Improving Our Health Care, Part I

THE OPEN MIND
Host: Richard D. Heffner
Guest: Donald M. Berwick, M.D.
Title: “Improving Our Health Care”, Part I
VTR: 5/16/01

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.

Appropriate, then, that my guest today, Dr. Donald M. Berwick, is not only a practicing pediatrician and Clinical Professor of Pediatrics and Health Care Policy at Harvard Medical School, but is 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’ve been reading through any number of my guest’s professional papers and speeches as well as pieces by and about the Institute for Health Care Improvement. And I want to begin today’s program by asking Dr. Berwick, though the IHI has been up and running for some time now, 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. Where do we have to focus “in”, doctor?

BERWICK: Well, we have to get straight what improvements we need to achieve to set the agenda of improvement clearly in mind. Naming the problem, so to speak. I also think the basic barriers, that the most important toxicities in the system right now are fragmentation. We’re just not working together cooperatively across boundaries and once we name the problems, we’re going to discover that we need to cooperate a lot more in order to make patients better off.

HEFFNER: But you know, I’ve read speeches in which you said that a long time ago, many years ago. What’s happened?

BERWICK: A lot’s happening. I think we’re much more aware as a public and as professionals of the gap between what health care could be and what it is . the gap is enormous and it’s been very, very difficult, psychologically, I think, to face up to the, to the challenge of change that we need to address. Once having addressed the gap, the problem is change. We can’t continue to do things in health care the way we’re doing them right now and expect anything to be different. The problems come out of the way the system is structured and built. The way we do our … the way we do our daily work. And that has to change if we really want care to improve.

HEFFNER: Where can the change begin? Where must it begin?

BERWICK: You know, everybody has to be involved. That’s really the problem here. I think it’s, it’s the reason why progress is so slow. Clearly the professionals need to welcome change. Doctors and nurses and other health care leaders today are, are really frustrated by not being able to do their work properly. And I think they need to move beyond the frustration and really start to ask what they could be doing differently. But they can’t do it alone. We work in organizations that need to provide technologies and supports so that physicians and nurses can do their work better. And we live in a context of financing and regulation and cultural belief that also affect whether we can improve care. I think we have to do it together, or I just don’t see it happening.

HEFFNER: What do you mean by “cultural belief?”.

BERWICK: Well, starting at the … in the bigger context of care, I think we have…an obsession in this … in the culture of American health care consumption that more is somehow better. That if we get the next operation done, or the next drug on board, or…or the next test done that somehow things will work out okay. That’s really not true. The cultural investment in “more” is actually producing harm as…as well as good. We need a public that’s more alert to the toxicities, the hazards that health care introduces into their lives, as well as the benefits it can bring. That’s one.

The other, I think, this is a personal belief, is that we’re over invested in competition as a solution to the, to the public health need. We think somehow if we can hospitals to struggle against each other, or get people who provide care to, to overcome each other, instead of overcoming disease, that we would be better off. That’s a bankrupt approach. We need a much more concerted, joined effort to make care better.

HEFFNER: It’s interesting that you say that because there are others who say that one of the problems is that there is no competition. It had been said on this program that you take the hospital in Salt Lake City that has developed many approaches to illness that you’d want to see replicated, but there is no competition between a hospital in New York, or in Boston, and one in Salt Lake City.

BERWICK: Well, maybe I’m…I am a minority, but I just am not a fan of that, that point of view. For a number of reasons. First of all, a lot of America is served by institutions that aren’t going to go away in a competitive market; they’re not going to be driven out of business, they can’t be. There are rural hospitals that are the only providers in their areas. There are inner city hospitals that are going to be the mainstays of care for very needy populations. We can’t beat them. Others can’t beat them, it’s a matter of them owning the issues of improvement and getting about that job.

Second, the American consumer knows that, that … especially those with chronic illness, and there are millions and millions of Americans with chronic disease, that they’re constantly crossing boundaries … they’re going from hospital, to hospital … from physician to physician, in-patient, out-patient care. If the different institutions that care for them regard each other as somehow enemies, how can the patient be…be cared for in transitions across these boundaries in a way that makes them safe and, and known?

