I think you know what a pleasure it is for me to be here to deliver the Ralph Alley Memorial Lecture. Unfortunately, I did not know Dr. Alley. But I do know from his friends and colleagues that my topic, "Medical Leadership and the Future of Health Care" is an appropriate tribute because he was a very special kind of leader: more interested in contributing to his profession than to his personal prominence; deeply concerned with the future by advancing the careers of young people, and with an unusual capacity to engender loyalty through deed as well as word. In talking about medical leadership to this audience, I am in danger of preaching to the choir. Of all the specialties of medicine, Thoracic Surgery is one that has a most legitimate claim to leadership. It is your specialty that represents leadership in medical technology, the defining characteristic of American medicine. Yours is a specialty that involves exquisitely choreographed teamwork to achieve truly astonishing clinical results with equally astonishing reliability, thanks to your leadership of those teams. And my being here this morning reflects your leadership in seizing the future by educating your members in health policy, through the partnership between the Foundation for Thoracic Surgery Research and Education and the Harvard Division of Health Policy Research and Education. That course, and I personally, have benefited from the leadership of Jack Matloff, Hal Urschel, Martin McKneally, and an outstanding group of your members who have made the exceptional commitment to take the course. Actually, there is little danger of preaching to the choir, for this talk will not be about leadership in familiar domains, but rather a much more uncomfortable kind of leadership that may--in fact must--upset the apple cart of medical practice. I will be talking about leadership to develop new forms of medical practice. and new systems of care. I think new forms, created and led by physicians, will be necessary or else health care of dubious quality will continue to be bought and sold like cornflakes. To explain what I have in mind, I will talk about the present system, offering a diagnosis based on signs and symptoms of what I see as its illness. I will discuss the pathologic physiology of this condition, related to a profound, chronic disorder of accountability--a type of stress disorder, secondary to the advance of medical technology. Finally, I will offer therapeutic recommendations, some of them in the category of tough love, that for some will be a ratification of what they are already doing. With that, let me begin: We all know that we are experiencing an exhilarating rush of technological innovation--what has been termed an advanced state of technical arousal--that is profoundly affecting our lives. From the laptop in our briefcases to the perfect landing of a fly-by-wire Boeing 777, we are all beholden to the ubiquitous microchip. That intoxicating rush of technological innovation is nowhere more apparent than in American medicine. After all, it is our defining characteristic, historically and globally. What is not widely appreciated is the extent to which our mode of practice has failed to keep up. What we do for patients is vastly different from what it was 40 years ago; how we do it has changed very little. Let me give you an example of what I mean. Suppose that in this year, 1999, we were to place on the bridge of a modern cargo ship, the captain/owner of a sailing vessel from the 1830s. How would he react? I suspect that he would be both confused and unable to function. There would be no masts or sails, the ship would be a great deal larger than his own vessel and he would be on a bridge that looked like an office. There would be no steering wheel, no binnacle and compass, only banks of computer terminals, switches and dials. One of the (only) two officers on watch would be sitting in a comfortable chair alternately looking out the forward windows and at a radar screen swept by a green line leaving occasional smudges. Occasionally a buzzer would sound, the officer would consult a dial that resembled a clock, and would turn off the buzzer by flipping a switch. Soon the ship would begin, by itself, to alter its course, responding, our resurrected captain would be told, to the autopilot directed by the Global Positioning System on a course programmed into the system months before. He would be surprised to learn that the ship was not owned by the modern captain, and he would be even more surprised that that captain was keeping in touch by radio and by computer with managers in a large company that did own the vessel. He would be amazed at the low cost of carrying cargo, that the ship was on a regular schedule, that it could reach Europe in less than a week, and that it was extremely safe, thanks to electronic navigation, fire detection systems, and advanced steel construction. While he might be confused at the office-like ambience of the modern bridge, he would probably not miss the uncertainty and sheer physical terror of voyaging under sail. A physician from the 1830s, placed in a modern physician's office would not be nearly so lost. The surroundings would be generally familiar--a waiting room, an office, an examining room. Asked to see a patient, he would take a history, starting with the chief complaint, do a physical examination not dissimilar from a modern one, and he would consider various diagnoses. Here he would begin to founder, although it is likely that he would at least be in the general area of the affected organ systems. When it came to diagnostic tests, more elaborate diagnostic possibilities, and consideration of therapies, modern technological medicine would take over, and our 1830s physician would be as much at sea as his seafaring contemporary. He would be at home, however, with fee-for-service payment, although he would be as outraged