Portal de Periódicos da CAPES

Overcoming militant mediocrity

2008; Elsevier BV; Volume: 198; Issue: 6 Linguagem: Inglês

10.1016/j.ajog.2007.11.056

1097-6868

Mark I. Evans,

Nursing Education, Practice, and Leadership

A privilege of being President of the Central Association of Obstetricians and Gynecologists is the opportunity to address the membership of the organization on a topic of the President's choosing. In the more than 20 years that I have been an active member, these addresses have generally emanated from 1 of 2 perspectives. There have been those talks, such as the last 2 years, that were personal reflections of watershed events in the President's personal or professional life; others have been philosophical or even very concrete assessments of the state of our specialty with calls to change aspects of the practice of obstetric-gynecology.I have known practically since the day I was given the honor of being President of our organization, that my talk would be a hybrid of the 2. Sometimes I can best summarize both my personal experiences as epitomized by 2 characters played superbly by the actor Tom Hanks. One was Forrest Gump in which many of us have witnessed the high and low points of history and felt like we were just going along for the ride. The other was Captain Jonathan Miller in Saving Private Ryan in which we have found ourselves in the middle of Omaha Beach.We have had to muster all possible resources just to survive and move forward under severe attack. Many of our best and brightest colleagues have become either direct casualties of the process or were, at the very least, collateral damage to attacks on others. As with Omaha Beach the only path to safety was actually to advance up the hill. Those who retreated were all cut to pieces.The last decade in particular has witnessed a profound change in the operations of all aspects of medicine. Before everyone gets too depressed, my thesis is that we can fight our way off Omaha Beach and up the cliffs, but that it will not happen until we recognize that the power to do so does not reside with politicians, lawyers, or administrators but only by us by regaining the professionalism that we were taught was the fundamental basis of being a physician.How did we get here? (Table 1) For medicine it was a continual process of gradually loosing control of our destiny to forces we chose not to fight. The oldest of our active members were trained in the 1950s and 1960s when being a resident meant literally living in the hospital, and technology was the coffee maker. In the 1970s medicine became a big business. The proportion of gross national product (GNP) related to health care began a steady increase particularly as the Medicare and then Medicaid programs begun in the 1960s began to be responsible for ever-increasing numbers of patients.TABLE 1Downward spiral from professionalismFinancial alignment between doctors and hospitals endsContinued use of outmoded technologyVariable quality controlAdministrators and "big business" take control of medical practiceMedicine treated as commodityShift from medicine as "career" to a "job"Incentives only for financial productivity not teaching or researchChairman relegated to enforcers not makers of policyResearch budgets calculated such that can only to be money losersFor profit chains out of controlPositions and privileges at complete discretion of administrationLegal system a sad jokeEvans. Overcoming militant mediocrity. Am J Obstet Gynecol 2008. Open table in a new tab By the late 1970s and 1980s patients were living longer, and incurring disproportionately large expenses even when in the terminal phase of a disease. One of my friends, a pathology resident at the time, almost got fired when presenting an autopsy conference. Instead of the usual pathophysiology progression, he did a "financial" autopsy showing how tens of thousands of dollars were reflexly spent in the last day of a hopelessly terminal patient that achieved no more good than would have been accomplished with $2 of morphine. Today, the hospital administrator would probably give him a medal.Having spent nearly 20 years in Detroit, the automotive industry commonly serves as my model. There are more dollars of health care in the average Detroit-made car than steel-now about $1500. It was only too many years later, that the Big 3 finally realized that they were making themselves noncompetitive and that someone else could and would do it better and cheaper. It is ironic that the bible for the Japanese auto industry was derived from the principles laid down by Edward Deming, a Detroit analyst and industrial guru. A whole industry of business consulting had to be created to fix the toxic organizational culture of antagonistic labor management confrontation created decades earlier by Henry Ford.How does this history lesson apply to health care? In attempts to control health care costs, during the Reagan Administration, the DRG program was first implemented in which hospitals would get a fixed amount per case. All of a sudden, the hospital cared what the doctors ordered from the laboratory and the pharmacy. The seeds of confrontation within the family began.By the beginning of the Clinton Administration, health care policy emerged as a leading political issue. "Hillary Care" was an attempt to take control of medicine under the wing and thumb of the government with all its associated financial and political sequelae. It was also an attempt to protect the trial lawyers from attempts to implement tort reform as liability concerns were becoming recognized beyond the doctor's cafeteria. A basic, but of course never publicly stated principle, was that by taking power away from the doctors, that organized medicine would be in a compromised position to fight the lawyers, insurance companies, and administrators.The initial plan was concocted by a small group of medical "outsiders" and was so convoluted and jury rigged that it clearly stood no chance of hoping