Medical Professionalism: Jousting at Windmills, or Seeking the Holy Grail?

For physicians, this is a “good news/bad news” piece…or more accurately, “good news/word of caution.”

First the good news.

We live in an era of increased anxiety related to our health. Too many people are demanding too many services for too much money resulting in less than optimal outcomes. The good news? Even in the face of substantial challenges and uncertainty, trust of physicians (and healthcare providers in general) remains high. In fact, according to Gallop polling administered over more than three decades, the US public continues to rate the honesty and ethical standards of physicians among the highest of all professions (see chart below, and CLICK HERE FOR LINK). Although physicians rank very highly, the nursing profession deserves credit for their solid lock on first place.

Perhaps more significant than the current high trust ratings, are the trends over the past 30-40 years. During this period, almost every profession has seen an erosion of public trust. Journalists, judges, lawyers, bankers, clergy and politicians all have all experienced major reductions in public confidence. This is perhaps not surprising given the increasing speed and transparency of information flow…familiarity breeds contempt.

Healthcare providers have bucked the overall trend, and are rated as more honest and ethical than they were in the mid-1970’s. In an era of uncertainty and change, it is very good news that the public still has a high degree of confidence in the providers of care.

Now for the word of caution.

The trust place in healthcare providers is not immutable, and cannot be taken for granted. A case in point, bankers enjoyed a stable and relatively high level of trust (41% Very High or High) as recently as 2005. By 2009, this number had plummeted to 19%, following the global economic meltdown.

Jain and Cassel emphasized this point in their 2010 article in JAMA, Societal Perceptions of Physicians: Knights, Knaves and Pawns? (CLICK HERE FOR LINK). Jain and Cassel refer to a 2006 book by economist Julian Le Grand, Motivation, Agency, and Public Policy: Of Knights and Knaves, Pawns and Queens. Le Grand observed the changing public attitudes regarding civil servants in Great Britain. Immediately following World War II, civil servants were held in the highest possible regard. Schoolteachers, physicians, policemen, child welfare workers and others were heroes, part of a concerted national effort that defeated Hitler. What followed, according to Le Grand, was an era of good will and public optimism that lead to an expansion of state services… “a triumph of collectivism”.

Today, the same groups that once were celebrated are viewed as part of a faceless monolith of public services that deliver low quality services for undesirably high tax rates. Part of Le Grand’s hypothesis is that as society’s view of the motivation of a profession changes (e.g., are they Knights, Knaves or Pawns?), there is a direct impact on public policy.

Knights are driven by virtue, and are predisposed to do the right thing. Per Jain and Cassel, physician knights are stewards of the healthcare system. They can be trusted to manage resources effectively. They are life-long learners because they have an inherent love of learning. First and foremost, they are advocates of the patient. If society believes in physician knights, the public policy implication is that minimal regulation is required…knights will do the right thing to protect us…just get out of the way and let them pursue their vocation.

Knaves are driven by self-interest. Money, fame and lifestyle considerations are of primary importance, and the needs of patients are secondary. Knowledge is acquired, or research is performed, out of some expectation of personal gain. If society believes in physician knaves, then public policy must prevent malfeasance. Rules and regulations must be established to guard against greed and monitor potential conflicts of interest that may impact patient care decisions. Think of the financial regulatory environment after the US housing market collapse.

The poor physician pawns blow where the breeze takes them, helpless to act and at the mercy of the environment. They do their required continuing education because they are told to do so. If you need them to order fewer lab tests, they will comply. If next month you want them to do more lab tests, they will comply. They are reeds in the wind. From a public policy perspective, physician pawns are mindless automatons; production units with little judgment, unable to engage in autonomous decision-making. Regulation must therefore be highly prescriptive. Since physicians cannot make decisions, society must carefully create a script for them to follow.

If you accept Le Grand’s premise, then public perception drives policy and regulation. However, I think it is more of a cycle, or more accurately, a spiral. Behavior of the profession drives public perception. Public perception drives regulation. But regulation also influences behavior (which drive perception, then regulation, etc.).

Imagine two good parents have three generally well-behaved and respectful children…a teenager, child and infant. The parents have faith in their children. The children seem inclined to do the right thing. Because of the trust the parents have in the children, they are given a high degree of autonomy. They are child knights. One weekend the teenager is involved in a momentary indiscretion (you may choose your indiscretion). The transgression was not heinous, but showed poor judgment.

