The 90/30 Conundrum: How To Change Medicine (If It's Even Possible)

Guest post by Aaron Schenone

Is it possible to change the healthcare industry?

I recently read an article entitled “Rebels at Work: Motivated to Make a Difference” a conversation with Lois Kelly. In her research she refers to the 90/30 conundrum where 90% of respondents agreed activating creative thinking can improve culture and drive innovation, yet only a third of those respondents were satisfied with innovative individuals’, the so called rebels, ability to provide that outcome.

Her research goes further defining these innovative individuals as creative, curious risk takers that aren’t driven by monetary gain, but by the ability to make a difference. They aren’t afraid to call out problems or be the first to do things differently. She also found people are uncomfortable with these individuals who challenge the status quo, circumvent the rules, question organizational leaders, and initiate projects without permission. Too often leaders react by throwing these habitual truants into the trapped box with the label “Rebel” on it.

It’s no surprise that innovative individuals gravitate to the world of entrepreneurship, starting their own organizations where they can create a culture that not only understands their purpose, but more importantly can provide an outlet for their ideas to make a difference in the world. We intuitively know some of these types of individuals such as Steve Jobs, and Richard Branson, but these individuals are in every industry and industry leaders are starting to recognize their value. People like Carmen Medina, former CIA Deputy Director of Intelligence, who supported the creation of a novel and dynamic approach to searchable actionable intelligence through a program affectionately called Intellipedia.

In medicine many of our innovative medical students and residents have had similar frustrations often being misunderstood and thrown into the trapped box with the label “Cowboy” on it. We feel misunderstood, locked out and all too often make an early exit from the very organizations and patients who need our ideas the most. I believe the 90/30 conundrum is a reflection on the challenges innovative people and organizational leaders have had in attempting to build trusting, productive relationships. It’s something that as innovative minded medical students and residents many of us have been battling since we sat in our first years of didactic lectures. We continue to ask whether actionable change is possible in such a large numbers driven industry.

Today, I believe it is possible to make actionable change in the healthcare industry. But to get there we must first gain the trust of our leaders. We must prove we’re not just cowboys without a cause; we’re passionate activists ready to drink H. Pylori to prove there’s a better way.

About: Aaron Schenone Third Year Medical Student in St Louis, studying clinical research in oncology

10 Ideas To Spark Health Care Change

What does the future hold for other industries? We can use these ideas as a springboard in our medicine culture.

A recent article from the online and print magazine Inc. titled: "10 Cool New Tech Ideas to Help You Market Your Business" showcases many innovative approaches that businesses are utilizing to engage their customers. While I think that these ideas are worth viewing from the marketing perspective, I think there is also great value in changing the perspective to view these ideas in terms of medicine and health care.

Specifically, how can we embrace these visionary ideas to help transform medicine towards a brighter future? Let's dive right in:

1) Facial recognition: imagine pulling out your iPhone or Android and taking a facial recognition photo and sending it to your doctor via your EHR platform. The software could read your facial expressions, wrinkles, and blemishes and compare this to a facial photo from 6 weeks or 6 months ago. Do you have difficulty sleeping (dark circles under your eyes), are you more stressed than usual (deeper wrinkle set) or are you getting too much sun (deeper skin blemishes)? The potential here is enormous.

2) Hyper Targeting: imagine being able to make recommendations to patients based upon pre-determined factors such as age, fitness level, diagnosis, medicine, supplements, etc. The software for this type of process already exists--we would just need to tweak it to make it work for health issues. So, patient Jane who shares characteristics with patient Mary could receive updates providing ideas for cooking, exercises, book choices, etc. This would not only personalize Jane's experience but also have the potential to improve her outcome as a patient.

3) Eavsdropping Apps: maybe we should rephrase this one as Preference Apps: allow patients to tell us about their lifestyle choices by what they focus on. Again, we could use the EHR as a platform where the patient would allow access to her smartphone apps, book, food, exercise preferences and we could then gain better insight into how the patient lives and walks. We could then make better holistic recommendations to her regarding all aspects of her life. As we know, health is more about our choices than anything else.

