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.
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