Transcript The Future of Medicine: A Case for Optimism & Hope

The Future of Medicine: A Case for Optimism
& Hope
Kent Bottles, MD
Vice President/CMO, Iowa Health System
Mississippi Hospital Association
[email protected]
Health Care’s Future
• The Past
• The Present
• The Future
The Past
Roy Porter
“From the Greeks to the first World War, its
tasks were simple: to grapple with lethal
diseases and gross disabilities, to ensure live
births, and manage pain. It performed these
with meagre success.”
Oliver Wendell Holmes (180994) Harvard Medical Professor
“I firmly believe that if the whole materia
medica, as now used, could be sunk to the
bottom of the sea, it would be all the better
for mankind – and all the worse for the
fishes.”
Father of Marion Sims, MD
“If I had known this I certainly should not
have sent you to college. It is a profession
for which I have the utmost contempt. There
is no science in it. There is no honor to be
achieved in it; no reputation to be made.”
Father of S. Weir Mitchell, MD
“After a while my father more distinctly
insisted on a choice, and I at last decided to
be a doctor, much to his disgust.”
AMA Report in 1851
• Survey of careers of 12,400 graduates of top
eight colleges in USA
• 26% clergy
• 26% law
• 8% medicine
• The proportion going into medicine was
lower among honors students
Charles W. Eliot
“The ignorance and general incompetency
of the average graduate of American
Medical Schools, at the time when he
receives the degree which turns him loose
upon the community, is something horrible
to contemplate. The whole system of
medical education in this country needs
thorough reformation.”
Hospitals
• Civilization has not yet reached “that state
of perfection where hospitals can be
dispensed with.” Dr. Wylie of Harvard
• Hospitals/Almshouses for poor who did not
fit into system of family care
The Present
John F. Welch, GE CEO
“If you’re not confused,
you don’t know what’s
going on.”
Change
“Change has changed – it has speeded up
and leads to a sickening anxiety (think of
the hapless passenger stuck in the back of a
taxi driven by an unblinking maniac). To
fall behind is to risk humiliation, loss of
status, poverty.” David Remnick The New
Yorker
Dissatisfaction with Medicine
• $27 billion a year for alternative care
• 48 percent of Americans in 2004
• They do not care that:
– Little scientific evidence that these treatments work
– Training is less for these healers
– Vitamin and herb companies are as profit driven as
pharmaceutical companies
New York Times, February 3, 2006
Dissatisfaction with Medicine
• Patients feel disappointed and betrayed by
physicians and hospitals
• Conventional medicine’s shortcomings:
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Misdiagnosis
Drug reactions
Failed surgery
Dismissive doctor
Confusing system in a hospital
Dissatisfaction with Medicine
“I think there is a powerful element of
nostalgia at work for many people, for
home remedies…People look around and
feel that the conventional system does not
measure up, and that something deeper
about their well-being is not being
addressed at all.”
Dr. Linda Barnes, medical anthropologist
Dissatisfaction with Medicine
“I think there is a powerful element of
nostalgia at work for many people, for
home remedies…People look around and
feel that the conventional system does not
measure up, and that something deeper
about their well-being is not being
addressed at all.”
Dr. Linda Barnes, medical anthropologist
Diane Paradise with recurrent
Hodgkin’s Disease
“They were giving me no guarantees; they
said it was experimental. That’s when I
started looking around…I had absolutely no
scientific reasons for choosing this route,
none. I just think there are times in our life
when we are asked to make decisions based
on our intuition, on our gut instinct.”
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The Future
Bran Ferren (Paraphrase)
“Trying to predict the future of healthcare is
like asking the Wright brothers at Kitty
Hawk if they were aware of the potential of
American Airlines Frequent Flyer Miles
Program.”
The problem with experts
• “One would expect experts to have reliable
information for predicting change and to be
able to utilize the information effectively.
However, expertise beyond a minimal level
is of little value in forecasting change.”
