Friday, April 16, 2010

Individuals and Institutions

Wife Marilyn just got a new knee. She was admitted to the New England Baptist Hospital in Boston early on a Friday, operated on later in the morning, and discharged to home the following Monday.

This was her second total knee replacement. Her first one was about a year and a half ago, also at the Baptist, but by a different surgeon.

When discussing the first operation, the Orthopedist said that surgery was a team effort. I haven’t dealt with many surgeons lately, but that was the first time I had ever heard one say that.

This time, it was clear that many of the procedures that were implemented during the extensive pre-operative work-up and the postoperative care had been standardized on an institutional basis. In earlier years they would have been based on the preferences of the surgeon.

The benefits of standardization can hardly be overstated. What is done has been collectively determined – hopefully based on evidence rather than on the preferences of individual doctors. It reduces the risk of error due to oversight or miscommunication. Standardizing protocols simplifies the work of all caregivers and makes them more efficient. It facilitates teamwork by increasing predictability.

It was also clear that the surgeon had the right to overrule the protocol – thereby avoiding the hazards potential in “cookbook medicine.”

It is to be noted that it is the hospital that provides the institutional framework together with the support, discipline and continuity that makes standardization and effective teamwork feasible.

Personal service will always play a major role in health care and so the qualifications, skills, and dedication of individual caregivers will always be critical. But we must accept that institutions are also essential. They must be trustworthy and we must learn to put our trust in them.

Thursday, April 08, 2010

When does more become too much?

It is often, though not always, the case that more is better. But there always comes a point at which more becomes too much.

Thanks to the advice and generosity of Chris Van Gorder, CEO of Scripps Health in San Diego, I have recently finished reading a book titled The Heart of Power by David Blumenthal and James Moroni, respectively of Harvard and Brown Universities.

Beginning with Franklin Roosevelt, the book discusses each President (except Ford) and the approach he has taken to healthcare-related issues.

One of the generalities arrived at by the authors is that a President’s success in pursuing healthcare legislation is dependent, in large part, on his ability to muzzle economists. They suggest that any President pursuing a healthcare agenda has to downplay the cost involved since it is almost impossible to get such legislation enacted if the ‘true’ cost becomes known. The influence of economists within the federal government has grown during this period and they can be counted on to express concern about the legislation being proposed, based on realistic estimates of its cost.

I have no idea whether President Obama has read the book or knows about it, but he obviously followed the advice of Blumenthal and Moroni. He was able to keep the economists under control and succeeded in getting a law passed. As with all other such legislation, the cost will surely be much greater than was represented during the debate.

The question is whether this is the time that more becomes too much. Time will tell.

Sunday, April 04, 2010

Should Doctors Have Bosses?

As a general rule, we believe that human activity is more productive and more efficient if it is organized and managed.

One prominent exception is patient care. Hospitals are organized and managed. Medical groups are organized and managed. Rehabilitation centers are organized and managed. But the actual care of patients is for the most part left in the hands of individuals.

Like many seniors, I am under the care of multiple physicians – a primary care doctor and specialists for particular conditions. They barely know each other and communicate rarely. When I have used the services of the hospital – either as an inpatient or in its emergency room - I have been cared for by practitioners of various sorts without anyone having overall charge of my case.

That, together with the absence of any accountability for how many and what kinds of services are used by these practitioners along the way, has to be an important reason for the high cost of care.

Why don’t we organize and manage care? The main reason, I think, is that doing so would mean that our doctors would have bosses and we don’t like that. We resist the possibility that the decisions of our doctors might be controlled, or at least significantly influenced, by people who serve as their “bosses.”

And yet, until care is organized and managed it will be inefficient and outcomes will vary.

That is a cultural issue that will have to be dealt with if we are to have true health care reform.

This page is powered by Blogger. Isn't yours?

FREE counter and Web statistics from sitetracker.com