THE OPEN MIND
Host: Richard D. Heffner
Guest: Donald M. Berwick
Title: “Improving Our Health Care”, Part II
I’m Richard Heffner, your host on The Open Mind. And this is another in a series of programs dealing with a theme that resonates widely and importantly in American life today. Namely, the quality of health care in our country and how to improve it.
It is also our second program with Dr. Donald M. Berwick, not only a practicing pediatrician and Clinical Professor of Pediatrics and Health Care Policy at Harvard Medical School, but also President and CEO of the Institute for Health Care Improvement, a non-profit organization dedicated to improving the quality of health care systems through education, research and demonstration projects and through fostering collaboration among health care organizations and their leaders.
Well I began our previous program together by asking Dr. Berwick what and where are the basic elements of health care in America that we must address now in order to achieve the improvements a good society deserves? And it’s undoubtedly a question to which we must return as a country, over and over again. Dr. Berwick, last time we were talking about perhaps over medication, perhaps too much enthusiasm on the public’s part, and I, I wanted to get back to this question of pharmaceutical advertising direct to the public. What, what would you do about it?
BERWICK: The Institute of Medicine in its most recent report on improving health care quality, it’s a report called “Crossing the Quality Chasm”, laid out a foundation for the kind of changes that are needed in the health care system. And I think it’s a great report. It said that there are three basic…kinds of changes we need. The…the names in the report are “Evident Spaced Care”, “Patient Centered Care” and “System Minded Care”.
The case of pharmaceutical advertising just raises those three issues… with point. The most important of them is “Evident Spaced Care”. Do we want a care system which assures that everyone gets the care that can help them, scientifically, known to help them, and avoids care and the costs and the hazards of care that scientifically can’t help them? We need to bring that mentality forward in a professional and public arenas, both.
I wish we could become a nation that makes the decision that we will get all the care that scientifically can help and not the care that can’t help. Medication is the first, maybe the first place, to start there. A lot of the medicines that people ask for and get can’t help them scientifically. In the case of antibiotics it may be as much as 50 or 60 percent of antibiotic use in this country. On scientific grounds, can’t possibly help them. I would like the public to be … somehow more and more aware that the, the commitment to evidence-based care is a matter of their safety and health. If we have that in place, the direct-to-consumer advertising is only another form of information to the public, which they can then consume with skepticism, as they ought to.
HEFFNER: Now, how many people do you know consume advertising of any kind with adequate skepticism?
BERWICK: Oh, I know, it’s, it’s a problem. But … health care maybe for centuries has operated with a theory that won’t work in the post-modern era, in my view. And that’s the theory that the, that the doctor knows better. That the, the expertise that we have due to our training and, and scientific education gives us somehow a form of wisdom that can be superimposed on, on the wisdom that the patient has. That’s not true. We’re asking for patient centered care. That means the values that you do apply, the choices that you do apply really, in the end, need to be those of the person who’s suffering and, and wants the help. We need the patient in the driver’s seat. The transition from professionally dominated care, in which we are the repositories of wisdom to highly cooperative patient centered, and I think patient controlled care, is going to be uncomfortable. It’s going to raise issues just as the one you, you raised of,of whether the public could be trusted to make the best choices for itself. I absolutely believe in the end it can. It, it’s a… It’s an evolutionary process, but I’m committed to it.
HEFFNER: Do you think that it is possible, let’s let’s say, we don’t have to be consumed by the idea that doctors are gods. Although I must admit I grew up in that culture, and probably retain a great deal of that feeling. So if I bow low before you, you’ll understand …
HEFFNER: … it’s because you are an M.D. But, when you put your emphasis upon patient control, how realistic is that as even doctors are further and further removed from the frontiers of scientific medical knowledge?