4) Augmented Reality: I have written about this before...I truly think that medicine and health will embrace the gaming of our society and incorporate virtual health/ medicine in a gaming type of structure. Doctors and patients will be able to interact in a meaningful way via a Sims like game-style approach. I'm excited to see this come to fruition.

5) Mobile: Codes and Spot Targeting: At first glance this one does not seem to fit into a future of medicine model, but I think we can be creative and start incorporating these Quick Response (QR) codes onto prescription meds and health related products. Maybe a patient can scan the code to learn about the side effects of medicine or be taken to a link to a forum where people are using this same medicine? Not sure, but there are many possibilities with this technology.

6) Video: the other day my kids and I were waiting outside in the car while my wife mailed some packages--we sent each other video texts back and forth to amuse each other while we all waited. We can do the same with patients--sending them quick, relevant and timely text messages could mean the world to them.

7) Incentives and Virtual Currency: we are seeing a thrust of different games and Apps that allow users to "win" points to be used elsewhere. We can do the same in medicine. We already see how well the Wii fitness games have pushed us in the same direction. We can take this several steps further where patients who play these games get points towards supplement purchases, coupons off medicines or office visits, etc. 

8) Social analytics: We need this in medicine to help us get a sense of how well we are reaching out to our patients/ clients. The faster we adopt the approach that seeks to reward physicians based upon how well they communicate with patients, the better. We have the tools for this, but are lacking in the will right now.

9) Web: this one is fairly obvious....we all have websites, but how can we interact with our patients better and make the web experience more valuable to each of them? This will be a perpetual challenge for time to come.

10) Deals: our patients are consumers and the sooner we create a practice environment that embraces this notion, the better. Who isn't looking for a deal? In medicine we tend to shy away from this mentality as we don't want to be too salesy, but the more confidence we have in the product we are selling, the less we are actually selling. In health and medicine we have been focused to acutely on the medicines themselves as the prescriptions, but the better product is the connections with our patients. So why not create better deals to help you connect with your patients?

I am sure that you can take these ideas and run with them in more expansive ways than I have. Change often occurs faster when we take advantage of "outsider" ideas and perspectives. We are all here because we are seeking much more than the routine medicine has shown us. These ideas can serve as a spark to help get you going. 

Healthcare Integration: Waiting For A Dr. Martin Luther King

Healthcare integration requires today what racial integration required on the 60's: strong leadership.

In one of our physician leadership training modules, we show the video of the 1963 civil rights march on the nation's capitol with the key note speech of Dr. Martin Luther King. It is easily accessible on youtube (search for "MLK's I have a dream").

The video has an incredible personal meaning for me. I remember watching the speech with my dad (he actually took the day off from work!) on our black and white RCA with its never quite focused rabbit ears, looking for faces in the crowd of friends whose parents allowed them to attend. Washington DC at that time was still very much a southern town and my overly protective parents were not willing to risk sending the center of their universe forth to do battle with the rednecks threatening to violently shut down the march.

Most physicians in our listening audience, however, while aware of the speech, have not actually seen or listened to it. (It is always a sobering task to ask for a show of hands from the physicians participants of those who weren't even born in 1963!) Their reaction, while not attached to personal memories of the speech, is no less profound. We then deconstruct the speech focusing on the qualities and traits of leadership. 

Racial integration in the 60's was recognized by the majority of Americans as the only way to fulfill the American principle of equality so eloquently stated in its Declaration of Independence. Integration's implementation, however, had a set of obstacles thought by most too difficult to "overcome". The separate but equal culture of American society had been in place for a hundred years. Federal versus states rights had a set of rigid borders resulting from verbal battle of our founding fathers and an intensely violent civil war. Racism was reinforced by legal statutes and conservative interpretation of Biblical scripture....

Fortunately we had a leader and he, as all great leaders, had a "dream"and the leadership skills needed for its fulfillment.

Healthcare integration is the only way to preserve the unique way healthcare is practiced in the United States in our present (and future) economic, demographic and political environment. ACO's and bundling of payments tied to outcomes and disease management are here to stay. Like the 60's and racial integration, we see the inevitability, but are focused on the obstacles too difficult to "overcome". Physicians are wed to autonomy and distrust group decisions, our reimbursement programs are perverse, our information technology is inadequate, patient care is complex and fragmented, regulatory statutes are difficult to change, ......

