COMPETENCE ABOVE ALL


The first principle of health care is to “first do no harm”. In the complex system that we live we seem to have forgotten to whom we are responsible. The duty of care and the equitable distribution of such has taken a back seat.  The comfort of the staff is vital but their competence is far more important to our patients. Many seem to believe that our staff members being “nice” is the key to care. ThIs misguided notion is taking us into the weeds and missing the real problem in many institutions. Our real problem is competence and consistency. If the goal of our system is to provide consistent and dependable care we must first stand up for equity. The equity I mean is equity of care standard.

The care delivered varies wildly and the reason for such disparity is as varied. Fortunately many institutions have noticed the problem but their solutions seem worse than the problem. The government has stepped in because we have not consistent applied the care we know to be best. The government has used the same consumerist benchmark of satisfaction that is used in retail sales as a proxy for care delivered. This approach is sub-optimal at best. It is not likely to be the best measure. However, our opposition to these measures will not improve patient care. What we need to recognize is that patient satisfaction can be a good proxy if we work in a system where competence is priority number one.

Patient satisfaction is a complex fickle beast. We cannot practice from the point of providing a ‘satisfying’ experience. Our care should be directed at proving the best outcome to all. The only way to provide such care is if our systems are focused on designing best in class care systems and staffing such systems with competent staff. In recent years our systems has fallen into the sad and despairing state were we have lost focus on care and the competence of our staff. The misguided first basis focus on the social behaviour of the staff is driving the best out of the system and putting out patients at the mercy of the less competent, but ” nice”.  If our purpose is best in class care and superior outcomes there is only one matrix that matters. We must provide our patients with the best trained staff. Our efforts must be evidence bases and physician driven.

WHERE IS THE CHECKLIST?


I have loved health care for as long as I can remember. I cannot imagine doing anything but providing care . What I have learned in the trenches is that the love of providing care is not enough. Over time i have realized that a fundamental problem with health care is not in the expensive of it but in the nature of the people in it. We want to provide care, but we bring into the system our biases. Those biases allow for less attention to be paid to some patients because of their language or skin color. We may say that we provide the same care to all patients, but as a black physician I see otherwise. My experience of the system at institutions where I am not known by members of staff is vastly different. The consequence of this uneven care is a system where those that can afford care and are the correction completion receive care that is more compassionate and timely.

How do we overcome the inherent bias in the system? The answer is not more training nor necessarily more diversity. The answer will be in the wide-spread use of evidence based payment structures. Our medical systems are complicated and expensive but are systems in name only. We have a complex string of components. All the parts are mostly well-trained and competent. However the results we obtain are not commensurate with the level of training nor the level of expense. The incongruity of expense and quality of results continues because those attempting to improve the system have not acknowledged or do not recognize the biases of the system. The gap in quality of outcome is most obvious in communities of color. The often given excuses are truly just that. Recognizing that there is a problem is the first step to a solution.

Paying for quality work is the only avenue to improved results. The question as to how we get better care for all patients is simple and complicated, but we have a great example in the aviation sector. My brother is an airline pilot and his training is extremity rigorous, but he starts his day with a checklist. He does not feel that his autonomy is being challenged, but that he is making sure that he does not kill himself. We in health care do not have any real skin in the game. Until the decision makers have some skin in the game we will not embrace what is necessary to make our constellation of components into a functioning system. Let us start delivering quality care by implementing checklists. Checklists are reminders of the quality in our options. The checklist is not for you it is for your parents and friends. That checklist is not for you, it is for that provider that is on her sixth surgery of the day. It is a nudge because she is tired. A checklist is for every one of us. It helps us by removing silly mistakes from our systems. For me the checklist is my hope that I will be treated like a patient deserving of care on the off-chance that I am a patient in a strange place where all that can be seen is the color of my skin.

THIS AGAIN?