HEFFNER: Don’t you despair then, since you say there is a need for basic cultural change, and we seem to be living once again in an increasingly Darwinian society on every other level, why not in medicine?

BERWICK: I’m very far from despair. I’ve never seen a more promising time. And it comes out of the aggravation that people feel. I think the professionals, those who lead health care organizations and the public are really generally aware now that things aren’t as good as they could be. And I think out of that can come some real social will for change. I’ve never been more optimistic.

HEFFNER: Based on what? Your own psyche? Your own approach to life?

BERWICK: [Laughter] Maybe. But, no … I think it’s, it’s a exciting, constructively aggressive minority in American medicine today that there are hundreds and hundreds of doctors and nurses I meet who, who are saying “we want change now. We understand this isn’t working.” We have a very frustrated group of health care institution leaders, CEOs, who are burned out and Medical Directors who wonder why they took their jobs. And a lot of them are turning to changes and answer … they’re saying they’re not going to give up. And we have a public that’s much more activated. Especially lately on the, on the issue of patient safety, which is … finally seems to be the, the label that has caught the attention of a significant proportion of the public who now understands something has to be different.

HEFFNER: Okay, the public understands that something has to be different. What has changed in the last couple of years since the emphasis was placed on numbers, the numbers of people who were damaged by mistakes, by systemic approaches that are bad. What’s changed?

BERWICK: It’s hard to say. The turning point was in November of 1999, I think, a rather historic thing happened which was the Institute of Medicine, which is the medical branch of the National Academy of Sciences, a very Blue Ribbon, very high end and rather conservative group, issued this very dramatic report called “To Err Is Human” that was front page news and network news for weeks. In fact, still is … I still get interviewed about that report. It’s funny, the report contained no new information, most of the research that was cited by the Institute of Medicine had been around for ten, twenty or even thirty years, but it was somehow all brought together in a single place by a trustworthy body and the press caught it.

The numbers were shocking to most people. Not, not to those of us who have been in the field for a long time. But we were saying that 40, 50, 100,000 Americans probably die each year due to their care … the care kills them instead of the disease. We also said, very importantly, it isn’t the fault of the doctors and nurses and others who give care … blame is going to get us absolutely nowhere. That these hazards from care are emerging from the, the way the work is structured, the design of care. And that good-hearted, well-intended human beings get kind of trapped in a system that can’t support them to act safely. So that the finding that there’s a serious problem, but it isn’t the people, leads to the third conclusion which is some real changes are needed. You might be able to tell me better than I can figure out why that moment, at that time, and those words, the public finally got that message.

HEFFNER: Well, it was the late John Knowles, who many years ago at this table, told me that going to a hospital is bad for my health.

BERWICK: Yes.

HEFFNER: That hasn’t terribly much changed, has it?

BERWICK: Well there, I don’t want to overstate the, the hazards. I mean when I was in training, I’m not that old, I dealt with children who were fated to die of diseases that today are curable. A leukemic admitted to my care 30 years ago… had a death sentence at the time they were diagnosed. Now 95% of them will live with certain kinds of leukemia. Children with complex cardiac disease can now get surgery and medical support that will allow them to live essentially normal lives. These, these are miracles. They’re very big changes. But along with this wonderful new technology and the way to understand the human body has come hazard. Every technology. Every approach. Every medicine introduces risks. And we have to build dykes… against those risks. And that’s what we fail to do. We, we are more complex, but not safer.

HEFFNER: You feel obviously that the computer can be a major help in building those barriers.

BERWICK: With caution. I mean it’s very important for the public and the professionals to know that every technology, even those put in to make things better, carry along new risks. So computers introduce hazards also. But on the whole, American medicine today is practiced, not even in a 20th century information environment. It’s practiced in a 19th century information environment. One, one of the great minds in American medicine of the last century was Professor Larry Weed at the University of Vermont, and, and Weed has said that if travel agents did their work the way doctors do their work, the travel agents would try to memorize airline schedules. We’re still working with very outmoded ways of processing information and that needs to change. We also rely on paper records, paper prescriptions, paper notes in an information age in which I, I order pizza on the computer, but I order medicine in my illegible handwriting. Doesn’t make any sense.

