Over at “Ohio Surgery” Buckeye Surgeon is not at all happy with the commencement speech that fellow-surgeon Atul Gawande recently delivered to Harvard Medical School’s graduating class. Today, Buckeye (a.k.a Jeffrey Parks, a general surgeon on the East Side of Cleveland, Ohio), summed up what he called Gawande’s “essential message”:
“Healthcare is far too complex for any one doctor anymore. So gear up to be an interchangeable part, a faceless drone who performs menial tasks according to checklists and algorithms. . . Don't be a Cowboy (in the romanticized, individualistic sense of a bygone era) . . . All that debt you've taken on to be a physician? It's so you can be an anonymous member of an integrated Team. Like a Pit Crew.”
No surprise, Gawande, who is a regular contributor to The New Yorker, makes his case in somewhat more eloquent terms: “The distance medicine has travelled in the [last] couple of generations is almost unfathomable,” he writes, comparing that span to the “vast quantum leap” his father made when he traveled “from his rural farming village of five thousand people [in India] to Nagpur, a city of millions where he was admitted to medical school, three hundred kilometers away. Both communities were impoverished. But the structure of life, the values, and the ideas were so different as to be unrecognizable. Visiting back home, he found that one generation couldn’t even grasp the other’s challenges. Here is where we seem to find ourselves, as well.”
Medical culture has been roiled by change, leaving some doctors who remain attached to the past dismayed. This was inevitable, Gawande says. In the past, physicians had only a handful of remedies. “Now we have treatments for nearly all of the tens of thousands of diagnoses and conditions that afflict human beings. We have more than six thousand drugs and four thousand medical and surgical procedures, and you, the clinicians graduating today, will be legally permitted to provide them. . .
“We in medicine, however, have been slow to grasp . . . how the volume of discovery has changed our work and responsibilities . . .” he added, “The rapid growth in medicine’s capacities is not just a difference in degree but a difference in kind . . . the reality is that medicine’s complexity has exceeded our individual capabilities as doctors.”
He told the graduates that In earlier decades, “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. . . We were craftsmen. We could set the fracture, spin the blood, plate the cultures, administer the antiserum. The nature of the knowledge lent itself to prizing autonomy, independence, and self-sufficiency among our highest values, and to designing medicine accordingly. 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.” '
Like many physicians who I have quoted on HealthBeat over the past four years, (Bob Wachter, Diane Meier, Jack Wennberg, Elliot Fisher, Don Berwick, Brent James, Peter Eisenberg, among others), Gawande explains that medicine is no longer a matter of “individual heroism.” It has become a ‘team sport.’”
In 1970 the number of clinical staff involved the care of a typical patient at Johns Hopkins hospital was 2.5 full -time clinicians, he reports. “By the end of the nineteen-nineties, it was more than fifteen. The number must be even larger today. Everyone has just a piece of patient care. We’re all specialists now—even primary-care doctors.”
But, Gawande warns, “a structure that prioritizes the independence of all those specialists will have enormous difficulty achieving great care.”
Nevertheless, “we still train, hire and pay physicians to be cowboys.” Med school students are not taught to collaborate with each other; they are flogged to compete. As for pay, when they graduate, physicians usually are reimbursed one by one, fee-for-service. The doctor who draws more patients and does more surgeries wins the game.
By contrast, health care reformers would like to see doctors paid as teams, with higher reimbursements going to those that work well together, achieving better outcomes for patients.
Buckeye, it seems, remains nostalgic for what he himself calls the “romanticized, individualized” model of the past–the doctor as Lone Ranger, a hero who takes full responsibility for his patients. Buckeye complains bitterly that in his commencement speech Gawande said “not a word about patient ownership”–as in this is my patient. (Never mind that this sense of “owning” the patient can undermine care. Some surgeons refuse to a let a palliative care team talk to “their” patients, reports Dr. Diane Meier, a pioneer in palliative care. Oncologists, too, may block a palliative consult, on the grounds that this is “my patient” and “she’s nowhere near that point,” i.e. death. “We’re planning on another round of chemo,” an oncologist once told Meier, referring to a cancer patient whose organs were shutting down in the ICU.)