Perhaps the parents will continue to regard their eldest as a knight. However, if he slips towards knave status in their eyes, the parents could respond by ramping up the regulation. Curfews might be added, expectations for frequent communication heightened, friends more carefully scrutinized, social media sites monitored, etc. What influence would this heightened level of supervision, and decreased parental trust have on the teenager and middle child? It is not unreasonable to expect the children might become less transparent; they might become less communicative; they might lie about friendships and activities. In other words, the regulation designed to protect the family and children accelerates the journey to knave status. The reactive behaviors influence the parents’ opinion of the child, stimulate more rules and oversight, and drive more knave-like behavior. The cycle continues.

But what of the infant child in the family? Raised in an environment of rules, restrictions and guardrails, the child develops without the opportunity to test boundaries, make mistakes and be rewarded for making good decisions. The infant potentially grows into a child who needs regulation to survive, incapable of working through difficult problems independently. The child pawn requires more and more detailed rules, as he appears incapable of developing independent moral thought.

So by way of analogy, physicians who act like knaves will drive public perception, which in turn drives regulation, which impacts behavior and the spiral continues. One concrete example: Medicare billing guidelines are very tightly linked to documentation of the history and physical examination (because physicians are viewed as knaves by Medicare, prescriptive documentation guidelines are enforced to prevent overbilling). One of the areas of documentation is the “review of systems” (ROS). The physician asks questions about symptoms attributable to a specific organ system – cardiovascular, respiratory, gastrointestinal, genitourinary, etc. Medicare defines four levels of charges, ascending in complexity and payment. For the lowest level, no ROS is required at all. The next level up, the ROS is “problem pertinent”, and can be limited to the system directly involved with the illness under evaluation. The next highest level requires documentation the physician asked the patient about 2 to 9 systems. The highest level requires the physician ask about 10 or more organ systems. Especially in the era of electronic medical records, where much documentation is driven by checkboxes, it is not unreasonable to assume that some of the 900,000 physicians in the country will over-document their review of systems – a very small number deliberately, a much larger number innocently. Healthcare systems and practices invest in audit systems to try and catch and correct these errors in documentation. Medicare ramps up investigations to try and catch those acting badly. More regulations are spawned, and the spiral continues.

So are physicians knights, knaves or pawns? An environment that is moving towards increased guardrails and regulation runs the risk of demoralizing the knights, and creating knaves and pawns. Recognizing this risk, physicians and healthcare providers must work to interrupt the cycle by committing to fundamental principles of professionalism. Individual physicians, and the advocacy and accrediting bodies representing them, must hold sacrosanct one principle: first and always, the duty of a professional is the protection and promotion of a patient’s health. All other forms of self-interest must be unequivocally secondary. Once commitment to professionalism starts to erode, we are headed down a path where the primary protector of a patient’s well being are the rules and regulations governing the physician-patient interaction – not the physician.

Pay-For-Performance and Unintended Consequences: The International Language

Pay-For-Performance (or P4P) is an important tool in our effort to improve the quality of the nation’s health care, and control cost.  It may prove to be a critical and effective tool. However, we need to tread cautiously; P4P is no panacea.

Central to all health care reform proposals, across the political spectrum, is the observation that part of our problem is perverse economics.  The economics are warped in (at least) two ways.  First, since the post-World War II growth of employee provided insurance, and the 1965 introduction of Medicare, consumers have largely been removed from any direct financial impact of the provision of medical services.  With no consequence to consumption, demand grows without restraint.  This long-standing dynamic is starting to be reversed as employers are steadily shifting more of the financial cost of insurance to employees.

The second dynamic is equally pernicious.  In any city in the United States we have physicians who deliver excellent, evidence-based care; who are great communicators with outstanding bedside manner; who achieve outcomes beyond those of their peers.  We also have doctors in the same city (or same practice) who are insensitive, abrupt, below average clinicians with below average outcomes.   I believe, thankfully, the former category substantially outnumbers the latter.  However, here is where the economics are twisted:  the good, kind and efficient doctor will see the same sort of patient and perform the same types of procedure as the gruff doctor with poorer outcomes.  Both doctors will submit a bill for a unit of service to Medicare, Medicaid or private insurance, and both doctors are paid exactly the same thing.  A consequence of the payment system in America is the only way for a physician (or hospital) to do better financially, is to do a greater volume, pure and simple.  The sole incentive is to do more, not to do better.

