Monday, November 5, 2012

Moving On to New Website

Thanks for following my blog which since 2007 has provided a home for my thoughts and musings about the challenges for doctors and patients to get the right care each time. This blog was the starting point for my first book - Stay Healthy, Live Longer, Spend Wisely - Making Intelligent Choices in America's Healthcare System.

I hope you continue to enjoy much of the terrific content here as well as follow me to my new home which features the latest commentary and insight at Davis Liu, MD as well as my newest book - The Thrifty Patient - Vital Insider Tips For Saving Money and Staying Healthy.

Of course you can still follow me on Twitter @davisliumd


Davis Liu, MD

Tuesday, October 16, 2012

NYT Kristof's A Possibly Fatal Mistake Shows Future of Health Care. It Isn't Good.

NY Times columnist Nicholas D. Kristof wrote a heartfelt piece "A Possibly Fatal Mistake" about his college roommate Scott Androes, who recently was diagnosed with metastatic prostate cancer. His story illustrates the problem with the current health care system.  It isn't about the lack of health insurance. It's about the obstacles all patients face in making the right decisions and the right treatment.

Something that will increasingly be harder with consumer driven health care.

Kristof lets his 52 year old friend, who is well-educated (graduate of Harvard, financial and pension consultant) and also was uninsured starting in December 2003, tell the story.
In 2011 I began having greater difficulty peeing. I didn’t go see the doctor because that would have been several hundred dollars out of pocket — just enough disincentive to get me to make a bad decision.
Early this year, I began seeing blood in my urine, and then I got scared. I Googled “blood in urine” and turned up several possible explanations. I remember sitting at my computer and thinking, “Well, I can afford the cost of an infection, but cancer would probably bust my bank and take everything in my I.R.A. So I’m just going to bet on this being an infection.”
I was extremely busy at work since it was peak tax season, so I figured I’d go after April 15. Then I developed a 102-degree fever and went to one of those urgent care clinics in a strip mall. (I didn’t have a regular physician and hadn’t been getting annual physicals.)
The doctor there gave me a diagnosis of prostate infection and prescribed antibiotics. 
Androes, after being diagnosed with metastatic prostate cancer, like most of us, would reflect on what went wrong.
I read Nassim Taleb’s book “The Black Swan” and imbibed his idea that you should keep an eye out for low-probability events that have potentially big consequences, both positive and negative. You insure against the potentially negative ones, like prostate cancer.

So why didn’t I get physicals? Why didn’t I get P.S.A. tests? Why didn’t I get examined when I started having trouble urinating? Partly because of the traditional male delinquency about seeing doctors. I had no regular family doctor; typical bachelor guy behavior.

I had plenty of warning signs, and that’s why I feel like a damned fool. I would give anything to have gone to a doctor in, say, October 2011. It fills me with regret. 
What can we learn about his experience and the future of our health care system?

Smart educated patients can make bad decisions

Androes is highly educated. If anyone should understand the cost benefit analysis of money and health, it should be a pension consultant educated at Harvard. He had opportunities to seek care sooner, but chose not to. Understanding this psychology is important as it is the underpinning of consumer driven health care - patients will choose more rationally if they have more financial skin in the game. Yet all I continue to see is evidence to the contrary.

First, Androes had many obstacles and not all related to lack of health insurance. He didn't choose to see a doctor when symptoms started in October 2011 because the cost didn't seem worth it. This is where our common sense and experience falls short. We've all had experiences of an ache, pain, or symptom. Many go away on their own. Androes like many other patients have this "success" and filed it away. Plus, work is too busy or important to put on hold (another major problem with the economic crisis of 2008) and personal health takes a back seat. The problem is our previous success with other symptoms may not necessarily apply to the current symptom.

It isn't clear if at that point he researched his symptoms with the always available Dr. Google. Unfortunately, like many patients he winged it hoping for the best. Had he thought about it some more, he might have realized that he never had urinary complaints prior to this episode. Having urinary problems are quite uncommon in young or middle-aged men.

So, Androes, like many others, he extrapolated his prior experience to his current situation, which may not have been appropriate.

Who has time to be sick? Don't "bet" on the wrong diagnosis with Dr. Google

Second, when he did have blood in the urine, Androes did consult Dr. Google. Dutifully, Dr. Google pulled up two possibilities. Infection or prostate cancer. Androes "bet" that it was infection. This is no different than "winging" it. Unlike the first episode of urinary problems, Androes clearly is informed about the possibility of cancer. Problem is he can't afford a catastrophic illness like cancer either from a financial or time point of view.

Here is the reality. None of us can afford it. There is never a good time to be diagnosed with cancer or any other serious life-altering illness. Yet is behavior is common among many patients I see. Their job or their financial assets are more important than their health. Androes "chose" to go after April 15th, after tax season, when it was most convenient for him. Dr. Oz nearly made a similarly bad decision regarding his colonoscopy and colon cancer screening a few years ago and then again when he failed to follow-up as recommended for colon cancer surveillance. Part of the reason we all fall into this cognitive trap is that for the most part, our body does a good job in running despite what we eat, our sedentary lifestyle, and long hours of work.
The most important financial asset is your health. With good health you can always make more money, with more money you can't buy good health.  So certainly, Androes had his less than optimal choices.

Did doctors miss a chance to diagnose prostate cancer earlier?

What about the health care system and doctors? Did we miss an opportunity?

Yes. It is possible there were two, though unclear if it would have made a difference in his case.

When Androes sought care with a doctor in urgent care and a urologist, he noted the former diagnosed him with a prostate infection and the latter did blood work. It isn't clear whether either doctor did a rectal exam to feel the prostate. A patient with metastatic prostate cancer with a PSA of 1,110 (normal range less than 4) should have a very abnormal prostate exam.

Had a prostate exam been done, either doctor had a very good chance in telling him he had prostate cancer prior to any confirmatory blood work. At that point, however, even with this knowledge it would have been too little and too late to alter the outcome or overall prognosis.

The second issue is whether the benefits of physical examinations or lab testing, like PSA, would have made a difference. Neither have been demonstrated to save lives. In other words, as a nation we might feel better that everyone gets an annual check-up or lab testing, but there is no scientific evidence that either help. Also, as noted previously, it isn't clear patients will seek preventive care for the reasons above.

So, how does this one story, which sadly is repeated too often by different writers and involves different protagonists, predict our health care future?

It does in the following ways:

Common sense does NOT apply to health care- four challenges in making good decisions about health

Common sense does not apply to health care. Patients may have symptoms they have never had before and erroneously assume based on prior experience, that this new problem is nothing to worry about. Denial is a powerful emotion and can cause inaction precisely when action is needed.

Second, when patients feel fine they don't protect against low probability but high risk problems. Will people buy health insurance? Will they demand for preventive screening tests that save lives? Will they willingly get vaccinated against preventive illnesses? Increasingly we see more parents choosing not to have their children immunized and then nationally see many preventive illness, like pertussis, return again with significant consequences.

Third, there are many obstacles preventing good decision making. Whether higher deductibles, copays, or simply working too hard to focus on one's health, people ignore their health until they have no choice or have symptoms. If Androes who had the good fortune of being educated at an elite Ivy League school made poor medical decisions, what are the implications for the rest of society? Patients should be more motivated to take charge of their health, yet it is likely the drive to consumer driven health care will make the nation's overall health care worse, not better. A similar experiment was attempted in retirement planning with devastating outcomes for retirees.

