Why Health Care Reform Won’t Happen Without Physician Leadership

This past week has been filled with great articles that show the stunning gap between what we know and what we need to do in health care to make it more affordable, accessible, and higher quality. In a recent piece by NPR, research shows that when it comes to treatment of low back pain, doctors are prescribing more powerful pain medications (narcotics) and ordering more imaging tests like MRI and CT scans when there is no evidence these are better than anti-inflammatories, time, and rest.

Reasons for gap? Solutions to make the care provided for low back pain more evidence and scientifically based, we first needed guidelines. In the past, we didn’t have guidelines. Now we have had guidelines for quite sometime. However, we also know it takes 17 years for an idea to spread to be commonly practiced and become the norm. So to help make change happen more quickly, people have tried to incentivize doctors and paying them to “do the right thing”. Other solutions have been to have patients pay more for these tests and initiate conversations with doctors about the appropriateness of such testing. The Choosing Wisely campaign led by Consumer Reports and other physician organizations like the American Board of Internal Medicine and American Academy of Family Physicians are educating patients and doctors what to do about low back pain.

Will these work?

At the same time, one of my favorite physician writers, Dr. Atul Gawande, writes in the New Yorker about “Slow Ideas – Some innovations spread fast. How do you speed the ones that don’t?”. He reviews how to decrease the death rate in childbirth. The ideas are not new, relatively inexpensive, and in theory should be easy to implement. Yet in the age of instant access to information and ideas, not all ideas spread or take root quickly. In fact, many do not take hold until there is engagement at a one to one level; individuals talking to individuals. Building familiarity or trust. Dare I say it, “coaching“. Indeed, norms and practices only change with this slow process even when it is the right thing to do.

Three Types of Change – Please Do X, You Must do X – With Carrots or Sticks

Yet most change, which interestingly are the solutions offered in the NPR piece, falls into categories Gawande identifies:

• The most common approach to changing behavior is to say to people, “Please do X.” Please warm the newborn. Please wash your hands. Please follow through on the twenty-seven other childbirth practices that you’re not doing. This is what we say in the classroom, in instructional videos, and in public-service campaigns, and it works, but only up to a point.
• Then, there’s the law-and-order approach: “You must do X.” We establish standards and regulations, and threaten to punish failures with fines, suspensions, the revocation of licenses. Punishment can work. Behavioral economists have even quantified how averse people are to penalties. In experimental games, they will often quit playing rather than risk facing negative consequences. And that is the problem with threatening to discipline birth attendants who are taking difficult-to-fill jobs under intensely trying conditions. They’ll quit.
• The kinder version of “You must do X” is to offer incentives rather than penalties. Maybe we could pay birth attendants a bonus for every healthy child who makes it past a week of life. But then you think about how hard it would be to make a scheme like that work, especially in poor settings. You’d need a sophisticated tracking procedure, to make sure that people aren’t gaming the system, and complex statistical calculations, to take prior risks into account. There’s also the impossible question of how you split the reward among all the people involved.

Whether following low back pain guidelines, having medical staff vaccinated, or even the simple basic task of hand washing, you can hear the same methods used by our health care system to make change.

So what will change the norms?

In Which Situations Will Change Occur?

My belief is that it is the microculture that doctors find themselves in. Doctors in physician led organizations seem to be leading in the areas of quality, service, and cost. Large academic medical centers are also a structure that produces this microculture. Could it be that physician leaders who engage on a one to one conversation over time initiate change more quickly and more slow ideas faster? The fantastic book, The Power of Positive Deviance: How Unlikely Innovators Solve the World’s Toughest Problems, demonstrates that to move norms and culture it is the time consuming building relationships over time that really matter. It describes many strategies on how to do that. Though time consuming, the change does not take 17 years and sticks. Another helpful tool is how to build relationships and have the right types of conversations with individuals. This is also addressed beautifully in the book, Tribal Leadership: Leveraging Natural Groups to Build a Thriving Organization.

We see our health care system not doing better because we do not have the structure or leadership to move the system because we have no system. There is no common leadership. There is no common culture. There is no common goal. Instead it is hundreds of thousands of doctors often working in small groups not having the types of conversation and the follow through needed to change norms or culture. This stunning gap of what we know works and what actually happens continues to harm patients. Whether accountable care organizations will be the right microculture to improve health care remains to be seen. What really matters is whether there is leadership at these organizations willing to have the difficult one to one conversations on a consistent basis. I believe that physician leaders, who both have clinical expertise and credibility, are best suited for this role.

We don’t have 17 years to wait for the best ideas to take hold.

What do you think?