Some studies show family physicians spend only 7-8 minutes with a patient in a typical visit.  It is not by their choice.  I know dozens, perhaps hundreds of family physicians.  As a group, they are wired to take time, engage in meaningful dialog, dig into complex interpersonal dynamics and try to understand how an illness impacts a patient as a human being.  This is why they chose their field.  Left to their own devices, most would happily linger with a patient for an hour or longer. 

The unfortunate economic dynamic prohibits this sort of interaction.   Family physicians are already among the poorest paid of physicians, earning less than half, or even a third of their specialist colleagues.  To pay office staff, cover overhead, keep the lights on and take home a reasonable wage, the typical doctor must see at least 30 patients a day.  I will do the math for you…over an 8-hour day, that works out to 16 minutes per patient.  Take from that time for documentation, phone calls, and sicker patients who demand more time, and you quickly get to 8 minutes per patient.

Enter P4P.  The concept is seductive in its simplicity.  Let’s stop paying doctors based on volume, and start paying them based on quality of patient outcomes and patient satisfaction.  On a purely intuitive level, this idea has almost universal appeal.  However, because something makes intuitive sense, does not necessarily mean it will work, especially when rolled out on a very large scale across a complex system.

I recently read two studies related to physician compensation as a tool to modify behavior.  Both studies had excellent and worthy goals.  Both implemented well-designed and rational compensation changes.  Otherwise, the two studies could not have been any more different, except for one other significant similarity… neither worked as expected.

The first study comes from an unexpected source:  a rural delivery system in a poor province of China.¹  The physicians in that community had two sources of income.  They billed for services in a traditional fee for service model – more volume, more income – and they were permitted to sell drugs at a substantial mark up.  The health care planners in the province were concerned that this payment mechanism was encouraging unnecessary service and over-prescription of medications.  The fix was to revise the compensation system.

The payment scheme was revised so that rural providers would now have three sources of revenue: 1) a base salary ($15/month); 2) a volume bonus ($0.06/outpatient); and 3) a quality bonus, based on defined metrics ($12.50/month).  The economic incentive to sell medications was eliminated.  Move the decimal point about three places to the right, and this payment system looks much like many US compensation models. 

Rational, thoughtful, well designed.  So what were the results?

The designers had a number of expectations. Spending would decrease on the village level.  Unnecessary care would be reduced, particularly to the young and healthy.  There would be a reduction in prescription of unnecessary drugs.  In fact, all these results were achieved, but with one significant unexpected consequence.  Sicker patients were more costly for the rural doctors to treat, and negatively impacted their quality metrics (and pay).  As a result, there was a sharp increase in the referral of the sicker patients to more expensive city clinics.  The net result after 5 years? No cost savings to the healthcare system.

From a small study in China to a massive study in the United States.²  Starting in 2005, ten physician practices were voluntarily enrolled in the Medicare Physician Group Practice Demonstration (PGPD).  These groups joined what was considered to be a precursor of Accountable Care Organizations (ACO).  Quality metrics were introduced, and cost saving monitored in the demonstration groups.  Any savings realized from more efficient, more effective care, would in part return to the physician practice.

From 2005 through 2009 there were 990,177 patients enrolled in PGPD practices.  In a quasi-experimental design, this group was compared to patients in non-PGPD practices, both during the trial, and for the four years preceding the trial.  Keep in mind, the practices that enrolled in this demonstration were best of class.  They would not have enrolled if they were not confident they had the ability to succeed. 

Like the Chinese study: good and noble goals, rational design.  The results?  Although not a total failure, the positive impact was limited to a relatively small subset of patients (see figure below, taken from the JAMA article in the footnotes).

For Medicare patients, over a five-year period, there were no statistically significant savings.  In fact, the statistical confidence interval was such it was possible the care was actually more expensive.

