Presented by: Sean Palfrey, MD, FAAP, Pediatrician and
Professor of Clinical Pediatrics and of Public Health at Boston
University.
I am a general pediatrician, and I love practicing medicine
...still. I love the science. I love working and playing with
children, well or ill, talking with and teaching parents how to
keep them well, and helping them heal.
Within my lifetime, our profession has changed profoundly. The
practice of medicine is exciting but extremely complicated
…scientifically, technologically, financially and academically.
And, we are at a breaking point. The fact is that in order to
address and take advantage of all the new elements in the practice
of medicine - we, (you and I) - have to rethink how to learn and
utilize all the new science, treat all our patients,
orchestrate and finance our practices, and train and work
with a new constellation of health professionals.
Every generation faces new challenges. I came into medicine when
most doctors worked in solo practices and general hospitals. Just
40 years ago, most of us had only rudimentary understanding of
micro-biology, immunology, and pharmacology. The genetic code was a
brand new concept. Doctors treated patients in the context of their
families, diagnosed illnesses on the basis of the patients'
histories and physical exams, and treated them with a small
formulary of inexpensive medications.
As a young pediatrician, it was possible for me to have a fair
grasp of pediatric medical science, diagnostic procedures I needed
to use, and available medications for children. In fact, as a chief
resident at Tufts, I ran the PICU and NICU, and knew the condition
of every child in the hospital. My colleagues and I felt fairly
confident that we were providing the children with the full range
of services then available.
Several generations later, residents and young physicians, who
have grown up in a world of exploding science and technology,
cannot begin to know it all. They are surrounded by specialists and
subspecialists in scores of fields, and research is feeding us new
information every day. These young people have grown up in a
digital world. They were, as our son John Palfrey says, "born
digital", and are "digital natives". They see the practice of
medicine in a whole new way.
I practice and teach every day, and when I walk onto the wards,
I find the students and residents sitting in a conference room,
working feverishly at computers, typing in orders, checking blood
and imaging results, requesting consults and reading reports and
recommendations for more tests and procedures. During rounds, even
in the guise of "family-centered" walk rounds, they spend most of
their time in the hallways or huddled around the foot of a bed
(near the wheeled computer), talking in impersonal and medical
terms about 31-B (really a child or young adult).
But it is not just the young physicians. In this new world - on
the wards and in the ICUs, in clinics and practices - all of
us, to varying degrees, hurry past our patients toward the bottom
line, more results, more tests. Almost everything important to us
is on-line, in a box or in the cloud. Despite huge reservoirs of
human warmth and dedication, doctors are distancing themselves from
their patients. We take histories and do physicals and transcribe
them into an electronic template. That's where the patients live.
They are stored, their data arranged and rearranged, like avatars
of their child-hosts, sometimes almost real.
Within our lifetimes, science and technology have redirected our
focus away from the patients themselves. Daily, scientists are
discovering the most basic mechanisms of normal physiology and
pathophysiology at the molecular level. Often, within months, these
findings are translated into tests, images, and new procedures,
each one more expensive than the last. This is so fantastic that we
all want to know it all, and take advantage of the new knowledge -
well before it's clear how useful this information might be for our
patient management.
Unfortunately, over these past decades, our health care system
has permitted, even encouraged, all of us to alter our practice of
medicine to embrace these new options without the necessary
discipline. Because manufacturers and insurers are by and
large competitive, for-profit companies, incentives, and few
disincentives, have been created for doctors to access new products
and see them as essential to good practice, and consumers look for
every benefit they can get covered, without knowing the risks and
benefits, or fiscal consequences.
Similarly, our fee-for-service system pays us and our hospitals
better if we order more tests, consult more specialists, and
perform more procedures. There are few counter-balances to doing
more, and we and our patients have become seduced into the
misconception that "more is better", and "more expensive medicine
is better medicine". Large quality studies have shown, however,
that by practicing this way, we have achieved few improvements in
health outcome. By adopting such an expensive style of practice, so
much money is spent on covered patients that there is not enough to
provide any health care at all for millions of Americans, and the
health care sector is jeopardizing the financial health of our
country's economy.