Fourth, people are increasingly devaluing the important of expertise and experience with the increasingly ease and availability of information on the internet. That isn't to say that non-experts cannot make a contribution to furthering progress. The challenge is that the availability of data provides many non-experts a false sense of certainty and absolute truth which is not necessarily true in medicine. We do have genomics, but it is in its infancy. We do have personalized testing, but it isn't clear if knowing the results will be medically important.  When dealing with the complexity of the human body, nuance and ambiguity are prevalent.

More patients are emailing me requesting for CT scans or MRIs because the office visit copay is too expensive. They don't feel that seeing a doctor, taking a detailed history or examination is worth it.

Yet, to counter the issues above it is doctors who can convince people to act in getting testing, treatments, and interventions when they don't want to emotionally or are uncertain what to do. It is doctors who can encourage patients to get preventive testing and immunizations when faced with the overwhelming amount of information and clutter from the media, the internet, and friends. It is doctors who can tell patients when they must seek care and when they can safely skip. There is medical science and then there is everything else.

However, this is not where our country is headed. Too many believe that to lower costs and improve health outcomes, patients must make better decisions. Patients will do so if they have more financial responsibility and more cost transparency.

Show me the evidence because I don't see it.
What I do see, unfortunately, is more cases like Scott Androes.

Wednesday, October 10, 2012

Is the Iron Triangle of Health Care a Law or an Observation?

A recent commentary in the Journal of the American Medical Association titled, "The Iron Triangle of Health Care: Access, Cost, and Quality" reflected that any health care system can only optimize two of the three elements - quality, access, cost.  A health care system which provides the finest quality and best access cannot do so without raising costs to unaffordable levels. An inexpensive health care system available to all cannot do so without sacrificing quality. The iron triangle of health care was introduced to me during my medical school training in the 1990s. Like many others, I simply assumed it was a fact. An immutable law. A fixed certainty that could not be altered any more than gravity.

What if this iron triangle isn't a fundamental truth or law? Why don't other industries have their own iron triangle? Is health care really different than aviation or computing?  Asking this simple yet basic question is something medical students and doctors don't ask. Fortunately, this was not the case for Harvard Business School Professor Clayton Christensen, author of the Innovator's Prescription. His book not only details the theory of distruptive technologies, but also how companies who do "disrupt" the incumbent companies and the status quo are the ones that ultimately provide goods and services which are more affordable, more accessible, and of higher quality. Might there be analogies for health care? Professor Christensen highlights aviation and computing as two examples.

Commercial flight for the masses was not a realistic possibility over a century ago when the Wright Brothers navigated their winged contraption in Kitty Hawk. Even decades later, as epitomized by Pan-Am in the 1960s, air travel was for the affluent and a special event. At that point, air travel was not accessible or affordable for the general public. Yet, in the 1970s, a Texas start-up known as Southwest Airlines provided discounted travel to the general public by offering low fares, no amenities, and a point to point service rather than hub and spoke system.

And traveling by air was never the same again.

Now, more people travel by air than anytime in history with unparalleled safety. More accessible. More affordable. Higher quality.

Computers had a similar beginning evolving from a product where only available to a few due to cost and complexity of the systems to now where computers are affordable, ubiquitous, easy to use and of even better quality than the past. One of the first computers in the 1940s, was Eniac, a huge and expensive mainframe computer which was not reliable, extremely complicated, and accessible only to academics. Years later, the general public typically accessed these mainframe computers at work via technicians. Access was limited. It wasn't until the late 1970s that desktop computers appeared. Hobbyists and others, like Steve Jobs, built computers which were less expensive and underpowered compared to the mainframe computers, but they were more accessible to the general public. It wasn't until many years later that subsequent computers became more affordable, more powerful, and more accessible in the form of laptops, netbooks, and now smartphones and tablets. More people had access to computing because the products were more affordable and of even higher quality.

And computing was never the same again.

Based on Christensen's model, we can predict that health care will indeed break the iron triangle and demonstrate it is not a law but an observation. The question is who will lead these changes? Insurers? Doctors? Patients? Entrepreneurs?

Our next generation of doctors must be trained in other disciplines outside of health care. We must collaborate and accept other ways of looking at the same challenges through the lens of other disciplines including business school. Yet, there is a loathing for this. There is the belief that health care is different. Yes, we can continue to talk about the iron triangle of health care and accept that as a reality.

We can also say no. The iron triangle is not a law but an observation. We choose a different path.

The truth is that this is the most exciting time in health care with the intersection of better medical understanding, the availability of technology, and the best and brightest minds working on the issues of better quality, better access, and lower costs. As doctors and educators, it is our job to make sure the next generation is equipped with the right mindset to team with others. If not, others will define the future of health care.

This is what worries me the most.

Wednesday, September 12, 2012

The Truth About Ovarian Cancer Screening - book excerpt

The New York Times editorial "False Promises on Ovarian Cancer" says it all. What is most concerning is that a third of doctors recommend what medical science shows not to be true: screening for ovarian cancer does NOT work.

Enjoy the excerpt from my book - The Thrifty Patient - Vital Insider Tips to Staying Healthy and Saving Money - and be smarter than 1/3 of doctors! Simple to read and incredibly informative.


Ovarian Cancer Screening

One of the most feared cancers for many women is ovarian cancer, which occurs in one out of sixty-eight women. Unfortunately, like many cancers (lung, pancreatic), there is no screening test that has been helpful to detect the illness early and reliably proven to save lives.

Until organizations like the American Cancer Society (ACS) recommend certain tests or examinations, everything you may hear on the news or from friends about breakthroughs in screenings is inaccurate.

In the latest update by the American Cancer Society, women are urged to seek medical care if they have had the following symptoms, which could be early signs of ovarian cancer:

  • Abdominal swelling or bloating (due to a mass or accumulation of fluid)
  • Pelvic pressure or abdominal pain
  • Difficulty eating, or a feeling of being full quickly
  • Urinary symptoms (having to go urgently or often)

Certainly many benign causes also can cause similar symptoms. If you have these symptoms, they are not typical for you, and you aren’t sure what the cause might be, check with your doctor. The ACS acknowledges that two tests often used to “screen” for ovarian cancer are the blood test CA-125, a tumor marker, and/or a transvaginal ultrasound, an ultrasound probe placed in the vagina to evaluate the ovaries. The update correctly notes that in women at high risk for ovarian cancer and those with no risk, neither test has been shown to save lives.

Unfortunately, until medical researchers find a better and more precise test, women will need to be observant about their bodies. This is the best medical science has in trying to detect ovarian cancer early.

Friday, August 31, 2012

Rock Health, Enterpreneurs, Doctors and Witchcraft?

I recently viewed health care through the lenses of a technology entrepreneur by attending the Health Innovation Summit hosted by Rock Health in San Francisco. As a practicing primary care doctor, I was inspired to hear from Andy Grove, former CEO of Intel, listen to Thomas Goetz, executive editor of Wired magazine, and Dr. Tom Lee, founder of One Medical Group as well as ePocrates.