The group that did seem to benefit was the Medicare “dually eligible”, that is, those patients with Medicare, who were also eligible for some portion of Medicaid benefits.  This group is primarily comprised of the disabled, and the elderly poor.  The dually eligibles also tend to suffer from multiple chronic illnesses, and have a disproportionately high rate of mental health issues, so it is not necessarily surprising they benefited from the enhanced case management typically part of an ACO, “medical home” model.

Two studies, different sides of the world, different cultures, aligning incentives in a rational manner…both with disappointing results.

This is admittedly a very limited and selective review of the literature.  Although at the time health care reform was passed there was a dearth of evidence to prove P4P actually works, there has been subsequent demonstration of efficacy, at least in select populations. 

What lessons can we take away from this? I think there are three:

• Often we see the need to improve care, and the need to engage physicians and other providers in supporting change. This usually leads to a conversation around “aligned incentives”. The groupthink sometimes seems to be, “if we could design the perfect compensation system, solutions to all these problems will fall into place.” It is clear; compensation design is not a magic bullet. 

• General solutions, widely applied over a large population, are not likely to be effective for all patients. A team-based, case management intensive model may work exceptionally well for an elderly disabled patient with multiple medical conditions. It may not be the right model for a healthy young adult. 

• More important than a payment system of accountability, we need to develop a medical culture of accountability. Compensation may be a tool in shifting culture, but it is only a single tool. 

¹ Wang H, Zhang L, Yip W, Hsiao W. An experiment in payment reform for doctors in rural China reduced some unnecessary care but did not lower total costs. Health Affairs. 2011; 30(12): 2427-36.

² Colla C, Wennberg D, Meara E, et al. Spending Differences Associated With the Medicare Physician Group Practice Demonstration. JAMA. 2012; 308(10): 1015-1023.  Click for link to article

AAMC April Blog Carnival

See A Thousand Points of Transformation featured on the AAMC's Wing of Zock Blog Carnival -- favorite blogs of April.

Book Review: One World School House: Education Reimagined by Salman Khan

Salman Khan, former hedge fund manager, is a darling of the TED talks circuit and a bit of an education reform celebrity.  His story begins with his younger cousin, who was struggling with math in spite of overall strong academic performance.  What started as a long-distance internet based family tutoring session, has grown into a cottage industry of YouTube based lessons—technologically simple, relatively short and digestible—which can be viewed, reviewed and mastered at the learner’s own pace (Incidentally, if interested you can brush up on your immunology or cardiac electrophysiology).  His book, One World School House: Education Reimagined, is part history lesson, part pedagogical treatise.  Although it has nothing directly to do with medical education, it is useful to read this entertaining and accessible work through the lens of a medical educator.

Khan’s fundamental contention is that the current educational system is based on the 18^th century Prussian model of public education—innovative in its day.  The system was developed to meet the labor needs of an increasingly industrial society, and “to create loyal and tractable citizens”.  The system was not intended to foster independent thinking, learning or creativity.   The theme of the book, and his work overall, can probably be summarized in his words:

The old classroom model simply does not fit our changing needs.  It’s a fundamentally passive way of learning, while the world requires more active processing of information.

Basic tenets of Khan’s world view include:

• Basic concepts must be fully understood and mastered before moving on to other more advanced concepts (think competency based, rather than time based education).

• Teachers can convey information, assist and inspire learners. However, we ultimately educate ourselves.

• Associative learning is critical. Per Khan, it makes no sense to put courses into discreet boxes—to divide learning into periods and courses with discreet beginnings and endings. As humans, we truly learn by associating information systematically with knowledge that is already deeply rooted in our memory. “…no subject is ever finished. No concept is sealed off from other concepts. Knowledge is continuous; ideas flow.”

• There is incredible inertia in existing educational systems. It is difficult to escape customs established for decades or centuries, even when it is clear the customs do not serve us well.

• The knowledge explosion and subsequent rapid pace of change requires a change in pedagogy. We can no longer approach education as a process of filling heads with knowledge, so learners can coast off that knowledge for thirty or forty years. If you have children in school today, more likely than not the job they will be doing has not been invented yet. It is critical that we teach people how to teach themselves, rather than perseverating on what they learn.

