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>> Al Mulley: Who can fix healthcare?
Some people think that doctors can fix healthcare.
Trust me, I'm a doctor; we can't.
Some people think that their elected representatives
or other policymakers can fix healthcare.
I don't think so -- not even presidents.
If presidents can fix healthcare,
Harry Truman would have done so just after World War II.
That's when the British, still reeling from the psychic trauma
of the near death of their nation,
with occupied territory twenty miles away and bombs dropping
on their capitol, reached out for a sense of personal security
in the form of healthcare security,
and formed the NHS in 1948, July 5.
Truman tried in this country, but he didn't come close.
Every president since has tried, I must say some more
than others, and we've just had a small victory, I think,
in a battle to achieve some personal health security.
The end of that story is yet to be written.
No, I don't think doctors or policymakers can fix healthcare.
They certainly can't do it working alone,
and I don't think they can do it working together.
They need you.
Now, some of you may be looking to your right,
looking to your left -- maybe me, but I don't know about him
or her, and some of you may be wondering,
I'm not even sure what the problem is;
how can I fix healthcare?
So who can fix healthcare?
Me? Her? Him?
I think you need to understand your role in healthcare,
and my guess is, you don't realize it.
Yes, you need to understand the problem, but you also need
to understand that it's the decisions that you make
about your health and about your healthcare,
that really drives the system.
We don't have time to get down in the weeds here,
so I'm just going to spend a few minutes talking
about the problem.
We are the richest country in the world, and we spend richly
on healthcare -- two point five trillion dollars,
seventeen percent of our GDP, roughly 50 percent more
than any other country.
Some of you may have read the newspaper this week,
about 20 percent increases in health insurance rates
for small employers in Massachusetts.
Those of you who work for the college know
that our employee costs
for healthcare are 13,000 dollars per year.
Increasingly, healthcare costs siphon money from payroll checks
and from profits, putting not only the health of people
at risk when they can't afford it, but the health
of our nation at risk.
And what do we get for this massive expenditure
in healthcare?
Well, if you look at the kinds of metrics that are used by the
WHO and others, we don't get nearly
as much as we think we do.
We're so fascinated with the high science
and the high technology that we don't pay sufficient attention
to the basics.
By basics, I mean life expectancy for men and women,
infant mortality rates, vaccination rates.
For most of the past decade, our country has ranked
in the mid thirties, despite the fact
that we spend roughly 50 percent more than anyone else.
Let me suggest that we don't have time to get in the weeds,
but there are some other important things
that you don't realize, and let's begin with a pop quiz.
Question. Healthcare is a good thing.
True, false, or it depends?
How many think true?
How many think false?
How many think it depends?
Okay. Let me try and give you a clue or two, for those of you
who are still wondering what the answer is.
If I were able to guarantee that you would be at the absolute top
of your game tomorrow at noon, physically, intellectually
and emotionally, with or without eight hours being poked
and prodded in the DHMC EW overnight,
which would you choose?
A good night's sleep, or being poked and prodded
by strangers in the glare of EW?
A second clue.
What if it was my sad task to tell you that either you
or a loved one would not be with us in thirty days?
Would you prefer that with or without three weeks
of intensive care that made the poking and prodding
in the emergency room look like child's play?
Which would you choose?
The respirator, the catheters, the infusions,
or peace at the last, at home with loved ones?
Now, healthcare is not a good thing in and of itself.
It's what economists call an instrumental good.
Healthcare is only good if it sustains or improves health.
Now, I've cheated a little bit on two counts.
First of all, I offered you a guarantee.
I pretended I had a crystal ball.
I don't. No doctor does.
Life is uncertain; healthcare is uncertain.
The uncertainty is interesting in healthcare.
Sometimes we're uncertain because nobody knows.
We just haven't done the research.
There may be a new treatment for heart disease, for cancer,
for breast cancer, but we just haven't done the research yet,
either because we haven't gotten to it, it hasn't been funded,
people didn't find it interesting.
You could call that kind
of a collective professional uncertainty.
On the other hand, sometimes the research has been done.
It's been done well.
It's just that it hasn't been interpreted
for the patient at hand.
The research was done in women.
Does it apply to men?
The research was done in young adults.
Does it apply to old adults?
And even when the research has been done
and interpreted correctly, it may not be there just in time
to help with the decision that doctor
and patient make together.
And, even when all of that happens, life is uncertain.
We can't predict what's going to happen to the next patient.
There, it's all about the risk attitudes that the doctor
and the patient bring to the decision.
Sometimes we like to think we can control the future.
Sometimes we like to pretend that we're not making decisions
in the face of uncertainty.
But it's critical that we make the distinction
between those things that we can control and those things
that we can't, and there's no sector
where that's more critical than in healthcare.
