Training the New Medical Hero
February 10, 2016
The legacy of Mason Sones, legendary 1950s-era Cleveland Clinic innovator in cardiac surgery, lives on in many ways, including the Clinic’s annual Sones Award. Historically, the winner has been a physician innovator who developed a medical breakthrough – a new treatment, a new pill, a new procedure. But of late the criteria has changed. Now the award goes to an innovator in health care delivery.
Although such symbolism is powerful, this is but one small step. There remains a mountain of work to be done in changing the culture of medicine, and it starts in medical schools.
What kind of heroes are medical schools and residencies supposed to create? The writers of the TV medical drama Grey’s Anatomy certainly had a point of view. I’m going to go in early … I’m going to go hard-core … I’ll be a kick-ass cardio god! That’s one of the shows main characters, Izzie Stevens, perhaps channeling Mason Sones himself while getting pumped up to scrub in for a difficult cardiothoracic surgery and to outcompete another resident in the process.
On the set of Grey’s Anatomy, the heroic physician performed the daring procedure, advanced the frontiers of the biosciences, or spotted the obscure symptom that led to the surprising diagnosis. The show was of course mostly fantasy. Nonetheless, its portrait of medical training and medical culture is not so far off the mark, even in 2016, several years beyond the show’s heyday.
Today’s medical schools need to produce a new breed of hero. Not only is the mainstream med-school understanding of what it means to “kick ass” obsolete, it is itself grounded in fantasy. The delusion is simple. It is that budgets for health care are unlimited.
We have witnessed several decades in which the forces of cost constraint have been so weak as to be irrelevant, and in which every incentive in the system has pointed in the same direction, towards more care. The culture has followed, as has the way we train students and residents. Most modern day physicians can recall being told during their training that their job was to only consider the patient in front of them. Worrying about budgets was somebody else’s problem. The result: Value-for-the-dollar in US health care is extremely low. It should be no surprise.
The new medical hero understands that budget constraints are real. As such, the new medical hero is deeply offended by every wasted dollar. She is offended because she understands that every wasted dollar does real harm to real patients. It may not be as direct as the harm of a misdiagnosis, but it is every bit as real. Every wasted dollar increases the cost of health insurance for all, increases the number of uninsured or marginally insured, and increases the prevalence of situations in which patients are forced into fraught tradeoffs between physical health and financial health.
Most critically, the new medical hero understands that opportunities for improving value-for-the-dollar in health care are omnipresent. She understands that these opportunities do not require breakthroughs in the biosciences, nor do they require high technology, nor do they even require original thinking. Instead, they require the application of common sense principles that have been talked about for decades but have been encaged by the perverse incentives built into fee-for-service medicine.
Consider a simple example. One physician innovator I spoke with built a small team to better serve economically disadvantaged patients as they transitioned from hospital care to primary care. The failures of the modern health system during this crucial transition are not complex. At the moment of discharge, many patients have a poor understanding of their medical condition and what they need to do to recover. Conversely, many physicians who treat these patients in the hospital have a poor understanding of the real-life constraints that these patients face, so they propose care plans and goals of care that are unrealistic. Finally, many of these patients simply have no access to primary care.
The solution, as this modern physician hero recognized, is equally straightforward. Assign such patients a guide. Someone who understands enough about both hospitals and the realities of poverty to bridge the communication gaps that undermine care. Someone who can stay in touch with the patient for one to two weeks after discharge and aid them in their recovery. Someone who knows local health care resources and can help the patient find a way into primary care. This guide need not be an MD, PA, NP, or RN. The role can be filled by a community health worker who is hired and trained for this specific role.
The outcome of this physician’s effort? Better outcomes and lower costs. A double win.
If this team of community health workers had been a new drug instead of new people delivering new services, there is little doubt that the drug would be labeled a blockbuster. Very few innovations in the biosciences lead to double wins. They typically add costs, and often in exchange for marginal or even dubious improvements in health.
Meanwhile, there are opportunities for double wins through innovation in health care delivery in every corner of the health system. For every one physician innovator doing this kind of work today, there is room for one hundred more.
Medical schools are doing too little to prepare students for this kind of work. The sciences remain dominant in the curriculum; the principles of value-based care are squeezed into the margins.