Healthcare Integration: Waiting for 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.

Autonomics Anonymous

Dealing with a disabling addiction: A challenge for physician leaders

What would you think if I sang out of tune,

Would you stand up and walk out on me?

Lend me your ears and I'll sing you a song

And I'll try not to sing out of key.

Somewhere in the near future we look through a one way mirror into a doctor's lounge. Scanning the the room we see a group of anxious individuals sitting in a circle.  They seem uncomfortable being here. Most look downward, trying at all costs to avoid eye contact. The one empty chair is soon filled by an energetic younger man with a clipboard.

"OK, who wants to start?"

No response. 

"Anyone?...No?...OK let's begin with Dr. Dave. Dave, start us off"

"My name is Dave and I'm an autonomic. I haven't demanded autonomy for three weeks now. It's very hard. I still have the urge to interrupt people and help them understand how their thinking process is flawed. I still find it hard to listen to people who are not as smart as I."

"Thanks, Dave. It is hard, but you're doing it. You're doing the hard work and we're proud of you.  Jim?"

"My name is Jim. I haven't demanded autonomy for three months now. The other day, I actually asked a Pharmacist for help!"

Jim is interrupted by applause and shouts of "Right on!, Great job, Jim, You da man!, Dude!"

"My name is Jack. I haven't demanded autonomy for six weeks." Yesterday, I attended a meeting with my team and complemented a nurse who came up with an idea to further reduce wound infections on our surgical floor."

The group again erupts with accolades. "Great work Jack! Way to go! Sweet!"

"My name is Kevin. This has been a very tough week. I came so close to behaving autonomously that I had to call Carl for an intervention....." Kevin begins to sob as others in the group approach and give him a group hug.

OK, not a likely scenario in the near future. But if we define addiction as a compulsive pattern of behavior that is obtained through repetition and persists despite evidence that it is harmful, then is it really a stretch to view our demand for autonomy as an addiction?

When we counsel patients with an addiction to tobacco, alcohol, or drugs, what do we recommend as the first step? We urge the patient to accept the fact that the addiction exists. Isn't it time for us to take that first step and at least recognize that as a profession we are addicted to autonomy? 

I'm not sure the number of steps involved in the Autonomics Anonymous program, but I think I know the first one.

Physician leaders need to confront their own demons with autonomy. Far too often physician leaders, because of their medical training indoctrination, are reluctant to ask for help with the skills they need to be more effective. A good coach or mentor is critical in developing effective leadership skills.

Take it from someone who has wrestled with the autonomy addiction. Ask for help. It is very uncomfortable the first time, but with practice it keeps getting easier. 

Yes I get by with a little help from my friends.

The Value Proposition for Healthcare: 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.  

Leadership Lessons Learned From Childrearing

Effective parenting, like effective leadership, is a demanding, often emotionally draining task.

I have attended leadership courses and conferences, read many books on leadership and many biographies of people I admire as great leaders: George Washington, John Adams, Alexander Hamilton, Thomas Jefferson, Abraham Lincoln, Teddy Roosevelt, Winston Churchill and Martin Luther King. I have been privileged to hold leadership positions in my practice and in my community. While I have learned from all of these sources, I credit my children with teaching me the most about what it takes to lead..

My wife and I, both physicians,  have been blessed with four wonderful children. (The woman just couldn't keep her hands off of me).  It seemed to us that if we could complete medical school and survive our training, raising children would be fairly easy. Gather the data, analyze it and act upon it. It took us a while to realize that being successful parents required a lot more EQ (emotional intelligence) than IQ. The same rule applies to leadership, EQ trumps IQ. Always.

A short parenting vignette and what it teaches about leadership

When our youngest returned from his first semester of college to inform us that he was joining a fraternity with a reputation that would put "Animal House" to shame, we were less than pleased. Our natural reaction was to immediately point out that 1) we weren't paying tuition so he could party, 2) that living in a environment filled with distractions wasn't the best idea for a kid with ADHD and 3) he was already struggling to pass his courses.  Fortunately for him (and for us) his three older siblings had taught us to explore the reasons for his decision. We bit our tongues as he told us how his future brothers would make sure he was studying, how he would focus more on his classes if he could enjoy his time away more and how this move was going to save us money. Instead of reacting emotionally (NFW!), we told him we would think about it and let him know our decision the next day.

The two of us both agreed that while the decision wasn't the stupidest one he had ever made, it certainly wasn't a good one. We openly expressed our anxieties that for all the obvious reasons, the decision could be disastrous, but agreed that telling him he couldn't join would not only make him want it more, but more, importantly, not allow him to learn to experience the consequences of a wrong decision. We were able to identify the long range goal: fostering a morally centered, independent, successful adult who contributes positively to his community, from our short term anxiety: watching our child flunk out of college. We worked out a proposal that focused on the long range goal while limiting (but not erasing) the short term consequences. We would let him join, but only for the rest of this year (two more trimesters). If his GPA didn't improve, back to the dorm it would be. Our job, however, was not to mandate the parameters, but help him set them himself.

