Chapter 1 Summary
Healthcare: How did we get here and where are we going?
David M. Lawrence, MD. CEO of Kaiser in the 1990s.
"Between the health care we have and the care we could have lies not just a gap, but a chasm."
- Institute of Medicine 2011
The textbook starts with a controversial chapter by Dr David Lawrence. I suspect it seems like common sense to those outside of medicine. Whereas most physicians I suspect will be enraged and in disagreement.
In it he blames most of the poor delivery of contemporary healthcare on the high degree of physicians autonomy, and paints a future of highly integrated care systems that likely will not require physicians to be at the core of healthcare delivery. I agree with his analysis, and discussed many of the similar issues in the talk 'Breaking the Medical Cartel'.
1. How did we get here?
The chapter starts with the usual facts of how the US healthcare system isn't that great. We already all know these numbers. The US system is "superb for some, but its costs are unsustainable, its quality and safety unpredictable, and the value it delivers (health/dollar invested) markedly lower than that found in other developed countries". Despite there being excellent clinicians within the system, patients find the system a "nightmare to navigate", and "impersonal, confusing, and fragmented".
"Poor designs set the workforce up to fail, regardless of how hard they try.
If we want safer, higher-quality care, we will need to have redesigned systems of care"
- Institute of Medicine 2011
After World War II most care was provided by solo practices. And in many ways, the system remains the same. Dr Lawrence inquires why the system remains unable to innovate or improve the delivery of care. Although the fee for service and billing structures are often blamed, "the payment systems is not a primary cause".
The primary cause is Physician Culture. And specifically its focus physician autonomy, physician exceptionalism, and the preference for intuition.
2. Physician Culture
This is the core of the chapter's argument and thesis. It starts in the United States in the 1930s with the formation of physicians as a group - after decades of quackery. The doctor would combined "science, experience, and judgment."
"A trained skeptic of the work of others, gathering his own information by carrying out an independent assessment of each patient, he prefers to work alone surrounded by his support staff, interacting with his patients on his terms.
Only when he reaches the limits of his largely self-deifned competence (or his tolerance for legal risk), does he refer the patient to another doctor, who repeats the same process."
(note, this is not a description of physicians working in the 1930s, but how we work today)
Medical training prioritizes autonomy as a core value. There are "few opportunities to-learn the skills of shared decision-making or to work in teams of physicians or other health professionals". This isolation continues as most physicians "practice in single-specialty groups of 10 physicians or less, and a third of all physicians work alone."
The principle of physician autonomy extends to physicians groups continuously working to limit the roles of other health professionals (such as nurses, nurse practitioners, pharmacists, paramedics, etc), whenever the scope of their practice is proposed to expand.
Physician autonomy is associated with a wide variation in practice style, and there is obvious retaliation against calls for greater transparency and accountability in work or outcomes.
The introduction of guidelines, best practices, and care pathways is viewed as "cookbook medicine", and something antithetical to the professional insights, clinical acumen. and personal touch of each physician to know best how to mange the unique needs of their patient's condition.
Isolated clinical practices, practicing with autonomy and minimal oversight are the norm and perpetuate a fragmented healthcare system.
3. Growth of Medical Science
Interesting, the chapter pits science against physician culture. Suggesting that the very progress seen within science and medicine is at its heart antithetical to the practice of physicians. At first this may seem counterintuitive.
Lawrence suggests that science is always trying to bring greater clarity, specificity, and accuracy to medical care. Science works to remove clinical ambiguity. It works to categorize and diagnose. To use data to move one away from intuition and the grey.
Ultimately, advances in both biological sciences, social science, and communicative science will allow new models of care to flourish. New models that rely on science and technology combined with non-physician care givers to delivery higher quality, more reliable, and less expensive care than the current physician model.
4. Changing demographics and demand
The growth of patient populations worldwide, combined with the shift to higher levels of chronic disease care, leave traditional physician models inadequately equipped to provide chronic disease care. Such care requires highly integrated organizations, relying primarily on non-physician care givers to work with patients to identify and modify their risk factors and manage chronic disease. Physicians are trained and organized to provide care in acute illness. Not the chronic illness that has come to dominate the current landscape.
In the contemporary medical model, non-physician care providers are only encouraged in places were there are shortages of physicians. They are not the norm.
5. What does this mean for the future?
Four 'battlefronts' are proposed, where physician culture and outmoded physician-dominated delivery models will come into conflict with new models for care.
A. Sick care delivery system:
Improvement to the sick care system, will come with a move away from isolated autonomous physician practices into integrated care practices (such as Kaiser, Mayo, or Virginia Mason).
Such a move will rely on information technology and industrial engineering to drive performance. Medicine is perhaps the only industry in the world that functions at one to two sigma as the norm (aka an error in patient care occurs at once every 10 times care is given, or at best every 100 times care is given). This is in contrast to many high performing companies that function at sig sigma (an error or two in every 1,000,000 times something is done).
B. Consumer-Health Ecosystem
The expansion of mobile monitoring and distributed information systems (aka cell phones) means that more services will be able to serve patients directly - without the need for a physician's office as the intermediary. The use of algorithms, information systems, and low-cost care personnel will be far less expensive, and more reliable than systems that are limited by physician availability and pace. Direct to patient systems will also be able to function 24/7 365 days a year, and also more effectively triage patient's than the standard model of primary care physicians.
C. New personalized medicine paradigm
Personalized medicine, with its focus on being able to recognize illness before it produces symptoms and complications, has the potential to make contemporary physician tools for diagnostics and therapeutics obsolete or outdated.
D. Accountable organizations
What will be the organizational and reimbursement strategy in the future? Who will control such organizations, and what will be the role of physicians in their leadership. It is difficult to anticipate how conflicts between clinicians and managers will be resolved.
6. Final Thoughts
"The sick care systems has become a collection of complex production processes, but efforts to improve performance have largely failed because of the overriding need to preserve an obsolete organizing model. The application of the tools of industrial design can help change this."