Not surprising, the most fascinating person, was the keynote speaker,
“Health care is like witchcraft and just based on tradition.”

Entrepreneurs need to develop technology that would stop doctors from practicing like “voodoo doctors” and be more like scientists.

Health care must be more data driven and about wellness, not sick care.

Eighty percent of doctors could be replaced by machines.

Khosla assured the audience that being part of the health care system was a burden and disadvantage.  To disrupt health care, entrepreneurs do not need to be part of the system or status quo. He cited the example of CEO Jack Dorsey of Square (a wireless payment system allowing anyone to accept credit cards rather than setup a more costly corporate account with Visa / MasterCard) who reflected in a Wired magazine article that the ability to disrupt the electronic payment system which had stymied others for years was because of the 250 employees at Square, only 5 ever worked in that industry.
Khosla believed that patients would be better off getting diagnosed by a machine than by doctors. Creating such a system was a simple problem to solve. Google’s development of a driverless smart car was “two orders of magnitude more complex” than providing the right diagnosis. A good machine learning system not only would be cheaper, more accurate and objective, but also effectively replace 80 percent of doctors simply by being better than the average doctor. To do so, the level of machine expertise would need to be in the 80th percentile of doctors' expertise.

Is it possible technology entrepreneurs can disrupt health care? He challenged any doctor in the room to counter his points.


Was it because everyone agreed? Were the doctors in the room simply stunned? Was there a doctor in the house? And where did he get that 80 percent statistic?

Was Kholsa serious that technology could make health care better by utilizing large data sets and computational power to clinch better and more precise diagnoses?  Was he simply being provocative to hear other points of view to learn even more? Like many others in the conference, he believes that giving consumers more opportunities, access, and choice to information about themselves and their bodies would empower them to do the right thing. He held up an EKG attachment to the iPhone which was just one of many consumer directed products in the pipeline his company has invested in.

Kholsa is a very smart and successful entrepreneur. Does innovation mean the two guys in a garage who come up with a radical idea or is it possible that innovation is having people with different experiences and point of view looking at the same problem as best selling author Malcolm Gladwell noted in his New Yorker piece Creation Myth -  Xerox PARC, Apple, and the Truth About Innovation? Surely to make health care better, technology entrepreneurs must engage with doctors. All the speakers before and after Kholsa spoke about the incredible value and insight different stakeholders to bring to the table.  The most vocal? The doctor entrepreneurs and those who worked with doctors to bring their ideas to market.

Kholsa's criticism of the health care system is completely valid. Can we do better in being more reliable, consistent, and creating a system process and design that is comparable to highly reliable organizations and industries? Of course. Can we be more systematic and doing the right things every patient every time on areas where the science is known to level of the molecule? Yes. Care must be incredibly simple to access, extremely convenient and intensely personal.

It isn't that we don't have smart people. Compared to a century ago more illness are understood, specific medications and treatment protocols can be designed. But we haven't solved it all. When we thought we knew it all, we were shown how little we truly knew. Thirty years ago, doctors predicted the demise of infectious diseases as a specialty, another footnote in medical texts as more powerful antibiotics and vaccines were available. Enter AIDS, the swine flu, and many super-bugs which have humbled our profession. Ask accomplished physician and writer Dr. Abraham Verghese about his experiences.  Dr. Verghese is rightly worried, as many others are, that even doctors are being too focused on the iPatient and not on the real patient as he writes in his New York Times op-ed Treat the Patient, Not the CT Scan. Is this what we want our health care system to look like?

Health and medical care is an incredible intersection of technology, science, emotions, and human imperfections in both providing care and comfort. As conference speaker Dr. Aenor Sawyer, an orthopedic surgeon from UCSF noted, we need to figure out how to have our different cultures of doctors, gamers, designers, and technologists interact. Fixing health care is more than simply "we know the problem and we know the solution". She reflected that the level of dedication, perseverance, and a willingness to make impact among the different groups demonstrates more similarities than differences.

I know health care can't simply be solved by smart people in Silicon Valley alone.  To solve health care we need everyone to collaborate. As Harvard Business School professor Amy Edmondson noted in her book Teaming

"For over a century, we've focused too much on relentless execution and depended too much on fear to get things done. That era is over...human and organizational obstacles to teaming and learning can be overcome...Few of today's most pressing social problems can be solved within the four walls of any organization, no matter how enlightened or extraordinary... Generating ideas to solve problems is the currency of the future; teaming is the way to develop, implement, and improve those ideas."
Perhaps Kholsa's call to action was simply an entrepreneurial mindset, but simply ignoring those who have chosen a field to improve and safe lives and who meet humanity everyday on the front-lines is problematic and dangerous. There are some things that may never be codified or driven into algorthims. Call it a doctor's experience, intuition, and therapeutic touch and listening. If start-ups can clear the obstacles and restore the timeless doctor-patient relationship and human connection, then perhaps the future of health care is bright after all.

Tuesday, August 21, 2012

Five Vital Skills to be The Thrifty Patient

From my upcoming book - The Thrifty Patient - Vital Insider Tips For Saving Money And Staying Healthy

Chapter 2 - The Thrifty Patient

Five Vital Skills to Staying Healthy and Saving Money

Throughout the book, we’ve covered various important aspects of getting the right care. It boils down to five separate but important areas you should be knowledgeable about: the doctor’s office visit, prescription medications, preventive screening tests and interventions, selecting the right doctors, and using the Internet. Each is also important to help save money. For example, learning how to communicate with doctors clearly about your concerns and needs as well as providing the doctor the information he needs can decrease the likelihood of unnecessary testing and medications. When seeing a doctor, the goal is to solve the problem you are having. It isn’t to get all of the imaging tests, lab work, or prescription medications available. When focused on the right goal, you get the right care and save money.

Sometimes, paradoxically, this may mean spending money to see the doctor to pick his brain and get his expertise. You may be tempted to ask for blood work or a MRI first and skip the office visit. Talking to a doctor seems so old-fashioned and out of date. Yet, as we will review, lab work and imaging tests are simply tools to help doctors. By themselves, without a good patient history, the test results have little meaning.

If your doctor recommends prescription medication, then there are ways to ensure that the medications you receive are effective and affordable. Many prescription medications are simply me-too or copycat drugs. Pharmaceutical companies market and promote these medications as aggressively as beer and soda. Don’t be fooled. When a medical condition is common, such as heartburn, seasonal allergies, high cholesterol, high blood pressure, and diabetes, save money by avoiding the latest advertised medication. There are often plenty of excellent and less expensive alternatives.

Focusing on prevention is extremely important. 

Getting screened for cancer and requesting vaccinations can keep you healthy. 

It isn’t particularly sexy, trendy, or even fun depending on these tests, but they can save your life. Periodically check out what the latest guidelines are, as the recommendations can change with continued medical research.

Identifying which doctor to go to is also important to getting the right care. 

It is extremely rare that any one doctor is the “best.” Don’t worry about finding the best, but rather focus on finding doctors who provide excellent quality care and who also listen to you. How do you determine if a doctor is good? How do you find one? Who is on your medical team? Should you always have a primary care doctor? If you need a specialist, how do you choose?

We also will review the use of the Internet and social media as a way to keep you informed. 