US health care costs twice as much per patient as the next most
expensive country in the world, and 3 - 5 times more than most
other first world countries. Yet we generate poorer health outcomes
year after year. The US ranks 50th in the world in terms of life
expectancy, 23rd in the world in terms of overall child health
measures, including neonatal mortality, quality of life years, teen
pregnancies, gun violence, and others.
According to the Congressional Budget Office, 5% of US gross
domestic product - $700 billion - goes to tests and procedures that
do not actually improve health outcomes, and the CBO further states
that future health care spending is the single most important
factor in determining the nation's long term fiscal condition. And
despite spending 2.7 trillion dollars each year on health care,
approximately 51 million Americans have no health insurance at
all.
We are at a very difficult juncture - a point where we have an
embarrassment of scientific and technological riches that we need
to learn to use optimally, yet we provide health care outcomes that
compare poorly with the rest of the world. Yin and Yang. So this is
a moment of huge opportunity as well as serious crisis.
When I wrote a Perspective entitled, "Daring to Practice Low
Cost Medicine in a High Tech Era" about all this last March in the
NEJM, within a few days we got 150 responses agreeing with my point
of view, not just from this country but from around the world as
well. These observations hit a nerve.
One doctor summed it up this way: "It is extremely revealing
that not a single response to this important article has disagreed
with its central premise - not a one! We ALL know what is going on,
but we seem helpless in the face of financial incentives and
pressures, political currents, legal threats, and our increasingly
impersonal and technophilic culture."
Physicians, both generalists and specialists, admitted that they
were ordering clinically unnecessary tests and procedures, even
when their clinical judgment urged them not to. They agreed that
most of these excessive and costly practices were caused by their
own medical curiosity, the easy availability of the tests, lack of
knowledge of their costs and cost-benefits, community expectations,
need for personal reassurance, and desire to protect themselves
from possible law suits. Many, from the US and Europe, from India,
Brazil, Thailand, Mexico, and other countries, reported that they
practiced one form of medicine in one setting and another in other
settings, but that the outcomes were little different.
What can we do?
It seems to me that there are three major categories we need to
address: First, we need to teach ourselves and our trainees to
balance the huge benefits inherent in the new science and
technology in this digital age with the age-old wisdom of basing
all we do on the patients themselves, and learn to incorporate
science into patient-based clinical judgment. Second, we have to
take cost, cost-benefit and genuine long-term benefits into account
with every patient at every level of practice. Third, we have to
restructure our Medical Homes, - re-configure the
incentives and priorities of our current health care system, train
and re-staff our medical homes, both outpatient and inpatient,
focus on prevention and minimizing the costs of our care, and plow
the savings back into our practices in order to empower them to
optimize the health of all patients.
Establishing balance in patient care:
All the new science, technology, and digital
communications we are being offered create remarkable opportunities
for the advancement of medical care. We all want to put them into
practice immediately, but it takes years to confirm the findings,
perform the translational research and measure cost-effectiveness
and long term outcomes. Then it takes more years before they are
incorporated into "best practice" guidelines.
I was taught that 80% of diagnoses could be made on the basis of
history and physical exam. This is still not so far wrong in terms
of acquiring the knowledge we need to know in order to help a
specific patient's body heal.
When students and residents first come onto a new service, their
supervisors focus on teaching them the new technologies - the lab
ordering systems, the note and discharge summary documentation, the
way to order consults and retrieve lab results and xrays.
Much more emphasis is placed on those tasks than on the thinking
processes they will need to use to evaluate and treat the new types
of patients on that particular service. As attendings, we need to
redirect some of their attention away from their computers, to help
them make as great a cognitive shift as a technical one, to prepare
them for treating their patients…not just the test results.
