Upstream Learning & Downstream Dysfunction: How to Train Leaders for a New Future

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“The arrogance of success is to think that what you did yesterday is sufficient for tomorrow.” – William Pollard

In health care right now, lots of people are talking about innovation as a generic way to describe the new holy grail to some of medicine’s biggest problems. Of course this line of logic might lead some to think medicine is in some state of “innovation-deficiency,”  a condition for which innovation replacement therapy is the clear and sole treatment. While this obviously isn’t always true, introducing new technologies and processes, if done the right way, can certainly help minimize waste, control cost, improve efficiency, and introduce equity into existing public systems.

So if medicine needs to up its innovation game, as many are suggesting, who’s it going to turn to? Where is the pipeline of leaders to fill the holy grail and how do you turn on the faucet of new and better ideas?

I’ve been thinking a lot about these questions over the past few weeks as I start my Fall semester at Harvard’s TH Chan School of Public Health. And no that wasn’t a name drop. It was a point of reference drop, to help place the problem I am about to describe, into context.

For the past 3 weeks I’ve been taking a pretty stand out course on quality improvement  taught by the incomparable Maureen Bisognano and her enviable squad of colleagues and friends. For a bit of background, Maureen is the President Emerita of the Institute for Healthcare Improvement, basically a healthcare innovation incubator based in Boston, and her friends include people like Don Berwick, Atul Gawande, Brent James, Ellen Goodman, and Derek Feeley, to name a few of the powerful speakers who inspired us. For 3 weeks, we reviewed international examples of ways to radically redesign the US healthcare system.

And then, I had fall registration.

Excited to push the boundaries of existing systems, I was eager to take classes across the University, and like Maureen showed us, find examples from other industries, sectors, and disciplines that could be applied to the great challenges facing medicine and build solutions that translate across public systems and private incentive structures. But to my surprise, that inter-sectional, open learning, not only wasn’t a requirement, but was incredibly difficult to find. And if it is hard to find at places branded on leadership, I worry it may be symptomatic of a larger issue.

Which got me thinking, just how are we going to train this next level of leaders when the educational pipeline through medicine looks remarkably similar to what was suggested in the landmark Flexnor Report in 1910, that established a system of medical education, that with few exceptions, continues today.

Courses continue to be divided by discipline, learners are isolated to their field of study, and for those who select to learn outside that box, they do so singularly, as a function of personal interest or a non-degree program rather than systematic integration of agents and ideas. Then is it any wonder why our systems remained silo’ed with divergent (and sometimes antagonistic) incentive structures despite overlapping public interests?

Don Berwick is often quoted as saying, “Every system is perfectly designed to get the results it gets.” In medicine, as we move upstream in our interventions for disease, to target root causes rather than downstream effects, we must do the same thing for the education pipeline. We have to challenge ourselves to teach future leaders how to think, reason, and execute rather than prescriptively guiding them, formally and informally, to reproduce the same system, with the same challenges we already have.

It has been more than 100 years since the last massive shift in professional medical education, perhaps parting with apprenticed dysfunction and practicing principled disruption is a good start.

 

 

 

Freeing the “Doc in a Box”

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The American healthcare system is set up to care for a certain subset of the population – sick people – people with chronic disease, acute illness, acute injury, and complex disorders like cancer or metabolic issues.

The problem is, this set up doesn’t create market incentives to care for the well effectively, or to identify those at risk for disease and efficiently and reliably intervene, at scale.

To reconcile this cognitive dissonance between sick-care and health-care, government agencies like CMS, are now funding population-based care strategies. The idea is, the healthcare system should anticipate patient needs at the population level, stratify those needs by risk, and disseminate preventative interventions locally, based on traditional indices like blood tests and screening protocols and emerging metrics like ICD-10 z-codes to identify social determinants of health.

Now that the federal government is redefining the relationship between communities and health systems, it seems logical to anticipate future opportunities to redesign one of the most outdated physician roles – the “doc in the box.”

But the baffling thing is, that is not what is happening.

Despite CMS’ new Accountable Health Communities Model and the NIH’s recent Precision Medicine Initiative, it seems the latest innovations in healthcare delivery are aiming to do what we are already doing – better – to map the genome, decipher codes in our blood, and screen with increasing precision to identify disease earlier and decrease associated health complications and systems costs.

But the building-based, physician-centric, model of medicine America has relied on for decades, maybe even centuries, isn’t serving us well anymore. The hands-on, face-to-face, one-on-one, physician-patient relationship is changing and the bedside, fee-for-service paradigm doesn’t fit how patients access information and more importantly, doesn’t pay for keeping patients well.

Thinking outside the “doc in a box”

In the future, instead of caring for thousands of people in a primary care panel, I think physicians will “care” for hundreds of thousands of people across a grid. And they will provide that care, in teams.

The grid will be color-coded by risk factors. Incorporating data from smartphone usage, credit card spending behaviors, typographical maps of cities that chart access points for public transit, healthy food, parks and recreation, public learning, and other staples of public life. Those access points will be rated by the degree of mobility they generate – socially, economically, and physically. High-rated areas will become models for low-rated areas, and low-rated areas will be first in-line for public resources to re-engineer the environment people live and grow in. This model places mobility, equity, and the capacity to maximize human potential at the center of innovations that create and sustain health.