The ease of accessing information can both be a blessing and a curse. Used correctly, information from the Internet, whether from trusted health care organizations, patient or doctor blogs, or tweets, can improve decision making. It may help you determine if a symptom requires medical attention or can be safely treated and managed at home. Yet the access to this information can be equally as problematic.

The Internet, much like the lab tests and imaging studies doctors use, is still a tool. Like any tool, it can be helpful or harmful depending on how a person uses it. A simple rule of thumb—if an answer or solution sounds too good to be true, it often is.

Increasingly, you are being asked to pay more for medical care and be more responsible in making medical decisions. Knowledge is power. It isn’t that hard. Let me show you how.

Five simple skills can make you a thrifty patient who is staying healthy and saving money.

Finally, just a brief primer on what you should do outside of where I work regularly, the medical system. For most of us, life is not filled with doctor visits. That’s a good thing. Sometimes you or a loved one does, however, need our help. This is the first step to getting you the skills you need to stay healthy and choose wisely.

Let’s get started.

Thursday, August 9, 2012

Update on The Thrifty Patient - Vital Insider Tips For Saving Money And Staying Healthy

New book is finally taking shape. A revised and streamlined version of my previous work with new content is nearly completed and will be available soon on Amazon and Kindle.

Here is a sneak peak of the first chapter!


Introduction –

Why This Book Matters To You

After you finish this book, you will know what I know when it comes to medical care. I believe it can be boiled down into these short but important phrases.
  • Newer isn’t necessarily better.
  • More isn’t necessarily better.
  • Common sense may not apply.
  • Staying healthy and well means sometimes seeking medical care.
  • You need to be informed and educated to get the best care.
Or I could burden you with statistics from the health care system
which you probably already know.
  • Twenty-three seconds.
  • Fifteen minutes.
  • Forty percent.
  • Medical costs.
  • Increasing dissatisfaction.
  • Worst among industrialized countries.
These are the questions to the previous answers.

  • Twenty-three seconds: How much time do you have before your doctor interrupts you?
  • Fifteen minutes: What is the average face-to-face time at a doctor’s office visit?
  • Forty percent: What is the misdiagnosis rate based on autopsy?
  • Medical costs: What is the leading cause of personal bankruptcy? Many had health insurance.
  • Increasing dissatisfaction: How does the public feel about the American health care system?
  • Worst among industrialized countries: How does the United States rank in terms of health care quality for prevention and treatment?
Staying healthy and well means sometimes seeking medical care. 
I could tell you that too many Americans die every year unnecessarily and too soon due to missed opportunities. Healthy patients forget to get screened for colon cancer or breast cancer. Heart attacks and strokes that could have been prevented occur. Grandfathers and grandmothers aren’t around to attend holidays, graduations, or spend time with their grandchildren. Parents leave their children alone because their cancer was caught too late. No one is the wiser to this.

Newer isn’t necessarily better. More isn’t necessarily better.
You may have noticed that increasingly doctors rush through office appointments and don’t listen. Too often blood work is done, medications prescribed, and x-rays ordered, and despite all of the additional treatments patients don’t feel healthier. Television, radio, magazines, and the Internet inundate you with the latest prescription medications or therapy promising you better health. The news warns you to check with your doctor about the latest therapy with quick, thirty-second sound bites. You are fearful that you might be missing something important that could save your life.

Common sense may not apply.
Increasingly more parents are not having their children immunized against preventable illnesses such as measles and pertussis (whooping cough). Now news reports note more cases. Some children die. Many have lost faith and look for alternative and more “natural” therapies. Doctors who are supposed to help guide you and distinguish truth from fiction are just too busy, so more people are relying on family, friends, and the Internet for medical advice.

You need to be informed and educated to get the best care.
To add even more stress, health insurance is becoming too expensive. Small and large companies are trying to control costs by offering health insurance with health savings accounts (HSAs). These plans have lower monthly premiums with high deductibles. Since 2004, these plans have become more common. Many patients are now asked to choose when to seek care and when to safely skip care based not only on their health needs but on their ability to pay, even as research consistently shows that they don’t want the financial responsibility to do so.

There is good news.
Despite all of these challenges, there is good news. You aren’t alone. When I took the Hippocratic oath to do no harm and help patients to the best of my ability, I didn’t realize that pledge included writing a book. I’ve always wanted to be a doctor. Never a writer. I hated English. I only took the class because I had to, not because I wanted to. 

Despite that, I am compelled to write because of what I know is occurring with alarming frequency in our country. Americans are skipping needed and recommended care that could save their lives and allow them to live to their fullest. Patients are more distracted, as life is more complicated and busier than ever. Households have both parents working, sometimes two jobs, just to make ends meet. They easily would make the right choice if someone would be willing to explain things in a simple, understandable manner. They would prefer a health care system that was so incredibly simple to use, convenient, and personalized that it would anticipate their needs so they could get the right care and get back to living life.

Instead, our health care system offers patients higher co-pays, deductibles, and out-of-pocket medical expenses. It shifts the burden of making the right choices to people who frankly are just getting by. It asks people to fend for themselves at a time when they need us, doctors, the most.

How do I know? Two things occurred that changed my life.

Wednesday, August 1, 2012

Doctors, Patients, or Insurers - Who Will Shape Health Care?

Recently New Yorker staff writers and best-selling authors Malcolm Gladwell and Atul Gawande addressed the question of whether the problem in health care is that patients are too reliant on doctors and don't have the ability to make decisions. In reading between the lines, is that the reason health care is not affordable and care not commoditized or consumer driven like other industries?

At a conference for America's Health Insurance Plans, Gladwell argued that patients or consumers have been unable to be more empowered because doctors, as the intermediary, held the power of knowledge much the same way chauffeurs did for the early days of the automobile and Xerox technicians did in the early days of photocopying. A person was needed to guide and assist the individual to get the job done. At some point, however, the technology became simpler. People began to drive their own cars and make their own photocopies. The mystique of the chauffeur and technician was lifted. Now everyone could drive. Everyone could make photocopies.

Is it possible that for health care and the health care system, which for many people is a system they interact with rarely and in an area (health / illness) where the uncertainty and stakes many be too "high", that individuals willingly to defer the responsibility to someone else? Gladwell hints that might be a possibility:
"A key step in any kind of technological transition is the acceptance of a temporary deficit in performance at the beginning in exchange for something else," said Gladwell. That something else can eventually include increased convenience and lower cost. He offered a number of examples, including the shift to digital cameras where early pictures were not as good as film and the advent of the digital compression of music, which he contends has made the quality of music worse....

The changes in film and music were accepted, he said, in exchange for new opportunities to arrange, manipulate, and personalize our pictures and music. "In healthcare we don't have the same stomach for that period of transition. That's striking to me."
The disruptive innovation that Gladwell is hoping for has yet to affect healthcare. It is possible that as more Silicon Valley start-ups focus on making medical care more convenient, worry-free, hassle-free, more personalized, and more accessible that the majority of individuals won't adopt them because doctors don't approve. The shift to a "temporary deficit in performance" may not be as acceptable even if less expensive and more convenient. As Gladwell notes in the case of dialysis, despite being around for over seven decades, patients in general still don't self-administer treatment, which would be less expensive, but rather continue to go to facilities which are overseen by doctors.