On rounds, in primary care clinics and practice apprenticeships,
it is crucial for us to model the invaluable hands-on skills our
masters taught us, and pass on to our residents and students, in a
disciplined fashion, the ways we learned to diagnose appendicitis,
pyloric stenosis, hydrocephalus, the differences between different
forms of cellulitis, the secrets hidden in rashes and murmurs, how
a child walks, the breathing pattern of an infant - disappearing
arts and techniques that give those who remember them critical
information the moment we see a child even across a room. I still
use the texture of a liver, prolongation of a respiratory phase,
transillumination of a scrotum, subtle variations in an optic disc,
even fun things like the response to my tickling an abdomen, or
having a child hop or play with a toy. These skills provide us
short-cuts to get the patient home, to the OR, or to the ICU, but
week to week I discover how little of this our students and
residents actually know, and how rarely we take the time to teach
them.
Another lesson is the importance of gaining social and cultural
understanding. We need to demonstrate the art of listening to our
patients and gaining their trust in order to discover details of
their illness they might not otherwise share. We wonder why some
people just can't break out of a cycle of disease. If you ask a
patient to take a medicine, but it contains something their
religion says cannot be consumed, no wonder the patient does not
heal as we expect. If they live in an apartment with ten cats and
their brother smokes in the closet, no wonder their asthma stays
bad despite so many changes in controller meds and courses of
steroids. If they have drug dealers hanging outside their door,
they may cling to the couch and the TV. No wonder they are
obese.
One of the things I love about my practice at BMC is that my
patients come from all corners of the earth, with many different
concepts of health, illness, prevention and treatment. I have to,
first, understand what they think, want and are afraid of, and
tailor my approach and therapy to those realities, and help them
understand the things my science and technology can offer. I have,
on occasion, let families coin or cup a dying child's back, because
if they don't, they feel they have not done everything they could
have according to their culture or religion.
Do these things improve the physical condition of a child or
adult? Who knows? Sometimes. But they certainly help the family's
sense that together we are doing what needs to be done. Children
and adolescents will relax and I can get a better physical exam
because I've learned how to settle them down and get them to trust
me. The parents will tell me more because I ask them a question
framed in a personally appropriate way. We see them as anxious, but
they may care much less about what I am interested in, the blood
gas or aortagram, than in some other question, and I can get good
compliance by addressing their concerns before mine. We need to
teach our residents and fellows these things by story and by our
example.
Excellent clinical care also requires the wise use of time. We
and our residents are perpetually in a hurry. They consider
everything urgent, even when it's not. They feel pressed to make
decisions rapidly and that that ability is a sign of skill,
knowledge and maturity. In fact, we want them to learn to think,
wait, watch, and learn to use time as a diagnostic tool. A general
surgeon in the US wrote, "We need to maintain the courage to let
some time determine the clinical course of investigation." A
pediatric endocrinologist wrote:" The "test of time" will
usually separate those with real disease from the normal variations
and self-limited problems if we have the patience to limit tests
and see the patient back." Time so often gives us answers as
to the direction an illness is going. We need to impress on
trainees the value of not treating or testing right away, slowing
the pace of decision-making a smidgen or more, examining their
patient again in a few hours or days, asking them new questions,
reconsidering.
I was told I would never know more stuff than after my years as
chief resident, and that was true. But I hadn't seen dozens of HUS
or Reyes or sickle cell crises or even serious asthma attacks, so I
needed a Sydney Gellis to tell me to jump or to wait. I still need
Paul Rosman to warn me that this is not the way a child should be
moving or walking or shaking.
Apparently the Stanford 25, a computer-based education program,
tries to impart a little of this type of wisdom to its students and
residents, but what we really want them to gain, through their own
experience and that of others, is "clinical judgment".
