PLEASE READ THE FINAL LECTURE INSTRUCTIONS SENT BY MY PROFESSOR. IT IS POSTED BELOW:

The “Final” Lecture
This is the final lecture for students in the health administration program. I hope it inspires, provokes thought, and helps direct your thinking about your future place as a manager/leader in the rapidly changing US health care system. At the end of this lecture, I want you to post your own perspectives on these thoughts, in the class conference provided for this purpose.

THE SCIENCE OF EVIDENCE-BASED PERFORMANCE
Over the course of the semester, we have been quite critical of the US health care delivery system. In many ways it clearly deserves it. However, there is also so much to look forward to which should create excitement among those of you who want to pursue careers in this industry. This lecture is really designed to serve as a capstone discussion of some of the key ideas I hope you take with you from this course as you graduate this program and go back into your work environment and continue with your life long learning.
Please note that this lecture does not directly conform to any required readings. It is really my own opinion after working in this industry for the past 25 years. However, I hope you find this essay a useful complement to the readings and issues we have discussed in chat sessions.

REMEMBERING HOW WE GOT HERE
Remember, the emergence of modern medicine is a relatively recent phenomenon. Before the civil war, physicians and other health professionals did not have much status or make much income; it was a part time profession that was a relatively insecure way to make a living. No parent wanted his or her son (at that time it was only sons) to become a doctor. Why? Because physicians could not do much of anything to heal people. The primary form of therapy was bleeding – this had not changed much since the sixteenth century. No wonder it was the family that was the source of virtually all-medical care in America during this period.
However, after the Civil War, several things happened that transformed American medicine. Clinical practice became founded on scientific research; as a result, new standards were created for clinical education. This allowed state governments to create strict requirements for professional licensing. And, with the advent of the nursing profession and the invention of antiseptic surgery, hospitals became reengineered as places for healing, instead of places for dying. While experts differ on the precise date, Harvard Professor L. Henderson has noted that 1912 became the great divide in American medicine:

“…for the first time in human history, a random patient with a random disease consulting a doctor chosen at random stands a better than 50/50 chance of benefiting from the encounter”

Celebrating the Achievements of the 20th Century
Thus, the twentieth century was a watershed for American medicine, because for the first time in our history, improvements in population-based health could be directly attributable to the caring professions and improvements in clinical care:
From 1900 to 2000, average life expectancy at birth increased from 49 years to almost 75 years.
Since 1960, age-adjusted mortality from heart disease has decreased by 56%.
Since 1950, age adjusted mortality from stroke has decreased by 70%.

The Current Challenges

However, as we move into the next century, we have learned that despite these advances, there are serious issues in the health care marketplace. First, geography is destiny – what you get depends on where you live. Dr. John Wennberg documented the wide variation in the use of tests, therapies, and procedures across the nation. He demonstrated that for many diseases, it is not whether you have insurance or not that is the single most important factor in determining what service you get for a specific condition, it is where you live. We really need to translate evidence-based research into practice to reduce the extreme variation in treatments for similar patients in different parts of the country.
Further, studies by the Institute of Medicine in 1999 found that avoidable medical injuries account for 44,000 to 98,000 deaths in hospitals annually in the US. In fact, more people die from medical errors in hospitals than from breast cancer or AIDS or motor vehicle accidents. Hospitals are becoming a major public health problem.
How good is American health care? Well, comparatively, we rank much lower than most advanced industrial nations on measures such as life expectancy, infant mortality, and overall satisfaction with the health care system. However, when it comes to treatment services, people come from all over the world to seek treatment in the United States. That said, when it comes to physicians and other health professionals “getting it right”, patients can expect physicians to recommend treatment consistent with the best medical evidence only about 54.9% of the time. Thus, while American health care is probably good comparatively, it could be much, much better.
Medicine used to be simple, ineffective, and relatively safe. Now it is complex, effective, and potentially dangerous. If you do not agree with this, just think about the toxic chemotherapy treatments that cancer patients receive. Thus, the importance of “getting it right” increases the risks dramatically for patients, especially those suffering from chronic diseases like cancer, heart disease, and diabetes.
One of the key reasons for the variation in services and injuries has to do with the clinical uncertainty that surrounds the practice of medicine. Medicine is complex, and most physicians (and anyone else for that matter) can only balance so many factors in their heads at any given time. In fact, according to psychologists, the magic number is seven, plus or minus two – we have limits on our capacity for processing information. Also, there is lack of valid clinical evidence for much of what is done in modern medicine. Of what is done in routine practice, the proportion of decisions that have a basis for best practice in the scientific literature ranges from about 10-20%; higher in some specialties and lower in others. The rest is opinion – not to say it’s wrong, much of it probably works. But it may not represent the best patient care.
The biggest factor affecting the complexity of medicine is the rapidly expanding evidence base of medicine. The first randomized clinical trial was published in 1952. Almost half of all clinical trials have been published in the past five years; today, there are over 12,000 published articles annually based on clinical trial results. During 2003, the US National Library of medicine added almost 10,000 new articles per week; this represents only 40 percent of all articles published worldwide in biomedical or clinical journals.