His colleague, Dr. Atul Gawande, countered that other industries, like "teaching, firefighting, and police work" still have intermediaries that do the work on behalf of the individuals. Gawande believes that the real issue is that the care we provide as doctors isn't integrated. We focus on optimizing each part of the health care system without looking across the entire experience of care. Extending this analogy to building the best car and using the best manufacturer for each part, Gawande notes:
building a car with Porsche brakes, a Ferrari engine, a BMW chassis, and a Volvo body. "Put it all together and what you have is an expensive pile of junk that doesn't go anywhere because the pieces don't work together,"
No where was the need for doctors to lead change and think about the entire experience for the patient more clear than a recent New York times piece by health reporter Tara Parker-Pope, titled "Too Much Medical Care". She chronicled her experience as an educated patient and parent of a daughter who suffered an ankle injury at camp. She started first with:
Pediatrician. Initial visit. 
One month later, still not better so she takes daughter to Sports Medicine specialist. MRI ordered.
Referral to Pediatric Orthopedic Surgeon. Another MRI. Blood work.

Slightly abnormal blood work.
Referral to eye specialist.
Referral to pediatric rheumatologist. More blood work. Another (3rd) MRI. Xray of hands.
Five months after original injury, daughter notes that her ankle still hurts. 
Finally, Parker-Pope takes back control. She consults with the sports medicine specialist who reviews the case with the pediatrician. The focus in back on the patient and pain relief. Soon, the daughter is back to resuming her activity.

In retrospect, what is most surprising is how long the entire process went and still the daughter's problem hadn't been solved. Three MRIs for an ankle injury. Four specialists. Three MRIs. Many blood vials drawn. Xray of the hands, though the ankle was the injured joint. It's not that Parker-Pope is naive or uneducated. She is a health reporter for the New York Times and has talked to many doctors and written many stories. The fact that she and her daughter were caught up in the health care system illustrates the challenges facing the public.

Solving the health care crisis will require both points of view offered by Gladwell and Gawande. We need both patient engagement as well as a more coordinated integrated health care system. It is however increasingly clear, particularly based on the New York Times piece, that empowered patients alone won't be able to bend the cost curve. Despite the easy availability of information via the internet and self-diagnosis, there is value to the "expert" in determining the right course of action. As both Gladwell and Gawande note in their previous works there is a need for 10,000 hours of deliberate practice to become expert and that even the experts need coaching for continuous improvement, respectively.

The real problem is whether the "experts" are willing to make the judgement calls that our training provides? When to refer? When not to refer? When to get the MRI? When not to get the MRI? When to prescribe antibiotics? When to hold ground and sympathize when it is a virus? When to comfort, empathize, and heal when it means stopping chemotherapy when treatment is futile? When to do surgery? When to hold off? Are we willing to have others observe us in action so we can be even better? If not, why not?

For health care to be better, doctors must lead the change. No one else can. Insurers and employers have exhausted strategies to make patients more accountable.  Increasing deductibles and co-pays indefinitely won't work. Despite the unprecedented access to information, empowered patients and other patient advocates will never be able to fully close the knowledge gap. That difference in knowledge, as Gladwell points out in his book, Blink, is what allows an expert to distinguish between an authentic piece of artwork and a very good looking fake.

It is also the difference between stopping a number of unnecessary referrals and the cascade effect of subsequent imaging, blood work, and appointments and instead focusing on the patient.

Who will shape health care? Doctors, Patients, and Insurers and in that order.

Or entrepreneurs who partner with doctors to solve our challenges so we can go back to focusing on healing patients.

Thursday, April 26, 2012

Why Understanding Teaming Is Critical for Health Care Leaders

Solving the American health care system crisis is among the most complex and important challenges facing this generation. Is it possible to provide high quality care with better access at a more affordable cost? Is this problem solvable or simply to complicated?  Though that answer is not yet clear, what is increasingly apparent is that a new type leadership is needed if there is any hope in achieving this goal.
Professor Amy Edmondson of Harvard Business school has crafted a practical evidenced based book on how leaders and organizations must approach the increasing complexity of problems they face. Unlike the mindset of execution, which was successful in the past, Professor Edmondson demonstrates that in an increasingly competitive global economy a different approach is needed.

Organizations must learn by teaming.

It is a must read for physician leaders or other leaders in health care.

She provides leaders a clear understanding of how individual and organizational psychology, the reality of hierarchical status, cultural differences, and distance can and do separate team members which can prevent successful teaming. Leaders can close these gaps by understanding the existence of these obstacles and by adapting their leadership style to support and facilitate teaming successfully. She demonstrates the challenges as well as the solutions where teaming has gone well and not so well (the "impossible" rescue of miners in Chile and space shuttle Columbia tragedy) with numerous case studies and insights.

Professor Edmondson also notes that leaders must also thoughtfully identify where the challenges they face fit on the Process Knowledge Spectrum (routine, complex, or innovation). Routine operations could be a car manufacturing plant where outcomes and certainty are known. At the other extreme, innovation operations, like an academic research lab, the outcomes and certainty are quite unknown. Hospitals are considered complex operations. Although the teaming framework applies in each of these three cases, the leader's specific behaviors and actions change. Having excellent outcomes and teaming necessitates matching the right approach to the correct operation.

Interestingly to maximize learning, conflict and failure are necessary for teaming to be successful. These can only occur if leaders create an environment of psychological safety. Learning thoughtfully from these failures and framing them as essential for continuous improvement and innovation is key for organizations to benefit from teaming.

Most importantly, the learning never stops.

Professor Edmondson provides many examples from health care as she has "spent an inordinate amount of time studying people in hospitals." In one example, she notes how two of four cardiovascular surgical teams studied successfully implemented Minimally Invasive Cardiac Surgery (MICS) because of how the leader framed the challenge. It was a shared learning experience. The other two teams failed because they focused on the individual surgeon rather than on the team. For doctors, being able to ask others for help is culturally difficult and yet vitally important given the increasingly complexity of hospitals and medical knowledge. She notes that the "single most powerful factor explaining success" among the the four teams was how the leader framed the challenge.

She notes that for 23 hospital ICU improvement teams, those most successful in changing were those "who engaged in the interpersonal learning behaviors crucial to teaming".

One of the three case studies is about leading teaming in a complex operations at Children's Hospital. The goal of Julie Morath, the chief operating officer, was to harm no patients and achieve a 100 percent in patient safety. She engaged her staff to solve the problems. She eliminated the tendency of the medical culture to view and blame a medical error as the fault of the individual. Instead via "blameless reporting", observers merely communicated what they saw and analysis followed. aBy creating a culture of psychological safety, the hospital learned from their "accident" and explored ways to improve the their care. As a result, the hospital became nationally recognized as a leader in patient safety.

"For over a century, we've focused too much on relentless execution and depended too much on fear to get things done. That era is over...human and organizational obstacles to teaming and learning can be overcome...Few of today's most pressing social problems can be solved within the four walls of any organization, no matter how enlightened or extraordinary... Generating ideas to solve problems is the currency of the future; teaming is the way to develop, implement, and improve those ideas."

