Monthly Archives: July 2013

Nobility Obliges

There is a reference to the concept of  “nobility obliges” as far back as Homer’s Iliad.  The super hero Spiderman hears something similar from his uncle.  The essence of this phrase is that when you have attained a certain real or perceived higher status in life much more is, and should be, expected of you.  A French novelist by the name of Honore de Balzac is credited with first penning the phrase “Noblesse Oblige” in a novel by the name of “Le Lys dans la vallée” published in 1836.

Medicine has been referred to as one of the noblest professions.  It is certainly a profession that ideally requires a degree of commitment and selflessness beyond all others.  Years of training attempting to understand, now at the nano-level, the complexities of the human body both in health and disease followed by a lifelong quest to stay current with the ever-changing bio-medical literature.  Then a daily battle to apply all of this information to a very heterogeneous population of human beings.   There is an incredible and unmatched responsibility in having another human being ask for assistance with maintaining the quality and/or quantity of their life.  Public opinion polls support the fact that people respect the profession and trust their providers (physicians and nurses).  In addition to the respect and trust afforded physicians the profession is also assigned a great deal of prestige and esteem.

The prestige and esteem (i.e. nobility) assigned to the profession of medicine does come with expectations (i.e. obliges).  The expectations/obligations are simply to live up to the high prestige and esteem that are associated with the  profession.  Physicians are expected and obliged to first and foremost be educated and compassionate advocates for the health care needs of every patient that they encounter.  There is an expectation that a physician will maintain competency in his or her specialty by ongoing professional education.  There is an obligation for physicians to practice their profession and apply their skills with an understanding that each patient deserves to be evaluated and treated  as an individual.  There is not an expectation for a perfect outcome every time but an obligation for a physician to always work toward a perfect outcome every time.

There are expectations that physicians should have of each other and obligations to each other and to the profession.  There should be an expectation that physicians work together always putting the patient first.  There should be an understanding that each specialty has unique skills and that it is often necessary to coordinate all of these skills for optimal patient care.  There is also an incredible obligation for physicians to protect the profession from external forces that want to reduce the practice of  medicine to an assembly line mentality.

So in summary the practice of medicine is still respected and looked upon as an esteemed and prestigious profession.  Those that hold the profession in high regard rightfully have expectations of the profession.  Physicians must continuously work to live up to and even exceed these expectations.  It’s an obligation that comes with the job.

Who is your CCO?

In the corporate world the position of Chief Cultural Officer, or CCO, is not new.  Large and successful companies such as Google and Staples have recognized the importance of culture as a strategy.  Customers are people and culture is important.  It is likely that the importance of culture in the business world relates to building relationships.  Relationships with customers and potential customers as well as relationships between employees.  These relationships undoubtedly can drive customer acquisition and retention.  Relationships provide comfort and make new and repeat purchases easier on the buyer.  High quality relationships also allow an organization to get the best work from the employees avoiding the galley-slave mentality.

While there has been no widespread move toward culture as a strategy in health care several successful organizations, such as the Cleveland Clinic Foundation, have appointed Chief Experience Officers, or CXOs.  Patients are people and the experience is important.  The experience is about human interactions and relationships.  Again, it is the culture that builds and defines the relationships.   Hospitals currently track the patient experience via the Hospital Consumer Assessment of  Health Plans Survey (HCAHPS) and the information is reported on the Department of Health and Human Service’s Hospital Compare website.  The survey tool from HCAHPS asks 32 questions of patients recently discharged from the hospital.  To date no clear association between the patient experience and patient outcomes has been demonstrated however it has been reported that the early studies suffer from significant methodological shortcomings (New England Journal of Medicine).  Prediction: it will be very difficult to associate the output of the current patient experience survey to objective patient outcomes.  Bottom line:  an association of the patient experience to outcomes doesn’t matter because the patient experience is important as an independent domain of how a health care system is performing!

The patient experience is the most important in a health care system but all of the relationships in the system matter.  A November 2012 article in the Gallup Business Journal reports on an initiative at the Cleveland Clinic to initiate a cultural shift.  One of the unique aspects of this initiative was the insight to realize that employee engagement was fundamental to the process.  Every employee (physician, nurse, housekeeper, gift shop clerk) was considered to be a caregiver.  This simple but powerful idea likely created a unifying focus for the entire workforce.

