The Next Cultural Transformation in Medicine, Part I

To understand the next cultural transformation in medicine, we first need to understand the last one -- the cultural transformation around quality.

Picture Track Coach Jones.  His team practices daily.  Every week, every member of the team runs a timed 100 meter sprint.  Anyone turning in a time of under 12.5 seconds is placed under heightened scrutiny for a week, and if a second subpar performance is turned in, he is booted from the team.  At the end of six weeks, Coach Jones feels his team is fast because no one runs the 100-meter at an unacceptably slow pace.  The speed distribution of the Jones team looks like this -- he cut the runners in the "red zone":

Track Coach Smith is in a school in the same town.  In practice, he measures everyone's 100-meter time.  An individualized training regimen is developed for every athlete, and personal improvement goals established.  Improvements made by all individuals are celebrated, even that of the slowest member of the team.  The speed distribution of the Smith team looks like this:

Against which team would you rather compete?  For which team would you rather run?  Which team will have the most long-term success?

Obviously, this is an extreme example to make the point.  We would all want to be part of the organization that takes the skills and talents people bring with them, and actively works to make everyone better.  The worst improve (and still, at times, need to be cut); the average improve, and some will excel;  the stars come closer to realizing their full potential, and set a new aspirational standard for others.

You do not have to roll the clock too far back in the history of health care quality to find a time we were virtually all playing for Coach Jones.  Quality improvement was a process of identifying the lowest performers—those with clear and unequivocal poor quality —remediating them, and failing remediation, getting them out of practice.  We actively cut our slowest runners, but did nothing to challenge or develop the rest of the team.  We assured ourselves our quality was high, because we actively policed our problems.

Dr. Don Berwick is an icon in quality improvement, at least in part due to his tremendous work with the Institute for HealthCare Improvement (IHI).  Back in 1989 he wrote an editorial for the New England Journal of Medicine encouraging the adoption of Deming-inspired, Japanese-operationalized principles of continuous process improvement.¹  He observed:

“…Not that the idea of continuous improvement is alien to medicine; self-development, continuous learning, the pursuit of completeness are all familiar themes in medical instruction and history.  Yet today, we find ourselves almost devoid of such thinking when we enter the debate over quality.  The disciplinarians seek out Bad Apples; the profession and its institutions by and large try and justify themselves as satisfactory.”

Over the past 25 years, we have fired Coach Jones, and hired Coach Smith.  Although we still have far to go, the culture of quality has palpably shifted.  We measure, compare, challenge and try and develop all our colleagues.  Those with major problems are supported to improve (but still, and hopefully rarely, “cut”); the average improve and some excel; the stars come closer to reaching their full potential, and set a new aspirational standard for others.  Most importantly, I do not believe this change is cosmetic or superficial — it reflects a great cultural transformation.  Most physicians believe in the power of continuous process improvement.  We want to play for Coach Smith.

Next:  The Next Great Cultural Transformation

¹Berwick D. Continuous Improvement as an Ideal in Health Care. N Engl J Med 1989; 320:53-56.

21st Century Healthcare System & the 19th Century Urban Horse

Eric Morris, pursuing a PhD in Transportation at UCLA in 2007 wrote an article entitled From Horse Power to Horsepower.  It is well worth reading through the lens of someone interested in health care reform and innovation.

Morris briefly relates the story of an urban planning crisis in the late 19th century -- the explosive growth of the urban horse.  The parallels between the plight of the Industrial Age city planners, and the Information Age healthcare planners are remarkable.

Cities at the turn of the century were in the midst of an equine perfect storm.  The urban population was skyrocketing.  As the population increased, so did the country's economic prosperity.  Growth in per capita income allowed more people to have access to a horse.  The explosion of inter-city rail transport increased the need for horses, to move goods from the train terminals to consumers.

You can almost hear the cries of non-sustainability.  The feed to maintain one horse required five acres of farm land.  A landmass the size of West Virginia would be necessary to support the horse population at its peak.  Waste was a major concern, and there were dire predictions of city streets buried in several feet of manure.  In fact, manure did fill vacant lots in piles up to six stories high.  A horse drawn vehicle neither accelerates nor decelerates quickly.  As a consequence, traffic was snarled, particularly at intersections.  Paradoxically, traffic fatalities were actually higher than in the age of the automobile (imagine if your Hyundai could be startled by an unexpected noise, and bolt of its own volition).

Enter the Incremental Innovators.

