Sunday, June 14, 2009

Positive Deviants

Dr. Atul Gawande is a general and endocrine surgeon at the Brigham and Women's Hospital in Boston, MA, who also writes wonderful articles for New Yorker magazine. One of his recent articles, The Cost Conundrum, is a disturbing in-depth exploration into why health care costs in McAllen, TX, one of the highest in the US, are twice as high as those in El Paso, TX, despite its similar demographics.

His most recent article was his commencement address to the graduating 2009 class of the University of Chicago Pritzker School of Medicine.

In his address, he related the story of a friend who ran a program to reduce malnutrition in Vietnamese villages but, like many humanitarian enterprises these days, had little funding. So instead of the usual methods advocated by outside experts, they used a low-tech approach.
They went to villages in trouble and got the villagers to help them identify who among them had the best-nourished children—who among them had demonstrated what Jerry Sternin termed a “positive deviance” from the norm. The villagers then visited those mothers at home to see exactly what they were doing.

Just that was revolutionary. The villagers discovered that there were well-nourished children among them, despite the poverty, and that those children’s mothers were breaking with the locally accepted wisdom in all sorts of ways—feeding their children even when they had diarrhea; giving them several small feedings each day rather than one or two big ones; adding sweet potato greens to the children’s rice despite its being considered a low-class food. The ideas spread and took hold. The program measured the results and posted them in the villages for all to see. In two years, malnutrition dropped 65 to 85 percent in every village the Sternins had been to. Their program proved in fact more effective than outside experts were.
Gawande then goes on to explain how the United States is now that village, with our crumbling economy, rising unemployment, and auto, financial and housing industries in serious trouble.
More than that, though, we in medicine have partly contributed to these troubles. Our country’s health care is by far the most expensive in the world. It now consumes more than one of every six dollars we earn. The financial burden has damaged the global competitiveness of American businesses and bankrupted millions of families, even those with insurance. It’s also devouring our government at every level—squeezing out investments in education, our infrastructure, energy development, our future.

As President Obama recently said, “The greatest threat to America's fiscal health is not Social Security, though that's a significant challenge. It's not the investments that we've made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation's balance sheet is the skyrocketing cost of health care. It's not even close.”
While a large part of those costs are administrative costs, the bulk of extra spending is due to extra tests, procedures, specialist visits and treatment—things that doctors control.
Yet studies find that in high-cost places—where doctors order more frequent tests and procedures, more specialist visits, more hospital admissions than the average—the patients do no better, whether measured in terms of survival, ability to function, or satisfaction with care. If anything, they seemed to do worse.
He points out that, like the researchers in Vietnam, we need to look for successful outliers if we are to solve our healthcare crisis. But while he zooms in to some degree of some unique models, he doesn't zoom in close enough. I think the "positive deviants" he and the rest of the country are looking for are IMPs—Ideal Medical Practices.

Small, low-overhead, cost-effective practices with unfettered access that have both highly satisfied patients and healthcare providers, with reproducible measures of success. Definitely outside the norm. I'm not talking about solo no-staff micropractices such as mine, although that could be part of the solution. I'm not talking about all primary care physicians becoming IMPs. As has been pointed out before, we don't have enough primary care doctors to take care of everybody if we adopted that model for the entire nation. It is the underlying principles behind the IMP model that need to be looked at more closely.

IMPs focus on that "secret ingredient" that has been disappearing from our current healthcare system for quite some time. Namely, the doctor-patient relationship. Study after study has shown that when patients have a relationship with their primary care doctor, quality rises and costs fall.

When I have the time to know my patients, their histories and symptoms, I can order appropriate, targeted tests rather than a scattershot battery of tests hoping to hit something. When patients have easy access to me, we can wait and see if symptoms get better rather than get that MRI or refer to a specialist on the 1st visit. When patients know and trust their doctor, they are more likely to get preventive screening tests and feel motivated to follow through with lifestyle changes. When patients know who is in charge of their healthcare, they are less likely to end up in the ER or hospital. Healthier patients mean less disease or at least better controlled disease, which results in lower healthcare costs.

Whatever healthcare reform ultimately looks like, it has to include the doctor-patient relationship as a centerpiece in order for it to succeed.

Gawande ends his address to the future physicians with these thoughts:
No one talks to you about money in medical school, or how decisions are really made. That may be because we’ve not thought carefully about what we really believe about money and how decisions should be made. But as you look across the spectrum of health care in the United States—across the almost threefold difference in the costs of care—you come to realize that we are witnessing a battle for the soul of American medicine. And as you become doctors today, I want you to know that you are our hope for how this battle will play out.
I graduated from medical school in 1987. One of the reasons that I went into medicine was because I didn't want to go into business. I never thought that medicine would turn out to be one of the biggest business battlegrounds ever. And yet, as in Tolkien's epic Lord of the Rings, the battle may ultimately be decided by someone small and seemingly insignificant.

You might even say, IMPish.