I've cheated in a second way.
I've talked about top of your game, perfect health.
That's that little figure over there on the left,
on the one hand, and death on the other.
There's a lot in between, isn't there?
We could talk about those dimensions of physical fitness,
of intellectual capacity, of emotional resilience --
all of those things contribute to the gradations of health
between perfect health and death.
And you know what, many people would be surprised
at how much they might disagree about how good
or bad a particular health state is.
For instance, men of a certain age; I won't mention it,
learn that their urinary functions declines
over the years.
They may have to get up once or twice a night
if they drink after 6 o'clock.
They may have to stop 2 or 3 times on a long trip.
They may have to sit on the aisle at an event like this.
And that can usually be fixed pretty quickly
with a surgical procedure,
but it almost always produces a certain odd kind
of *** dysfunction.
Some men are perfectly happy to trade away *** function
for some improved urinary function; others are not.
They disagree.
When a woman is told that she has breast cancer,
she might feel that keeping her breast is not terribly important
to her, and it would be just awful
to have breast cancer occur in a breast that she chose to keep.
Another woman might feel just the opposite.
They might disagree.
It's this uncertainty and disagreement
that makes healthcare so complex,
and I think you can begin to see why your role in sorting
out the complexity is so important.
This is after Ralph Stacey,
Management Organizational Behavior professor
in Hertfordshire, England.
It's called a Stacey diagram.
Basically, when uncertainty is low about getting B if you do A,
and disagreement is low about how good or bad B is,
decision-making and execution can be simple.
When uncertainty is high and disagreement is high,
decision-making and execution can be chaotic.
Most of life and certainly most of healthcare,
is in this zone of complexity.
It's the profession's job to reduce the uncertainty as much
as possible, but remember, there's going to be
that irreducible uncertainty left.
It's not the profession's job to try and get people to agree,
to try and get two men to agree about the tradeoff
between urinary function and *** function,
two women to agree about how bad it is to live without a breast,
how bad it is to live with the prospect of a recurrence.
Now, this complexity is very interesting,
and it may remind some of you of the phrase, "fog of war."
Fog of war is the phrased used when people have
to make decisions in a great hurry.
And those decisions are made in the face of uncertainty
and ambiguity, and often faulty intelligence.
It's often a phrased used when things aren't going well.
I think we're dealing with a fog of healthcare.
What can we see in the fog of healthcare?
Well, forty years ago, Jack Lindberg, who went from Hopkins
to Burlington, discovered something very unusual.
He went there to try and document that some people
in Vermont were getting far less care than they needed.
In the process, he discovered that variation in rates
of surgery were dramatic.
You could grow up in one town and be three, four,
five times more likely to have your tonsils
out by the time you were fifteen.
You could grow up in another town
and be six times more likely to have your uterus
out by the time you were fifty-five than in another town.
So geography was destiny.
The medical care wasn't driven by the science.
The care you got depended more on where you lived
and who you saw than who you were and what you cared about.
So what else can we see in the fog of healthcare?
That work extended to what's now the Dartmouth Atlas.
Over three thousand hospital market areas coalesced
around three thousand hospital referral regions.
People who live on the West Coast are twice as likely
to have back surgery than people who live on the East Coast.
People who live in Seattle, men who live in Seattle,
are six times more likely to have a radical prostatectomy
for prostate cancer than men who live in Connecticut,
but they're also more likely
to have alternative treatments for prostate cancer.
The real variation here is how hard you look for the cancer
in one place as opposed to another.
There's also great variation on the little things.
You know, there are eighty million people,
eighty million adults over age twenty
with hypertension in the United States.
I'm sure there are quite a few here.
And occasionally, you'll get your blood pressure medicine
changed, and you'll be told to come back
to monitor the effect of that change.
You could be told to come back in two weeks, two months,
two years, and no one has done the experiment
to tell us which is the best.
Given that there are eighty million people
with high blood pressure, that's a pretty expensive bit
of ignorance, isn't it?
Do you know that there are some parts of the country
where people see eighty specialists
in the last six months of life; others where they see eighteen;
where they spend sixty, seventy days in the hospital
in the last six months of life;
others where they spend twenty-seven;
ten days in the intensive care unit,
others where they spend two.
Again, huge financial costs but real human costs, too.
The majority of people who say clearly that they want to die
at home die in the hospital.
This work has been going on a long time,
emanating from Dartmouth.
It took Atui Gawande's article in June of 2009
to catch the President's attention.
And what he said was, this is a problem we've got to fix,
and again, I'm here to tell you that you don't realize
that you're the only ones who can fix it.
I think that if you think about leading us out of the fog
and how you can do that, it's worth pausing for a minute
and thinking about leadership in the fog of war
and in the fog of healthcare.
