The New Health Dialogue

Credit: Amanda/Flickr

This blog post was originally delivered as a speech by Shannon Brownlee to the Aligning Forces 4 Quality National Meeting in Denver, Colorado on May 19, 2011.

What we have on our hands is an industry poised on the brink of collapse. Costs are spiraling out of control, government is frantically waving its hands trying to find a solution to an impending doom that many players in the industry still refuse to acknowledge as real. Competition has triggered an arms race gobbling up all the available resources, generating massive short term profits while eviscerating the long term stability of the industry. Reformers grasp for a foothold while everyone else seems to be keeping their foot on the accelerator, and the experts tell us it’s only a matter of time. In fact, it will happen in 2048… the earth will run out of fish.

You thought I was talking about health care, didn’t you?  I’m talking about the collapse of the world’s commercial fisheries, but I could have been talking about health care. In 2006, a Canadian scientist named Boris Worm released a paper predicting the collapse of all global commercial fisheries by the midway point of the century.

If you think medicine has nothing in common with fisheries, think about this. The Health care sector just had its own doomsday clock reset. Last week, the annual Medicare trustees report predicted the Medicare hospital insurance fund will be exhausted by 2024.

That’s not very far away.

******

We talk all the time about how health care has ignored the lessons of other modernized industries. Usually we’re talking about learning from Toyota plants, or Netflix warehouses, or the airline industry.  There are many things to be learned from those examples.

But today I want to talk about what we can learn from a very different industry. The fishing industry.

But I also want to talk about the power of idealism, and the power of cooperation. There will be many paths towards a better health care system, a system that is actually patient centered, that is fair.

That gives patients the care they need, and no more – and the care they want, and no less.

I want to start with the story of how the fishing industry is saving itself and how that example opens one of the many paths towards health care salvation.

Does anybody watch the “Deadliest Catch?” It goes basically like this. It’s very cold.  Being a native of the other great non-contiguous state of Hawaii, I like to watch cold activities on TV more than participate in them. “The Deadliest Catch” is one long, frigid thunderstorm during which crazy Alaskans engage in a frantic race to catch as much king crab as possible in the few short days of the season.  

The result is a job so dangerous that Alaskan crab fishing has earned the dubious distinction of deadliest job in America.

Why are these fishermen engaged in this fatal race? Because the king crab fishery suffers from a classic case of tragedy of the commons.

The tragedy of the commons is the term that philosopher Garrett Hardin coined in the 1960s to describe what happens to resources that are open to public access. He paints the archetypal scene. A town has a common pasture for its shepherds to graze their sheep. Each shepherd faces a decision. He asks, “What is the benefit of adding one more sheep to my herd.” He gets the full benefit of another sheep, and the field gets one more overgrazer. The tragedy here is the town shares the burden of the overgrazing. The shepherd himself does not suffer in the short term. In fact, he benefits in the short term by adding another sheep to his flock.

The only rational response for any individual shepherd is to keep acquiring more sheep. Anyone who chooses to have fewer sheep, maybe an enlightened soul fearing for the future of the common green, only ends up leaving more grass for someone else’s flock. Hardin himself said it best:

“Each man is locked into a system that compels him to increase his herd without limit--in a world that is limited. Ruin is the destination toward which all men rush, each pursuing his own best interest in a society that believes in the freedom of the commons. Freedom on a commons brings ruin to all.”

It turns out, crab fishing suffers from a tragedy of the commons.  Alaskan crab fishing runs on a quota system of the maximum allowable total catch for the season. Think of that total as the village green. Once the season starts, every boat rushes out to catch as big a share of that quota as possible.

The frantic rush and disregard for weather leads to many deaths, but also a floating arms race. Each captain wants to buy as big a boat with as much crab catching equipment as he possibly can to bring in as many crabs as fast as possible.  

No captain has any incentive to do anything but take as much from the ocean as allowable. If he doesn’t, someone else will.