Although at times, the conclusions from her twenty years of research and observation seem counterintuitive, her findings and stories woven into a actionable framework and structure makes Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy compelling. It is destined to be a classic reference for leaders today and in the foreseeable future as they lead their colleagues and organizations into confronting and solving increasingly complex problems and challenges.

Professor Edmondson hopes that her book will enable organizations to execute at a higher level only "when leaders empower, rather than control; when they ask the right questions, rather than provide the right answers; and when they focus on flexibility, rather than insistent on adherence... When people know their ideas are welcome, they will offer innovative ways to lower costs and improve quality, thus laying a more solid foundation for meaningful work and organizational success."

She succeeds at every level.

Thursday, April 5, 2012

Will Doctors or Patients Bend the Cost Curve?

The American Board of Internal Medicine (ABIM) and nine other professional medical societies announced that doctors should perform 45 tests and procedures less often than currently done because there is no good medical evidence that they add any value. Specifically, a xray or other imaging for low back pain in an otherwise healthy individual or an EKG as part of a routine physical, just add a lot of unnecessary cost to the health care system as a whole and don't provide doctors or patients any meaningful information that would be helpful in improving health or arriving at the right diagnosis and treatment.

The ABIM partnered with Consumer Reports to create a new campaign called Choosing Wisely and are joined also by collaborators like employers (the National Business Group on Health, the Pacific Business Group on Health), hospital safety (the Leapfrog Group), and labor unions (SEIU).  The mission is simply to have doctors and patients deliver and receive care that is medically necessary, based on evidence, avoids harm, and minimizes duplication.

The real question is - will it work? Will doctors follow what their professional societies recommend?

Though Choosing Wisely is a laudable attempt to make medical care better quality, the truth is doctors won't likely follow these guidelines from their medical societies. If it was that easy, we would not have this problem! Even today, it is still a challenge for the medical profession to have all doctors wash their hands correctly every patient every time, get immunized routinely against influenza, or even not to prescribe antibiotics for coughs, colds, and bronchitis due to viruses! What is more disturbing is that doing these basic interventions did not impact a doctor's income. Some on the list of Choosing Wisely, however, will.

Take a look at the recommendations by the American Gastroenterological Association specifically around the need for repeat colonoscopy after a normal one.

Do not repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals.

Yet, if a doctor does fewer colonoscopies, which is the right thing to do, that also means his income will decrease. In the fee for service reimbursement system, doing fewer procedures means fewer things to bill for. As noted in a previous post, a new patient to my practice wanted a repeat colonoscopy 5 years after her prior one because it was recommended by her doctor even though she had no family history and a completely normal test!

Will patients protest if their doctors offer one of the 45 recommended tests, treatments, or procedures highlighted to be avoided? Are they ready for this new world? Perhaps according to the NY Times piece "Do Patients Want More Care or Less"? 

“People are more receptive to conversations about medical interventions having both pros and cons” says Dr. [Michael Barry, president of the Informed Medical Decisions Foundation, a nonprofit group that promotes sound medical thinking]. “Traditionally, newer and more aggressive interventions were often assumed to be better.” But there are hints of a shift, he says: “When patients are fully informed, they tend to be more conservative.”... [he] believes patients are ready to hear the message. He cites popular books like “Overtreated,” by Shannon Brownlee, and “Overdiagnosed: Making People Sick in the Pursuit of Health,” by H. Gilbert Welch. These are among a slew of books in recent years written by health experts on the dangers of the “more is better” attitude about health care.
Yet, we should also be skeptical about this perspective. Research has consistently shown that there is no value for an annual physical or check-up, yet how many people still have one "just to be safe?" Although there is a small number of patients who are empowered and question their doctors about the treatment plan, the fact is most patients expect their doctors to make the best choices on their behalf. If a doctor recommends an antibiotic for a sinus infection or suggests a MRI for low back pain, will a patient really say no? In general, it takes a doctor more time and energy to educate a patient on why an antibiotic or MRI isn't necessary, how an individual's personal experience is different than those of their friends and family who all got antibiotics and MRIs in the past, and to do so in a caring and compassionate way.

If we expect doctors or patients to bend the health care cost curve this way with more education, better communications, and encouraging patients to talk to their doctors about the appropriateness of care, we will fail.

But increasingly there is a trend I am seeing which will bend the cost curve. Patients are increasingly questioning the need for expensive imaging tests not because they want to only get the right care proven by evidence, but because they have high deductibles and copays that require hundreds of dollars.

This would be good news except now instead of having a conversation and an examination with a doctor to determine if a MRI is needed for back pain, more patients are now simply calling in and asking for a MRI. After all, isn't talking and touching a patient and the healing aspect of a doctor patient relationship simply antiquated in a time with technology? It is now taking more time and energy to educate a patient why an office visit actually is more valuable than imaging!

If there is hope to make care more affordable and of even higher quality, then it will be because doctors have shouldered this responsibility. Our commitment won't be the result of our professional organizations rolling out an educational component, or the media highlighting the "waste" in our system, but rather it will be questions each of us will need to answer. Is doing no harm also mean avoiding unnecessary testing? Will we do the right thing even when it is hard? If there should be some optimism, then it should be that the current and next generation of doctors will lead this change.

This spirit and responsibility is best captured by Dr. Bob Wachter, professor and chief of the division of hospital medicine. chief of the medical service at the University of California San Francisco Medical Center, chair-elect for the ABIM and the "father" of the hospitalist movement, in his keynote address to the Society of Hospital Medicine.

“We need to be great team players, but we also need to be great leaders,"
“We need to embrace useful technology, but we can’t be slaves to it … improve systems of care, but welcome personal and group accountability. Strive for a balanced life but remember medicine is more a calling than a job. And think about the patients’ needs before our own. These are core and enduring values even as we move into this new era.”
“We have big targets on us and I think they are appropriate,” said Dr. Wachter. “There are others who should have targets as well, but the main target has to be us. Change is impossible if we don’t embrace change.”
In the end, it will be doctors who can bend the cost curve.

Thursday, March 8, 2012

Part II - What Doctors and Healthcare Can Learn from the New England Patriots

Although my team, the New England Patriots lost Super Bowl XLVI to the New York Giants in one of the most exciting and tense games in recent memory, reviewing both the pre and post game coverage provided even more learning for doctors and healthcare than my prior post. One can demand excellence and still fall short. When one fails to achieve the intended goals, the learnings can be as important if not more so than when one is successful. In the latter, you assume that you understand the reason for success. In the former, you must investigate to determine problems. It is the approach that matters.

CEO of the Patriots, Robert Kraft noted in a post Super Bowl conference that statistically every NFL team has a 6 percent chance of reaching the Super Bowl and consequently a 3 percent chance of winning. Over the past decade, the Patriots have been in half of them. An impressive statistic considering other teams have equally dedicated players and coaches who also are focused on success. So what makes the Patriots so successful?

One learning is the true meaning of teamwork. Sure football is a team sport, but are the players and coaches truly a tight knit team on the same page for excellence?  Prior to the 2002 Super Bowl, players were introduced onto the field individually by name. Hearing your name called out and then running out onto the field to a crowd of screaming fans undoubtedly is a thrill for every player, particularly when it is the Super Bowl. Yet for the Patriots that year, this was not the case. Earlier that season at an away game, a mix-up in the team introductions had the team unprepared. Instead of the usual player introductions, the team instead raced onto the field as a team rather than individually.

