17 August 2018
Dear Interested Readers,
The Future Will Be What We Make It
Francis Fukuyama, an American philosopher, wrote The End of History and the Last Man in 1992. In his book he argued that there would be no more social evolution beyond liberal democracy and capitalism. He thought that they were here to stay and represented the apex of social organization. Perhaps they could be further refined, but they would not be replaced. Fukuyama got a lot of people thinking, and his ideas initiated some arguments with those who weren’t so sure that he had it right.
We have had a little more history since 1992 when it looked like the collapse of the USSR’s brand of Communism and the end of the cold war did signal the ultimate victory of democracy and capitalism. Today democracy is being stressed by Chinese communism and its economic success, as well as by a resurgence of right wing movements with governments influenced by religious fundamentalism and nativism. Some of us even worry about a drift toward an authoritarian future in America under the guise of making America great again by putting America first. I wish Fukuyama had been right. Perhaps his prediction was just premature and we are living through the last desperate attempts to structure a more comfortable world for a privileged few.
About five years ago, near the time I retired, a patient sent me a book written by one of her cousins, Sidney Lowry, a prominent UK physician who has practiced in Boston, Britain, Northern Ireland and Bermuda. Lowry purposefully parodied Fukuyama’s book in the title of his 2011 book about the future of healthcare, The End of Medicine and the Last Doctor, published in the UK by the Royal Society of Medicine Press. In his preface Lowry says that he isn’t predicting the collapse of the NHS in the UK, or even the demise of American healthcare, but he does believe “neither can be sustained in its present form.” As one reviewer wrote:
Sidney Lowry, a cancer expert, believes that we are entering an age in which machines and a much larger array of health professionals will hold sway over clinical treatment. But the machine, he points out, has no compassion.
The reviewer goes on to quote Lowry:
“The triumphs and limitations of the technological age must be embraced and a new era of medicine accepted. This will be an era in where the physician no longer holds sway and where the future of health care will look very different.”
The story he tells is realistic and reflective of what he has observed during a long career in both countries. He is blaming no one, and he is not pining for a lost past. The end of healthcare as we have known it is a product of healthcare’s success and of the associated technological advances. These days a patient with a chronic cough isn’t coming to his doctor so that the physician can do a good chest exam with his stethoscope. He is expecting a diagnostic study, either an MRI or a chest CT.
Lowry sees this moment as a fourth phase in the history of medicine. We are living in the logical conclusion of the experiences that we have had. His four phases are:
- Phase One: the nineteenth century, the germ theory is established.
- Pase Two: beginning in the 20s with the discoveries of insulin and penicillin. The wide use of immunization for many illnesses made things even better.
- Phase Three: programs of health education, prevention, protection, and screening led more people to exercise, give up smoking, and seek longevity through a healthy lifestyle.
- Phase Four: well underway now, is about molecular biology and the eradication of many causes of premature death. We now have more reason to think about the issues we will face in our eighties and nineties, and how life ends long after the years our ancestors could expect, three score and ten. They died long before they had a need for “life care” facilities and never had a need for end of life conversations.
Lowry’s view of medical history is a little different from Don Berwick’s three eras of medicine, but they share some of the same concerns. Lowry is a radiation oncologist; so maybe that explains his way of parsing medical history. His divisions may not resonate with you, but he, like Berwick, is trying to set the stage for a discussion of the future. Lowry is concerned about rising healthcare budgets, resources “wasted” on care at the end of life, malpractice, and the resultant practice of defensive medicine. He is most concerned by what he calls the loss of compassion, and “a rise of the worried well” with their demands further aggravating the stress of practitioners. Lowry’s logical conclusion is that the practice of medicine has changed. We should think about what that means. Asking how we are adapting to the new realities makes sense. Healthcare has changed. It will continue to change, and as it does the experience and roles of healthcare professionals will, by necessity, change.
How is your world changing? Are you living out Dr. Lowry’s forecast? It seems that each of us has options. I fear that a majority of doctors and healthcare professionals are practicing as if nothing was changing. Their objective is to get through this day, return the calls that came in today, empty the inbox, close their charts, and get out of the office with a little time remaining in the day for self and family. I followed that pattern for a long time except that after I had a laptop and my records were available on a secure line at home, I would leave the office after the last patient, and hope that I could have a few hours of respite, and then finish my work before going to bed. It was an endless loop.