Fishermen push for a larger allowable crab catch, and fishing grounds become completely overfished because the incentives leave no one concerned with long term sustainability. It’s all about getting yours while the getting is still good.

Right now, this tragedy of the crustacean makes for good TV, but if history is any example, the Discovery Channel should be looking for its next big thing. Tragedies of the commons are doomed for collapse.

The Grand Banks, off the coast of Nova Scotia, is the perfect example. At one time, the Grand Banks cod fishery was the single most productive food source on Earth. By the time Canadian scientists recognized the decline in fish population, and put a moratorium on fishing in the Grand Banks, it was too late.

What doomed the Grand Banks? Rapidly improving fishing technology and weak data were two factors. The 1960s and 70s saw the introduction of hugely powerful trawlers that could drag massive nets through the ocean. What was happening to the fish stocks was a little unclear.

There was a third, crucial factor: A fishing industry that had a lot of money sunk in that technology, and a stubborn, hide-bound culture.  With so much capacity built up, and a long tradition of the fishing community, the individuals were unable to recognize their shared responsibility for their common resource until it was too late.

The collapse of the cod population was sudden, it was unstoppable, and it devastated fishing communities up and down the northeast.

******

I don’t know about you, but I hear echoes of health care in these two fish stories, the story of the Deadliest Catch -- the mad race to catch as much as possible -- and the collapse of the Grand Banks.

If we let the same thing happen to health care, it will be orders of magnitude worse. According to the Bureau of Labor Statistics, the health care workforce is more than 14 million people, all rushing headlong into a collapse spurred on by perfectly rational self-interest in a tragedy of the commons.

Instead of fish being the common resource devoured, think about health care dollars. Right now we have the same free-for-all in health care that we have in fishing.  Our health care system has ended up overbuilt like our fishing fleets.  We have what has seemed until recently like buckets of money for health care, open for the taking, encouraging everyone to devour up as much of it as possible. But unlike fishing, we haven’t gotten to the point of setting annual catch quotas. Right now, Medicare spending is the open sea, and the health care sector is doing its level best to extract as much out of it as possible.

I’ll give you an example of how health care is a little like the Grand Banks cod fishery. The number of prostatectomies, surgical removal of the prostate, rose by 50% from 2005 to 2008. Is this because the incidence of prostate cancer is rising? No, in fact prostate cancer rates are declining. So what’s going on?

Robot surgery. Its fancy name is Robotic-Assisted Laparascopic Prostatectomy, or RALP. Instead of cutting the man open, the surgeon uses a scope and robotic tools.  In 2004 robotic-assisted surgery counted for only 15% of all prostatectomies. That number had risen to 80% in 2008.

Why did that raise the total number of prostectomies? Because it lowered the barrier for surgery. Men have been sold on the idea that robotic surgery was less invasive, it took less time to recover, and therefore it’s safer and easier.

But here’s the cruel kicker. Robot surgery has been sold as a superior alternative to open prostatectomy, but the evidence suggests that it isn’t. Rates of incontinence and impotence are about the same as open surgery. And those are side effects that really matter to men. More than half of men have long term impotence or incontinence or both. The other problem with robotic surgery is it takes a really long time to get good at it. It takes a urologist about 1,000 procedures before he’s reasonably proficient.

What does that mean for patients 1 through 999?

And the final tragic twist to this story: Many men end up having to go in for an open prostatectomy a few months after their robotic surgery. That’s because the surgeon often misses a chunk of prostate tissue and the man’s PSA is still rising.

So why is every hospital so eager to buy a surgical robot? Because it’s good for patients? No, it’s good for revenue. It’s a new technology that nets health care dollars by bringing in more patients. 

Here’s another way health care is a little like the Grand Banks. There are 6 hospitals in Indianapolis that do angioplasties and stents, and bypass surgery. Six, for a population of less than 900,000. The city as a whole has more than a dozen hospitals, and six of them are doing this high end, high profit procedures. In order for all six to stay in business, they must be pulling people in off the streets. If you’ve got a beating heart, you’re be an appropriate candidate for a catheterization.  

