| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 1997;64:1451-1455
© 1997 The Society of Thoracic Surgeons
Central Plains Cardiothoracic Surgery LLC, Wichita, Kansas
Abstract
Introduction by Martin F. McKneally, MD
This address introduces an informed new leader who demonstrates our specialty in action. As you read Paul Uhlig's inspiring words, you will be proud of the spirit that is stirring in the wheatfields of Kansas and throughout the specialty. Like a cardiothoracic resident who learned transplantation immunology, Paul brought "the right stuff" to the right place. As the first Alley-Sheridan Scholar-in-Residence, he had a startling and stimulating impact on his fellow students and teachers at Harvard's Kennedy School of Government. The "impact factor" of cardiothoracic surgeons, reflecting their unique combination of knowledge, judgment, problem-solving skill, and commitment to effective action, is sorely needed in the restructuring of health care. Former President of The Society of Thoracic Surgeons Ralph Alley showed how important strategic surgical thinking can be. As advisor to the New York State Department of Health, he introduced peer review of cardiac catheterization and cardiac surgery, using professionalism for quality improvement instead of government regulation.
The skills required for effective action during the current health care revolution include a thorough understanding of policy development, health economics, government, and the political process. Paul's writing reflects the broad population viewpoint we need to develop, while preserving a fundamental value of our specialty, exquisite sensitivity to the trust and care of the individual patient. We need more Alley-Sheridan Scholars. The Thoracic Surgery Foundation for Research and Education is promoting development of health policy skills in cardiothoracic surgeons as an important part of its mission. There is early evidence of progress. Three Society of Thoracic Surgeons presidents, the vice president, the treasurer, secretary, and chair and many members of the Government Relations Committee are among the 150 scholars who have completed the 10-day executive course. Their recent success in The Society of Thoracic Surgeons' initiative to clarify thoracic practice expenses reflects the strengthened tactical skills and strategic thinking of our leaders.
It is the greatest possible honor and privilege for me to reflect with you about my year at the Kennedy School. As the end of the year grows near, it seems that I am more aware than I have ever been of things around me. The sky seems brighter, the clouds whiter, the trees more beautiful than ever before. When I was a resident at the Massachusetts General Hospital, there was one period in the spring when I had not seen the sun in about 7 weeks, arriving at the hospital early in the morning when it was still dark, and leaving in the evening after sunset. But we had a window at the scrub sink in the operating room that looked out over a little park. I used to enjoy looking out of that window and watching people sitting in the sun. It helped me keep things in perspective. I remember thinking, "One day I, too, will sit in the sun." In many ways this year at the Kennedy School has been my chance to "sit in the sun," and to take a fresh look at the changes occurring in my profession.
Reflecting on the Kennedy School year, it seems that the experience can be summarized in two ideas: mental models and strategy. Mental models are the basic patterns of thinking we use to organize the experiences of our lives. Consider how these models are formed by imagining a little child first beginning to explore the world. At first for that young child, nothing makes sense. The world is a rich sea of experience with no apparent order or pattern. Soon basic rhythms of life—cycles of light and darkness, sleep and wakefulness, hunger and satisfaction, aloneness and human interaction—begin to press themselves into that child's awareness. From these experiences, the first rudimentary mental models of the world are created.
Mental models are often referred to as "paradigms." The term "paradigm" was popularized by Thomas Kuhn in his book The Structure of Scientific Revolutions [1]. Kuhn looked at the mental models, or paradigms, that have shaped scientific thought. An example of a paradigm that later changed in a revolutionary way was the notion that the earth was the center of the universe. This paradigm was the basis for understanding planetary motion until Copernicus shattered that way of thinking.
Our mental models determine how we interpret what we experience in the world around us. Take for example the fever, cough, and rigors of pneumonia. We are conditioned by the mental model we learned in medical school to interpret fever, cough, and rigors as symptoms of a more fundamental process, which is a bacterial infection of the lung. This constellation of symptoms, together with the disease process of bacterial infection, is the paradigm we call pneumonia, and it is used to explain and predict a particular illness.