Large stagecoaches, or omnibuses, enabled more people to travel with fewer horses.  However, a large omnibus still required eleven horses per day to operate.  Rails were laid in city streets, decreasing friction and cutting in half the number of necessary horses.  Stop signs and yield signs were innovations of the age of the urban horse.  A cadre of crosswalk sweepers were employed to maintain manure-free street crossings for pedestrians.

It is obvious to all what ultimately solved the crisis was not the Incremental Innovators, but the Disruptive Innovators.  The internal combustion engine was perfected.  Streets were paved with asphalt.  Henry Ford introduced principles of mass production and the assembly line, dramatically bringing down costs and democratizing automotive technology.

There are some lessons to be drawn from the transition from horse to car.

Once the disruptive innovation hit, it hit with a vengeance.  The pace of change was dizzying.  In 1900 there were 8000 cars registered in the United States.  By 1915, that number had ballooned to over 2.5 million  (United States Department of Transportation).

The sudden transformation was unexpected.  It is unlikely the public servants of the day, concerning themselves with waste removal and grain transport challenges, ever envisioned the transformational impact of the automobile.  What is this disruptive innovation today?  What game-changing technology, treatment, system of care or societal disruption will make our current menu of challenges seem quaint?  On the other hand, what are we innovating around today that is merely extending the life of the old system?  Today our industry is contemplating fundamental changes to the doctor physician interaction --  virtual visits -- group physician visits -- primary care clinics in retail shopping chains.  Do these constitute disruptive change, or are they the street sweepers of the early 1900's, working to accommodate a failing infrastructure?   The disruption will come, and when it does I suspect the speed of change and adoption in 2012 will be swifter than in 1912.

The automobile was made widely available, even to those of limited means.  The technology grew from novelty to luxury to necessity in a generation.  It is likely our "automobile analog" will be in some way related to the wide spread availability of inexpensive high-speed broadband access.  Rapid communication and data transfer is already fundamentally changing almost every facet of our life.  Healthcare will be no different.

The disruptive innovation may spring from any number of directions.  For anyone interested in healthcare innovation, Eric Topol's The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care should be required reading.  Well organized and written to be accessible to the lay reader, Dr. Topol covers in detail the wide range of changes in health, driven by access to information, remote monitoring and care tools, the growth in practical importance of the human genome (democratization?),  big data and more.  Perhaps one of these is the seed that will produce automobile-like disruption of healthcare.


(Note:  I learned of the Eric Morris article referenced above in a casual conversation.  I was unable to find a source drawing an analogy to healthcare.  If you are aware of a reference, please let me know so I may credit it appropriately).

Cloud of HealthCare Anxiety, Part II: Workforce

Back to the Cloud:

Is there a looming physician shortage?  We have a national history of being notoriously poor at projecting workforce needs.  However, the answer seems to be a resounding "yes".  In 2006, the Association of Academic Medical Colleges published projections of a national shortage of 62,900 physicians in 2015, growing to 130,600 in 2025.   PPACA (the health care reform bill) will likely worsen the shortage by increasing demand.

Their are many factors driving this shortage:  Lack of new medical school development, absence of funding for new residency training programs, aging population, etc.  For now, we will just concentrate on the demographics of the physicians.

The following graph (from a North Carolina Institute of Medicine study) is cannot be digested at a glance, but makes a few important points:

The figure compares two years -- 1980 and 2004.  The "blue bar" histogram to the right is the number of physicians of every age during the year in question.  The green histogram presents the same information for female physicians.  There are a number of important take-aways from this figure.

First of all, the same "pig-in-the-python" dynamic at play in the general boomer population holds true for physicians as well.  In 1980, the largest population of physicians were in there 30's and 40's.  By 2004, practicing physicians tended to be in thier 40's and 50's.  In another decade or so, the largest mass of practicing physicians will cross the threshold of 65, many becoming consumers rather than providers of healthcare.  Demographic Issue One:  physicians will be retiring.

Issue Two:  What impact will the reform environment have on the timing of those retirements?  In this age of uncertainty, it remains to be seen if physicians will retire at the historic norm, or if those who are able will opt out early rather than deal with the shifting sands.  

The other obvious observation from the histogram is Issue Three:  the younger workforce is now at least 50% female (probably slightly greater than 50%).  The fact that women are so thoroughly integrated into the physician workforce is a desirable, necessary and long overdue.  However, from a planning perspective this shift has a significant impact.  Female physicians, in aggregate, over the course of a career, equate to between a 0.7 and 0.8 FTE.  Female physicians as a group tend to drop in and out of the workforce, and are statistically more likely to work part-time.  Now that the workforce is more than half female, the impact is of consequence.