as we are at having to plead with a utilization reviewer. It is not surprising that our mode of practice, what Paul Uhlig has termed the "social architecture" of health care has changed so little. Healing, after all, has been a function in every society, and its history is the history of the human race. Although healers have always had some technology, medical science is at most 450 years old since Vesalius set us on an empirical course by anatomical dissection. And it is only in the last 60 years, since the invention of antibiotics, that technology has been sufficiently complicated to challenge the traditional model of practice. Medical technology has had to shoulder its way into the much older relationship of healer to patient, and it has not been an easy task. One of my colleagues at Harvard turned up with a 1959 issue of Life magazine in which the lead story was based on public lament about the way in which modern medical technology was destroying the personal relationship between physician and patient. Doctors, it charged, were more interested in exotic diagnostic tests and complicated treatments, than in knowing their patients as people. Now, of course, there are signs that we have the opposite problem: that medical practice, as presently conceived and organized, is having some difficulty in applying consistently the most modern technology and best practices to the care of a surprisingly large number of patients. The data to back that unpalatable assertion come from recent studies of three areas: practice variation, patient safety and quality of care. Dr. John E. Wennberg of Dartmouth Medical School, for example, has demonstrated wide geographic variation in care of women with breast cancer. The decision to use lumpectomy vs mastectomy seems to be based more on regional patterns of practice than either best practices grounded in research or the personal preference of patients for one or the other form of treatment. (1) Another line of research--studies of patient safety and medical error-- raises somewhat different concerns about traditional modes of practice. Lucian Leape , extrapolating from reviews of hospital charts, estimates that 180,000 patients each year die partly as a result of medical errors. (2) That is the equivalent of three jumbo jet crashes every two days! Many physicians are skeptical that things are that bad. But even if Leape is exaggerating three-fold, that is still the equivalent of one jumbo jet crashing every two days. Is that really a lot better? The medical errors Leape discusses include missed diagnoses, failure to treat promptly, drug overdoses, giving the wrong drug, and failure to get a follow-up culture to check for antibiotic resistance when the patient does not respond to treatment. Even though errors occur in as few as 1% of the many events that happen to a patient in the course of an illness, this is a much higher error rate than is tolerated in many other industries that apply technology to human safety and welfare. As Leape points out, commercial aviation, nuclear power generation and naval aviation have all been successful in vastly improving the safety of their operations. And what these other industries know about error prevention--which is a great deal--could help us do a much better job. The problem is twofold: first, our certainty that information from other industries does not apply to us (a response typical of threatened industries) and second, our reliance on a system of care that assumes that doctors can practice safely and at the highest standard if only they are sufficiently intelligent, well trained, and conscientious. As a result, we have not made use of a considerable body of findings from human factors research that demonstrate that human error is inevitable, but can be minimized or prevented by creating systems around individuals that make it much more difficult or even impossible for them to make mistakes. Medicine is thus very different from other high hazard professions--piloting airplanes, running nuclear power plants--that rely heavily on the simplification and standardization of processes, and on a variety of technological aids to improve the safety of their work. We tend to reject such solutions as "cookbook medicine" that violates our professional autonomy and fails to take into account the fact that each patient is different. Finally, there is deep concern in some quarters about the quality of care that is actually being delivered to our patients. Two recent studies reported in JAMA found that 21% of all antibiotic prescriptions given to children and adults in 1992 were used to treat colds, respiratory infections and other conditions for which antibiotics are ineffective, risking adverse drug reactions and increasing antibiotic resistance. (3, 4, ) Another study, also reported in JAMA, studied elderly patients who had suffered myocardial infarction. Seventy-nine percent of them had not received Beta-blockers. Over the next two years, this group had a 75% greater death rate than those who had received the medications. (5) A recent consensus report of the Institute of Medicine titled "The Urgent Need to Improve Health Care Quality" reviewed many of these studies. (6) The report identified three categories of quality problems. The first was underuse: failure to immunize 100% of children, or prenatal care begun too late to prevent the complications of pregnancy would be examples. (Contrary to expectations, a number of the studies cited by the report found that underuse was more common in fee-for-service than in managed care plans.) Misuse, the second category, involves injury from the preventable complications of treatment and is related to medical error. The report cites research indicating that there are, on average, 2,000 patient injuries per year from the administration of medication in each large teaching hospital studied. Twenty-four percent of