Pay it Forward

DrAbelsonConnects is on vacation during the holidays. We hope you’ll enjoy this post originally published in October 2010.

The film, “Pay it Forward, depicts young Trevor McKinney, engaged in an intriguing assignment from his new social studies teacher, Mr. Simonet. Trevor must create an opportunity to make a positive difference in the world. Trevor conjures the notion of not “paying back” a favor, but “paying it forward.” He intends to repay one good deed, by generating several new ones on behalf of three new people. Trevor’s efforts reverberate, not only in the close circles of his life which include his mother, and physically and emotionally scarred teacher, but in widening ripples of people completely unknown to him

Recently, Methodist experienced “pay it forward.” The following story is true with the exception of altered details to protect confidentiality. This summer, a 90 year old retired accountant working at a local store, sustained 6 hours of chest pain before taking a bus to the Methodist Emergency Room. Arriving early in the morning at 6:45 a.m., he remained resolute in desiring a rapid evaluation enabling him to return to his work shift. The Emergency/Observation Center team scrambled to honor his wishes. Discharged by 12:50 p.m. he completed a full evaluation including a stress test. Appreciative of the team’s assistance in helping him meet his work obligations, the professor, sent a check for $1,000 allocated to aiding less fortunate individuals unable to afford emergency care.

His generosity paralleled attempts by the Emergency Center and the Pharmacy at Park Nicollet Methodist Hospital to identify ways to fund low cost or free prescriptions for patients unable to afford discharge medications.  Emergency Center team members, inspired by the generosity, donated $7,000 through matching gifts.

The Emergency Center team “paid forward” a good deed to the patient by honoring his desire to return to work in the afternoon. The patient “paid forward” with a donation for those unable to purchase prescriptions. His gift prompted a cascade of others “paying forward” with matching donations.

Please use comments below to reflect on the relationship between “paying it forward” and our work

Dealing with Tragedy: Remember What You Live For

“What do you live for?” is an important question at Park Nicollet. The question embodies the “noble cause” of health care. Living for something is an essential part of wellbeing. Our role at Park Nicollet is to support wellbeing by enhancing the ability of people to participate in life as fully as possible. We’ve made the question the theme of Park Nicollet’s marketing campaign with billboards that feature patients and families saying what they live for.

It is on days like Friday when we are powerfully reminded of the important things we live for.

Tragedy in Connecticut

I am sure that all of you share in my deep sadness and sorrow following Friday’s shootings at Sandy Hook Elementary School in Newtown, Connecticut.

At this writing we know that 28 people were killed, 20 of them children between the ages of 5 and 10. The 20 year old gunman also shot and killed his mother and killed himself.

Like many of you, one of my first reactions was to think of my own family and loved ones and to be grateful they are healthy and safe. President Obama, in addressing the nation about the shooting, had a similar response.

“I react not as a President,” he said, brushing away tears, “but as anyone else would, as a parent. I know there’s not a parent in America who doesn’t feel the same overwhelming grief that I do…our hearts are broken today…Our hearts are [also] broken for the parents of the survivors as well. As blessed as they are to have their children home tonight, they know that their children’s innocence has been torn away from them too early and there are no words that will ease their pain.”

Emotional costs of responding to tragedy

We all pay a cost when we confront tragedy. Something or someone we value has been taken from us and we must find a way to move forward.

This circumstance confronted my own family and community last September when a friend of mine was killed along with four others in an act of workplace violence. (I wrote about this in a previous blog entry.) My friend left behind his grieving wife, children and grandchildren who must find a way to carry on with their lives. I was moved by the strength of my friend’s wife, who visited with the families of the wounded at a hospital less than two days after the death of her husband. This terrible event hit close to home and was a reminder to all of us to be grateful for the things we live for.

We also confront these issues in our professional lives. First responders, police officers, firefighters, emergency response personnel and those of us privileged to practice medicine know what it is like when you have to set aside your personal feelings and treat the victims of tragedy.

On Friday, as police officers were still searching the school, victims were transported to Danbury Hospital, just eleven miles away. The hospital was forced to go on lockdown and activate their emergency response team to quickly react to this unforeseen and unimaginable tragedy. As victims were brought into their emergency room on stretchers, I am sure they had to suppress their own emotions to treat these children under challenging and stressful circumstances.

