine Physicians. This also allows the movement of treatment to areas that are more convenient and less costly for the patient. Free-standing "Minor Trauma Centers" are unlikely due to the restrictions on specialty hospitals and the fact that they would share the same "value network". A more likely scenario is for the "Incumbent" Trauma Centers to internally develop "Minor Trauma Center" sub-specialty areas on the same physical site as the major Trauma Center. While this is already happening to some degree at very busy trauma centers out of necessity it is not the norm at most centers. So if two-thirds of a Trauma Surgeons patients are being evaluated downstream by NP's and PA's then what is the Trauma Surgeon going to do?

Move upstream

The Trauma Surgeon will do what any service provider does in a mature market. They will need to go upstream. Most facilities already utilize the Trauma Surgeons skills to cover Urgent and Emergent General Surgery so this is not a new market. There has been a great deal of discussion among Trauma Surgeons and the current view is that they should become Acute Care Surgeons. In case anyone in the medical community hasn't noticed we already are Acute Care Surgeons. I think we need a more radical "sustaining innovation". Moving upstream means acquiring new skills to meet the demands of the market in which they most commonly practice. If Trauma Centers in the United States continue to see shortages of Neurosurgeons, Orthopedic Surgeons and Plastic Surgeons then it is up to the Trauma Surgeons to develop the skill sets and the training programs necessary to provide those services. As those specialties move further upstream to ambulatory surgical centers, specialty hospitals and non-trauma centers they will leave behind them a void in the availability of essential services. As NP's and PA's move in from below and surgical specialists exit from above there will come a time when the Trauma Surgeon will need to step up and move as well. If we are going to do it then I suggest it is better to lead than follow. I don't think Dr. Cowley would mind.

Evolution, Natural Selection, and Our Healthcare System

Healthcare Through the Eyes of Darwin

In Geoffrey A. Moore's recent book, "Dealing with Darwin: How Great Companies Innovate at Every Phase of Their Evolution", he examines a company's or industry's ability to adapt to challenges in the marketplace as a Darwinian exercise in natural selection. As I read this book I couldn't help but ask, "Do the changes we see in our Healthcare System fit into to this type of model?" and "If our Healthcare System is evolving, where does it currently stand?"It is probably just as important to ask, "And what is it evolving into?" Moore contends that innovation is what drives an industry's evolution. He writes, "If you are going to be successful with innovation, you have to understand that different categories (along the life-cycle) reward different types of innovation at different points in time." Those "categories have a beginning, a middle, and an end." Much of his book focuses on technological innovations but he is quick to point out it can also refer to a business model innovation. This is what got me interested because I think we are experiencing a series of innovations that will continue to fundamentally change the face of healthcare.

The Life-Cycle of Innovation

Moore breaks down the category-maturity life cycle of a technological or business model innovation into five categories. They are in order of their appearance in the life cycle: The Technology Adoption or beginning of the innovation followed by The Growth Market, The Mature Market, The Declining Market and The End of Life Market. So how and where does our Healthcare System fit in? I think it begins at the cornerstone of the system. If we think of the Patient-Physician relationship as the core of the established paradigm for delivering healthcare, then the real question is, "Where does this "business model" fit in the category-maturity life cycle?" Some may argue it is in the early phases of the Declining Market but I think it is more likely in the late phase of a Mature Market. As I have suggested in previous posts I believe what we are witnessing is the emergence of a new paradigm for delivering healthcare that is displacing the established paradigm. In accordance with this is the idea that the traditional core of the established paradigm, that is the Patient-Physician relationship will undergo a radical change. If so, then what evidence exists today to suggest this may be happening?

Business Structure

In order to approach this question we first have to understand the type of business architecture we are evaluating. Moore breaks this out in to two major types: The complex-systems architecture and the volume-operations architecture. By definition healthcare tends to be a volume-operations model which are more consumer oriented businesses. The goal is to "generate both volume and a variety of offers" or in this case services. They are "optimized to meet the three basic values of retail markets: price, availability, and selection." Translating that into healthcare that means low cost, easy access, and choice of services that meet the standard of care. Innovative solutions will not only need to address each of these values but do it in a way that fits with the life-cycle category of a maturing market.