• There is value to mixed aged classrooms. When there are learners at various degrees of progress it promotes an atmosphere where everyone can learn at their own pace. In addition, it provides opportunity for learners to to be leaders—the more advanced can help those still trying to master concepts.

• Testing has a limited (but important) role. Tests can measure quantity of information learned, at least when the test was taken. Tests are less able to measure “quality of minds [or]…character”.

• The current day university plays an important credentialing role—because you have completed this degree, you therefore have these skills. If competency and proficiency could be reliably measured, the credentialing role of education could be decoupled from the educational role.

This work is a rapid read, and worth the time.  It is not an academic treatise, and does not purport to be.  At times Khan’s enthusiasm for his subject, and his apparent success, leaves the reader feeling like his approach is an educational panacea (which he takes great pains to deny).  But his concepts resonate at an intuitive level.  He raises important fundamental questions about the nature of education in the information age.  His encouragement to move forward without waiting twenty years for a randomized trial is an important message in an era of reform.

With regard to medical education, although the work does not explicitly discuss the training of physicians or healthcare providers, it does align with some of today’s pressing concerns.  How do we provide high quality education at an affordable cost to our citizens, and to the world?  In an environment where information is increasing perishable, how do we turn a commitment to “life-long learning” from hollow platitude to a fundamental educational principle?  As medical knowledge is increasingly integrated, how do we evolve from a silo approach to knowledge acquisition, to one in which our new bit of genomics learning is associated with what we have already learned in cardiology, immunology and population health?  If you think these questions are important, Mr. Khan’s book is worth an investment in your time.

Incentives, Culture and Engagement

For a moment, imagine any group of people faced with great change, disruption or transformation -- a corporation, university, health system, department, family. Now here is a rhetorical question. You have a choice of joining one of two groups. In one, team members are aligned around a common mission and purpose; a diverse group of great brains are all working together in an environment of trust and collaboration to address fundamental and existential questions. In the second, the environment is best described as "every man for himself."  The members of this team are equally bright, equally talented, but not aligned behind any common mission.  To which team would you want to belong?

The answer is obvious, but begs the additional question: how do you create an engaged, aligned organization? Part of this effort often involves alignment of incentives. But how effective are incentives in driving a culture of engagement? There is significant evidence to support the answer -- not very.

The Daniel Pink YouTube posting The Surprising Truth About What Motivates Us is worth a six minute investment in time to begin to understand the nature of incentives. The contention of the piece is two fold. First, economic incentives may be effective in increasing the production of highly repetitive tasks, although the effect may be perishable and require ongoing escalation of the incentive to maintain the desired effect. Second, incentives directed at highly complex cognitive tasks have the paradoxical effect of decreasing the desired behavior.

Given the entertaining format of the Pink piece (stop motion white board cartooning), it is tempting to dismiss this as pop psychology. However, there is ample evidence to back up the conclusion.

The origin of this area of behavioral psychology has its roots back in the 1960s. Hertzberg published a study recently reprinted as a classic article in The Harvard Business Review, One More Time: How Do You Motivate Employees?.  Based on qualitative research from a variety of blue collar and professional groups, a common and persistent theme emerged. Groups were asked to identify factors in the workplace that, when present, drove extreme satisfaction and engagement; conversely, they also ranked factors that drove disengagement. Hertzberg's parlance, hygiene factors (e.g. compensation, company policies, relations with coworkers, etc.), when absent, or when present in the negative, where liable to create dissatisfaction and disengagement. However, when present in the positive, these factors do not drive extreme engagement. Pay someone poorly, they are likely to be dissatisfied. Pay them extraordinarily well, you are unlikely to buy their satisfaction or engagement.

Hertzberg went on to describe intrinsic motivators -- items like achievement, recognition and doing meaningful and important work. The results were exactly the opposite. Intrinsic factors, when absent, do not drive extreme dissatisfaction. However, when present in the positive they do drive rabid organizational fans. Similar observations have been made with groups of physicians. ¹

 

Intuitively this makes sense. Imagine a highly competent, experienced and motivated school teacher standing in front of a room full of students, and committed to bringing out the best in each of them. The teacher feels a responsibility to develop and challenge the best and the brightest, to help them reach their potential.  The teacher also feels a responsibility to lift up those who are lagging behind.  At the end of the day, satisfaction comes from making a positive impact on as many students as possible, and satisfaction emanates from a sense of professionalism. The teacher is motivated to constantly explore new and innovative methods of reaching the students, and these efforts are celebrated and rewarded.