Because mental models are so fundamental to the ways we interpret our world, when new experiences do not match our models our thinking becomes difficult, even to the point of distress. Eventually, we develop new models and become comfortable again. But until we do, we have great difficulty understanding what is happening to us.
The distress we feel about our health care system right now is caused by a shift in our mental model of health care, about how health care resources should be utilized. This change in our mental model of health care is not just that we now have a new system, managed care. The change in our mental model of health care is much more profound. It is the recognition that we have reached limits of what we as a society can spend for health care.
In the traditional paradigm of health care, the physician did everything possible for everyone who might benefit, regardless of cost. Fifty years ago, we could do everything possible for everyone who might benefit, because there was much less that we could do. Today, with so much possible in so many areas of medicine, our best efforts have taken us to a limit of what is possible in terms of societal resources. This is true in every country.
Technology has given us the capability to care for people in ways we never could before, and the existence of insurance and Medicare have let us separate our decisions about care from the responsibility of paying for that care. The truth is that as a nation we are unwilling to admit we can now do more good for individuals than we can afford as a society. This simple but profound reality lies behind every issue in health care today. It is not a comfortable reality.
As a nation we have responded by bringing competitive market forces into health care in an effort to lower costs. The power of those market forces is astonishing. For most of this century, we have actively discouraged advertising or price competition in health care. For the past 30 years, these prohibitions have lessened, and in the past several years they have fallen away rapidly. The market is equilibrating, and the changes that come with this process of equilibration are profound.
The extent to which long-standing institutional structures are being overturned and the rapidity with which this is happening are startling to even the most forward-thinking observers. With the multiplicity of new forms, no single organizational structure has yet emerged as a dominant structure that is clearly superior to all others. The frustrations of both patients and providers with for-profit health maintenance organizations, the most common new model, suggest that this will not be the long-term solution to our health care difficulties.
Most economists believe that market forces are our best tool for optimizing efficiency. But we are beginning to see that what competition gives us in health care may not be in our best interest as a nation. Newly competitive systems often do not provide for research, education, and other necessary investments in our medical future, or provide the safety nets built into our present systems for those unable to pay for their care.
Most managed care plans function by restricting access to care. Financial incentives have been created that reward efforts to limit services and restrict access to patient care. Many Americans have responded angrily to these initiatives, especially when profits are perceived to have been made at the expense of patients, as care has been denied.
Cost has become our primary focus in health care, and this emphasis distracts us from what our real task should be. Rather than focusing on strategies to lower costs alone, we should instead focus on improving what we do, with lower cost being an important part of that equation. This is an important distinction. Instead of giving less care, we must work to give optimum care, in more efficient ways. The exciting part of health care reform is considering how real process improvements in health care can be achieved. The way we will significantly improve how we care for patients lies in the general direction of what we now refer to as "quality."
Although doctors and nurses try hard to assure that the best quality of care is provided to patients, what we would like to provide for our patients and what we actually provide are farther apart than we may realize. If we believe that the practice of medicine is firmly grounded in objective science, and if we accept that "common health problems occur commonly," we would expect the number of treatments and procedures provided to patients to be uniform across the country or at least to vary predictably for good reasons.
In fact, what has been found is that many procedures, even common ones, are not provided uniformly throughout the country. Instead, they vary widely by geographic region in ways that are not predictable. Interestingly, similar patterns of variation have been found worldwide [2].
These findings have led observers to suggest that inappropriate or "unnecessary" procedures are being performed. Others have suggested that just the opposite must be true, that we are not doing enough. But whether there are too few or too many procedures, one conclusion is certain: there is evidence for a missing dimension in the science of medical decision making.
Why is it that medicine, which is grounded in the objectivity of science, has such wide variations in how that science is applied in patient care? This question defines the state of the art of quality measurement today: we measure certain things very well and certain others very poorly.
