Archive for July, 2009
In my 25+ years of practicing internal medicine, I can recall the frequent sensation of impending doom, frazzled nerves, and mild nausea as I entered the room to see many of my difficult patients. I had often failed to move their care forward, diagnose their myriad complaints, or improve their health despite my best efforts. Even after referrals to multiple specialists, innumerable diagnostic tests, and extensive harangues attempting to convince them to change their lifestyle, I had only succeeded in increasing my sense of futility, and questioning my ability as a clinician.
There is considerable agreement that the status quo of health care delivery in the United States is not sustainable and that it is not providing optimal care for all Americans. Many see the major goal of health care reform as decreasing the per-capita cost of care and increasing the quality of care. One of the obstacles to achieving health care reform is the enormous gap between what the health care experts believe and what the general public believe about staying healthy.
My life, both personally and professionally, has taken many turns, to my present position as chief knowledge officer of the Institute for Clinical Systems Improvement (ICSI). During that time there has been a major transition in the roles of ICSI and my personal role in our ongoing activities. This has led to an increased understanding of what is needed to support truly innovative, potential disruptive interventions among our member organizations.
Kent Bottles: The Ideal Doctor/Patient Relationship: Can Doctors Ever Know What Will Benefit the Patient
What is the ideal relationship between doctor and patient in 2009 America? In 1927, in a famous essay titled “The Care of the Patient,” Francis Peabody described the personal bond between these two actors as the source of the “greatest satisfaction of the practice of medicine.” (JAMA, 1927, 88: 877) (http://www.bmcb4.org/Peabody.htm). During my medical school days in the late 1970’s at Case Western Reserve in Cleveland, this personal bond was talked about a lot.
Friday I went on a field trip to Epic, the company that supplies electronic health records (EHR) to most hospitals in Minnesota. Epic is located outside of Madison, Wisconsin in the little town of Verona which is about a $66.00 taxi ride from the Madison airport. They bought about 450 acres of farmland and are raising a lot of new buildings. The one I had my meetings in was very fancy and full of eclectic art–it was furnished like a fishing lodge. There is also an Ice Castle meeting room and an intergalactic meeting room with stained glass windows and planets. You get the picture.
In my 35+ years as a physician working in quality improvement, I’ve had some small successes, but as I’ve often commented–“the landscape of my career in quality improvement is littered with the carcasses of well-designed, well-conceived, and well-constructed projects.” Since my move to ICSI, I’ve begun to understand the naivete which doomed my work. Despite my energy, and those few stalwarts who worked with me, the strategy of “waiting patiently” was successful in ensuring there would soon be a return to business as usual.
After suffering significant setbacks in well-being through the financial crisis of
2008-2009, America seems to be on the mend. In June 2009, the nation’s
well-being climbed to 66.8%, the second highest level ever recorded since Gallup and Healthways started its monthly “Well-Being Index,” which provides a measure of the rating Americans assign to their current quality of life and expectations for the future.
In it’s sentinel work, Crossing the Quality Chasm, the IOM committee noted that the gap between the quality of care our citizens deserve and the quality they receive is not a gap, but truly a chasm. They go on to identify many of the reasons for this chasm, and outline six areas of focus to reduce that gap. In the years since the original publication of that report, there has been much homage to the content of the report, but many challenges and barriers to the goal of bridging that chasm persist.
“Because social effects lag behind technological ones by decades, real revolutions don’t involve an orderly transition from point A to point B. Rather, they go from A through a long period of chaos and only then reach B. In that chaotic period, the old systems get broken long before the new ones become stable. In the late 1400s scribes existed side by side with publishers but no longer performed an irreplaceable service. Despite the replacement of their core function, however, the scribes’ sense of themselves as essential remained undiminished.” (Clay Shirky, Here Comes Everybody)
Last summer in my role at ICSI as director of communications I met with a patient who was in our DIAMOND (Depression Improvement Across Minnesota, Offerings a New Direction) program. This program changes how care for the depressed patient is delivered and paid for in primary care. The patient, who I’ll call Bill, was jittery, withdrawn and uncomfortable, but he was improving under the DIAMOND program, and wanted to help others beat this disease, so allowed me to interview him.