The Problem With Physicians Like Him
Author Thomas H. Lee, MD, writes that the problem with medicine is people like him: primarily men, in their 50s and beyond, who learned medicine when it was more about art and less about money. “We were taught to go to the hospital before dawn, stay until our patients were stable, focus on the needs of each patient before us, and not worry about costs,”¹ he writes in the April 2010 issue of Harvard Business Review. “We were taught to review every test result with our own eyes—to depend on no one.” They were taught, Lee writes, that the only way to ensure quality was to adopt high standards and maintain them, using an approach that fundamentally will not meet the current cost-containment and quality demands on health care. While acknowledging that greed and incompetence do exist in medicine, Lee maintains that the biggest driver of cost increases is medical progress: new drugs, tests, and devices that are entering a system too fragmented and chaotic to absorb them cogently. The answer is a new kind of leadership at every level of health care, from the integrated delivery network to the physician practice. The first task of these new leaders is to understand that outcomes are what matter, not how many MRI studies physicians order or how many patients they see. The second is to accept that there is a place in medicine for value. The third and most important task is to subscribe to the belief that outcomes and values cannot be achieved without teamwork. Once leaders of a new breed accept the preceding maxims, they can begin to lead by articulating the vision for change, acknowledging the importance of clinicians who might resist a new way of working while making it clear that the new order is better both for patient care and for business. An example of this new breed is Delos M. Cosgrove, MD, a cardiac surgeon who became CEO of the Cleveland Clinic in 2004 and immediately made performance measurement part of his plan. Available at first only internally, the outcomes data are now accessible on the Web. Seattle’s Virginia Mason Medical Center was also cited by Lee, who notes that its patients-first commitment extends even to practice patterns in its beautiful, light-infused cancer center, where physicians come to patients (instead of the other way around), and office space is bunched in cubicles in the middle of the center. New Idea and New Structure Lee maintains that this focus on performance is a complete departure from the prevailing conventional wisdom among providers, which holds that true quality cannot be measured. If things are to change, the organizational structure of hospitals will need to be redesigned around the needs of patients, rather than those of physicians. Having separate units for cardiology, cardiac surgery, cardiac anesthesiology, and radiology, for instance, creates redundant administrative costs and dysfunction in the form of turf battles, Lee maintains. Misaligned incentives of physicians (paid per visit) and hospitals (paid per DRG) breed antagonism. “Large-scale organizational changes like these require strong leaders and a cultural context in which they can lead,” Lee writes. “For obvious reasons, such leaders gain additional leverage if they are physicians and their organization employs its [physicians]. At the Cleveland Clinic all physicians are on one-year renewable contracts, which sends a powerful message about the importance of team spirit.” The best way to foster buy-in on performance measures is to create a common method of measurement. For example, when Massachusetts announced that it would collect and post bloodstream-infection rates, Lee’s institution, Partners HealthCare™ (based in Boston), got serious about the issue. Two hospitals had long reported different rates of infection, but hospital A, which had the higher rate, discounted the data because the hospital used a method (drawing blood through indwelling catheters) with a higher false-positive rate. Only after hospital A adopted the other hospital’s method (drawing blood using a fresh skin prick) and discovered that it still had a higher rate of infection did it get interested in exploring what else hospital B did differently. “When data are uniform and reliable, leaders can push for the standardization of best practices throughout an organization,” Lee writes. The organization went one step further and started to apply colored tape to catheters that were inserted in the emergency department under less-than-ideal circumstances, as a signal to other caregivers to replace them soon as possible. Lee notes that although this directive did not come from above, it was the senior managers who created the impetus and the environment for change. Team Spirit Because physicians see themselves as what Lee calls “heroic lone healers,” getting them to work in teams represents a culture shift, but a critical one. Lee offers the example of Geisinger Health System, Danville, Pennsylvania, where hospital readmissions have been cut in half. He attributes this achievement to a team approach to patient management, monitored by care-coordinator nurses who pay close attention to complex cases (especially when patients are about to be discharged) and determine when a patient needs to see a particular physician. “Not long ago, in the strict hierarchy of medicine, nurses were largely regarded as technicians whose job was to follow orders,” Lee writes. “No decision was made without a physician’s knowledge and consent. The notion of a nurse as a critical contributor and independent decision maker on a clinical team would have seemed absurd.” In a setting such as Geisinger Health System, physicians are required to hand off considerable responsibility to nurse practitioners if they are to get improved performance in measurements that are likely to play a greater role not only in who gets paid, but in payment rates as well. Lee says that increasingly, the fortunes of physician groups will depend on teamwork. Get Used To It Health care teams are well advised to look at performance improvement as a process, rather than as a project with a finite endpoint. The best way to do that is to adopt a culture of process improvement and make use of the tools of that trade: lean management, data collection, brainstorming, intervention, and impact analysis. Virginia Mason Medical Center found its way when CEO Michael Rona happened to sit next to Boeing’s director of lean management on a plane flight. Rona began taking teams to Japan to study the Toyota Production System, resulting in reduced costs, improved quality and service, and a strengthened balance sheet. Brent James, quality officer at Intermountain Healthcare, Salt Lake City, Utah, runs a highly respected process improvement program that helped Geisinger Health System, which offers such courses in turn. Lee identifies autonomy as the primary cultural barrier to a more collaborative approach to health care. Physicians, Lee writes, “have historically seen themselves as their patients’ sole advocates, with the rest of the world divided into those who are helping and those who are in the way.” To promote the acceptance of teamwork and process improvement among physicians, Lee recommends three steps: • since altruism is at the core of most health care professionals, appeal to that impulse; • physicians are mesmerized by data, so put data collection and sharing at the center of your program; and • define a strategy around patient needs; they are what health care is all about. The number of people who need to be trained is the square root of the number to be influenced, Lee writes. An organization of 100 people can begin by training 10; one with 10,000 needs to train 100.