Meanwhile, the Esperanza Clinic, just outside Indianapolis, which serves the poor, is open on Monday’s and Fridays. It’s doctors volunteer their time. And an enterprising employee went to the stores that the clinic’s patient’s go to – Walmart, Goodwill, and got 12 of these businesses to donate $100 a month. That pays for lab work for the clinic.

We are locked in a competitive environment in which nobody wants to be the one that gives up revenue in order to make the system sustainable. Meanwhile, a clinic that cares for the poor has to go begging to pay for lab work.

What happens to Indianapolis when health care dollars start drying up? At least one of its hospitals is likely to fail. Catastrophic collapse of a hospital is devastating, just as the collapse of the cod schools devastated fishing communities in Canada.

When St. Vincent’s hospital closed in New York City in 2009, it left 3,500 people without a job, and nearly a billion dollars in unpaid debt. In many communities and large cities, the hospital sector is the largest employer other than government. When hospitals collapse, it’s devastating to local economies. Usually it is safety net hospitals that fail first.

In Washington DC, the most recent hospital to close was DC General, in southeast. When it was open, DC General delivered 37% of care that was uncompensated. It was taking care of the poor. It was a level 1 trauma center, which was important in that community, and for better or worse it was a main site for primary care. That left 1 hospital in southeast, which is now in bankruptcy.

Meanwhile, northwest DC, where the middle class and well to do folks live, is awash in beds.

We have a commons in health care. That commons includes health care dollars, and health care jobs. It includes our investment in health care resources, like beds, and medical schools. But the commons here is actually bigger than just the health care sector. . . . It is our entire economy.

I can say one good thing about the Congressman Ryan’s “Path to Prosperity” plan for balancing the federal budget. His plan takes on the sacred cows of the federal deficit:

Medicare and Medicaid.

I probably don’t need to remind anyone that the extraordinary effort directed at health reform is not just about the quality of health care. What you and other health care reformers are doing is crucial to bending the cost curve, and I don’t think it’s an exaggeration to say that the economic well-being of the nation depends in part on your efforts.

No pressure.  

******

So health care is a little like fisheries. Technology is driving utilization. The health care sector is overbuilt in many places. And hospitals are for the most part unwilling to forego short term profits in order to preserve the commons. And that commons is our ability to have a vibrant economy and continue paying for health care.

But here’s the good news. Just as the collapse of fisheries like the Grand Banks serve as a cautionary tale for health care, fishery success stories can serve as a model. Innovators in the fishing industry are figuring out sustainable solutions that have something to tell us about a sustainable health care model.

One of those success stories is in Quintana Roo, in Mexico. Part of the reason I chose it as an example is because it's fun to say the name, Quintana Roo. It’s on the eastern side of Mexico, near the Yucatan Peninsula. The town of Punta Allen, in Quintana Roo, is about 40 miles south of Tulum. To get there you have to drive a couple of hours on a dirt road. There is electricity for only a few hours each day. But every lobster fisherman in the village is relatively prosperous, at least for Mexico. So prosperous, many own second homes in the city of Merida. There is a recycling center, a library and a health clinic. And their lobster fishery is thriving.

How did Punta Allen do it? Like most fishing villages in the region, the fishermen all belong to a cooperative. Nearly every other cooperative operates under open access rules. Anybody can fish anywhere. And their catches have been dwindling.

But the fishermen of Punta Allen took a different approach. Each fisherman has rights to a location on the ocean floor. And each fisherman builds several cement structures, which serve as homes for the lobster. The fisherman catch small lobsters in a nearby lagoon, transfer them to their cement lobster hotels, and then let the lobsters mature. When Hurricane Gilbert nearly wiped out their fishery, the community instituted rules prohibiting anyone from taking female lobsters, so that the lobster population could rebuild. They were willing to make a shared sacrifice for the good of the community, and for the good of the commons.

