By Jack Cochran, MD, FACS, Executive Director, The Permanente Federation
Is excellent good enough?
As physicians, we are trained to diagnose and treat disease. We dedicate ourselves to searching for cures and perfecting procedures that will restore the health of our patients. Over the last 50 years, we’ve made some remarkable progress. We’ve reduced the death rate from heart disease by 32.5% with a better understanding of primary and secondary prevention and advances in treatment. We’ve made similar progress in cancer care with better treatment options through radiation, surgery, chemotherapy, and genomics. We’ve changed an HIV diagnosis from a hopeless death sentence with limited treatment options to a manageable, chronic condition.
These truly excellent accomplishments in medicine have been life-changing for millions of people. But is excellent good enough?
While we have made great strides in clinical care, the American dream is faltering. Americans are more obese, more medicated and more in debt than at any other time in the history of our nation. One-third of our nation’s total health-care spending, about $750 billion per year, is wasted on unnecessary treatments, redundant tests, and uncoordinated care . Health Care Reform will have limited impact on this waste. While the rate of increase of health care spending has slowed in recent years, the United States still spends 2.5 times more than most developed nations on health care . U.S. health care spending is on track to reach $4.8 trillion in 2021, almost 20% of our gross domestic product .
This trend, compounded by one of the longest and most serious economic downturns we have ever faced has created a crisis for families, businesses, and communities that is tearing the fabric of the American dream. Health care is right in the middle of this crisis. The total cost of health care for an average family now exceeds $20,000 a year. When I began practicing as a surgeon, health care was at 10 percent of the GDP. Now it is at 18 percent of the GDP. These are investments health care have taken away from education, the environment, and infrastructure.
This has happened on my watch. I do not want an 18 percent drain to be the legacy of my generation. This insidious drain on families’ hopes and futures has to stop, and the trajectory in health care needs to change. Rather than causing despair and disappointment, it should be a positive enabler for a better life – physically, personally, socially, financially and psychologically. As an industry, we need the will and the resolve to create an inflection point and declare that excellent is not good enough.
Creating an inflection point to transform health care
It wasn’t too long ago when health care was centered around the doctor’s office or hospital. Physicians practiced with minimal support staff and subscribed to one journal. The problems physicians faced could be solved using the knowledge and skills they acquired in medical school. Patients went to the doctor’s office for all the information on their condition and for treatment. That was the industrial age of medicine.
Today, health care is much more complex. Physicians are accountable for a population of patients, whether the patients come in to the office or not. There are now more medical journals than physicians could possibly read or digest on their own. What physicians learned in medical school is no longer sufficient. Often, patients have extensive information about their diseases from Google searches and online patient communities like PatientsLikeMe. In these instances, physicians still play an important role as a trusted source – helping patients interpret the information they find and providing more context, evidence, and nuance so that patients and physicians can make informed decisions together. However, make no mistake, the locus of information and “power” has moved from the doctor’s office to the patient.
We’re forging the information age of medicine. In order to be effective, we must optimize the use of information, technology, tools and teams. We need to turn masses of patient data, science, and clinical evidence into clinical knowledge. This information must be available to patients, physicians, and care teams. And they must have access to technology and tools to make the right thing easier to do. Physicians and care teams should have clinical decision and panel support tools that not only put the latest evidence at their fingertips, but also enable them to provide personalized care to each patient.
Transforming health care into a learning industry
We need to make health care a “Learning Industry.” The inflection point won’t come from one bright leader or one superb organization. We have a wide range of inter-connected issues in health care. We can spend time blaming different parts of the industry for these challenges, or we can realize that we can influence and accomplish much by working together. We need talented people who have deep expertise in specialized areas and at the same time an understanding of the broader impact of their actions. We need to draw from all parts of the industry; harnessing our collective knowledge from the practice of medicine, the pharmaceutical industry, and medical research; as well as from a variety of disciplines, such as policy, economics, and engineering. We can only achieve this inflection point by being interconnected, by working collaboratively, by learning together. We can’t treat our way out of this crisis, we must learn our way out of it.
Health care needs to become a community that embraces measurement, comparison, acknowledgement, learning, and improvement. As physicians, we believe, and have every intention, that we are providing the highest quality care to our patients. But it is only when we measure and compare our performance that we can see if we are truly providing the best possible care or if there are gaps in our preventive care and treatments. Once we have the appropriate data, clinical guidelines, and resources, we can engage patients and close those care gaps. And then we won’t just believe we’re providing the best care; we’ll have proof. We must have the openness and spirit of collaboration to achieve this. We must also be willing to share our failures as broadly as our successes. As physicians, we often hear about the latest breakthrough treatments or procedures, but we are much less likely to hear when those procedures produce complications in the long-term.
Our greatest responsibility is to be good ancestors
As I look back on my career, I consider the legacy I will leave behind for my 6-year-old grandson and the generations that follow. Today, we talk about accepting “accountability” in health care for a patient population, across the continuum of care. Dr. Jonas Salk, inventor of the polio vaccine and one of the most important innovators in medicine, took a longer-term view of what accountability meant. Dr. Salk asserted that “Our greatest responsibility is to be good ancestors.”
By building a learning coalition, we can learn from challenges and successes across the health care industry. The innovations that can transform our industry are out there. They’re just not everywhere yet. We need to become rapid learners through connectivity, openness, discipline, collaboration, and a sense of curiosity. Organizations like the Institute for Healthcare Improvement, Alliance for Community Health Plans, American Medical Group Association, and Department of Defense are fostering connections among health care organizations as well as other health care stakeholders, and their efforts are gaining momentum.
The American dream is faltering. We need to restore hope and give some of the 18 percent back to the American people. Ultimately, within each of us must be the resolve. Resolve is not about hard work and dedication. Those are table stakes. It’s a relentless focus on the reality and the mission. The future is going to be tough, but it’s in our hands. We have the ability and talent to create that inflection point that transforms health care and restores the American dream for future generations. Our patients, families, and communities are depending on us.
What kind of ancestor will you be?
This commentary was originally posted on The Health Care Blog.