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.

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.

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.

One of the basic premises at HealthCareRedux.com 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.

Quality is the holy grail of health care.  In the United States an entire industry of health care quality has been created.  Unquestionably, some of these health care quality initiatives have resulted in better patient care.  However, one has to question the overall return on investment of the health care quality initiatives over the last decade.  We invest an enormous amount of resources in improving healthcare quality but if the return on investment is poor the opportunity cost is enormous.  The resources could be better utilized elsewhere.  If the current health care quality initiatives have not resulted in great improvement why not?  Sometimes a dangerous discussion to have.  Often those who have the audacity to challenge a health care quality initiative are perceived as uncaring dinosaurs and dullards who just want to maintain the status quo when in reality most of the time just the opposite is true.  The current establishment of health care quality and patient safety does not encourage challenges.  If the assumption that the current health care quality industry is significantly under performing then what are the possible explanations?

First, there is an incredible drive in the health care quality industry to do something rather than something meaningful.  A 2007 publication entitled “The Tension between Needing to Improve Care and Knowing How to Do It” appeared in the New England Journal of Medicine.  The author’s main message was that in the field of health care quality and patient safety the focus is often on haste and action rather than evidence.  They outline and review the dangers of this approach.  Health care quality and patient safety is such an important field so why shouldn’t initiatives be held to the same evidence based standards as therapeutic interventions.  They mention that medical errors are the eight leading cause of death in this country but we don’t apply evidence based criteria to qualit yand patient safety as we do for treating the first seven leading causes of death.  Haste over data.

A second, and possibly more important, reason that the health care quality industry is underperforming is the complete absence of discussion of the human factor.  Avedis Donabedian was a physician and is considered the originator of modern health care quality research.  In 1966 he published a paper entitled “Evaluating the Quality of Medical Care.”  Donabedian is credited with deriving the “structure-process-outcomes” model of health care quality research.  He had a long and distinguished career and essentially established the foundations of health care quality.  Donabedian was also a true scholar and thinker.  Toward the end of his career he said:

“Systems awareness and systems design are important for health professionals, but they are not enough. They are enabling mechanisms only. It is the ethical dimensions of individuals that are essential to a system’s success. Ultimately, the secret of quality is love. You have to love your patient, you have to love your profession.  If you have love, you can then work backward to monitor and improve the system.”

Donabedian, after a career of research on systems and operations realized that an organization’s success is mostly about the people and the culture in which they work.  There is no structure or process that can prevent bad things from happening when the people factor is bad.  Alternatively, good people with a love for their work can overcome bad structure and process.

How can physicians love their patients and their profession in the current environment when everyone is an adversary?  How can physicians enjoy their work when there are legions of people, who themselves have never practiced Medicine, telling them how to do things better?  These same people add nothing to the quality of the care.  They just encourage everyone to generate more utilization at a lower cost.  That is the only training they have and that is what they are hired to do.

The successful health care system of the future will create the environment and culture where providers can love their patient and their profession.  The first step will be restoring the practice of Medicine to a profession and establishing a culture of caring.  All else will then fall into place.

The health care system in the U.S. is in the process of change.  While it took the economic reality to drive change the system can also be described as dysfunctional in many dimensions.  Hopefully we can finally get this right.  Any meaningful improvement in health care will require the involved stakeholders (patients, providers and payers) to completely disconnect from the current disastrous steady state.  The changes need to be as deep as they are wide.  The Institute of Medicine recently published “Best Care at Lower Cost. The Path to Continuously Learning Health Care in America.”  The authors note that professionals in health care are “overwhelmed” by initiatives to improve care and that any initiative that focuses on incremental improvement and adds to a clinician’s daily work load are unlikely to succeed.  The expert authors suggest transformational change.  We need to transform health care beginning with a foundation that focuses first and foremost on the relationship between a patient in need of health care services and the professional who provides those services.  It needs to be a ground up, not top down, restructuring.

At a recent meeting of an organization that is in the process of assembling an integrated delivery system a leader mentioned that he was receiving calls from around the country to see how he is going to do it.    Those in leadership positions at other organizations are aware that change is inevitable and want to learn from the brave in the front of the line.  If the plan is simply to improve operating margins by 5% via aggressive pursuit of efficiencies the calls will stop and the callers will look elsewhere.  They are looking for innovations.

When something has been so bad and dysfunctional for so long you could argue that it is even beyond a transformation.  It may be best to just CTRL-ALT-DEL health care and start over fresh with a new vision.  Thus, it may be advantageous to be building something new.

Health care now needs leaders who have:  (1) the heart to acknowledge that this is a service that a civilized society can and should provide to all citizens at some basic level, (2) the brains to devise a new system, and (3) the courage to implement the new changes in the face of multiple special interest groups that have only self-serving interests.

No one is making the culture argument.

Fundamental, sustainable and meaningful change in the health care system isn’t going to be achieved by new policy or operational initiatives.  No, the more important changes that need to occur involve a transformation of how all involved think about their role in the system.  All stakeholders (patients, providers and insurers) need to reassess and redefine their values and norms.  This is the culture argument and it has been absent in most, if not all, discussion regarding health care reform.

The absence of cultural transformation in the health care debate is understandable in that it is a concept that is difficult to define and/or measure and even more difficult to create and/or change.  But the importance of culture to the success of an organization, or in this case an entire industry, has been well documented.  Peter Drucker, a legendary management consultant, is credited with the saying: “Culture eats strategy for lunch”.

Why is culture so important?  It provides clarity and focus.  It allows for efforts to be aligned and directed to a common goal.  In addition, the values and norms of a group’s culture lead to the actions and behaviors of the group.  People are empowered to act in accordance with the culture.  There is less policy driven micromanagement.  It allows an organization to be less “top-heavy”.

A management professional once said: “You can get a sense of an organization’s culture based on what people are talking about”.   If this is true then there is a lot of work to do in health care.  While there has been a significant amount of discussion about quality and value in health care from outside the industry the talk inside is still for the most part focused on the same old nonsense.  The discussions are still focused on generating as much output as possible at the greatest level of efficiency.  This culture of utilization at the greatest possible efficiency (i.e. the corporate model of medicine) has been one of the main reasons that we now have a crisis.

For those interested in creating the successful health care organization of the future developing a culture of quality and value is imperative.  While this may seem a less tangible goal then optimizing a balance sheet it is absolutely crucial to success.  Everyone in the organization must understand that quality and value take precedent over all other issues and everyone in the organization must be empowered to act and innovate toward quality and value.

Once all energies are focused on a culture of quality and value then the next challenge is to have the culture generate strategies and operations that result in a functional health care system.   For the few who do currently talk quality and value this has also been a challenge.  Admittedly it is easy to talk about a culture of quality and value but to create the working model is more difficult but an absolute necessity.