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Monday, November 17, 2014

Physician, Heal Thy System

OK, I finished this book this weekend.

Many, many dots to connect. Notwithstanding my many churlish blog comment critics ("BobbyG is an EHR vendor shill," "how many patients have you treated? You're not a doctor, your views are irrelevant"), I have always been a physician champion, for deeply personal reasons going far beyond the academic and theoretical. This book provides ample support for that view.
I love being a physician. I love it for many reasons, but the main one is because of what I am able to do for people like Antonio. And the incredible thing about being a doctor is that every one of the almost one million physicians in the United States has a similar story— not a cleft lip necessarily but a story in which the physician changed someone’s life in a magnificent way. Countless specialists and primary care physicians alike have stories in which they literally saved a life— reached in and rescued the patient from the edge of the precipice. Or they saved many lives— of children, expectant mothers, and aging grandparents. The joy and satisfaction in those moments for physicians is unlike any other experience.

To reach the point where we can do these things requires years and years of hard work, including the rigor of a heavy science load in college followed by the unrelenting demands of medical school. Academic work combined with clinical training builds the skills that gradually transform the student into a clinician who advances to residency training and fellowship, ranging from three to eight years. Only then comes the great reward: the ability to care for people who need you.

This is the heart of the matter. Physicians love being doctors because we have the privilege of being able to calm fears and alleviate suffering— to change and save lives. This is what motivates doctors virtually every single day of their lives. When the structure and culture in which physicians work are well aligned, it is a most rewarding job.
But something has gone wrong in the physician world, and it is urgent that we fix it. Fundamental flaws in our system make it more difficult and less rewarding than ever to be a doctor... 
We ask the question “What is a physician?” because the doctor’s role has evolved over time, with a particularly rapid evolutionary acceleration in recent years, and many physicians feel confused or resentful about the direction that health care has taken. The deal is not what they signed up for. It is not only the ever-expanding volume and complexity of the clinical work that they face. Far too many physicians also find themselves working amid circumstances characterized by chaos and waste, being encouraged to practice defensive medicine, and being pressured by excessive regulation and hectoring insurance companies...
The physician’s evolution requires shifting from an Industrial Age model of care to an Information Age model of care. In the Industrial Age model, the doctor focused on illness. He (nearly always he), worried about each patient, one at a time, making his clinical decisions in conditions of virtually total autonomy. There were wonderful aspects to this care. It was often highly localized and intensely personal. There was a warmth to it that was derived from a sense of a physician’s responsibility to family, friends, and community.

But there was no information technology, there were few sophisticated diagnostic techniques, and there was a limited use of other team members able to provide highly valuable care. Doctors knew what they knew. There were fewer sources of information and knowledge about new medical techniques, and innovation spread at a glacial pace.

In the Information Age, physicians take responsibility not just for individual patients but also for managing populations of patients— those with diabetes, for example— to make sure patients are fully up to date on all of the treatments and measures that improve their overall condition. Information Age physicians skillfully use electronic medical records, clinical registries— data on large numbers of patients and the internet— to help determine the most effective treatments and provide a great deal of care outside the doctor’s office. In the Information Age, metrics are central to delivering the best care to patients, many of whom engage in deep research related to their conditions on a nearly endless variety of websites dedicated to diseases, cures, and treatments. Too often, the question in health care for physicians is how many patients you can see today. But in the Information Age, the better question is how many patients’ problems you can solve today— and this speaks to the role of physician as leader in the Information Age.

It is not just physicians who are operating within the Information Age. Increasingly, it is, as we have noted, patients as well. The Information Age model requires disruptive innovation to the health care system by holding doctors responsible for all six of the Institute of Medicine’s essential elements of quality care: that it is safe, timely, effective, efficient, equitable, and patient-focused.

But is this fair? Is it reasonable to ask doctors to become something more than they have been? Some physicians chafe at the Information Age model. Most physicians already feel overwhelmed—understandably so. They are asked to do too much in a system that too often thwarts their efforts as much as it enables them.

