Starting With Curious

When people find out what I do for a living, the first response is most often something along the lines of “That must be so hard.”  (That’s when they find out I’m a pediatric emergency physician; when they hear I’m also an administrator, it’s more of a sneer.)  My reply is typically that most kids are pretty healthy, and most of what I see is fortunately not that serious or ends well.  Which is true.  But the fact is, sometimes it is hard.  All of us in medicine have ways of coping with those difficult times, with patients who suffer and whom we can’t help as much as we’d hope to, with the child that dies.  But, as discussed in a recent New York Times article, too often that coping mechanism is to distance ourselves.  This detachment – which can cross over into callousness or cynicism, as documented famously in Samuel Shem’s novel The House of God – is contrary to the various oaths we take when entering the medical profession, in which we pledge to be compassionate and empathetic to the sufferings of those we care for.  It can play out in several ways.  Some physicians focus on the intellectual aspects and science of medicine.  For others, emotional detachment along with time and economic pressures can lead to burnout.

For all of us, underemphasizing the humanism and altruism, combined with the increasing emphasis on medicine as a business, can lead us to feel like we are in an occupation, rather than a profession – a calling.  We can forget what it is about medicine that gives it real meaning.  Work hour restrictions, preauthorizations, shared savings and pay-for-performance:  these are some of the reasons why many long-practicing physicians say medicine has changed for the worse, and they wouldn’t recommend it to their children.

Perhaps we need to be reminded of the old-fashioned commitment to the well-being of a patient, to being a healer, as a counterweight to economic and administrative pressures to be efficient.  Lest we get too nostalgic, however, let me put in a plug for the administrators.  As noble as the sentiments expressed in the Oaths of Hippocrates and Maimonides are, the singular focus on the individual patient can blind to the equally real needs of others, and more importantly, the fact that those needs must be balanced.  There is only so much health care to go around.  While we like to think that when we are sick, we want everything done and money is no object, that sentiment is typically expressed when we are not paying for it.  The decrease in health care utilization that accompanied the economic downturn of 2008 and beyond shows that money is, in fact, an object, at least for many people.  And with a few extraordinary exceptions, not many of us providers are willing to work without pay (and quite decent pay at that).  In a world of limited resources, we need to balance our commitment to healing the person in front of us with the commitment to the health of society as a whole.

Those who provide the care and those who manage it need to understand each other better. We need to recognize the filters through which we see the world, accepting that a diversity of views is the best way to see the big picture.  I believe as a provider, I may need to err on the side of connecting with and advocating for my individual patient.  The administrator may need to be more vigilant about the efficient use of resources.  But we must appreciate that we are all working toward a common purpose – serving our patients and their families – and a common vision of having the healthiest kids in the country here in our own community.  Each of us can find meaning in what we do, and have an impact in our own way.

It shouldn’t be surprising, in a time of shrinking payments to providers, that turf battles among those providers are increasingly common.  But we need to make sure that we don’t just hurt ourselves in the rumble.  Or worse, forget about what is best for our patients.

Round 1 in the gang war seems to be between physicians and advanced practice providers.  Many see APPs as an important part of addressing both the excessive cost of healthcare and the access issues that arise from an inadequate supply (or maldistribution) of physicians.  On the one side are the APPs, who are advocating for changes in state regulations that place limitations on their scope of practice.  Currently, 17 states and DC allow independent NP practice, 21 (including Wisconsin) require a collaborative agreement with a physician, and the rest require direct physician supervision.  Although the evidence is mixed on whether expanded scope of practice contributes to lower cost or better access, there is no evidence that it leads to worse outcomes.

Yet lined up on the other side is organized medicine.  The AMA, American Academy of Pediatrics, and American Academy of Family Practice have all issued reports decrying expansion of scope of practice for NPs.  (The politics indeed makes for strange bedfellows.  For example, both the AAFP and AAP emphasize the additional years of training for physicians compared with NPs.  Yet the total pediatric training for family physicians is far less than that for pediatricians, and is likely very comparable to the duration of pediatric training for a pediatric NP.  And certainly, a PNP with several years of experience after training has seen a whole lot more pediatrics than a new FP residency grad.)  In addition to lobbying state legislatures to maintain practice restrictions, the medical associations pressure insurers to limit payments for NP services.  Even when permitted by state law to practice to the full extent of their license and training, NPs are frequently not credentialed by insurers to bill directly.  In response, nurses are lobbying for a requirement that NPs be included in any plans offered in the new health insurance exchanges.

There is a real discussion to be had about how we develop a workforce to meet the medical needs of children in the evolving healthcare environment.  But can we call a truce and focus on the real issues?  Let’s be honest: this is not primarily about patient safety, or quality of care – it’s about preserving jobs and incomes.  One (not normally extreme) columnist went so far as to call the medical profession’s efforts to limit NPs “a protection racket.”  That’s harsh.  But it doesn’t serve us or our patients for health professionals to be rumbling with each other.  It seems clear that there is a legitimate role for advanced practice providers in meeting the primary and specialty care needs of children, and that role includes independent or collaborative practice in many cases.   That doesn’t mean NPs and MDs are interchangeable.  But the two disciplines need to acknowledge the filters through which they see the world and come to agreement on how we can ensure the right provider for the right patient in the right circumstance.  Or our patients may get caught in the crossfire.