Keeping families connected

Here at Park Nicollet Methodist Hospital, we have our own emergency preparedness plan that is ready to be activated in the event of an emergency. In fact, our team has spent the past two months working with regional hospitals, Minneapolis Police, Minneapolis Public Schools and the American Red Cross to create plans and procedures for how to reunite parents and school children after a mass casualty event, such as happened Friday. 

Park Nicollet and other health systems do this because we know what our patients, families and communities live for: the health and well being of each other.

I am glad we prepare for such emergencies, but I pray that we never have to respond to something as tragic as the school shootings in Connecticut.

What do you live for?

I live for the well being of my family and friends. I live for making an impact in how healthcare contributes to well being —including affordability.

We all live for things that are important to us. Please use comments below to share your feelings and tell us what you live for.

Touch and Technology in Patient Care

At one clinic, an experienced physician uses the tips of his fingers to probe a patient’s neck and feel for any abnormalities. At another clinic, a young physician uses the tips of his fingers to launch a smart phone app that details the symptoms of thyroid disease.

Which physician is practicing the most effective kind of medicine?

The tension between touch and technology in healthcare is a familiar problem that has become more acute with the ability of app designers to make sophisticated diagnostic resources available to clinicians at the tap of a finger on portable mobile devices. Does the use of smart phones and tablets by clinicians improve the care they provide, or does it put a barrier between them and their patients?  Does it create a generational divide between colleagues? Does it take us farther away from one of the first things we learn in medicine, the laying on of hands?

I experienced a similar generational divide 40 years ago during my medical training. My cardiology mentors received their training before the advent of echocardiograms. They spent many minutes bent over patients, carefully listening to subtle heart sounds to find evidence of valvular heart disease, congestive heart failure and pulmonary hypertension. I could never hear what they heard and instead relied on the results of phonocardiograms and echocardiograms. My endocrine mentors diagnosed thryroid disorders from the speed of ankle reflexes; I used blood tests. Other mentors, trained before the advent of C-T scans used palpation (touching the patient) and plane XR’s to diagnose- I relied on C-T scans. At the time, I did not understand how listening and touch contributed to healing- I only focused on how much more efficiently I could diagnose by using new tools. Only later in my practice did I come to appreciate the importance of touch (as I described in my earlier blog post, “Rituals”)

A recent New York Times story took this issue a step further and looked at the generational divide that some feel is developing over the use of mobile technology in patient care. In her article “Redefining Medicine with Apps and iPads,” reporter Katie Hafner creates a fascinating juxtaposition of two physicians at the University of California, San Francisco Medical Center who share the same goal of providing outstanding patient care but with from different perspectives. I encourage you to read it.

The story follows a third year resident in Internal Medicine, Alvin Rajkomar, as he uses his iPhone and an app called “MedCalc” to help him provide patient care. The story also focuses on a 66 year old physician at the same hospital, Paul A. Heineken, who worries that younger physicians may be losing the ability to rely on human touch to treat and comfort patients.

For Dr. Rajkomar, according to the reporter, mobile technology is “a black bag of new tools: new ways to diagnose symptoms and treat patients, to obtain and share information, to think about what it means to be both a doctor and a patient.”

But Dr. Heineken says “’I tell [residents] that their first reflex should be to look at the patient, not the computer…’ And he tells the team to return to each patient’s bedside at day’s end. ‘I say, don’t go to a computer; go back to the room, sit down and listen to them. And don’t look like you’re in a hurry.”

My feeling is the best approach lies somewhere in between. Personal contact and human empathy are essential to patient care and must not be overlooked – nor should we overlook the value of medical and mobile technology to aid in care and to give us more time to be with our patients.

Personally, I like what another physician quoted in the article says: “Just adding an app won’t necessarily make people better doctors or more caring clinicians…What we need to learn is how to use technology to be better, more humane professionals.”

In other words, we should use technology not just to find answers, but to help us become more humane to our patients and to ourselves.

In other words, we must use Head + Heart, Together.

This article and the issues it raises are perfect examples of why we need our internal culture of Head + Heart Together. We must use the evidence-based medicine and technological resources that are in our Heads and combine them with the healing relationships and compassionate care that come from our Hearts, and bring it all Together to create experiences that benefit our patients, families, teams and communities.

