Lately I have been thinking again about the prescience of one of my most important mentors, Dr. Robert Ebert, who was Dean of Harvard Medical School when I was a student there. In my last blog post I cited a talk Dr. Ebert gave in 1967 at Simmons College, and I mentioned that it was a Triple Aim speech delivered 40 years before we had the Triple Aim. In today’s post I want to comment in more detail on that talk, and on the impact Dr. Ebert has had on me and on my thinking about healthcare quality and delivery.
In retrospect, it appeared that in that speech, the 1967 Kate McMahon Lecture at Simmons College, Dr. Ebert was describing once again the deficiencies of the current state of healthcare and medical education and he was also advocating for the trial of new approaches in delivery, finance, and education as steps that could be taken to resolve the problems as he had so eloquently summarized two years earlier with his admonition:
“The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”
The personal impact for me was that part of his solution was to create socially responsible physicians. Let me rephrase what I said above for emphasis. When I first found the speech in 2008 and read it, it was almost as if I had discovered a well meaning plot with me as a target and that the script or screenplay that contained that plot became the story of my forty years as a physician. Almost everything that I would do and would be, the focus of what I cared about, had been revealed or predicted in that speech.
Dr. Ebert did not try to hide his intentions about redirecting the training experience that my classmates and I were about to receive. Near the end of his speech he says:
“Above all, the student must actively participate in such programs. He can learn from lectures and seminars but he must experience a new kind of social responsibility within the clinic if he is to be influenced in the future. He must see experiments in the delivery of health care. He must be made aware that the practice of medicine is now a group responsibility and he must learn to work closely with others. He must be made as aware of the social problems of medicine as he is of the biological problems.”
In essence what he was describing was the Harvard Community Health Plan which would be launched two years later as a teaching practice of the Harvard Medical School which is a role that Harvard Vanguard Medical Associates continues to play even now.
What particularly strikes me today are Dr. Ebert’s concerns about how difficult delivering adequate care to the “urban poor” would be. Once again his thoughts from a half century ago read like an editorial from the most recent issues of Health Affairs or the New England Medical Journal. Read below and see for yourself. I have included his concerns also for rural America.
In this speech Dr. Ebert offers many solutions that have been adopted if you realize that care in community hospitals is now supported by the ability to transfer the critically ill to larger hospitals by helicopter as he invisions and suggests. What is most important (and I have put this and other significant points in bold face type that is not in his presentation) is that I wanted to emphasize the fact that he considers the problems of the urban poor to be even greater than the medical problems of rural America. He discussed these ideas in the sections of the speech following his review of the fragmented care in hospitals and the inadequacies of the current medical training. They are in sections entitled “The distribution of medical care” and “The organization of health care”. Please read them! I have posted the entire speech on Strategy Health Care.com as a resource for you since a clean copy is hard to find on the Internet.
Dr. Ebert on the distribution of medical care:
Closely linked to the evolution of the modern hospital is the problem of the distribution of medical care. There are two groups who have suffered from the changing pattern of medical practice: the rural population and the urban population occupying the central city. Both groups present special problems, and both require new approaches to solutions. Most of you are familiar with the problem of the rural community. Here the general practitioner is the mainstay of the medical care system, but as he grows older he is not being replaced. Community after community attempts to recruit new family physicians only to find that young physicians do not wish to practice alone in a small town.
The reasons are not hard to find. Most young physicians specialize and are unwilling to practice alone; they are more and more dependent upon the well-equipped modern hospital, and finally their wives worry about the availability of good schools. [This reference to “wives” and his use of male pronouns in reference to doctors may be the only pieces of evidence that the document is almost 50 years old.] Once again, curiously little imagination has been exercised in seeking solutions to this problem. In an age of modern transportation, when the evacuation of wounded from the jungle by helicopter is routine, [Those of you old enough to remember know that war in Vietnam was producing evidence on the evening news on a nightly basis showing wounded soldiers being taken from the jungle by helicopter with IVs running] it should not be too difficult to plan the care for rural communities. It would take a different kind of organization of physicians, however, and would require a kind of teamwork with other members of the health professions which physicians have been reluctant to provide except within the walls of the hospital.
It also would demand a new role for the regional community hospital. The central city presents a different problem and one of greater magnitude. Few of the general practitioners who practiced in the city have been replaced, and the modern specialist serves the suburbs more than the city. The city or county hospital or large urban voluntary hospital provides most of the care for the urban poor. Often the actual medical care is good, particularly for the acutely ill patient, but too often it is care without dignity. Service is frequently fragmented among different hospitals for members of the same family, and even when paid for it tends to retain the trappings of charity. It is not surprising that the urban poor have sought a different kind of solution.
The medical programs sponsored by OEO [Office of Economic Opportunity] can be criticized on many grounds but they have endeavored to give the community itself a voice in how it is to receive care — and the community does not want the charity clinic. Columbia Point [the first Federally Qualified Health Clinic] is too expensive to replicate, and it has not solved the problem of its relationship to hospitals. But it has demonstrated a number of important points.
- First, the health problems of the urban poor are intimately linked with their socio-economic problems, and they cannot be solved by imitating the care given in the suburbs.
- Second, more than the physician alone is required to provide these services; a well-organized team is essential.
- Third, the community itself profits from a sense of active participation in the project.
These are important lessons, and the physician can display a new kind of social responsibility in contributing to the solution of the problems of urban health.
Dr. Ebert on the organization of health care:
The provision of medical care in the rural community and in the central city will require a different kind of organization of medical resources than has existed in the past. The physician must learn to work more closely with social workers, nurses, visiting nurses, in fact all of the members of the health professions. There must be a sensible division of labor so that the physician performs those services which only he can do, and other duties are delegated to appropriate members of the health team.
To a degree this has already been accomplished within the hospital, but team effort must be extended to provide care at all levels. This is not an easy problem for it will be necessary to make the most efficient use of expensive manpower and still maintain the personal nature of medical care. I believe this can be done but it will take innovation and will require of the physician a new kind of responsible social action.
Care for the chronically ill and for the elderly, who so often suffer from chronic disease, is a particular case in point. Chronic illness is increasingly common and it cannot be handled effectively if it is thought of as an exclusively medical problem. The social, emotional and economic impacts of chronic disease must be understood and intelligently dealt with. Here the physician must share the responsibility with others who have special skills to offer.
Dr. Ebert’s speech reveals that we have been concerned about the issue of healthcare disparities for a long time. Concern alone and the efforts and hard work of organizations like the Whittier Street Health Center are not enough. Don Berwick tried to address these issues in his failed campaign for governor and he has been a champion of the need for more focused and effective attention to these issues for many years.
The concept of the Triple Aim is a start but we need to be realistic that if we are ever going to raise the life expectancy in our economically challenged neighborhoods to match the experience in wealthier neighborhoods that are just a few miles away geographically but worlds apart in the experience of health, we will need to do a lot more than just extend coverage that gives the possibility of a “suburban” like benefit package to residents of these challenged neighborhoods. Leaders like Mayor Walsh understand the problem and I am convinced that he understands that Boston’s collective expectations require vast improvement in the quality of health and life in these neighborhoods.
