For health care to be better, doctors must lead the change

Recently New Yorker staff writers and best-selling authors Malcolm Gladwell and Atul Gawande addressed the question of whether the problem in health care is that patients are too reliant on doctors and don’t have the ability to make decisions. In reading between the lines, is that the reason health care is not affordable and care not commoditized or consumer driven like other industries?

At a conference for America’s Health Insurance Plans, Gladwell argued that patients or consumers have been unable to be more empowered because doctors, as the intermediary, held the power of knowledge much the same way chauffeurs did for the early days of the automobile and Xerox technicians did in the early days of photocopying. A person was needed to guide and assist the individual to get the job done. At some point, however, the technology became simpler. People began to drive their own cars and make their own photocopies. The mystique of the chauffeur and technician was lifted. Now everyone could drive. Everyone could make photocopies.

Is it possible that for health care and the health care system, which for many people is a system they interact with rarely and in an area (health / illness) where the uncertainty and stakes many be too “high,” that individuals willingly to defer the responsibility to someone else? Gladwell hints that might be a possibility.

“A key step in any kind of technological transition is the acceptance of a temporary deficit in performance at the beginning in exchange for something else,” said Gladwell. That something else can eventually include increased convenience and lower cost. He offered a number of examples, including the shift to digital cameras where early pictures were not as good as film and the advent of the digital compression of music, which he contends has made the quality of music worse.

The changes in film and music were accepted, he said, in exchange for new opportunities to arrange, manipulate, and personalize our pictures and music. “In healthcare we don’t have the same stomach for that period of transition. That’s striking to me.”

The disruptive innovation that Gladwell is hoping for has yet to affect healthcare. It is possible that as more Silicon Valley start-ups focus on making medical care more convenient, worry-free, hassle-free, more personalized, and more accessible that the majority of individuals won’t adopt them because doctors don’t approve. The shift to a “temporary deficit in performance” may not be as acceptable even if less expensive and more convenient. As Gladwell notes in the case of dialysis, despite being around for over seven decades, patients in general still don’t self-administer treatment, which would be less expensive, but rather continue to go to facilities which are overseen by doctors.

His colleague, Dr. Atul Gawande, countered that other industries, like “teaching, firefighting, and police work” still have intermediaries that do the work on behalf of the individuals. Gawande believes that the real issue is that the care we provide as doctors isn’t integrated. We focus on optimizing each part of the health care system without looking across the entire experience of care. Extending this analogy to building the best car and using the best manufacturer for each part, Gawande notes:

… building a car with Porsche brakes, a Ferrari engine, a BMW chassis, and a Volvo body. Put it all together and what you have is an expensive pile of junk that doesn’t go anywhere because the pieces don’t work together.

Nowhere was the need for doctors to lead change and think about the entire experience for the patient more clear than a recent New York Times piece by health reporter Tara Parker-Pope, titled “Too Much Medical Care.” She chronicled her experience as an educated patient and parent of a daughter who suffered an ankle injury at camp. She started first with:

Pediatrician. Initial visit.

One month later, still not better so she takes daughter to sports medicine specialist. MRI ordered.

Referral to pediatric orthopedic surgeon. Another MRI. Blood work.

Slightly abnormal blood work.

Referral to eye specialist.

Referral to pediatric rheumatologist. More blood work. Another (3rd) MRI. X-ray of hands.

Five months after original injury, daughter notes that her ankle still hurts.

Finally, Parker-Pope takes back control. She consults with the sports medicine specialist who reviews the case with the pediatrician. The focus in back on the patient and pain relief. Soon, the daughter is back to resuming her activity.

In retrospect, what is most surprising is how long the entire process went and still the daughter’s problem hadn’t been solved. Three MRIs for an ankle injury. Four specialists.  Many blood vials drawn. X-ray of the hands, though the ankle was the injured joint. It’s not that Parker-Pope is naive or uneducated. She is a health reporter for the New York Times and has talked to many doctors and written many stories. The fact that she and her daughter were caught up in the health care system illustrates the challenges facing the public.