What we measure well today is whether something works or not at the level of a specific treatment for an individual patient. What we do not measure well yet is what combination of treatments work well at the level of populations. The absence of uniformity of medical care from region to region does not mean that the quality of our health care is poor in one region or another. What it means is that our technology for measuring and implementing what is best is not yet well developed at this broader level of populations.
It is important to recognize that quality measurement at the populations level is, indeed, a new technology in health care. It is easy to lose sight of this fact when so much of health care takes place at the most highly developed levels of technologic innovation. In fact, we stand at the threshold of a new era of medical discovery concerning our understanding of how medicine is practiced. Progress is being made in many areas of study, such as clinical epidemiology, outcomes research, applied information technology, and systems-based approaches to practice that will dramatically improve the quality and efficiency of what we do [3–8].
These new sciences within clinical medicine are reshaping traditional ways of caring for patients, not by restricting care, but by actively improving care based on objective evidence. It is a process of coordinating what we do on a very large scale, much in the same way that care is coordinated in the open-heart operating room on a smaller scale: unique skills and resources are brought together in an orchestrated fashion to achieve what could not be accomplished otherwise.
Perhaps the most striking observation about coordinating health care at this "system" level is that right now we do not really have "systems" of health care at all. Health care has been called the last major cottage industry, in which individual practitioners care for specific illnesses of individual patients. Although this is less true today than 50 years ago, it is still more true than not.
Our present understandings tend to look at specific drugs, procedures, or tests in isolation. Our horizon is limited in time, restricted to the immediate consequences of the events being studied. This way of thinking is part of a philosophy that concentrates primarily on individual patients cared for by individual physicians or teams of providers, with little thought to the resources that are utilized in our efforts to attend to their problems.
We must never forget the importance of each individual patient. But as we become more aware of the limits of our health care resources, we must broaden our vision if we want to care for all of our patients well. Our proper response is a new vision of health care that is inclusive of the individual and also of populations, that helps us see ourselves as individual providers and as collaborative care givers working within systems. This is not "cookbook" medicine. Rather, this is a new layer of knowledge about what we do, to be used wisely in the service of individual patients and of society as a whole.
Organizing such systems of care, making them both effective and efficient, defines our challenge. We have not asked the question of quality in quite this way before, because we have not needed to. Our efforts to measure and improve the ways we provide care come directly from this deeper source: we must do better, for otherwise we have no choice except to do less for our patients. And we will not tolerate this.
There is one cautionary note we must remember with regard to improving the efficacy and efficiency of medical practice. This has to do with things that are easy to measure and things that are hard to measure, and how, when things are hard to measure, we sometimes make the mistake of assuming that they do not matter.
It is easy to measure dollars, or days in the hospital, or infection rates, or the number of nurses per patient in the intensive care unit. It is much harder to measure compassion, or dedication, or placing the welfare of the patient before our own.
Our systems of measurement do not always recognize the importance of these intangible values. In the same way that "standard of living" does not mean the same thing as "quality of life," and in fact the two may move in opposite directions, what we can measure easily in health care does not always account for everything we want our health care system to provide.
Many health care reforms designed to maximize efficient use of resources that can be measured easily often have the paradoxical effect of minimizing intangible resources that matter just as much or more when we are the ones being cared for.
We must be careful to find ways to measure everything that is important and not forget the values that are hard to measure. They really do matter. And, somewhere along the way, we need to remember to care for those who give the care. We forget this all too often, and we wear out way too soon.
If these changes define the immediate future of health care, broader issues of health and wellness, and their origin in our ways of life, are the distant horizon toward which we seem to be moving. We have tended in this century to focus on health as an individual attribute, and illness as an individual problem. As we become more aware of the importance of the social determinants of health, we are beginning to recognize that what we now call diseases may in fact be viewed productively as symptoms of deeper problems within the fabric of our ordinary lives and our social institutions. Today, though, we are far from such a holistic synthesis in our collective wisdom.