Late Phase, Mature Market

In order to address the three basis values of the healthcare market, the system has approached this in a predictable fashion. What makes me think we are in the late phase of a mature market is the emergence of two types of innovations that are characteristic of this phase in this type of market. One addresses "customer intimacy" and the other addresses "operational excellence". According to Moore, a type of customer intimacy innovation seen in the late phase of a Mature Market is referred to as an "experiential innovation". It is the "ultimate refinement ...where the value is based not on differentiating the functionality but rather the experience of the offering." An example I see emerging in the primary care market of our healthcare system is the "boutique medical practice" that is becoming more popular. This is where a primary care physician limits the number of patients in their practice and delivers highly personalized care for each patient at a premium. Patients have 24/7 access to a highly qualified physician but at a cost. While this type of practice cannot be applied to the whole Healthcare System it does carve out a niche that is very functional for both the physician and patient who can afford it.

A Glimpse into the Crystal Ball

The other type of innovation Moore discusses looks at "operational excellence" where the "primary reward is a lowered cost structure that enables either price reductions, capital reinvestment , or higher profits." The specific type of innovation seen in the late phase of a Mature Market is referred to as a "value migration innovation". "The key principles of value-migration innovation are, first, to sense the erosion in value in the established roles, second, to anticipate where the migration of value is headed, and third, to get there before your competition." Moore notes, "...it migrates to cost-reduction enablers, maintenance providers, and outsourcers." I think this is already happening in the field of Primary Care with the introduction of such sources of services as MinuteClinic, QuickClinic and Medspot. These are clinics staffed by Nurse Practitioners and Physician Assistants who evaluate and manage a limited variety of relatively minor health problems. In the case of MinuteClinic they utilize a proprietary software system that assists their staff and guides medical decision making to ensure consistency. It can be considered just another phase along the road to our Healthcare System's evolution but I think it is also the beginning of something more radical. It is the first step toward what will ultimately lead to a disruptive innovation that will characterize the new emerging paradigm for our Healthcare System.

Say What?

All medical decision making will eventually be made through an interface that best utilizes the most up-to-date, state of the art health information. That interface, whether it be a human provider or a virtual reality provider will be networked to a system that has embedded within it a medical decision making protocol that when used exceeds the capabilities of a human functioning without one. I'll admit it remains to be seen if that is really the direction it will go but sooner or later it will either become more or less evident. Time will tell, but then again that is one of the key ingredients natural selection requires.

It's Time for a Universal Health Information Rating's System

Actually The "Rolls-Royce" of Rating's System

Last week the New York Times published a story titled "Low Fat Diet Does Not Cut Health Risks, Study Finds". It referred to an article published in the Journal of the American Medical Association (JAMA) which examined the associated health risks of a low-fat diet. Much has been said during the week about the article but what caught my eye was a comment by Dr. Michael Thun, who directs epidemiological research for the American Cancer Society. He is quoted as describing this study as "the Rolls-Royce of studies". While I'm sure most people would interpret this to mean "a very good study", it is not without its critics. The expression "Rolls-Royce" implies a very high standard, however most people do not know exactly what that range of that standard is. This is the problem with using such a descriptive phrase in an article which appears on the front page of the New York Times and is a lead article on its internet edition. We can do better and we have.

A Better Standard Already Exists

Most people are probably unaware that physicians and researchers do have standards to describe the quality of the evidence and recommendations that are used in medicine. It is a product of the evidence based medicine (EBM) movement that is rapidly becoming a more influential part of our Healthcare System. There are accepted methods to grade both the evidence and recommendations that are published. For instance, the Society of Critical Care Medicine (SCCM.org) as well as other notable medical societies frequently publish guidelines which are available on their websites. One such guideline, "Surviving Sepsis Campaign Guidelines" utilizes a modified methodology for its grading scheme. The evidence is graded best to worst (I-V) as well as any recommendations (A-E) promoted based on that evidence. What makes these guidelines particularly useful is that a reader can not only identify the source of each piece of evidence but also the standard on which to judge the strength of the evidence or recommendation. This type of ratings system is sorely lacking for the overwhelming majority of health information websites.

Is That Website You're Visiting HIT Worthy?

With more and more people flocking to the internet and using it as a source of health information, what assurances do any of us have that the information we obtain is accurate? The URAC (Utilization Review Accreditation Commission) is one that attempts to achieve a standardization process for this issue. The URAC is an organization that accredits health care organizations including health information websites. According to their website they update the standards for accreditation every three years. They require websites to: disclose sponsors and financial backers, identify how the website develops information, use evidence based information, have a quality oversight committee and maintain privacy and security standards. What having the URAC seal of approval on a website doesn't assure is that a grading of the evidence or recommendations will be provided as well. The quality of acceptable evidence can vary greatly. While URAC is a step in the right direction, bear in mind, so far they have only accredited just under 300 websites.