Solving the health care crisis will require both points of view offered by Gladwell and Gawande. We need both patient engagement as well as a more coordinated integrated health care system. It is however increasingly clear, particularly based on the New York Times piece, that empowered patients alone won’t be able to bend the cost curve. Despite the easy availability of information via the internet and self-diagnosis, there is value to the “expert” in determining the right course of action. As both Gladwell and Gawande note in their previous works there is a need for 10,000 hours of deliberate practice to become expert and that even the experts need coaching for continuous improvement, respectively.

The real problem is whether the “experts” are willing to make the judgement calls that our training provides? When to refer? When not to refer? When to get the MRI? When not to get the MRI? When to prescribe antibiotics? When to hold ground and sympathize when it is a virus? When to comfort, empathize, and heal when it means stopping chemotherapy when treatment is futile? When to do surgery? When to hold off? Are we willing to have others observe us in action so we can be even better? If not, why not?

For health care to be better, doctors must lead the change. No one else can. Insurers and employers have exhausted strategies to make patients more accountable. Increasing deductibles and co-pays indefinitely won’t work. Despite the unprecedented access to information, empowered patients and other patient advocates will never be able to fully close the knowledge gap. That difference in knowledge, as Gladwell points out in his book, Blink, is what allows an expert to distinguish between an authentic piece of artwork and a very good looking fake.

It is also the difference between stopping a number of unnecessary referrals and the cascade effect of subsequent imaging, blood work, and appointments and instead focusing on the patient.

Who will shape health care? Doctors, patients, and insurers and in that order.

Or entrepreneurs who partner with doctors to solve our challenges so we can go back to focusing on healing patients.

Davis Liu is a family physician who blogs at Saving Money and Surviving the Healthcare Crisis and is the author of The Thrifty Patient – Vital Insider Tips for Saving Money and Staying Healthy and Stay Healthy, Live Longer, Spend Wisely.

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  • Steven Reznick

    Doctors will change the system for the better if and only if there are economic incentives for them to coordinate care, act as patient advocates and see the whole patient not just the isolated immediate problem. Payment for cognitive services and evaluation and management services is what is missing and is the key. You can organize ACO’s, patient centered medical homes or whatever catchy phrase or name you choose to use in the 21st century. As long as the disparity in reimbursement for a simple skin biopsy is higher than for stopping a patient with impaired renal function from having an imaging study requiring a dangerous contrast dye load then coordination of care will be missing. On the other hand patient education and common sense and patience is required as well. Sometimes things just take time to get better and require time and rest to improve. There is very little patience and understanding of how beneficial tincture of time is. I relate the story of a twenty year old admitted with heat sickness, hypokalemia ( low potassium level) and rhabdomyolysis who was greatly improving within his first twenty four hours of fluid resuscitation and electrolyte ( internal chemical) correction using intravenous fluids. He was told at 7am by his internist and nephrologist that he was improving but would not be ready to go home for at least another 24 hours. He was told that he would be seen again by his doctor in the early evening. At 11 AM he called his doctor to complain that he wasnt being kept current on his condtion. He asked for an hourly Tweet to keep him current. Clearly there was a difference in his expectations and reality. Common sense , individual responsibliity and having a doctor you trust to coordinate your care and advise you are what is needed in the future. I am not sure the insurers, the employers and the politicians will permit that.

  • civisisus

    “For health care to be better, doctors must lead the change. No one else can”

    Believe what you want Dr. Liu. Doctors have had their chance to lead. For a lot of reasons, not all of their own making, doctors have not genuinely led population health care innovation as often as you might guess. But what’s more important is this: you work for us, doctors. You always have. We just haven’t always acted like it.

  • James Siegel

    Have to agree with civisisus… Doctors have had plenty of opportunities to lead. Until our medical programs in the U.S. are not bought and paid for by the drug companies, NOTHING is going to change. The REAL healthcare revolution starts by telling people the truth about nutrition. The truth that the foods we’ve been eating for the past 50 years are increasingly poisonous. That “fat free” and “carb free” and every other catchy concept of the past decade is absolutely toxic and a direct threat to your long term health. But we won’t do that b/c the government would have to admit the FDA isn’t working to protect the health of our citizens, its working to make sure that big food and big pharma get their way.