Is a fishery a perfect parallel to health care? Of course not. But there are a couple of aspects that seem worth emulating.

First is the recognition that sustaining the system requires behaving like good stewards of a valuable resource -- Good stewardship.

This is a notion that has not always been part of the way providers think about their job. But it will be. The American Board of Internal Medicine is promoting the idea that being a good steward is an integral part of medical professionalism.

Second is the willingness to share sacrifice in order to enjoy a shared benefit.

In Indianapolis, there’s no way all six hospitals can keep their cardiac units. As the flow of health care dollars dries up, as it will sooner or later, somebody is going to fail. And a catastrophic collapse of a hospital is devastating to a community.

Writ large, we are facing catastrophic collapses and disruption across the health care system.

The most important lesson here is that securing the long term sustainability of our common resource, in this case health care dollars and a functioning health care system, requires the willingness to bear the short-term social and economic costs of reigning that system in.   

But getting the health care sector to do just that, accept short term sacrifices for the sake of long term sustainability, is incredibly hard to do. In health care, just as there were on the Grand Banks, there are powerful interests invested in the status quo. Today they’re reaping profits, even as we barrel collectively into insolvency.  Just as in the Grand Banks, those powerful interests have invested heavily in technology and personnel. In many communities, we have too many hospital beds.  Too many CT scanners. Too many MRIs.

In some places in this country, there are more MRIs in a single city than in entire provinces in Canada. It’s a wonder people’s cars on the streets don’t swerve back and forth as they pass by the magnetic fields around the hospitals.

*******

There is a direct relationship between the capacity of the local health care sector and how much we spend per capita. There is also a relationship between the capacity of the local sector, and the amount of unnecessary, wasteful, and potentially dangerous care patients receive. Places where we see high per capita spending, and high rates of overtreatment, are generally over-endowed with medical resources. I’m talking about places like McAllen Texas, for example. I imagine most of you have read Atul Gawande’s piece about McAllen in the New Yorker.

But McAllen is not alone.

Los Angeles is practically wall to wall hospital beds. It is carpeted with little hospitals that were built by physicians who settled there after World War II. There are 30,000 doctors practicing in LA county alone. That’s one doctor for every 333 people. It has the highest per capita concentration of doctors in the country, and not very many of them are in primary care. And Los Angeles has one of the highest per capita rates of Medicare spending in the country.

Texas Governor Rick Perry recently gave a speech where he threatened that Texas might secede from the union if it is forced to comply with the Affordable Care Act. That might not be such a bad thing.  Medicare spending in many parts of Texas, not just McAllen, is out of control. It’s going up faster than most other parts of the country. Losing Texas would solve some our Medicare insolvency problem.

But Texas and Los Angeles are not alone. In many parts of the U.S. we have too many specialists, and not enough primary care doctors. Too many catheterization labs. Too many ICU beds. And the end result if we don’t get a grip on this system is the Medicare trust fund is going to run out of money.

To put this in perspective, federal spending on health care has already exceeded federal spending on Defense. That’s really surprising to a lot of people. Federal spending alone is more than we spend on defense, even fighting two wars.

What does that say about our ability to pay off the federal debt? None of us wants our children to live in a country with an economy that looks more like Greece than Germany, but we could if we doing get a grip on health care spending.

Not that I’m trying to pressure you.   

But reform is going to take a new sense of stewardship. And it’s going to take some shared sacrifices. Someone will make less money in the short term. Ignoring that while trying to talk about “cost control” is dishonest. Some people will lose their jobs, or their jobs will change. Some hospitals will have to close, or turn some of their wings into hospice beds and outpatient clinics.

And we're making these predictions with full knowledge about the huge influx of new patients in the form of 30 million newly insured. And that’s with the increasing needs of the aging of the baby boomers. In many parts of the country – Boston, Los Angeles, pretty much all of Texas, Florida, all of New Jersey, downstate New York – we have enough capacity to absorb the newly insured and the rising needs of the baby boomers.