It also positions physicians among a team of professionals who operate integrated public systems. Those systems will be powered by data algorithms that understand the connections between human physiology and the lived experiences that nurture or threaten that physiology, to ultimately predict risk rather than simply identify existing disease, early.

If future systems can predict risk at scale and are oriented to respond those risks with mitigating resources or information that informs and supports patient decisions, then in the future, physicians will also be expected to be architects of resource distribution, partners in city planning, advocates for social justice, and champions of equity.

There will likely always be a need for physical care of patients with ailments that require  treatments best administered at the bedside. But the advent of technology to provide remote care, analyze multi-variant data that predicts human behavior, and supports patient and provider decision-making with rapid access to information and resources, shifts the future of medical practice outside of buildings.

With a new legion of ancillary providers, it is time to free the “doc in the box” and expand the vision of medical care to include the future of physician practice.

What an Oreo can Ad to Medicine

OreoHow do you prepare for something that doesn’t exist?

In medicine, what tools will be required to build a better future for providers, patients, and the many advocates who work to make health realized?

Like our predecessors before us, embracing an unknown future will likely require solutions that are part rigorous methodology and part instinctual art. I am confident that the rigorous methodology that makes science unique among fields of scholarship will continue to advance discovery in health and disease management. But how can modern-day physicians and health advocates use the art of our practice to increase health literacy, connect the dots between health and society, and optimize our relationships with complementary fields?

When I saw the Oreo Super Bowl ad, I knew. This is what medicine should be doing. Not pushing sugar sweetened products, but utilizing moments to capture national attention around a singular idea – health.

For those of us interested in the exciting opportunities new technology offers the field of medicine, Oreo taught us that capturing national attention may be as simple as fostering thoughtful application of new media; media that for all said purposes, is free (although the thoughtful application part definitely requires a significant investment…more on that in future posts).

It is clear that consumers are now making decisions in the context of an online network of peers where they collectively share cultural experiences and discuss trending topics in news and popular media. This is an incredible opportunity to key into consumers who are looking for health information, information that data suggests some are using to make health decisions. Interacting with patients on their timetable, moderated by their thoughts and comments, and based on their personal priorities, allows medicine to have a greater impact beyond the confines of our offices and medical centers. And I’m not just talking about e-visits (although this is an interesting and potentially great idea), I’m talking about engaging a national audience in a conversation about health, identifying partners in this work, and aligning all of our interests to reach a common goal – health.

Part of preparation for any unknown outcome is recognizing opportunities to take steps in the right direction. New technology, like that promoted by incubators like Rock Health and thought leaders like Wendy Sue Swanson, MD and Bryan Vartabedian, MD, will definitely define the future of our field; a future that I hope is rooted in simplicity, transparency, and good old customer service.

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Innovation in Medicine

I am becoming more and more convinced that the greatest opportunity to impact patient behavior and lifestyle choices (the single greatest contributor to one’s health) begin in the community and the idea that a clinic is the catalyst for change or hub of health promotion is obsolete.

What if instead of placing more value (square feet) in “innovative” buildings where doctors exist, we placed value (money) in innovative solutions centered in our communities, where the circumstances that beget health disparities exist? What if some* health issues are really social justices issues – shared problems that are contingent upon resources, access, education, and literacy? If that is true, as I believe it is, then doctors don’t have all the answers and clinics aren’t the only cure.

So the question becomes:

How can our institutions of health bend toward the need and stay relevant in the spaces where people live, work, and play?

I have one idea.

Social media – or the technology and web-based tools used to connect people, resources, and ideas – offers an incredible opportunity for physicians to meet patients where they are, and the data suggests, patients are online. Advancing community engagement initiatives in medicine demands new solutions to complex and challenging problems. Future success relies on how well medicine, as a field, takes advantage of the technology to broadly disseminate credible health information in a space where patients set the agenda. Moreover, using social media to create partnerships between key stakeholders in community health, including community advocates and local and state government, can revolutionize our current models of care and add civic engagement to a physician’s repertoire of treatment modalities.

Admittedly, social media is not the entire solution. But, embracing new technologies to eliminate traditional barriers that prevent the medical system from responding to healthcare needs in holistic and systemic ways, is an important start. Future work must address the potential health disparities that may be created when access to health information is contingent upon access to the internet. However, much is being done to advance mobile health solutions to ensure that everyone benefits from the sharing of information and pooling of resources likely to mark the new age of social media in medicine.

Exploring the uses of social media in medicine is a growing interest of mine and I am fortunate to be connected to a few leaders in the field who are really blazing the trail including Wendy Sue Swanson, MD, Bryan Vartabedian, MD, Ricky Choi, MD, and Heidi Roman, MD. Click on their name and follow them on twitter!

What do you think about social media in medicine?

Footnote: * Some medical problems clearly require medical care that can best be provided in a hospital and/or clinic setting and patients with such ailments rightfully deserve the benefits new technology and innovative medical strategies may bring to bear on their treatment course. This statement is only meant to highlight the growing number of patients who rely on our healthcare system because of problems that currently lie outside the purview of “physician” responsibilities. This illustrates the need for partnerships between physicians, patients, community advocates, and local government to collectively address the needs in our communities that beget major health problems and significant health disparities.