This sense of patient ownership goes back to the days when there was just one doctor and one patient. And that one doctor knew what was best for his patient. To Buckeye a doctor’s “personal accountability” is all. It defines what it means to be a physician and “put your heart and soul into this noble calling.”
A More “Patient Centered” View of Medicine
Gawande’s view is less romantic and, I would argue, more “patient-centered.” He warns that a system which “prioritizes the independence” of each of those fifteen specialists caring for an individual patient “will have enormous difficulty” achieving excellent care. When fifteen independent private practitioners “consult” on one patient, they don’t necessarily consult with each other. Doctors who prize their autonomy just aren’t very good at coordinating care, or following guideline.
“We don’t have to look far for evidence,” Gawande adds. "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.”
As UCSF’s Dr. Bob Wachter has said, “teamwork is at the center of the patient-safety movement.”
Do Patients Really Need Fifteen Physicians?
Still, many hospital patients wonder: “Why are so many doctors involved in my case? Isn’t that part of the problem–too many cooks, not enough communication? Why can’t just one doctor take care of me? What happened to the idea of “my doctor?”
Yes, sometimes too many specialists are called in unnecessarily, and this can be a sign that a hospital is inefficient, “fishing” for a diagnosis, casting a wide net by running a dozen tests or more, rather than taking a careful patient history, actually listening to the patient, and narrowing down the possibilities before ordering the tests.
But the days of “my doctor,” the hero who I can count on to know everything are gone. The truth is that, given the complexity of 21st century medicine, a very sick patient may well need those fifteen pairs of hands, not to mention fifteen minds. As Gawande points out, no one health care worker can do everything; no one doctor knows enough to provide the best care. Physicians need to listen to each other, nurses and other health care specialists, respecting each others’ knowledge.
I recall what Dr. Peter Eisenberg, Medical Director at California Cancer Care, wrote in a wonderfully candid guest-post published on HealthBeat two years ago: “Do you want to go to a doc and be treated according to his treatment plan after an hour-long visit?” he asked. “Or would you rather that he present your case, along with the pathology slides and the imaging studies, to a group of other docs representing a number of disciplines (medical, surgical and radiation oncology, diagnostic radiology, pathology, nursing, social work, dietetics, pain control, pulmonary, gastroenterology, etc.) to be viewed and discussed?
“Smart docs are not afraid to consult with the smarter (or more experienced) docs at the university and even send patients there to get their treatment if the care is complicated and not well–known to us,” he added.
Better Care Means Physicians Collaborating In a “System”
Gawande ends his essay by declaring that physicians should be concerned about the “unsustainable growth in the cost of care.”
“Medical performance tends to follow a bell curve,” he observes, “with a wide gap between the best and the worst results for a given condition, depending on where people go for care. The costs follow a bell curve, as well, varying for similar patients by thirty to fifty per cent. But the interesting thing is: the curves do not match. The places that get the best results are not the most expensive places. Indeed, many are among the least expensive. . .And the pattern seems to be that the places that function most like a system are most successful.
“By a system I mean that the diverse people actually work together to direct their specialized capabilities toward common goals for patients,” he explains. "They are coordinated by design. They are pit crews. To function this way, howver, you must cultivate certain skills . . .
"For one, you must acquire an ability to recognize when you’ve succeeded and when you’ve failed for patients. People in effective systems become interested in data. They put effort and resources into collecting them, refining them, understanding what they say about their performance.” (Here Gawande is suggesting that physicians take an interest in those “algorithms.” that Buckeye finds boring.)
“Second, you must grow an ability to devise solutions for the system problems that data and experience uncover. When I was in medical school, for instance, one of the last ways I’d have imagined spending time in my future surgical career would have been working on things like checklists. Robots and surgical techniques, sure. Information technology, maybe. But checklists?
“They turn out, however, to be among the basic tools of the quality and productivity revolution in aviation, engineering, construction—in virtually every field combining high risk and complexity. Checklists seem lowly and simplistic, but they help fill in for the gaps in our brains and between our brains. They emphasize group precision in execution . . . Making teams successful is more difficult than we knew. Even the simplest checklist forces us to grapple with vulnerabilities like handoffs and checklist overload. But designed well, the results can be extraordinary, allowing us to nearly eliminate many hospital infections, to cut deaths in surgery by as much as half globally, and to slash costs, as well.”