What fisheries show us is that solving the problem requires the fortitude to make that sacrifice now, if we want to have a health care system and the money to pay for it in the future.

I’ll confess, I’ve been feeling discouraged lately by the enormity of this task, and by the resistance to change.

Paul Levy, former CEO of Beth Israel Hospital in Boston, used to write a blog called Running a Hospital. A good part of the time his blog was all about why things won’t work. ACOs won’t work. Global budgets won’t work. Doctors won’t give up fee for service – which to my mind is one of the central reasons we’re in this mess. Now that Paul has lost his job he writes a blog called Not Running a Hospital. At least he has a sense of humor.

But there’s a lot of “it will never work” out there. And much of it translates into, “We don’t want to have to make any sacrifices.” That can be discouraging to see. To counter my feeling of worry, I’ve been reading about some of the great social movements in history.

Probably the most incredible movement of all was the abolitionist movement in 18^th England. At the time, England dominated the slave trade. It was British ships that plied the coast of Africa and transported slaves in barbaric conditions. It was the British who supplied American and Caribbean sugar growers and cotton plantation owners with a steady supply of human cargo.

We look at it now and cannot imagine how it could be hard to abolish a barbaric, inhumane, disgusting trade.  But back then, slavery was the norm, and had been for all of human history. Back then, freedom, not slavery was the peculiar institution.

And just as in health care today, there were powerful economic interests aligned against the abolitionists. You could say the economy of Great Britain was fueled by the blood of Africans.  The slave trade itself was hugely profitable and it supported the economies of slave ports like Liverpool, Bristol, and London. Slaves produced the bulk of the sugar Brits put in their tea, and the cotton that drove the mills of the Industrial Revolution.

The abolishment of the slave trade in England began with 12 men gathered in a room above a print shop in London. Its members included John Newton, the former slaver who wrote the hymn, “Amazing Grace.”

London has monuments to kings, soldiers, and politicians, but no monument to one of the first, and greatest social movements in history. A movement that began when a 25 year old clergyman named Thomas Clarkson dismounted his horse, sat by the side of a road, thinking about all he knew about slavery, and said to himself:

“Some person should see these calamities to their end.”

Some person should see these calamities to their end

It took them 50 years, but the abolitionists did see the slave trade to its end. And at no small sacrifice on the part of the British people. More than 10,000 citizens in the city of Manchester, which depended up its cotton mills, which were fueled by the labor of slaves in the Americas, signed a petition condemning the slave trade.

******

The anthropologist Margaret Mead once wrote:

“Never doubt that a small, thoughtful, committed group of citizens can change the world. Indeed, it is the only thing that ever has.”

The health reform movement is full of thoughtful, committed citizens, and that’s an extraordinary feeling. But, like abolitionists, we need our elephant moment. They were able to show, through testimony and drawings of slave ships, and citing the number of slaves who died in transit, just how barbaric the trade was.  

That was not an obvious idea at the time, but they were able to make the idea that slave trading was wrong, and they moved people emotionally.

******

So we need some elephants if we want to transform health care. The notions of stewardship, and shared sacrifice are a start. But we also need a vision of the future.

Have any of you thought about what a really good health system might be like? I’m not talking about a financing system, like single payer. I’m talking about the actual delivery of care.

Until recently I hadn’t thought about it much either. We’ve spent a lot of time examining the current system’s failings. But what would a high-value, compassionate, patient centered system be like?

I imagine a health care system in which patients would no longer feel like widgets . . . and providers would no longer feel like factory workers in a shop where the conveyor belt is going too fast.

In the primary care setting especially, providers would spend enough time actually listening to their patients to know what ails them, but also what pleases them.