Then 9/11 happened. For the remainder of the season, the Patriots found it fitting to continue dash onto to the field as a team as the nation came to grips of an unspeakable assault on our country.

Hours before 2002 Super Bowl kick off, head coach Bill Belichick notified his team that the NFL and television network required that the team be introduced as individual players. To come out as a team would be in violation of policy.

What did the team want to do?

They ran out as a team. The first time ever that has occurred. As noted on ESPN by former 49er quarterback and football analyst Steve Young, that tradition has continued to present day and shifted the focus back from the individual to the team, the right thing for football.

And perhaps this is the right thing for doctors and the health care system. How often do hospitals and health care organize themselves around having the "best" doctor? How often do people ask, who is the "best" surgeon, internist, oncologist, cardiologist. Is medical care really about one person or is it about having the right team? Dr. Atul Gawande, author, New Yorker writer, and surgeon, noted in his commencement speech titled, Cowboys and Pit Crews, at the Harvard Medical School in 2011 that today.

“[Medicine’s complexity] has exceeded our individual capabilities as doctors…
The core structure of medicine—how health care is organized and practiced—emerged in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves... But you can’t hold all the information in your head any longer, and you can’t master all the skills. No one person can work up a patient’s back pain, run the immunoassay, do the physical therapy, protocol the MRI, and direct the treatment of the unexpected cancer found growing in the spine. I don’t even know what it means to “protocol” the MRI.”

“...We don’t have to look far for evidence. Two million patients pick up infections in American hospitals, most because someone didn’t follow basic antiseptic precautions. Forty per cent of coronary-disease patients and sixty per cent of asthma patients receive incomplete or inappropriate care. And half of major surgical complications are avoidable with existing knowledge. It’s like no one’s in charge—because no one is. The public’s experience is that we have amazing clinicians and technologies but little consistent sense that they come together to provide an actual system of care, from start to finish, for people. We train, hire, and pay doctors to be cowboys. But it’s pit crews people need.”

It really should be about the team and not the individual. This is particularly true when it comes to medical errors. When a wrong site surgery occurs or a medication is administered at a dosage that exceeds safe usage, the question in health care is - "Who is responsible?" As noted safety expert and UCSF professor Dr. Robert Wachter notes in a 2004 interview when a medical error occurs at a hospital -

"...people invariably point fingers at that place and person and lose sight of the systems failures that are really responsible. Look at it this way -- ask anyone if they've seen a medical error and they'll immediately tell you a story about one. Could it possibly be that all doctors and nurses are careless and stupid? Or, perhaps, does the ubiquity of the problem indicate that something deeper and far more interesting is going on?"

So in the true meaning of teamwork, should something happen, the team is accountable not necessarily the individual. The team owns the problem and does not leave the individual alone, unsupported, or in shame. Even after the most recent Super Bowl loss when many people picked up on individual player errors of dropped passes, including one from wide receiver Wes Welker, one of the most sure handed receivers in the NFL, which likely would have resulted in a Super Bowl win, no one from the team scapegoated him or others. As quarterback Tom Brady put it in the post Super Bowl press conference -

You win as a team and you lose as a team. Certainly it wasn't one play is the reason that we lost today. Everybody feels that we could have done more....

There was some missed opportunities.
When surveyed on the Boston Globe on who should be blamed most for the Super Bowl loss, quarterback Tom Brady, head coach Bill Belichick, the Patriots defense, or the receivers Aaron Hernandez or Wes Walker, the majority of votes distributed the blame evenly across the team. It was not just one person.

Yet in health care, we do a terrible job in supporting others when errors happen. We often assume the individual was at fault rather than a collective fault or system failure. Health care professionals who have dedicated their lives to saving lives are devastated. Some commit suicide after a medical error.

Finally the last learning is leadership, having a vision, and understanding what really matters. All season long as his young defensive unit was getting dogged in the press as being among the worst in giving up total yards to other teams, Belichick calmly noted that it wasn't about that statistic which mattered, but what was the win - loss column. Hard to argue with that as this team did make the Super Bowl.

Belichick is known to resist the status quo. He's a football coach, not a fashion model, yet was mandated by the NFL to wear Reebok sanctioned clothing on the sidelines to look nice. What did he do? He picked up the ugliest piece of clothing he could find, the hoodie.

There was no way to opt out of that deal so Belichick considered the fashion options laid out in front of him, and selected the most unstylish outfit, a grey hooded sweatshirt. He began wearing it each week. Only not before having the sleeves cut off to make it even less attractive.

“It’s comfortable,” Belichick said in explaining his fashion choice. “I carry my stuff in my pouch.”

What about chopping off the sleeves?

“I have short arms,” Belichick said.

The irony is the “BB hooded sweatshirt” became a hot seller. It was so bad, it was cool. It now comes in all sizes and colors, even women’s versions. They sell for about $80
As a coach and leader, he knows what really matters: putting his players in a position to win. This is what leaders do and what players and analysts noted repeatedly up to the game. Belichick does everything possible for them to succeed. Near the end of the game, Belichick understood that the Giant offense had a high probability of scoring a touchdown and he needed to give his future hall of famer quarterback Tom Brady time to score. So he asked his defense to let the go ahead touchdown to go through to allow maximum time on the clock.

Good move? Well the outcome and the win for the Patriots didn't happen. But, it was the right leadership decision and recognized by Giants quarterback Eli Manning, who "had ordered [Giants running back] Bradshaw to take a knee."

Do we in health care have these leaders who can create environments that allow doctors and other care providers the opportunity to be successful? Do we have leaders who truly have vision and know what really matters?

Even without a Super Bowl win, we can still learn a lot from the New England Patriots. A true culture of teamwork matters and exists when we can still support each other not when things go smoothly, but when things don't. We need to have leaders who not only have vision, but also the discipline to do the right thing and challenge conventional thinking and the status quo.

Only then can health care truly transform and be what Americans want and deserve. 

Though I look forward to next year, there obviously is much unpredictability in which team reaches the Super Bowl. I'm certain the Patriots will have another successful year.

Congratulations to the NY Giants and their team, coaches, and leadership.

Unlike football, where there is next year and they need to perform for a game at a time, for us we need to get a win with every patient everyday at every moment. Our performance can never lapse.

Monday, January 9, 2012

What Doctors and Healthcare Can Learn from Tom Brady, Bill Belichick, and the New England Patriots

As the new year starts, I'm eager for a fresh start and working on improving myself both physically and emotionally. I'm also eager for the NFL playoffs and seeing how my favorite team, the New England Patriots, fares under the leadership of Coach Bill Belichick and quarterback Tom Brady. Doctors and health care can learn much from their examples.

Over the past decade, the New England Patriots have been dominant appearing in 40 percent of the Super Bowls played and winning 3 out of 4. Nothing prior to 2000, would have suggested this superior performance with playoff appearances only six times from 1985 to 2000 and two Super Bowl appears, both losses.  Their new head coach Bill Belichick hired in 2000 had a losing record in his prior stint at Cleveland. Their current quarterback Tom Brady was drafted in the second to last round.

