Sunday, October 30, 2011

AMCs: Off target and lacking a sense of urgency

As noted in a previous post, I was impressed negatively by a Mt. Sinai hospital paid op-ed that extolled the virtues of academic medical centers while making no reference to the role that such centers could play in improving the quality of care delivered in America.  While acknowledging the attributes of AMCs, I said:

But these statements fail to tell the story of how academic medicine, in many institutions, is failing the American public.

It does not, for example, explain why many AMCs have been slow to adopt proven tools of process improvement to reduce harm to patients and improve efficiency. 

It does not explain the  persistent lack of transparency in many such institutions with regard to clinical outcomes, notwithstanding the documented value of such transparency in improving quality and safety. 

It does not explain why the medical schools that own or are affiliated with many AMCs have failed to train their students in how to use the scientific method to improve the delivery of care.

It does not explain the huge variation in practice among residents and attending physicians, giving lie to the concept of evidence-based medicine.  

It does not explain the reluctance of many AMCs to engage patients and families in the design and delivery of care.

A friend referred me to a summary of TEDMED talk by Daniel Kraft, which reinforced these points:   

Notably Daniel spoke about how when he finished his training at Massachusetts General Hospital 15 years ago the hospital still functioned, from an delivery standpoint, in about the same way as it does today, with specialty silos, defined training hierarchy, etc.

I am guessing that Daniel's talk was mainly on how to leverage new technologies in the health delivery system, but his observation applies more generally, too.

Ironically, one of those Mt. Sinai op-eds (John Morrison and David Muller, "Science and Medicine in the Service of Society," September 10, 2010) made related points:

Historically, medical schools emerged within universities primarily to educate physicians, yet Master’s and Ph.D. programs centered at medical schools now produce the vast majority of the scientists trained in biological arenas relevant to medicine.

All too often, these programs simply co-exist, isolated by different curricula and cultures. If we are to maximize our capacity to impact clinical practice through scientific discovery, we need to produce leaders in biomedicine and health care who see themselves as members of large, interactive teams committed to clinically relevant breakthrough science.

Meanwhile, Michael Nielson in the Wall Street Journal notes that networked science uses "online tools as cognitive tools to amplify our collective intelligence. The tools are a way of connecting the right people to the right problems at the right time, activating what would otherwise be latent expertise."

He notes, though, that this is not rewarded in the field:

Even if you personally think it would be far better for science as a whole if you carefully curated and shared your data online, that is time away from your "real" work of writing papers. Except in a few fields, sharing data is not something your peers will give you credit for doing.

How interesting that people in academic medicine are able to see the need for a more integrated, cooperative, and collaborative approach to medical training, research, and work flows when it applies to the advance of basic science and technology, but they have yet to modify the structure of their academic centers to allow such behavior to thrive.  And, beyond that, they remain blind to the idea of applying those same concepts to the actual delivery of care.  Were they to do so, we could be saving thousands of lives right now, well before the next great cures to disease are developed.

Example:  At a recent meeting of medical academic leaders, the president of one center proudly reported over the growth in faculty, in enrollment, in buildings, and so on at his institution.  Someone asked him about systematic quality improvement.  He cited improvements on Press-Ganey results, acting as though this was the surrogate for quality improvement.

Off track and too slow, folks.  Too slow.  As we have seen, if you don't start to define the important clinical improvement issues and make progress, the government will do it for you and do it wrong.

Recall what Captain Sullenberger said, ""I wish we were less patient. We are choosing every day we go to work how many lives should be lost in this country."

"We have islands of excellence in a sea of systemic failures. We need to teach all practitioners the science of safety."


Steven Davidson said...

From Facebook:

Steven Davidson Your piece is mostly on target, but there are islands of sanity. Notably Jim Yong Kim, MD, PhD, President, Dartmouth College (formerly of Harvard) who I quote every day in my email tagline thusly, “. . . the rocket science in health and health care is how we deliver it.”

Paul Levy said...

Dr. Kim is one of my heroes!

Anonymous said...

" And, beyond that, they remain blind to the idea of applying those same concepts to the actual delivery of care. Were they to do so, we could be saving thousands of lives right now, well before the next great cures to disease are developed."

I suspect this blindness is because this sort of activity lacks the glamor of a new surgical procedure or genomic advance, and the attendant prestige/promotions/$$ rewards. But how insightful you are, Paul, to point out (repeatedly) that this activity directly saves lives, and in much greater quantity than the more glamorous ones. This is why Dr, Peter Pronovost is such an important pioneer in this field. I only wish others were more willing to emulate him.


Dr. Fred said...

Paul,Thank you. You are on target as always. As a biomedical investigator for 30 years I am now fully on board. I am presently trying to apply my scientific skills to improve quality and safety. I have realized that we need to approach this problem from many angles. First everyone must understand human error and how to prevent what normal human mistakes, secondly we need to understand that we can apply manufacturing principles like Toyota Production System, third and as you indicated we must work as effective teams, fourth we need adaptive leaders who are eager and willing to bring about change (as you did), and finally we need to apply organizing techniques to change our presently dysfunctional cultures to return our focus on the key goal, improving the health and well being of our patients.

Paul Levy said...

Yay, Dr. Fred! Exactly!

Barry Carol said...

This subject is well out of my area of expertise but it seems that one of the bigger challenges is to get cultural buy in from doctors, especially when they’re not employees of the hospitals but independent contractors with practice privileges. Administrators need to be prepared to revoke privileges even from highly regarded rainmaker docs when appropriate to establish credibility. They also need to stand behind nurses and techs that are willing to risk speaking up when they see mistakes being made by doctors, especially surgeons.

I also wonder to what extent Dr. Provonost’s excellent work on patient safety was influenced by the tragic circumstances that caused Josie King’s death at Johns Hopkins in 2001.

Bruce Ramshaw said...

Paul, you are right on target, as usual. This is why I quit my position as a tenured professor (Chief of General Surgery) and left a traditional academic medical center to start a new academic medical center model. Any system is designed to produce the results it is designed to produce (and one of the outputs of our current health system model is the physician and administrator behavior). I believe changing our academic medical center model requires a new system structure for care delivery if we are going to see significant and sustainable improvement.
Barry- I just saw Dr. Pronovost give an excellent talk yesterday at the Planetree Conference in Nashville yesterday. The death of Josie King and his promise to her mother to personally try to improve safety is a major motivator for him (he describes this in detail in his book).