Last night, I had the pleasure of attending the Massachusetts Medical Society Resident and Fellow Section (RFS) meeting. Though largely intended to be a work meeting in order to elect board members and delegates, the keynote speaker at last night’s meeting was none other than Dr. Don Berwick, the former CEO of the Institute for Healthcare Improvement (IHI) as well as the former head of the Centers for Medicare and Medicaid Services (CMS).
For those of you who don’t know, Dr Berwick is one of the great writers and speakers in modern medicine and is passionate about primary prevention, health care quality, and patient safety. Personally, I put Dr Berwick on the same level with other influential clinician-writers such as Dr Atul Gawande in their relentless pursuit to transform healthcare. Dr Berwick’s speech last night was titled “Clinical Leadership in Healthcare Reform.”
Berwick started the speech by telling the story of the Choluteca bridge in Choluteca, Honduras. Built by the US Army Corps of Engineers in the 1930’s, the bridge spans the Choluteca River and was designed to withstand the severe weather that often strikes southern Honduras. The bridge has endured over the years and withstood its greatest test in Hurricane Mitch struck Honduras in 1998. Even though the city of Choluteca suffered heavy damage, the bridge survived unscathed.
There was just one problem – the heavy rains and fierce winds from Hurricane Mitch altered the course of the Choluteca River, so that the river no longer ran under the bridge.
Healthcare in the United States has become like the Choluteca Bridge. Despite all of the technological advances and the improvements made in the health of our citizens, the health care industry itself has not changed the way it practices medicine. And yet we are living in an era where the landscape surrounding healthcare has dramatically changed, but healthcare remains solid and formidable and unbending to that change.
Berwick argues that it is time for a new type of healthcare, one that is both patient AND provider centered, one that is coordinated, safe, and high quality. He remarked that in order to achieve that system, tremendous change and improvement is needed. In order to achieve that improvement, three things are necessary. First and foremost, we must be willing to recognize and freely admit that the status quo is not good enough. Merely stating that improvement is needed is an indictment on the current system, stating that we can and must do better.
Once we are willing to admit that we can and should improve, there are only two other requirements: setting an aim and putting in the effort. We need to set a goal of where we want medicine to go, and then we need to invest in the effort to get there. These seem like relatively simple ideas, but in reality are incredibly difficult to do. But perhaps the hardest for everyone to admit is that what we are currently doing isn’t good enough.
One of the residents at the dinner asked how exactly do we get physician buy-in to implement changes. Berwick’s response was relatively simple. The current fee for service system that pays physicians revolves around volume-based payment. Those payments to physicians, especially from CMS, have been steadily declining due to budget contraints. We already know that volume-based care is poor quality and not good for patients, but in Berwick’s own words “volume based care for the physician is like running in on a gerbil wheel. Who’s really happy in that scenario?” Berwick went on to say that what physicians don’t realize is that they would ultimately be happier with patient and physician-centered health care. The biggest problem is bracing for change and the actual transition from our current rigid “bridge” to something that actually spans the river.