Be it technology, experience or generational divides, we can bridge any gaps when we all share the values of Head + Heart, Together.

Please use comments below to share your experiences with using technology to improve patient care and to improve the quality of time that you spend with patients or supporting patient care.

Curiosity

Today, NASA scientists are announcing the latest findings in their search for life on Mars, reporting data from the “rover” that travels the surface of the planet looking for signs of life. What is the name of NASA’s rover? “Curiosity,” named after the force that sends people forward in life to ask questions and search for answers. 

Maintaining a sense of curiosity is an attitude that enhances our lives. Being curious implies withholding judgment and being open to new ways of thinking. Life is about learning when we are curious. Every interaction is an opportunity to learn.

This outlook is summarized well by Shynru Suzuki, a Zen monk whose own sense of curiosity led him to found the first Buddhist monastery outside of Asia and help popularize Zen Buddhism in the United States. In his book “Zen Mind, Beginners Mind” he wrote:

“If your mind is empty, it is always ready for anything, it is open to everything. In the beginner’s mind there are many possibilities, but in the expert’s mind there are few.”

The etymology of the word “curiosity” derives, in part, from the Latin root “cura,” which means to care. We care when we are curious.

Curiosity will be a great asset for us as we approach January and start bringing two thriving cultures together and begin integration with HealthPartners. What can we learn from our HealthPartners team members? What can we do better together?

I learned this personally from my own family’s experience with HealthPartners. My son, daughter-in-law and their two children live in St. Paul. They are HealthPartners members and receive their care at a nearby HealthPartners clinic. Dan and his wife glow when they talk about their experience at HealthPartners, describing it as “hassle free.” He says he is never told that “you need to check with your insurance company” before he and his family receive care. It’s a process that leaves them raving about their experience.

I am grateful that my family is treated well by HealthPartners. (After all, I am a member of HealthPartners health plan, as are most of you.) But it was also eye opening for me to realize that my son does not differentiate between his experience as a patient and his experience as a member. It is a fully integrated process that occurs seamlessly and behind-the-scenes; all he knows is that he and his family have a great experience from start to finish.

Dan’s views helped me overcome the blinding biases of my “expert mind” and realize I had much to learn about the benefits of integrating care with financing (health plan functions). This is one small example of how maintaining an open mind and a sense of curiosity will help us realize our full potential as we move forward with HealthPartners in the New Year. I hope you will join me in the excitement of discovering the new things Park Nicollet and HealthPartners will be able to do as a combined organization.

Please use comments below to describe examples of blind spots from your “expert mind” or instances of when you learned through adopting the attitude of “beginners mind.”

Thanksgiving: What a difference a letter can make

A recent article, published in the Journal of Clinical Oncology by our own Steve Duane M.D., brought tears to my eyes. Steve is a physician in the Park Nicollet Hospice Program. In his article, Steve movingly describes his experience with junior high students in the “Growing Through Grief” program sponsored by the Park Nicollet Foundation.

Growing Through Grief is a school based program that offers grief support and education to children who have experienced the death of a loved one. The program provides grief support groups, individual counseling and continuing education for staff and the community. (Click here if you would like more information about Park Nicollet’s Growing Through Grief program.)

In his article, Steve tells the story of a sixth grader reading a letter from his mother (which he keeps on his smartphone). The boy’s mother, who died of cancer when he was 5 years old, wrote the letter prior to her death.

The article prepared me for Thanksgiving as I consider the many Park Nicollet team members who have died this year and am aware of additional losses and tragedies suffered by co-workers. As I read Steve’s story, I feel grateful for my health and the health of those I love. Please feel free to use the comment box below to share your thoughts on the things for which you are grateful on Thanksgiving.  

Here is Steve’s article.

What a Difference a Letter Can Make

by Steven F. Duane⇓

© 2012 by American Society of Clinical Oncology  

I learned an important life lesson recently from a sixth-grade student: a letter from your mom can make all the difference.

All too often, oncologists find themselves in the difficult position of sitting across from a dying patient who is also the mother or father of young children, discussing end-of-life care. In my practice, such conversations usually involved young women with metastatic breast cancer. When the delicate topic of the patient’s children was broached, tears were inevitable. There is perhaps no greater sadness than that of a mother who is about to leave her children behind forever.