It appears that the health care industry is inching toward embracing culture as a strategy.  Culture facilitates both the subjective and objective outputs of this complex system and connects the two.  It is the culture that drives the relationships and its the relationships that drive the experience.  It is the culture that sets the foundation for the efficient delivery of evidenced based care by engaged and energized professionals.  It’s too important to ignore.  Someone needs to own the culture initiative.

Tell Me What You Do Again And Why It’s Important?

If health care was deconstructed back to first principles all that would remain would be a patient and a physician.  Reconstruction would then involve adding components that enhance the value of the service provided from the physician to the patient.  There are so many people and layers now.  Health care has become incredibly complex but there is no clear evidence that this complexity translates into better care.  Maybe just another great example of a Rube Goldberg machine.  Could it be that there are people and their processes in this system that just add expense with no significant return on care delivery, quality improvement or cost savings?  There has always been a tendency to make things bigger but not necessarily better.  How much waste is present in the administrative suites?  There are personnel hired whose job on paper is related to making care better or more cost-effective.  They never come in contact with a patient.  An objective person would assume that this requires a close, collegial working relationship with the physicians delivering that care.  Is this occurring?  Can the physicians in the system attest that certain non-patient contact personnel actually enhance care?

The Institute of Medicine (IOM) has estimated that as much as 25% of the excess cost in the health care system can be attributed to excess administrative costs.  This amounts to $190 billion dollars.  Another $130 billion of excess cost is from inefficiently delivered services.  These inefficiently services are occurring in the era of managed corporate medicine.  Every player in the system needs to contribute to the mission of making health care better and affordable.  This includes providers, patients, payers and those in health care administration.

The return on investment of everyone who collects a paycheck from a health care system should be assessed.  Special attention should be focused on those who never come in contact with a  patient.  It is likely that the return in this group is especially low and great cost savings, without compromising care, could be obtained by eliminating or at least reducing these positions.  To assure that the process is objective a committee composed of many disciplines could be assembled.  Those who have no patient contact would be given a certain amount of time to research and prepare a presentation.  They would then present to the committee.  Each non-patient contact employee would have to present evidence that justifies their existence in the system.  Is there an evidence based argument that their position improves quality or decreases cost?  Some have minions of staff and resources.  Is it all necessary?  If there is an evidence based benefit to the position?  Could it be done more cost-effectively?

The delivery of health care from a physician to a patient, as well the administration of that health care, must be evidence based and simplified.  It’s the only pathway to quality and efficiency.

See Me, Feel Me, Touch Me, Heal Me

The credit for the title goes to the Who.  “See Me, Feel Me”  is the name of a song from the 1969 album Tommy.  Were the Who visionaries?  Did they look into the future to see health care in the 21st century?

This post is based on a personal experience.  Not too long ago a father takes his daughter to the pediatrician for what was going to be the last visit before transitioning into adulthood.  The appointment was for a physical examination required for the college admission process.  The group of pediatricians had provided great care for almost a decade.

The visit started as per past routines with a very courteous greeting.  However, it was soon obvious that there were now external forces at play and that this visit would be different.  The focus of the visit quickly turned to the lap top computer that was 8 feet away in the corner.  It started with a review of the medical history.  Time was 2 minutes.  Eye contact time = 0.  Distance from patient = 8 feet.   Then a long list of symptoms each acknowledged with the click of a mouse.  Time was 2 minutes.  Eye contact time = 0.  Distance from patient = 8 feet.  On to the physical exam.  Wasn’t sure what was going to happen here.  With telemedicine on the horizon there may be a day when the physician can stay in the chair or even not be in the room.  But yes the computer was abandoned for the exam.  Time was 5 minutes.  Eye contact 1 minute.  Distance from patient appropriate.  Now back to the computer for a wrap up.  Time was 2 minutes.  Eye contact = 0.  Distance from patient = 8 feet.  Eleven minutes in the office.  For over half the visit the focus was on the computer which was 8 feet away from the patient.

Is there a real benefit to this method?  Isn’t the amount of documentation the same irrespective of when it is done?  In other words was time saved by doing the documentation during the visit as opposed to at the end of the day?  And if it can be shown that you can see a few extra patients in the day is it worth it?

The actions always speak louder than the words.   The focus of this visit was on rapidity and documentation.  One could argue that this “wellness” visit may be completely different from that for a patient with a medical problem.  Would be interesting to see if patients with real medical problems have the same experience.  In that humans are creatures of habits the sick visit most likely isn’t much different from the wellness visit.