Again I find myself looking at the Affordable Care Act, aka ObamaCare and wondering how did we get here? With a rapidly aging population and escalating costs some changes were inevitable. We spend more per patient but get worse results. I have heard and read many blaming the newly arrived sicker immigrants and the lazy minorities. Those attitudes represent the bias in the healthcare system were minority patients are often not treated with the respect they deserve and often get substandard care.  As a minority physician I saw this a Medical student and choice to do rotations in areas with significant minority populations. What I realized is that poor care is not a choice of commission, it is most often a result of omission. The truth is that most patients get great care, but the system often gets it wrong with minority patients. Having family members with great insurance and serious chronic medical issues puts the disparity in care front and center. Lack of insurance is not the most significant problem. The problem is bias. On countless occasions, care is significantly delayed for no apparent reason. As a physician I can make that statement with confidence, because I have experienced it on many occasions. That loud minority patient is not just loud, but loud because after giving the system the benefit of the doubt she or her family is still sitting waiting for urgently needed care. I usually do not announce that I am a physician and thus get to experience the treatment I often heard about but did not believe. I am here to affirm the assertion, if you are a minority patient you will get poor treatment.

Will any of the changes of ObamaCare make the care of minority patients any better? I am not sure, but at least outcomes are being closely tied to pay. Yes I went there. Tying objective criteria to payment is an excellent means of encouraging improved care. We might not want to accept that outlook, but if we expect our patients to take their medications as prescribed why shouldn’t payers expect us to provide evidence based care. If we would enforce some self-regulation we would not be here. For minority patients we are hoping that our care improves with the general expectation of higher standards. This is our hope for ObamaCare.

As a physician I wonder about the goals of Obamacare and lament the loss of freedom. I dread the arrival of the heavy hand of government regulation. The problem is that as physicians we have not been good stewards of our privilege. As a group we are reactive not proactive. Unfortunately we are once again reacting to the new paradigm. Many of these changes have been in the works for significantly longer than the discussion that  surrounds ObamaCare. Instead of organised self-regulation we now have government mandates. These mandates are not the answer, judicious self-regulation is the answer. We need to examine the new paradigm and workout a constructive path to achieving our goals.

No matter what our goals are, the constant absurd chatter about the evils of the law is a waste of precious time. I suggest a more constructive conversation would be to evaluate how we got here, look for the future challenges and proactively respond. We are problem solvers. Let us look closely at the issues and solve the problems before the government goes further in destroying the practice of medicine.

TIMELINESS


All of us have our quirks. The question is, can the people around you live with them. On most days I think the people around me can survive. Mine is my drive for efficiency. I once was told that the fastest way to get a task done is to do it the right way the first time. If you work with me you have heard that before and you know that my way is the only correct way. Thanks for the indulgence. What motivates me is accomplishing a task in as few steps as possible. In health care that can be a challenge.

In the world of rising cost and decreasing reimbursement the imperative in healthcare is keeping cost to a minimum. My take is that patient safety is the first goal followed closely by efficiency. Some may wonder about that combination but I posit that they are one and the same. If your question is how so, let me expand by looking at one of the most frequent complaints in healthcare. Timeliness. What is timeliness and do you respect it?

The most offensive ‌thing to me is inefficiency. Inefficient use of time is the highest form of disrespect. The fundamental question is do you respect others. As importantly, do you respect your reputation. You first have to show respect for yourself before you can respect others. Respect motivates and challenges. It creates internal expectations that demand attention. The expectation that you must be the best at each task demands attention to the details of the task. Attention to the small details of the task shows others your commitment to success and will reinforce your reputation for succeeding at your goals. We all want the successful and self motivated on our team. Respect for one’s reputation means always doing ones best, including being on time. Respect for time, I posit carries over into ones preparation for treating patients and will result in better care being delivered.

Unfortunately many in our society have come to equate the cost of their time to value. Value is not defined by cost equations, but by the totality of benefit provided to others. Your time is not more valuable than that of others. As a physician I try to respect my patient’s time. However that attribute is not universally acknowledged and  that  leads to delivery of less than optimal care. The lack of preparation for our patients is reflected in lack of respect for the time of patients and results in us going for the easy fixes instead of the optimal. The easy fix is destroying the reputation of the Medical Profession. “ObamaCare” and Government regulation is just the latest scapegoat for the total lack of respect that physicians have for time and timeliness and by extension our patients. This directly affects our reputations, but too many don’t see the connection. Patients have become a number not because of the business of medicine but because physicians have not shown enough respect for our patient’s time. Too many physicians see patients as a captive audience. Even if our patients do not have many options we should still treat them with the respect they deserve. All of natures children deserve respect and humans no less than our cats or dogs. If we do not reverse this trend, one day we will wake up and find that we are not the only ones taking care of patients. Truth be told that reality is already here. Welcome to the evolving world order.