David McCullouch from Group Health talks about taking care of diabetics. Rather than homing in on the numbers, the almighty hemoglobin A1C, he asks his patients, “What do you like to do?” Because he sees his patients as people, not as bags of disease. He wants to help them do the things they care about. He knows he can’t cure their diabetes, but he can help them learn how to do what they love in spite of it.

Another quality of my idealized health care world: The acute care hospital would no longer be where all the action is. Primary care would be available, local, and it would be the source of far more services than it now provides. Nutritional counseling. Truly coordinating care for chronically ill. The emergency room would no longer be filled with people who should have gone to see their primary care doctor.  

In other words, we have to shift a lot of the money that is now trapped in the acute care hospital sector, and shift it downward, towards lower intensity care. Towards primary care and allied health professionals.We are probably going to pry it out of of the hands of some hospitals, unless they come to recognize the need for shared sacrifice.

Another quality in my idealized health care world? Providers would no longer view every patient as a lawsuit waiting to happen. There are many paths towards this ideal, but one of them may be shared decision making. Patients would be part of decisions about elective care. No decision about me without me. We would make sure they understand the tradeoffs involves in PSA testing, and knee replacement, bypass surgery, angioplasty and stents.

Patients and their families would be at the center of decisions around the end of life. How many of you have an elderly parent, spouse, or sibling? How many of you feel confident that your loved one will be cared for with compassion; will get his or her pain managed well and; will receive the kind of care, the intensity of care that he or she prefers in the last weeks of life. Whether he or she wants chemo right up the very last minute, or wants palliative care and is thinking about getting the words “do not resuscitate” tattooed on her chest. It’s a sad commentary that people who work in health care policy, who provide health care, who work on consumer engagement, can’t ensure that the people they love get the kind of death that they want. In my idealized health care world, how we die would not be determined by which hospital we happen to be loyal to and the particular style of practice the providers have adopted when it comes to treating frail, elderly dying patients. It would be determined by we the people.

We would have a robust science of health care delivery. We would constantly measure and learn. How many endocrinologists does it really take to care for 1,000 diabetics? How many NICU units does a population need? We would base our allocation of resources on the needs of communities, not the financial incentives of the acute care hospital. So a community clinic in Indianapolis that serves the poor would not have to go begging for $100 donations from local businesses while six hospitals rake in money doing cardiac procedures that at least 15 percent of their patients don’t need.

Finally, in this ideal world, the joy and dignity of caring for patients would be restored. It is an incredible privilege to be party to the most momentous events in people’s lives. In births, deaths, sickness. Doctors and nurses often have to fight very hard to hold on to that sense of satisfaction in a system that is constantly pushing them to deliver more and more and more care -- as fast as possible.

Like all people, doctors want dignity, honor, respect.  And when those rewards are not present, some seem to have substituted a substituted a desire for more money. Patients want much the same things. Dignity, respect, and they want to be comforted. And when they don’t get them, they have substituted the desire for more care, and more technological care.

******

What are some ways to achieve this gleaming health care system in the clouds?

How many of people have gone to your local hospital and said, what are you willing to sacrifice in order to put patients at the center of the care you deliver? What are you willing to sacrifice in order bring down spending?

Nobody wants to think about sacrifice, nobody wants to be the first hospital to forego revenue, to reduce admissions. Nobody wants to cut down on excess CT scans – because somebody else in the community will steal those patients and reap the reward. It’s the tragedy of the commons.

But there are hospitals and hospital chains out there that are stepping up to the plate. Take the Carillion Clinic, in Roanoke Virginia. Under the leadership of a visionary CEO and his team, this chain of hospitals is transforming itself into an organized, salaried group practice. It is not easy. Their chief financial officer spends a lot of sleepless nights because the hospitals forego revenue in order to do the what’s right for patients.

And not everybody in Roanoke is on board. Early on every radiologist but two walked out, hoping they would cause it to crash and burn. Hospitals managed to make do with temporary help and they kept their radiology department together until they could hire physicians who were willing to invest in a better health care future. But it was not easy.