The impact of this exploding knowledge base on the individual clinician is enormous. Within three to four years after board certification, internists – both generalists and subspecialists – begin to show significant declines in general medical knowledge. About 14 years post certification, almost 70 percent of these physicians would not have passed the American Board of Internal Medicine certifying exam. To maintain current knowledge, a general internist would need to read 20 scientific articles a day, 365 days of the year. This is an impossible task. According to Lawrence Weed:

“Until now, we have believed that the best way to transmit knowledge from its source to its use in patient care is to first load the knowledge into human minds. And then expect those minds, at great expense, to apply the knowledge to those who need it. However, there are tremendous ‘voltage drops’ along this transmission line for medical knowledge.”

A Path Forward?

Many advances have been made in clinical practice to address some of these issues. For example, the use of practice guidelines has been a major benefit to facilitate the use of these data in clinical practice. However, when these abstract guidelines hit real patient care, experience shows that (with very rare exceptions), no protocol fits every patient; and, more importantly, no protocol perfectly fits any patient. Thus, many people believe that a learning system needs to be put in place to apply these practice protocols in ways that either improves medical outcomes, cost outcomes, or both. Physicians have to begin learning what other professionals in other industries have known for decades; it is more important that you do it the same way than you do it the “right” way. When you do something the same way:

Error rates fall, because there is less complexity, fewer mistakes
Costs fall, because both the clinician and the staff are more efficient
Best practices emerge, because you can begin to apply the scientific method to systematically improve
These observations suggest that health professions, health administration, and health care delivery are in the midst of important and profound change. There is beginning to emerge a evolution in clinical care from craft-based practice where individual physicians work alone, handcraft a customized solution for each patient, based on vast personal knowledge gained from training and experience, to profession-based practice, where groups of peers operate together treating similar patients in a shared setting, where care plans are executed in coordinated delivery processes (e.g., standing order sets), in which individual clinicians adapt to specific patient needs. These are not just clinical solutions, they require management solutions to get the systems right. Research on team-based profession-based practice suggests that it produces better outcomes for patients, eliminates waste, reduces costs, and increases available resources for patients, and it is the foundation for useful shared electronic data; but only with strong clinical and administrative leadership.

Many unknowns exist with this evolution. Is profession-based care much cheaper than traditional care? The problem is that profession-based care is uniquely designed to eliminate unnecessary care, but we also know that many patients are being underserved as well, and not benefiting from evidence-based medicine. What organizational forms and management traits will best facilitate profession-based care? Experts always thought that tightly integrated health care systems were the best ipso facto organizational forms to facilitate these arrangements. However, with the advent of telemedicine and other technologies, virtual patient care teams can be constructed to facilitate this model as well. Many experts believe that team practice IS the new standard of care; however, how this standard will diffuse throughout the health care system – speed, organizational form, etc – is yet to be determined.

I believe these are exciting times in health care. Like the turn of the twentieth century, when technological innovations in health care created many breakthroughs to improve population and personal health care, here at the turn of the twenty-first century we are seeing similar breakthroughs in information technology and health care organization that may have a similar breakthrough in improved practice, management and health. These changes will not be easy, and may actually be disruptive for a time. However, you are very likely to be working at a time when major transformations will profoundly impact health care organizations. A wise physician, Sir William Osler, lived through the transformations at the turn of the twentieth century and had this to say to physicians who graduated after World War II:

“I am sorry for you, young men and women of this generation. You will do great things. You will have great victories, and standing on our shoulders, you will see far, but you can never have our sensations. To have lived through a revolution, to have seen a new birth of science, a new dispensation of health, reorganized medical schools, remodeled hospitals, a new outlook for humanity, is not given to every generation.”

Here at the beginning of the 21st century, are we on the cusp of a second revolution in health care? Ehealth, patient-centered care, team-based practice, rapid and varied organizational innovation such as patient centered medical homes and accountable care organizations arising from the Affordable Care Act are potential indicators that we may be on that cusp. On the other hand, maybe we are not. You can both observe these changes and be part of the system that is constantly resisting change and reacting to them or, you can be part of a new management philosophy in the health system that takes the path less traveled. As budding leaders in the new world of health care delivery, I hope this course has given you a few insights, commentary and data to choose wisely!

Next Steps

Time for your thoughts on these trends and any observations about management and leadership that are relevant for success in this rapidly changing health care environment.

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