Hold on to Your Heart

The following is a commencement speech given by ABIM Foundation President and CEO, Richard Baron, MD, at the University of Texas Southwestern Medical School’s 2014 graduation ceremony.

“Your institution has ceded to me the last 15 minutes of your medical school instruction – how should I use it? One more time through the complement cascade? Or, as Dr. Seldin might have it, a final discussion of salt wasting in chronic renal disease, or, perhaps, the causes of metabolic acidosis? My guess is that you would sleep through that (as I slept through so many medical school lectures), but the good news is that many of those things are going to change–dramatically–over the course of your careers. Change in medicine is a constant, sort of. Many things DO change, but some core things don’t. Let’s spend some time reflecting on that.

Hippocrates didn’t write about essential thrombocytosis, Benjamin Rush, an 18^th century Philadelphia physician and signer of the Declaration of Independence, never made a diagnosis of osteoporosis and William Osler did not review hyperparathyroidism in his Principles and Practice of Medicine. Now, none of these men were considered ignorant or uneducated during their medical lives; to the contrary, all were thought to be excellent physicians in their day. But you can’t make a diagnosis of thrombocytosis if you don’t have a way to count platelets, you can’t diagnose osteoporosis without DEXA scanning and you can’t make a diagnosis of hyperparathyroidism if you don’t have access to sophisticated clinical chemistry laboratories. At any given time, we do what we can do with the theories, knowledge, technology, payment and culture that we have available at that time.

T. S. Kuhn, a famous historian of science, is the guy who coined the term ‘paradigm shift’. He observed that scientists tell their history as a linear saga of continuous improvement: in our conventional ‘textbook’ history, we just get smarter and smarter and better and better. But Kuhn realized that we have real ‘discontinuities’, ‘inflections’, where the very way we think about science changes. He calls those ‘scientific revolutions’—paradigm shifts—and says they happen when science is failing to solve problems society believes are ‘important’. Well, I think it is pretty clear we are failing to solve a lot of the problems society deems important, and I think we are in the middle of a pretty big paradigm shift right now.

What are the ‘important problems we are failing to solve?’ Care is too expensive; it is of inconsistent and unreliable quality; and the experience of patients in the health care system is not wonderful. This has been summed up in the ‘Triple Aim’, which is at the heart of our national health care strategy: increase quality, improve patient experience and decrease total cost of care. No problem, right? We ALL know how to do that, right? Or maybe we don’t. More about that in a minute.

But medicine has actually had a LOT of ‘scientific revolutions’ with big changes in what we do and what we believe ‘works’: Rush was a big fan of bleeding and purging, and Osler treated typhoid fever with cold baths. So what DOESN’T change in medicine? What can you all hang on to over the course of your own changing medical lives?

In their book, A Philosophical Basis of Medical Practice, Pellegrino and Thomasma define medicine as ‘a meeting of at least two personal intentions, one seeking help and the other offering it.’ Over the course of my own career in practice and in policy, I have never found a better definition of what I was trying to do, a better way to frame and understand the myriad micro- and macro- choices facing me and my colleagues. My patients were the ones seeking help; I was the guy offering it. Sometimes, I got it right; lots of times, I got it wrong. I would be trying to use what I knew in the service of my patients.

A year ago at this time, I had the incredible good fortune to be standing at the Hippocratic Studio on the beautiful Greek island of Kos: big, grand ruined buildings. Maybe what UT Southwestern buildings will look like in two or three thousand years?  We don’t know much about the specifics of the patient experience there, or the techniques the doctors used. And I suspect the intricate theories under which you are developing the latest biologicals to treat lupus will be obscure to those tourists clambering over the ruins of your labs and trying to figure out what went on here. But I am certain that however they did what they did at the Hippocratic Studio at Kos, the people who came shared the predicament of our patients today, and the workers in the Hippocratic Studio shared that same durable intention: to help. So with all the things that will change over the course of your careers, perhaps you can hang on to that.

I was lucky enough to practice medicine for almost 30 years in the community in which I lived in Philadelphia. A century before I did, so did Dr. Owen Wister. In 1857, Dr. Wister wrote to his wife:

I was almost afraid that I might not be able to write today, for last night I came home early, with the intention of going to bed by 12 o’clock but at that hour was called out, returned at 2, was again called out at 2:30 and finally appeared at 6, in time to get a bath, eat breakfast and go out for the morning at 8. (This was, of course, before ACGME put in Duty Hour restrictions!)