We have no illusions about how difficult change in health care can be, especially among doctors. Dr. Gene Lindsey, former CEO of Atrius Health in Boston, has worked diligently in recent years to shift the culture of his organization, and he has found this to be exceedingly difficult work. “There is so much anxiety in the physician community,” says Lindsey. “Adaptive change is enormous work. It means giving up things we thought were bedrock.” He cites the example of a physician who is a true expert in his clinical field and then must go through lean training— learning a variety of lean management tools and methods to improve quality , safety, and efficiency. “So you go from being completely competent in an area to being a novice in a new domain. There are a lot of heated conversations.” Many doctors argue that the essence of their job is clinical: that a good doctor focuses on the condition with which a patient presents and then uses her or his skill and training to cure the problem. And many physicians will always cling to that definition exclusively, insisting that matters such as access, cost, and such are better left to administrators and policy makers.

Cochran, Jack; Kenney, Charles C. (2014-05-06). The Doctor Crisis: How Physicians Can, and Must, Lead the Way to Better Health Care (pp. 30-33). Public Affairs. Kindle Edition.
Episodically, you come across a book that inspires tremendously and adds serious value. This is one of them. Like these. And these. And these. And this. (I could, -- and will -- go on.) The Doctor Crisis is optimistic and documentably informed, all while painfully candid (it contains a sobering lookback into the public CusterFluck that was the Kaiser-Permanente Colorado experience). Not Polyanna-ish in the least.
Most physicians already feel overwhelmed—understandably so. They are asked to do too much in a system that too often thwarts their efforts as much as it enables them.
That is simply true. Recall another of my recent posts wherein I cite this book (below).

The healthcare workforce today. Where do we stand, and what should we do to expand and improve it?
Dr. Jauhar's book was widely panned for being "whiny." While I would not agree with that (I found it to a great degree quite forthright), I would categorize it overall in line with the Dr. Cochran's comparison of "cynic vs dissenter."
...I did not offer solutions to the problems that the physicians raised. I did not commiserate with “yeah, everything sucks.” I just listened. And what I heard at clinic after clinic, from physician after physician, was that they were deeply unhappy and often angry.

At one clinic in particular , I found that the staff was not angry so much as they were infused with a sense of futility. It was as though they were at a dead end and there was nothing they could do.

During the Listening Tour, I learned a critical lesson: the difference between cynicism and dissent. Cynics are characterized by a sense of hopelessness and futility and do not present alternative solutions along with their criticism. A dissenter, however, wanted to work to make the organization more effective. Thus, I learned a valuable lesson: Dissent has value, while cynicism has none.

Dissent can be just as angry as cynicism but comes with engagement: I care enough to be angry about the situation here. Dissent comes with ideas for change and solutions for improvement. Dissent is forward thinking and solution oriented. Cynicism is futile, hopeless, and negative [ibid, pp. 56-57].

This, below, is the crux of the Cochran-Kenney case.
In a paper titled “Physician Leadership in Changing Times,” authors Jack Cochran, Gary Kaplan, and Rob Nesse, pose a critical question: Who shall lead, and why?
The notion of joint or system wide accountability is gaining prominence, but which stakeholder— physicians, hospitals, health plans, or others— will lead delivery system transformation? We believe it must be physicians (emphasis added). Among all providers, physicians have a disproportionate impact on the health care system, and therefore have a disproportionate opportunity and responsibility to lead change. Patients experience their own health and the health care system in many ways: physically, socially, psychologically, and financially. As the first and primary point of contact with the health care system for most patients, physicians must therefore act as caregivers , teachers, trusted information sources, and fiduciaries for their patients . They cannot and should not opt in and out of accountability toward their patients in any one of these roles.
This powerful statement serves as a redefinition of a physician’s role— perhaps a broader definition than ever before. The authors insist that “physicians are ideally positioned, and in fact compelled, to take responsibility for helping shape the health care system— not just their own practice— to better serve patients’ physical, social, psychological, and financial needs. That is a huge task, and it cannot be accomplished with passivity or indifference.” 
Some doctors will respond by saying that they already lead— they lead their office staff, their practice, their specialty, and so on. There are also many outstanding physician leaders at major medical centers, medical schools, professional societies, research institutes, and more— examples that demonstrate the potential of physician leadership. Yet throughout the profession an enormous amount of leadership potential remains untapped, and this cannot continue. Talented physician leaders must come off the sidelines and assert themselves more broadly, for never before has the health care industry so urgently needed vision and leadership... [ibid pp.33-34]
"The Doctor Crisis" is an excellent, thought-provoking read. It had me immediately reaching back to, among many others, Maccoby's "Transforming Health Care Leadership."

Improving health care organizations means changing cumbersome bureaucracies into dynamic systems that are patient-focused, cost-effective, and propelled by collaborative learning. This requires culture change, and the first change will be with leaders throughout the organization. No one can do it alone. Leaders need to work together and enlist willing partners and collaborators to achieve these goals.