"So here's the deal", we informed him the next day, "We know that you are trying your best to stay in school and that this is a struggle for you. We admire your persistence. It sounds to us like you see joining the fraternity as an opportunity to do better in school. Could you tell us how you will be able to tell whether this decision is consistent with you goal?"

He thought about this for a while and surprised us with his proposal. If his GPA didn't go up at least a half a point in ONE trimester, he would move back to the dorm. 

A few weeks later while we were worrying how far his GPA would fall and whether he would stick to his agreement, we received a call from him telling us that he had made a mistake. He should have listened to our concerns about the fraternity. He wanted our OK to move out of the fraternity BEFORE the end of the trimester while he still had a chance of improving his GPA.

So what lessons did we learn from our previous parenting experience that helped us influence(read: lead)  our son to make the right decision. 

 1. Parenting (leadership) is all about influencing others to make the right decisions, not about making the decision for others. When others make their own decisions, they own the decision. They are committed to its outcome and, most importantly, committed to its consequence.

2. Parenting (leadership) is about optimism. It's easy to get caught up with all the things that could go wrong when we enable others to decide. After all, who knows better than us how to do things right? But the more we can infuse others with the optimism that they can problem solve, the less likely they will fail and the more likely they will continue to succeed.

3. Parenting (leadership) is about trust. It's a leap of faith to allow others to make critical decisions, to relinquish control. It's hard work to establish and maintain trusting realtionships with others. But the work is worth the long term gains that trust accomplishes.

4. Parenting (leadership) is about controlling our amygdale (emotions) and empowering our cerebral cortex (reason). We process information that stimulates our amygdale. Others share information that is threatening or evokes fear (too often in a threatening or intimidating manner). Our mammalian amygdale based instinct is toward fight (respond in a hostile manner) or flee (ignore) the information. Effective parent (leaders) separate the message from its emotional context. In the above example, fro instance, through a time out. Decisions made while emotions are prevailing are seldom good ones.

5. Parenting (leadership) is about long term vision. It's about keeping the focus on the ultimate goal rather than controlling the process. Sometimes allowing others to fail is more important than in solving their problems for them.

6. Parenting (leadership) is about accountability. It's about holding ourselves and others accountable for our actions and thier results. If we adopt your plan, what will be the metrics of success, how and when and who will we measure them?  

Effective parenting, like effective leadership, is a demanding, often emotionally draining task. I would argue that nothing, however, is more rewarding.

Someone Needs to Run the Asylum: Why Physician Leadership is the Answer

We physicians are understandably worried that the push to save money in health care will compromise the care of our patients.

We have witnessed botched attempts to balance the health care budget on the backs of providers and patients: arbitrary reductions in length of stays, denial of payments for "unnecessary" procedures, capitation, etc.

Physician leaders have an opportunity today to lead the way forward to improve care and save money. The solution is quality, measured by patient centric metrics. Physician leaders need to set the bar high and demand consistent patient centric quality care from all of their colleagues.

A true story (the names have been changed to protect the guilty) serves as an example of an opportunity to increase quality and reduce health care costs.

I received a call last week from my cousin Cheryl, who lives in a suburb of Philadelphia. Cheryl has a neurological disorder that is exacerbated by stress. By the tone in her voice it was clear her health was at risk.

Her 50 year old husband, Ron, was admitted at 0200 on a Saturday to a local hospital after awakening with severe sub sternal chest pain described as "someone sitting of my chest". Ron has a well documented history of GI reflux, but also has multiple risk factors for coronary disease.

Ron's ECG was normal and his initial set of cardiac enzymes were normal. He was admitted to the hospital service of a cardiologist. Cheryl was calling at 1100. The cardiologist had not yet seen Ron. When Cheryl questioned the nurses about the expected time of his arrival, she was told that Dr. Jones had made his rounds already and would not be back until the next day.

Cheryl had, understandably, some important questions that she would have loved to ask the cardiologist. Did Ron have a heart attack? Did Ron have something else wrong with his heart? How serious was the present scenario? Should her 20 year old daughter take the train from her University in Maryland and miss her classes next week? Should Cheryl inform her chronically ill elderly mother of the situation? How long will Ron be incapacitated? Who would help her in his absence?

Dr. Jones showed up early Sunday morning. He was covering for several other cardiologists and had limited time to answer Cheryl's questions. He did inform her that Ron did not have heart attack. He might have cardiac disease, however, and therefore could not go home until a stress test was performed. Since it was Sunday, the treadmill could not be performed until Monday morning.

Ron did have the treadmill performed on Monday (late in the afternoon; there were others waiting as well). The treadmill was normal and a GI consult was ordered. Ron had the sense to check himself out of the hospital rather that wait another day for the gastroenterologist.

I don't claim to know the culture of cardiology throughout the country. I do know, however, that there is no hospital in the Seattle metropolitan area where this scenario would have occurred.