After allowing time for the patient to cry and to say whatever she felt up to saying, I often talked gently about ways that I hoped might help my patient and her children cope a little bit better with such an unthinkable loss. One idea that I sometimes suggested was for the patient to write letters to each of her children to open on special occasions in the future, after the patient was gone—letters for certain birthdays, graduation, or a wedding day. Despite making this recommendation, to me the act of writing such letters had always seemed impossible. And I also often wondered how these letters would be received by the child—would the communications from a long-gone parent be eagerly anticipated and prized, or would they instead be dreaded, summoning ghosts and painful memories of a desperately sad time? Whenever I imagined that future birthday or wedding day, I could see an image of the letter being opened and read, but my thoughts were unable to go any further.

Enter the sixth grader who taught me just how important those letters can be to the recipient.

I was asked to attend a support group for kids who had lost a loved one. This group is open to sixth through eighth graders and meets weekly in a local junior high school. The two group facilitators had been inundated with medical questions from the students, and the counselors asked me to attend one of the group meetings to help answer some of these queries. I accepted, but I had some reservations about talking with junior high school students, especially as it has been almost half a century since I was that age myself.

I arrived at the meeting early and was led to a room that was near the school principal’s office. The room was large and stark, making it seem more suited for detention than for baring one’s heart. The kids filed in slowly; eventually, six students comprised the group. They looked so young as they talked about band practice, compared homerooms, and speculated about this evening’s basketball game. “So, are you the doctor?” one boy eagerly asked. “Yes,” I said, knowing that my gray hair and necktie had likely already answered his question.

The facilitators began by asking each student to introduce themselves and briefly recount the story of their loved one’s death. Cancer was the common theme. Questions quickly followed. Initially, these questions were easy, straightforward ones that I had answered many times before. How did the cancer get to my mom’s brain? Why does chemotherapy make a person so sick? But soon the questions began to cover more uncomfortable matters. What does it mean that I dream about my dad? Is it OK that I am mad at God for taking my mom? It quickly became clear to me that these kids had been forced to grow up faster than children should, and they were demonstrating maturity and wisdom well beyond their years.

One young boy grew quiet, and the counselor noted his bowed head looking down. “Are you OK?” she asked. His soft response was, “It’s just not fair. Sometimes it makes me so angry that my mom had to die.” The counselor repositioned herself, now sitting next to the boy with her arm around him. (There are uncelebrated heroes on this earth, and I realized that I was witnessing one of them in action). “What do you do when you feel this way?” she asked him.

He looked up, paused briefly and said, “I read my mom’s letter. I was reading it just now.” He volunteered, “Would you like to see it?” After a few questions from the group leaders probing whether it would be OK, we collectively asked the boy to share the letter.

He explained that his mom died of cancer when he was 5 years old and she had written this letter just before her death. He had not been given the letter until he was 8. Now, he keeps a copy of his mother’s letter on his smart phone, along with her picture.

He showed us what the letter looked like and then started to read it. It was clear from the sound of his voice that he had read it many times before. The letter was brief, encouraging, sad, loving—and obviously deeply treasured by the boy. He shared with us that whenever he feels really down or angry, he rereads his mother’s letter. “Reading it always makes me feel better, more relaxed. I feel connected to my mom.” As he pocketed his phone, I could see a noticeable change in his expression and his posture—calmer and more settled. Fortified by his mom’s courageous letter, the young man now appeared ready to move ahead, both with the rest of his day and with the rest of his life.

A deep uneasiness stayed with me for days following this experience. My thoughts bounced back and forth between my previous conversations with dying parents and what I’d heard that afternoon from the group of young students. I felt a great sadness reflecting on the profound losses that they had experienced, and yet what kept resurfacing was appreciation of the courage and resilience that I had witnessed. So, bravo to that dying mother who somehow found the courage to write a critical letter to her 5-year-old son. Bravo, too, to that resilient young man, whose mother is now memory, but who is using her words to help him find his way in life, just as she had hoped he would. What a difference a letter can make.

Irritability and Compassion

Most interactions between staff and patients and their family members go well. Occasionally, we disappoint. A colleague recently told me the following poignant story about Janet Stensgaard, a parking lot attendant on the Park Nicollet Methodist Hospital campus. The story illustrates how each of us has the potential to reach out to patients and improve their outcome even after they feel dejected and disappointed.