The time for racial integration was the 60's, the time for healthcare integration is now. The missing ingredient is a cadre of physician leaders with a "dream" and the leadership skills needed for its implementation.

Concierge Medicine, Social Justice & Sex at 100

Some of my medical colleagues who champion the cause of “social justice” bristle when they learn that I practice concierge medicine. 

They fervently believe that it is somehow more noble to practice Soviet-style medicine in America than it is to take professional responsibility for delivering excellent, individualized medical care to their patients.  One of the benefits of being sanctimonious about private doctors who practice in a capitalist model is that you can blame some of the crappy medicine you deliver on your benevolent, utopian system, which claims to be “fair” to everyone.  How convenient.  But what are the consequences of focusing on clinical algorithms, electronic medical records, and the forced “fairness” that comes down from the Politburo?

Today I saw a 99-year-old patient in my office who is on my indigent medical care program.  She pays me $5 per visit, just so that she’s got some skin in the game.  (Quiet…I don’t want my social justice critics to know that I actually see people who can’t afford to pay my concierge fees.)  This elderly woman has diabetes and has been in the ICU twice over the past year with urosepsis, on the sepsis protocol.  Last week she was taken to a local ER at a hospital where I do not practice.  She had a recurrent kidney infection, despite receiving rotating prophylactic antibiotics and intravesicular gentamycin given to her by an expert urologist.  I was never called by the ER physician, because I am merely the patient’s attending physician – a point that is irrelevant to most ER physicians, given that virtually every patient in the ER is now admitted to the “hospitalist team.” 

Instead of admitting this frail, 99-year-old diabetic for IV antibiotics and careful monitoring, the ER physician opted to treat her as an outpatient with generic Keflex.  This would not have been my approach, but I have to agree that it certainly was “cost effective.”  Fortunately, my patient survived this “UTI algorithm.”  The doctor also opted to treat her hyperkalemia with equal efficiency, giving her a single dose of oral Kayexalate, which she promptly vomited after arriving at home.  Luckily, she did not have a cardiac arrest from her hyperkalemia, especially in light of the fact that they did not bother to hold her ACE-inhibitor, which was contributing to her elevated potassium.

As my patient left the ER, the medical team dutifully handed her the ubiquitous, and always helpful, discharge instruction sheet.  This document no doubt met all hospital and governmental regulations for educating people about pyelonephritis and hyperkalemia.  Although my patient is legally blind and cannot read standard print, I’m sure she found this 4 page document very comforting.  More importantly, the purveyors of social justice can rest assured that they followed all of the guidelines set forth by the Politburo and did their duty to deliver the same level of care to everyone, regardless of income, ethnicity or social standing.   

Had my 99-year-old patient been able to read this information sheet, I’m sure she would have found it helpful to know that she should “refrain from having sexual intercourse until after all of her kidney infection symptoms had resolved.”  I don’t know about you, but there is nothing that irritates me more than seeing a non-compliant, centenarian who continues to have sex while being treated for an active pyelonephritis.  The only way to prevent these elderly nymphomaniacs from reseeding their genitourinary tracts is to put it in writing!

What we are now seeing is just the beginning of medicine by administrative committee.  If you think I am misusing the term “Politburo”, just wait until you see what happens under the Department of Health and Human Services in the name of ObamaCare.

The Disappearing Independent Physician

In a recent post I noted the trend among physicians to sell their practices to hospitals.

The recession coupled with the passage of the healthcare reform initiatives has pushed many physicians into simply throwing in the towel and walking away from the independent practice model.

This month in Smart Money is an article entitled Say Farewell to the Family Doctor.  It's an interesting read.

The articles continues the discussion about physicians becoming employees of hospitals and describes the impact this change is having on the physicians, patients, and the economics of medicine.  