So Why is This Important?

In order to transition from the established paradigm of delivering healthcare to a new paradigm of delivering healthcare any prevailing source of health information must be reliable and trusted. As people seek the low cost and easy access of health information on the internet they will, in time, begin to demand that the available information is high quality and reliable. Most of these websites maintain an extensive "terms of use" that seeks to limit their exposure to liability, but as physicians discovered a long time ago with "consent forms" there is only so much you can do to hold back the tide of medical liability attorneys once there is a breach in the levee. There is an even more important reason to insist on a quality rating system for health information and that is because it can be a useful means to educate people not only on the existence of such a system but also on the widely varying array of quality that currently exists. There are simply too many snake oil salesman on the internet. There are guides on how to evaluate health information but I suspect most people choose not follow them very effectively, if at all. A simpler, more easily identifiable system is going to be needed as more and more people seek out the internet for health information.

Collapse & Our Healthcare System

The Three Main Reasons: Values, Values and Values

There is a quote in Jared Diamond's latest book, "Collapse: How Societies Choose to Fail or Succeed", that I think summarizes what I see happening in our Healthcare System today.

"That proves to be a common theme throughout history and also in the modern world...: the values to which people cling most stubbornly under inappropriate conditions are those values that were previously the source of their greatest triumphs over adversity." (p. 275)

The values of the established paradigm for delivering healthcare are conflicting with the values of an emerging paradigm for delivering healthcare. It is our insistence on maintaining those established values which is the source of some of our greatest conflicts in our Healthcare System.

Values vs. Values

Several years ago I repeated an exercise that I originally did almost fifteen years ago. This is how the exercise works. Take out a piece of paper and write down as many values as you believe are near and dear to your heart and soul. From that list choose twenty that you claim as your top twenty values. Take your time because this is really an important exercise. Let's call this final list of twenty your most cherished core set of values. Now take that list and rank them in terms of their importance to you. How I did it was to create a matrix with the value list written down one side of the paper and an identical value list across the top of the paper. Value by value compare them and make a notation on the matrix as to which value ranks higher. For instance compare health vs. security or love vs. success. When you have completed the list put it away for a period of time. In my case it turned out to be twelve years. It wasn't by intention, life just passed by very quickly during those twelve years. At the end of the time period pull out the original unranked list and repeat the same exercise. When I did it the results absolutely amazed me.

The Changing Value of Values

Remember to use the same list as the original, that is (was) your most cherished core values list. I figured some of the values might move around one or two places on the rank order of importance but I had no idea that some of my core values would move so far up and down. I initially created the rank list just after I completed medical school. It was a thrilling and anxiety laden time. The competition to do well in medical school was intense. Honors grades are sought out to insure matching in a better residency program. In the final two years these grades are primarily determined on how you perform on your clinical rotations. The approval of your senior residents and attendings is paramount. Looking at my value list from those days it was not too surprising that "approval" was on it. I'm still amazed how high I ranked it at the time. Twelve years later it dropped to the bottom of the list and in all likelihood would have fallen off had I not used the same list. In retrospect, "approval" probably was very important then, but my life is much different now. As I age I also noticed that "health" moved up on the list from its previous position. Integrity, honesty, freedom and trust remain near the top as they did for the original rank list. There are some values which are more resistant to change then others.

"I changed the most by not changing at all."
Eddie Vedder of Pearl Jam

Since that time I've gone on to further develop the list and discovered something interesting. I do have a core set of values that remains at or near the top of the list which are fairly constant and enduring. There is also a set of values that can change over time as my life circumstances change. They remain valued but their relative importance adjusts based on where I am at in my life. It is not that I didn't value "health" at a younger age. I did, that is how it got on the original list. It is just as I get older I value it even more and therefore relative to other values it rises on the list. As it rises on the list it guides the choices I make in life. (That is another way of saying those days of partying until the sun comes up are long since gone.) If you have any doubt about the relative value of values think about one of our major current political debates. Civil liberties versus homeland security. The 9/11 terrorist strike became one of those life circumstances that framed the nature of how we debate that issue today. Before 9/11 it would have been a different discussion.

Adapting to Our Future

So what does this have to do with our current Healthcare crisis? Everything, I think. It seems there is a constant stream of debate on this issue. Some have gone so far as to say our Healthcare System is going to collapse in the near future. I doubt this, but do believe that our currently established model for delivering healthcare is being transformed into a new model. The established paradigm is making way for an emerging new paradigm. What we are experiencing as a crisis is the heat and sparks caused by the friction of values passing each other on our national ranking list. It is not that we don't value those values that supported the established paradigm for delivering healthcare as it has done successfully for years, it is that we are coming to believe other values need to be more valued to support the new paradigm for delivering healthcare.