This experience is a great example of how the focus of health care has moved away from the patient.  They gave in to the corporate model of medicine.  Just running faster on the little hamster wheel.  Most of the time it is just easier to acquiesce.  But will the patients tolerate this model or will they demand better?  They should.

Open-Book Management for Health Care

One of the great mysteries in the health care system involves trying to asses what care really costs.  Many of the thought leaders in the reform movement are convinced that more transparency in pricing and cost will allow consumers (read patients and payers) to comparison shop and use basic economic pressures to obtain value.  A great idea.  What about the pressure on providers to deliver value?  Wouldn’t it make sense to have the  providers on the front line equally educated with respect to price and cost?  If providers understood price and cost they would be in a better position to provide value to the consumer.  Most front line providers (physicians, nurses, others) are as equally in the dark as patients and payers with respect to price and cost.  This information seems to be locked away in an administrative vault somewhere.

Open-book management is a strategy in which the financial information of a business is shared with employees at every level.  The concept was originated in 1993 by a business author by the name of John Case who worked for Inc. magazine at the time.  It  gained popularity when a then manager by the name of Jack Stack and a group of employees purchased a failing business unit within International Harvester and transformed it into a successful venture.  Mr. Stack went on to write about the experience in two books: “The Great Game of Business” and ” A Stake in the Outcome”.  Mr. Stack stresses a culture of ownership.  One of the main themes is that if employees are engaged, educated, encouraged and have equity in the outcomes then you have leveraged an important aspect of success.  A nice summary of the key points in the later book have been outlined by a business consultant by the name of James Altfeld and are available as a pdf file here.  If the concept of open-book management sounds good start with this review.

Is the timing right for open-book management to be applied to health care?  If providers knew the cost factor associated with each process and piece of equipment and office supply it would likely be eye-opening.  Many expensive habits and routines could and would be abandoned.  Even in the world of evidence based medicine and comparative effectiveness research the cost factor must be understood.  If research demonstrates that two treatment are equally effective but there is a significant cost differential then cost should be the deciding factor.   Every provider must first and foremost do what is best for patient outcomes and only providers are in a position to decide what is best.  Why not empower the same group with cost and financial data as well.  It just makes too much sense.

While some have described a downside to open-book management there seems to be no reason, other than protecting turf, that this methodology should not at least be trialed with physicians and other health care providers.

If it works with those on the floor of the factory is there any reason to think that it wouldn’t also work with trained health care professionals?

Guilty as Charged

One of the basic premises at is that a successful remake of the health care system will occur when Medicine is restored to a profession and a new culture is created.   Physicians can and should occupy nearly every key leadership role in the new system.  The full responsibility for care outcomes rests with the physician.  No other person or discipline in the system has the training to interpret and apply results from the bio-medical literature  so that care can be evidence based.

More than anything a leader needs the respect of those around them.  If a leader is going to ask others to make personal issues secondary to a greater good then the same should be expected of the leader.  Leadership by example.  To be perceived as credible and virtuous  leaders of the transformation of the health care system  physicians must realize that the first changes to be made are all within.  Most surveys still reveal a high degree of public support, confidence and trust in physicians.  In fact more so for physicians than politicians and health care administrators.  However the personal and professional  imperfections present can not be ignored or swept under the rug.  With respect to personal issues there are those who still see doctors as arrogant,  rude, condescending, greedy, egotistical, uncaring and the list goes on.  At the professional level there are still some physicians practicing well below an acceptable competency level.  Also, it would be naive to deny that there are some physicians who have abused the system for personal financial gain to the detriment of their patients and the system.  Bad people or response to a bad system?  Doesn’t matter.  The profession as a whole needs to plead guilty as charged and address all of these issues.

Is there something to be learned from those in the profession with personal or professional blemishes?  Nature or nurture?  Bad apples to begin with or simply a weaker breed breaking under the pressure of an ever-increasing adversarial environment?  If the culture of the health care system truly was focused on quality and not just output would a physician then spend more time with patients?  Would these interactions be more personal?  Would the physician spend more time reading and engaging in other activities to maintain competency?  Would any of this improve outcomes and/or the system as a whole?  Again it only matters in that it provides a potential remedy.  But no excuses for bad behavior-ever.  Excuses and lack of action will hurt the cause.  The profession will need to continuously look for problems within, acknowledge them and fix them.  Look inward first.