over all the land mines laid in its path. However, many of its elements still happened with many of the same distressing results. The proportion of the health care dollar that went to physicians as opposed to hospitals, insurance companies, administrators, liability premiums steadily increased, and with it the financial and political power of physicians plummeted. The physician became the traffic cop and no longer the captain of the ship. Layers of administrators were put in between doctors and decision making in medicine, and too much time was needed to appeal knee jerk rejections of medical plans by administrators whose bonuses depended on not spending money on health care. Often the least qualified health care providers, including nurses and those with no medical training at all were telling subspecialists how to take care of their patients but not taking responsibility for the outcomes. The law specifically exempted plans from liability exposure for their decisions.The incorporation of technology and industrial methods for quality control and innovation were remarkably patchy. By and large, medical practices were not evolving with the technologies. The Federal government formed the National Center for Health Care Technology under President Carter. Dr Hanft who just spoke was in charge of it. I spent time there. We have long known how to transfer technology from the bench to the bedside. We never learned how to get rid of the old things cluttering up the bed. The Clinton administration often talked about the 10 million new jobs they created. Actually it was 15 million new ones, and 5 million old ones were eliminated.With the new millennium, the boom and then crash of fiber optic cables, and Y2K forcing updating of computers, it has become just as easy—and cheaper—to do business half way around the world as down the hall. This has made the world flat, and medicine is part of the world.The change in demographics is dramatic. The proportion of American medical school graduates in obstetrics-gynecology residencies has fallen from 95%-65% over the last dozen years. Women will soon comprise 50% of the specialty. Residencies are 75% women, and the current applicant pool is 90%. In fact, the Board and CREOG scores of women are higher than the men. A gender shift is to be congratulated not bemoaned, but I worry that it may have gone so far as to make men "unwelcome" and that would have serious sequelae on the specialty. There is the perception among "the good old boys" that women leaders will not fight back as aggressively as men would. Thus, it is not surprising that obstetric-gynecology has been especially disadvantaged resulting in a disproportionate attack on the power, influence, and money in our specialty. The truth is, that on average, women physicians work about 20% fewer hours than men—for very understandable reasons. The resulting decreased income production to cost ratio, however, has real consequences, which must be acknowledged before they can be mitigated. Furthermore, a lower proportion of women than men physicians attend meetings, seek grants, and go for national leadership positions that has a ripple effect across multiple issues.Big business has taken over health care. The large corporations, who pay for much of it, including GM being the largest consumer of Viagra in the country, wanted MBAs not MDs running the show. A new layer of administrative costs, including corporate profits ensued such that the proportion of health care dollar going to health care, per se, has dramatically fallen. The recent Medicare Part D drug coverage mandating no negotiating with the drug companies has accelerated the hemorrhage.A generation of professional managers has emerged, who have been taught that running doctors and hospitals is no different than running a Burger King. Medicine is just another consumable. Production quotas, schedules, and profit margins can be calculated just as for widgets. To achieve these quotas, however, the culture of medicine had to be changed. In earlier generations trainees were taught that they alone were to be the stalwart professional being solely responsible for their patient's welfare. The new model said, you are the third violin on the left, do not squeak. We went from individualism to cookbook approaches. This has not been all bad, but the era of the craftsman has virtually disappeared. Hardly anyone could do a forceps rotation or a breech delivery even if there were no alternatives. Insurance companies refuse to acknowledge that some operators are better than others, and unless everyone can be considered a willing and equally capable provider, then they will pay no one.The change can perhaps overly simplistically be described as altering medicine from a career to a job. Particularly at the resident level, shifts, work hour rules, and shared responsibility to the point where no one feels either in charge or particularly responsible have created a culture of amorphous accountability rather than a personal professional one. With that has come a sense of personal priority over career responsibilities and created a sense of entitlement. I put in my hours, I go home, and do not dare criticize me or my work. Leaders mumble concern for quality, but do not back it up with personal accountability. With fewer physicians needing to take care of more patients, technology and physician extenders have been incorporated into the care paradigm. The military model of systems designed by geniuses needing to be operated by morons takes hold.We learned many years ago, that people alter their behaviors to how they are actually incentivized, not by platitudes of how it should be done, ie, follow the money. Routinely, in many organizations, academic and otherwise, physician salaries are adjusted by their dollar production volume. Rarely, does one get ever bonused for academic accomplishment. Under such circumstances, doctors are not stupid. The boss may talk publications, but he/she only pays for patient