When even a child of the 60s and 70s like me is connected via texting, Twitter, Facebook, etc., it’s safe to say that the digital revolution is over, and digital won.  The last holdout, it seems – the analog equivalent of the tsarist White Army – is health care.  Sure, we have robots for surgery, telemedicine for remote diagnosis, and an increasing use of electronic health records by hospitals and providers, but it still feels very old school.  Sort of like education: even if you take notes on an iPad, attending a lecture is still a very traditional method of learning.  Health care is still very provider- and facility-centric.  To paraphrase the NY Times columnist Thomas Friedman, the world of health care has still not gotten very flat.  Yet there are some steps toward leveraging new modes of communication that have the potential to disrupt the model of health care delivery.

Many people today use texting as their primary means of communication, but it is seldom used in medicine.  Expanding its use would not only be more patient-centered, but may really improve efficiency.  We recently ran a trial of texting appointment reminders to patients in our sickle cell clinic, which has a traditionally high no-show rate.  The day after text reminders were sent, only 1 of 14 patients did not come for their appointment.  Anyone who has ever dealt with a teen knows that this is a group where texting may provide a particular opportunity to vastly improve provider-patient communication.  Providers and staff appear to be open to the idea of greater electronic communication, but some barriers are apparent.  One is reimbursement: under current payment systems, electronic communication is a service for which it is difficult to collect a fee.  Another concern is confidentiality, though some progress has been made to ensure that texts or other electronic messages are secure, such as a HIPAA-compliant messaging app.

Texting of course, while seemingly radical by the conservative standards of health care, is not exactly a disruptive technology.  But some providers are pushing the envelope with “virtual clinics,” where almost all interaction is electronic.  Check out, for example, these examples in New York and Minnesota.  Experience is limited, especially regarding outcomes, but these experiments suggest that at least two elements of the triple aim – lower cost and better experience – can be met.

Medicine is clearly moving toward being a true team sport.  Many of the proposed innovations in care delivery and payment depend on a collaborative approach, with individuals from multiple health professions playing a role.  Perhaps the clearest example is the patient-centered medical home.  Which all sounds great, until you start to ask different people what they mean by a “team.”  Many physicians have a, well, physician-centric concept of a team, where the doctor serves as “quarterback” or “captain.”  And while teams generally need leadership, you can imagine that a nurse, social worker, or pharmacist might have a less enthusiastic embrace of a team where she or he can, by definition, never be the leader.  It’s not that physicians are trying to be uncollaborative.  However, medicine has traditionally been structured hierarchically (e.g., doctors write “orders,” not “requests”).   And this is reinforced throughout the training not only of doctors, but other health professionals as well.

To move toward a truly comprehensive, collaborative team approach, this approach needs to be embedded into the education of all potential team members, right from the beginning.  By the time medical and nursing students have completed their four years of school, patterns of thought and behavior – cultural constructs – are already developed.  This is why there has been an increased interest in interprofessional education, defined by the WHO as occurring when “students from two or more professional learn about, from, and with each other to enable effective collaboration and improve health outcomes.”   MCW’s Community Medical Education Program is exploring the possibility of incorporating interprofessional education into the curricula at the regional campuses, in conjunction with the other health professional schools in those communities.

Dr. Melanie Dreher, Dean of the Rush University School of Nursing, recently gave a presentation sponsored by the CMEP on interprofessional education.  She noted some of the dominant cultural constructs about medicine as a hierarchy that need to be revised, and the potential for interprofessional education to do so.  I’ll call out two.  The first is what I mentioned above, the idea of a team revolving around a single leader (typically a physician).  She offered the counterexample of situational leadership, where leadership of the team is flexible depending on the issue being addressed.  For example, if the issue is one of polypharmacy, then a pharmacist might assume the role of leader; if it is one of support services, perhaps the social worker.  An analog is the Orpheus Chamber Orchestra, a group in which the role of conductor is shared and rotated among all members, depending on the piece to be performed.  As they see it, it is not the conductor who is the center, nor even the musicians – it is the audience.  The other cultural construct is that of how we measure contributions to the team.  It can’t be by RVUs generated, or papers published, or referrals received, which ignores equally important roles played by many of the members.  Dr. Dreher offered the basketball example of Shane Battier of the Miami Heat, whom Michael Lewis referred to as the “no stat All-Star.”  He is considered one of the best defensive players in the league. But he has few points, rebounds, or assists –the conventional measures of success – and is therefore undervalued compared with high scorers, although statistics suggest that there is a stronger correlation between Battier’s playing time and the team’s record.

A true team approach means we need to fully utilize and recognize the unique knowledge, talents, and approaches provided by every member of that team.  Engendering that attitude, and teaching the actual skills of teamwork (which are separate from the skills inherent in being a doctor, nurse, or pharmacist) means we need to break down the silos in which health professionals learn.  It’s not a terribly new concept: when I was in medical school, the physician assistant students and medical students took several of their preclinical classes, such as anatomy, together.  It fostered a sense of collegiality and mutual understanding.  But is has not become widespread.  As we evolve toward a more collaborative model of health care, the way we educate health professionals must adapt as well.