Hospitals that make the commitment to becoming responsible stewards of a new and better system will probably lose some patients to competitors.  But giving an inappropriate patient a catheterization, or back surgery, or CT scan, or whatever it is, simply because he will walk down the street to a competitor is unethical. It may be good business, but its bad medicine.

These are very hard realities to face, but they have to be talked about and they have to be addressed.

One way to address this is through implementing shared decision making. Minnesota, Puget Sound and Maine have begun this effort. Every AF4Q community could do the same. Choose just two elective procedures to start with. PSA testing and PCI – angioplasties and stents.  Find payers who will purchase patient decision aids, and pay providers a small premium to share decisions with their patients.  It may fail, but the seed will have been planted.

Number two -- look at the way your communities have invested in health care resources. We are awash in technology, and if it’s there it will be used, whether or not it’s the right thing for the patient.

Number three -- We should make it OK for doctors to think about cost. Recent study by Elizabeth Stuebing and Thomas Miner, U of Florida, wote a paper with the all time best title: Surgical Vampires and Rising Health Care Expenditures.

They ran an experiment. They made residents aware of the cost of unnecessary daily blood draws on patients who were on the road to recovery from surgery. Over 11 weeks, they saved $55,000 in unnecessary blood work. That’s one unit on one hospital. How many services might be amenable to such a simple fix? The answer is hundreds. And even if this doesn’t work over the long run, it’s worth trying.

Experiment. Let 1,000 flowers bloom. The time for timidity is long gone.

Number four -- tell the truth.  All providers need to be open about their outcomes, error rates, rates of nosocomial infection, readmissions. Come clean.  And then they can show how they can get better.

We can’t improve what we don’t measure, and we won’t improvewhat we can hide.

It took the LeapFrog Group publishing rates of elective inductions to get hospitals to finally step up to the plate and announce they were going to do something about it. Yet where do you think LeapFrog got it’s data? From the hospitals themselves. Those hospitals could have looked at their own data long ago and decided to have a little chat with their OBs.

And now that they’ve been outed, will LeapFrog have to keep after them? Because reducing rates of elective inductions will probably reduce the number of infants who need to be in the NICU. And unless you fill your NICU with babies, you will lose money on the sunk costs. These hospitals that have been induction mills may need to shrink their NICUs.

Transparency is crucial to change.

Truth telling extends to your local press. The press is your ally, both in truth telling and in offering praise to those who make the effort to improve. The press is also crucial to getting patients to do their part. They have to make sacrifices too. The most important sacrifice they must make is letting go of their belief that more is better. That if they just find the right doctor, who will give them the right treatment, they can live forever. They will also have to let go of their belief that the rest health care system may be screwed up, but their doctor and their hospital are above average. Lake Wobegon has the corner on that.

Every provider in this country can do a better job, even the ones we’ve held up as model systems. I gave a talk at the University of Wisconsin, in Madison, shortly after my book was published. I showed the doctors some data on variation in how patients are cared for in different regions. Madison looks pretty good compared to a lot of places.

One doctor stood up and said, “If the care we are delivering is better than average, then heaven help the rest of the country.”

Jack Wennberg says there are 4 stages of acceptance on the way to health care reform.  To me they sound a little bit like Elizabeth Kuebler Ross’ stages in dying. Denial, Anger, Grief and Acceptance. Here are Jack’s stages on the road to health care reform:

Stage 1. “The data are wrong.”

Stage 2. “The data are right, but it’s not a problem.”

Stage 3. “The data are right; it is a problem; but it is not my problem.”

Stage 4. “I accept the burden of improvement.”

We have to accept the burden of improvement. We have to be bold. Try things. Be willing to fail. Above all we have to remember our common humanity. Remember that medicine is a higher calling, and what you are doing here today is part of a grand, a vital, and incredibly powerful social movement that simply has to succeed.

Because if it doesn’t, we’re all sunk.

No pressure.