Wednesday, April 02, 2008

More from Brent James

Another part of the Silverman Institute's inaugural event was a grand rounds presentation by Brent James for our medical staff. When I saw the title of yesterday's talk -- Quality health care for the 21st century: A new outlook for humanity -- I said, "Wow, that's pretty expansive!" As it turned out, it was an accurate description of the talk. Let me try to provide some highlights.

First, we were grounded by the fact that the main determinants of health (in terms of how long we will live) are:
-- 40% Behavior (tobacco, alcohol, and obesity)
-- 30% Genetics
-- 20% Environment and Public Health
-- and only 10% Health Care Delivery (hospitals and clinics).

In 2006, the US spent $7100 per person, or 16% of GNP, on the last category. The trend in this cost is dramatically upward. What do we get for all that money?

Much of the US system is based on the rapid response aspects of health care. In contrast to other countries, where the emphasis is on primary care, we spend a lot on treating those problems. We provide better access to specialists and to technology, and we do not ration these services as they do elsewhere. Accordingly, the US mortality rate for heart attack and trauma, for example, is well below Europe. But the impact on overall mortality of our progress in these secondary care arenas is overwhelmed by the impact of a strong primary care emphasis in other countries.

James cites "the rule of rescue" as a reason for this. This is defined as "the imperative people feel to rescue identifiable individuals facing suffering or death." (Jonson, 1986 -- Sorry, I don't have the full cite and can't find it.) Our health care delivery system is skewed in this direction.

Ironically, other countries are now finding an increased demand for rescue care and so are seeing large financial pressures emerge in that segment of their own systems. (See my post below on Tuscany's desire to expand emergency services.)

After this overview, James turned to the problems in our system. As he notes, these actually emerged as a result of the design of the medical system through the 1900's, and he quoted Albert Einstein as saying, "Today's problems are often yesterday's solutions." Here are the problems:

-- Well-documented massive variation in practice based on local medical myths.
-- High rates of inappropriate care.
-- Unacceptable rates of preventable care-associated patient injury and death. (Hospitals are actually the #4 or #5 major public health problem in this regard!)
-- A striking inability to "do what we know works".
-- Huge amounts of waster and spiraling prices that limit access.

Why have these problems emerged? We continue to rely on the "craft of medicine", in which each physician practices as an independent expert -- in the face of huge clinical uncertainty (lack of clinical knowledge; rapidly increasing amount of medical knowledge; continued reliance on subjective judgment; and limitations of the expert mind when making complex decisions.).

We can begin to overcome these problems by practicing medicine with a "Shared Baseline" approach (a form of LEAN production) in which you measure, learn from, and (over time) eliminate variation arising from the professionals -- while retaining the variation that arises from the patients. He terms this "mass customization." This will assisted by full use of electronic medical record capability, and it will need to be done to make full use of EMRs. Finally, care needs to be organized around the team of caregivers, and not the individual practitioners.


John Norris said...

"The Rule of Rescue" a term created by AR Jonsen.

Jonsen, AR 1986, ‘Bentham in a box: technology assessment and health care allocation’, Law,
Medicine and Health Care, Vol 14, pp172–4.

(I am not able to verify this citation, but got it from "The Rule of Rescue" Richardson J, McKie J. Centre for Health Program Evaluation.

Paul Levy said...

Thanks, John.

Anonymous said...

Yep, the days of the individual practitioner are dwindling. Hospitals and docs have to get married (at the risk of repeating myself). I think this will have both positives and negatives, but there it is.

nonlocal MD

Anonymous said...

This approach demands more than the development of and adherence to evidence-based protocols. This trend is happening rapidly. It also requires the humility and mutual respect inherent in teamwork, and an elevation of QI leaders within institutions. Is the craft of medicine adapting to this?

Dr. Incognito said...

This post has been selected as this week's winner of the Scrubby Award by Along with this recognition comes a free (no-strings-attached) pair of red scrubs.

Paul Levy said...

Awesome! But with no strings, how will the pants stay up?

Dr. Incognito said...

That thought occured to me as I was writing the comment, but I let it go. Good to see you're not afraid to share your sense of humor:)

Gilles Frydman said...

It looks like part of Brent James presentation talked about exactly the same issues that have comnsumed Larry Weed for many years. For example, in his presentation at IHI in 2006 L. Weed said: "The unaided human mind is not a reliable instrument for this processing of information in the solution of patients’ problems. It should not be licensed to try the impossible. Yet, medical education and licensure permit physicians to try exactly that. Even worse, the legal credentials conferred on physicians insulate them from competition by less expensive caregivers who would otherwise choose a better way to practice medicine. Non-physician caregivers equipped with software tools optimized for medical information processing could outperform physicians, and thereby avoid vast error and waste, all at much lower cost."

It is possible, even probable, that in the end, the only solution to overcome the problems mentioned by Brent James will require a deeper paradigm shift than what can be achieved by the LEAN management philosophy, applying to healthcare entities some of the ideas developped in Eric Von Hippel's Democratizing Innovation. The sooner you'll involve the end-users of your system (the engaged and informed patients we call e-patients) to help in the innovation process necessary to solve some of the failures of modern hospitals the faster you'll be able to produce profound results, IMHO.

Mark Braunstein said...

I found the Jonsen paper here:

and it definitely uses the term "rescue" in the sense that Brent James intends.