these injuries were preventable, and each of them added, on average, almost $5,000 to the cost of the hospital stay during which it occurred. (7) The third category, overuse, was also found to be common. The report comes down hard on the inadequacies of the system of care that I have identified: "the burden of harm conveyed by the collective impact of all of our health care quality problems is staggering." And it goes on to sound the alarm of urgent need for rapid change . "Meeting this challenge demands a readiness to think in radically new ways about how to deliver health care services and how to assess and improve their quality. Our present efforts resemble a team of engineers trying to break the sound barrier with a Model T Ford. We need a new vehicle or, perhaps, many new vehicles. The only unacceptable alternative is not to change." Let me now describe some of the characteristics of our present system of care that seem to me to contribute to these problems. These characteristics relate to professional accountability, and reflect a compromise solution to an inescapable conflict between professional autonomy and accountability. Our present system represents such a compromise that was reasonable in a less technologically sophisticated era, but which, I am suggesting, may have outlived its usefulness. Organized medicine in this country has vigorously and successfully defended the autonomy of individual practitioners against threats from organized, corporate practice since at least the late 19th Century when large industrial concerns made forays into marketing their employee health services to the general public. Arguing the primacy of patient choice of provider, and the importance of an unfettered contract between doctor and patient, the American Medical Association fought off a series of later government attempts to organize practice, ending with its successful campaign to defeat Harry Truman's program by labeling it "socialized medicine."--an effective ploy in a rabidly anti-communist era. It was only the political power of senior citizens that defeated the AMA's opposition to Medicare in the mid-1960s. (8) In the system we are used to, we are trained and acculturated to feel that we own our professions. In a sense, we temporarily rent that profession to patients when we enter into the duty of care. In turn, we rent facilities, or perhaps more accurately we are squatters in facilities like hospitals, clinics, or even health systems, in order to care for our patients. But at no time do we turn over our profession to another entity than ourselves. There is a double rationale: First, we feel we need continued ownership so that our patients can trust our fidelity to our duty of care, unfettered by outside liens, so to speak. We promise a clear title to our services (to muddle the metaphor a bit.) Second, we need to have the autonomy conferred by ownership in order to respond to the individual variability of patient needs. We must be able to assert that no contract or set of directions binds our freedom to respond to individual variations in what patients require. This system has certainly been highly satisfactory from our point of view; it makes the practice of medicine one of the few human activities, other than the arts, where there is great technical autonomy to do what one thinks is right without a lot of argument and negotiation. Accountability in this system is almost all internal, which means that it is actually very little. Of course we are responsible to our professional societies, to state licensing boards, and to malpractice lawyers. But most of the time that accountability only turns on when we are already in trouble. We are also accountable to our patients for the elements of care that patients can judge. That too is significant, but does not really touch the middle ground between palpably bad care with bad outcomes, and the top ranks of care measured by true medical miracles. The downside of this arrangement from the point of view of society, is the flip side of what makes it attractive to us--namely that there is very little external accountability. Or at least that was the case until very recently. There are a number of areas in which we have been spared external accountability. The first is fiscal accountability. The traditional definition of duty to the individual patient was that we should prescribe everything that might be helpful. That meant that we were not supposed to consider costs in rendering care. But as costs have increased, we have discovered that we have been spending money for which other people are accountable. Those other people are the purchasers of care--self-insured employers, Medicare and Medicaid agencies --and their agents, the payers for care--insurance companies, managed care companies, etc. When you are spending money for which other people are accountable, you should not be surprised if they insist on influencing how you are spending it through various controls on utilization. (9) And they should not be surprised at the rancor that their often uninformed decisions arouse in people like us, whose tacit expectation was that they would be free of external constraints in caring for their patients. The second external accountability that we have avoided is the need to demonstrate the quality of what we do to some outside group. The traditional system located quality in the values and the professionalism of the individual practitioner. When there was less to know, and less to know how to do, that system worked pretty well. In our current era, marked by a deluge of new knowledge, new technology, and new demands on our time, including new demands to be fiscally accountable, the system has serious limitations. And we have had precious little help in being accountable for quality. Until recently, there have not even been the aggregate data represented by studies of practice variability