In 1858, while his wife was vacationing in the hot springs at Saratoga, he wrote to her explaining why he could not join her:

At this moment I have in my care some people severely and dangerously ill, and so affected that I could not ask them to see anyone else, not that anyone else would be less suitable, but I am their physician- they have confided to me what must have cost them no trifling sacrifice of feeling, and can I ask them to uproot this in order that I may yield to a temptation [to travel]?

As I did and many of you will, he often took care of friends and their families. When his friend’s son became ill, he sent for Wister. This is from his friend’s 1858 diary entry: He [Wister] came at 5 yesterday.  [Little] Sidney no better but no worse. He ordered Dover’s powders.  Came again at 10 last night. He then told me that it was membranous croup, but that the child was better & he thought he could check the disease.  . . .  He came again this morning, and the baby was better . . . there was no longer cause for anxiety.  What a great thing is science. But for this, our baby would in all probability have died, as many thousands die for want of skillful treatment.

‘Dover’s powders’? Science ‘a great thing’? Guess we’ve had some scientific revolutions since then.

With Wister’s romantic image firmly in mind, let’s get back to that ‘changes’ thing. There ARE going to be huge changes, because we need to figure out how to achieve that Triple Aim. I want to reflect on three broad transformational forces affecting all of you that will be bringing us closer to Triple Aim outcomes. I believe you can make sense of them using your intention to help as your compass. The three areas: information technology; payment systems; and the organization of physician practice and health care delivery.

I know it’s a cliché to talk about how computers are changing everything, and not just in health care. As I noted earlier, there is a constant iterative dialog between how we do medicine and the technology we have to do it with. In general, people use technology to solve a problem. Computers found an early use in medicine built into the machines that gave us advanced imaging, and computers also found a path into health care, as they had in so many businesses, to handle financial transactions: billing, coding, claims processing. These were both ‘familiar’ uses of computers: solve a business and financial problem and understand pathological and healthy anatomy. But the ‘revolutionary’ use of computers in health care will come from the continuous availability of ‘numerator-denominator’ data about our performance as a core feature of medical practice.

We used to hold ourselves accountable for ‘knowing what to do’ – who should and who should not have a mammogram? Now we are holding ourselves accountable for knowing the answer to the question, ‘Of all the women I saw last year who SHOULD have had a mammogram, what percentage of them actually DID?’ It used to be we doctors only had data like this was when we did studies: we paid chart abstractors to audit charts and count things, but only for research. I believe this continuous understanding of your performance will be as much a part of your practice as using a stethoscope was for Dr. Seldin.

Many have said that computers are a barrier to patient centered care; I simply don’t believe that.  All technology CAN be used as a barrier—which of us hasn’t plugged into the safe silence of our stethoscopes while ‘listening’ to our patients?—but it can also be a tool used to help us achieve very patient-centered goals. A colleague tells the story of a 70-year-old engineer who, at his first visit, thrust out his hand and said, ‘My name’s Chuck Schiedle, rhymes with Needle.’ Now Schiedle had an odd spelling, S-C-H-I-E-D-L-E, which folks would reliably and predictably mispronounce. My colleague ‘tricked’ his EHR to show, to whomever opened the chart, right under the name, the phrase “Schiedle, rhymes with needle”. He figured out a way to use his EHR to achieve a very patient-centered goal: ‘everyone in my office will get your name right.’ You will not learn that use of information technology from the many compliance officers you will meet who will explain the requirements of Meaningful Use, but it is clear that this use of an EHR was pretty ‘meaningful’!

In my own practice, we referred many patients for screening colonoscopy, a clearly valuable clinical preventive service. Our standard approach, using our EHR, was to advise the patient to do it, print a letter they could take to the GI office, and encourage them to schedule the appointment. I know you will all be shocked to learn that many patients simply didn’t follow through! So we tried another approach: we asked patients if it would be OK for us to share their contact information by e-mail with the GI group we usually used, and we worked with the GI group to agree that, upon receiving this information, they would call and offer appointments. Guess what happened: the rate of completed colonoscopy using the ‘paper referral’ method was 29%, but it was 42.9% for patients with e-referral. That is a 47.9% relative improvement in the rate at which colonoscopy was actually completed on those patients!

You will have many opportunities of your own to figure out how to use information technology to meet the needs of your patients. Don’t let the Meaningful Use police circumscribe all your creative uses of technology!

Payment systems in health care are also going to change pretty dramatically during your career, but before you despair and get influenced by colleagues who tell you how terrible all these changes are, keep a few things in mind. Payment and systems to administer it will always be challenging for doctors, and they will always be imperfect. Physicians used to be a lot more economically marginal in the U.S. than we are today. Consider this advice, offered by Benjamin Rush in an 1805 book written for medical students and young doctors:

‘The resources of a farm will prevent your cherishing, even for a moment, an impious wish for the prevalence of sickness in your neighborhood.’