Today I had a phone conversation with a patient who had a very poor experience in one of our specialty departments. There was one little bright light…

 As she left the parking lot, the patient obviously was in distress. The parking attendant  [Janet Stensgaard] recognized her unhappiness, and asked her what was wrong. The patient told her that she had just had a miserable visit with a doctor and was really upset. The attendant then said “well then you surely shouldn’t have to pay for the parking,” voided the parking ticket,and then wrote down the number for patient relations and gave it to her.

That attendant is a hero, demonstrating sensitivity, compassion, initiative and courage.

I spent time with Janet to learn more about the interaction. Janet told me about the disturbing personal news she received herself on that particular day. As a result, rather than causing her to feel irritable and oblivious to the plight of the woman in front of her, her own struggles triggered a sense of compassion. “Perhaps this lady also received bad news,” said Janet.

Janet’s words made me look at myself. How do I interact with others when preoccupied by my own personal issues? Often I react with irritability rather than compassion. Meeting Janet was the highpoint of my week. Her actions and words inspire me to improve how I deal with others when I am distressed.

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Please feel free to comment. We encourage a free exchange of ideas but, as always, we reserve the right to remove comments that make personal criticisms or attacks on individuals or specific businesses.

Medical Ethics and the Flu

I’d like to share with you a blog post I recently sent to all Park Nicollet team members regarding the importance of vaccinating healthcare workers against the flu.

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“Beneficence” describes our ethical obligation to act in the best interest of others; non-maleficence denotes our ethical duty to “do no harm” (a common principle in healthcare).  Patients and families trust that we act in their best interest and we avoid harming them.

We place patients in harm’s way, thus violating our ethical principles, when we in healthcare do not immunize ourselves against influenza. As individuals we have a duty to our patients to receive influenza immunization. As a healthcare leader, I have an ethical obligation to assure patients that Park Nicollet will not harm them by exposing them needlessly to influenza.

According to a study in the Journal of the American Medical Association, influenza kills an estimated 36,000 people each year in the United States (although the actual total can vary widely). Most of these deaths occur in individuals who are in compromised health from age and chronic disease. Because of their compromised health, these individuals end up in our hospitals and clinics where we have the obligation to protect them from being exposed to life threatening influenza.

According to the National Foundation for Infectious Diseases: “Healthcare professionals are frequently implicated as the source of influenza in healthcare settings. [Horcajada, Salgado, Harrison] This is particularly troubling for the high-risk patients in their care, who may be at increased risk of severe complications, including influenza-related mortality. Outbreaks have been documented in high-risk patient care areas, including organ transplant units [Malavaud], long-term care facilities [CDC 1992], and neonatal intensive care units. [Cunney]

We in healthcare don’t do an adequate job of preventing the harm of transmitting influenza to patients. A recent survey by the Centers for Disease Control found that only 66.9 percent of healthcare professionals reported having influenza vaccination for the 2011-12 season. The national goal is 90 percent.

Many healthcare organizations approach their ethical duty to not transmit influenza to patients by making yearly influenza vaccination a condition of employment (or masking if there is a legitimate medical or religious reason to not receive the vaccine). This is similar to our requirements for proof of Measles/Mumps/Rubella immunization, Hepatitis B protection and regular Mantoux testing looking for evidence of tuberculosis. The Centers for Disease Control (CDC) found that 95 percent of workers in hospitals that required vaccinations got them compared with only 68 percent in hospitals without such a rule. [MMWR, 9-28-12]

Critics of organizations that mandate influenza immunization generally cite lack of 100% effectiveness of the vaccine and also raise issues about personal choice. I don’t buy either argument. Even if influenza immunization is less than 100% effective we still have a duty to do everything we can to not transmit influenza to our patients. U.S. Supreme Court Justice Oliver Wendell Holmes, Jr. summarized the fallacy of the personal choice argument. Known for his blunt opinions,  Holmes said: “The right to swing my fist ends where the other man’s nose begins.” In other words, autonomy of choice does not imply the right to hurt others. 

Park Nicollet does not have mandatory vaccination, but we do make it easy for you to receive vaccine at no cost at all of our hospital, clinic, specialty centers and office locations. I hope Park Nicollet can achieve a 95 percent rate of influenza immunization using our current voluntary approach.