I enjoyed the article, but the last paragraph really gripped me. Here it is:

Still, Mikell acknowledges, "doctors don't want follow-the-directions, cookbook medicine." And for many physicians, the idea of following new rules triggers a much larger unease at giving up their independence—a feeling of loss, both for the businesses they built and for their patients. Back in Bozeman, Blair Erb, the sole cardiologist in town, is a picture of resignation as he prepares to sign a contract with Deaconess. "I feel defeated," Erb says, looking around at the office furniture he and his wife, Liz, chose from a catalog years ago. The weathered ranchers and bundled-up women that come through his door mostly express disbelief when they hear that this frank-talking Tennessee native will sell his practice. His staffers say they're not looking forward to the questions the hospital's medical records system will soon prompt them to ask patients. (Do you wear a bike helmet regularly? Do you have a smoke detector?) "We'll try to retain as much professional independence as possible," Erb says, gazing at the hospital building, whose bulk he can see through his window. "But the fact of the matter is, we'll have a new master."

This paragraph was especially poignant to me since Dr. Erb is a former president of the Wilderness Medical Society and an author in our Expedition & Wilderness Medicine textbook.  

Regardless of one's stance on all the healthcare reform initiatives, it is difficult to watch this generation of physicians enter the twilight of their careers with frustration and disappointment. These men and women-- and their loyal patients-- deserve better, and our society will soon feel the impact of the loss when they and  their practices are gone.  

Update on Apr 15, 7:42 AM by Greg Bledsoe MD

Note:  I wanted the readers to be aware of a correction to this post.  The Dr. Blair Erb who is mentioned in the Smart Money article is the son of the Dr. Blair Erb who was the president of the Wilderness Medical Society and an author in our Expedition & Wilderness Medicine textbook.

The Value Proposition For Health Care: A Challenge For Physician Leadership

In health care there is nothing more complex than the simple.

In a recent New England Journal of Medicine article, What is Value in Health Care?,  Michael Porter, a Harvard trained PhD in business economics, makes a compelling case for defining, measuring and rewarding value in health care. By shifting our focus on value, simply defined as quality divided by cost, we can lower costs and improve quality.

The elegantly written article shows that value is what drives consumers.

Not quality. Most of us wouldn't shell out $100,000 for a  new automobile, regardless of its quality.

Not cost. We wouldn't buy a new car for $5,000 if we were convinced it would spend most of its time in the repair shop. Honda and Toyota have been kicking Detroit's butt because of value. Most of us see Honda or Toyota automobiles as providing high quality and low cost. It's time we move health care in the direction of value.

The value proposition is easy to understand, but its implementation will be complex.

There are three complexity challenges that will require effective physician leadership:  

1. Defining and measuring quality outcomes
2. Identifying and understanding the true costs involved in delivering care
3. Shifting the paradigm of our health care culture from a physician-centric to a patient-centric one

Dr. Porter outlines some of the challenges in defining and measuring quality outcomes. These include the fragmented and insufficient state of medical informatics, the length of time needed to track outcomes, and the dynamic nature of quality outcomes.

He explores the difficulties in measuring costs (not charges) across a continuum of care. Dr. Porter also recognizes that to properly measure value, one needs to identify the proper consumer. In health care the proper consumer is the patient, not the physician. The culture therefore needs to be patient-centric.

As an economist, Dr. Porter presents a well nuanced analysis of the first two hurdles in achieving value in health care: measuring quality outcomes and tracking costs acurately. He may, however, have underestimated the challenge involved in the third: moving from a physician-centric to a patient-centric culture.

Our physician-centric health care culture has deep roots. It is planted in the elitist soil of medical school selection, fertilized by the academic docents of physician indoctrination, and nurtured by the competition skewed by a physician friendly supply-demand curve with further nutritional supplements supplied by a perverse payment incentive system.

The future culture of patient-centric healthcare will not take root in today's American health care soil unless the current physician-centric culture is uprooted. No one should underestimate this task's importance nor its challenges.

Uprooting the current physician-centric culture before it uproots the foundation of the American health care system is the biggest challenge facing our physician leaders. This task will require effective physician leadership in academic medical centers, in hospitals, in outpatient clinics, and in our medical societies. It's time to develop and support effective medical leaders by teaching them the leadership skills required for success.