Many years ago, I went to business school to learn the language of business. I did learn that language and can talk about EBITDA as well as the next guy. I also learned a different way of thinking than the method of thinking I learned in medical school. I worry now that, as we attempt to have doctors be more like business people, we may lose a central ethic of medicine – the focus on the individual in need who sits in front of you rather than the population you serve.
I was a busy practicing doctor when I decided to attend the Northwestern University Kellogg School of Management in the 1980s. I was trying to understand the language of budgets, strategy and planning that I found myself discussing at meetings I attended as part of my various roles in the hospital, in national health policy meetings I attended, in the insurance industry and in government. I knew that in medical school, while I had not learned to “be a doctor” I had learned a way of thinking and a language that was needed in order to truly gain the experience to become a physician. I went to business school to learn the way people in management thought and to learn their language. I say their language because I never planned to be in that world; rather I planned to stay a practicing doctor while being more effective in the business and policy meetings I attended.
A Yiddish proverb states, “Der mentsh trakht un Got lakht” which loosely translates to “Man plans and God laughs” and so it was for me. I planned to stay in the practice of medicine and have found myself for the past twenty-five years instead in the world of business and management. I never forgot however, the single patient viewpoint and went into the management world believing that I had to be the voice for that single patient who could easily be lost in the reams of data and trends that are part of the business and policy world.
The challenge of applying a management way of thinking while also thinking like a doctor was exemplified by three articles published recently. An excellent article entitled “What is the Right Number of Clinic Appointments” by Ishani Ganguli, Jason Wasfy and Timothy Ferris from Harvard Medical School started my thoughts racing to the difficulty of attempting to improve systems while keeping the individual patient at the forefront. I know that this group at Massachusetts General Hospital has been a strong voice for excellence in primary care for many years. In the article the authors make an argument for optimizing office visits and comment on the savings that could be generated by Accountable Care Organizations if guidelines were followed for return office visits. They suggest that even though the United States has low visit rates by international comparisons, the rates may still be too high. They suggest more studies comparing scheduling data to individual disease diagnosis and treatment guidelines in order to examine variation in clinician-specific follow up rates. They do put in the perfunctory statement that “of course individual clinical judgment should always inform the frequency of visits” as a safety valve. However I find that a bit disingenuous. We know that doctors who deviate from the guideline norms are at risk for lower pay and at risk of being labeled a “bad doctor.” The scarlet letter of deviating from guidelines can inhibit seeing patients more frequently even when that is needed for optimal patient care. The authors, while thought-leading physicians, are only applying population analytics – a management approach – rather than incorporating the medical approach that requires addressing the unique needs of each individual.
“The Ethics of Patient Care” by William T. Branch, another excellent voice in primary care ignored the population/management approach and focused on the individual human needs one is supposed to learn in medical school. He describes the need for “small acts of kindness during the course of caring” as an ethical requirement of medicine. He goes on to say, “For the physicians, mastering these skills required no less effort than mastering medical science. Keenly observing patients’ emotional concerns, responding appropriately and always compassionately and respectfully, and listening attentively to patients requires years of willful practice before becoming habitual.” He speaks of the “moral mandate” of physicians, and I would add of all health professionals, that should inform the “whole of a physician’s work. “ Dr. Branch speaks from a medical, not a business and management perspective and ignores the challenge of limited resources in our healthcare world.
We then have the business perspective and the medical perspective. Both are valuable. How do we reconcile them? The article written by Dr. David Shaywitz entitled“Lowering Health Care Costs Is Hard Because Every Patient Is Unique” addresses this dilemma. He notes that people, who have the misfortune to be patients, often have their own ideas of what they want from their relationship with a health professional. If, in outcomes studies we only look at the pure physiology, we miss the outcome desired by the patient. This is especially true in outpatient, office medicine. Dr. Shaywitz asks, “Will value scientists ultimately capture or obscure what most patients seek from their physicians?” He finishes his article by stating that the answer will “require the ability to embrace the messiness of disease and the complexity of patients, rather than providing idealized solutions that impress in the boardroom but flop in the examination room.”
Most studies of variation and optimizing care focus on single disease states. In the article by Ganguli, Wasfy and Ferris they take this approach of focusing on guidelines for visits related to single diseases and use the example of stable angina. They do not account for the messiness of people who have multiple illnesses, multiple risk factors, complex work lives, complex social structures, and emotional fragility. The “messy patient” (from an analytic point of view) is often more the norm than the idealized single disease patient. In my own experience, I am always struck by the broad variation in disease even before one entertains the context of a person’s life. In one study we recently did at Accolade, looking at one company of approximately 50,000 covered lives, we found that the top twenty-five diagnoses only accounted for 57% of the total medical costs. The list of all diagnoses for this relatively small number of people ran into the hundreds. It turns out that the uncommon, in aggregate, is common in medicine. When you add in the life context of the person, the individual variation is immense. Into that cauldron of variation, a good physician must also be looking for the unlikely event that may not be seen on a trend line or in a data report that can be of high consequence to the patient.
Unless we are more attuned to the language and particular challenges of medicine, within the business and public policy world we will develop solutions that do flop in the examination room. Those types of idealized solutions will ultimately lead to failure in the business and policy arenas as well. Solutions must work for the complex individuals who become patients in order to be successful for millions who need care.