And a century later, in New York City, it was not much better. In 1895, John Sedgwick Billings, a Hopkins-trained socially connected doctor, tried to set up a private practice and wrote to his wife:

‘If my patients would only pay up!  But that is the hopeless despairing cry of every D–n Fool of a young doctor in New York- or elsewhere.’  

We’ve come a long way from there, of course, with insurance companies and governments mediating payment arrangements for patients and enabling a much more capital-intensive health care system with many more machines and laboratories and pharmaceuticals than we ever could have gotten without them, and WAY higher incomes than any 19^th century physician dreamed of. But I think it is fair to say that one of our major problems in health care could best be described as ‘defective procurement’. Payers, committing to pay for health care services on behalf of patients, precisely specify what they are buying, so we have a clear definition of a right knee MRI. Having created a world in which payment for those services is available, we sure get a lot of them. The problem is, nobody WANTS a right knee MRI! They want to play tennis, or crawl around with their grandchildren, and we haven’t figured out how to buy THAT.

Well, I think the best way to understand payment change is as a continuing effort to buy what patients really need, and to encourage all of us to organize institutionally to deliver that. When an elderly lady falls and breaks her hip, if all goes wonderfully well, she will be treated in an ER, go to an OR, have a successful operation and go home. And then she will get separate bills from an ER group, a hospital, a radiologist, an anesthesiologist, an orthopedist, and maybe a physiatrist or physical therapist. All of those services were completely predictable from the moment she fell and broke her hip, but we pay for them one at a time. You wouldn’t buy a watch or a car that way, would you? You know it would cost more and be harder to assemble, right? Well, we aren’t going to keep buying health care that way either.

As you see and experience these dramatic payment changes, realize they are not about you! There is nothing ‘natural’ or ‘automatic’ about the payment system we have, which has many perverse consequences. Your future leadership as physicians will be desperately needed in making it work better for the patients all of us serve. And, of course, changes in payment are going to drive changes in the way care is organized.

Unlike Dr. Wister, we are not solo actors working in farm houses at 3 AM. The image still inspires us, as well it should: somebody has a need, somebody is offering to help. Today, we can do more for our patients than Dr. Wister could EVER do in those farm houses. But we do it the way advanced societies achieve amazing things, like building the new hospital I toured earlier today with Dr. John Warner, an interventional cardiologist turned construction supervisor and hospital CEO: we do it in complex teams of highly differentiated function.

As physicians, you will have a critical role on those teams: sometimes as a leader, sometimes as a follower. Those teams need to focus on putting together the things patients actually want and need from health care. You may be the orthopedic surgeon who does the amazing knee operation, but you need an OR staff to support you, a billing group to pay you, multiple other health professionals to get her moving and playing with her grandchildren, and an IT team to assure that everyone touching her has the critical information they need to provide safe, informed care. NO ONE has a privileged role in this besides the woman with the broken hip. EVERYONE else is working together to meet her need, reliably, efficiently and well. Always remember that our patients are not ‘guests in our hospital’; we are ‘guests in their lives.’

But back to Dr. Wister. I have some bad news about him: he crashed and burned doing practice at the pace I have described. You, too, are going to face many pressures to lose your idealism and become cynical. You are going to encounter colleagues who tell you ‘you need to understand how the world REALLY works,’ who invite you to substitute their despair and frustration for what you aspire to and think is possible, and you will need some survival skills to help you. So, in conclusion, I’ll offer a few:

• Stay curious and seek understanding. When you see something REALLY dumb (you’ll see a LOT of that), work hard to imagine why somebody thought that was a good idea, how that could be understood as trying to solve a different problem than the one occupying you at the moment you encounter it. And try to find a better way to solve BOTH problems, yours and the other person’s.
• Seek value congruence in all the institutional affiliations you make – the deeper, the better. Don’t go anywhere for the money or the prestige.  You’ll regret it.
• Stay focused on your patients: it’s not about you.  YOU are about THEM!
• Perhaps most important: DO take that vacation with your spouse that Wister didn’t take, and DO take the day off to see your kid in the school play. You will be a better doctor because you did!
• And don’t ever forget all those people who got you here. Celebrate with them your wonderful beginning as a doctor, and let them remind you who you are and why you do what you do every day.

Thanks for giving me the chance to share your magnificent day!”

Richard J. Baron
President and CEO, ABIM Foundation