BERWICK: It’s, it’s very realistic. The frontiers of medical knowledge, the…the enormous outpouring of scientific information in, in our medical world needs to be digested, understood, and put in the hands of both doctor and…doctors and patients by some intermediaries that will help them digest the information and put it in useable forms. That’s, that’s one problem. But the, the more important arena, to me, of…of patient controlled care, self-care, is one of the most exciting cutting edge areas in all of…of clinical research today. Take a diabetic patient. Diabetes is a, is a problem, essentially, of blood sugar regulation. So to manage diabetes properly you measure your blood sugar and adjust the medications and the diet that affect your blood sugar. Well, the traditional view says that, that control system is the doctor’s … the patient’s the object of physician action: physician measures the blood sugar, understands it, develops a sense of the pattern, and changes the medication, let’s say to adjust to the patient. We now have research literature that shows if, if diabetic patients learn, as they can, to measure their own blood sugars, to put them on their own charts, to map them into their own… rule base for, for managing medication, with the physician’s initial help, the diabetic patient can far better manage his or her own blood sugar than a doctor ever could, as, as a…as a rather remote resource. The same goes for asthmatics, or people with hypertension, for people with all sorts of chronic diseases. We’re learning that patients can take over their own care to an extent we really didn’t imagine twenty years ago.
HEFFNER: Well, I was fascinated by the fact that your organization put out, the Institute for Health Care Improvement, put out this pamphlet on “Idealized Design of Clinical Office Practices.” Obviously, you feel that it is possible to change the whole physical structure, the whole system by which you doctors relate to us patients.
BERWICK: Oh, yes. There’s a, there’s a joke that says, “a definition of insanity is to keep doing the same thing and expect a different result.” That’s, that’s the challenge for health care. We have tremendous gaps in quality of care. We’re not evidence based, as we should be. We’re not patient centered. And we’re not cooperative. Those are, those are effects of the way the system’s built right now. We can yell at the doctors, or, or complain as patients, or sue if we want. Nothing’s going to change. That, that’s not change, that’s just…that’s just whining. Change means re-design. It means, it means building it from scratch. My father was a doctor in a small town in Connecticut. He spent his whole career there. And I sometimes imagine if you were to videotape him at his desk seeing patients, and then watch me see patients today … and you show the patients … show the two videotapes side-by side. And you say… took away the computer that’s on my desk, they’re the same. We’re doing the same stuff. It’s the same deed, it’s the same sequences. It’s not going to work. The idealized design in clinical office practices is a project our Institute started three years ago. We invited health care organizations, with physician practices to join in and, and really think about re-design. Forty-two practices joined … two from Sweden and forty from the U.S. And it’s been one of the most exciting things I’ve been involved in. We’ve, we’ve re-designed access, so many of the practices today have something called “open access scheduling”. It basically means you can call today, name the time you want to come in and that’s when you’ll come in. There’s no appointments, you just come when you want.
HEFFNER: What changes make that possible?
BERWICK: Giving up old habits of scheduling. Deciding, for example, that, that releasing the schedule, having “open” time in the mornings, for that day’s work. It’s doing today’s work today. It’s far better than this booking the patient four or six weeks out. It means giving the receptionist at the front desk a lot more power to decide how to allocate the time through the day. It means making predictions about when patients are likely to come in and model, and, and…and making sure that the, the physician and nurse time is allocated to when the patients are going to come. They’re fundamental changes, but they, they violate old habits. We’re also trying to change interactions.
HEFFNER: What do you mean?
BERWICK: I, I once heard the phrase “every patient is the only patient”. I love that. It’s…it’s a vision. It says that, that we don’t get to say how the patient has to act or what the patient has to want. Or we don’t get to call something “noncompliance” when it’s actually the patient making a choice. We, we need to honor every individual need and…and value that the patient, one at a time, brings to us. Well, that means we have to customize the interactions in ways we don’t normally do it today.
We have to understand what each individual patient wants much better. They don’t always want visits. Another part of idealized interaction is to, is to meet the need in the best way to meet that need. Sometimes patients call for questions. They don’t need a visit, they just need an answer. Sometimes they want a lab result. They don’t need a visit, they need a lab result.
I can get information on where my Fed Ex package is on the Internet. I can’t get my lab report on the Internet. That’s old thinking. If we broaden the terrain of interaction, offer patients more options to get care in the form they need it, everyone is better off.
We’re also trying to increase the degree to which we’re science based. And probably the most important element there is that practices need registries, they need memories. I need to know I have 380 diabetic patients in my panel, and 202 of them have been in for their eye checks. But a hundred odd haven’t and they need to be reached out to and brought in. It’s a practice with a memory. And right now we have practices that are always catching up. We don’t have electronic records in this country. We have … patient records are hand written today. That’s got to change, or we can’t organize the care to, to meet the needs of the patient.