Knowledge leaders are also needed to network with people outside the organization to bring new ideas and knowledge into the system. A destructive myth that is all too common in many health care organizations is: “We know best.” A not-invented-here syndrome rejects thinking from outside the organization and makes life miserable for able knowledge leaders. In one well -known health care organization, they either reject ideas that come from outside the system or, if they adopt an idea, they rebrand it with their own name. They have a habit of not referencing the original author. Learning organizations pride themselves on the ability to learn from many sources and also understand the need to recognize original contributions to their thinking, both from within and outside the organization.
Another commonly believed myth is that physicians will only follow physicians , and as one MD hospital director commented , “When MDs become administrators, they are no longer considered physicians.” However, physicians and other health care professionals will follow a leader with the knowledge and personality qualities essential to change bureaucracies into learning organizations. It is a myth that these leaders need to be caring ombudsmen. The leaders we need sometimes pull people outside of their comfort zones. It is also a myth that a good leader has all the answers . The leaders we need are able to make use of the knowledge and learning of all collaborators.
Maccoby, Michael; Norman, Clifford L.; Norman, C. Jane; Margolies, Richard (2013-07-29). Transforming Health Care Leadership: A Systems Guide to Improve Patient Care, Decrease Costs, and Improve Population Health (Kindle Locations 645-659). Wiley. Kindle Edition. 
Indeed. I've studied both of the Maccoby leadership books. An invaluable repository of the multifacted psychological and cognitive characteristics of "leadership."

One aspect of "The Doctor Crisis" had me jumping for joy -- the authors' recurrent citation of variations on the word "toxic" in the context of healthcare workforce culture.
Partner Physician as partner means being a great team member and recognizes that the surest route to sustained quality care is through effective teamwork. An essential component of teamwork is not only how team members band together to care for the patient but also how team members treat one another. Physicians who have collegial professional relationships often get the most out of their teams. Partnering is about stepping up and addressing challenges that impact the ability of the team to care for patients; it is about identifying and eliminating barriers to excellent care. It is also about understanding information technology systems and making sure all team members are using the system effectively.

Physicians need to be central to the development of strong teams and to work with nurses, pharmacists, medical assistants, and others to ensure that they too have careers that are relevant, interesting, and satisfying. Some physicians condescend to nonphysician leaders from both hospitals and health plans. Yet a true physician partner— working closely with these leaders— can accomplish a great deal. Arrogance and condescension are toxic elements in a team setting. ["The Doctor Crisis," pp. 40-41]

Play to Win had a powerful emotional impact on many at KP Colorado. One was Dr. Ellsworth (not his real name), a charming, popular physician. But over time, with the toxicity and dysfunction of the medical group , his outlook deteriorated along with that of many other physicians. It was not uncommon for Ellsworth to complain about one aspect of the medical group or another. [ibid, pg. 84]

Too often, the medical culture in the United States tolerates bad behavior by doctors. The culture permits some doctors to be rude, dismissive, and condescending to anyone without an MD after their name. This egocentricity is toxic. What if Dr. Smyth (not his real name) creates an intolerable atmosphere in the clinic? By creating an environment of fear and instability, patients are at risk. It’s 3 a.m., and a patient is having a problem. The nurse is unsure what to do. She believes that there might be an issue, but she knows that Dr. Smyth is on call and that he can be trouble. The nurse thinks it through: If I call Smyth at 3 a.m. it could be ugly, so maybe we’ll just see if we can get the patient through the night until the hospitalist is on at 7. [ibid, pg. 87]

...Dr. Woodley (not the physician’s real name), a new hire, was highly talented and technically proficient. But early on it became clear that Woodley was often condescending and dismissive to staff members. Nothing like this had emerged during the recruitment and orientation periods, yet Woodley was persistently difficult from day one.

Staff members complained, and we— the leadership team— listened. Staffers told us that they were intimidated by Woodley and were routinely belittled, made to feel incompetent. A couple of staff members were so deeply shaken by the mistreatment they received from Woodley that they went on medical leave.

Leaders sat down with Woodley. “This is what we stand for,” we said, “and these are our expectations. We told you this when we hired you, and we told you this at orientation. And this is how you’re going to get evaluated, and it’s not going to go well.”