I would like to turn now to the relationship between society and the health care professions, and a sense of a higher purpose of health care. I was taught that medicine is a profession of service to others, and that when we accept the privilege of caring for the sick, we also accept the responsibility of placing our patients' welfare before our own.
Doctor Martin McKneally once gave a lecture entitled "Who Owns Medicine?" By this, he questioned whether medicine is something that we can use for our own purposes. His answer was that medicine is not owned, but held in trust, to be used in the service of others. By our years of study we have earned the privilege of carrying it for our time, of improving it if we can, of defending it if we must, and of passing it along to those who follow when our time of service is ended.
Doctor Samuel Thier [9] also addressed the issue of our values, and our responsibilities, by using the words of former Supreme Court Justice Brandeis, who noted that a profession is a keeper of a body of knowledge that it advances and passes on to the next generation. A profession has a code of ethics that includes service to others. A profession sets and enforces its own standards. And a profession values performance above reward.
Doctor Thier wrote that this is the basis of the social contract between society and the health care professions. And it is not an optional contract. Whoever accepts the privilege of caring for the sick must also accept the responsibility of putting the patients' welfare first.
This contract with society takes on a new dimension in the world of managed care. In managed care, responsibility for the welfare of the patient, which comes with the privilege of caring for the patient, extends beyond the physician to anyone whose decisions determine or impinge on care. The same responsibility required of the physician is required of anyone who is involved in decisions about the way care is given, up to and beyond the corporate board room.
This is the nature of the agreement with society, and society will insist that it be enforced, as we are seeing now in editorials and in our state legislatures across the country. There is some comfort in this at the bedside.
Rightly or wrongly, the future of our health care system is being decided by a social and political process with many participants. The restructuring of our health care system is not finished. In fact, it is probably just beginning. Some of the changes that are occurring are encouraging. But many of the changes are distressing. Our institutions are being redefined, our values are being profoundly misunderstood, and fundamental ethical principles seem to be forgotten.
Rather than being discouraged about the changes in health care or giving up, it is necessary for us to try to understand what is happening and to respond in creative, positive ways. For those who see these issues clearly and who feel them deeply, there are spirits to mend, wounds to bind up, and action to be taken.
Our goals are to make health care resources go farther and to preserve our fundamental values as we do so. We must recognize that our structures will be different. It is not the old structures we must work to preserve. It is the spirit that animates those structures.
We will accomplish this by developing coordinated systems of care based on the new sciences of clinical medicine. These will be fundamental process improvements, based on objective evidence of what works and what does not work at the level of populations as well as the level of the individual patient. We will increasingly recognize that health and illness are deeply rooted in the ways we live, and will design health care systems that are much more integral to our communities and our daily life. Finally, we will incorporate into our practice an appropriate concern for cost and efficiency, as a new ethical principle in a world of recognized limits to health care resources.
As we pursue our goals, we must:
Footnotes
Presented April 15, 1997, at the Harvard Faculty Club as the graduation dinner address at "Understanding the New World of Health Care," a John F. Kennedy School of Government Executive Course, Harvard University, Cambridge, MA.
For the academic year 1996–1997 Dr Uhlig was the Thoracic Surgery Foundation for Research and Education Alley-Sheridan Scholar-in-Residence at Harvard University's John F. Kennedy School of Government.
The Alley-Sheridan Scholar-in-Residence program, and the executive course "Understanding the New World of Health Care," are ongoing initiatives of the Thoracic Surgery Foundation for Research and Education developed to increase awareness and expertise within the specialty of thoracic surgery concerning issues of health care policy.
Address reprint requests to Dr Uhlig, c/o Carolyn Earnest, RN, Central Plains Cardiothoracic Surgery LLC, 1035 N Emporia, Suite 270, Wichita, KS 67214 (e-mail: pnuhlig{at}aol.com).
References
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