care.As the financial underpinnings of medicine and specifically academic medicine have deteriorated, the impact has been seen across the board. No longer does the academic physician see patients 1-2 days a week, and teach or do research the rest. Now many such "academics" have to see patients 9-10 sessions per week, pay for the inefficiencies of academic practice, and we have seen a dramatic fall in research and the teaching enterprise for our residents and students. ABOG examination scores have fallen, and passing grades have had to be lowered to keep up the percentage of students who pass. I sometimes think that we are training a generation of nebbishes. They know everything about finding data on Google, but cannot follow a labor curve, interpret monitor tracings, let alone understand forceps, breech deliveries, or have ever heard of a double set-up. Those going into academics are treated to statistics of decreasing funding opportunities, disappearing protected time, and living in a culture in which research is only valued for its immediate financial impact. Grant monies are becoming increasingly difficult to be obtained by clinician scientists. Only the full time research PhDs are likely to be successful. Monies that are available from industry come with specific obligations and are often geared toward the marketing of a specific product.The "me" generation has now taken over many professions, including medicine. We have achieved a culture of what I have coined: militant mediocrity. Poor performance, poor attitude, and a sense of entitlement have collectively often replaced a sense of responsibility. A trade union mentality has emerged among physicians that used to only be found significantly down the food chain of ancillary personnel.The department chairman used to be a near deity. The hospitals and in some cases with the willing collaboration of the Dean's office have relegated the department heads from coronals to drill sergeants; some chairs are no more than stools. Now often their authority extends little beyond picking the textbooks, making schedules, enforcing budgets, and settling personnel disputes. Many institutions no longer even bother to put out research reports for the year. The academic credentials of chairs have diminished considerably and in some places practically disappeared. The real authority is the 27-year-old MBA from the Dean's or Hospital President's office who often defines the departmental mission. Research is often a 4-letter word. When I was chair in Philadelphia, we increased the NIH research funding from nothing to more than $2 million in the first year. Because NIH caps salaries reimbursable for physicians at levels below their actual rate, the hospital and school decided we were losing money because of the gap between those numbers. They conveniently forgot the physicians did not cut back on patient care, and they did not include any of the indirect payments to them that far exceeded any gap. With that kind of accounting, no research program could ever break even. The hospital was run by the same corporation whose abuse of the outlier payment mechanism for care of the underserved resulted in their getting more than list price for hospital services. Eventually, the Feds caught up, and Tenet has settled for a $900 million fine for their actions which was actually just the tip of the iceberg, but the CEO got to keep the more than $100 million per year he was making. The Feds are now protecting Tenet against numerous further actions by aggrieved physicians, patients, and communities. Recently, Tenet named a new member of their board of directors to help with government relations receiving a salary of about $500,000 per year and generous stock options—Jeb Bush. Gee, I wonder if those 2 items are related.Hospital administrators take courses on how to keep disruptive physicians in line or get rid of them. The definition of disruptive can often being defined as being anything that puts power back in the hands of the physicians and away from administration. In some cases, hospitals have managed to sustain the concept that if a physician reports hospital violations of law to a state or federal agency, which are then in fact confirmed to be correct, that such a physician can still be removed from the hospital staff as being "disruptive." Hospital executive committees are often stacked to include a majority of physicians whose employment is solely at the discretion of the administration. Is anyone surprised that such physicians would never oppose the hospital President in any decision? Likewise, in an effort to maximize revenues, for profit chains regularly tout "benchmarks" for supplying ancillary services, nursing ratios, and use of tertiary services as mechanisms to lower staffing whose source is never documented or can be challenged. The burden falls on the practicing physicians. A spoken hospital philosophy was "inadequate care is better than no care."At the same time as administrators were laying off support personnel, hospital chains such as Tenet in the late 1990s and early 2000s were reporting record profits. Most executives have in their offices, pictures of their families, awards, and mementoes. The one that has struck me as mind boggling was in the office of a Tenet hospital president who proudly displayed a framed letter from the CFO of the national corporation praising him for having the courage to "fire all those nurses" —over the objections of the doctors and staff—to successfully meet his quarterly budget.More and more burden falls directly on the physician to make up the gap. At the same time, lack of infrastructure increases liability exposures, but there are fewer eyes watching over the process so that the chance to make errors substantially increases. The legal system has become a very expensive joke. Probably, 80% of what is substandard care never becomes litigated, and the vast majority of actual law suits are unmerited. A cadre of "experts" will say anything