In medicine, not all good ideas are created equal.
That's basically the stance Atul Gawande, M.D., took Sept. 21 when he delivered the keynote address during the opening session of the 2016 AAFP Family Medicine Experience (FMX) here.
Speaking to an audience numbering in the thousands during the opening session of the 2016 Family Medicine Experience, renowned author and researcher Atul Gawande, M.D., lauds the hard work family physicians do every day, calling it "the most life-saving and life-improving work of our time."
For the renowned surgeon, author and medical researcher, grasping the complexities of today's health care environment and understanding why system transformation is so difficult to achieve began by pondering the question of "why some good ideas in medicine seem to spread effortlessly and incredible quickly, and why other good ideas in medicine turn out to be incredibly hard and complicated and seemingly impossible to make happen."
Gawande hearkened back to the early days of surgery to make his point, comparing two seminal events that forever changed that specialty: the introduction of anesthesia and the advent of antiseptic practices.
Visible vs. Invisible Effects
In a paper published in the Nov. 18, 1846, issue(www.nejm.org) of The Boston Medical and Surgical Journal (known today as the New England Journal of Medicine), Henry Jacob Bigelow, M.D., reported on the first cases in which anesthesia was used during surgery.
- During the 2016 Family Medicine Experience in Orlando, Fla., opening keynoter Atul Gawande, M.D., examined reasons why some medical innovations catch on virtually overnight, while others lag far behind.
- He suggested that ideas with more visible and immediate effects gain traction more quickly than those in which the effects are not immediately apparent.
- Gawande applauded family physicians' ability to work collaboratively with patients to successfully tackle such "invisible" complex medical problems.
After the paper was published, word of the innovation spread rapidly, according to Gawande. "Within weeks -- no Internet, no phone calls, copies of the journal had to travel by ship across the ocean -- by Christmas, it was being used in every capital in Europe," he said. "Within six years, there was not a hospital in the country that was not using anesthesia."
Contrast that with the introduction of antisepsis. First reported in a series of Lancet articles by Joseph Lister in 1867, the use of antiseptic practices (cleansing of the patient's skin and the instruments used, as well as handwashing and other antiseptic measures) cut down the incidence of infection -- "the biggest killer in surgery" -- by 80 percent.
And yet a generation later, surgeons still were not following these basic techniques, said Gawande. At the turn of the century, they still wore the same blood-stained garb procedure after procedure, he noted, and "handwashing and basic skin cleansing remained perfunctory."
"Now why would one idea spread -- we would call it virally -- and why would the other idea not spread for a generation?" he asked.
It certainly wasn't for lack of incentive, Gawande noted. "If you had a patient who died, they didn't pay their bills, and all of the surgery was paid (for) in cash."
Was the level of complexity to blame? Sure, there was some effort involved in following all the meticulous steps involved in antisepsis. "But anesthesia was so complicated that we had to create a whole new specialty," he pointed out.
"The reason one moved and the other didn't, I think, was tied to a couple of things," Gawande stated. "Anesthesia has a visible and immediate effect on a problem -- pain. You can see it go away, and you can see it come back."
Contrast that with infection, he said, which is largely invisible. "Infection does not appear for a week or so after surgery. So you're asking people to try to solve a problem that is invisible to them and has a delayed effect."
But there's a second factor at work here, said Gawande. "Both of these are good for the patient, but only one was actually good for the doctor.
"Anesthesia made the doctor's job incredibly easier -- you did not have a screaming patient on the table." Surgeons could take the time to do things right, he said.
Antisepsis -- which, in those days, consisted of a carbolic acid solution -- was, by contrast, all about "pain now for gain later."
Shifting to a modern-day example, Gawande pointed out that Viagra became the fastest-selling drug to ever hit the market for the same reasons anesthesia took off like a rocket: "Immediate and visible effect," he said to raucous laughter, "and it was good for the doctor."
Unfortunately, he added, "Most of our most important ideas just aren't like that."
Doing the Hard Work of Transformation
With smoking on the decline in the United States, hypertension is now the nation's pre-eminent health problem. Yet about half of people with hypertension, Gawande stated, do not have their illness under control. Why? "You're asking them, and asking the clinician, to make an investment in an invisible problem now for the sake of gain later," he observed.
Asthma, coronary artery disease, mental illness -- all share the same dilemma: Far too many patients with these conditions receive incomplete and inappropriate care. Patients and clinicians alike feel the difficulty inherent in addressing this "pain now for gain later" scenario.
"And out of this comes this desire for transformation," Gawande observed. He then sketched out the "medical way" of trying to achieve this transformation.
- Stage 1: "You should do X." This involves training clinicians to do certain things or do things a certain way, according to Gawande. "You should do this for hypertension; you should do the following things for opioid addiction," he said. "And it is effective; people do change what they do as a consequence of learning, but it doesn't get you past that 50 percent of people with high blood pressure actually receiving the care."
- Stage 2: "You must do X." This is where clinical guidelines, incentives and penalties come into play, Gawande explained. "We're going to pass guidelines; we're going to have malpractice litigation; we're going to have regulations; we're going to make a law that you can't prescribe without doing X, Y, Z. Or, if we're feeling nice about it, we will do pay-for-performance. And it works -- a bit," he said. But because the rules in this system aren't always adapted to the real world, they can be hard to follow. And all of these elements are symptomatic of the pain of trying to do things that are really important but that have invisible and/or delayed effects.
- Stage 3: "Systematize it." Although other industries have been using this mantra for years, the medical community is just beginning to embrace the idea, said Gawande, which is all about making things simple for all participants. "You have to make it so that it is easier to do than it would otherwise be."
But how to get started? A self-proclaimed checklist fanatic, Gawande ticked off a number of systems that can help clinicians accomplish their goals for patient care -- from defaults built into health technology tools to new team designs to automated audit and feedback systems and more. It's really about asking questions such as, "What could we do to make it easier for patients with high blood pressure to actually come under control?"
Gawande went on to outline various systematization approaches he and other researchers around the globe have evaluated. In some instances, investigators encountered barriers to systems implementation, including clinicians' initial perception of infringement on their autonomy. Ultimately, however, it became clear that embracing humility, discipline and teamwork offered a surer path to better care for patients.
Although the clinical findings varied from study to study, Gawande said, all of the research on the use of systems to optimize patient outcomes highlighted a common theme: the critical importance of communication -- both among the individual members of the health care team and with the patient and his or her family and caregivers.
One study, in fact, demonstrated that early communication with terminally ill patients about their information preferences and care goals and then honoring their expressed wishes actually lessened their anxiety and depression and extended their lives.
Leveraging Patient Relationships
Gawande recognized family physicians as the specialists who epitomize the five Cs of primary health care:
- being the patient's first point of contact with the health care system;
- providing comprehensive care that includes preventive, promotive, curative and palliative elements;
- coordinating the patient's care across all levels of the health care system and with all other health professionals;
- ensuring that care is continuous throughout the patient's lifetime; and
- providing patient-centered care that recognizes not just the patient's health needs, but also his or her values and life preferences.
It's their unparalleled relationship with patients that permits family physicians to work with them to invest the time and effort needed to tackle "invisible" problems such as hypertension, and Gawande lamented the fact that FPs aren't adequately recognized and rewarded for their value.
"No one asks me if taking out a thyroid cancer saves money. No one asks if putting in a pacemaker saves money. And if being good at what you do means that people simply live longer, have better lives, better function and less suffering, then that is what our health care system is for, and that is what we should pay for," he said to thunderous applause.
"I think that what you do is the most life-saving and life-improving work of our time."
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