With all the microbiology and pathophysiology our students
get taught, they do not understand how effective most bodies are at
healing themselves. One of our most important challenges as
physicians has always been to decide when, how, and even if, we
should do anything at all to help this process. It is sometimes
difficult to reassure everyone, (including ourselves) that
intervening too soon or too intensively may not give the body the
time and opportunity it needs to do its own work, and learn from
it, to gain immunity for instance. More medicine is often not
better medicine. More expensive medicine isn't either. We have
often seen that treating with broad spectrum antibiotics is not a
wise choice for instance, and by treating things that may not need
to be treated, like H. pylori, appendicitis or otitis media, our
patients may do worse rather than better.
Our ability to heal our patients depends both on our clinical
skills and on our understanding of science and technology. Our
patients are not simply the sum of their data, as vast as that
might be, they don't really exist inside a computer, and we need to
keep reminding ourselves that it is our cognitive skills as
physicians that really make us good healers.
Taking cost, cost-benefit and established long-term outcome
measures into account at every step of practice
We order too many tests and procedures for a number of reasons:
uncertainty of clinical understanding, academic or personal
curiosity, fear of not knowing or doing the right thing, practice
incentives or disincentives, money, or perceived community
expectation of standard practice.
My use of the word "daring" to practice low cost medicine in a
high tech era clearly touched a nerve. Many people pointed out in
response to the Perspective that it does take courage not to order
lots of tests, consults and procedures, for a variety of
reasons.
First, we are by nature intensely risk-averse. We don't want
anything to go wrong for our patients, and want to know everything
that might be relevant. We feel that doing everything is the best
practice and the best way to prevent harm. We test to explore and
reassure ourselves, and in some cases the patient or the family,
instead of trusting our clinical judgment, and ordering no, or only
the obviously necessary tests and interventions, watching our
patients, giving them signs and symptoms to watch for, and seeing
them again in a matter of hours, days, or months.
We need to teach students and residents the subtleties of
differential diagnosis that focus on the likely, and how to use
history and physical exam to clarify probability before we roar off
chasing zebras. Our residents and students tend to chase zebras
right out of the starting gate, because the tests are there, and
they want to show us that they've thought of everything and covered
every base. We need to give them our permission, instruct them, to
focus on common conditions first, uncommon presentations of common
things next, and only, when the likely causes seem unlikely, should
we focus on the uncommon conditions. A doctor from Belgium
noted: "This has indeed high consequences (and not only in the US)
on costs and quality of medicine and it keeps young doctors from
becoming good and reasonable physicians."
In primary and urgent care practice, I urge residents to order
almost no studies year to year. One of my respondents wrote: "I
talk people out of CT and MRI scans all of the time. They
appreciate being set free from the lunacy that has overtaken the
practice of medicine." If a child has pneumonia by history
and physical, treat it only if it looks bacterial, and watch. In
hospitalized patients, I urge residents to be disciplined, to
decide when the most informative time would be to do a test. It's a
matter of pride not to repeat them if at all possible.
Our specialist consultants are in the same bind we are, perhaps
worse. They seem to feel required to address every possible
diagnosis our patient might have. One ID specialist wrote: Nowhere
in medicine is the pressure to over-treat more evident than in the
area of infectious diseases. The development of practice guidelines
which have been developed in the spirit of zero tolerance for
failure is forcing us to leave no stone unturned, medical homes and
overtreat. There is no room for "watch and see". Those
are certainly not "best practice" guidelines, and need to be
reframed.
Another specialist commented: "I (a practicing Neurologist)
could not make a living if I didn't routinely perform EMG testing
in my office for example. Only 10% of EMGs are necessary." If
I ask a cardiologist for their opinion on a murmur, most feel an
obligation to perform an EKG and echo regardless of their clinical
opinion (it's covered by insurance after all, and if the patient
should turn out to have some obscure disorder which they missed
because they didn't do an echo, or cardiogram, or CT scan, they
might be sued). It's the same for the pulmonologists or the
geneticists .