Because of effective physician leadership the cardiologists and ER physicians in our area have instituted chest pain observation units for just this sort of problem. If Ron was visiting me when this unfortunate incident occurred, he would have been admitted to a chest pain unit and, when the third set of enzymes came back negative, he would have had a diagnostic test and discharged within 24 hours. The family would have received appropriate answers and short term outpatient follow up.

The family would be happy to have their loved one home quickly, to have their anxieties addressed and resolved. His care in a chest pain observatory unit would not only have provided patient centric quality, but would have saved two days of unnecessary hospitalization costs. Multiply the thousand of dollars saved here by the number of times this kind of scenario occurs and fat, not muscle, disappears from the health care budget.

Physician leaders should be examining the way health care is delivered from a patient centered perspective. Influencing their colleagues to rethink outmoded physician centric behavior will require the mastery of leadership skills. The alternative is to let the lunatics continue to run the asylum.

Bigger Isn't Better; Better is Better

Breaking The Paradigm of Quantity: A Challenge for Physician Leadership

One of my favorite Jackie Mason jokes goes something like this. A potential customer enters a store whose sign in the front window proclaims: "WE SELL NOT JUST BELOW RETAIL.  WE SELL BELOW COST!". He skeptically approaches the store's proprietor and asks, "How can you manage to make a living selling below cost?" "Simple" answers the owner, "We make it up with volume!"

When I tell this joke to  Hospital CEO's or CMO's they laugh until I suggest that they may be doing the same thing with their medical staff strategy: bigger is better. The bigger the medical staff and the bigger their referring volume the better the hospital's bottom line. The bigger the size of a physician's practice the better the quality of the physician. "He/she must be a great doctor, look at the size of his/her practice and how many patients he/she refers!".

This unfortunate strategy has lead to a stampede of practice acquisition, joint ventures, and "institute models" that have, for many, succeeded in bigger referral patterns for hospitals. Unfortunately, few of these bigger systems are actually better. In fact, the acquisition of heterogeneous physician groups with the accompanying variation in practice styles, work ethic, quality and culture have made put further strains on the search for medicine's holy grail: consistent, measurable, efficient and excellent outcomes.

One could argue that this strategy didn't make a lot of sense even when it was embraced in the bygone days of fee for service. It made even less sense when DRG's were introduced and will prove fatal once bundling of all services and ACO's (capitation on steroids) take hold. Organizations that will succeed are those who invest now in developing excellent physician leaders: those who can influence, model and hold others accountable for consistent, measurable, efficient and excellent outcome. This will often require trimming rather than enhancing the number of physicians with admitting privileges.

The winners here will be those systems that recognize bigger isn't better: better is better.

Medical Leadership: You Can't Win the Iditarod With a Team of Pit-Bulls

Medicine is no longer a single doc in a silo.

I, as well as most of my colleagues in medical leadership, trained in the era of the medical pit bull. The most desirable medical schools and training programs were the ones where only the strongest were admitted and the toughest survived (and we're not talking just about the patients!).

We loved the Professor and Attendings who put the most unrealistic demands on us. We mocked colleagues who complained. Being on call every other night meant missing half the patients. Leaving the hospital before 9 PM on your "night off" showed a lack of commitment. Asking for help showed weakness and incompetence. Sensitivity was seen as a barrier to optimal performance.

We pit bulls did well in an era when medical practice and care delivery were performed in silos. Trained for autonomy, we ruled in an environment that encouraged and rewarded such. You can't beat a pit bull one on one.

Imagine now a "team" of pit bulls. Imagine them harnessed together and expected to pull a sled laden with enormous weight over the most difficult of terrrain with minimal resources. Not a pretty piucture. Maybe we need to train more huskies and less pit bulls.

But wait, you say, medical schools have changed since the days of purges and leaches. They are investing in diversity, sensitivity training, and communication. Perhaps, but there are still a lot of us pit bulls on the faculties and, more importantly, in positions of leadership and authority in healthcare delivery systems.

While we're training future sled dogs, we need physician leaders today who can get the pit bulls to pull the sled together. this is our challenge now and for the foreseeable future.

Effective physician leadership requires a combination of traits and skills. Fortunately many physicians already possess leadership traits: passion, self-confidence, and knowledge. Unfortunately, however, most need to learn leadership skills: mastery of emotional intelligence and crucial conversations, relationship management, and team building. With proper training, motivation and commitment, these skills can be acquired.

The era of medical autonomy, silos and fragmentation is over. The fantasy of the pit bull cannot be sustained by our financial and demographic reality. The only way to maintain healthcare quality, reduce its cost and increase its distribution is to integrate its delivery along the broadest of continuums. Unexplained variance must be eliminated, outcomes must be tracked and performance metrics must be measured. All of these challenges will require cooperative rather than autonomous behavior. This is our Iditarod sled. We need trained physician leaders who can help us drag this sled together to the finish line.