for a buck, and it is both sides not just plaintiffs.How do we fix this?For better or worse, here are my thoughts. Medicine is no fun anymore, because we have lost control of our destiny and have gone from being professionals to being cogs in someone else's financial wheel. We have to take back control of medicine, and we have to do it by restoring both the name and reality of professionalism in everything we do (Table 2). That means, for example, raising the quality of what we do, insisting that we perform not just to the standard of care but well beyond it. At the same time we cannot just fight the concept of being sued for poor outcomes by putting obstacles in the way of the plaintiff lawyers; we have to do better and give adversaries less to shoot at. About 10 years ago, I had the opportunity to address the ACOG leadership at the ACM. My complaint then and still now is that organized medicine worries too much about the borderline between lousy care and malpractice and not enough about getting the most advanced care into routine practice and raising the bar across the board.TABLE 2How do we fix this?Take back control of medical centersChange the model of referralsMeasure everythingBe the best at somethingPerform beyond the standard of careShared care requires more coordinationCreate true centers of excellenceUse TechnologyTackle the liability crisisMentor the next generation of leadersRestore the professionalism of medicineEvans. Overcoming militant mediocrity. Am J Obstet Gynecol 2008. Open table in a new tab 1. Complete control of medical centers, departments, schools, and programs cannot be in the hands of nonphysiciansToo many decisions have been based on quarterly profit motives with disregard to patient care. A balancing of financial performance with optimizing patient care has to be reinstated. We went from nonprofit systems drowning in red ink because they could not adjust to changing reimbursement models, to for profits where the CEO denied an inpatient psychiatric ward a cable television box for 50 patients to be occupied every day to save $10 a month. That hospital declared a profit that year of $40 million and gave a multimillion dollar bonus to the CEO. If physicians were in a position to exert real influence over such a situation, that would not happen.2. Let's change the model of referralsSince the managed care era, gatekeepers to expensive tertiary services have commonly been the lowest trained not the highest trained. Whether they be nurses or even family practitioners, they should not be telling a board-certified obstetrician-gynecologist that he or she cannot send a patient to a subspecialist for optimal care. The model in use is actually backwards. We should have high level screening to see who can be triaged downward, not upward. We have shown this model to decrease costs and improve outcomes.3. Measure everythingYou cannot fix what you cannot measure. Computerization of records and reminders to perform scheduled tests, screens, and referrals could keep thousands of serious facts from becoming mistakes that fall through the cracks. The infrastructure of medicine needs to be standardized with same language billing, insurance forms, codes, and charts.4. Teach our students and residents to be the best at something and not just adequate at everythingMy own practice has been very subspecialized in reproductive genetics, multiples, and fetal therapy. A 1980s Kentucky Fried Chicken (KFC) campaign slogan said "Do one thing, and do it right." I am a firm believer in the KFC approach to tertiary medicine. Ten years ago Karl Podratz said our residents were not getting enough surgical training before being allowed to operate on patients without supervision. The theme was that we needed to do a better job in preparing the next generation of obstetrician-gynecologists. Bob Sokol saw us at the crossroads—again. I thought it was actually in the "cross hairs" of those who would like to make our lives so difficult that we beg for nationalization of health care. To combat this, we need more efficiency and compartmentalization of delivery of specialized services with the understanding that the already understood principle that the same person does not do CVSs and exenterations now extends to many more aspects of obstetrics-gynecology.5. The changes in demographics of medicine, and obstetrics-gynecology in particular, have also created a shift mentality and sometimes lack of individual accountabilityThe need to balance training, patient welfare with individual and family obligations is reasonable, but political correctness has swung so far to where even pushing residents to see how much they know can be considered bordering on harassment.Sharing care requires coordination, an agreed on plan across the care givers, and seamless integration of action. None of this is actually new and has been pontificated on for years. What needs to happen is the development of a compensation mechanism that is worth the time of the individual doing it to really play traffic cop. This is what managed care was supposed to be about, but instead the bean counters and stockholders were generally more interested in denying care at the front line to maximize quarterly profits and not worry about the downstream consequences as somebody else's budget would take the hit. Loudly stated slogans often obscure the real message.The emergence of women leadership is to be congratulated but must be accompanied by the recognition that the defense of our specialty and patients requires a tenacity equal to those in other specialties trying to encroach on our territory. Decreasing reimbursements, skyrocketing liability costs, and lower physician productivity are all working against us. Fewer hours means fewer patients and dollars. We are in a war with no rules. Either fight back hard or accept second-class status. It will be up to the next generation of obsteric-gynecologic leadership to decide that. The CAOG is paralleling the national trend in