In reality, what I want first from a subspecialist is their
balanced, professional opinion, based on the knowledge and
experience they have that I don't: "Your patient is most likely to
have this, though these other things are possible, but much less
likely. What would you like me to do?" It's the same with a
surgeon. Given the choice, I look for surgical colleagues who
respect my, and their, history and physical exam and will give me
well-considered advice, someone I know who would rather examine
than image, who will talk to my patient and use his or her clinical
judgment before performing some procedure. I choose surgeons who
won't take every tonsil or appendix out, who has expert examination
skills, and doesn't insist on imaging before they see a
patient.
The second reason we order too much is that we are scared that
if anything should go wrong, we will be sued, and colleagues might
look at us as being careless or irresponsible. We feel pressured to
test and treat more aggressively because guidelines for "reasonable
care" and "reasonable outcome" are so difficult to define in the
almost infinite spectrum of human illness. Our practices have
become increasingly influenced by fear of "malpractice" and less by
the inspiration to heal through "best practice".
Our cornerstone of "first do no harm" has crumbled into a pile
of self-protective tests and procedures.
We, the scientists and clinicians, need to establish the
boundaries of scientifically, personally and fiscally responsible
practices for our profession, or others will do it for us, as they
have. We need to define "excellent practice" more broadly and
flexibly, and build what we consider to be optimal metrics of high
quality performance and reasonable expectations for health
outcomes, taking into account the full range of issues including
patient comfort, feeling of well-being and respect, appropriate use
of technology and available resources, and the constraints of
personal and pubic finance.
A generalist wrote us: A young patient of mine recently suffered
a ruptured appendix while the surgeon waited eight hours to obtain
a CT scan, even though the clinical history and physical findings
were absolutely typical. We are wrong if we don't speak out
critically, both as individuals and as a profession, of this kind
of practice. Our patients would thank us for it. If we were more
honest and self-critical, we could argue more effectively against
the malpractice system. We need to defend practice guidelines that
help us practice better medicine, not more expensive medicine. One
doctor in India wrote a long response with many cogent comments. In
one section he said: Only when we stand together, and start to
re-place the emphasis on talk to the patient, look, feel, move,
think and then investigate, will we actually improve the practice
of medicine and actually have satisfied patients with good health
care for all at a reasonable cost. We can then direct the money to
the needy patients and not waste it."
You and I do need to advocate for tort reform, probably a
no-fault system, such as is being experimented with in Vermont. It
is hubris to believe that we can prevent illness or death in any
particular case. We need to establish the standards and
support each other in following them. It is hugely important for
physicians to work with lawyers and legislators on such a new
system so that it can truly serve the best interests of our
patients and the public health.
I realize that we have a very difficult road ahead. There is
obviously an enormous vested interest in the legal profession, and
many benefit from such a lucrative system. Nonetheless, we must
try. I wrote a follow-up piece to my Perspective in the
Massachusetts Medical Law Report advocating this, and in contrast
to the huge response I got in the NEJM, there was thunderous
silence. But as one doctor had written: "Until the financial and
legal incentives are aligned with good care, bad care will
continue."
The third reason we order too many tests is that we don't know
the cost, the cost-benefit, the accuracy, or the relevance of the
tests or procedures available to us. There are no obvious
disincentives to excessive test ordering and many incentives. Data
on the specific costs and the serious consequences of ordering
unnecessary tests, are rarely publicized by our hospitals or health
plans, yet in the hospitals and regions that have begun to do this,
like the Intermountain Group in Utah, the programs have resulted in
remarkable savings due to uniformity of well-reasoned and
consensus-driven community practice.
A doctor in Ireland sent in this anecdote: "When new
practitioners join our private practice, having left the state
systems where allegedly 'no-one pays', invariably they order maybe
10-15 thousand euro of laboratory tests in their first month or so
and are shocked when they are confronted with the costs of their
actions and the realization that the patients will actually have to
pay for these tests. Their behaviour does modify as a result and
they will invariably order quarter of the cost in tests in the
subsequent months."