  • stephanie hegland

    Would also have to agree with civisisus… though in my experience, doctors’ are more controlled by fear of malpractice and a need to protect themselves and their organizations, than to serve the patient, thus Parker-Pope’s repeated MRI’s. And I mean no disrespect to the physician community. Our litigious society has created this dynamic.

    Case in point: I’ve taken a teenager to an ER for difficulty breathing. Let me back up by saying, we actually started at the adjacent urgent care (doing my best to use resources wisely!) – And were referred to the ER because urgent care staff was not comfortable treating breathing difficulties.

    After 8 hours in the ER, an ambulance ride to the children’s hospital was deemed necessary. Note: breathing difficulties stopped within an hour of arriving at the ER; and every scan and blood test possible had ruled out anything of consequence. Transfer to the pediatric hospital was not for further testing, but because the community hospital did not have a pediatric floor.

    As an educated consumer of healthcare, I knew, I KNEW we 1) didn’t need an ambulance ride, and 2) didn’t need to transfer to a pediatric ER… but when it’s your child and these “experts” tell you what needs done, it’s emotionally impossible to refuse.

    I finally put my foot down at the children’s ER when they wanted to admit her overnight. When I asked what services would the hospital provide that I wasn’t able to provide at home, and the answer was nothing, we left. But only after I signed off accepting full responsibility for my child’s welfare.

    In the end, the diagnosis was anxiety. An extended bout of coughing had likely bruised a rib and made deep breaths painful, creating fear that something was really wrong. I’m pretty sure the ER doctor at the first hospital knew that to be the issue, and every subsequent scan, test and blood draw were to confirm his own believe and prevent me from feeling she hadn’t done her job.

    • Davis Liu, MD

      Agree. Would not your experience have been better if the doctor had made
      that judgement call and sent you home after the ER visit? Yes, the
      litigious society has made it more difficult and one bad outcome can
      make any doctor second guess every diagnosis, but would it be better for
      doctors to make choice than to have patients deal with the emotional
      worry if they did the right thing? Thanks for the comment.

  • Keegan Duchicela, MD

    Great post. Very interesting example about dialysis.

    Regarding comments by stephanie and civisisus – I agree that physicians haven’t led health population health innovation and appropriate resource allocation… but that’s simply because it’s not part of their training and it really never has been.

    Imagine you’re a physician with a panel of patients and you have ‘x’ number of dollars to “manage their health” – population health at its best. You have data that that shows you can either spend ‘x’ number of dollars to provide 1000 of your patients an extra 0.1 years of additional life expectancy OR give 4 of your patients 25 years of additional life expectancy. Are these decisions for a doctor to make?

    In a world with finite resources, these are the decisions we should be explicitly discussing… but we haven’t, because these are HARD discussions – mix in politics and a resistance to discussing end of life issues, its no wonder we are willing to spend any quantity of money no matter how little benefit.

    Because at the root of it… we still want the doctor to work for us. When your doctor suggests or recommends a treatment, you don’t her to factor in the financial situation and health of the other 999 patients in their panel. When you are sitting in their office, you want them to be treating YOU, and not “managing” you as part of their patient panel and it’s global budget set by CMS.

    • southerndoc1

      Very well said. Thanks

    • Margalit Gur-Arie

      Fantastic comment!

      But is the issue really one of insufficient resource allocation? Most other countries are doing OK with half the resources we are applying to the problem and with some exceptions they all seem to not be in need of morbid accounting practices.
      Perhaps if we didn’t spend the first 25 cents of every dollar on things unrelated to care and if we didn’t promote an environment where pricing is set according to the seller’s size and clout, we would find that our finite resources are more than enough to satisfy everybody’s medical care needs.

    • Davis Liu, MD

      Agree. We do have hard discussions that as a society we must have.

  • Jen McDonough

    Interesting article – thank you for sharing. As a mom to a child with a chronic lifetime condition (type 1) and one that has invested heavily in time, efforts and money (paid cash out of our own pockets for $30,000+ in medical related expenses and spent ~48 days in two years at an out of state research facility to help find a cure), I applaud the effort to put the patient first.