HEFFNER: You know, doctor, when I have subjects here that deal with things that come from the political science area … social sciences, I frequently will refer to John Milton’s, from the Areopagitica, “whoever knew truth put to the worse, in a free and open encounter”. Incorporating your basic faith in people’s ability to accept these changes, but … in a free and open encounter, we’re not that well educated, as a people. You, you spoke at the beginning of our first program together about cultural change. Isn’t this idealized design of clinical office practices, isn’t it based upon an assumption about … not the inherent wisdom of the American people and of their medical practitioners, but of their knowledge, which we don’t provide. We don’t educate people to make use of this approach. Or of many of the approaches it seems to me that you, you take. You seem to assume that you’re going to deal, not just with a re-educated medical practice or practitioners, but an educated public.
BERWICK: I think we’re on a long journey. So, I don’t, I don’t assume it can…it will happen with a snap of the fingers tomorrow. But I think we have to start. I have some evidence. I … the experiments that are done, even with relatively low educated populations, on self-care, for example, show that the vast majority of patients rise to that challenge very quickly. Inner city mothers with children with asthma, taught to care for the asthma with self-esteem and, and autonomy, can do it. We know it. It’s in the literature.
So I think we’re making a lot of assumptions about what people can’t do, without a lot of evidence to back those assumptions up. I know we’re talking about change, that’s the point. But I, I have a lot of trust in the…in the ability of people to rise to the challenge of participating in their own care. And, in the medical profession, to make the changes we’re talking about.
HEFFNER: It’s so interesting to me, in so much of what you’ve written … again and again and again, and addressed to your fellow professionals, you talk about leadership, you talk about aims. You talk about a willingness to set a standard and meet it. Yet, there was one of the papers … let’s see it was … there is so much here that … you, you set standards … you said, on April 22, 1999, you said, “Let’s promise that in 36 months — three years — the best care will be the norm. Two years have gone by. Two of the three years you allowed us. Now, I’m not trying to dampen your enthusiasm because God knows that’s what has to … is the only thing that’s going to make change. But … how much progress? How much progress in the area of the end of life?
BERWICK: Not enough. You need to make changes as vast as we’re talking about. We need will, we need new ideas, and we need persistent execution, so that we, we carry through the changes that are needed. I would rate the three differently. The will is building. I have no question in my mind … the, the number of people in this country that want changes to occur and that are willing to…to point their finger at the hill and say, “take that hill”, is way up from what it was ten years ago. I think it’s, I think we’re at the threshold of something very important in terms of recognizing the need. The ideas are there. We have a very rich scientific and health services research literature. If we wanted to take better care of asthma, the ideas are there. We know how to do it. And if we don’t know how to do it in this country, others do.
HEFFNER: What …
BERWICK: … there’s a globalization of this effort that is really exciting.
HEFFNER: That’s what I wanted to ask you about. What about other peoples?
BERWICK: Well, I’m a fan of the U.S. and proud to be here. But I’ll tell you in some ways I sometimes wish I was working in, in one of the systems I see overseas. For all the criticism that’s … that the UK gets for the National Health Service, it’s an inspiring… and, and sincerely invested system of the whole, in a way that we don’t have today. I’ll give you an example. There was a report in Western Europe about three or four years ago about cancer care in the Western democracies. And it showed that England…and the UK as a whole, had relatively poor cancer outcomes compared to other countries in the…in Western Europe. They were at the bottom. We had in 1998 the… a similar report in the US, called “The Report of the National Cancer Policy Board”. And it found enormous gaps in cancer care in this country. That is, many cancer patients don’t get the best care. In England, the Prime Minister, the Secretary of State for Health and the entire National Health Service became mobilized to tackle the problem of deficient cancer care in that country. And they are making astounding progress. Already nine regions of 35 in that country are making “good” progress in … much better care for at least five important cancers. In the United States we’re still basically trying to decide what to do about the problem. There are good initiatives started in the National Cancer Institute, but we haven’t formed a national agenda to improve cancer care with anywhere near the vigor that the UK has.