• “No matter how much evidence exists that
seers do not exist, suckers will pay for the
existence of seers.” Armstrong
The problem with experts
Shanteau: between-expert agreement is
below 50%
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Stock picking
Livestock judging
Clinical psychology
Pathologists making surgical pathology
diagnosis of some malignant tumors
– Olympic gymnastics judging
The problem with experts
• No expertise in broad fields: decision making,
policy, strategy
• Expertise is not fungible
• Thomas Watson of IBM (1943): “I think there is a
world market for maybe 5 computers.”
• Harry Warner (1927): “Who the hell wants to hear
actors talk?”
• 1984 to 1999: 90% of fund managers
underperformed Wilshire 5000 Index
Environmental Overview
• Quality
– Deaths
– Over- Under- Mis-use
– 55% of indicated care
• Demographics (44 m)
• Disparities: racial,
ethnic, socioeconomic
• Variation in practice
• Threats to health
• Disruptive
Technologies
– Medical
– Information technology
• Move to transparency
Root Cause Analysis – Key
Drivers of Health
Driver
Definition
% Contribution
Behavioral Choices
Diet, physical activity, sex, substance
abuse, stress.
40%
Genetics
Genetic make-up that creates a predisposition to certain illnesses.
30%
Social Circumstances
Education, employment, income, poverty,
housing, crime exposure, social
cohesion.
15%
Medical Care
Access to and quality of medical
treatment.
10%
Environmental Conditions
Exposure to toxic substances, pollutants,
accidents and infectious diseases.
TOTAL
5%
100%
(Source: “The Case for More Active Policy Attention to Health Promotion”; McGinnis, Williams Russo; Knickman); Health Affairs,
Vol. 21, No. 2, March/April 2002)
Approaches That May Help
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Highly reliable organizations
New understanding of feedback
New understanding of conflict
New understanding of transparency
Uncertain, Changing Environments
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Professor Karl Weick
Organizational behavior and psychology
University of Michigan
How to “manage the unexpected”
Does not involve predicting the future
“Highly reliable organizations” that are
“mindful”
Highly Reliable Organizations
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Focus on failures and learn from them
Do not simplify the complex
Hyperaware of operations and surroundings
Build in resilience to keep errors from cascading
out of control; errors fixed before become disaster
• Distribute decision-making up and down
• Make sure there is not group think
• Diversity of opinion, not just the boss’ ideas
Feedback
D Stone, et al, Difficult Conversations, 2000
“Delivering a difficult message is like
throwing a hand grenade. Coated with
sugar, thrown hard or soft, a hand grenade is
still going to do damage…And keeping it to
yourself is no better. Choosing not to
deliver a difficult message is like hanging
on to a hand grenade once you’ve pulled the
pin.”
Feedback
“If we try to avoid the problem, we’ll feel taken
advantage of, our feelings will fester, we’ll
wonder why we don’t stick up for ourselves, and
we’ll rob the other person of the opportunity to
improve things. But if we confront the problem,
things might get even worse. We may be rejected
or attacked; we might hurt the other person in
ways we didn’t intend; and the relationship may
suffer.”
Gary Klein’s Master Coaches
G Klein, Intuition at Work, 2003
• Do not jump right in with advice
• Assess situation from other’s point of view
• Joint conversation about how the situation
looks from multiple points of view
• Create a context for all parties to learn
Klein’s Firefighter Captain
“The firefighter explained what he was
trying to do, and the captain realized it
made sense. Just because it wasn’t what the
captain expected didn’t mean it was stupid.
The captain explained why he expected a
different strategy, and described its
advantages, but acknowledged the strengths
of the strategy the man had used.”
Klein’s Firefighter Captain
“‘And you know what?’ the captain told us,
in the third workshop session. ‘We’ve been
okay ever since. That firefighter didn’t have
an attitude problem. I was the attitude
problem.’”
Ben Zander, Mahler’s 9th,
Philarmonia Orchestra of London
• Conductor notices violinist is playing well, but is
slouched, and appears indifferent
• Violinist comments that bowings are faulty
• Zander reworks bowing and during performance
notices violinist is impassioned, totally enraptured
• The player who looks least engaged may be the
most committed member of the group
• A cynic is a passionate person who does not want
to be disappointed again.
