The new medical paradigm

Atul Gawande in his commencement address at Harvard Medical School lays out the challenges facing the medical profession of the future. And it is not technology he focused on but rather the ability to work in teams to provide patient care. He argues against the prevailing culture of the specialist and the super specialist and instead offers the view that medicines complexity has exceeded our individual capabilities as doctors and there is need to shift to a different paradigm in the coming years. A thought provoking piece….

“ We are at a cusp point in medical generations. The doctors of former generations lament what medicine has become. If they could start over, the surveys tell us, they wouldn’t choose the profession today. They recall a simpler past without insurance-company hassles, government regulations, malpractice litigation, not to mention nurses and doctors bearing tattoos and talking of wanting “balance” in their lives. These are not the cause of their unease, however. They are symptoms of a deeper condition—which is the reality that medicine’s complexity has exceeded our individual capabilities as doctors."

"The core structure of medicine—how health care is organized and practiced—emerged in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves. One needed only an ethic of hard work, a prescription pad, a secretary, and a hospital willing to serve as one’s workshop, loaning a bed and nurses for a patient’s convalescence, maybe an operating room with a few basic tools. We were craftsmen. We could set the fracture, spin the blood, plate the cultures, administer the antiserum. The nature of the knowledge lent itself to prizing autonomy, independence, and self-sufficiency among our highest values, and to designing medicine accordingly. But you can’t hold all the information in your head any longer, and you can’t master all the skills. No one person can work up a patient’s back pain, run the immunoassay, do the physical therapy, protocol the MRI, and direct the treatment of the unexpected cancer found growing in the spine. "

It was calculated that in 1970, 2.5 full-time equivalents of doctors were required to look after a patient. By the end of the nineteen-nineties, it was more than fifteen. The number must be even larger today. Atul continues “Everyone has just a piece of patient care. We’re all specialists now—even primary-care doctors. A structure that prioritizes the independence of all those specialists will have enormous difficulty achieving great care.

We don’t have to look far for evidence. Two million patients pick up infections in American hospitals, most because someone didn’t follow basic antiseptic precautions. Forty per cent of coronary-disease patients and sixty per cent of asthma patients receive incomplete or inappropriate care. And half of major surgical complications are avoidable with existing knowledge. It’s like no one’s in charge—because no one is. The public’s experience is that we have amazing clinicians and technologies but little consistent sense that they come together to provide an actual system of care, from start to finish, for people. We train, hire, and pay doctors to be cowboys. But it’s pit crews people need."

He argues that we need "to understand how to provide what society most needs: better care at lower cost. And the pattern seems to be that the places that function most like a system are most successful. By a system I mean that the diverse people actually work together to direct their specialized capabilities toward common goals for patients. They are coordinated by design. They are pit crews. To function this way, however, you must cultivate certain skills which are uncommon in practice and not often taught.

For one, you must acquire an ability to recognize when you’ve succeeded and when you’ve failed for patients. People in effective systems become interested in data. They put effort and resources into collecting them, refining them, understanding what they say about their performance.

Second, you must grow an ability to devise solutions for the system problems that data and experience uncover. When I was in medical school, for instance, one of the last ways I’d have imagined spending time in my future surgical career would have been working on things like checklists. Robots and surgical techniques, sure. Information technology, maybe. But checklists?

They turn out, however, to be among the basic tools of the quality and productivity revolution in aviation, engineering, construction—in virtually every field combining high risk and complexity. Checklists seem lowly and simplistic, but they help fill in for the gaps in our brains and between our brains. They emphasize group precision in execution. And making them in medicine has forced us to define our key aims for our patients and to say exactly what we will do to achieve them. Making teams successful is more difficult than we knew. Even the simplest checklist forces us to grapple with vulnerabilities like handoffs and checklist overload. But designed well, the results can be extraordinary, allowing us to nearly eliminate many hospital infections, to cut deaths in surgery by as much as half globally, and to slash costs, as well.

Which brings us to the third skill that you must have but haven’t been taught—the ability to implement at scale, the ability to get colleagues along the entire chain of care functioning like pit crews for patients. There is resistance, sometimes vehement resistance, to the efforts that make it possible. Partly, it is because the work is rooted in different values than the ones we’ve had. They include humility, an understanding that no matter who you are, how experienced or smart, you will fail. They include discipline, the belief that standardization, doing certain things the same way every time, can reduce your failures. And they include teamwork, the recognition that others can save you from failure, no matter who they are in the hierarchy.

These values are the opposite of autonomy, independency, self-sufficiency. Many doctors fear the future will end daring, creativity, and the joys of thinking that medicine has had. But nothing says teams cannot be daring or creative or that your work with others will not require hard thinking and wise judgment. Success under conditions of complexity still demands these qualities. Resistance also surfaces because medicine is not structured for group work. Even just asking clinicians to make time to sit together and agree on plans for complex patients feels like an imposition. “I’m not paid for this!” people object, and it’s true right up to the highest levels.”

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The problems of making health care work are large. The complexities are overwhelming governments, economies, and societies around the world. We have every indication, however, that where people in medicine combine their talents and efforts to design organized service to patients and local communities, extraordinary change can result.”