Now let us introduce a hypothetical incentive. A bonus will be paid based on the number of students passing a standardized end-of-year examination, compared to a statistical peer group comparison. Let us further assume the unobtainable -- that this metric is perfect. That is, it is risk adjusted based on the characteristics of the class. Socioeconomic factors, school resources, strength of the family unit, local crime rates, etc. are all controlled. The incentive will be applied on a level playing field.

What is the likely impact? We may very well see increase in pass rates; but at what cost to our star teacher? To earn the incentive, the teacher could well ignore the gifted in the class --they are assured of passing. Similarly, the less academically successful could be written off -- they will not pass even with Herculean effort. The incentive is designed to bring more marginal students up to a common baseline, which by its nature is probably below typical expectations for the average student. The teacher will be celebrated by the organization and recognized by peers for generating better numbers; not for innovative techniques. Perhaps the teacher will deliberately change the approach in the classroom to maximize performance; that is, teaching to the test. Perhaps the teacher is so firmly rooted in a sense of professionalism that the commitment to all students will not be abandoned, even though the organization does not seem to value the effort. In either case, the teacher viewed to be more successful in the new incentive system, but less satisfied, and less engaged.

It is not difficult to imagine analogous dynamics in healthcare or medical education. We can develop incentives to drive specific, measurable clinical outcomes. We can measure success of educational efforts based on certification exam scores. But we need to pause and reflect what could be lost in the process.

The quote "Culture eats strategy for breakfast" has been attributed to management guru Peter Drucker. I would amend this: A culture of professionalism eats incentives for breakfast. There is certainly an important role for metric driven organizational goals. However, there is pernicious danger in placing blind faith our ability to create culture through perfect alignment of incentives. 

¹ Cassel CK, Jain, SH. Assessing individual physician performance: does measurement suppress motivation? JAMA. 307(24):2595-6, 2012 Jun 27.

Change Management: Is the Juice Worth the Squeeze?

Change in the US healthcare system is likely coming on a scale not experienced for generations. (see Feb 12, 2013  and Feb 15, 2013)   It is useful to pause and reflect upon the responsibilities leaders in our field have to help anticipate and manage the process of change.  In particular, under what circumstances does a leader deliberately take a group of people – physician practice, clinic, hospital, delivery system, teaching program – through a deliberate and orchestrated change management process?  One critical question: Is the juice worth the squeeze?

There are a number of theoretical academic management models of change management.¹    One model was developed and popularized by William Bridges who publishes widely in this area, both in traditional print media and on-line.  The following figure is adapted from Bridges’ work:

Bridges’ schema of change management has distinct Kübler-Rossian overtones (see “Curve A” above).  In this model, organizations go through a mourning process for the old world order, before the new can be embraced.  During the “Endings” period people are encouraged to let go of the old ways – often ways that met with success in the past .  The “Transition Zone” is a zone of discomfort.  Some people may leave the organization; others will marshal their creativity to find ways to succeed in the new era.   In “New Beginnings” some will display new behaviors, developed to meet the demands of the new playbook, and ultimately become role models for others.

The impact of the change is felt in “Curve B”.  During the process, the overall level of anxiety increases, peaks and ultimately returns to baseline as the change becomes the new normal.  Directly related to the waxing and waning of group anxiety, organizational performance will actually decrease, before rebounding – this is the critical point – to a level of performance higher than where it started ("Curve  C").  The organization must endure the expected rise in anxiety (the squeeze) in order to enjoy the ongoing benefit of enhanced performance (the juice).

We have plenty of examples of looming changes in healthcare and education – shift from volume to value payments, curricular innovations, group physician visits, team based care, competency-based rather than time-based education to name only a few.  Here are a few questions to ask prior to embarking on a deliberate change process.  If none of these conditions exist, you may want to pause and reflect carefully before launching a major change initiative:

• Does my organization have a commitment to a particular strategy, and are current behaviors incompatible with this strategy?  (e.g., we think the our future success depends on innovations in training providers to thrive in a new delivery system – department chairs are focused on building research programs).