and prescribing patterns to help us determine how we compare to others. It is only recently that specialty board recertification has been a requirement, and it is important to note, that in comparison to some other hazardous industries, board certification and recertification have no legal standing. To place our traditional system in some perspective, let me give another far-fetched example. Suppose the airline industry were organized in the same way as health care. Pilots would be free to choose the kind of aircraft to fly, the routes to take, when to take off, and when to land. They would be allowed to use aircraft by companies that owned the planes in return for the company collecting a fare from the passengers for the trip. There would be no requirement that pilots be certified on the latest aircraft, or be forced to file a flight plan. After all, every day the weather is different, and there is subtle variation in the performance of the aircraft. How could anyone fly by some mandatory cookbook or checklist? The pilot would bill the passengers directly, citing the importance of preserving the bond of trust between them. If you as a passenger were planning a trip from San Antonio to New York, you would ask your neighbors, business associates and travel agent to suggest a pilot who had a good reputation for flying that route. You would be interested in the pilot's on-time and safety record, but would likely be somewhat frustrated because the Airline Pilots Association insisted that some routes and some airplanes were more difficult to fly and therefore the data were not representative of the actual skill of the pilot. Do I have any takers for this arrangement? The point is that, like pilots, we hold peoples' lives in trust based on our skills, our capacity to keep up with medical knowledge and technical advancements. Yet surrounding our profession there are few of the safeguards of quality and performance that protect us when we fly. The result is absurd conversations in which well-meaning, worried representatives of medicine talk about how to influence the culture of medicine to ensure the performance of physicians, other health professionals and health care institutions. Should the outcomes of all physicians' work be made publicly available as are those of cardiothoracic surgeons in some states? Can technology be harnessed to assist in the process? Or does the answer lie in a rearrangement of economic incentives to ensure quality and safety? You may remember that once upon a time, not too long ago, managed care was supposed to take care of many of these problems by ensuring system coordination, compliance with standards of quality, as well a reduction of cost. Unfortunately, the implacable dynamics of market forces has dimmed that rosy picture. In fact, it can be argued that managed care as currently implemented, has made all of those goals demonstrably worse, because managed care has not really restructured the delivery of care, it has only laid on an additional complication. Many managed care companies, particularly those that are for-profit, keep a tight hold on financial risk because that is where the money is to be made. Through utilization review and paying providers discounted fee-for-service, they seek to reduce cost by a combination of restricting certain kinds of care and pushing productivity so that physicians are forced to cut corners on time spent with patients, waste time in justifying their work, and be constantly annoyed at the intrusion on their practices. Struggling with discounted fee-for-service leaves them with neither incentives nor time to restructure care to eliminate waste and inefficiency, nor do they have real incentives to get involved in prevention or disease management. Members of the public generally like their own plans, but deeply mistrust managed care in general because they are afraid that expensive, life-saving procedures will be denied if they need them. The industry, through its trade association, continues to profess high motivation to improve care and serve the public, but is implacably set against real accountability by fighting to defeat patients' bills of rights, external review of grievances, and legal liability for their decisions. Of course, to their credit, many of the not-for-profit plans do share financial risk with providers, have effective grievance mechanisms, and offer programs of prevention and disease management. Nonetheless, in general, managed care has failed to fulfill its promise as an approach to improve the delivery system. It is time to move on from diagnostic assessment to some treatment recommendations. In doing so, I will act more like a surgeon than an internist or a psychiatrist, by boldly suggesting a course of action without all of the facts that might help with the decision. First, I think that we must recognize the real source of our problems. That the traditional delivery system has failed may be more a matter of historical inevitability than simply a result of out of control costs, or even the perverse imposition of market forces on a public good. Technological change has always driven profound social and economic dislocation. It was the swiftness of the Viking long ships that extended their reach from Newfoundland to India. It was the English longbow that defeated the French knights at Agincourt and ended the military dominance of the nobility. And it was technological breakthroughs in the early 19th Century that made inevitable the replacement of individual producers of goods and services by large industrial enterprises that could take advantage of new technologies in ways that small producers could not. (11) Until about 1840 in this country, there were no corporations in the modern sense. Small, independent entrepreneurs who operated what they owned conducted all business, both manufacturing and commerce. They might be small manufacturers, store