To Be Or Not To Be: Master Of Our Domain

Locus of Control in the Healthcare Crisis Storm

The problem with a paradigm shift is that by the time most people realize it is occurring it is already fully embedded itself into society. The Industrial Revolution is a prime example of a paradigm shift that occurred in western civilization that transformed us away from an agrarian society in a relatively short period of time. In the United States the majority of our society went from rural farmers to urban factory workers over the course of one century. From a historical perspective that is a blink of an eye. What if such a grand transformation is occurring today in our Healthcare System? Would we recognize it, and if we did what would be our response? Do we believe we are up to such a task?

Step 1: See the gathering storm in the distance

The first question we may want to consider is, "Is there a paradigm shift even occurring in our Healthcare System?" If you believe, as I do, that there is one occurring, and it is not obvious to the world, then we must seek evidence that such a shift is indeed occurring. If you do not believe one is occurring it is not incumbent upon you to provide proof that one is not occurring. Let's face it, paradigm shifts do not occur very frequently to justify a large number of people spending an undue amount of time chasing after proof of their non-existence. Proof of their emergence is therefore generally sought out by those who suspect one is occurring. There is one caveat for those who believe a change in the weather is not occurring: Don't forget to stow some inclement weather gear just in case.

Step 2: Prepare for a change in plan

If a paradigm shift was not occurring, could one be initiated and therefore radically transform a troubled Healthcare System? The examples of major paradigm shifts and the individuals who contributed to them are numerous (Copernicus, Newton, Einstein). The Industrial and Digital Revolutions were less any one individual and really more a growing series of individuals and groups who contributed to the changes that became essential for those paradigm shifts to occur. If one were to occur it would most likely occur in the fashion of the Industrial and Digital Revolutions. That is, over time and as a result of many contributions culminating in a radically transformed and improved way of delivering healthcare to our society. It can happen even if it is not happening. I just happen to be one of those who believes it is already happening.

Step 3: Design the best plan possible

If a paradigm shift is occurring and you recognize it, can you alter its course or modify its affects? That is, can an individual or a group exert an influence over the paradigm shift and shape its course? If you believe one can initiate a paradigm shift there is a tendency to believe you can change its course. What strikes me as curious in this attempt is that the concept of a paradigm shift has at its core the revealing of a fundamental truth that was not previously known. Paradigm shifts can also utilize available resources in a unique manner so as to transform the prevailing established paradigm. Altering it is best accomplished by understanding it better in order to improve it. To do otherwise is an attempt to bury it or to tarnish it in such a way as to hide it once again from society. I think this is why Thomas Kuhn proposed that a true paradigm shift is always different and better. If you believe you can alter its course, the time and energy you spend is better focused on improving the new paradigm. The substance of the debate is not over if it can be altered so much as what is the nature of the new paradigm and what is the best way to go about enabling and improving it?

Step 4: Act on yourself as well as your environment

The final question I leave for today is, "If a paradigm shift is occurring and you are caught in its wake can you alter or modify your response to it?" This is the essence of locus of control. If it is occurring and you have no control over it or yourself then you place yourself in the hands of fate. It therefore doesn't matter if one is occurring or not because you can't control it. (See advice under Step 1.) If, on the other hand, you feel a greater sense of control in the world, you will want to modify the paradigm shift and your response to it for the better. Proving a paradigm shift is occurring is only important to those who feel they have some control over what is happening in the world around them or at least how they will respond to it. So are you master of your domain?

Step 5: Leave the world a better place than when you arrived

The fundamental objective of a Healthcare system is to improve the health of that system's society. We are in the midst of a Healthcare crisis in the United States. There is a tendency to blame it on greed, incompetence and corruption of the individuals who contribute to our system. What I''m suggesting here is that our current Healthcare system has outgrown itself and is undergoing a transformation into a new system. The crisis happening before our eyes is the affects of an established paradigm of delivering healthcare struggling to sustain itself as a new paradigm for delivering healthcare is emerging . We can choose to see it or not. If we see it, we can choose to work to improve it as it emerges, or not. As we see it emerge and begin to affect us we can choose how we wish to respond to it, or not. If you believe you have a choice, those choices ultimately begin with seeing the transformation in the first place. We must start seeing the better system we need.

The Jetson's Age, Are We There Yet?

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.

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.

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.

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.

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.

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.

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.

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.