HEFFNER: Well, then why do, why do you say … when I talk about the electronic age, or the age of the computer … what are the dangers that you say, “hey, look, any change in technology brings about things that we’re not so happy about.”

BERWICK: Computers do good things. But they also have some bad effects. Let me give you two examples. Once a computer’s in place, the system’s automated, the… the safety net of human vigilance can decrease, I can begin to rely on the machine taking care of something when … and fall asleep at the wheel … that can happen. And we need ways to maintain human vigilance even while the computer’s doing its good work. The other thing computer and technology do that, that’s hazardous is they, they make the state of the system invisible. If you know what I mean.

HEFFNER: No. Tell me.

BERWICK: It…Once the machine takes over, if you want to know, “ is the process going okay, are things all right, are things going as planned” many … in many cases you can’t know, you can’t find out. You can’t tell what’s really happening. It’s equivalent to being on hold with no Muzak. You don’t know if you’re still connected or not. This kind of disconnection from the work, where the work becomes invisible, is a big hazard of technology. We still need human beings.

HEFFNER: Well then, how does a…how does a medical college, a medical school teach its students how to balance those things? Do they?

BERWICK: There’s progress, but we’ve got a long way to go. There are gaps in the way we currently train doctors and nurses, still. They’re changing, but not fast enough. We still, I think, in general train physicians and nurses and other health care professionals that they have to know everything in their heads…in their heads. So we teach them to use knowledge in their head, but not knowledge in the world. The…the new curricula that we need would make our physicians and nurses much more comfortable with accessing on-line information, diagnostic support at the point of care. Currently the culture of medicine would make it be an insult if the doctor would open a book or turn on a computer when he or she is making a decision. That’s actually the way it needs, it needs to become.

I have a wonderful story by the Dean of the American Health Care Safety Movement, Lucien Liep, he’s a wonderful former professor of surgery, now the real spokesperson for the safety movement. And Liep tells the story, he was a very skilled pediatric surgeon, of what he would do if he was doing a new operation. He was going to do a new operation, unfamiliar to him. He’d read the textbook the night before. He’d write down notes to himself on a index card about how to do the operation. And then he’d put the index card in his office, leave it there, come to the operating room, having memorized it, and try … and go through the surgery looking as if he actually was master of the…the information. Hopefully he was, but that’s a pretty, pretty flawed approach. What he should do is put that index card right in front of him, in front of everybody, and follow the check list, just like a pilot does when he’s flying a big airplane.

HEFFNER: You know, you use the analogy, the metaphor of the pilot flying a plane and I noticed that in the safety movement that’s done a lot. You use industry generally and you use…air traffic, air travel specifically. Why?

BERWICK: A number of reasons. First is the evident success of…of the aviation industry in improving its own safety. It’s improved 20 fold in a period of about 50 years. Health care has not improved safety demonstrably at all in that same period of time. So we … something’s going on there. More to the point, I think health care shares with aviation and nuclear power and some other industries, the property of being a high hazard environment. Very complex things are going on, the risks are ever present … there are human beings in inter-relationships just as there are in an aircraft carrier, a nuclear power plant or an air plane. We can learn a lot from how other industries have become ultra safe. Aviation today has a safety record of about parts per million or ten million … you have to take…you have to take about ten million air plane flights before you stand a 50 % chance of dying. The actual calculation is you’d have to fly on an airplane for 20,000 years before, on average, a single fatality will occur.

HEFFNER: Which is not true in a hospital.

BERWICK: In a hospital you have to lie in a bed for five years before a single fatality will occur. That’s a…that’s a vast difference. I’m very intrigued by the…by the approaches that aviation’s been using to make things safer. And they absolutely…read chapter and verse into health care, if we could open our minds a bit about it.

HEFFNER: Yet, when I go to my physicians, and I go too often, unfortunately, I wonder how can they know this much? How can they possibly keep up with advances? And you’re saying they can’t.

BERWICK: They can’t. They can’t. If they spent their time reading even the mainstream medical journals and tracking the most important issues in their clinical specialty they’d have no time to see patients. There’s a…there’s a tradition in medicine that I have to read it all, and know it all. We have to go up a level from that and say, “Somebody has to read it all and know it all and convey it to me in a way I can really use”. So … a lot of good work like that going on now, but that’s part of the culture shift we talked about to…to identify that as professionalism.