So what was their secret for success? Nothing particularly earth-shattering. It was and still is a relentless focus on continuous improvement by practicing deliberately and explicitly. This is an important learning for the US healthcare system which consistently lags that of other industrialized countries when measured on quality outcomes.

In general, doctors don't focus on how medical care is delivered. We don't focus on our own continuous improvement, which is a far different philosophy than individual athletes in professional sports. In our profession and in our training, we also typically don't focus on ensuring that the care we provide is consistently reliable over a period of time with our diverse medical team.

Yet, success in the NFL is based on whether a group of individuals, which composition may differ annually, can execute the plan well every time.

For the team to do well, it first relies on the individual player to do well. Take the Patriots' quarterback Tom Brady. He is currently among the best quarterbacks in the NFL playing today. Some argue he may be the best ever to play the position. Was he destined for greatness early in his career?

No. In fact, Brady doubted his abilities early on while at Michigan. Change started to occur when he adopted a different mindset presented by one of his mentors, Michigan associate athletic director Greg Harden. It isn't about just talent that will result in success, but in fact a focus on improving one's skills which allow the possibility to be the best. Though he did succeed at Michigan, Brady was drafted in 199th by the Patriots in 2000.

What did he do? The future hall of famer simply did what he learned at Michigan - learn the position better than anyone else and be deliberate about his practice. His NFL rookie year was unremarkable. In the following year, as a second year quarterback, he started off slowly. He steadily improved to the point that when the Patriots were in the Super Bowl, he led the team to a final winning drive. Brady became the youngest quarterback ever to win a Super Bowl.

Despite reaching the pinnacle of a football career in January 2002, he hasn't stopped improving his skills. When asked recently to impart some wisdom to NFL quarterback rookie and Heisman trophy winner Cam Newton, Brady said this –
You always realize that you can always be better. You can always be a better friend, a better player, a better teammate, and always try to find ways to improve. I go out there and be the best teammate I can be; because the goal in life is to win.
Yet how often do doctors work specifically on themselves and improve what they truly control, that is their own individual skills and talents? How often do we each work hard on improving our clinical acumen, communication skills, surgical techniques, or diagnostic skills? As doctors after we have finished our advanced training via a residency or fellowship program, we don't seek opportunities to improve skills we believe we have mastered. In fact, we bristle at continuous improvement as New Yorker writer and surgeon Dr. Atul Gawande notes in his article Personal Best.
Nearly every élite tennis player in the world [has a coach]. Professional athletes use coaches to make sure they are as good as they can be.

But doctors don’t. I’d paid to have a kid just out of college look at my serve. So why did I find it inconceivable to pay someone to come into my operating room and coach me on my surgical technique?
Gawande tries an experiment and convinces a mentor, who he respects highly, to observe him in the operating room. Gawade reflected that in the debriefing with his mentor
That one twenty-minute discussion gave me more to consider and work on than I’d had in the past five years. It had been strange and more than a little awkward having to explain to the surgical team why Osteen was spending the morning with us. “He’s here to coach me,” I’d said. Yet the stranger thing, it occurred to me, was that no senior colleague had come to observe me in the eight years since I’d established my surgical practice. Like most work, medical practice is largely unseen by anyone who might raise one’s sights. I’d had no outside ears and eyes.
Gawande observes that in health care
...the capabilities of doctors matter every bit as much as the technology. This is true of all professions. What ultimately makes the difference is how well people use technology. We have devoted disastrously little attention to fostering those abilities.
So individually, each doctor can and should focus on improving his individual abilities and to know his position the best, to be a doctor's doctor.

But there is more. Health care isn't just about one position, one profession, or one doctor. Providing complex medical care is like leading a football team of 53 players of which only 11 are on the field at any given time to play offense, defense, or special teams. For success, each individual must do his job consistently and reliably every time. Anything short of that is incredibly obvious.  Failings unfold weekly to tens of thousands of fans in the stadium and millions watching via instant replay, the internet, and ESPN. Success and failure is dictated by a win-loss record until the season ends and the cycle repeats itself.

The Patriots have been exceptional in the past decade not only because of having Tom Brady but also for the many other individual players who are focused not only on making their own skills better but to do so for the benefit of the team. Previous "troublemakers" and prima donna wide receivers Randy Moss and Chad Ochocinco, when joining the Patriots have been quiet, humble, hard-working, and focused on improving and contributing to the team. This team focus comes directly from the top with head coach Bill Belichick. Profiled recently by NFL films, note how he leads and prepares his team deliberately to think ahead, anticipate problems, and execute the plan consistently in practice. Though each player is a paid professional and should know the game instinctively, Belichick takes no chances. He says the following to players in practice - 
I want to call out the situation, pay attention.
I don't care whether you are part of it or not.
First and ten, plus 50, alert for what.
Ok, they have no time outs. The ball is on the one yard line. Tell me what is going to happen here.
We got 40 seconds and need a field goal, two minutes.

We good on every thing fellas? No questions? We're good?

(confiding to his son) - Those situations are just as good for the coaches as they are for the players. Makes everybody think about what I might want to call here.

Like [Tom] Brady he's thinking one thing, Billy (Patriots' quarterback coach) is thinking something.  We want them both thinking the same thing you know.
The win-loss record as well as playoff appearances, conference championships, and Super Bowl wins are consistent with high performance outcomes. Impressive considering that every other team in the NFL has players and coaches each driven to excel. What might healthcare learn from the Patriots head coach?

Can doctors and staff work together and regularly drill on scenarios both likely and rare? Can we use checklists and protocols and modify accordingly much the same way a coach changes the playbook? In medicine, we assume that that everyone knows his task when it comes to code blues and emergency surgeries. We also assume that everyone knows his task when it comes to mundane stuff like drawing up medications or discontinuing orders in the hospital. We are then stunned when adult heparin is given to babies in the ICU and the blood thinner coumadin isn't stopped when a resident doctors is interrupted with a text message with significant consequences to the patient.

We often blame the individual rather than ask can it be about something else that increases likelihood for success?

We don't fully appreciate the discipline or the processes needed to create a highly reliable organization. What we don't have are physician leaders who can take the care we provide to the next level. Note the comments from Dr. Thomas Lee, network president of Partners HealthCare System and professor of medicine at Harvard Medical School in a podcast regarding his article in Harvard Business Review - Turning Doctors Into Leaders.
[Doctors are] taught to rely solely upon themselves. They don't necessarily work well in teams. They don't think about the bigger picture, because they've been taught to focus just on the patient in front of them. respond to the pressures created by all this [medical progress which causes rising costs, quality challenges, and chaos that patients experience] is for providers to get more organized and adopt systems that will bring order to the chaos. But that takes leadership. It takes the kind of leadership where you can persuade clinicians to work together in teams, as in almost every successful business, they already do.
For the US healthcare system to improve and succeed in providing highly reliable and safe care to everyone, it will require individual doctors to be like Tom Brady and ask - is there something I can do even better? It will require some doctors to be like Bill Belichick and ask - is there a process and discipline I can provide to allow the team that I lead succeed?

Doctors can and must lead the changes that everyone in the country wants from our health care system. There is no other group best suited to the task.

The question is - are doctors ready to step up?

Go Pats!


Related Posts with Thumbnails