Our patients entrust their lives with us. That trust drives a sacred duty for us to receive influenza immunization.

Please feel free to comment. We encourage a free exchange of ideas but, as always, we reserve the right to remove comments that make personal criticisms or attacks on individuals or specific businesses.

Unwavering commitment to patients, community

As I watch news reports of the devastation caused by Hurricane Sandy on the East Coast, I feel sorrow for the human suffering and continued concern for people who live in the path of the storm, including some of my own relatives and friends who live on the Eastern Seaboard. I’m sure that many people reading this also have relatives and friends who live in affected areas of the East Coast. My thoughts go out to you and your loved ones.

I am also deeply affected by the brave response of healthcare workers caring for patients at the center of the storm. New York University’s Lagone Medical Center evacuated more than 250 patients throughout the night, carrying them down as many as 15 flights of stairs with only flashlights to guide them. Nurses carried four newborns from their Neonatal Intensive Care Unit, pumping air bags by hand so the babies could breathe as they descended the stairs and were transferred into waiting ambulances. This work of astonishing heroism represents the best of our profession.

While very different and not nearly as damaging, I remember with pride the response of our Park Nicollet team members during the December 2010, 17 inch snowstorm with strong straight line winds that brought the Twin Cities to a halt, closed the Metro Transit system and collapsed the Metrodome roof. Methodist Hospital and Park Nicollet Clinic staff went through extraordinary efforts to keep our hospital and clinics open. Many team members had remarkable stories of driving or walking through the storm so they could get to work (one team member skied 8 miles on unplowed roads to get to his shift on 2 North). Clinic staff cared for patients and shoveled walkways to keep our Urgent Care centers open. More than 65 clinicians and staff stayed overnight at Methodist to make sure essential services were provided without interruption.

We all know the feeling of commitment to our patients and our community, and the effort that it takes to keep a health system running 24 hours a day, 365 days a year. I’m sure you will join me in expressing our admiration and support to all healthcare workers and all people who are affected by this catastrophic storm on the East Coast.

Teamwork essential in life and at Park Nicollet

Laura O’Donnell is a Certified Medical Assistant with Park Nicollet Senior Services. She has worked here for 11 years and also spent six years as an Air Force medic.

In her free time, Laura enjoys making jewelry and sometimes exhibits at local arts and crafts shows. In July, Laura was exhibiting at “River Town Days” in Hastings, a beautiful town encompassed by three major rivers. Suddenly, the tranquil sounds of a summer festival were replaced by screams.

A four year old boy walking along the shoreline fell into the Mississippi River. Laura immediately ran toward the screams and waded into the river where she joined a team that formed a human chain to reach the boy. Laura was waist high in water and right in the middle of the chain, flanked by two men on either side of her. They scooped up the boy and passed him from arm to arm until he was out of the water and safely reunited with his parents.

Laura did a wonderful and heroic act that day. It’s something I’m sure we’d all like to think that we would do under similar circumstances. But there’s one other factor that might have made other people think twice about jumping into the river.

Laura can’t swim.

Laura is very modest, avoids drawing attention to herself and is reluctant to share this story. But her coworkers at Senior Services and her friends are sharing her story with others. That’s how it reached me.

No matter what size, an organization must function as a team to succeed. Laura represents .0125% of our current work force. But she also represents one of the most important qualities that we need in every Park Nicollet team member to succeed — teamwork. Laura joined a larger group to accomplish something she could not have done alone. Not being a swimmer, she also left her comfort zone and relied on her other team members to help her achieve a very important goal.

Teamwork will be even more important as we join forces with HealthPartners in 2013 and begin to integrate our systems. While the size of our teams may expand, the success of our teams will still depend upon every individual combining their skills with other team members to achieve goals.

Some of us may have to leave our comfort zones to do this. Laura had to leave hers to jump into the Mississippi River. Laura became stronger, however, because she joined a team that combined their skills to accomplish something that none of them could accomplish alone. I am confident that our tradition of team work at Park Nicollet will provide us with important tools to succeed as a combined organization with HealthPartners.

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Please feel free to comment. We encourage a free exchange of ideas but, as always, we reserve the right to remove comments that make personal criticisms or attacks on individuals or specific businesses.