• Is the organizational behavior that needs to change damaging the organization? (e.g. inattention to known regulatory requirements).

• Is the anticipated improvement in performance significant?  If you presented to results of the process to an objective observer, would they be impressed or lulled to sleep?

• Is the anticipated improvement, once obtained, sustainable, or just a one-time event (e.g. a single year improvement in productivity)?

• Is the organization sufficiently stable to weather the transition?  Is it already engaged in too many disruptions and transitions?

In an unstable environment, leaders have responsibility to instill as much discipline around change as possible.  To paraphrase the Serenity Prayer:

"God grant me the serenity 
to accept the things we do not need to change; 
 courage to change the things we must;  
and wisdom to know the difference."

¹    McDeavitt JT, Wade KE, Smith RE, Worsowicz G. "Understanding Change Management" Am J Phys Med Rehabil. 4(2) pp 141-43, 2012.

Academics and Care Delivery: A Necessary Symbiosis in an Era of Reform

(Note: I originally wrote the following content in April 2012 for the Wing of Zock, the blog run by the Association of American Medical Colleges).

At the 2011 AAMC Annual Meeting in Denver, I participated in a panel called “Organizing for Success during Reform,” which showcased a variety of care and research initiatives designed to align academics with the goals of health care reform at AMCs throughout the country. In some way, I think this may be the wrong question. Rather than asking how to align academics with health care reform, we need to start with a stronger alignment with health care.

My core message was the desirability (if not outright necessity) of aligning our academic infrastructure with the core mission of the health system. The growth of Carolinas HealthCare System (CHS) over the past 30 years has been dramatic: from a single public hospital, to 33 hospitals in two states and over 9 million patient visits. This growth creates the potential for an incredible clinical laboratory. We have access to patients representing all aspects of diversity: ethnic, economic, urban/rural.

During the same period, our research and education programs have grown as well. It is our fundamental belief that the academic programs planted in the middle of a strong health care system create great opportunity to strengthen our education and research efforts. At the same time, the academic core should produce real value back to the system…specifically by enhancing our ability to deliver high-quality, efficient patient care to a broad geography. Regardless of the outcome of health care reform, we believe this is a model for the academic health system (as opposed to academic medical center) of the future.

A case in point: Several academic medical centers in North Carolina participated in a study on lung cancer funded by the American Cancer Society. The study showed that African-Americans who are diagnosed with lung cancer have a delay in definitive treatment from the time of diagnosis compared to Caucasians; one of many health care disparities documented in the literature. The identification of these disparities is good and important work. However, the academic health system of the future will have the vertical integration necessary not only to identify a care delivery problem, but to correct it.

So how can we actively work to build this linkage between organizational mission and academic capability? I outlined one small step in that direction: the formation of Carolinas HealthCare System Research Centers of Excellence (COE). We developed an internal RFP process to select and fund two COEs. Applications were based on the following criteria: Investigators had to represent more than one specialty. More important, there had to be evidence of geographic diversity. That is, the investigators were expected to produce a realistic plan to leverage the scope and scale of CHS to begin to work in our large clinical laboratory. Finally, as part of the outcome measures, successful applications were expected to have a measurable impact on one of the six Institute of Medicine Aims for Improvement.

To date, one center has been funded: the Carolinas Trauma Network Research Center of Excellence. This center builds on a substantial base of clinical and academic excellence. Its objectives are:

▪ To develop and maintain an efficient multidisciplinary infrastructure to support the conduct of trauma-related research across the continuum of care provided by CHS

▪ To facilitate collaboration across disciplines, facilities, and scientific methods to contribute to the evidence base in trauma care

▪ To identify and prioritize the most critical issues challenging delivery of care for trauma patients across all CHS facilities

▪ To contribute to the science of conducting trauma research on challenging patients in challenging environments

▪ To use Comparative Effectiveness Research strategies to identify the safest, most effective, and least costly treatments for injured patients

▪ To leverage the strengths of this COE and CHS to attract external funding to support trauma related basic and translational science, clinical research, and population-based/implementation research.

In a way, the funding of the COEs is an experiment in itself. Can we deliberately drive synergies between the care delivery system and academic excellence? As a large, mission-oriented organization, it is our responsibility to try.