Woodley replied that it was all about efficiency. “I’m just efficient, and if these people are slow, they’re going to have to get faster, because I’m efficient.”

Efficiency is great, we agreed, but collegiality and effective teamwork are critical as well. We set up a formal performance evaluation and gave Woodley a six-month improvement plan with crystal-clear standards and expectations. Incredibly, the behavior did not change. Woodley continued to abuse staff members, creating a toxic environment in the clinic. So, a high-quality, highly functional clinical doctor who just simply couldn’t— or wouldn’t— treat staff well was dismissed. [ibid, pp. 92-93]
I have repeatedly used the phrase "psychosocial toxicity" on this blog while discussing what I feel to be key elements of "high performance healthcare delivery teams." e.g.,
My recent posts have ruminated on what I see as the underappreciated necessity for focusing on the "psychosocial health" of the healthcare workforce as much as focusing on policy reform (e.g., P4P, ACOs, PCMH), and process QI tactics (e.g., Lean/PDSA, 6 Sigma, Agile), including the clinical QI Health IT-borne "predictive analytics" fruits of ""Evidence Based Medicine" (EBM) and "Comparative Effectiveness Research" (CER). Evidence of psychosocially dysfunctional healthcare organizational cultures is not difficult to find (a bit of a sad irony, actually). From the patient safety-inimical "Bully Culture" down to the "merely" enervating emotionally toxic, I place it squarely within Dr. Toussaint's "8th Waste" (misused talent).
I repeat yet again:
A psychosocially healthy workplace is a significant profitability and sustainability differentiator.
I stand by that view. See my July 19th, 2014 post Medical Error, Interop, and the Patient Safety-Health IT nexus.

Lots more to think about and report (there's so much good work out there in the literature). Need more coffee at the moment. Buy the Cochran-Kenney book. I get nothing for touting it, btw.


Just as Dr. Toussaint added an "8th waste" (misused talent) to the traditional Lean methodology's "Seven Wastes," In The Doctor Crisis we encounter "The Quadruple Aim," which supplants the traditional "Triple Aim" of the progressive healthcare reform ideal.
Dr. Bodenheimer and his University of California San Francisco colleague Rachel Willard made a valuable contribution to “In Search of Joy in Practice,” conducting seven of the twenty-three primary care site visits covered in the report. After studying the seven practices, Bodenheimer and Willard authored a paper titled “The Building Blocks of High-Performing Primary Care: Lessons from the Field” for the California Health Care Foundation in which they observed that primary care in the United States “is undergoing a transformation— from physician-centered practices to patient-focused teams.” Bodenheimer believes so strongly in the importance of clinician morale that, he says, “the Triple Aim should be a quadruple aim, with clinician and staff satisfaction a necessity to achieve the other three aims.”...
The work by Drs. Sinsky, Bodenheimer, and their colleagues is instructive and inspiring, for they have broken out of the narrow definition of a physician as healer and embraced the concept of physician as healer-leader-partner. In doing so, they have taken on broad accountability for their patients’ health care, going beyond the clinic in search of improvements and joining together with others in a collaborative process that enhances the strength and power of their recommendations. They have identified improvements that seek to summon the idealist and enable the healer in all physicians to alleviate suffering and save lives..
We need a new deal with physicians. Just as the doctors in Colorado needed preservation and enhancement of careers to trigger a surge in the quality of patient care, so too do we need a comparable deal now for the nation. This work to preserve and enhance physician careers is so critical that, as Bodenheimer says, “the Triple Aim should be a quadruple aim, with clinician and staff satisfaction a necessity to achieve the other three aims.”
Physician compacts are deals that health care organizations make with their doctors. More and more organizations throughout the country are turning to compacts to make as explicit as possible what the organization can expect from doctors and what doctors can expect from the organization... [The Doctor Crisis, pp. 118-120, 178]
This book hits all of the by now familiar best practices process QI notes (including adroit use of Health IT for data-driven analytics across the board), but goes well beyond that into detail regarding explicit "compact"/"code of conduct" workforce culture policy--policy that is essentially "Just Culture" material. e.g.,
Colorado Permanente Medical Group [CPMG] physicians demonstrate commitment to our patients, practices, and one another by providing high-quality, responsible medical care in a professional manner. 