It's pretty clear, rules
of command are pretty clear in the fog of war.
An officer gives an order; the troops follow
or face court martial.
It's different in healthcare, isn't it?
You don't face court martial
if you don't follow my orders as your doctor.
In fact, you know that it's my responsibility to look
out for your interests and try to elicit your concerns.
What does this illness, the potential treatments,
the potential outcomes mean to you?
You are the principal; I am the agent.
The goal is to be sure that you get the care you need
and no less and the care you want and no more.
This is a very simply rule that people who talk
about complexity point to as the way out of the fog.
Simple rules, direction setting, the care you need and no less,
the care you want and no more.
A second simple rule.
There should be no decisions made in the face
of avoidable ignorance.
Anyone want to argue with that?
Every decision, every decision, about health
and healthcare should be informed
by both professional knowledge and personal knowledge
of the kind that we've been talking about.
And if we can do that, we're not just talking about your welfare
and the costs of healthcare,
because if we had your knowledge,
we would be doing far less aggressive care in lots
of domains that we don't have time to talk about.
If we had your personal knowledge factored
into decisions, we would also have your revealed preferences.
Those of you who remember Adam Smith in the Wealth of Nations,
unless we know what you care about,
unless you're informed enough about the choices that are made
to reveal your preferences, we have no information with which
to shape the healthcare system by investing or disinvesting
in different capacities to do things.
Might we have too many intensive care units?
Might we have too many cardiac care surgery suites?
So we've lifted the fog a little bit; the care you need
and no less, the care you want and no more;
no decision about health and healthcare should be made
in the face of avoidable ignorance.
This may all sound good, but it's going to be hard.
It's going to be hard.
I'm not sure that you appreciate how hard it might be.
First of all, you have to up your curiosity.
I've been trying to do that.
You also have to recognize that you need some competence.
How do I understands my choice in the context
of my values and consequences.
This is hard stuff.
The uncertainty applies to all of the diagnostic tests.
Those of you who learned Bayes' theorem in finite mathematics,
I learned it from Jon Kim.
He recognized that part of this fog
of healthcare is the haze of Bayes.
It's hard to keep these conditional probabilities
and other things sorted out.
Computers can do it easily,
and that's where decision support comes in.
But you're at least going to have to recognize the importance
of understanding the pitfalls that one can fall into.
But in addition, there needs to be courage.
How do I accept, how do you accept,
the personal responsibility for decisions that influence health?
You're not going to have to do it alone.
The complexity of healthcare requires that the best thinkers
from across disciplines come together.
That's where the ideas for innovating
and developing healthcare that minimizes the misalignment
of interests between patients and physicians,
between principals and agents, that contributes so much
to the waste in our healthcare economy,
that's where that comes in.
And we're not just talking about the science disciplines,
medicine, public health, the hard sciences.
We're talking about the social sciences,
and we're also talking about the humanities.
But the best thinkers across disciplines need
to be intentionally connected to the best doers across contexts.
The very best ideas
for redesigning care will succeed wonderfully
in some contexts but fail miserably in others.
Unless you have a portfolio of contexts, you're going
to discourage some very good ideas.
And both the thinkers and the doers need
to be working very closely with the best communicators.
We've always had a focus on basic science
and medicine in this country.
I've already alluded to that, what is the pathophysiology.
Clinical science, what is the diagnosis
and the appropriate intervention.
The first Center for the Evaluative Clinical Sciences was
founded here in 1989.
That's the question, does the intervention work
and is it valued?
What we're talking about is applying the same discipline
of science, but also discernment from gathering experience
from across contexts, and recalling that,
the science of healthcare delivery.
I want to close with one quick story.
Jack Wennberg was not the first to discover the variation
in tonsillectomy rates among children.
J. Alison Glover did in 1938.
He called it the "Strange Bare Facts of Incidence."
Children in different school districts in England
and Wales were ten times more likely than others
to have a tonsillectomy.
Mortality rates with tonsillectomy as opposed
to medical treatment were eight-fold higher;
ten-fold greater exposure,
eight-fold greater risk of death.
When he read that paper on Wimpole Street
at the Royal Society of Medicine in 1938, the representative
from the Medical Research Council said,
"This seems to be an operation for no particular reason
and no particular result."
The President of the Royal Society of Medicine said, "Yes,
and isn't it a shame that so many children died."
Anesthetic deaths for an operation
with no proven benefit.
The same variation in tonsillitis can be raised
within countries and among countries persists to this day.
Remember the curiosity.
What if a parent had asked: how do you know
that this is right for my child?
What if you asked every time you had a recommendation:
how do you know that this is right for me?
If not here, now and us, where,
when and who will fix healthcare?
Thank you.