HEFFNER: You obviously think it’s possible to do that. You obviously think that even with our burgeoning public … with the numbers, the sheer numbers of people who are looking for medical care …

BERWICK: Yeah.

HEFFNER: That this can be done.

BERWICK: Yes. It makes it more important as our population ages, and we’re aging … these issues become more and more consequential. The more times you go to the doctor, the more chances there are for things not to go well. It makes it more important to get it right the first time.

HEFFNER: And you’re … you still remain optimistic, and I think that’s a function of your personality. Of your mindset. Because what you describe is so horrendous.

BERWICK: It’s very serious. But I, I had the great fortune of meeting the people doing the work, the doctors and the nurses, meeting the public. I get to…I get to interact with everybody. I, I don’t find many villains. I find a lot of people who are confused and searching for each other. And that makes me very optimistic.

HEFFNER: You say, and it’s interesting, you’ve said it several times, “doctors and nurses”. And so frequently I’m aware of…the line between them …

BERWICK: Oh.

HEFFNER: … when doctors talk about doctors and doctors …

BERWICK: …[laughter]

HEFFNER: …not doctors and nurses …

BERWICK: Well, I mentioned fragmentation is a big issue. There are different kinds of…of division in health care. All of it harmful. There’s institutional barriers … moving from your home to the hospital to a nursing home back to your home. Each of those involves transitions among organizations that may not even talk to each other. My own father, I remember, when he was sick, broke his hip, was in…was in a hospital … had a very extensive physical therapy evaluation, in a…a good hospital. Was then transferred to a nursing home, and I noticed there was no physical therapy going on and I, I asked the nursing home “well, why…why haven’t you started the p.t.?”. And they said, “Well, we haven’t done the evaluation.” And I said, “But they did, the hospital did.” And they said, “Well we don’t use the hospital’s evaluation.” That’s nonsense.

The other…Another important kind of division is the one you cited, which is, among professions … doctors, nurses, pharmacists, respiratory therapists, technicians, managers have a tradition of accusing each other, or meeting separately when a patient relies on them to meet together. I once asked a 15 year old boy patient of mine, he’d been sick for 15 years. He had a chronic illness … short bowel syndrome. His name was Kevin, I said, “Kevin if you could change one thing about your care to make it better, just one improvement. What would it be?” He said, “would you please talk to each other?” And…and, I thought he was right.

HEFFNER: And you feel that there is no real reason behind this … these splits. There is nothing that one could say, “Well, it’s necessary that we stay here, you stay there”.

BERWICK: I’d probably need an anthropologist’s help to, to know. There are reasons, the reasons lie, in…in many areas. Financing is one, we get paid separately, and in fact we get paid in some sense competitively. Physicians oppose giving nurses the right to write prescriptions. Because there’s revenue, there’s, there’s dollars attached to the opportunity to write prescriptions … beyond their concerns about the quality of care. We also have developed historically different vocabularies. There’s a “nursing record”, there’s “nursing diagnoses”, there are “nursing habits”. And there are physician habits and these create tribes of, of … tribes with …their own vocabulary, their own… their own belief system. We have ethics which differ among professions. We have the Hippocratic Oath for physicians. And nurses regard themselves as protecting the patient as a whole. The manager regards themselves … himself or herself … as a steward of social resources as if each were pledging to a different ethical standard. When indeed, I think all need to bear obeisance to the same ethical constitution which is “serve the patient.” We’ve got this history of separateness and it’s going to be important to break it. I work with nurses every day. I trained for eight years to become a fully qualified doctor. I never trained a single hour with nurses. It wasn’t part of the training.

HEFFNER: Tell me what you mean by that. I don’t understand because I belong to that culture that assumes that, of course, it’s the doctor who knows.

BERWICK: [Laughter] No one who has been through training knows that. You show up on the floor and…and if you’re not ready to listen to what the nurse who’s been there 30 years longer than you knows, you’re going to…you’re going to mess up. We are a team. 70 million Americans, probably more, have a serious chronic illness. Those people spend their lives in a journey through a system meeting different professionals, different organizations, and they … their safety, their…their health, their dignity depends on these people talking to each other so that they can smooth a pathway on this journey. And it’s…it’s no one person anymore. No…no single person takes care of a patient anymore. Not…not most patients, not most of the time.