This, says Gawande, “brings us to the third skill that you must have but haven’t been taught—the ability to implement at scale, the ability to get colleagues along the entire chain of care functioning like pit crews for patients. There is resistance, sometimes vehement resistance, to the efforts that make it possible. Partly, it is because the work is rooted in different values than the ones we’ve had. They include humility, an understanding that no matter who you are, how experienced or smart, you will fail.” (“Humility” is a virtue that makes Gawande stand out as an exceptional physician. Read his first book, Complications where he discloses his own failures and close-calls, without blaming his superiors, his colleagues, or his patients.)
These new values also “include discipline, the belief that standardization, doing certain things the same way every time, can reduce your failures,” he adds. “And they include teamwork, the recognition that others can save you from failure, no matter who they are in the hierarchy.
“Resistance surfaces,” he explains, “because medicine is not structured for group work. Even just asking clinicians to make time to sit together and agree on plans for complex patients feels like an imposition. ‘I’m not paid for this!’ people object, and it’s true right up to the highest levels.”
As for the use of the checklists that Buckeye Surgeon describes as part of the “menial tasks” that Gawande would assign to doctors, the author addresses this idea that checklists are somehow demeaning in The Checklist Manifesto: “It somehow feels beneath us to use a checklist, an embarrassment. It runs counter to deeply held beliefs about how the truly great among us – or those we aspire to be – handle situations of high stakes and complexity. The truly great are daring. They improvise. They do not have protocols and checklists. Maybe our idea of heroism needs updating." (For more on the need for checklists, scroll down to my May 24 post: “The Medicare ‘Crisis’: A “Shaggy Wolf Story” and search for “checklists.”)
Humility, a belief in teamwork, understanding that following evidence-based guidelines is essential. . . “These values are the opposite of autonomy, independency, self-sufficiency,” Gawande acknowledges. “Many doctors fear the future will end daring, creativity, and the joys of thinking that medicine has had. But nothing says teams cannot be daring or creative or that your work with others will not require hard thinking and wise judgment. Success under conditions of complexity still demands these qualities.”
He ends by congratulating his audience: “You are the generation on the precipice of a transformation medicine has no choice but to undergo, the riders in the front car of the roller coaster clack-clack-clacking its way up to the drop. The revolution that remade how other fields handle complexity is coming to health care, and I think you sense it . . . Two years ago, the Institute for Healthcare Improvement started its Open School, offering free online courses in systems skills such as outcome measurement, quality improvement, implementation, and leadership. They hoped a few hundred medical students would enroll. Forty-five thousand did. You’ve recognized faster than any of us that the way we train, practice, and innovate has to change. . .”
Do Ezra Klein, Paul Krugman, Goozner, and I Dislike Doctors?
Full disclosure: In his complaint about Gawande’s speech, Buckeye wrote: “Is it any wonder that Dr Gawande is the very Messiah of future healthcare delivery to people like Maggie Mahar and Ezra Klein?"
My response: First, I’m flattered to be compared to Klein, if only in a “guilt by association” context. Ezra and I don’t agree on everything, but I greatly admire his work both as a writer and as a reporter –insightful, often original, delving into complicated, controversial topics where many bloggers and journalists fear to tread. (I should add that in the past I have enjoyed Buckeye’s blog and have quoted him on HealthBeat.)
I am troubled, however, that some physicians seem to believe that journalists and bloggers who favor health care reform are “anti-physician." Last week , Dr, Kevin Pho (a.k.a Kevin MD) published a provocative column arguing that “there’s an underlying tension between physicians and health policy experts. Health policy experts take subtle jibes against physicians in their analyses, with many feeling American doctors are overpaid, which exacerbates health costs. They tend to be politically progressive, and generally dismiss the issues that most doctors care deeply about. Medical malpractice, tort reform and the cost of medical education, for instance.
