Facing Today’s Issues
The entirety of health care expense in the U.S. is estimated at $2.5 trillion per year – this is four times the defense budget. In fact, if U.S. health care was spun off as a separate country, it would have the 6th largest economy in the world!
And most of this money is spent through actions triggered by the pens of doctors.
While the Rand Corporation has estimated several forms of waste, both Rand and experts at Dartmouth University have projected that 30 percent of health care dollars are wasted in clinical decision-making, fragmentation of care and poor management. That sums to roughly $750 billion per year – or equal to the stimulus package. Recovering a fraction of this could pay for the current proposals providing coverage for the uninsured… recovering more would yield a major financial stimulus to the non-health care elements of our economy and to millions of individual Americans.
As agents of this expenditure, doctors are vital in this strategy. They did not create the problems leading to the waste in health care spending, but they can be part of the solution.
Every doctor must go through medical school and residency to practice medicine – the majority being trained within the borders of the U.S. This represents an opportunity to train physicians differently to meet this new challenge of not just managing disease, but also managing societies’ limited fiscal resources.
Current Training vs. Future Training
The Association of American Medical Colleges and other national organizations have, for a number of years, urged medical schools and residencies to stress “systems-based practice” – the ability to recognize and utilize the resources needed to provide optimal and safe patient care – as an important yardstick of graduate competence. There is, however, little evidence that this has become a major component of training in most locations. A recent survey of medical educators suggested this competency has been “least well” accomplished, in spite of the emphasis upon it. The president of Dartmouth, Dr. Jim Yong Kim, said in a recent interview, “There's not a single medical school that I know of that actually teaches the delivery of health care as one of the essential sciences.” Thus, there is a growing awareness of importance but not an educational tectonic shift as yet.
There are virtually innumerable ways to train doctors to help control health care costs; giving better care at the same time. Here are a few examples of what can be done differently more fully leveraging whatever Congress produces.
Doctors get very little training as “managers,” and yet many medical schools co-exist with universities that also operate business schools. If doctors decide when and how to spend the health care dollar, shouldn’t they – as defacto managers of the largest industry in the world – get some training in the concept of management? Understanding the system as any other corporation will help doctors see the impact their decisions have.
The health care environment is profoundly complex – doctors swim upstream every day, trying to use a combination of compassion, brainpower and technology to cure disease. All around doctors are systems – of ordering tests, using sophisticated equipment, communicating with specialists and patients. What students typically lack is training in continuous quality improvement techniques, such as working in a team with administrators and other ancillary workers. As a patient, you may experience this if you’ve had the same test twice in one week, not heard back from your physician or had trouble scheduling an appointment.
Researchers at Dartmouth have analyzed the entire Medicare database for years, and the number of unnecessary tests and procedures performed each day in the U.S. has grown, contributing to perhaps the largest component of waste. Training medical students to be conscious as doctors of these behaviors can potentially reduce needless medical spending.
Finding Tomorrow’s Solution
At the Columbia-Bassett Program, we have developed a new medical training model addressing these issues in a curriculum designed to graduate doctors capable of leading health systems promoting quality of practice and cost-effective delivery of care. During the past two years, we piloted the program with a terrific small group of medical students from Albany Medical College. Next fall, our first class of 14 Columbia University medical students will enter the Columbia-Bassett track.
This new curriculum breaks medical students’ training down into four components: Systems, Leadership, Integration and Management (SLIM).
The doctor-patient relationship is an important tool for providing quality care. At Bassett, students follow patients for a year: picking up a patient in the emergency room with chest pain, seeing their stress test in cardiology the next day, going to their cardiac catheterization the following week and observing their bypass surgery two days later. If this same patient has an appointment in primary care, or a GYN exam, the student goes to this as well. The net result is unique insight into the doctor-patient relationship. The patients come to see the students as advocates; the students see the plight of patients in the complex and confusing milieu of modern medicine.
To understand the roles each member of the organization plays, students “interview” the leaders of Bassett Healthcare. So, the Chairman of the Board, the CEO, and many other leaders answer three questions: What is your job? What are your goals? How will you execute those goals? In this way, they come to understand the systematic workings of their environment.
Students also join a major organization committee, such as Informatics or Patient Safety, receiving an administrative committee chair mentor to learn what the committee does and how it accomplishes its work.
Going beyond treating the disease, students also learn preventative care and implement a cause-related project. Last year, a student was assigned to a group working to raise awareness of better hand-washing compliance. How does an organization change habits so that people wash their hands 100% of the time? What is the system to achieve this? How do you monitor it? This student learned that the basic problem-solving ingredients remain constant across all issues.
As students become more aware of the larger role they play in the health care system, they are also exposed to the effects of this role. Students participate in a series of lunches where they hear from a range of speakers: under or uninsured patients seeking health care, small business owners struggling to pay health care premiums for employees, lobbyists working with Congress to obtain more money for hospitals, legislators and Beltway leaders, and so on.
Based on personal testimonials, last year’s participating class felt changed by the unique experience and inspired to make the health systems around them better. Common sense would dictate this is a good thing.
We designed this particular structure for our environment but, honestly, it was easy to implement and not very expensive. Our program may serve as a model, but every teaching hospital is chock full of opportunities that could be packaged to convey similar learning.
It is certainly desirable that the daunting amount of waste in health care be reduced, and hard to believe doctors are not the best people to accomplish most of this. But it will only work if health care reform devises a system logical enough for doctors to function effectively and efficiently within.
Dr. Weil conceived and leads the Columbia-Bassett Medical School program and is a graduate of the Columbia College of Physicians and Surgeons.
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