HEFFNER: What is the impact, we have little time left for this program, and then we’ll go on to another … I hope you’ll stay where you are, What’s the impact of “better living through chemistry” upon all of these problems that you outline?

BERWICK: Double-edged. We’ve had a tremendous amount of progress in the pharmaceutical world. We have wonderful new medications that help us treat depression, and cancer and heart disease with great efficacy. It’s brought at least two problems with it. The first problem is that every new medicine has new threats. And we need to be very alert to those and sometimes the old stuff is better. We learned that with “Phen-Phen”, a…a drug proposed for the treatment of obesity. That patients were angry when…when anyone suggested that this drug could be withheld for any reason … cost or any other. Turns out it was a toxic drug with a dangerous side effect that, that now, thank goodness, we understand. Drugs bring hazard. They also bring tremendous cost. I know one very good health care organization in the Mid-West that recently told me that its…of its total cost of giving care, medications were 7% of the total cost five years ago. They’re 22% of the total cost today. Almost more than the hospital care so we are giving … we are seeing an explosion of costs… which we need to be very skeptical about.

HEFFNER: Skeptical?

BERWICK: New doesn’t mean better, always. Sometimes the older, cheaper, safer drug is where we need to go. We have a study in Colorado that shows that 30% of the children in the Colorado Medicaid system, who have an…a simple first ear infection, a very common infection in children, are getting nuclear weapon antibiotics. They should be on simple antibiotics that cost $5, instead they’re getting antibiotics that cost a hundred, a hundred and ten dollars. I’m not sure exactly why, but I know those kids are being exposed to medications they don’t need, at a very high cost and with extra side effects. We, we have to stay our hand a little bit and not be so interested in what’s so new.

HEFFNER: Well, now you say you don’t know why, but you must have some guesses that you’ve made.

BERWICK: Different people have different reasons. Some of the doctors will say that patients are demanding the drugs. And that they have to give it to the patient or the patient will leave. And we do have a new wave in this country of direct consumer advertising of medications. So maybe patient demand is up. We have drug companies sending detail men into doctors’ offices, convincing them that the drug is important. And we have doctors who ..

HEFFNER: They’ve always done that.

BERWICK: They always have, but there’s always a new drug. And, and I guess doctors are part of the American culture … technophilic … you know, wanting, wanting the new stuff. Instead, maybe, maybe a kind of conservatism would be wiser.

HEFFNER: What about the matter of advertising directly to the consumer? How do you feel about that?

BERWICK: I have mixed feelings about it. I think one important change that we need in this health care system is transparency. I don’t think we need blame, but I think we need openness, I think daylight really helps. And I think, if, if the drug companies get to talk directly to consumers, in some sense that’s daylight and I applaud it. On the other hand, if we have a consuming public that isn’t skeptical about that, that doesn’t wonder if maybe this isn’t the next phen-phen, the next … or something they don’t need, but are being convinced that they do. If the public isn’t sophisticated about it, they’re going to end up…putting pressure toward more instead of better, and…and thereby themselves incurring higher costs and…and more, more side effects, more toxicities. I…I would like to see us go toward transparency and public education hand-in-hand, and I think we’ll be better off.

HEFFNER: By transparency, we have one minute left, I’m getting the signal … do you mean honesty?

BERWICK: Honesty, openness, daylight. We…we are a very important profession, a very important industry, we do very important things. We should tell people what we’re doing, all the time, right out in the open.

HEFFNER: You’re talking now about the medical profession.

BERWICK: And the hospital and health care industry at large. Our results, our acts, our deeds, our, our investments, our choices should be matters of public record, not secrets.

HEFFNER: Dr. Berwick, I, I … there are so many, many, many things to discuss about this to understand … you don’t think we’re any of us, any one of us … the media, the medical profession … that we’re doing a good enough job in getting to the public.

BERWICK: We can all do better, and we’ll be even better if we tried to do it together.

HEFFNER: Okay, well, let’s try and do it together, by doing another program. Stay where you are, Dr. Berwick. But thank you for joining me today 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.