HEFFNER: Isn’t that to some extent because the Brits have said … “this is a national and governmental concern?”
HEFFNER: … we don’t say that.
BERWICK: No. We don’t have a … we don’t truly have a national health care policy in this country. In the UK there was a commitment made in the late 1940s to universal care. And they’ve done it. There are problems in the British system. But one of the problems is not that a British citizen can’t get care. In the United States we have over 40 million people that don’t have adequate insurance, and many of them can’t get the care they need. Today a…a Black child born in inner city Baltimore or Washington, if he … a male child has a life expectancy eight years shorter than a, than a White child. And in a girl, it’s, it’s six years shorter. That…that’s the biggest predictor of health status in this country, is the color of your skin. And, and by a National Health Policy and an aim … I mean a decision to close that gap. I can see that kind of decision being made in the U.K., or in Sweden, or in, in Holland. I don’t see that kind of decision made with … the firmness we need in this country.
HEFFNER: Would you … would you want to have a single payer insurer … insurance system for the whole nation?
BERWICK: It’s a very, very complex question. And even the definition of “single-payer” is tough. But I’ll tell you this … there is no Western Democracy today that has made substantial progress in improving its own health care system without having some form of consolidated payment and organization of care. This country is so fragmented in its approach to care that, that I sometimes …. as I go to sleep at night, wish that we could move to a much more … what I would think is rational, payment system in which we, we can make some decisions as a nation about what’s going to get better.
HEFFNER: Do you feel that we have … any nation has the … but a large nation, such as our own, has the resources, has the riches to provide the kind of care for each citizen that you want?
BERWICK: Absolutely. Yes. This is a, this is a very … it’s a very confusing dialogue, but if you look at the facts, things get a little clearer. We do not have the highest health status in the world. Far from it. We have populations that are vastly underserved. We have enormous gaps in our quality of care. And yet we spend 30 to 40 percent more per capita on health care than any other nation on earth.
BERWICK: I think because we…we’re bemused with technology. We oversupply forms of care that we don’t need … there are…there’s excess in our system in, in technologies that other countries have brought under control, and give…provided just enough of. And we, we … we pay the piper later rather than sooner. That is, we, we … by failing to meet needs we have to pay anyway for the consequences of those failures to meet needs. The child with asthma, who we don’t reach out to in the inner city … to control their asthma, to get to educate the parents to take care of that child better, to, to bring the disease under control, that child’s going to be in the Emergency Room in two weeks. And we’ll pay that bill, and maybe in the hospital a week later, and we’ll pay that bill. If you don’t do it upstream, you’re going to pay downstream.
HEFFNER: We think of ourselves as a good, humanitarian people. We don’t seem to be acting that way in this area. Do we?
BERWICK: I must agree with you. As … one by one … we’re humanitarian. I can’t overstate the good will that I find in the system. It’s like drilling for oil … to ask people in health care, patients and doctors and nurses, to help improve … it’s like drilling for oil, they can’t wait to help. One by one they’ll show up. But as a collective, what promises are we making?
The Institute of Medicine report says we should make six promises. And I think they’re the right ones. That our care should be safe, and it isn’t. That it should be science based and effective … we should, we should use the science we know, reliably. And we don’t. It should be patient centered. The patient should be in control, every patient should have their own medical record … with unfettered access to their own medical record. Should be able to get information when they want it, in their own terms. We should be timely. We keep people waiting everywhere and that’s got to decrease. We should be efficient. Stop the pure waste out there … the supplies and equipment and capital that we don’t use. And we should be equitable. Close the racial and ethnic gaps. I regard those as promises, and, and we … we can’t make promises like that one at a time. One individual at a time, it has to be done as a region, anyway. And probably as a nation.
HEFFNER: You say “as a region”, that’s very interesting. Is there a movement in that direction?
