June 4, 2009 Speech at the HSPH Commencement 2009
We have arrived, I think, at a difficult point in human history. For millennia, before this moment in time, we had little knowledge of what to do to improve and sustain the health of human beings. We lived in ignorance. The average longevity of a person was under 40 years. The body, and how it failed, was largely a mystery.
The 20th century, however, brought an age of remarkable discovery. In the last century, scientists have come to recognize more than 60,000 different diseases and disorders that can afflict the human body — 60,000 different ways the human body can fail. And they have discovered methods of prevention and treatment for nearly all of them — if not to cure them, then at least to alleviate their worst harm and misery.
That knowledge has ranged from how to construct sewage systems well, to how to provide intensive care technologies. And that knowledge is continuing to grow. But having discovered so much, we have hit, in this new century, a new problem — how to actually deliver on all that has been learned.
When Alexander Fleming discovered penicillin in 1928, it was, I think, a kind of fake-out for the future of medicine and for public health. Fleming gave us a simple injection that could cure numerous infectious conditions, and it led us to believe that managing disease would be easy and cheap.
June 12, 2009 Speech at the University of
Nothing in medicine is without risks, it turns out. Complications can arise from hospital stays, drugs, procedures, and tests, and when they are of marginal value, the harm can outweigh the benefit. To make matters worse, high-cost communities appear to do the low-cost, low-profit stuff—like providing preventive-care measures, hospice for the dying, and ready access to a primary-care doctor—less consistently for their patients. The patients get more stuff, but not necessarily more of what they need.
Fixing this problem can feel dishearteningly complex. Across the country, we have to change skewed incentives that reward quantity over quality, and that reward narrowly specialized individuals, instead of teams that make sure nothing falls between the cracks for patients and resources are not misused. President Obama, I’m pleased to say, committed to making this possible in his reform plan to provide coverage for everyone. But how do we do it?
This is an approach we’re actually familiar with in medicine. In surgery, for instance, I know that I have more I can learn in mastering the operations I do. So what does a surgeon like me do? We look to those who are unusually successful—the positive deviants. We watch them operate and learn their tricks, the moves they make that we can take home.
Likewise, when it comes to medical costs and quality, we should look to our positive deviants. They are the low-cost, high-quality institutions like the Mayo Clinic; the Geisinger Health System in rural
We know too little about these positive deviants. We need an entire nationwide project to understand how they do what they do—how they make it possible to withstand incentives to either overtreat or undertreat—and spread those lessons elsewhere.
I have visited some of these places and met some of these doctors. And one of their lessons is that, although the solutions to our health-cost problems are hard, there are solutions. They lie in producing creative ways to insure we serve our patients more than our revenues. And it seems that we in medicine are the ones who have to make this happen.
Here are some specifics I have observed. First, the positive deviants have found ways to resist the tendency built into every financial incentive in our system to see patients as a revenue stream. These are not the doctors who instruct their secretary to have patients calling with follow-up questions schedule an office visit because insurers don’t pay for phone calls. These are not the doctors who direct patients to their side-business doing Botox injections for cash or to the imaging center that they own. They do not focus, the way business people do, on maximizing their high-margin work and minimizing their low-margin work.
Yet the positive deviants do not seem to ignore the money, either. Many physicians do, and I think I am one of them. We try to remain oblivious to the thousands of dollars flowing through our prescription pens. There’s nothing especially awful about that. We keep up with the latest technologies and medications in our specialty. We see our patients. We make our recommendations. We send out our bills. And, as long as the numbers come out all right at the end of each month, we put the money out of our minds. But we do not work to insure we and our local medical community are not overtreating or undertreating. We may be fine doctors. But we are not the positive deviants. `
Instead, the positive deviants are the ones who pursue this work. And they seem to do so in small ways and large. They join with their colleagues to install electronic health records, and look for ways to provide easier phone and e-mail access, or offer expanded hours. They hire an extra nurse to monitor diabetic patients more closely, and to make sure that patients don’t miss their mammograms and pap smears or their cancer follow-up. They think about how to create the local structures and incentives to make better, safer, more appropriate care possible.
I recently heard from one such positive deviant. He is a physician here in
Related previous posts:
Related story from a Pabrai Meeting attendee (told via the Corner of Berkshire & Fairfax):
During dinner, Mohnish told the story of when he told Charlie Munger about Atul Gawande (the brilliant surgeon who wrote two excellent books and the essay "The Checklist"). Mohnish asked Gawande whether Munger had contacted him:
Gawande: "He did. He said he really liked my books and what I was doing. Interestingly, a couple weeks after I talked to him I got, in the mail, a handwritten envelope from him. I opened it up and inside was a check addressed to me for $20,000. I called him up and said 'Mr. Munger, I got your envelope. Thank you for the check, but I can't accept this.'"
Munger: "No, no, use it for something good."
Gawande: "Sir, I'm a surgeon. I'm seeing patients all the time. I can't really just spend $20000 to do 'something good.'"
Munger: "No, no, you're smart. You'll figure something out."
Gawande: "Okay, if you really want me to do something with it, I can give it to the Harvard School of Public Health."
Munger: "You fool! If I wanted to give it to the damn Harvard School of Public Health, I would've written a damn check to the Harvard School of Public Health."
Gawande then decided to send it back. A week later, he opens his mail to find another envelope from Munger.
Inside were two checks for $20000. One to Gawande, and one to the Harvard School of Public Health.