obstetric-gynecology with membership demographics switching to predominately female at younger ages (Figure). Our Board of Trustees is already more than half women.6. Create true centers of excellence and have real data to prove itOutcomes have been shown in numerous fields to positively correlate with specific expertise and experience. In England, there is one Center for Neurological Disease in London that I coined the term a "quaternary" center that gets all the very rare cases from all over the country. I spent time there as a student. Data from many fields show that in such specialized centers, outcomes are better, and the ultimate costs are cheaper even including travel.7. Use technologyMany of the costs and the great advances of medicine have been a direct correlate of computers, genetics, and new pharmaceuticals. The incorporation of new technologies has been very haphazard in American medicine. There is a well-documented paradigm for the evolution of technology incorporation in America. Under institutional review board approval, a small number of physicians develop a new approach for the care of a limited number of patients. Eventually, publications and other publicity create a market. Insurance has yet to usually cover the services, and a period of boutique availability emerges. Patients often travel around the country for leading edge services. With the internet, the ability for patients to find out about new treatments has expanded geometrically. In my own practice, as many as 50% of multiples come by airplane. Eventually, insurance coverage begins.8. Discriminate by experience and qualityAt some point, the original providers cannot handle all the volume, and new players begin to get into the game. There is often, however, a disconnect between the operators generally accepted as the logical second generation and those who actually set up centers. In vitro fertilization and CVS are good examples. A maximum increase in use is accompanied by a skyrocketing of complications. Insurance companies plead that they cannot—I say will not—discriminate among providers for whom they will reimburse. They will pay either everyone or no one. This is used as an excuse to delay payments for services that could render better care. Likewise, the typical 2-4 year delay in getting a CPT code, eg, for nuchal translucencies, means that thousands to millions of patients did not get the best care available.9. Tackle the liability crisisThere are too many people feeding at the trough sucking away too many resources that could go to improved health care, improved education, or to sponsor new research. Huge jury awards get the attention of the bean counters, but only represent a minority of the problem. Caps, intimidation, and cookbook medicine approaches do not attack the core of the problem. We cannot tolerate the now often seen scenario that only the most junior of our colleagues who have little experience and therefore no case history are the only ones who can get covered. At the very least, insurance can no longer be all or nothing premiums. Switching to a total service coverage, premiums per case, or other mechanisms to not force our most experienced physicians to work either flat out or not at all would be an important first step.All of this is predicated on the core adoption of a philosophy of do it right the first time. The Mayo Clinic model of having a limited numbers of physicians doing all the surgery is unpalatable to many. While it absolutely will not work everywhere, it can work more places than it is used, and it has been shown to improve outcomes. We must also do a better job in managing cases. Bad medicine does not get any better when defended by bad lawyering.10. Mentor the next generation of leaders of our fieldAs an overgeneralization, boys through their more extensive participation in team sports as children have been more accustomed to sublimating individual goals for team ones. They are used to being coached and trained early on to teach others. This culture extends to professional development. I always told my fellows that they needed to learn 4 skills. Medicine, science, administration, and business, and that this could not all be accomplished during a 2-year fellowship. Making sure women get the same training and indoctrinated in the philosophy of passing it on has to be more firmly emphasized if we are to train a new generation of leaders.All of the above can be categorized under the rubric: take back professionalism. Adopt the Ritz Carlton mentality. For those of us who have ever stayed at both Motel 6s, and Ritz Carltons, one obvious difference is the way in which employees deal with questions and requests from guests. Ask where the bathroom is at Motel 6, and someone might point you in a given direction, and sometimes even the correct one. At Ritz Carlton, employees are told that they are to stop doing whatever it is they are doing, and personally escort you to the bathroom door. The concept is that you own a problem until and unless you have fixed it or passed it off appropriately to someone better able to handle it. Doctors used to be told that their patient was their responsibility—period. That has morphed in too many respects to send them down the hall. A change of culture brought that about. We let it happen. Until we reverse the underlying philosophy of herd accountability and abandon a militant acceptance of mediocrity as being the norm, we cannot take control back. This will not all be fixed overnight, and there are too many forces pulling in conflicting directions for there to be a straight forward "Iwo Jima" moment—at least anytime in the near future. At the same time, we cannot get by with most ignoring reality, while others just stand at the barricades The most realistic hope, and not even that is assured, even with everyone actually pulling together in the same direction, is another Tom Hanks role. Jim Lovell in Apollo 13 was the prototype for a "successful failure."The attempt to take