owners, ship captains who owned their vessels--the story was the same: there were no managers who were paid to operate businesses that other people owned. The distribution of goods was accomplished by market transactions between these independent owner-operators. Some of them were agents, supercargoes, or general merchants who took possession of the goods on their way to the final destination, but none of them were employees of large enterprises; all of them were independent entrepreneurs. The picture changed dramatically around 1840. By then, cheap coal from newly developed anthracite mines in Pennsylvania had made it possible to develop factories with steam-powered machines that could turn out large quantities of high quality goods much less expensively than could the cottage industry of owner-operated workshops. These factories began to hire large numbers of workers and a few managers to deal with the much more complicated factory technology. Steam engines, powered by coal, created the railroads, which replaced low-tech canal boats and horses and wagons. Because railroad trains were complicated to run safely at high speeds, the railroads had to set up tables of organization, job descriptions, memoranda, and the other paraphernalia of administrative hierarchy, becoming the first truly modern industrial organizations. They also created a new group of professionals -- paid managers who typically made a lifelong commitment to their companies. In moving work outside the home, this technological revolution brought about a social and economic revolution, and created the world as we know it. I think it is arguable that the technological revolution in medicine is driving a similar economic and social revolution in the way we deliver care, replacing individual practice with larger, more organized systems. A symptom of the need for such a revolution is the lack of accountability that our traditional medical system--a kind of cottage industry--suffers in bringing the new technology to the care of patients. In these terms, cost containment through managed care is an inadequate attempt to deal with the lack of fiscal accountability, which is another symptom of the need for reform in the delivery of care. Arguing by historical analogy, dangerous as that is, it may be that what lies ahead inevitably is more organized systems of care, which, I feel, must be created and led by physicians. Only a few years ago, that statement would be little more than a pious hope, or wishful thinking. Now the situation is quite different; we have had a ten-year experiment in the management of health care by non-clinical leaders, and that may be enough to convince us that there must be a better way. Moreover, many, although not all physicians understand where we are, and are rapidly gearing for battle to recapture health care. The Thoracic Surgery Foundation education program is an immediate example; in addition, all across the country, physicians are enrolling in MPA, MBA, and non-degree management programs in record numbers. They are finding these programs intellectually stimulating and solid preparation to play their part as leaders. Having recognized the situation, what principles should physicians consider in transforming the delivery of health services, including medical services? First, and perhaps most important, we must transform our approach to our health care organizations. We must nurture them as the instruments of good care rather than as platforms to support professional virtuosity. In their important study, entitled "Built to Last" two Stanford University professors, James Collins and Jerry Porras, identified the characteristics of 18 corporations that are widely regarded as the most outstanding business organizations in this country. (12) To tease out the nature of success they compared these corporations with corporations in the same industries, of approximately the same age, that were good, but not "visionary," the term they applied to their 18 exemplary companies. A startling finding was that the founders of Sony, Hewlett Packard, and 3M set their sights on creating great corporations, not great products, and especially not great profits. Their assumption, which turns out to have been correct, was that great products and great profits would follow naturally if they were successful in creating a great company. Instead of squatting uneasily and warily in our hospitals and health systems, we need to invest ourselves in them because in my view, it is only great health care organizations that can manage the new medical technology in the service of patient care. I had a first-hand brush with this issue recently. The evening speaker at a meeting of the Executive Session on Medical Error and Patient Safety at the Kennedy School was Paul O'Neil, the CEO of Alcoa. He was there because he has made worker safety the organizing theme for Alcoa. As one of Alcoa's 100,000 employees in 20 some countries around the world, you would have to work there for 700 years before losing a workday because of an accident on the job. His aim is to reduce the rate further so that you would have to work there more than 2,000 years before losing a day. Over and over, he slipped into his talk that he seeks to make a great company that engages the passion of those 100,000 workers through a host of measures, including worker safety. In terms of my focus on accountability, it is significant that early in his administration of the company, when an 18 year old worker was killed in an accident in one of the plants, O'Neil announced to his executive group, "We killed that young man, and we have to make sure that we learn from that accident." By that statement he held himself and his executives accountable for worker safety throughout the company. The result is that any time even one worker day is lost because of an accident in any plant, the accountable man |