We need to have much easier access to the research on the
costs, outcome measures, accuracy and clinical relevance of these
tests and procedures. The AAP, and I'm sure the AMA and MMS, are
constantly being asked what members get in exchange for our dues.
Building such national, or even regional databases and making them
available to us all through our practices, and in our EMRs, would
provide the membership, and the country, a great service..
Building a universal Medical Home System, inpatient and
outpatient -
A fully-functioning out-patient and in-patient medical
home should be centerpiece of high quality, comprehensive,
cost-effective, patient-centered care. This is where all the
scientific and technological advances we have been discussing are
blended together with our clinical judgment to greatest advantage,
and where the benefits of such a system are most obvious.
The focus of all efforts in the medical home is on the patients
at the center. It provides the incentive to practice the best
possible medicine at the lowest possible cost since all the gains
should come back to profit the patients and the operation of the
center itself, to make it as high functioning, coordinated,
responsible and effective as possible.
The Medical Home concept actually emerged in the late 1960s as
general pediatricians realized they needed a way to centralize all
the scattered information that was being generated about their most
complex patients by the new breeds of specialists scattered about
in hospitals and elsewhere. Generalists, soon to be called primary
care physicians, started to organize centralized record systems and
medical passports to collate all the information in one place, and
urge all clinical providers to communicate more effectively with
each other through the center. Similarly, as the medical care
of these patients became increasingly complex, and as clinician
groups started to serve the needs of a wide variety of patients,
from the healthy young to the resource-poor, to the complex elderly
patients, and children with serious special health care needs,
twenty four hours a day, it became clear that many different types
of staff professionals were needed in the primary care
sites.
The goal of a good medical home is to integrate primary care,
emergency care, consultative, and inpatient care, and enable
patients and involved clinical professionals to access all
appropriate health information and create a coordinated,
individualized health plan for each patient. Our young physician
colleagues, tech-savvy and well-trained as they are, are enormously
important to medical home development because they live in this
world, and can help us build in the most effective communication
and information systems.
At this moment, though, we don't have anywhere near enough
doctors, nurses or other personnel to offer medical homes to all
patients who need them. The shortage of generalists has been
recognized for some time by the federal government, and a
multi-billion dollar new initiative has just been announced to
recruit and train new primary care providers. However, the
way we are training residents, at least in pediatrics, offers them
disproportionately little outpatient training since their rotations
are too often driven by service needs of the medical center,
not by appropriate educational needs.
In addition to physicians, though, we need to develop and train
whole new categories of health professionals. We have struggled to
extend the old roles into the new paradigms, but are now realizing
that we need make fundamental changes. Medical Homes need
clinicians with various sorts of training, call them what you will,
nurses, patient care coordinators and support staff.
For decades, I have had the pleasure of working with a wide
variety of trainees, clinicians and health practice professionals.
For instance, I often have community health undergraduate students
working with me in clinic. It is a wonderful way for them to learn
medicine while assisting my practice. They join me with patients,
enter the visit data into our EMR and retrieve information for me.
This is an emerging profession called "scribes". I have worked with
primary care nurses who knew my patients as well as I did and could
assist them and me with almost every element of practice. Our
patient care coordinator is one of our most essential team members.
Our social workers not only help with family problems but
coordinate much of our basic mental health care. For a decade I
have worked with lawyers from the Medical Legal Partnership to
advocate for our patients legal needs. I have also worked with
nurse practitioners for decades, and know that they do many things
better than I can, just the way residents know more than I do and
medical students can teach me the most current basic science.
We all need each other and should not see ourselves as
competitors. Just as we should be partnering with lawyers to
solve the huge malpractice challenges, we need to work with nursing
and many other health professional administrations to solve the
country's massive staffing and personnel shortages. We should
be welcoming and eager to partner with them so that each of us can
be using our knowledge and training most effectively and be more
satisfied in our clinical roles (unless you're totally happy with
the balance now, which I doubt). This is not simply an issue of
efficiency, or financial resources, or the national economy, it's
the future of quality health care.