“It’s a subtle physician-antagonistic response that policy wonks on the progressive side —Goozner, Ezra Klein, Maggie Mahar, and Paul Krugman, to name a few — occasionally make that only exacerbates the discord,” he added.
“And doctors can be antagonistic to policy experts,” Pho conceded. “As most wonks are not physicians themselves, doctors generally discount their opinions, since they haven’t gone through the rigors of physician training, and are shielded from the day to day realities of practicing medicine . . . But if we are to fix our health system, both sides need to come together.”
“Patients still trust their doctors,” Kevin concludes. “Which is why it baffles me when policy experts don’t give doctors many olive branches when making their health reform arguments. Given the rancor surrounding the debate, it seems that reformers could use all the support they can get.” Pho suggests that as peace offerings, Krugman, Klein, Goozer and I should argue for tort reform and drop any suggestions that physicians are overpaid.
Here, again, I am named in very good company– Krugman, Goozner, Ezra. I am not at all offended by Kevin’s remarks. I consider him a friend. He often cross posts HealthBeat pieces that Naomi or I have written on Kevin M.D. And I consider his one of the best health care blogs out there. I have invited him to guest-post on HealthBeat where, if he chose, he might debate me in areas where we disagree.
But I am disturbed that Kevin, like Buckeye, sees me and other “reform wonks” as “subtly antagonistic to physicians.” On HealthBeat, I have addressed many of doctors’ concerns, including the relatively low compensation for primary care doctors, geriatricians, pediatricians, palliative care specialists and others who spend most of their time practicing “cognitive medicine” (talking to and listening to patients.) I also have argued that the cost of medical education should be subsidized so that young doctors do not graduate bowed down by tens of thousands of debt.
I totally agree with Kevin’s argument that “to successfully reform our health system, doctors need to be at the forefront, not policy experts.” But I am puzzled when he says that health care reformers should offer “olive branches’ to physicians by supporting malpractice reform and nixing any notions about reducing doctors’ pay.
This suggests that Krugman, Klein, Goozner or I have had some input into health care reform policy. I don’t know about Goozner, but I’m pretty sure Paul Krugmn didn’t receive calls from the White House asking for advice while they were hammering out the Affordable Care Act. (I truly wish the president had named Krugman one of his top economic advisers. But Krugman was outspoken in endorsing Hillary during the primary. I greatly admire his courage and honesty. But his did not position him for a place in the inner circle.)
Nor have any of us ever claimed to be a doctor, or even, as they say, “played a doctor television”– not even Ezra, despite his considerable success on TV.
Physicians should recognize that the Affordable Care Act is based, almost entirely, on ideas developed, not by “health policy wonks,” or government bureaucrats but by doctors. “Shared decision-making;” “accountable care organizations;” the idea of “bundling payments;” “checklists” to reduce medical errors and infections; the need for “end-of-life counseling;” the warning that we are “over-testing” patients; the call to reduce “over-treatment”; the need for “systems” to improve patient care; the call for “Healthcare IT” to reduce errors . . . These were the brain-children of doctors–and not just ivory-tower physicians, as some opponents of reform claim–but of physicians such as Steve Woloshin, Lisa Schwartz, H. Gilbert Welch, Jim Weinstein, Nortin Hadler, David Kibbe, Peter Provonost, Ken Kizer, Diane Meier, Atul Gawande, and many others while they were working in private practice, in VA hospitals, in private hospitals, and elsewhere.
At the same time, I think Kevin M.D raises critical issues in his post. These days, physicians feel beleaguered. I understand that. Some who want to duck the most difficult problems in our health care system have begun to demonize doctors, fingering them as the culprits who have pushed costs skyward. In Money-Driven Medicine, I tried to explain that we all are implicated–patients as well as doctors, medical schools, hospital administrators and others. I am especially critical of those who run our for-profit medical industrial complex (drug-makers, insurers, device-makers, and some hospitals). Typically, they put shareholders’ interests and the interests of top management ahead of patients’ interests.
Finally, I agree with Kevin MD that "tension" between physicians and progressives who write about health care, advocating for change, can only hurt patients. We should talk to each other.