A few random observations from the Society of Hospital Medicine’s annual meeting in San Diego:
There are about 1600 people here, most of whom I don’t know. How did this happen?
People still seem pretty jazzed about their jobs and lives. The meeting has not lost its soul, nor its sense of wonderment or of family. That’s a very good thing, since these intangibles can be easily lost with time and size.
Certain issues seem to bubble up in every hallway conversation:
- Are you co-managing surgical patients yet?
- What’s the core job description of your hospitalists?
- Are you having trouble recruiting?
- How do you say no to relentless demand for hospitalist coverage?
Viz recruiting, in this morning’s panel discussion, John Nelson asked audience members to raise their hand if their program was recruiting for new people. About 90% of people did so. How many hospitalists hailed from places weren’t looking for new recruits? About 3 hands went up. (By the way, if you’re an academic hospitalist and you want to move to SF, please drop me a line!). In case anyone was wondering whether the field’s growth curve is flattening…
Don Berwick’s keynote address was, of course, powerful, poetic, and inspiring. A few key points:
The U.S. healthcare system is terribly broken. “We don’t have the best healthcare, just the most,” he said. To support this point, he cited the Wennberg/Fisher variations data, which shows that expensive regions in the U.S. spend $3000 more each year on Medicare patients than others, yet generally deliver crummier care. It is sobering stuff.
Don described the key role of systems in fixing the mess, using the familiar quote, “Every system is perfectly designed to obtain the results it gets” (a quote often attributed to him, but originally uttered by Dartmouth’s Paul Batalden).
He went on to illustrate the importance of human factors in safety. Quickly glance at this triangle:
Did it say “Paris in the spring”? OK, read it more slowly. Get it – it actually says Paris in the the Spring. Just one example of how the human brain takes shortcuts to get us through our days, shortcuts that can lead to mistakes. “We need dikes built around human frailty,” he said. On teamwork, he added, “Safety in healthcare depends on interdependencies, not on heroism.” All great stuff, very well said.
Then came the most controversial portion of his address. While lauding hospitalists for their focus on improving hospital quality and efficiency, he challenged the large and enthusiastic audience to think more broadly about its work. He described a new paradigm, which he calls the “Triple Aim” – the point being that we should aim for a system in which three key variables are optimized:
- the experience of care (including its quality and safety),
- the per capita cost of care, and
- population health (which, he acknowledged, is linked more to individual behaviors like weight, smoking, exercise, and nutrition than anything that doctors do).
In today’s healthcare system, he observed, it is no one’s job to try to achieve the Triple Aim – and in fact, many people live quite nicely off the system’s waste and errors. That includes hospitalists, since many hospitalizations are the result of outpatient failures, even mistakes. In the perfect world, he notes, hospitals would celebrate having empty beds, not full ones – since this would mean that we were achieving the Triple Aim.
To illustrate this point about caring about the big picture, not one’s own little silo, he quotes from Garrett Hardin’s brilliant 1968 essay, The Tragedy of the Commons – which describes a hypothetical small pasture used by a large number of herdsmen [I’ve quoted a few more lines than Don did in his talk]:
the rational herdsman concludes that the only sensible course for him to pursue is to add another animal to his herd. And another; and another…. But this is the conclusion reached by each and every rational herdsman sharing a commons. Therein is the tragedy. 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 in a commons brings ruin to all.
He pushed hospitalists to heed the Commons, recognizing that we are now part of a large herd – one more physician specialty – munching from this small pasture of U.S. healthcare resources, and that our eating too much may not leave enough grass for the next cow. I’ll buy that.
But his push for hospitalists to focus their professional energy on the “Triple Aim,” while inspiring, struck me as being both unrealistic and in some conflict with his arguments about systems. “I can’t work any harder, and neither can you,” he said, as a preface to the “improve the systems, not the people” mantra. I agree. In a hospital world filled with mistakes, inefficiency, and waste, is Dr. Berwick arguing that hospitalists should somehow muster the bandwidth to also focus on improving population health (so much of which is about personal behaviors, social status, and risk factor mitigation)? If he means that we need to pay attention to inpatient-outpatient transitions, then sure – that’s close enough to our core mission that we must include post-discharge transitions as being well within our bailiwick.
But if he is asking hospitalists to somehow take on the problems of the uninsured, or poor access to primary care, or unhealthy diets or hygiene, then I disagree. Where does it end? Why then not world hunger or global warming? Yes, we need to be good citizens when we hang up our white coats to leave the hospital, but, speaking personally, if I can help improve the quality, timeliness, efficiency, equity, safety, and patient-centeredness of hospital care, I’m going to call that a pretty good day.
Anyway, a very thought provoking and enjoyable day. Looking forward to tomorrow, including my closing keynote address (I’m traditionally asked to give the closing speech at the SHM conference, which is either a complement to my ability to keep people in their seats, or an effort to inflict me on the fewest possible victims). In any case, hope to see some of you there.
And to all of you who have come up to tell me how much you like the blog, thanks!