You might have noticed that great change has already occurred in the lives of the practitioners suffering as I just described. Their schedules are crammed, the problems they face are more complex, and they must deal with more and more social issues that they are ill prepared to manage. The demands from their patients are greater, and because they did not change the way they engaged with the demands of the day, their work days have become a lot longer.
Although theoretically we all have options, and could attempt to respond to the demands for change that bomb us from the external environment, we are constrained by the organizations where we work, or the colleagues with whom we work. Unlike our fore-bearers in practice who were able to function independently as recently as the mid twentieth century, there is little that we can accomplish with many patients without some form of collaboration. It is hard to practice in a new way if those around you do not share your understanding of the need to change.
Had Lowry not been writing from the perspective of practice in the UK, perhaps he would have chosen to construct his “phases” of healthcare as a function of how practice is organized. Even the NHS, in place since the late 1940s, has changed. 70 years ago healthcare in America was a cottage industry with independent solo practitioners able to personally meet the needs of most of those patients who came to see them for care. Now we have a new reality of dependence on a complex collection of interdependent businesses and their suppliers who are making decisions based not on the patient’s wants and needs, or on the issues that constrain the practitioner, but rather on the issues of finance and what is most profitable for them. These organizers of care, and the owners of the technology define the new pathways of care.
When I was trying to lead a medical group there was nothing that occupied me more than thinking and planning for the future. My message was not always well received. The choices that all medical leaders of the era had were limited. Many of us felt either misunderstood or ignored, no matter how hard we tried to advocate for proactive change with our timelines of prediction or supporting data that we attempted to capture on slides in a way that would convince our colleagues that transformation was a necessity and not an option. The choices were:
- Anticipate that change is coming and do something before the fact.
- What until change comes and then react to the reality.
- Deny that change will come. If it comes denounce it, or call it something else, and hope that it will go away. Blame it on others.
Many of us anticipated a return to risk based contracts and the need to understand the principles and practice of population health. We accepted the benefit of value based compensation. We embraced the importance of demonstrating quality and patient satisfaction. We planned for shortages of critical providers by advocating that everyone work “at the top of their license”. We tried to manage rising costs from suppliers by naming preferred providers. We saw the threat of the emergence of competitors providing care on demand. We expected the relative declining reimbursement from Medicare and Medicaid. We prepared to meet the changes in patient demands based on increasing use of the Internet and advocated for “patient portals.”
The key decision that seemed centrally important was to determine what must be protected from change, like time with patients. Difficult finance problems could not be allowed to threaten professional values of compassion, patient centricity, safety, and equity. Efficiency and effectiveness were manifestations of good stewardship and could not be protected by slashing critical programs or reducing staffing without redesign and elimination of ineffective or wasteful processes. Some of us saw Lean as a methodology that would incorporate the wisdom of those doing the work into how these decisions were made.
After we decided what must stay and be protected, the next step was to decide what we could eliminate. Again, a methodology that drew from the wisdom of the practice was the way to avoid error in these critical decisions. After waste was considered and eliminated, the final step was to determine what needed to be invented, created, or acquired to optimally respond to the change.
Then as now, it was highly likely that the response to change would require acquiring some new skill or capability. Almost all change is driven by external forces, and again the thoughtful members of the practice were the ones who needed to be heard. They would be the ones to sell the need to those who were having trouble keeping their heads above the rising tide of change. If you accept that you must change to continue to fulfill your mission and achieve your goals, you are acknowledging the unavoidable reality of a learning curve.
The time for preemptive change has passed for most of us. The options that face most of healthcare now are to try to catch up, or to ignore change and hope something else happens. I think Dr. Lowry was right when he suggested that medicine was ending as we have experienced it either as providers, or as patients. If you have a very narrow definition of “doctor,” then we are likely to also see that last doctor 1.0. Perhaps he has already left the building. What is still evolving is doctor 2.0. I see continuing change as the new normal. Physicians and other practitioners are facing change at a faster pace than new models of iPhones come out, so if you are still in mid career, expect to see doctor 10.0 before you retire.