With the explosion of science and specialization, medical and
health education needs to evolve as well. A century ago, the first
Flexner Report transformed the education of physicians, creating
specialties and specialty training. A few years ago a new Flexner
Report was developed for the 21st century. There is also a massive
new Future of Nursing Report. I don't think either of them is broad
enough in scope or vision to create the professional training
tracks or curricula we will need.
All health careers training curricula probably should start earlier
than college and cross-fertilize each other. Students should share
courses across disciplines (students in all tracks need more
science early on, and more training in psychosocial and
multicultural health elements). There needs to be a vastly greater
emphasis, and money spent, on prevention. All of us know that if we
can prevent infectious diseases, obesity, diabetes, asthma and
dozens of other expensive and debilitating chronic illnesses,
everyone would be better off.
More emphasis on prevention and practice efficiencies, including
a better division of labor and the ordering of many fewer tests and
procedures at every point, could save each practice many thousands
of dollars a day while allowing us to see more patients. If we are
pro-active, we should be able to build an affordable care
organization system that allows us to keep those savings in our
medical homes. This is one feature of ACOs that really makes sense
to me. Thus a cycle of higher quality, more efficient, preventive
care might take hold, making everyone healthier, possibly
wealthier, and certainly happier.
Advocacy for change in the larger system:
I am hoping that the new health care reforms we create over the
next few years will dismantle the structural and economic
constraints we currently practice under. You and I all need to make
and advocate for change in the health care system. We're actually
at a time when this can happen. Massachusetts is designing it's new
health care system, and you and I need to be in there, with our
administrators, our public health care colleagues, our lawyers
and legislators to redesign the incentives and disincentives
built into this crazy pay-for-test, pay-for -procedure and
document-all-day- long insurance system.
We lost most of the last rounds because we, the health
care providers who knew what our patients needed, either felt
powerless or disinterested, and were reluctant to get involved. But
the health plans and insurance companies, with their profit-driven
priorities, forged ahead and set up systems and regulations
destined, and subsequently proven, to produce more expensive, less
effective care, and we all whined.
As long as the profits generated in the "business of health
care" are directed into the pockets of corporate investors and
administration, the costs of health care at every step, from the
costs of medications to fees for testing, imaging and procedures,
will continue to surge. Profit simply creates too many conflicts of
interest to allow frugal practice. The incentives are all
backwards. If a profit motive must exist anywhere, the money
created needs to flow back to improve patient care. Otherwise, we
will bankrupt the US health care system, which we seem well on the
way to doing.
You and I have huge responsibilities as clinicians. Some of the
most basic, day to day problems are ones only we can change. And we
have to swallow our pride and work with others who can help us. We
all want to be the best doctors in the world for our patients, but
we are obviously failing in the current system. There was a
well-known creature in our house as our children were growing up
named "Not-me, Not-me". But it is us. If the well-being of
our patients is really our top priority, then we are the people who
must make these changes through our own day to day practices. If we
don't, someone else will make them for us, because the country
can't go on like this for long. And then, no one will be happy.
I do a lot of legislative health care advocacy for children here
in Massachusetts, and it is obvious that I am listened to because I
advocate for my patients needs, first, and my own needs second. I
tend to lead with: "this is what needs to change for my patients",
and then, "In order for me to accomplish this in practice, the
system needs to enable me in these ways." Legislators did sit up
and pay attention when I published my Perspective, because I was
able to point out to them how changing incentives in the crazy fee
for service system in place now could change the face of health
care financing.
A different Oration:
This is a very different Oration from the one I originally
wrote. That one had graphs and slides to illustrate my points. But
as I struggled with it, I realized that I don't like working from
slides in a talk that is mostly a thought piece, so I decided to
give this talk this way.