Best Care at Lowest Cost – new Institute of Medicine report

The Institute of Medicine (IOM), an independent, nonprofit organization that is part of the National Academy of Sciences, issued a major report recently called “Best Care at Lower Cost.”

At 450 pages, it’s a big report and it’s garnering big headlines in the news media – but not, unfortunately, a lot of insight. Most news coverage focuses on the IOM’s estimate of the amount of waste in health care: $750 billion per year. It’s an appalling number that we must not tolerate.

But what are some of the underlying reasons that we have a health care system that tolerates so much waste? Why does the United States spend more than any other nation on health care (18% of our Gross Domestic Product) and achieve poorer outcomes than much of the rest of the world?

Such a question is too complex for most news media reports. One of the reasons, according to Mark Smith, MD, Chair of the IOM committee that wrote the report, is…well…complexity. Speaking at a press conference on the day the report was released, Dr. Smith said:

“There are really two issues at stake. One is the cost, a problem well known to all of us. But part of what’s new about this report is our attempt to grapple with the issue of complexity, the complexity of health care, both in its biomedical and organizational aspects. In our view, trying to both acknowledge this complexity and come up with ways of dealing with it, both for individual clinicians as well as clinician organizations and for patients, is part of the path forward.”

The IOM identifies this problem on page one of their report, summarizing the issues at stake:

Health care in America presents a fundamental paradox. The past 50 years have seen an explosion in biomedical knowledge, dramatic innovation in therapies and surgical procedures, and management of conditions that previously were fatal, with ever more exciting clinical capabilities on the horizon. Yet American health care is falling short on basic dimensions of quality, outcomes, costs, and equity. Available knowledge is too rarely applied to improve the care experience, and information generated by the care experience is too rarely gathered to improve the knowledge available. The traditional systems for transmitting new knowledge—the ways clinicians are educated, deployed, rewarded, and updated—can no longer keep pace with scientific advances. If unaddressed, the current shortfalls in the performance of the nation’s health care system will deepen on both quality and cost dimensions, challenging the well-being of Americans now and potentially far into the future. (“Best Care at Lower Cost,” pg. S-1).

The report highlights some of the reasons for waste, many of which I have written about previously, such as unnecessary variation (see “Health Care and Zip Codes”), overuse of medical tests and diagnostic procedures (see “More is Magic” and “Unnecessary Tests and Treatments in Health Care.”) and lack of care coordination (see “Steve Jobs and Coordinated Care”).

Among the report’s recommendations are:

• Clinical decision support: Accelerate integration of the best clinical knowledge (“best practices”) into care decisions.
• Patient-centered care: Involve patients and families in decisions regarding health and health care, tailored to fit their preferences.
• Community links: Promote community-clinical partnerships and services aimed at managing and improving health at the community level.
• Optimize operations: Continuously improve health care operations to reduce waste, streamline care delivery, and focus on activities that improve patient health.
• Digital infrastructure: Improve the capacity to capture clinical, care delivery process, and financial data for better care, system improvement, and the generation of new knowledge.
• Data utility: Streamline and revise research regulations to improve care, promote the capture of clinical data, and generate knowledge.
• Financial incentives: Structure payment to reward continuous learning and improvement in the provision of best care at lower cost.
• Performance transparency: Increase transparency on health care system performance.
• Broad leadership: Expand commitment to the goals of a continuously learning health care system.

The report says there are many stakeholders in our complex health care system that must find a way to work together to achieve progress, including patients, health care professionals and health care delivery organizations, professional societies, health insurance plans and other payers, government regulators, and private businesses that develop new medical products and technologies. The report states that “…achieving the vision of continuous learning and improvement will depend on the exercise of broad leadership by the complex network of decentralized and loosely associated individuals and organizations that make up the health care system.”

Or, as Dr. Davis put it bluntly at his press conference, “Health care now must be a team sport.”

What we must do as health care leaders is to embrace the findings of the report and work with patients and key stakeholders to bring about change so that we can improve the quality of care, improve the experience of our patients and make health care more affordable for everyone.

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Please feel free to comment. We encourage a free exchange of ideas but, as always, we reserve the right to remove comments that make personal criticisms or attacks on individuals or specific businesses.