Which brings us to Issue Four: the new generations --  Gen Xers, Gen Ys, Millennials.  Much has been written about cultural differences in the ascending generations (e.g. less loyalty to organizations, more value on work-life balance).  This generational change is probably real and of consequence on it's own.  But we need to add to this meta trend the cultural changes occurring in medicine.  For mostly good and appropriate reasons, medical students, interns and residents are mandated to limit their work hours.  To most of society, establishing a work-hour limit of 80 hours per week does not seem like much of a limit.  In medicine it is a seismic cultural change.  Place the millennials, already predisposed to seeking "balance", in an environment that tells them it is their professional obligation to never work more than 80 hours a week, and we are invariably going to produce a different sort of physician -- hopefully one that is more humanistic and empathetic, but clearly not one who is going to work 100+ hours a week and take call every third night.  This may be (probably is) good policy, but it has implications for a workforce already challenged to meet the pending demand.

How will healthcare meet the future workforce shortages?  Expansion of medical schools is underway with a vengeance, but will not be enough.  Residency training programs are not growing, due to lack of support, which undercuts all the great efforts of the schools.  There will still be a gap to be filled, and we will need to look to fundamental redesign to meet the challenge.  Non-traditional providers, advanced care practitioners, group visits, electronic visits will likely play a role, along with solutions not  yet conceived.

Next: Disruptive Innovation

Cloud of HealthCare Anxiety, Part I: Demographic and Economic Realities

Cloud of HealthCare Anxiety, Part I: Demographic and Economic Realities

These postings are committed to the belief that the salvation of the health care system in the United States will not spring spontaneously from a single brilliant piece of legislation.  It will not come from a single new care delivery philosophy, nor a new trend in ambulatory care design.  It will not come from CQI, PDSA or Lean.  All these things will have an impact, but none will result in a system that delivers high quality outcomes at an affordable price in a sustainable manner.  The ultimate salvation of the system will emerge from a thousand points of innovation...patients and providers and educators and researchers around the country -- and around the globe -- experimenting with new delivery systems...new technologies...new methods of training the next generation of providers.  The challenges are great.

We are on the cusp of the greatest transformation in the management of health since the advent of antibiotics and anesthesia.  As in any time of great change, it is rife with uncertainties and anxieties.   The "The Cloud of HealthCare Anxieties" (see below) looms over the profession.  It impacts career choices of the young.  For those later in careers, it sometimes encourages early egress from a profession which can and should keep aging providers meaningfully engaged with important work.

Demographic and Economic Realities

The math is inescapable.  The baby boom population is now hitting retirement age.  Over 8,000 Americans turn 65 every day.  As the pig-in-the-python generation begins to retire, there are certain realities at play.  We (the boomers) will consume more healthcare services.  We will visit the doctor more often.  We will develop more chronic medical conditions.  Much of this is the inevitable consequence of growing older.  Some is due to changes in diet, exercise and habits that make us more susceptible to disease.  Whatever the reason, we will consume more healthcare resources.

This increased demand is will be accentuated by generational and technological trends.  We are an entitled generation.  We have enjoyed an unprecedented standard of living.  We want what we want, we want it now, and we want it at the best possible price, in the most convenient manner possible.

The increased demand will occur in the face of increased transparency of data.  We want to comparison shop.  We want comparative quality information on-line.  I imagine few people purchase a car today without checking on-line ratings.  The same will be true of healthcare decisions.  Consumers will demand information, and in the absence of perfect information, incomplete information will do.  The numerous sources of online information about quality of physician care -- deeply flawed today --- will continue to grow in depth and sophistication.  However much some may wish, the genie will not go back in the bottle.

The increased demand will occur in the face of a $16.5 trillion federal debt.  It will occur during implementation of the Patient Protection and Affordable Care Act, a trillion dollar piece of legislation that relies on unproven (and likely overestimated) expense savings, and neglects minor "rounding errors" like the unbudgeted $330 billion needed to correct the Sustainable Growth Formula.

As we have more people to serve, and less resources with which to serve them, we simultaneously invent more things to do for people -- more diagnostic tests, more pharmacologic options, more high tech procedures.

Bottom line, there will be less resources available to support a system with increasing demands.  A bad combination.

Next: Workforce