    Having worked in medical admin Roles for 20 years I have also seen the frustrations from caregivers and patients.

    Thank you for posting and for not being afraid to be bold in speaking out for change that will enhance patient care.

    Live Beyond Awesome.
    Twitter: @TheJenMcDonough

  • Charity Singleton

    This is a great article. What I see missing here is an integration between healthy care and sick care. In our culture, these two are entirely different. We go to doctors when we are sick, but we take care of ourselves 99% of the time when we are healthy without really seeing how the two are connected. Helping people understand at a very granular level that the amount of time they are sleeping, the food they are eating, the OTC and Rx drugs they are taking, the exercise they are or are not getting, the stress they are deflecting or absorbing – all the things patients control – is part of taking control of their healthcare. Having doctors participate through more integrated counsel in all of the ways patients live out their healthy lives will mean more cooperation and adherence when doctors speak to their sick lives, I believe.

    • davisliumd

      Good points!

  • Joel Selmeier

    The reason that patients are too reliant on doctors and don’t have the ability to make decisions is that they don’t have the information necessary for it to be any other way. There has not been an unprecedented access to the information that the patient community needs. There has been increased access only to the kind of information a med student would need to pass a test. The knowledge that patients and patient advocates need actually to be empowered is unavailable. They can find out more about a hairdryer they might buy than about the surgeon who is going to cut them open or the facility in which that will be done. Patients need objective information about success rates, not details about how to do the procedure.

    No one anywhere gathers OBJECTIVE information about success rates. That and the cost are the two most important things that a patient must have in order to be empowered and neither are available to patients. Try to find a primary care physician, or any other doctor, whose success rate has been monitored by an independent third party. Try to find a hospital that has tracked which nurse was present in 80% of their iatrogenic infection cases.

    This information is not known because it is not in the interest of medicine to know it. That is the root of the problem – that conflict of interest. Doctors cannot lead the change because it is not in their interest.

    Among the self-serving beliefs cherished by members of the medical profession is the idea that the well-being of patients is their highest priority. No matter how much knowledge doctors have, medicine run by them always has been and always will be unreasonably dangerous because of their conflict of interest. They are not airline pilots who go down with the plane. They are brokers with no skin in the game. Brokers with no skin in the game got us the mortgage meltdown and got us the kind of medicine we have. The well-being of caregivers is their highest priority, not the well-being of patients, no matter how much they persuade themselves of the opposite. They have to be there for the next patient, right? They cannot let any of their patients ruin their careers, right? There is no check on this.

    The medical community does not even keep track of the long term effects of its treatments in order to evaluate itself. I’ve never met an physician who had any idea of what happens to patients who get injured in medicine. They are not just ignorant of the world they create for their patients, they are in denial about it. Otherwise they would not be so confident about the value of their care and so out of touch with the downside of it.

    When patients have accurate information about who and what is effective and affordable, they will know better than to go where it is so unsafe and/or so expensive that they would be better off living with the illness than exposing themselves to treatment. When patients have the information necessary to choose to go to where it is safe and affordable, then the places that are not safe and affordable will have to change or go out of business. Until then physicians, with knowledge based more on rumor and self-interest than they ever will admit to themselves, will continue to send patients into harm’s way. That’s why medicine currently is our greatest source of unnecessary injury, death and personal bankruptcy. And it always will be that as long as caregivers are driving the change.

    Caregivers currently do not have the perspective to see this. If it ever is explained to them sufficiently to enable them to understand it, what they will understand is that they are only human and must accept they they are subjective and self-interested more than they can control, and so they must enable others to drive the change. That would start with enabling third parties to evaluate their success rates.

    The average consumer in the USA spends 12 hours doing research on cameras before buying one. Think how much they would do on the breast cancer treatments of their mothers, daughters, wives and themselves if the information were available to allow them to understand which treatments worked how well and how often. Caregivers imagine they know the answers to that, and speak as though they do, but from one to the next their recommendations are in disagreement, because no one currently tracks that information objectively. So patients do not have the ability to make informed decisions.

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