BERWICK: Yes. I see in, in market areas, collectives forming that are very inspiring. In the Pittsburgh area, for example, the current Secretary of the Treasury, Paul O’Neill, who was at that time head of Alcoa, called together the leaders of the metropolitan area in Pittsburgh, and said, “Can’t we make some promises here?”. The two promises they’ve started with is … no infections acquired in health care. And, no medication errors. Now those are only a beginning. But can you imagine an entire … it’s really a region… promising that? It’s pretty inspiring. It can get people going. I see good, good work like that around…in the San Francisco area. Possible in the Pacific Northwest. And there’s some really interesting stuff going on in New England, especially among those who give cardiac care in New England; something called the Northern New England Cardiac Disease Study Group has actually reduced mortality from heart surgery 24%, as a result of cooperative action in a region. So, I think regional efforts have some promise. My preference is that we do it as a nation, as a whole, though because I think that’s where the…the most leverage would exist to spread knowledge and to build well.
HEFFNER: The people who are going to live up to the promise of medicine. People who are entering nursing school, medical school, dental school, etc. today … what do you think about them …
BERWICK: Oh, they’re the best …
HEFFNER: What are they like?
BERWICK: They’re great. You know, one of our problems was, you know, “Can you trust the consumer? And is information technology good? And who should be in control?” They’re passed that. They’re in the post-modern era, They’re in a consumer society, they know now to use the computers, they’re…they manage themselves as projects, and, and they’re ready. They’re far readier than, than those of us who have been here 20 years now.
HEFFNER: Yeah, but how about the attitude toward what their role is, what their objectives … personal objectives are? You can’t want to make a decision, “Well, should I be a corporate lawyer, or should I go into medicine? Should I go into business, or should I go into medicine?” And I gather that for some time, doctors’ incomes had risen so …
HEFFNER: … that there were people who went into the field, who wouldn’t live up to the promises you want to make. They couldn’t.
BERWICK: I’ve been teaching a course at Harvard College this year to, to young kids … you know, 20, 21 year-olds, and…some of them are becoming … are going to… want to become doctors. And I asked them, you know, what…what’s the buzz … you know when you tell your roommate that you’re going to go to medical school? What do they say? And a remarkably large number of them said they get criticized, that people are saying, “Why would you do that? Why would you be a doctor?” And because, because of the issues of income loss and control and some of the demoralization of the profession. The roommates are wrong. It’s a, it’s a great profession and I’m telling these people that, if … when they get into it, they’re going to understand that the … you know, the privilege is still there. It’s just that there are all these new possibilities, once we understand health care as a system. So, so they have to learn to be different kinds of doctors … citizen doctors … citizens in the system. Educators. The word “doctor”, I think, is… came from the Greek for “teacher”, not ”boss”. And, and if they can get that straight and get a commitment to evidence-based care, putting the patient at the center and in control, and cooperating, as the primary professional obligation, they’re going to have a “blast”, and that’s what I’m telling them.
HEFFNER: Okay, you’re talking about the patient in control …
HEFFNER: …but isn’t the feeling that there are so many other elements, not the patient, but the HMO, the government …
HEFFNER: … etc., in control.
BERWICK: Yeah. That is a serious issue. The, the … it’s somewhat easier, well, we know … we know what to do. I mean who could say that care shouldn’t be safe, or…or not science based. That would…that’s not … that wouldn’t be a fair position. So the aims, actually, are pretty easy. Honesty’s not easy … aims are … but the aims are clear. We also get a pretty good shot at how things should be organized. I think we have great models to follow now, if we want to re-build the care system. What we … the contextual issues, the environmental issues that you’re mentioning are very serious ones. Payment is very fragmented right now. So that doing the right thing can lose you a lot of money. I asked 50 hospital CEO’s last year, “If I said, ‘I could show you how to reduce admissions for congestive heart failure at 50%, would you want it?’” And they kind of shook their heads cause they knew it would go, it would be a negative hit at their bottom line. We’ve got to change that.
HEFFNER: Dr. Berwick, you have to come back and talk about that too, sometime, but thank you so much for joining me again on The Open Mind.
BERWICK: You’re welcome.
HEFFNER: And thanks, too, to you in the audience. I hope you join us again next time. And if you would like a transcript of today’s program, please send four dollars in check or money order to: The Open Mind, P. O. Box 7977, F.D.R. Station, New York, New York 10150
Meanwhile, as an old friend used to say, “Good night and good luck”.
N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.