There is one final strategic opportunity, working together for the future that we want. Change is inevitable, but it is possible to change its shape and vector. None of the responses to change that I have suggested can be easily managed by an isolated individual. The most effective strategy is to respond to change together. The first step is to name the problems. After naming “the problems” from our individual perspectives, the next and most difficult step is to negotiate the intersections of our concerns. After that discernment, we can continue to define a new set of objectives and the solutions to try in the pursuit of those hopes. There is a buddhist saying that suggests that if you meet a man in the road who says that he alone has all the answers, kill him. Some buddhist philosophers may disagree with me, but the admonition has always suggested to me that no one has all the answers, and that those who make the claim are dangerous. Lean teaches us that we all have something to contribute. Collaboration is not a platitude. It is a necessity.
We could come together around common causes like truly universal access and quality care. We have already articulated a pretty good objective: Better care for everyone, healthier communities, healthcare delivered at a sustainable cost that leaves adequate resources for other collective needs. We could call it “three goals for a better future through change,” or something that is a little more cryptic, like the Triple Aim. I think that Dr. Lowry would agree.
August: Rapid Oscillation Between Monsoon and Magnificence
The weather has been a challenge to many of my late summer plans. I am sure that a careful examination of records will show that what we have experienced for the last few weeks has been completely within the range of “common cause variation.” It’s just that when you get a little past the standard deviation from what your experience has established as normal it seems like something has happened that suggests the system has been irreversibly altered. When it comes to weather we are all a little confused about where we stand in reference to the future, or more importantly, what we as an individual might do about it other than to try to reduce our own carbon footprint and vote against any politician who isn’t at least open to the concept that our collective actions are changing the environment.
The picture in today’s header shows the interface between monsoon and magnificence. The sky is “low” and grey despite the fact that the heavy overnight rain has finally stopped, and it is well past mid morning. I took the shot expecting that there was nothing to look forward to but more deluge. That was the prediction. What I did not know when the picture was taken was that for once the weatherman was wrong. He was saying to expect more of the same for several days to come. Within a few hours the sun was out, and the humidity had dropped as our sauna like air was replaced by cool breezes from the northwest.
This week we have enjoyed a reuniting with friends from Germany. It was as if they brought the better weather. They arrived simultaneously with the meteorological miracle. The visitors included a woman who spent six months with us more than thirty years ago before going back to Bavaria to begin her university studies. Our dear friend is named Heike. She now has a successful career as an independent publicist and videographer. She lives with her husband and twelve year old son in a village on the Rhine a few miles from Drachenfels. If you have ever watched an ad on television for a Rhine River cruise with Viking, you have seen her neighborhood. We have visited her and her family twice. In 1995 we saw her at her hometown, Lindau, a medieval walled town on the Bodensee (Lake Constance) in Southern Bavaria. In 2013 we saw her in her home on the Rhine. The visit of Heike and her family overlaps with the visit of my son, his wife, and our two young sons from California. It’s been a great reunion since Heike has known my son since he was four!
Heike’s husband works in healthcare in Germany. On a long walk I learned that his company supplies healthcare workers with educational materials of all sorts: written, on line, and video. Currently they are working on products that improve the care provided to the elderly in their homes. He likes living in a “socialist” environment where citizens can expect good healthcare, up to date infrastructure, more free time for family and friends, and a good education for their children. He does not not mind the fact that 45% of his income goes to various taxes. The value that he gets seems worth the exchange. I think he has a point of view that is educated by a different life experience compared with most Americans. He was living in Berlin when the wall came down. He looks forward to a world without walls and much less focused on the concerns of individual nations or groups. He is not sure how it will happen, but he believes that we are slowly moving toward a more harmonious global community. In the old “two steps forward and one step back” dance of progress, he admits that we, both Europe and the US, may be in the one step back position, but believes that the sum of all our steps is forward.
Martin Luther King, Jr. said it best when he paraphrased Theodore Parker and said, “The arc of the moral universe is long, but it bends toward justice.” Sadly, it is a very long arc, and many have suggested that King implies a passive process. I do not believe the either Dr. King or Barack Obama, who frequently referenced the quote, were nieve or were advocating for us to just wait until things get better. I think that my German friend, Dr. King and President Obama all realize that history’s arc is very long. They would advise those of us who share the dream of a better world that is defined by justice and universal peace to do more than just passively wait.
I hope that the weatherman has at least one more error in his future. He is calling for rain over the weekend where I live. We are eagerly anticipating the arrival of our youngest son and his wife from Brooklyn. Sunshine is what I am hoping for. We have plenty of vulnerable outdoor family plans. I hope that wherever you are the weather will allow you to enjoy some mid August magnificence.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