In meeting this commitment, CPMG physicians will: 
1. Interact with other physicians , practitioners, and staff in their department, CPMG Leadership , and contacts in the community in a collegial, supportive, and professional manner.
  • Give feedback to colleagues in a professional manner.
  • Give corrective feedback to staff in a respectful manner away from patients and other staff. Take concerns about a colleague which cannot be resolved directly to the department chief. 
  • Express dissenting views in a respectful manner. 
  • Accept responsibility and seek solutions to problems.
  • Give candid and timely feedback on peer/ staff evaluations. 
2. Provide excellent service to patients and internal customers:
  • Communicate patient care plans, consultations, and treatments back to referring providers. 
  • Maintain strict patient confidentiality.
  • Treat members as valued customers.
  • Maintain appropriate provider-patient boundaries.
  • Be punctual in all medical care settings (medical center, hospital, etc.).
  • Maintain high-quality provider-patient relationships by any member satisfaction measurement (Art of Medicine, Patient Satisfaction, etc.).
  • Attempt to resolve patient concerns.
  • Assume responsibility in general for decreasing his or her patient waiting time for appointments when the wait is unacceptably prolonged.
  • Respond appropriately to hospitals, page operators, and others.
  • Be flexible in accommodating changes in patient demand to best meet the needs of the patient and the medical group.
  • Balance multiple and at times unexpected or conflicting demands of patients.
  • Clearly explain the plan for care to the patient to better ensure patient compliance and satisfaction.
  • Demonstrate courtesy, respect, and a caring attitude to patients in order to enhance the provider-member relationship. 
  • Control emotional reactions toward patients and others.
3. Support the Principles of Medical Practice (Policy No. 5.03, Appendix A) and be careful stewards of our members’ resources. 
4. Participate as members of the health care team:
  • Meet work unit requirements and equitably share in the workload to ensure the department's needs are met.
  • Participate in Quality Assurance activities and follow accepted clinical guidelines.
  • Attend and participate in departmental meetings and team improvement activities.
  • Schedule time-off requests in a fair and collaborative manner subject to department needs.
  • Avoid maligning or undermining colleagues to patients or other physicians and staff, either verbally or in writing
  • The supervision of and collaboration with midlevel practitioners is strongly encouraged.
5. Contribute to the success of the Medical Group: 
  • Be an advocate of Kaiser Permanente and its principles.
  • Follow the policies and directives of the Board of Directors and administration.
  • Support and participate in the development and implementation of strategic change initiatives. 
[This Code of Conduct was not intended as an exhaustive statement about professional conduct and did not limit the discretion of Medical Group management in addressing concerns regarding conduct.] (ibid, pp. 194-196)
"Just Culture." See in particular Marx's "Whack-a-Mole: The Price We Pay For Expecting Perfection."

While some physicians make no bones about their irascible disdain for anything that impinges on their "autonomy" (particularly when it comes from non-clinician superiors), the authors note that
Throughout their careers, physicians have been continuously tested and measured. After all, every physician went through a challenging undergraduate course of study in the sciences just to be able to make it to medical school. As medical school students, they work to absorb immense amounts of clinical learning . Then comes the rigor of residency. Every step of the way for those ten or more years of education and training, these young men and women are measured on performance. They understand what it means , and in the vast majority of cases they welcome it. For most, it affirms their commitment to excel. [ibid, pg. 88]
Yes, assuming a Just Culture, I would add. The physician must internalize the necessity and desirability of becoming Healer-Leader-Partner within his/her own workplace culture if the goal of truly effective patient-centered care is to be realized.
Physician, Heal Thy System.

Dr. Toussaint on "Leadership."

Gemba is another useful word from the Japanese. Literally translated as “workplace,” gemba refers to the place where real value is created in an organization. Senior leadership of most companies spend shockingly little time there. If the CEO does appear in the intensive care unit or a busy emergency room, it’s usually a backslapping tour, meant to underline his authority and spread the idea that he both cares about and keeps a close eye on operations. At Toyota, on the other hand, going to the gemba meant assisting operations: looking for problems or improvement opportunities and finding out what workers need to stay on target. It means getting to know, first hand, the issues facing front-line workers and helping to work out solutions. It means learning, not teaching and telling.
Toussaint, John; Gerard, Roger (2010-06-06). On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry (Kindle Locations 1315-1320). Lean Enterprise Institute, Inc.. Kindle Edition.
"It means learning, not teaching and telling."
Indeed. apropos, brings to mind another of my endless reads.

Below, from one of my irreverent REC slide decks:

"Lean Champions." Uh, that would be "leadership."



More to come...

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