Conflict
Parker Palmer, The Courage to Teach, 1998
“Conflict is open and sometimes raucous but
always communal, a public encounter in
which it is possible for everyone to win by
learning and growing…Conflict is the
dynamic by which we test ideas in the open,
in the communal effort to stretch each other
and make better sense of the world.”
Evaluate 2 Dimensions of Conflict
Michael Roberto, Why Great Leaders Don’t Take Yes for an Answer, 2005
• Affective Conflict:
– How much anger over decision
– How much personal friction in group
• Cognitive Conflict:
– How many disagreements over ideas
– How many differences about content of
decision did group have to work through
Insufficient Candor
• Meetings like golf, not
hockey
• Planning focus on
producing reports
• CEO rarely gets
feedback from ranks
• Concern for protocol
across silos
• Workers wait for CEO
before giving opinion
• Same people dominate
decision making
• Sr. management
rubber stamps
• CEO rarely hears from
presenter re criticism
JFK’s Changes After the Bay of Pigs
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Abandon protocol & deference to rank
Skeptical generalist not silo representative
Included lower rank & outside experts
Subgroups to develop plans
Bobby & Sorensen play devil’s advocates
President did not attend early meetings
Work product: arguments for alternatives
Klein’s Pre-mortem
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Imagine complete failure after a decision
Brainstorm different paths leading to failure
Identify probability and severity of paths
Should we make a different decision
Plan to prevent paths to failure
Summarize learning & communicate
Conduct post-mortem & compare with pre-
Evaluate Health of Debate
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Few questions to better understand others
Group stops searching for new information
Members have stopped revising proposals
People have stopped asking for help re data
Same argument repeated more loudly
Stopped admitting concerns about own idea
Less outspoken members withdraw
Transparency
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Internet provides same information to all
Public skeptical of experts
Blogs
Buying a car
Hotels.com
Aetna transparency of physician charges
Transparency in Healthcare
• Class action lawsuit against Virginia Mason
for $1,133 bill for cutting a toenail
• WSJ article: “Angry Patients Vent Online;
Doctors Sue to Silence Them”
• NY Times article: FDA, company knew of
heart device defect
Transparency
• California law: hospitals have to reveal
chargemaster accounts
• HSA consumer driven plans transparent
websites with costs & outcome data
• Medicare reveals outcome data for hospitals
on treatment of MI, CHF, pneumonia
New Tools for Patients to Price
Healthcare WSJ, June 13, 2006, D1
• Aetna: Cincinnati pilot to expand in August
• UnitedHealth: negotiated rates with dentists
• Cigna: cost ranges for CTs, MRIs, PET
scans in New Hampshire, Wichita
• www.floridacomparecare.gov;
http://hospitalpricing.sd.gov;
www.wipricepoint.org
New Tools for Patients to Price
Healthcare
• Medicare: payments to hospitals for 30
common procedures
www.cms.hhs.gov/HealthCareConInit/01_O
verview.asp
• Drug Cost Information:
www.myfloridarx.com;
www.destinationrx.com
Transparency
• Renton, Washington based Valley Medical
Center proposal to extend its public hospital
taxing district to Maple Valley, Black
Diamond was voted down by 94%
• Valley Medical Center’s initial ballot
proposal left out fact that a yes vote would
lead to taxes to pay for the hospital
The Check Is Not in the Mail
Milt Freudenheim, NY Times, May 25, 2006
• www.athenaPayerView.com
• Rejection of claims by insurers
– Aetna rejected most with 14%
– UnitedHealth rejected more than 10%
– Wellpoint rejected more than 10%
• Number of days between service/payment
– Humana: 29 days
– Champus/Tricare: 41.4 days
Enron
• “This fuels the government and boards and
investors to continue to push for more
accountability, more transparency and better
management.” G. A. Stamboulidis in New
York Times, 5/26/2006
• Ken Lay: 10 counts guilty
• Jeff Skillings: 19 counts guilty/ 9 not guilty
Philadelphia Inquirer May 22, 2006
• Hospital Infection data low: too low?
• Local rates are far below the rest of Pa.
Experts fear underreporting, saying it only
hurts patients
Transparency vs. Accountability
• Negative feedback
before or during a
decision
• Negative feedback
after a decision